NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrice '£ PRACTICE OF SURGERY. THE PRACTICE SURGERY. BY JAMES MILLER, F.R.S.E., F.R.C.S.E., SURGEON IN ORDINARY TO THE QUEEN FOR SCOTLAND; •URGBON IN ORDINARY TO HIS ROYAL HIGHNESS PRINCE ALBERT FOR SCOTLAND J PROFESSOR OF SURGERY IN THE UNIVERSITY OF EDINBURGH; CONSULTING SURGEON TO THE ROYAL INFIRMARY; ETC. ETC. ETC. HIRD AMERICAN, FROM THE SECOND EDINBURGH EDITION EDITED, WITH ADDITIONS, BY F. \Y. SARGENT, M.D., ONE OF THE SURGEONS TO WILLS HOSPITAL. illustrate ij QTfjrtt $un&r*& an& Niiutten JBnflrabittljH on ©Boob. i.-.m. ;.'i) ijuu ; 11010 V .-J PHILADKLPHIA: BLANCHARD AND LEA / VO rAHSp 12 53 Entered according to the Act of Congress, in the year 1853, 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 Pennsylvania. PHILADELPHIA: T. K. AND P. O. COLLINS, PRINTERS. THE EDITOR'S PREFACE. In preparing the present Edition of Professor Miller's Treatise On the Practice of Surgery, the Editor has endeavored, so far as he was able, to supply any omissions which the author may have accidentally made, and has suggested such amendments as appeared advisable. The matter thus added will be found incorporated with the text, inclosed in brackets, thus [ ]. A large number of additional wood-cuts have been introduced into the reprint, chiefly to illustrate objects described but not figured by the author. They are taken in most instances from the last edition of Mr. Fergusson's Practical Surgery, from Mr. Lawrence's Treatise on the Eye, and from Professor Gross's excellent Monograph On the Diseases and Injuries of the Bladder. " The favor with which Professor Miller's contributions have been re- ceived, renders it unnecessary to pass any encomiums upon them, far- ther than to state that the Second Edition of the Practice of Surgery, if which the present issue is a copy, is a great improvement upon the first; and that, in connection with the volume on the Principles, it forms one of the best expositions of the present state of Surgery in the English language. Philadelphia, July, 1853. * CONTENTS. CHAPTER I. Operations pagh 18 CHAPTER II. INJURIES OF THE SCALP. Bruise of the Scalp . Wounds of the Scalp . Wounds of the Temporal Artery 22 27 30 CHAPTER III. INJURIES OP THE CRANIUM; AND THEIR CONSEQUENCES. Concussion of the Brain ....... 32 Compression of the Brain ....... 43 Compression by Extravasation of Blood ..... 47 Extravasation between the Bone and Dura Mater .... 47 Extravasation of Blood on, or in the Brain ..... 48 Abscess of the Dura Mater . . . . . . .51 Fractures of the Cranium ....... 56 Fissure ......... 56 Fissure at the Base of the Cranium ...... 57 Fracture, without Displacement ...... 60 Fracture with Displacement ....... 60 Punctured Fracture ........ 63 Fracture of the External Table, alone ..... 65 Fracture of the Inner Table, alone ...... 66 Depression without Fracture ....... 66 The Operation of Trephining ...... 66 Wounds of the Brain ........ 69 Lodgement of Foreign Bodies ... ... 70 Hernia Cerebri . . . . . . . .71 Paracentesis Capitis ........ 76 X CONTENTS. CHAPTER IV. . DISEASES OF THE SCALP AND CRANIUM. Erysipelas of the Scalp . Tumors of the Scalp . . Pericranitis ....... Affections of the Cranium ..... Fungous Tumors of the Dura Mater .... CHAPTER V. AFFECTIONS OF THE ORBIT, AND ITS CONTENTS. I. Affections of the Orbit. Orbital Inflammation ...... Wounds of the Orbit ...... Tumors of the Orbit ...... II. Affections of the Evelids. Injuries ....... Foreign Bodies ...... Blepharitis ....... Ophthalmia Tarsi ...... Hordeolum ....... Encysted Tumors ...... Hypertrophy of the Upper Eyelid .... Cancer of the Eyelids ..... Closure of the Eyelids . Lagophthalmos ..... Ptosis ....... Trichiasis and Distichiasis .... Entropion ...... Ectropion ..... Blepharoplastics ..... III. Affections of the Lachrymal Apparatus. Epiphora ..... Inflammatory Affections of the Lachrymal Sac Fistula Laohrymalis .... Obstruction of the Nasal Duct Obliteration and Absence of the Nasal Duct Dacryolithes ..... Affections of the Lachrymal Gland . Encanthis .... CONTENTS. IV. Affections of the Eyeball. 1. Affections of the Conjunctiva. Simple Conjunctivitis . Purulent Conjunctivitis Strumous Conjunctivitis Granular Conjunctiva . Pterygium Pannus. 2. Affections of the Cornea. Corneitis Abscess of the Cornea Ulcer of the Cornea Opacities of the Cornea Staphyloma of the Cornea Conical Cornea Over-distension of the Cornea 3. Affections of the Sclerotic Coat. Sclerotitis ..... Staphyloma of the Sclerotic . 4. Affections of the Choroid Coat. Choroiditis ..... Muscae Volitantes .... 5. Affections of the Iris. Iritis ...... Changes in the Pupil and Iris. Occlusion of the Pupil Formation of Artificial Pupil . 6. Affections of the Retina. Retinitis ..... Amaurosis ..... 7. Affections of the Crystalline Lens and Capsule. Cataract ..... Dislocation of the Lens 8. Affections of the Humors. Hydrophthalmia .... Synchysis Oculi .... Glaucoma ...... Ophthalmitis ...... Wounds of the Eyeball .... Xll CONTENTS. Entozoa . . . . Tumors of the Eyeball Extirpation of the Eyeball Congenital Deficiency of the Eyeball Strabismus . . . . CHAPTER VI. AFFECTIONS OF THE NOSE. Fracture of the Nasal Bones Lipoma of the Nose Nasal Polypus Rhinolithes Epistaxis The passing of Nasal Tubes Foreign Bodies in the Nostrils Congestion of the Schneiderian Membrane Abscess of the Septum Narium Ulcers of the Nostrils Ozasna .... Lupus .... Rhinoplasties Partial restoration of the Nose CHAPTER VII. AFFECTIONS OF THE SUPERIOR MAXILLA. Collection of fluid in the Antrum Abscess of the Antrum Polypus of the Antrum Tumors of the Superior Maxilla Extirpation of the Superior Maxilla Wounds of the Face . Warts of the Face Erysipelas of the Face Spasm of the Face Neuralgia of the Face Tumors of the Cheek . Sinus of the Cheek Salivary Fistula Fracture of the Os Malae CHAPTER VIII. AFFECTIONS OF THE FACE. CONTENTS. CHAPTER IX. AFFECTIONS OF THE LIPS. Harelip ...... Ulcers of the Lips ..... Cancrum Oris ..... Cheiloplastics ..... CHAPTER X. AFFECTIONS OF THE PALATE Congenital Deficiency .... Velosynthesis ..... Ulcer and Exfoliation .... CHAPTER XI. AFFECTIONS OF THE TEETH. Crowded Teeth ..... Caries of the Teeth ..... Toothache ...... Extraction of Teeth ..... Hemorrhage after Extraction Tartar on the Teeth ..... Recession of the Gums .... Injuries of the Teeth ..... CHAPTER XII. AFFECTIONS OF THE JAWS. Parulis ...... Epulis ...... Tumors of the Lower Jaw .... Extirpation of the Lower Jaw Caries and Necrosis of the Lower Jaw Fracture of the Lower Jaw .... Dislocation of the Lower Jaw Anchylosis of the Jaw .... XIV CONTENTS. CHAPTER XIII. AFFECTIONS OF THE TONGUE. Glossitis . . . • • Wounds of the Tongue . Ulcers of the Tongue . Hypertrophy of the Tongue . Induration of the Tongue . Erectile Tumor of the Tongue .... Removal of Portions of the Tongue .... Division of the Frsenum Linguae .... Ranula .....•• Tumors beneath the Tongue .... Salivary Concretions ..... CHAPTER XIV. AFFECTIONS OF THE UVULA AND TONSILS. GMema of the Uvula ...... Elongation of the Uvula ..... Tonsillitis ....... Abscess of the Tonsil ..... Ulcers of the Tonsils ..... Hypertrophy of the Tonsils ..... Malignant Disease of the Tonsils .... CHAPTER XV. AFFECTIONS OF THE PHARYNX. Pharyngitis ....... Pharyngeal Abscess ...... Stricture of the Pharynx ..... Spasm of the Pharynx ..... Paralysis of the Pharynx ..... Sacculated Pharynx ..... Tumors of the Pharynx ..... Foreign Bodies in the Pharynx .... The passing of Instruments by the Pharynx CHAPTER XVI. AFFECTIONS OF THE (ESOPHAGUS. Stricture of the Oesophagus ..... Foreign Bodies in the Oesophagus 03sophagotomy ...... Palsy of the Oesophagus ..... CONTENTS. XV CHAPTER XVII. AFFECTIONS OF THE EAR. Foreign Bodies Polypus of the Ear Otitis .... Otorrhcea .... Abscess of the Mastoid Cells Otalgia .... Deafness .... Perforation of the Meiubrana Tympani Hemorrhage from the Ear Hypertrophy of the Auricle Otoplasties .... Congenital Occlusion of the Meatus CHAPTER XVIII. AFFECTIONS OF THE NECK. Glandular Enlargement and Abscess Hydrocele of the Neck Tumors of the Neck Opening of the External Jugular Vein Torticollis .... Wounds of the Throat Bronchotomy Foreign Bodies in the Windpipe Asphyxia .... Injuries of the Larynx The accidental swallowing of boiling water, acids, or other Spasm of the Glottis . Laryngitis .... I. Acute Laryngitis a. Laryngitis Simplex . b. Laryngitis GSdematosa c. Laryngitis Fibrinosa Diphtheritis, or Cynanche Membranacea d. Laryngitis Purulenta II. Chronic Laryngitis a. Thickening of Mucous Membrane b. Follicular Disease of Larynx c. Chronic OSdema Glottidis . d. Ulceration of the Larynx . Warts of the Larynx . Stricture of the Windpipe Formation of Matter near the Larynx Laryngotomy . irritant fluids XVI Tracheotomy . Bronchocele, or Goitre Tumors over the Thyroid Gland Enlargement of the Thyro-hyoid Bursa Hernia Bronchalis Disease of the Cervical Vertebrae CONTENTS. PAGE 277 281 285 Jursa 285 285 285 CHAPTER XIX. AFFECTIONS OF THE ARTERIES OF THE NECK AND SUPERIOR EXTREMITY. Deligation of the Carotid ....... 287 Deligation of the Arteria Anonyma ...... 288 Deligation of the Subclavian ....... 288 Deligation of the Axillary ....... 291 Deligation of the Humeral ....... 292 Deligation of the Arteries of the Forearm ..... 293 Wounds of the Palmar Arch ....... 294 CHAPTER XX. AFFECTIONS AT THE BEND OF THE ARM. Venesection ....... Accidents of Venesection ..... Affections of the Bursa over the Olecranon . 295 296 297 CHAPTER XXI. AFFECTIONS OF THE WRIST AND HAND. Ganglia, and Thecal Collections Paronychia Onychia Onyxis Contraction of the Palmar Fascia Tumors of the Metacarpal Bones and Phalanges Other Diseases of the Metacarpal Bones and Phalanges Hypertrophy of the Fingers .... Congenital Deformities of the Hand 298 298 300 300 301 301 302 303 303 CHAPTER XXII. DISEASES OF THE ARTICULATIONS OF THE SUPERIOR EXTREMITY. Disease of the Shoulder-Joint Resection of the Shoulder-Joint Resection of the Elbow-Joint Resection of the Wrist 304 305 307 308 CONTENTS. xvii CHAPTER XXIII INJURIES OF THE SUPERIOR EXTREMITY. Fracture of the Clavicle Fracture of the Body of the Scapula . Fracture of the Acromion Fracture of the Coracoid Process Fracture of the Neck of the Scapula . Fracture of the Neck of the Humerus Fracture of the Shaft of the Humerus Fracture of the Condyles of the Humerus Fracture of the Ulna . Fracture of the Radius Fracture of both Radius and Ulna Fracture of the Metacarpal Bones Fracture of the Phalanges Dislocations. Dislocation of the Clavicle Displacement of the Angle of the Scapula Dislocation of the Humerus, at the Shoulder Dislocation of the Radius and Ulna, at the Elbow Dislocation of the Ulna, at the Elbow Dislocation of the Radius, at the Elbow Compound Dislocation of the Elbow . Dislocation of the Wrist Dislocation of the Fingers Dislocation of the Thumb CHAPTER XXIV. INJURIES AND DISEASES OF THE SPINE. Concussion of the Spinal Cord Compression of the Spinal Cord Fracture of the Spine Dislocation of the Spine Lateral Curvature of the Spine Disease of the Bodies of the Vertebrae Lumbar and Psoas Abscess . Spina Bifida .... Malignant Disease of the Spine B xvm CONTENTS. CHAPTER XXV. INJURIES AND DISEASES OF THE CHEST. PAGE Fracture of the Ribs ...... • 346 Dislocation of the Ribs 347 Fracture of the Sternum 347 Caries and Necrosis of the Ribs and Sternum 347 Hernia of the Lungs, or Pneumocele 347 Wounds of the Chest .... 348 Haematothorax .... 350 Pneumothorax ..... 351 Paracentesis Thoracis.... 352 Wounds of the Heart..... 359 Paracentesis Pericardii .... 359 CHAPTER XXVI. AFFECTIONS OF THE MAMMA AND MAMMILLA Irritable Mamma Mammitis, Acute and Chronic Chronic Abscess Lacteal Tumor Hypertrophy . Pendulous Breast Partial Hypertrophy Various Tumors of the Mamma Extirpation of the Mamma . Affections of the Mammilla . 361 361 362 •363 363 363 363 364 365 366 CHAPTER XXVII. AFFECTIONS OF THE ABDOMEN. Abscess of the Abdominal Parietes Tumors of the Abdominal Parietes Bruise of the Abdomen Wounds of the Abdomen Artificial Anus Fecal Fistula . Pelvic Abscess Retro-Uterine Sanguineous Tumors Ovarian Dropsy and Tumors . Fibrous Tumors of the Uterus Gastrostomy . Gastrotomy Affections of the Diaphragm*. 368 369 371 ■">—/> 373 374 374 381 382 382 385 CONTENTS. CHAPTER XXVIII. HERNIA. Reducible Hernia ..... Irreducible Hernia ..... Incarcerated Hernia ..... Strangulated Hernia ..... Oblique-inguinal Hernia .... Ventro-inguinal Hernia .... Femoral Hernia ..... Umbilical Hernia ..... The other Varieties of Hernia CHAPTER XXIX. AFFECTIONS OF THE RECTUM. Abscess Exterior to the Rectum Rectitis ...... Fistula in Ano ..... Fissure and Ulcer of the Anus Hemorrhoids ...... Polypus of the Rectum .... Prolapsus Ani ..... Stricture of the Rectum .... Irritable Rectum ..... Hemorrhage from the Rectum Injuries of the Rectum .... Foreign Bodies in the Rectum Imperforate Anus ..... Artificial Anus ..... CHAPTER XXX. CALCULOUS DISEASE. Urinary Calculi ..... Formation and Varieties of Calculi . Renal Calculi ...... Vesical Calculus ..... Treatment of Stone in the Bladder . Lithrotripsy ...... Lithotomy ...... Varieties in Lithotomy .... Palliation of Vesical Calculus Urethral Calculus ..... Prostatic Calculus ..... Calculus in the Female . . . •. XX CONTENTS. CHAPTER XXXI. AFFECTIONS OF THE BLADDER. Cystitis ...... Irritable Bladder ..... Haematuria ...... Incontinence of Urine .... Retention of Urine ..... Retention of Urine in the Female Puncture of the Bladder .... Extravasation of Urine .... Injuries of the Bladder .... Tumors of the Bladder .... Displacement of the Bladder .... CHAPTER XXXII. AFFECTIONS OF THE PROSTATE. Prostatitis ...... Abscess of the Prostate .... Simple Enlargement of the Prostate Malignant Disease of the Prostate CHAPTER XXXIII. THE VENEREAL DISEASE. Gonorrhoea ...... Gonorrhoea in the Female .... Syphilis ...... The Simple Venereal Ulcer .... The Ulcer with Elevated Edges, and its Results The Hunterian, or True Chancre The Phagedaenic and Sloughing Sores, and their Results Condyloma ...... Bubo...... A General View of the Subject The Use of Mercury in Syphilis Syphilis in the Child ..... Syphilis in the Female Pseudo Syphilis .... CONTENTS. CHAPTER XXXIV. AFFECTIONS OF THE URETHRA. Stricture ...... Urinous Abscess ..... Urinary Fistula ..... Laceration of the Urethra .... CHAPTER XXXV. AFFECTIONS OF THE TESTICLE. Orchitis ...... Fungus of the Testicle .... Scrofulous Testicle ..... Tumors of the Testicle .... Irritable Testicle ..... Atrophy of the Testicle .... Hydrocele ...... Hydrocele of the Cord .... Haematocele ...... Cirsocele ...... Tumors of the Cord ..... Castration ...... Impotence ...... Spermatorrhoea ..... CHAPTER XXXVI. AFFECTIONS OF THE SCROTUM AND PENIS. Erysipelas of the Scrotum ..... Elephantiasis of the Scrotum .... Chimney-Sweeper's Cancer ..... Priapism ....... Phymosis ....... Paraphymosis. . . . . . * . Hypospadias ... .... Hyperspadias ....... Imperforate Urethra ...... Malignant Disease of the Penis .... Amputation of the Penis ..... XX11 CONTENTS. CHAPTER XXXVII. AFFECTIONS OF THE FEMALE GENITAL ORGANS. Inflammation of the Vulva . Abscess of the Vulva . Thrombus of the Vulva Warty Excrescences of the Vulva Oozing Tumor of the Labium Pruritus of the Vulva Malignant Ulcer of External Parts Tumors of the Labia . Hypertrophy of the Clitoris and Nymphae Fleshy Excrescence in the Orifice of the Urethra Laceration of Perineum Vaginal Fistula Stricture of the Vagina Obliteration of the Vagina Imperforate Vagina or Hymen Foreign Bodies in the Vagina Prolapsus of the Vagina The Passing of the Female Catheter , Plugging of the Vagina Leucorrhcea . Inversion of the Uterus Prolapsus of the Uterus Displacements of the Uterus Stricture of the Cervix Uteri Uterine Polypus Extirpation of the Cervix Uteri Malignant Disease of the Uterus PAGE 590 592 592 593 593 593 594 594 594 594 595 595 603 603 603 604 604 605 606 606 612 614 616 617 618 620 621 CHAPTER XXXVIII. OPERATIONS ON THE BLOODVESSELS OF THE LOWER EXTREMITY. Deligation of the Aorta Deligation of the Iliacs Deligation of the Femorals Deligation of the Popliteal Deligation of the Tibials Deligation of the Peroneal 625 626 628 631 632 634 CONTENTS. xxiii CHAPTER XXXIX. AFFECTIONS OF THE JOINTS OF THE LOWER EXTREMITY. Morbus Coxarius ....... Resection of the Hip-Joint ...... Change of Form in the Hip-Joint ..... Affections of the Knee and Ham ..... PAGE 635 042 642 643 CHAPTER XL. INJURIES OF THE LOWER EXTREMITIES. Fractures. Fractures of the Pelvis Fractures of the Femur Fractures of the Patella , Fractures of the Leg Fractures at the Ankle Fractures of the Foot Dislocations. Dislocation of the Pelvis Dislocations of the Hip Dislocations of the Knee Dislocations of the Patella Dislocations of the Ankle Dislocations of the Tarsus Dislocation of the Metatarsus Dislocation of the Toes Subluxations and Sprains of the Lower Extremity Injuries of the Tendo Achillis and Gastrocnemius Muscle CHAPTER XLI. AFFECTIONS OF THE FOOT. Talipes Flat-foot Podelkoma Corns and Bunions Onyxis and Onychia Exostosis of the Distal Phalanx of the Great Toe Contraction of the Toes XXIV CONTENTS. CHAPTER XLII. AMPUTATION. Amputations of the Superior Extremity. Amputation of the Fingers Amputation of the Thumb Amputation of the Wrist Amputation of the Forearm . Amputation of the Elbow-Joint Amputation of the Arm Amputation of the Shoulder-Joint Amputation of the Scapula Amputations of the Lower Extremity. Amputation of the Toes Amputations of the Foot Resection of the Ankle Amputation of the Ankle Amputation of the Leg Amputation of the Knee-joint Amputation of the Thigh Amputation of the Hip-joint . Affections of Stumps LIST OF ILLUSTRATIONS. 1. Couvre-chef bandage for the head 2. Double-headed roller for the head 3. Four-tailed bandage for the head 4. Compress applied to the temporal artery 5. Extravasation of blood beneath the dura mater 6. Plan of abscess of the dura mater 7. Fissure at the base of the skull . 8. Punctured fracture of the cranium 9. Trephining the skull 10. Cancerous ulcer of the scalp 11. Interstitial absorption in progress in the 12. The same advanced 13. Mercurio-syphilitic caries of the skull 14. Ulcer of the cranium healed 15. Ivory exostoses of the frontal bone 16. Large exostoses of the cranium, internal 17. Large internal exostoses . 18. Encysted tumors of the lower eyelid 19. Entropion of both eyelids 20. Mr. Guthrie's operation for entropion 21. Ectropion of the upper eyelid 22. Ectropion of the lower eyelid 23. Operation for ectropion, by excision 24. Operation for ectropion, par glissement 25. Fistula lacrymalis 26. Operation for fistula lacrymalis 27. Style for the lachrymal duct 28. Encanthis 29. Diagram of the vascularity of internal an 30. Catarrhal conjunctivitis 31. Granular conjunctiva 32. Double Pterygium 33. Corneitis . 34. Myocephalon 35. Staphyloma 36. Conical cornea 37. Staphyloma of the sclerotic, in profile and external d external ophthalmi XXVI LIST OF ILLUSTRATIONS. FIGURE PAGE 38. The same, in front view 131 39. Iritis .... 133 40. Iris-knives of Sir W. Adams 138 41. Coretomia 138 42. Maunoir's scissors 139 43. Tyrrell's blunt iris-hook 139 44. Extensive opacity of the cornea 139 45. Corectomia 139 46. Sharp iris-hook 140 47. Extraction of cataract 147 48. Beer's cataract-knife 149 49. Mr. Tyrrell's do. 149 50, 51. Curved cornea knives 149 52. The curette and Daviell's scoop 149 53. Depression of cataract 150 54. Scarpa's needle, front and side view 150 55. Reclination of cataract . 150 56. Place for incising the conjunctiva, in strabismus 158 57. Elastic wire speculum for separating the lids 159 58. Small toothed-forceps ...... 159 59. Small probe-pointed scissors ..... 160 60. Small iris-knife ....... 160 61. Blunt silver hook ...... 160 62. Lipoma of the nose ...... 163 63. Mucous polypi of the nose ..... 164 64. Deformity of face, caused by nasal polypi 165 65. Plugging the nostrils, for epistaxis .... 168 66. Belloc's instrument for the same .... 169 67. Plan of flap for a new nose ..... 174 68. The same, modified by Mr. Liston . 174 69. Partial restoration of the nose ..... 177 70. Abscess of the antrum Highmorianum .... 180 71. Large osteo-sarcoma of the upper jaw .... 181 72. Tumor of the upper jaw, with lines of incision for its removal 182 73. Portrait after the removal of the upper jaw 183 74. The twisted suture •••... ' 191 75. Malgaigne's operation for harelip .... 191 76. Instrument for supporting the wound after the operation for harelip 191 77. Simple harelip, and plan of operation . 192 78. Double harelip, and plan of operation . 192 79. Cancer of the lip . 193 80. Plan of operation for the removal of the same . 193 81, 82. Plan of operation in cases of extensive destruction of the lip 194 83. Volsellum...... 197 84. Plan of staphyloraphe .... 197 85, 86. Knives employed by Mr. Fergusson in staphyloraphe 198 87. View of the parts, in connection with Mr. Fergusson's operation fo p staphyloraphe ..... 108 88. Caries of tooth .... 201 LIST OF ILLUSTRATIONS. xxvii FIGURE PAGE 89. Purulent cyst at the fang of a decayed tooth . . . . 201 90. Application of the tooth-key ...... 202 91. Forceps for removing teeth from the upper jaw 202 92. Forceps for the lower jaw . . . . . . 202 93. Cyst at the root of a decayed tooth .... 206 94. Osteosarcoma of the lower jaw ..... 207 95. Osteocephaloma of the lower jaw .... 207 96. Extirpation of the lower jaw ..... 207 97. Caries and necrosis of the lower jaw .... 210 98. Four-tailed bandage for fracture of the lower jaw 211 99. Glossitis ......... 213 100. Excavated malignant ulcer of the root of the tongue . 214 101. Expansion of the lower jaw, by pressure of the tongue 215 102. Salivary calculus ...... 219 103. Excision of the tonsils, by the knife . 223 104. Fahnestock's instrument for removal of the tonsil 223 105. Stricture of the gullet ...... 230 106, 107. Forceps for the pharynx and oesophagus . 232 108. Mr. Wilde's ear speculum ..... 236 109. Large fibrous tumor of the neck .... 251 110. Venesection in the neck ..... 252 111. Jorg's apparatus for torticollis .... 253 112. Wound of the larynx ...... 257 113. Acute oedema glottidis ...... 265 114. False membrane in croup ..... 267 115. Sponge probang for the larynx .... 268 116. Warts in the larynx ...... 273 117. Stricture of the windpipe ..... 274 118. M. Garin's instrument for opening the trachea 278 119. Ordinary canula for the windpipe .... 278 120. Dr. Gairdner's tracheal canula .... 279 121. Specimen of bronchocele ..... 282 122. Cystoid appearance of a section of bronchocele 282 123. Relative position of the subclavian artery 289 124. Deligation of the humeral, radial, ulnar, and palmar arteries 293 125. Venesection at the bend of the arm .... 295 126. Loss of the thumb, from paronychia .... 299 127. Appearance of the bones of the thumb in paronychia, after maceration 299 128. Large enchondroma ...... 302 129. Scrofulous necrosis of the bones of the finger, after maceration 302 130. The position of the flap after resection of the shoulder-joint 305 131. Plan of an operation by Mr. Fergusson, for resection of the shoulder joint ........ 306 132. Appearance of the scapula, in this case, after maceration 306 133. Incisions for resection of the elbow .... 307 134. Caries of the elbow ...... 308 135. Ordinary site of fracture of the clavicle 309 136. Simple bandage for this fracture .... 310 137. Dr. Fox's apparatus for the same .... 311 xxvm LIST OF ILLUSTRATIONS. at the elbow the wrist 138. Fracture of the body and acromion process of the scapula 139. Fracture of the coracoid process of the scapula 140, 141. Fracture of the glenoid cavity and neck of the scapula 142. Fracture of the olecranon process of the ulna 143. Mr. Mayo's splint, for compound fracture of the forearm 144. Fracture of the distal extremity of the radius 145, 146. Dr. Bond's splint for the same 147, 148. Dr. Hays's splint for the same 149. Partial fracture of the ulna 150. Dislocation of the head of the humerus 151. Dislocation of the radius and ulna, backwards 152. Dislocation of the elbow 153. Dislocation of the radius forwards 154. Compound fracture of the elbow 155. Anterior dislocation of the radius and ulna at 156. Posterior dislocation of the same 157. Dislocation of the thumb 158. Noose, for restoration of the same 159. Fractured spine 160. Dislocation of the spine, front view 161. The same in profile 162, 163. Permanent curvature of the spine, by rickets 164. Continuous absorption of the bodies of vertebrae, from the pressure of an aortic aneurism 165. Caries of the vertebrae, the bones macerated 166. The same during life 167. Caries of the vertebrae . 168. General emphysema 169. Carcinoma of the breast 170. Secondary carcimona of the breast 171. Fungus haematodes of the mamma 172. The Glover's suture in wound of the bowel 173. Strangulated hernial protrusion 174. Plan of inguinal hernia 175. Appearance of a large inguinal hernia 176. State of the parts in hernia infantilis 177. Plan of femoral hernia . 178. Large femoral hernia 179. Ordinary site and appearance of femoral hernia 180. Strangulated crural hernia 181. Hernia Littrica 182. Plan of operation in fistula in ano 183, 184. Speculum ani 185. Prolapsus ani .... 186. Stricture of the rectum 187. Urate of ammonia 188. Crystals of uric acid 189. Oxalate of lime 190. Crystals of ammoniaco-magnesian phosphate LIST OF ILLUSTRATIONS. XXIX 191. Crystals of cystine 192. Uric calculus 193. Triple phosphate calculus 194. Oxalate of lime and urate of ammonia calculus 195. Mulberry calculus 196. Hempseed calculus 197. Triple phosphate calculus, on a nucleus of uric acid 198. Ammoniaco-magnesian phosphate calculus 199. Fusible calculus 200. Section of the same 201. Cystic-oxide calculus 202. Section of the same 203. Section of an alternating calculus 204. Bladder containing a calculus in fragments 205. Sounding the bladder 206. Double canula and syringe 207. Mr. Weiss's urethral forceps . 208. Large screw lithontriptor, of Mr. Weiss 209. Views of the extremity of the same 210. Mr. Fergusson's lithontriptor . 211. The same, in its application 212. The same .... 213. A new French lithontriptor 214. Plan of lithotripsy 215. Plan of the lateral operation of lithotomy 216. Dr. Physick's forceps, for tying the internal pudic artery 217. Instrument for catching urethral calculi 218. Prostatic calculi .... 219. Weiss's metallic dilator . 220. Trocar, for puncturing the bladder by the rectum 221. Plan of the different points for puncturing the bladder 222. Polypous growths from the mucous membrane of the bladder 223. Fungous tumor of the bladder . 224. Congenital extrophy of the bladder 225. Ordinary catheter 226. The prostatic catheter 227. Warts on the penis 228. The Hunterian chancre . 229. The sloughing sore on the penis 230. Acute phagedaena on the penis . 231. Chronic phagedaena on the penis 232. Condylomata 233. Mr. Stafford's straight lancet catheter 234. Mr. Fergusson's instrument for dividing stricture 235. Lallemand's urethral porte caustique 236. Fistula in perineo 237. Acute orchitis 238, 239. Puncture of hydrocele 240. Haematocele of the scrotum XXX LIST OF ILLUSTRATIONS. FIGURE 241. Treatment of varicocele by compression 242. Elephantiasis of the scrotum . 243. Chimney-sweeper's cancer 244. Phymosis 245. Paraphymosis 246. Deligation of the external iliacs 247. Deligation of the common iliac 248. Carte's instrument for the treatment of aneurism by compression 249. Ligature of the popliteal 250. Ligature of the posterior tibial, at various points. 251. Ligature of the anterior tibial, at various points 252. Articular caries affecting the hip-joint . 253. Wasting of the muscles and elongation of the limb, from disease the hip-joint..... 254. Effects of the advanced stage of morbus coxarius 255. Spontaneous luxation of the hip, in morbus coxarius 256. Anchylosis after morbus coxarius 257. Section of the same .... 258. Head of the femur and acetabulum altered by chronic deposit 259. Section of the femur thus altered 260. Housemaid's knee 261. Fracture of the neck of the femur, within the capsule 262. Section of the same .... 263. Impacted fracture through the trochanters 264. Long splint ..... 265. The same applied .... 266. Dr. Physick's long splint 267. Handkerchief for extension 268. Gaiter for the same purpose 269. " The American splint" 270. Maclntyre's splint, modified by Mr. Liston 271. Diastasis of femur .... 272. Mr. Lonsdale's apparatus for fracture of the patella 273. Fracture of the fibula, with the splint applied . 274. Compound fracture of the leg, on Maclntyre's splint 275. Apparatus for swinging a broken leg . 276. Compound and comminuted fracture of the leg 277. Fracture-box ..... 278. Dislocation of the hip on the dorsum ilii 279. Reduction of the same, by the pulleys . 280. Dislocation into the ischiatic notch 281. Dislocation into the foramen ovale 282. Reduction of the same .... 283. Dislocation on the pubes 284. Reduction of the same .... 285. Compound dislocation of the astragalus 286. Treatment of rupture of the tendo Achillis 287. Talipes equinus ..... 288. The same, after division of the tendo Achillis . LIST OF ILLUSTRATI ONS. XXXI FIGURE 289. 290. 291. 292. 293. 294. 295. 296. 297. 298. 299. 300. 301. 302. 303. 304. 305. 306. 307. 308. 309. 310. 311. 312. 313. 314. 315. 316. 317. 318. 319. Talipes varus The same, dissected Flat-foot .... Podelkoma Onyxis of the great toe . Exostosis of the great toe The ordinary tourniquet Signorini's compressor . Mr. Skey's tourniquet . The flap amputation of the thigh The corresponding stump The circular amputation of the thigh The corresponding stump Amputation of the finger Amputation of the three middle fingers Amputation of the thumb and its metacarpal Amputation of the wrist The tourniquet applied to the brachial artery Amputation of the forearm Amputation of the arm . Amputation of the shoulder Amputation of the foot . Amputation of the ankle Malan's flat tourniquet, applied to the poplite; Amputation of the leg . The forceps employed Amputation of the thigh Amputation of the hip-joint Neuromata of stump Necrosis of the femur, after amputation Sequestrum detached bone THE PRACTICE OF SURGERY, CHAPTER I. OPERATIONS. It is a favorite phrase, by which operations are stigmatized as the " opprobria of surgery." Nothing can be more unjust. Safely and expeditiously to remove parts which accident has rendered totally use- less, and which would prove highly injurious if longer attached to the body; to take away diseased formations, or other noxious substances, and, at the expense of but brief suffering, to dispel torture which had rendered existence a burden for previous weeks, months, and years; to accomplish such results, though it be by blood and suffering, is alike creditable to the operator and beneficial to the patient. It is not the operation—but the operation unseasonably, unnecessarily, unskilfully performed—that brings disgrace; and to refrain from operating when we are loudly and plainly called upon to do so, would carry not only opprobrium to surgery, but guilt and shame to the surgeon. In former times, it is true, operations were the disgrace of our art. Knives, hot irons, screws, files, gimlets, gouges, hammers, and saws were employed with cruel and ignorant recklessness. Of late years, however, every good surgeon has sought not only to simplify and diminish the number of instruments, but also to use them as seldom as possible. He does not hesitate to employ them, when his knowledge and experience intimate that they have become indispensable; on the contrary, he will then pro- bably be urgent in their application, knowing that an early wound may save much after-suffering. But, in the first place, he will exert all hn skill and all his powers, by milder measures, so to counteract injury and restrain disease, as to supersede the necessity of operating. To effect this, is doubtless the true triumph of his profession; and to this triumph he often attains. But he must be Utopian, indeed, who can seriously hope that the period will ever arrive, when operations shall have alto- gether ceased to be required. Modern surgery, accordingly, while anxious to limit the necessities for operation, is not the less aware of its importance as a means of cure; and has not only directed attention towards its improvement, but also extended its application, and with the happiest result, to diseases formerly without remedy. Many patients, 18 OPERATIONS. for example, are now by the knife freed from morbid growths and natural deficiencies, who were formerly left an unprotected prey to deformity and disease. A prominent cause of modern improvement in the art of operating, is an increased simplicity of the instruments, their arrangement, and use. On this subject, one who was pre-eminently distinguished among the operators of the present day, observes:1 "Our armamentaria should contain simple and efficient instruments only; the springs, grooves, notches, and curves, seeming to be chiefly intended to compensate for want of tact and manual dexterity. The apparatus, though simple, ought to be in good order, and should always be placed within easy and convenient reach of the operator, so that he may be in a great measure independent of the lookers-on; who, owing to anxiety or curiosity, hurry and agitation, are apt to hand anything but what may at the instant be required. He will consider well what place he himself may most con- veniently occupy during the operation; and, having obtained proper assistants, he will make sure that they all understand what is expected of them. In short, before he ventures to begin, he will ascertain that everything is arranged, and in proper order; more particularly, that the t cutting instruments have good points, that their edges are keen, and that the joints of forceps and scissors move freely and readily. The princi- ple, too, on which the instrument is made to cut should be well con- sidered. Every knife is to be looked upon as a fine saw; the teeth of some are set forwards, and these cut best from point to heel, as does a razor; but the greater number are set in the opposite direction—for example, the common scalpel and bistoury—and act efficiently only in being drawn from heel to point. "The skin, and in many instances the subjacent parts, should be divided at once and completely, by a single incision made lightly and rapidly—the parts being placed in a state of tension by the fingers of the surgeon or of an assistant—for the pain experienced is in proportion to the pressure and tardiness of movement in the instrument applied. Partial division of the skin, in tails left at each end of an incision, is also to be avoided; for the pain of such a cut is unnecessarily severe; and, besides, such wounds are not so available, as they would otherwise be, for the intended purpose of evacuating fluid, for permitting the extrac- tion of foreign bodies, or for the dissection of morbid growths. Also, the pausing of a surgeon in the midst of a dissection, and the resort to fresh and more extensive incisions of the surface, is not only always awkward, but attended with additional and unnecessary pain to the patient. Every cutting instrument should be well balanced, and placed in a steady, smooth handle; the point should either be in a line with the back, which ought then to be perfectly straight, or both edge and back should be equally convex, with the point corresponding to the middle of the blade. ° "The form and size of the instrument ought always to be in propor- tion to the extent of the proposed incisions, as regards both their length and their depth; nothing can be imagined more cruel and reprehensible 1 Liston, Operative Surgery. OPERATIONS. 19 for example, than an attempt to remove the lower extremity of a full- grown person with a common scalpel, or dissecting-knife. If an exten- sive incision is necessary, an instrument should be employed possessing length of edge sufficient to separate the parts smoothly and quickly. Should the operator, on the contrary, be required to cut on important parts—to perform a delicate dissection of the living tissues—he will choose a short-bladed instrument, with a handle rather long and well rounded; and, after the superficial incisions have been effected, he will hold it as he would a writing-pen, lightly but firmly, so that he can turn the edge, and cut either towards or from himself, as occasion may re- quire. A small well-made scalpel, with a good point, and less convexity than those usually employed, is the instrument best adapted for such a purpose. Grooved probes and directors should be used as little as pos- sible. "With a little practice, incisions may be made upon the most delicate parts without risk, one layer being cut after the other. And if any instrument is wanted to make the proceeding more safe—if the closely investing fasciae of a hernial tumor, for example, are to be cau- tiously raised—dissecting-forceps will be found the most convenient in- strument for elevation previous to incision. " In dividing the skin, the knife, whether a scalpel or a bistoury, is to be held and entered with the point and blade at right angles to the surface. It is carried with a decided movement down to the subcutane- ous cellular tissue; the blade is then inclined towards the part to be divided, and by a rapid and slightly sawing motion—as little pressure being applied as possible—division is effected to the desired extent. The incision is finished by withdrawing the knife in a position perpendicular to the surface, so as to divide the entire thickness of the skin, at the extremity as well as at the origin of the wound. For dexterously effecting such manipulations, the fingers must be educated; and diligent practice in the dissecting-room will be found the best foundation for surgical dexterity, as it is for sound surgical knowledge it is only when we have acquired dexterity on the dead subject that vfe can be justified in interfering with the living." By practice, the pupil will be enabled to use either hand almost equally well; and none should neglect to attain this power—for an ambidextrous surgeon possesses great advantages as an operator.1 An ordinary degree of expertness is within the reach of any one who will industriously seek for and improve the opportunities for its acquire- ment; but yet a certain combination of natural qualifications is undoubt- edly necessary to the attainment of pre-eminence in operative surgery; a great operator in one respect resembling a great poet—nascitur, non fit. The importance of these natural gifts did not escape Celsus. " He must be young, or at most but middle-aged," says he, " and have a strong steady hand, never subject to tremble. He must be ambidextrous, and of a quick, clear sight. He must be bold; and so far void of pity that he may have in view only the cure of him whom he has taken in hand; and not, in compassion to cries, either make more haste than the case 1 The making of wounds, with a view to the promotion of their cure, has been already considered. [Principles, 3d Am. Ed. p. 605.) 20 OPERATIONS. requires, or cut less than is necessary, but do all as if he were not moved by the shrieks of his patient." The coolness and courage thus inculcated are among the most valuable natural gifts of the surgeon; and it would be well did every patient remember that they are equally important in himself, for on his steadiness and patience under suffering much of the celerity and success of an operation may sometimes depend. In the present day, however, the operator is much less dependent on his patient than he was wont to be; in the great majority of cases the latter being absolutely passive in his hands, because quietly recumbent under the influence of complete anaesthesia. The obtaining of such quietude and non-resistance, the abolition of pain, the mitigation of shock, and various other advantages affecting both operator and patient, from the judicious use of chloroform, have been already fully considered,1 and on that subject it is not necessary again to enlarge. The necessity for an operation, in any case, having been clearly established, our object is to perform it as safely and expeditiously as possible. The mere absence of protracted pain confers a most import- ant advantage on the reparative powers of the system; and, so far, celerity is commendable, when chloroform is not employed. But it is a very common, as well as dangerous error, to suppose that excellence is always commensurate with the rapidity of performance. In the great majority of cases, haste is incompatible with safety; while the latter is the paramount object in view. Tuto et celeriter is the operator's motto; but the tuto precedes its accompaniment. And now, more than ever, as has already been stated (Principles, 3d Am. Ed. p. 722), haste and hurry are altogether inexcusable. The student, as an ope- rator, should learn to be rapid; but rapid, because skilful; and rapid only when safe. And, in some procedures, he will not fail to learn that attempted rapidity must ever prove injurious. Perhaps a more common, and still more serious error is—the imagin- ing that operates constitute the greater and more important part of Practical Surgery* The student is very apt to be led away by the more garish and imposing parts of his profession, to the neglect of that which is in truth by much the more valuable; and he may also forget that, in after life, he will be only occasionally called upon to perform the greater operations, while daily he must exert his general knowledge and skill as well as his minor handicraft, to avert the necessity for the knife's em- ployment. In the case of a diseased joint, for example, he is not at once to contemplate amputation or resection. Such procedure is the ultimatum, not the initiative of his art. Local depletion, rest, counter- imtation day timed and conducted, pressure, splints, attention to the general health (Principles 3d Am. Ed. p. 484), these-to some apparently a simpler, but in truth a far higher adaptation of knowledge-conspire, and often with success, not to mutilate the frame and endanger life, bu to save both life and limb, at little or no cost of either pain or danger. Again, in the torturing complaint of stone in the bladder, it is doubtless a great ma ter to be able, by a speedy operation-severe, and perilous to life though it be-to free the patient from his misery. And the accom- 1 Principles of Surgery, Appendix, 3d Am. Ed. p. 699, &c. OPERATIONS. 21 plished surgeon must be at all times competent to undertake fearlessly this hazardous procedure. But it is surely a higher exercise of a better skill, and both the means and the result will prove infinitely more cre- ditable and satisfactory, if, by the internal use of simple remedies, and suitable attention to hygiene, the disease shall be in its very origin frus- trated, pain and danger dispelled, and health and comfort restored—all without the infliction of a scratch, or the loss of one drop of blood. In the case of injury, too, the paramount importance of general treatment will be found equally to obtain. The surgeon is ready, at a moment's warning, to amputate skilfully a crushed limb, which has obviously no chance of retaining its vitality, and which, if not speedily removed, must inevitably peril the whole frame's existence; and when, by such severe operation, he succeeds in averting the greater calamity, he has most just ground for self-gratulation, and may truly say that a good thing has been done by his art for suffering humanity. But when, in the case of an injury, a shade less severe, there is a doubt whether or not the limb may be enabled to resist the threatened gangrene; when he hesitates not to give to his patient the benefit of that doubt; when, by great patience, care, and skill, he arranges the mangled fragments in their proper place, retains them so by suitable apparatus, affording due support, and yet permitting no undue pressure, regulating the play of the general circu- lation, controlling the efforts of the vis vitse—in short, averting both local 'and general disaster, and bringing the healthful action of reparation to complete, though it may be slowly, its valued process of cure; and when ultimately a thorough and permanent success crowns such patient and anxious labors, surely the cause for self-gratulation is increased a hun- dred fold; the surgeon may well say that a far better thing has been done by his art; and the discerning public will not fail to award a higher and truer meed of praise. The advance of surgery will ever be found characterized by a corre- sponding decrease of its operations, both in amount and in severity. The true object of our mission is not to cut, but to cure. See on this subject, John Bell's large Treatise on Surgery; and the various modern works on Operative Surgery, more especially those of Liston, Fergusson, and Skey. CHAPTER II. INJURIES OF THE SCALP. Bruise of the Scalp. The scalp is especially liable to severity of contusion. It is a part much exposed to external injury; it is stretched over dense resisting bone; it is possessed of very considerable vascularity; and its arterial branches, being neither inactive nor minute, are apt to part with blood freely when torn. Hence, when external violence is applied, the higher results of contusion are very apt to follow (Principles, 3d Am. Ed. p. 690). The integument may give way ; causing a contused wound, of greater or less extent, whose margins will slough and separate, and which will not heal without considerable suppuration, and a corresponding amount of attendant inflammatory action. Or, the skin, at first unbroken, may slough to a greater or less extent; either immediately, from the direct effect of violent contusion ; or secondarily, by inflammation induced in a part whose vitality had been only lowered by the bruise, not annihilated. Or, the integuments remaining entire, blood is copiously extravasated from ruptured vessels; breaking up the areolar tissue, and producing a large fluctuating tumor—sometimes forming rapidly, with tension of the skin, and much pain in the part. Or, subsequently to sanguineous infiltration, inflammatory action may be lighted up in the implicated texture; inducing suppuration of an unhealthy kind, with a consider- able amount of constitutional disturbance, and with a risk of the latter being unfavorably affected by the suppuration assuming the asthenic, diffuse, and infiltrating character (Principles, 3d Am. Ed. p. 222). The danger of such occurrences must be remembered in the prognosis. But the ordinary result of bruise, in this locality, is the formation of a bloody tumor ; blood escaping more or less freely from torn ves- sels, and accumulating in the part; while room is made for its recep- tion, partly by disruption of texture, partly by that which remains entire being pushed aside and condensed. As already stated, the integument is tense or not, according to the rapidity and amount of extravasation. At first, the indications by touch are uniform through- out the whole swelling, all the blood being as yet fluid ; and uniform fluctuation is more or less distinct, with elasticity. Soon, however the blood in part assumes the solid form ; and then the characters of the tumor change. At the circumference, there is a hard, resisting rinntinued at some points to the depth of two lines, at others of a line or more; and on opening the skull, the only departures from the normal condition of its contents, seemed to be an increased compactness and firmness of the structure of the brain, cerebellum, and medulla oblongata, and a diminution of bulk of these parts, so that they no longer filled the cavity of the cranium as completely as is usually the case. Littre' attributed this decrease in bulk CONCUSSION. 35 to the violence of the shock, and to the want of elasticity of the brain; and the suddenness of death to the immediate cessation of the distribu- tion of nervous influence.' Sabatier, after noticing the case related by Littre, sa}7s: " I saw the same thing in a person who died suddenly from a blow on the head. The brain did not fill the cavity of the cranium, and a vacant space could be seen between the brain and the inside of the bones of the head."—(Guth- rie, p. 8.) It is stated in the excellent Compendium of Surgery of Desnonvilliers, Bdrard, and Gosselin (torn. ii. p. 606), that another similar instance is reported without any more details, in a These of the Faculty of Paris. —(Boyn, 1813, No. 55.) " Richerand and Delpech, who are said to have recorded similar cases, only refer generally to the observations of those who have preceded them. " O'Halloran, of Limerick, gives a more positive testimony on this point, and says: "The pericranium and skull were uninjured; the dura mater adhered to the latter; there was rarely any extravasation of blood, and this but slight, and out of the reach of any instrument. In a word, I could get no information, except that in those who died soon after the accident, I have sometimes thought the brain did not completely fill the cavity of the cranium."—(Guthrie, pp. 7-9.) Dupuytren states (Lemons Orales), that after violent concussions of the brain, terminating in immediate death, no appearance is visible of separation, rupture, or contusion of the nervous structure; which, how- ever, he adds, seems to have lost its consistence, and tears upon the least effort; and the brain, deprived of blood, shrinks, collapses, and tends to occupy a smaller space. It will be noted that, in the instances hitherto cited, death followed the accident very speedily. In others, where the fatal termination was delayed, certain more unmistakable alterations have been witnessed. Many distinguished surgeons doubt the correctness of the observations made by Littre', and others concerning the lessened bulk of the brain. Mr. Guthrie says (p. 9): " Chopart believed that Littre" s case was much exaggerated, in which opinion I fully coincide; and place little or no reliance on the statement made by him, and so implicitly admitted since his time. I am not willing to believe that a diminution of the size of the brain, or its subsidence from the inside of the bones of the cranium, is more thin an accidental circumstance, which may or may not be de- pendent on the shock which takes place, although it be followed by immediate death." M. Ndlaton also views these cases in the same light, and thinks that the apparent diminution in the size of the brain is de- ceptive, being really due to escape of the cerebro-spinal fluid during the autopsy (op. cit. p. 574). But, in the work of Desnonvilliers and his associates, from which we have already quoted, p. 607, we find this objection very ingeniously answered. The cerebro-spinal fluid always escapes more or less in every autopsy, and consequently, there should 1 Littre, in l'Histoire de l'Academie Royale des Sciences, volume for 1705, p. 69. Am- sterdam, 1707. 36 CONCUSSION. always be an apparent diminution in the volume of the brain; and, if in these particular instances of Littre, Sabatier, and others, the brain occupied less space than usual in the cranial cavity, the residuum was not a vacuum, but was filled by the cerebro-spinal fluid, which increases or diminishes according to the less or greater space occupied by the brain; an increase of the fluid proving a diminution in the bulk of the solid. The diminished volume of the latter may be supposed to be due to suspended or enfeebled circulation through the arteries, to the expul- sion of blood from the veins into the sinuses, and to the centripetal com- pression exercised upon the fibres and molecules of the nervous structure by the concussing cause. If death does not take place until after some hours have elapsed, the anatomical lesions, as we have said, are somewhat different; and we think that a pretty well marked gradation of local injury may be traced in different cases, bearing a considerable degree of harmony with the severity of the symptoms manifested during life, if this be protracted sufficiently to allow the patient to recover from the immediate effect of the accident. Commencing with the instances recorded by Littre' and others, as already detailed, in which the local lesion was apparently slight, and yet death ensued so promptly as to afford no time for the circulation to recover from the depression occasioned by the shock of the accident, we meet with another limited number of observations which seem to mark the earliest stage of revival. Desnonvilliers records the post- mortem appearances found in the brain of a young man of twenty-three years of age, who, having been arrested for the commission of a grave crime, dashed his head violently against the wall of his dungeon, as did Littre's patient. He was found immediately afterwards senseless, in which condition he remained for three quarters of an hour, when con- vulsive movements came on, and he died whilst preparations were being made to remove him to an hospital. At the examination, a wound was found rather more than two inches long opposite the left parietal pro- tuberance ; there was also an ecchymosis of the eyebrow and the upper eyelid of the same side. There was no trace of fracture or wound of the skull at any point; internally, there was not the least extravasation of blood, either between the bones and the dura mater, in the pia mater, or in the brain; nor was there any contusion or laceration of the nerv- ous structure; the consistence of the latter seemed normal, and it appeared to be altered only in being speckled and dotted with blood, which also exuded more abundantly than usual when the substance of the organ Avas incised and gently pressed between the fingers. In another case, a man thirty years of age fell from a considerable height upon his head; he was taken up entirely unconscious, deprived of sensibility and muscular power, and remained thus in a state of com- plete prostration for eight hours, when he died. The lesions in this instance were of a complicated kind; upon the left side of the head there was a comminuted fracture of the bone, with depression and laceration of the brain over a limited extent; upon the right side, and directly opposite the seat of the other injury, was a contusion of the brain, limited to its cortical portion and extending over a space of CONCUSSION. 37 about four inches square; there was no extravasation of blood, either upon the surface or in the substance of the brain; but the entire mass of the organ was injected with blood, and when its substance was incised the cut surface was covered with red dots. The authors state that they have met with several other cases of an analogous kind. —(Desnonvilliers and Berard, op. cit. p. 606.) Next in order come the cases described by Nelaton, the peculiar appearances of which, he says, were first pointed out by Sanson. They are found in persons who have died after having presented symptoms of concussion of the brain ; the duration of the symptoms, however, is not stated. This alteration consists in minute extravasations of blood, as large as the head of the smallest-sized pins, disseminated through the substance of the brain; they are not mere drops of blood which have escaped from the cut vessels, but real clots, which may be raised up as such upon the point of a knife. They are found upon the periphery, and also towards the centre of the brain; they exist beneath the point at which the injury was received, in the vicinity, and at distant points; they are sometimes quite numerous, sometimes very few in number. And M. Nelaton has never found them unless after violence inflicted upon the cranium, excepting in cases of the "capillary apoplexy" of Cruveilhier.—(Nelaton, op. cit. p. 574.) There is still another group of cases, in which the symptoms of con- cussion are more or less speedily succeeded by those of a more serious character, in consequence of more severe and extensive injury, as frac- ture of the bones with depression, compression of the brain from hemorrhagic effusion, laceration of its substance, &c. Such are the cases recorded by Dr. Bright.1 Dr. Bright had not met with any instances identical with those described by the authors whom we have quoted: but the inferences which he draws from those which he did witness are such as are equally deducible from the others. He says, at page 410 : " What is the immediate state of brain producing the symp- toms of concussion ? Of this we can only judge from the nature of the injury traceable when death occurs; and as that often happens without the concussion having been so severe as to prove the immediate cause of the fatal result, we have sometimes an opportunity of investigating the early appearances; and almost the only appearances which can be considered peculiar, are the minute lacerations of the brain and vessels, which occur both upon the surface and deep in the substance of the mass; and we are led to conclude, that the violence done to the brain, if it does not always go the length of producing these appearances, has at least such a tendency, and that it is this rupture of the brain, or an approach to it, with some consequent congestion in the vessels, which gives rise to the peculiar symptoms of concussion." Dupuytren first, and systematic French writers since his time, have drawn a distinction between concussion and what they term contusion of the brain, and have associated with the latter a particular set of symptoms. It seems to us, however, that contusion of the brain is occasioned by the same kind of cause as concussion, and that the lesions 1 Reports of Medical Cases, vol. ii. pp. 403-411. 38 TREATMENT OF CONCUSSION. which are stated to characterize the former are the same in kind as those which distinguish the latter, being in fact merely exaggerations of these, and accordingly indicated generally by aggravation of the same symptoms. It is asserted that in contusion we have from the first convulsive movements, great agitation, partial paralysis,, &c, con- tinually increasing; while concussion is attended with a complete absence of movement, somnolence, &c, gradually passing off. But in the first example of concussion which we have cited from Desnonvilliers, convulsive movements were observed almost immediately. The lesions of the brain in concussion, as we have detailed them, afford a satisfactory reason for the plan of treatment which Mr. Miller has so admirably laid down; and they also explain why the patient should be subjected to the watchful care of the surgeon, and to a judi- cious regimen, for a considerable time after the reception of the injury.—Ed.] Treatment.—This necessarily varies according to the severity of the injury and the intensity of its results ; but more especially is it different at different periods of the case. In the first stage—that of depression —if we act at all, it will be with the view of favoring at least the com- mencement of reaction. An opposite procedure were plainly at variance with common sense; but, unfortunately, it is found to be not equally at variance with common practice. A man stunned by a blow or fall, and laboring under simple concussion, is often bled on the instant—or an attempt, at least, is made to bleed him—by the rash and thoughtless practitioner. In other words, a fresh and powerful agent of depression is exerted on the general circulation, when such depression is already great, and has probably brought life to the very verge of extinction. If blood flow from the wound in venesection, under such circumstances, perhaps life is lost; at all events, the direct untoward result of the in- jury is aggravated; and the case is rendered both more urgent and more protracted than it otherwise would have been. The lancet is certainly not to be used, during this stage. In many cases we should be little more than passive spectators. The depression is not extreme, nor giving indications of long continuance; signs of reaction, on the contrary, are slowly manifesting themselves; and we await the natural progress of events. Not altogether idle, however. Although not engaged in active treatment, we are prepared for activity, when circumstances shall call for our interference. The patient is stripped and put to bed. His whole body is carefully examined. He cannot tell us whether or not other parts have been injured, besides the head. Besides an anxious investi- gation as to the existence or not of other internal injuries (Principles, 3d Am. Ed. p. 106), we must ourselves carefully examine each joint and bone ; detecting fracture or dislocation, and having it immediately recti- fied, while circumstances are all so peculiarly favorable for the required manipulations (Principles, 3d Am. Ed. p. 679). On recovering his' senses, he has not to complain of a painful and distorted limb, now for the first time observed; but finds what was distorted duly replaced and already some way advanced in the process of repair. The head is 'care- fully shaved ; and is placed on pillows, considerably elevated. If wound TREATMENT OF CONCUSSION. 39 of the scalp exists, hemorrhage is arrested, if need be; and approxima- tion is effected in the ordinary way. Should the depression prove great and continued, plainly indicating risk to life by syncope, something more is required of the practitioner. He endeavors gently to originate reaction. Warmth is applied to the surface, and friction is used over the chest and abdomen. If this be not sufficient to turn the course of the symptoms, a stimulant enema of turpentine is given. If still the progress be downwards, an attempt is made to convey to the stomach some warm tea, or soup, or wine and water ; and stimulants are held to the nostrils for insufflation. These last, however, are always to be warily managed, so as to avoid risk of injury by their too free application to a patient at the time insensible of pain; and the giving of fluids by the mouth, too, must be effected with care, lest they pass into the air-passages, and produce asphyxia. So soon as reaction has begun, we cease from our auxiliary efforts, and again become passive onlookers; completion of the second stage being always safest in the hands of nature. If stimulants are used at all internally, it must be only in urgent circumstances, and with much caution ; begun with a sparing hand, and repeated warily. And, in general, we are well content to do nothing in this way, knowing that moderate depression is a favorable occurrence, and that premature cessation of it, especially when followed by abrupt and marked reaction, is apt to prove most injurious; for, at first, we can never be certain that the case is one of pure concussion. There may be a lesion by laceration of the brain's substance. During the existence of concussion's first stage, the case remains, practically, one of concussion still; circulation is weak in the torn part as elsewhere; extravasation of blood does not take place from the open vessels ; valuable opportunity is afforded for their closure by natural hemostatics; and, when at last, it may be after some hours, the natural reaction slowly sets in, and circulation is proportionately restored, still no escape of blood occurs, and the symptoms may remain those of mere concussion to the last. Whereas, h%d the period of depression been abridged, and reaction rendered not only premature, but also abrupt and active, circu- lation would have been restored in the injured part ere the open vessels had closed, blood would have been extravasated, and compression of the brain must have ensued ; or, even if no lesion of the brain have occurred, the case being, in all respects, one of mere concussion, still premature and excessive reaction is most hazardous, by tending not only to kindle an inflammatory process in the brain or its membranes, but also to secure its being of an aggravated, and, perhaps, uncontrol- lable character. Thus, then, it is plain that two great errors may be committed in the treatment of the first stage of concussion. Blood may be drawn prema- turely; lowering the vital powers still farther unnecessarily, untowardly, perhaps fatally. Or stimuli may be imprudently employed too soon and too freely, hurrying on reaction, and endangering life, either by compression, in consequence of extravasation of blood, or by an inflam- matory process of an urgent and untoward character. Let both errors be studiously avoided, for each is of a most grave nature. While we 40 TREATMENT OF CONCUSSION. take care that the depression does not proceed too far, let us beware of doing anything to effect either a premature or an excessive reaction; and, when we attempt to fulfil the former indication, let us beware both of inducing asphyxia, by the misconducting of ingesta ; and of causing troublesome excoriation and subsequent inflammation in susceptible and important parts., by the spilling of irritant stimuli upon them. In the second stage, while reaction is in progress, we have still either hand ready, to favor, or to repress, yet very often find it prudent to abstain from active interference; leaving the task, almost entirely, in the more skilful and competent hands of nature. We content ourselves with carefully excluding all source of excitement, either to the general circulation or to the brain's function—more especially light and noise; and cold is continuously applied to the shaven scalp, by wetted cloths, or by evaporating lotions. Such treatment is not calculated either to thwart or to prevent the normal amount and form of reaction; while, at the same time, it leans to the side of repression sufficiently to guard against the excess of reaction, which, not improbably, is speedily to threaten. It may happen that, though the reactive effort is well begun, it ceases, flags, and retrogrades; a period of depression again sets in, and this relapse looks more formidable than did the first effect of the injury. Under such circumstances we are no longer inactive spectators, but commence a cautious system of stimulation, as formerly explained. If, on the other hand—as more frequently happens—reaction threatens to prove both "fast and furious," we interpose our repressing agency. We empty the bowels by the exhibition of an aperient enema; and aid this, by the more leisurely working of an internal purge. Seclusion from light and noise, elevation of the head, and continuous application of cold, are most carefully maintained. And if still the action is sthenic and in excess, we prepare to obtain a sedative result by bloodletting. In the third stage, when reaction is plainly in excess, and inflamma- tory symptoms are fast developing themselves, the treatment is decidedly and actively antiphlogistic. Quietude and seclusion are more strictly enforced than ever; it being all-important to obtain rest, of the organ affected, as completely as circumstances will permit. Blood is taken from both the system and the part; by venesection or arteriotomy, and by leeching. And such depletion is repeated as oft and as freely as circumstances seem to demand. Purgatives are actively administered; and it is well to remember that in inflammatory affections of the cranial contents, especially, powerful doses are required. Antimony or aconite may be given. But when the substance of the brain is plainly indicated as the site of the crescent inflammatory process, we do not hesitate to place the system rapidly under the influence of mercury; having full warrant for this in the delicacy of structure and importance of function which are involved (Principles, 3d Am. Ed. p. 168). Calomel is o-iven in small doses, frequently repeated; and, usually, it is neither necessary nor expedient to combine it with opium. Not necessary, for there is a sluggishness of action in the intestinal canal, engendered by the di«ea*e and consequently but little risk of the mineral proving purgative • and not TREATMENT OF CONCUSSION. 41 expedient, lest we endanger the production of narcotism and consequent determination of blood to the part affected. Sometimes delirium, with convulsive movements, continues after full* bleeding, and is aggravated by its farther repetition. In such circum- stances, the pulse and other characteristics of nervous reaction (Princi- ples, 3d Am. Ed. p. 160) will be found; and relief will follow the ex- hibition of opium, guarded by antimony (Principles, 3d Am. Ed. p. 171). In the antiphlogistic management of advanced cases of injury of the head, the occurrence of convulsions is by no means to be considered as sufficient warrant for continuance and pushing of the antiphlogistics —especially bloodletting; for, often, they are found to be of an asthenic, or purely nervous character; aggravated by antiphlogistics, alleviated and checked by amendment of diet, and cautious exhibition of opium. The brain and membranes, having recovered from the inflammatory process, remain long weak, and require still a watchful and patient care. Light and noise must not be soon or abruptly admitted. Conversation, reading, thought, or other exercise of the mental powers must be dis- couraged. Even the functions of special sense should be held in com- parative abeyance. The head is kept shaved, elevated, and cool. Food is sparing and non-stimulant. The bowels are kept freely moving. If resolution do not occur, exudation and effusion take place; com- pression of the brain supervenes on the concussion; coma is formed; and the case beeomes one of the utmost danger. There is now no toler- ance of active antiphlogistics. The lancet is laid aside. Purging is cautiously continued. And the main reliance is placed in powerful counter-irritation. Even without effusion, recovery from concussion is often tedious and imperfect. The eye remains wild and vacant in expression; memory is impaired; conversation is childish, and often incoherent; sometimes the demeanor is timid and gentle ; sometimes the patient is very irascible, and apt to be moved to much violence. In short, there remains an im- becility of the whole mental powers. In other cases, certain only of the mental faculties thus suffer; and of these, memory is the one most frequently affected. Sometimes the recollection of all past events is either lost or obscured ; sometimes a portion of these remain tolerably vivid and distinct. Sometimes the past is untouched, and the present only affected. Extraordinary results have occurred, in regard to lan- guages ; when the knowledge of a plurality of these has been previously possessed by the patient. Certain of them have gone quite from him; and on recovery from the first effects of concussion, he has spoken with fluency, and continued to do so, in a tongue to which he had been long a stranger,1 Again, intellect may remain clear and entire, while special sense sus- tains an injury. Hearing and smell may be lost, impaired, or perverted. Weakness of sight, with or without squinting, is no uncommon result. Such remote and chronic consequences of concussion may prove but temporary; or they may remain for life. The affections of the mind are especially liable to prove obstinate; and ought always to receive a 1 Sir A. Cooper's Lectures, p. 112. 42 CONSEQUENCES OF CONCUSSION. very guarded prognosis. The treatment found most suitable consists in a mild alterative mercurial course, with moderate and long-continued counter-irritation; a uniformly lax state of the bowels, and occasional purging ; a most carefully regulated diet; restriction to moderate exer- cise of both body and mind, but more especially of the latter; avoidance of all sources of mental excitement, especially of such as are known to be besetting to the patient; the use of the cold shower-bath; and resi- dence in genial exposure and climate. Many patients recover, to all appearance, perfectly from concussion; and yet are subject to frequent and unpleasant remembrances of the injury. On attempting any usual exertion, either of mind or body, or on the occurrence of any otherwise trifling stomachic or intestinal dis- order, intense headache supervenes, with some fever, and perhaps at- tended with disorder of sight or other special sense. Or, by even slight indulgence in wine, they are liable to undergo great mental excitement, little short of temporary delirium or insanity. Such persons, it is ob- vious, ought to pay great attention to regimen, to the state of the bowels, and to the avoidanoe of all circumstances likely to excite, or cause determination to the cranial contents. Indeed, it may be laid down as a safe general rule, that all who have once sustained any considerable concussion of the brain, must ever after regard their head as a weak point, which requires constant prophylactic care. And, for some time immediately succeeding the infliction of the injury, this truth should be more especially forced upon them. For, many most serious cerebral disorders have been the result of premature return to bodily exercise, mental occupation, or pleasures of the table, after a concussion thought at the time to be but very trivial. A very insidious, and consequently dangerous, affection of the brain is apt to ensue as a remote consequence of concussion, more especially in young people. A slight injury of the head has been received by a blow or fall; and its immediate effects seem to be satisfactorily recovered from. Weeks—or, it may be, months—afterwards, the patient is out of health; he loses color, appetite, flesh, and energy both of body and mind; he is subject to headache, and occasionally complains of giddi- ness ; the skin is dry and feverish; the secretions are altered; the eye has an unwonted expression, rather of languor than of excitement; the stomach is irritable, and occasionally rejects food; sleep is disturbed and unrefreshing. The ordinary remedies, directed to stomach, skin, and bowels, fail to relieve. The general ailment continues slowly to advance. By and by, the head symptoms assume a pre-eminence ; and, at no distant period from that event, symptoms of pressure on the brain become plainly manifest. Most probably the issue is fatal. An in- flammatory process has been slowly advancing in the cerebral substance; suppuration has at length occurred; and, in consequence, it is not un- likely that an acute accession has supervened on the previous chronic change of structure. It is very obvious how the inobservant practitioner must be apt to mistake the true nature of such cases. The head is not suspected of originating the evil, until-towards the close; when treatment, however suitable, can prove of but little avail. Diet is attended to, laxatives COMPRESSION OF THE BRAIN. 43 are given, then alteratives; and then, probably, tonics: all without relief; the last class of remedies inevitably inducing marked aggrava- tion of the disorder. It may be that the treatment is from the first of a tonic nature, and blindly persevered in, notwithstanding its manifest failure; the result is consequently still more untoward; and coma is rendered more early, more urgent, and more hopeless, than it otherwise might have been. The treatment, on the contrary, should be such as to counteract a chronic inflammatory process ; conducted with such care and skill as the importance of the texture implicated so imperatively demands. Leeches are applied to the temples or occiput; and are re- peated, perhaps, once and again. The head is shaved, and moderate counter-irritation is patiently maintained. A mild course of mercury is given. The intestinal and other excretions are attended to. Diet is sparing, and most carefully regulated. All excitement of both body and mind is avoided. And such treatment must be duly maintained, notwithstanding the patient, or other inexperienced observers, may not scruple to say that its rigor is quite disproportionate to the importance of the case. The surgeon knows the insidious and covert nature of the evil with which he is called upon to cope; and is not deceived by ap- pearances. His main difficulty may lie in enforcing the measures which he knows to be essential. It were well that patients were in general as fully convinced, as are the members of the medical profession, of the truthfulness of the axiom, that "no injury of the head is too slight to be despised;" and that whenever any serious concussion has been sus- tained, the greatest prophylactic caution is expedient, long after the infliction of the injury.1 It is needless to expose the unsuitableness of the operation of trephin- ing, in all cases of simple concussion. Compression of the Brain. It is unnecessary here to consider the question, Whether the sub- stance of the brain is capable of condensation by pressure or not. We know that pressure applied to it, according to its suddenness and in- tensity of application, produces derangement of the functions of that important texture; and the consequent train of symptoms, varying in degree, are usually termed those of "compressed brain," or of "com- pression." In concussion, the whole brain is affected; in compression, a portion only may be acted on. In the one case, the cause of disorder is of temporary application; in the other, it is of some duration. The symp- toms, therefore, may naturally be expected to differ. In concussion, the depressing effect on the heart and general circulation is immediate and prominent; and the patient lies pale, cold, and pulseless. In com- 1 "It will in general be found very difficult to persuade a person who has had what may be called only a knock on the pate, to submit to discipline, especially if he find himself tolerably well. He will be inclined to think that the surgeon is either unnecessarily apprehensive, or guilty of a much worse fault; and yet, in many instances, the timely use or the neglect of this single remedy (bloodletting), makes all the difference between safety and fatality."—Pott, i. 47. 44 COMPRESSION OF THE BRAIN. pression—the injury being usually limited to but a part of the brain— the heart's action may, at first, be little if at all affected; the skin,_ conse- quently, may retain its natural warmth and hue, and the pulse its ful- ness. In concussion, immediately fatal, death takes place by syncope. In compression, the fatal result is due to coma. The essential peculiarity of the latter is, "that respiration takes place imperfectly, and ulti- mately is suspended, probably by reason of the defect of sensation. ^ The circulation, and sometimes the animal heat, not only continue entire up to the moment when the last breath is drawn, but even survive the respiration for a short time ; during which time, of course, venous blood moves along the arteries; but the venous blood, according to the general law established in the physiology of respiration, soon ceases to make its way through the capillaries of the lungs, and the circulation is therefore soon brought to a stand.....We know from physiology, that the part of the nervous system which must be specially affected in these cases, when the failure of respiration is the immediate cause of death, must be at the sides of the medulla oblongata; but the part visibly injured is often considerably distant from this.1 Pressure may be made on the brain in various ways. By extravasa- tion of blood; in its substance, on its surface, or between the membranes. By formation and accumulation of pus, or other products of the inflam- matory process; also, either cerebral or intra-membranous. By fracture of the cranium, with depression of the broken part or parts. By lodge- ment of foreign bodies in the brain, or on its surface. By the formation of adventitious growth, in connection with either the cranium or its contents; exostosis, osteosarcoma, or osteocephaloma of the cranium; tubercular, or other tumor of the brain or its membranes. It is probable that compression is also occasioned by mere congestion ; a state of over- distension of the bloodvessels, with advancing serous effusion. It is highly important to bear in remembrance, that symptoms pre- cisely similar to those ordinarily produced by compression of the brain may be, and frequently are, induced by other circumstances, when no apparent pressure is in operation. Certain poisons, for example, have this effect. But what is of more consequence in a surgical point of view, such a train of symptoms almost invariably attends on disorgani- zation of the cerebral tissue by inflammatory action; and that, too, when the inflammatory products seem to be of such a nature as not to occasion pressure in any great degree. In surgery, we have chiefly to do with those examples which are in- duced by depressed fracture, extravasation of blood, inflammatory exuda- tion, and suppuration. The most characteristic symptoms are found affecting the respiration and the pulse. Breathing is slow, laboring, and loudly stertorous; in concussion it was gentle and sighing. A peculiar whiffing, by the mouth, is not unfrequent, during expiration—as is observed in smoking, or in the ordinary repose of heavy sleepers; it is a. symptom of untoward portent. The pulse is distinct and full, usually glow, but often at first not much altered as to frequency—not unfrequently intermittent; in 1 Alison, Outlines of Pathology, p. 8. COMPRESSION OF THE BRAIN. 45 concussion it was from the first rapid, low, and feeble, perhaps wholly imperceptible. Loss of consciousness is more complete than in concus- sion ; the patient cannot be roused by any movement or noise. Loss of sensation is more complete; he may be pinched, or burnt, without in any way evincing perception of pain. Special sense is wholly dormant; he neither sees, nor hears, nor smells; at least, no result follows the appli- cation of stimuli to the eye, ear, or nose. Power of motion is wholly gone; the voluntary muscles are relaxed, flabby, and powerless; the limbs lie loose and incapable of motion. The eye is fixed; its pupils are dilated, and insensible to light. The skin is of a normal temperature, or perhaps even warmer; not unfrequently wet with perspiration; in concussion, it was cold, pale, and shrunken. The sphincters are re- laxed ; feces pass involuntarily. Expulsive muscles are similarly affect- ed ; the urine is, in consequence, retained; or, from paralysis of the sphincter as well, the urine may pass off involuntarily, not in a stream, but insensibly by drops. Such is the general character of the symptoms peculiar to compres- sion; varying, of course, in degree, according to the amount or nature of the injury sustained. They are of immediate or secondary accession, according to the cause; immediate, when the consequence of sudden hemorrhage, depressed bone, or impacted foreign body ; secondary, when the result of tardy extravasation, suppuration, or inflammatory exuda- tion. However originating, they are, after a time,' masked and modified by the results of the inflammatory process, which seldom fails to become established in the injured part. But the brain has the power of recovering from the effects of pressure to a certain extent, even although the agent of compression undergo no alteration; the organ seeming to accommodate itself gradually to its change of circumstances. Thus, in depressed fracture, symptoms of compression may be at first marked and even urgent; and yet may pass off in a day or two, without any elevation of the depressed portion of bone. This being borne in mind, we can readily understand how, by the time that the inflammatory process has begun, the symptoms of com- pression, at first considerable, may have in a great measure passed away; and how the case, consequently, may only present the ordinary symp- toms of urgent inflammatory action in the brain and its membranes. This is something more than mere masking of compression, by the in- flammatory process; it is supersedence. Certain functions of the brain are plainly re-established, though perverted; convulsive movements of the limbs occur ; and delirium may supervene. Compression may, like concussion, prove directly fatal, the patient perishing by coma; or, when the cause of pressure is removed, or even, as already stated, independently of this, the symptoms gradually abate, and the patient slowly recovers; or, ere yet any great mitigation in the symptoms of compression have occurred, those of an urgent inflamma- tory process kindled in the injured part become established, and these prove fatal; or, a similarly fatal issue may take place through inflam- matory action, even although the immediate effects of compression had seemed to have been recovered from. The indications of treatment adapted to compression are sufficiently 46 CONCUSSION AND COMPRESSION. simple. To remove, if possible, the compressing cause ; to watch the subsequent favorable progress of the organ to resumption of its normal state and function ; to interfere, if need be, to avert inflammatory action; and to oppose the untoward advance of this, when, unfortu- nately, it has become established. When symptoms of simple compres- sion persist, without any opportunity being afforded of removing the cause of pressure, to maintain, by suitable means, the action of the heart and lungs; so as, if possible, to afford time for the brain, by accommodating itself to its altered circumstances, slowly and imperfectly to resume its functions. Between pure examples of concussion and compression of the brain there is no difficulty in drawing a sufficiently broad distinction, in prac- tice, as well as in theory. The one, a case of syncope ; the other, of coma. In concussion, the symptoms immediate ; insensibility usually incomplete; the organs of special sense capable of being roused; the muscles contractile, and the limbs, under strong stimulus, undergoing movement; the breathing soft and gentle ; the pupils not uniformly dilated, though insensible to light; the pulse rapid, small, indistinct, perhaps for a time imperceptible ; vomiting; no involuntary evacua- tions ; the skin cold, pale, and shrunk. In compression, the symptoms not necessarily immediate; insensibility complete; the organs of special sense incapable of being roused; the muscles relaxed, paralyzed ; the limbs motionless, until recession of the state of compression, and advance of the inflammatory process ; breathing labored, slow, and snoring; the pupils dilated and insensible ; the pulse slow, distinct, perhaps full, sometimes intermittent; no (or seldom) vomiting ; feces passed invol- untarily ; retention or dribbling of urine; the skin warm, and often bedewed by perspiration. But it is very plain that comparatively seldom will pure examples of either state be presented to the surgeon. The blow or fall which pro- duces severe concussion, is very likely to cause also laceration of the substance of the brain, or rupture of a vessel in the membranes, whence blood will escape, sooner or later, inducing a certain amount of com- pression. And, on the other hand, the injury which causes compression, whether by fracture or extravasation, must, at the same time, and pri- marily, have caused more or less concussion. In consequence, the two states, and.their corresponding symptoms, are often, nay, usually, more or less commingled. According to the preponderance of either class of symptoms, the case receives its title ; and, sometimes, it is not easy to say to what side the preponderance is inclined. There is one class of cases, however, sufficiently distinct. The ordi- nary symptoms of concussion follow an injury of the head, and the patient rallies from them. Consciousness is completely restored, and is retained for some time. But, without the operation of any new exter- nal cause, insensibility returns; unconsciousness is more complete than before; and the symptoms now will be found presenting the characters of coma. Here is a combination of concussion with compression, yet COMPRESSION BY EXTRAVASATION. 47 there is no difficulty in separating the case into its two component parts. The first insensibility was that of concussion ; the second is undoubtedly due to compression. Jf the interval of consciousness have been brief— of hours—the compressing agent is, doubtless, extravasated blood ; if it have been of considerable duration—days—the compressing agent is pus, or other inflammatory product. It is right, also, to remember that, not unfrequently, part of the insensibility attendant on injuries of the head may be attributable to intoxication; and that, although this influence is of a transient nature, and to that extent favorable, yet that it predisposes to inflammatory accession. Compression by Extravasation of Blood. Escape of blood may take place immediately on infliction of the injury, or not until reaction has followed the direct effects of concussion. During the depressed state of circulation which obtains during the first effect of the injury, no blood may escape from even extensive cerebral laceration ; but, if reaction be both speedy and intense, even the slightest lesion will be certain to afford a dangerous amount of that fluid. The extravasation may be variously situated ; between the skull and dura mater; between the membranes; on the surface of the brain— on its hemispheres, or at its base; within the ventricles; or infiltrated into broken-up cerebral substance. For practical purposes, it is suffi- cient to divide compressing extravasations into two great classes; those which are exterior to the dura mater, and those which are within that membrane. I. Extravasation between the Bone and Dura Mater. Fig. 5. One of the effects of a fall or blow on the head is, by disruption of the soft parts constituting the scalp, to produce more or less swelling by sanguineous infiltration of that texture. Occasionally, a similar result is pro- duced on the internal aspect of the part of the cranium struck, in the areolar and vascular connections of the dura mater with the bone. These being torn, escape of blood follows; either at the time, or subsequently on reac- tion; or at both poriods; sparingly at first, more profusely afterwards. If any considerable vessel have been torn, the extravasation may be expected to be both instant and great. By such abnormal accumulation of blood, the dura mater is proportionally bulged inwards ; and Compression Of the brain Extravasation of Wood, separating the Dura •i i.„ mi„ VO.^/1 «>r, :„ Mater from the Cranium, at the ordinary site, necessarily results. The blood, as in by ^^ of ^ middl; mwilngeal artcry; tt. other examples of extravasation, is at (Liston.) 48 COMPRESSION BY INTERNAL EXTRAVASATION. first fluid, but sooner or later assumes the solid form ; or, rather, by coagulation it separates into clot and serum. Extreme cases of this nature, it is plain, are most likely to occur when the injury has been inflicted in the course of the middle meningeal artery. And, to occasion rupture of that vessel, it is not essential that fracture of the superimposed bone should take place. Mere concussion may suffice. If compound fracture exist, the blood is more likely to escape externally, than to accumulate, to any inconvenient amount, between the bone and membrane. As indications of the event: In addition to the ordinary symptoms of compression, we have the peculiar site and nature of the injury. A smart blow has been received in the course of the meningeal artery; and is speedily followed by urgent symptoms of compression. Such compression may be so grave as to cause death, by its direct effect. Or, farther escape of blood ceasing, the brain begins to accom- modate itself to the amount of pressure already applied; at the same time, the compressing agent is being gradually diminished in bulk by absorption of the extravasated blood; and the patient slowly recovers. Or the inflammatory process is kindled after a time; and unhealthy suppuration is apt to ensue ; reinducing symptoms of compression, more urgent than before, after perhaps a considerable interval of conscious- ness. Treatment.—When the circumstances of the case are such as to leave little doubt as to the occurrence of this form of extravasation, at an ac- cessible and defined portion of the skull, we can have no hesitation—if the symptoms of compression are urgent—in using the trephine; for the purpose of exposing the site of extravasation, and effecting relief by evacuation. If the blood be still fluid, it escapes at once; if coagulated* the solid portions may, if need be, be detached by a probe—delicately used. Unfortunately, we cannot be certain, in almost any case, of the exact site of the extravasation; and, consequently, both our operation and prognosis require to be extremely guarded. A concussing blow operates chiefly on two parts of the cranium ; the part struck, and the part im- mediately opposite; the one effect often termed the coup, the other the contrecoup. It not unfrequently happens that extravasation takes place in the latter situation; not at the part struck. But, failing in our search at one point, we are scarcely warranted in making a similar attempt at the other; for the extravasation may be yet elsewhere in a site not as- certained, and perhaps inaccessible. If the symptoms of compression be not urgent, we do not interfere by operation. The brain gradually recovers. The extravasation is slowly absorbed. Our duty is to avert inflammatory action, if possible, by the ordinary means; to moderate it, should it occur. II.—Extravasation of Blood on, or in the Brain. As already stated, the blood may be variously situated; intramem- branous; diffused on the surface of the hemispheres, or at the base of the brain ; within the ventricles ; or infiltrated into the cerebral tissue. COMPRESSION BY INTERNAL EXTRAVASATION. 49 And, unfortunately, the most careful examination of the history, symp- toms, and progress of the case, will often not enable us to ascertain, with anything like certainty, the exact site of the evil. The symptoms are those of compression ; more or less urgent in their character, and more or less speedy in their accession, according to the site, amount, rapidity, and time of the extravasation. Usually, the es- cape of blood is not immediate—at least to such an extent as to cause symptoms of decided compression—but secondary, on the occurrence of reaction. The patient may have been from the first insensible, by con- cussion ; and this minor insensibility may be simply merged in the major insensibility of compression ; or between the two there may be a greater or less interval of consciousness. The cerebral or membranous lesion, which permits the sanguineous escape, may follow on a concussive injury of the cranium; on extensive fracture of the cranium, with or without depression; on mere fissure of the skull—more especially when this is situate at the base; or on a penetrating wound of any kind. There is the same prognosis as in the case of extravasation exterior to the dura mater. The brain may recover, and the extravasation be absorbed; or the brain, recovering partially from compression, suffers, perhaps fatally, by inflammatory accession, immediate or remote; or the compression is most urgent, and directly terminates existence by coma. Rapidity of extravasation is more important than the amount; and the site of the escape is of more consequence than either. A com- paratively small quantity of blood rapidly, or at once, extravasated, will induce more urgent symptoms of compression than twice the amount which has slowly oozed from the torn vessels; and while a large flat coagulum may press with comparative impunity on the upper and ante- rior part of the hemispheres, a slight amount of blood acting on the base of the brain, more especially at its posterior part, never fails to induce the most serious and urgent consequences. Treatment.—Prevention may be in our power. Concussion may occur, along with slight lesion of the cerebral substance ; and from this lesion little or no blood may escape during the period of depression. The injury having been such as to engender a suspicion of these cir- cumstances, it is plainly our duty to protract and repress reaction; when it does occur, to endeavor that it proceed slowly and calmly; or, if need be, by bleeding from the system, to reinduce the state of depres- sion, and maintain it during a second period; the object being, to afford time and opportunity for efficient occlusion of the injured vessels by natural hemostatics. If too late, or otherwise unable, to prevent, we may yet hope to moderate and limit the extravasation. And this is to be effected by opposing reaction, keeping the patient quiet, with the head elevated, applying cold to the head, face, and neck, interdicting all nutritive ingesta, taking blood from the system, as circumstances may require, and acting freely on the bowels by purgatives. Our object still is to have not only the general circulation quiet and gentle, but to have blood circulating within the cranium as sparingly and as calmly as is compatible with such maintenance of the cerebral functions as is essential to life. Extravasation having ceased, we hope that in due time the symptoms 4 50 COMPRESSION BY EXTRAVASATION. of compression will begin to abate, the brain accommodating itself to the compressing agent, and this latter beginning to diminish by absorp- tion. We ward off inflammatory symptoms, should they threaten, and maintain strict rest, quietude, and regimen ; the last being very rigidly limited in regard to both fluids and solids, in order that there may be a state of system not only unfavorable to inflammatory accession, but also favorable to absorption of the extravasated blood. Unfortunately, we have no direct means of assisting in the latter indication. A paramount indication undoubtedly is removal of the compressing cause, the extravasation. This can be artificially effected only by operation, by removing a portion of the cranium, puncturing the mem- branes, if need be, exposing the site of extravasation, and permitting, if not effecting, external discharge. Were the operation of trephining capable, always, or even often, of achieving this result, it would be held as generally advisable in such cases. As it is, however, the profession is much divided upon the question, some in favor of, others opposed to the proceeding. Among the latter we would beg to be enrolled; and for the following reasons: 1. It is difficult, if not impossible, to determine at what part of the periphery of the cranial cavity the extravasation has occurred; whether at the point struck, or at the site of the contrecoup, or at some other part, superiorly or laterally, or at the base. 2. It is equally difficult, if not impossible, to determine pre- vious to the operation, at what part the extravasation has occurred as regards the diameter of the cranial cavity; whether between the mem- branes, on the surface of the brain, within its ventricles, or in its broken up tissue. 3. Supposing that the extravasation has been reached and exposed, it may be found either difficult or impossible to effect its removal. Coagulation has taken place. The fluid portion trickles away at once, but the clot is expanded in the form of a flat and broad cake, which cannot be dislodged and extruded without the infliction of such farther mechanical injury as shall render the occurrence of dis- astrous inflammatory action inevitably certain. 4. Supposing that the coagulum has been exposed and not removed, the patient is obviously much more unfavorably situated after than before the operation. Now, there is a certainty of inflammatory accession, in addition to the unre- lieved evil of compression; and, under the combination, it is but too likely that life may give way. Before, there was but the compression; inflammation might have been averted; the brain, by accommodation, might have gradually recovered. Thus, then, we hold, that in the case of compression by extravasated blood, the operation of trephining is to be considered as generally inap- plicable. Operating, we are uncertain whether or not the trephine is over thesite of extravasation; we are uncertain whether it may be neces- sary to puncture the membranes of the brain; and, that having been done, we may still fail in exposing the blood; we are uncertain of being able to remove the blood, even after it has been exposed; and we are almost certain to light up an inflammatory process of a most urgent, ABSCESS OF THE DURA MATER. 51 and perhaps unmanageable character. In other words, we are sure to inflict injury, by perforation and exposure; we may succeed in coun- terbalancing this injury by a preponderating amount of benefit, by extrusion of the compressing agent, the escaped blood; but we are fully more likely to fail in obtaining the contemplated advantage; and then the proceeding proves to be altogether injurious. But to all general rules there are exceptions. And here the excep- tion consists in those cases of injury applied in the course of the middle meningeal artery, immediately followed by urgent symptoms of com- pression, with or without fracture of the skull, in which we can have little doubt of the following circumstances: 1. That the compression is caused by extravasation of blood; 2. That the blood has been extra- vasated at or near the point struck; 3. That the extravasation is situate exteriorly to the dura mater; 4. That the blood is yet mainly fluid, and therefore likely to escape readily outwards, on an aperture of communi- cation being established; 5. That even if it have coagulated, extrusion may yet be effected, without necessarily exciting inflammation, either in the brain or in any of its membranes. Under such circumstances, we need not hesitate to apply a trephine to the injured part—when the symptoms of compression are sufficiently urgent to demand direct inter- ference—with the full hope of affording most important and salutary relief. We can also conceive it possible, that an injury may be sustained at a part of the cranium not connected with the course of the meningeal artery; that the symptoms of compression by extravasation may be both very urgent and very plain ; and that the surgeon, after careful examination and consideration of the case, may feel satisfied that the site of extrava- sation corresponds to the part struck. The trephine is applied. If blood be found at that part, exterior to the dura mater, the issue is most fortu- nate. But if no blood be found, two questions naturally arise : Are the membranes of the brain to be perforated? or is another part of the cranial contents to be exposed by reapplication of the trephine ? The latter question is certainly to be answered in the negative; the former, in the affirmative, only when the dura mater is elevated through the trephine-hole, tense, comparatively non-pulsating, perhaps fluctuating, or otherwise affording tolerably distinct evidence of the sought-for blood being lodged beneath. Compression by the Accumulation of Pus between the Cranium and Dura Mater. Such an occurrence may be preceded or not by sanguineous extrava- sation. There may be at first disruption of the dura mater from the internal surface of the cranium, with accumulation of blood between; perhaps to such an extent as to cause compression of the brain. This organ slowly recovers; and the patient seems convalescent. But, after some days, the inflammatory process is kindled in the injured part; suppuration occurs, and the internal bruise degenerates into an un- healthy abscess. Or there may be no previous extravasation. The bone and dura 52 ABSCESS OF THE DURA MATER. mater sustain a shock by the injury, but undergo no disruption either of themselves or of their connections. There may be at first some symp- toms of concussion, and these pass away; but convalescence is inter- rupted by febrile disturbance of the system, followed by symptoms of compression. The inflammatory process has been established in the cranium, in the dura mater, or in both; and abscess forms between. The inflammatory action may have originated in the membrane, or in the connections of this with the bone; or in the bone; or it may have begun in the diploe, causing abscess there, and extending inwards; or the origin may have been exterior to the cranium, in the soft parts, secondarily involving the corresponding portion of the interior. If a portion of the cranium have been rudely stripped of its peri- cranium, it may die; but it does not necessarily do so—as was formerly stated. Should necrosis take place, and involve the whole thickness of the skull at that point, there is necessarily detachment of the dura mater, interposition of pus between it and the bone, consequent bulging inwards of the membrane, and proportionate compression of the brain. But detachment of the pericranium, with advancing necrosis of the external part of the bone, does not necessarily imply a corresponding state of matters within. The issue may be, and often is, merely an external exfoliation. The dura mater is a more important and efficient membrane than the pericranium, as regards vascular nutrition of the bone. Detach the dura mater, and the bone may hardly live; strip off the pericranium, and exfoliation is by no means inevitable. If the injury have not only denuded the external table of its invest- ing membrane, but have also removed, at a corresponding point, the dura mater, by disruption and consequent extravasation, necrosis of the portion of bone so circumstanced, necessarily involving accumulation of pus between the dura mater and cranium, is inevitable. Also, if the dura mater be alone detached, and subsequently suppurate, necrosis of the entire thickness of the bone is still more than probable; though there may not be even an external wound. However occasioned, the symptoms of compression from this cause differ very obviously from those produced by extravasation of blood. They are not of early occurrence; days, and sometimes weeks, elapse between their accession and the infliction of the original injury. Whereas, compression by escape of blood is either immediate, or re- moved from the time of infliction only to the extent of a few hours, at the utmost. Also, in the case of abscess, the symptoms of compression are invariably preceded by signs of the inflammatory process which causes the suppuration. As regards the result, the difference is still more striking. In compression by blood, the extravasation may cease, the blood is absorbed, and the brain recovers. But, in compression by pus, the compressing agent is ever on the increase; the abscess enlarges more and more; and pus is but little amenable to absorption. The bone is exfoliating, and, if it were separate, the matter would doubtless find an outward escape; but exfoliation is a tedious process; ere it has been accomplished, the membrane, growing more and more' tense and itself involved in structural change, ulcerates, or sloughs; purulent ABSCESS OF THE DURA MATER. 53 irruption takes place inwards ; and a more extensive, serious, and un- controllable inflammatory action necessarily ensues. Or, previous to the giving way of the dura mater, a minor yet equally fatal inflamma- tory extension inwards, by contiguity, may have occurred. Or a sad complication may take place, by invasion of all the symptoms of pyaemia. Or, independently of any such aggravations, the primary evils of fever and compression may prove fatal. The symptoms denoting formation of this dangerous abscess are two- fold; as affecting the system, and as affecting the part. A man receives an injury of the head, without fracture of the cranium. He may under- go concussion or compression by extravasation ; one or other, or both : or he may not. If he does so suffer, he rallies; and, for a time, seems advancing favorably towards complete recovery. But, after some days, he becomes restless, wakeful, and generally uneasy; his pulse rises and gets hard; the skin is hot and dry; and the other symptoms of inflam- matory fever present themselves — moderate or intense, obscure or manifest, according as the inflammatory process happens to be chronic or acute; very frequently it is the former. Pain is complained of in the head ; the eyes change their expression; and the cerebral functions begin to evince disorder. Rigor occurs, and is repeated. Suppuration is begun; and then supervene, more or less rapidly, the symptoms of compression—masking, in their turn, those of the inflammatory cha- racter. Then, as to the part. The bone is in a state of necrosis ; and this condition will certainly be indicated externally. If there be a wound, the granulations, instead of presenting the appearance of health and healing, will disappear, or become pale and glassy; and the discharge may for a time cease—returning thin, non-laudable, perhaps sanguineous. If the pericranium be exposed, it will be found separating more and more from the bone beneath, with pus interposed. If the bone be denuded, it will be found white, dry, sonorous, non-vascular—in fact, at first dying, and speedily dead. If the scalp have not been divided, either by ac- cident or by design, it is the seat of what is termed "the puffy tumor;" a swelling of greater or less extent, caused partly by accumulation of pus between the necrosed bone and its pericranium, partly by change of structure in the soft parts exteriorly, which are involved more or less in the extending inflammatory process, and are consequently the seat of effusion and exudation. Indeed, this " puffy tumor," though a valuable and peculiar sign of the internal evil, is not to be regarded as of a special nature; being only the ordinary product of ripe inflammation ; oedema by serum externally, infiltration Fig. 6. Plan, illustrative of Abscess of the Dura Mater, a. The cranium, b. A suppurated space left by detachment of the dura mater, c. Ditto, by elevation of the pericranium; b and c con- stitute the central space of true inflammation: d, the arc of active congestion; e, that of simple excitement; c, d, e, constituting Pott's puffy tumor. 54 ABSCESS OF THE DURA MATER. by fibrinous exudation more deeply, and accumulated pus overlaying the bone (Principles, 3d Am. Ed. p. 118). These symptoms, local and constitutional, occurring together, denote interior suppuration at the injured part. The local signs "following a smart blow on the head, and attended with languor, pain, restlessness, watching, quick pulse, headache, and slight irregular shiverings, do almost infallibly indicate an inflamed dura mater, and pus either forming or formed between it and the cranium."1 Treatment.—The general principles applicable to the treatment of abscess must be carried out, if possible. The pus must be evacuated externally ; and that at as early a period as possible; as soon as we are satisfied, by conjunction of the local and constitutional signs, that matter has formed. The local symptoms alone are not a sufficient warrant for operative interference ; neither are the constitutional; but, when they come together in a marked and plain form, the surgeon is culpably negligent who withholds the trephine. By this instrument— chosen of a large size, to make the probability all the greater of dis- closing the suppurated part—the dead portion of bone is perforated; and then the abscess is discharged externally, with immediate relief to the symptoms of compression. Be it remembered, however, that those of inflammation still remain, perhaps aggravated by the addition which the injury of the operation has occasioned. Antiphlogistics must still be continued; and much careful management is required, even in the most favorable cases, ere the patient is conducted to safe completion of the cure. It may happen that the inflammatory action is not checked; but, spreading both widely and in depth, proves ultimately fatal. In short, while it is obvious that the only chance of the patient's safety is by artificial evacuation of the matter, it is equally plain that the opera- tion alone will not suffice, but must be followed up by the most careful general treatment. It has happened that the abscess, burrowing between the dura mater and bone, has eventually reached the internal ear, and discharged itself externally by the meatus ; the patient recovering. But, obviously, such an occurrence is a rare exception to a general rule, and cannot be trusted to in practice. If, on removing a portion of skull by the trephine, matter is not found, a question arises whether our efforts at direct relief are to cease, or whether farther exploration is to be attempted. Is the dura mater to be perforated, in the hope that the site of abscess irfay prove to be beneath ? Not, if the membrane present its usual normal characters at the part exposed; level, moving synchronously with the cerebral mass, smooth, of a brownish hue, and showing something of a silvery lustre. But if it be protruding through the cranial aperture, flocculent, non- pulsating, and either too dark or too pale in color—and, more especially, if it afford anything of a feeling of fluctuation when touched—we need not hesitate to puncture, and need not doubt to find an issue of purulent or other fluid from the wound. If the dura mater appear sound, and its puncture consequently be unwarrantable, are we permitted to re- 1 Pott, vol. i. p. 41. ABSCESS OF THE DURA MATER. 55 apply the trephine; either at the site of contrecoup, or in the immediate vicinity of the first application ? Either of these procedures may be warrantable, if the symptoms of dura-matral abscess are peculiarly marked, and the surgeon is thoroughly convinced of its existence. But, as can readily be understood, the latter site of reapplication is the preferable. And, as already stated, a large size of trephine should be employed at first, to anticipate the necessity of such repetition. Only in very extreme cases, should the site of contrecoup be trephined. Hav- ing failed in the indicated spot, we proceed to other explorations with great uncertainty. Fortunately, however, it is comparatively seldom that the site of abscess is elsewhere than at the injured part. But, if the case be under our cognizance from the first, we have a higher aim than the mere exercise of our art by operation; seeking to prevent the formation of abscess, not to attempt its cure. The patient who has sustained an injury of the head, of any severity, is carefully watched throughout the whole period of convalescence; and the first symptoms of inflammatory accession within the cranium are met by active and sustained antiphlogistics—more especially bloodletting, quie- tude, avoidance of all stimuli of both part and system, low diet, purga- tives, and perhaps calomel; assisted, if need be, after a time, by counter- irritation.. When suppuration has taken place either in the substance of the brain pr on its surface, the case is obviously not amenable to direct surgical interference, and may scarcely fail to prove fatal. Cure is beyond our reach; but prevention was not. And the latter indication should suffi- ciently occupy our regard in the previous treatment of the injury. When a severe scalp-wound has been sustained, with bruising or fissure of the bone, it is not uncommon for the character of the wound to de- generate as-in the case of dura-matral abscess, with some constitutional disturbance of an unpleasant character. But neither the meningitic symptoms, nor those of compression, appear. Suppuration has taken place in the diploe. If fissure exist—perhaps extending only through the external table—pus will be found slowly oozing outwards. Enlarge- ment of the chink is necessary, however, for more free evacuation. If there have been no previous solution of continuity, the trephine may be used for removal of a portion of the external table. The mischief may extend inwardly, and dura-matral abscess form, as previously stated; but, fortunately, such is by no means the invariable result; and is indeed little likely to take place, if suitable treatment have been adopted. If phlebitis occur in the diploe, the case becomes eminently serious; partly on account of the direct effects of this disease; but mainly from the risk of pyaemia (Principles, 3d Am. Ed. p. 225). After injuries of the head, abscess of the liver is by no means uncommon; and it is 56 FISSURE OF THE CRANIUM. probable that at least many of these cases are connected with unhealthy suppuration, with phlebitis in the diploe. Fractures of the Cranium. In the child, much violence may be sustained by the cranium, with impunity. The osseous tissue is then elastic; it yields to the force, and is temporarily depressed, but without solution of its continuity; and, after a time, the depression is gradually effaced by a vital resilience, independent of external aid. In the adult, and more especially in the aged, the bone is of a much more brittle nature ; and less force succeeds in effecting solution of continuity, more or less extensive. The skull may be merely fissured, or the injured part is broken into fragments, implicating the whole thickness of the bone, with or without depression of these ; or the external table alone is broken ; or the inter- nal table exclusively suffers ; or both are penetrated by a sharp-pointed weapon, the internal sustaining the greater amount of injury. The fracture may be at any part of the periphery of the cranium, or may traverse its base; and, farther, it may be either simple or compound. The dangers attendant on the injury are various: 1. By concussion. 2. By extravasation of blood within the cranium. 3. By.excessive escape of blood externally from the wound. 4. By displacement of the fractured portions inwards, causing compression. 5. By inflammatory action, occurring in either the brain or its membranes. The treatment will comprise various indications calculated to oppose these several results. Fractures of the cranium, whether simple or compound, unite only by definitive callus (Principles, 3d Am. Ed. p. 658). Want of provi- sional callus, doubtless, may delay completion of the healing process; but all incommoding of the brain or its membranes by osseous bulging is avoided, which, otherwise, could not fail to occur. Fissure. Capillary solution of continuity is, in itself, a thing of but little im- portance. But the shock which has caused it may well occupy our attentive regard. The fissure itself, indeed, may, in its formation, have proved an actual advantage, rendering the concussion less intense and less hazardous than it might have been had the ringing calvarium remained entire. The fissure may be short, and bounded by suture ; or it may traverse several of these, and be of great extent. It may take place at the part struck, or at the site of the contrecoup. It may be conjoined, or not, with rupture of the dura mater at the fissured part; and, if 'it be so conjoined, compression by extravasation is likely to ensue. When the injury is situate at the base of the cranium, it is usually associated with such rupture; and extravasation occurring at this site, even to a slight extent, we have already seen to be of the gravest import (p. 49). The symptoms attendant on fissure are usually those of concussion in the first instance; and these may be followed by those of compression FISSURE AT THE BASE OF THE CRANIUM. 57 by extravasation. Inflammatory accession is not unlikely, giving the ordinary train of symptoms, varying according to the part and texture involved. And these, again, may be merged in the symptoms of com- pression by suppuration. If the injury be compound, the existence of fissure is ascertained by the finger or probe. If it be simple, the fissure may very probably elude detection, the case being treated as one of simple concussion. Long ago it was the custom, in the treatment of this injury, to expose the fissure throughout its whole extent by incision, and to apply the trephine repeatedly in its course, probably in the hope of liberating extravasated blood. But no one now thinks of thus aggravating what is in itself comparatively simple. It is time enough to take up the trephine when symptoms of compression, by blood or by pus, are so plain and so urgent as to demand its use. It is not often, as already explained, that on the first count we are called upon to operate; and, if we have seen the case from the first, it may be our jown fault if we have to interfere on account of the untoward result of inflammatory action. The treatment is chiefly expectant. We await reaction from the effects of concussion; watch the period when extravasation is likely to occur, and, if need be, then interfere—repressingly. That period of danger having passed, we are again quiescent, though alert; looking out for symptoms of inflammatory accession, and ready to oppose these with energy, should they appear (p. 40). Fissure at the Base of the Cranium. Solution of continuity, in this situation, is usually a fissure; disrup- tion, more or less extensive, without comminution or displacement. The fissure may either extend through previously compact bone, or be a kind of diastasis—separation of the sphenoid from the temporal bones, for example, at the original points of union. As already stated, it is generally accompanied with laceration of the dura mater and internal hemorrhage; and, consequently, is invariably attended with the greatest danger to life. The important parts of the brain implicated are almost certain to be compromised in function, sooner or later, either almost immediately by extravasation or by inflammatory action at a more remote period. The injury may be occasioned in various ways. The head may be crushed laterally, as by being jammed between a wheel and a wall or post; or, while the body is at rest, a severe blow is received on the vertex; and the strain of the shock, communicated through the temporal bones, produces a splitting of these, or tears open the connections with the sphenoid;1 or the body, falling, alights on the vertex; and the 1 " If a force be applied to the vertex, the superior borders of the parietal bones resist displacement downwards, inasmuch as their inferior borders «annot be thrown outwards in consequence of their being supported laterally by the overlapping of the squamous portions of the temporal bones ; while the temporal bones, as M. Malgaigne has pointed out, are themselves supported by the zygoma, which constitutes on each side a true but- tress sustained by the superior maxillary bone. A shock, then, applied to the vertex, is directly transmitted to the temporal bone, and propagated through its petr.ous portions to the posterior part of the body of the sphenoid bone, the parts which most fractures of the base of the cranium traverse."—Brit, and For. Med. Rev. No. 29, p. 174. 58 FISSURE AT THE BASE OF THE CRANIUM. Fig. 7. spinal column, carrying both the weight and momentum of the body, is driven down upon the cranial base, the basilar process being probably broken through ; or, falling from a height, the patient alights on his breech, or on his heels ; and, again, a concussion sufficient for disruption may be so communicated to the cranial base. The extravasation is not always slight; it may be great, one or more of the large venous sinuses having been torn ; then the symptoms are from the first most grave, and cannot but end fatally and soon. The circumstances which lead to a suspicion of fracture at the base of the skull are : The kind of injury inflicted, such as already described; symptoms of compression, early and severe ; escape of blood from the ears, nose, mouth ; and discharge of a watery fluid from the ear, sometimes in considerable abundance. The last symptom, often termed " welling of the ear," is not immediate, but occurs after some days have elapsed. By some it is considered to denote escape of serous fluid from the sac of the arachnoid; others, contending that the phenomenon has been known to occur when certainly that sac was not opened into, believe that the fluid is but the serum of extravasated blood, trickling through the fissure; by all it is held as a sign of most untoward import.1 [In addition to the theories men- tioned by the author as to the source of the fluid in question, it has been supposed by some to be the liquid of Cotunnius, contained in the cavities of the internal ear. But the objections to this view are, that the discharge from the ear, after such injury, is far too abundant to be thus accounted for, having occasionally amounted, it is said by Nelaton, to nearly a quart; the flow is likewise increased by the patient's blowing the nose, or taking a full inspiration; and, moreover, a similar fluid has escaped from the nostrils as well as the ear, after fracture at the base of the cranium (Nelaton, op. cit. p. 565). Another supposition is, that the serous discharge is owing to the escape through the fissure in the cranium of the cerebro-spinal fluid. This theory, which seems to be better supported than any other, is advocated upon the grounds that it accounts more satisfactorily for the amount of the discharge in certain cases ; that the chemical composition of the two is identical; that when a careful anatomical examination of • Laugier, Archives G6ne"rales, Aout, 1845; also, Brit, and For. Med.-Chir. Rev. A%ril, 1850, p. 342; Ranking's Retrospect, vol. ii. p. 100. Fissure at the Base of the Skull, involving the occipital and sphenoid bones. The patient fell from a ladder on the vertex, and lay coma- tose for some days before death. Extensive extra- vasation was found over the cerebellum and middle lobes of the brain. (Liston.) FISSURE AT THE BASE OF THE CRANIUM. 59 the lesions have been made, they have been found to be such as would permit of the escape of the cerebro-spinal fluid by rupture of the con- taining membrane ; and that experiments instituted by Robert, for the purpose of testing the validity of this explanation, have served to confirm it (Nelaton). Against the assertion that the fluid is merely the serous part of the blood, effused by rupture of bloodvessels, are the conclusive facts that the amount of coagulum found bears no proportion to the quantity of the liquid poured out, and that the chemical composition of the serum of the blood and that of the latter are not the same.—Eo.] Bleeding from the nose, mouth, or ear, following on severe injury of the head, is always suspicious, more especially if the patient be found in a state of insensibility. But, let it be borne in mind that such a combination of circumstances by no means certainly denotes the existence of fracture at the base ; the insensibility may be that of concussion or of intoxication; the bleeding may proceed from mere laceration of the Schneiderian membrane and of the lining of the meatus, and from injury of the tongue by the teeth. When, however, we have such bleedings accompanied by urgent insensibility, obviously of the nature of coma; when the head symptoms either remain unimproved, or advance unto- wardly ; and, more especially, when by and by the " welling of the ear" appears, we may safely conclude that fracture at the base has occurred. [Another sign of fracture at the base of the cranium is ecchymosis beneath the conjunctiva of the globe of the eye and of the eyelids, particularly of the inferior. The manner in which this phenomenon is produced is obvious enough, and it is evidently an indication of value, as maintained by M. Yelpeau. Fracture of the bones concerned in the formation of the orbit, must be ordinarily accompanied by sanguineous extravasation from rupture of vessels ; and as the cellular tissue sur- rounding the eyeball, and connecting the conjunctiva to the sclerotic, is loose and yielding, it readily allows the blood to insinuate itself into its texture, and even, perhaps, to separate it more or less from its connections, until the fluid shows itself anteriorly upon the globe and beneath the integuments of the lid. In order, however, that this sign shall possess any exclusive value as indicating fracture within the cranium, it must be unaccompanied by external evidences of violence received upon or near the eye, as this cause might of itself occasion the ecchymosis in question without any internal lesion.—Ed.] The treatment must plainly be-prophylactic and expectant, as already advised in the case of compression by inaccessible extravasation. There is no room for direct operative interference. If the compression be happily got over, we must then be very watchful of inflammatory acces- sion. In all cases prognosis is unfavorable ; the majority prove fatal, either immediately by coma from extravasation, or more remotely from the effects of inflammatory action. But it must be remembered that fissure of the cranial base may occur without any characteristic symptoms being evinced, the patient seeming to labor under mere concussion. The fissure may have been slight, and the solution of continuity may have been confined to the bone alone. The membranes, remain entire, and there is no inward 60 FRACTURE WITHOUT DISPLACEMENT. escape of blood. Compression, by extravasation, necessarily does not supervene; and inflammatory danger may be warded off by ordinary care. Such cases, however, are of comparatively rare occurrence. Fracture without Displacement. The most common solution of continuity in the cranium is not a mere fissure, but a fracture, analogous to comminuted fracture of the long bones, reducing the injured part to the condition of being broken up into one or more fragments; and these may or may not be displaced. When there is no displacement, the dangers to be apprehended are such as are common to other injuries of the head, apparently less severe; concussion, excessive reaction, bringing either compression by extrava- sation or untoward inflammatory action; or a more insidious inflamma- tory process, occurring at a more remote period. The fracture may be simple, or compound, or with wound (Principles, 3d Am. Ed. p. 649). The compound is necessarily of a more unfavorable character than the others; danger by inflammatory action being greater and more probable'. But the difference is, on the whole, not so marked as between corre- sponding injuries of the bones of the extremities. It is possible that the existence of a communicating wound may prove even an advantage, by permitting outward escape of inflammatory or other effusions, and so saving the important internal parts. The treatment is prophylactic and expectant; according to the gene- ral principles already explained. There is as little necessity for imme- diate trephining, as in the case of mere fissure. If the injury have been sustained at the lower and anterior angle of the parietal bone, and is speedily followed by urgent compression, it may be advisable to apply the trephine in order to afford a freer vent for the meningeal hemorrhage. But, usually, the aperture already existing is sufficient for an outward drain. And again, should symptoms of compression by suppuration supervene, at a more advanced period, operative interference may be necessary to effect a free evacuation. In general, however, there is no necessity for the use of the trephine. Fracture with Displacement. If the fractured portion, or portions, be displaced inwards, the brain is more or less incommoded, and symptoms of compression ensue; proportioned usually to the amount oT depression, and to the relative importance of that part of the brain which is injured. The upper and anterior surface of the brain, as formerly stated, may bear a very con- siderable amount of compression with comparative impunity. The injury may occur without corresponding wound of the soft parts; but usually the fracture is compound. ^ The dangers are formidable. 1. By concussion. 2. By extravasa- tion of blood. 3. By the results of inflammatory action on the brain and its membranes. 4. By compression, caused by the displacement. The first three are to be opposed by fulfilment of the ordinarv indi- cations. The last is to be removed by operative interference. But in regard to this the question at once arises: Whether, in all cases of FRACTURE WITH DISPLACEMENT. 61 depressed fracture, operative interference, for the purpose of replacing the depressed portion of bone, is necessarily demanded ? Formerly, the answer was in the affirmative; at present, it is not so. Elevation of the depressed portion is had recourse to, with two remedial objects in view ; to remove the cause of compression, and consequently the symptoms of this, when they exist; and also to remove a likely exciting cause of inflammatory action from the portion of cerebral tissue and membranes acted upon by the depressed bone. When the symptoms of compression are great and urgent, there is no room for hesitation ; it is plainly the duty of the surgeon at once to attempt removal of the cause ; and ful- filment of the former of the two indications is sufficient warrant for re- course to the operation. But if symptoms of compression either do not exist, or are slight, and are recedent rather than gravescent, the case is very different. If we operate then, it is only to fulfil the latter indica- tion ; removal of the exciting cause of an apprehended inflammatory process. And then this other question arises: Whether the continued pressure of a smooth portion of depressed bone, or the injury inflicted by performance of the operation, is the more likely to excite an unto- ward amount of inflammatory action? Experience has answered to the effect, that the greater risk is encountered by recourse to operation.1 And, consequently, the rule is, to refrain from operation in all cases of ordinary depressed fracture, in which symptoms of compression do not exist. Farther, we know that the brain has the power of slowly recovering under a certain amount of pressure, even when that pres- sure continues undiminished. And, consequently, the rule of non-in- terference is extended also to those cases in which the symptoms of compression exist, but are by no means urgent, and seem to be slowly receding rather than on the increase. In young subjects, the call for artificial elevation must be especially urgent before it can with propriety be obeyed. For in them, it is to be remembered, a system of mutual accommodation may be said to be in progress ; the brain not only be- coming accustomed to its altered circumstances, but the compressing agent being also gradually withdrawn—the bone, by its inherent elasti- city, slowly reapproaching its former level. In the adult, there is not the same resiliency; but then too something is done, on the part of the bone, to favor complete recovery of the functions of the incommoded organ. For after some considerable time the depressed portion is found to have become wonderfully smooth on its internal surface, and bevelled at its margins, by absorption ; not ceasing to press, but now pressing with all gentleness on the parts beneath. In ordinary fracture with displacement, therefore, we do not inter- fere by operation unless symptoms of compression not only exist, but are urgent. And in these cases the operation may not wholly succeed, the compression being perhaps by blood as well as by bone. In all 1 Abundance of cases are on record, testifying the power which the brain has in bear- ing long-continued pressure, with comparative impunity, so far as inflammatory accession is concerned. One very remarkable instance is related by Sir A. Cooper (Lectures, p. 128), in which certain symptoms of compression endured for upwards of thirteen months, in consequence of the existence of depressed fracture; complete and almost instant recovery following removal of the depression by operation, at the end of that period. 62 FRACTURE WITH DISPLACEMENT. other cases, we content ourselves with the expectant and prophylactic treatment, as if depression did not exist. When the fracture is compound, comminuted, and depressed—that is, when fragments are not only displaced but completely detached from the rest of the cranium—we of course do not hesitate, in all such cases, to remove the loose fragments, with gentleness and care, whether symp- toms of compression exist or not. Also, let it be understood, that when, in a case of compound frac- ture, with displacement, sharp fragments seem to be dangerously in contact with the dura mater, much more, if this membrane be pene- trated or punctured by them, we ought as soon as possible to raise or remove the offending portions, whether head symptoms exist or not; for in no other way can violent inflammatory accession be averted. When operative interference is determined on, the indications to be fulfilled are sufficiently plain: to expose the parts, by suitable incision of the soft textures superimposed; to use the sound margin of bone, as a fulcrum, on which the elevating lever may rest; to insinuate the extremity of the lever beneath the displaced part, and to effect replace- ment with as little violence as possible. For the insertion and working of the elevator, sufficient space may already exist; if not, this is to be acquired, by gently lifting away a loose fragment, or by removing a portion of the sound bone, by means either of the saw or of the tre- phine. After the operation, much antiphlogistic care must neces- sarily be maintained. [Mr. Guthrie, whose experience in cases of injuries of the head has been very ample, remarks: " The difference between a simple and a compound fracture of the leg is often considerable ; it is more often dependent on degree; and when the fracture is nearly transverse, and the skin cleanly divided, the difference between it and a simple frac- ture of the same part is little more than one of time. I suspect this to be the case with an injury of the head, and my experience induces me to believe that the difference between the two states in fractures of the skull has been exaggerated; so much so, that I place no reliance on the supposition that there is more real danger in a case of fracture with depression, in which the scalp has been divided, than when it has been only bruised and not divided; and I apprehend that in all cases in which a fracture with marked depression is known to have occurred in an adult, it is the best practice to divide the scalp and ascertain the nature and extent of the depression." (On Injuries of the Head, p. 103.) And again, at page 111, he says : " When a fracture is accompanied by depression, and the broken portion or portions of bone would seem to be driven into the dura mater, or the brain, or to press so unequally upon them that as much mischief is likely to ensue from leaving as from removing them, and especially in an adult or middle-aged man, less harm will in general follow from ascertaining the fact, by dividing the scalp, and removing the broken pieces, than by doing nothing, more particularly when the presence of a foreign body is ascertained. If there be no symptoms indicative of mischief below the fractured part, the surgeon must then decide, after the best estimate he is able to make, of the probable evil which will occur from allowing the broken or de- pressed portions of bone to remain. PUNCTURED FRACTURE. 63 " I have said, that in young persons the brain will bear a greater degree of pressure and of irritation with impunity, than it will in per- sons of mature age, and that by far the greater number of cases in which recovery has taken place after fracture and depression of the skull, with injury of the brain, and even loss of its substance, have occurred in children, or in persons under the adult age ; greater reliance may therefore be placed on the powers of nature in them, and less fre- quent recourse may be had to the aid of operative surgery in order to prevent mischief than in adults, even when the bone is fractured as well as depressed." J. L. Petit, after relating the history of two remarkable cases of injury of the head, in each of which a depressed portion of bone was not elevated, and a portion of the inner table was separated and found adherent to the dura mater ten years afterwards, says: " Two or three of such wounds out of a thousand will get well without operation, but the remainder will die without it."—(Guthrie, p. 115.) And the motive for operative procedure, even in the absence of symptoms of compression, in cases of fracture with known depression of the bone, is, to our mind, obvious and sufficient; the absolute infre- quency of recovery from this accident without operation, is acknowledged; if symptoms of compression do not at first exist, but should supervene after that period has passed when such phenomena can reasonably be ascribed to extravasation, they can only be explained upon the supposi- tion that inflammation of the membranes of the brain, together, pro- bably, with the same affection of the brain itself, has taken place, a condition certainly exceedingly unfavorable to the success of the opera- tion, rendering it a much more grave expedient than if it had been practised as soon as depression of the bone had been ascertained, parti- cularly in hospital practice. We would submit, therefore, that in these cases, surgeons may carry their fears of trephining too far for the welfare of their patients.—Ed.] Punctured Fracture. By the term " ordinary fracture, with or without displacement," is meant injury done by an obtuse body, causing solution of continuity throughout the whole thickness of the bone, and producing fragments com- Fig. 8. posed of both tables of the skull, sepa- rated from their general connection in nearly equal proportions. A smooth, uniform, non-penetrating surface is con- sequently presented by the depressed portion to the brain and its membranes. But when a sharp-pointed substance, as the point of a poker or pitchfork, the corner of a spade, shovel, or ham- mer, or the ansrle of a sharp stone, im- -, ,i • Punctured fracture, at a; at 6, the dura pinges on and penetrates the cranium, mater represcnted dctached> and gpiculfB of the nature Of the injury is Very dif- bone lodged in the vacant space. 64 PUNCTURED FRACTURE. ferent. The external table is crushed by the penetrating body, to an extent proportionate to its lodgement. But the inner table, being much more brittle, gives way to a greater extent. It is broken up into frag- ments, usually small and spiculated, which, being driven inwards by the force of the blow, penetrate, or at least seriously irritate the coverings of the brain, producing inflammatory action. This may be general, in- volving the brain itself, and to the last degree dangerous; or it may be limited to the injured dura mater, causing abscess there, a result still most perilous to life. And to accomplish the latter evil it is not neces- sary that the fragments of the inner table should penetrate, or in any way mechanically injure the dura mater. It is sufficient that they are detached from the general cranium, and remain unremoved; they neces- sarily die, and, as sequestra, they inevitably become surrounded by purulent formation. The rule of practice, then, comes to be plain. Whenever we are satisfied that punctured fracture has occurred, in other words, that the kind of fracture is such that splintering of the internal table is certain, we cannot too soon proceed to operation. We trephine immediately, so as to expose the fragments, and admit of their being carefully and efficiently removed, Unless they are taken away, antiphlogistics are practised in vain ; inflammatory action becomes established at the part, sooner or later abscess forms, and then we find ourselves compelled to operate for relief of compressed brain, under very unfavorable circum- stances. The least result is abscess of the dura mater; but it may be, that even the questionable chance by operation is not afforded, the inflammatory action having proved general, cerebral as well as menin- gitic, and speedily carrying off the patient. Taking the most hopeful view of the case, a necessity for operation is certain to arise, at some stage. And surely it is most prudent to operate at that time which plainly is most promising of an auspicious result. Better to operate at once, removing the paramount exciting cause of inflammatory action, and probably averting all casualties, than to attempt, subsequently, to retrieve or limit danger and disaster, already sustained. The rule as to operation, then, is very different in the case of punc- tured fracture, from what is applicable to any other injury hitherto considered. We at once proceed to the operation of trephining, whe- ther head symptoms are present or not. The mere existence of this form of injury is an amply sufficient warrant for our interference. Head symptoms, and those of a most urgent kind, are certain to super- vene, if the operation be withheld; and they can be averted only by early removal of the splintered fragments resting on the dura mater. After the operation, antiphlogistic treatment must be sedulously main- tained. As in the case of concussion, it may be difficult at first to persuade the patient, as yet suffering but little, of the propriety of instantly sub- mitting to treatment which may seem to him unnecessarily severe, and indeed quite unwarrantable. This obstacle is to be overcome by a calm jet earnest exposition of the certain danger which otherwise awaits him. Obviously, it is our first duty to come to a just conclusion as to the FRACTURE OF THE EXTERNAL TABLE. 65 existence or not of this, kind of fracture. A most minute examination is accordingly made. The scalp is freely divided, if need be, to expose the fractured point to sight as well as touch ; and by a gentle yet determined use of the finger and probe, we endeavor to satisfy ourselves thoroughly; assisted in our decision by regard to the mode in which the injury has been inflicted. Penetrating cuts of the Cranium—as by a sabre, axe, or sharp spade —often closely resemble punctured fracture, as to the kind of injury done to the inner table, and the immediate necessity for operation. When the cut passes sheer through both tables, the inner one is usually splintered ; and the fragments press inwards, untowardly. They must be removed. The chasm of the wound is often sufficient to disclose their presence and site, to finger or probe; and it may suffice for re- moval also. If not, room is to be made by application of the trephine, or saw, as may seem most convenient. [Mr. Guthrie was, we believe, the first to call particular attention to this kind of injury; and the observations which he has made concerning them, in his treatise on Injuries of the Head, prove the importance of a careful examination by a probe. In the first instance which he cites, in which an officer was struck on the head by a woman with a tomahawk, a wound was made into the left parietal bone, and he was knocked down ; he soon recovered, however; a simple treatment was instituted, and the case was looked upon as a very favorable one ; until the four- teenth day, he sat up daily and shaved himself; then, he observed that the left corner of »his mouth was distorted, and his right arm partially paralyzed; the paralysis increased, he became comatose, and died. At the post-mortem examination, the inner table was found fractured, sepa- rated from the diploe, and driven through the membranes into the brain, which, at the point wounded, was in a state of suppuration (pp. 86-87). The examination, which Mr. Guthrie recommends for the purpose of ascertaining the true state of the case, consists in introducing a blunt probe into the wound, by which the depth of the inner table can be determined, and, of course, the question settled whether or not it be depressed, and the extent of the depression. Had this exploration been made in the case which we have quoted, a more suitable treatment would have been instituted—by elevation of the depressed bone—and the patient would, to say the least, have been much more likely to recover.—Ed.] Fracture of the External Table, alone. This is not an uncommon result of comparatively slight violence done to the calvarium, by bodies either sharp or obtuse. The external table alone gives way, and is perhaps driven inwards on the diploe. The most marked sample of the injury is afforded by fracture over the frontal sinus ; in other parts of the calvarium, the accident occurs only in those of middle age, in whom diploe, with marked distinction between the cranial plates, exists. No operative interference is required, except in the case of the frontal sinus, and then elevation of the depressed 5 6Q OPERATION OF TREPHINING. part is expedient. The treatment is, locally and generally, antiphlo- gistic. But, as formerly stated, inflammatory action may become ex- cessive, and extend inwards; and suppuration in the diploe may lead to suppuration also on the internal aspect of the bone, necrosis of the implicated part ensuing. Under these circumstances, the operation of trephining is likely to be required, to relieve compression. Sometimes diploal phlebitis, with its sad consequences, ensues ; too often baffling all treatment. Fracture of the Inner Table, alone. Fortunately, this is of comparatively rare occurrence ; for, the outer table remaining entire, we have no means of ascertaining the nature of the injury, at the time of infliction. It may follow on a sharp concus- sing blow ; in a patient who, by reason of age or other cause, has a vitreous table of unusual brittleness. The table may be simply severed, and not much depressed; then head symptoms are likely to prove both slight and transient. But, more probably, there is comminution as well as displacement; and then the usual hazard is incurred from the de- pressed and perhaps penetrating spiculae. The trephine is likely to be called for, after a time, on account of dura-matral abscess. Depression without Fracture. As already stated, this occurs only in children, in whom bones are more prone to bend than to break. A dimple is made in the skull by external violence, and is slowly effaced by virtue of the inherent elas- ticity of the tissue. For a time, there may be symptoms of compres- sion ; but seldom of a marked character; and still more rarely urgent. Operative interference is neither necessary nor expedient. The treat- ment is simply antiphlogistic; and prophylaxis is long maintained (p. 42). The Operation of Trephining. The Trephine is a circular saw, worked by a light and rapid move- ment of the hand, whereby a portion of the skull is divided, and may be removed. For its application, complete exposure of the bone is necessary. If a wound already exist, it is enlarged to the necessary extent. If there be no previous wound, a crucial or other incision is made; so that, by reflection of flaps, the required exposure may be effected. The pericranium is carefully raised to an extent sufficient to admit of the free play of the instrument; but no farther. The centre- pin, sharp-pointed, having been made to protrude a short way beyond the serrated edge, is securely fixed there by its screw. And then, by firm pressure, accompanied with a slight rotatory motion, the centre-pin is fixed in the bone, so as to steady the instrument in its first movements on the external table. The teeth of the trephine are usually set so as to work from left to right; and it is well to have the crown fluted, on its lower half—this being found to favor its free play. The turnings are OPERATION OF TREPHINING. 67 made steadily and rapidly; with very light pressure after the centre- pin has been fixed; and the light pressure is exerted only during the movement from left to right. When the sulcus has advanced to such a depth as is sufficient to retain the saw steady in the groove, the instru- ment is withdrawn, and the centre-pin pushed back entirely; to proceed with it still protruding, were not only to do what is unnecessary, but also to encounter much risk of injury to the dura mater at the latter part of the operation. The plain crown is reapplied, and worked steadily as before. There is no occasion for hurry; the operation itself, so far as the sawing of the bone is concerned, is comparatively painless; besides, it is usually undertaken while the patient is insensible; and in those cases where sensibility remains, experience has shown that anaesthesia by chloroform may be practised with perfect safety (Princi- ples, 3d Amer. Ed. p. 733). If diploe exist, a change of sound and feeling is imparted to the operator, intimating that the saw has passed the external table. Then the instrument is worked very warily ; and it is well to remove it from time to time, examining the sulcus with a probe or toothpick, to ascertain whether or not, at any point, section of the inner table may have been completed. If an aperture be detected, then the instrument, when reapplied, is inclined to the opposite side, and moved with increased caution and lightness. Want of parallelism in the two tables of the skull renders such precautions essential to a safe performance of the operation. Section having been completed at all points, the detached circle is to be removed. Perhaps it may come away in the crown of the instrument. If not, dislodgement is effected by the point of a lever, or by forceps ; and the circle is gently with- drawn ; in this step of the procedure, as well as in the last of the saw- ing, much care being taken to avoid injury to the dura mater. If any rough or sharp points are found on the margins of the aperture, these are to be removed by the elevator; otherwise, the dura mater might sustain injury. [A very useful expedient in some cases is thus alluded to by Mr. Guthrie, op. cit. p. 130. " A musket-ball, striking directly against a bone, sometimes makes a hole not larger than itself, with or without any radiating fracture; and one trephine, if properly applied, will often embrace the whole of the mischief, and admit of the removal of the broken pieces. The trephine should be of a large size; and, as a centre- pin cannot be used, it may be made to turn very well, in most cases, in a flat but thick bar of iron, having a hole in the middle, of such size only as will admit the outside of the polished trephine to turn in it. Sufficient support for the instrument will be obtained by this means, until it has made a groove in the bone for itself, when the operation may be continued as it would be in an ordinary case after the removal of the centre-pin. Botal and Percy both allude to contrivances of this kind as eminently useful, and I have myself found it very advantageous."—Ed.] When the operation is undertaken for elevation of depressed bone, it is seldom necessary to remove an entire circle. All that we desire is room sufficient for raising the depressed portion, and removing frag- ments if need be; and this can usually be accomplished by fixing the 68 OPERATION OF TREPHINING. Trephining, a, the sound portion of cranium; 6, the depressed The centre-pin fastened on the brink of the sound portion. centre-pin on the brink of the sound bone, and so removing by the saw only a segment of the circle. The operation, and the object for which it was undertaken, having been accom- plished, the flaps are carefully replaced, and the general wound is invested by tepid water-dressing; care being taken that no undue bleeding takes place from the scalp ; and, in regard to this point, it is to be remembered that vessels which do not bleed during the state of depression, may part with their contents freely on the establishment of reaction. Above the water-dressing it is well to place a few turns of a bandage, lightly applied, so as to afford support (p. 28); and this is more especially necessary when deficiency of the cranium happens to be considerable. The wound, in other respects, is treated in the ordinary way ; union taking place by the second intention. Of course, rest is absolute, severity of regimen is extreme, and antiphlogistics are held in readiness for some considerable time after the operation. It has been proposed to replace the removed cir- cle of bone, after completion of our object, in the hope of its becoming reunited; but such hope has been proved vain, as might have been expected. When the wound has healed, the dura mater is found to have become incorporated with the soft parts exteriorly, and the breach in the cranium is not filled up by bone, but by dense membranous formation. A meagre film of new bone may be found at the mere margin of the aperture. And this, in time, extends centripetally ; apparently by the slow secretive action of the parent bone alone, the pericranium, dura mater, and other soft parts, seeming to be incapable of ossific action. At the margin of the aperture the new bone may be of similar thick- ness with the cranium; but, as it extends, it shelves rapidly; becoming very thin as it ^ approaches the centre. Many years are required ere osseous reparation is complete. And, in consequence, it is expedient for a long time to guard the imperfect part from external injury, a piece of leather or metal being worn over the cicatrix. At one time, trephining was frequently performed,' and on grounds much too slight. From the preceding remarks, the following brief deductions may be drawn, as to its present use : It is had recourse to, 1. On account of punctured fracture, as soon as possible, whether head symptoms exist or not; the object being to remove splintered fragments of the inner table. 2. On account of depressed fracture, accompanied with urgent symptoms of compression, when elevation of the depressed portion cannot otherwise be effected. 3. On account of dura-matral abscess, when local and constitutional symptoms sufficiently concur in pointing out the existence and site of this morbid condition • the object WOUNDS OF THE BRAIN. 69 being to effect external evacuation of the pus. 4. On account of urgent compression caused by extravasated blood ; only when the cir- cumstances are such as to indicate the seat of extravasation, and when that happens to be accessible. Occasionally, the surgeon has been called upon to trephine, in cases of epilepsy, in which the disease seemed to be connected—in the relation of effect and cause—with a depression of the cranium, the result of former injury; or, in which circumstances seemed to point with much plainness to a certain spot of the cranium—perhaps the seat of internal enlargement of either a globose or spiculated character. The operation, under such circumstances, is of doubtful expediency; but may be per- formed, at the suspected spot, in obedience to the urgent entreaty of the patient or his friends. Trephining has also proved successful on account of neuralgia de- pendent on inward growth from the cranium.1 In general, it is well to avoid applying the trephine in the direct course of the middle meningeal artery, or over the longitudinal sinus; yet, if it seem of decided importance that the instrument should be ap- plied at such localities, the risk of hemorrhage need not deter us. A compress of lint, directly and accurately applied, will readily restrain the venous bleeding (Principles, 3d Am. Ed. p. 354); and if a similar application fail to stanch the arterial flow, the osseous canal, in which the vessel is usually imbedded, may be temporarily plugged by the insertion of a small portion of wood or cork (Principles, 3d Am. Ed. p. 345). Wounds of the Brain. The brain may sustain an incised wound, as by a sabre cut; a con- tused and lacerated wound, as by depressed fracture; a punctured wound, as by the thrust of a bayonet, pike, or any other sharp-pointed weapon; or a gunshot wound, of the class "contused and lacerated," by the penetration of a bullet. The likelihood of disaster is grave and imminent; by extravasation of blood, in the first instance ; by inflam- mation and its results, secondarily. Treatment requires to be propor- tionally watchful and energetic. Incised wounds may simply penetrate, or partially detach a slice of the organ. Such a flap is not to be at once removed, but should be re- placed along with the corresponding investing textures, in the hope that reunion may occur. Examples are not wanting of a fortunate result.2 In contused and lacerated wounds, a certain amount of inflammation is inevitable. It is our business to moderate and control this by the ordinary means, so preventing disorganization and protrusion of the cerebral tissue at the injured part. In punctured wounds, inflammation is not inevitable, unless foreign matter lodge, yet it is very likely to occur. The antiphlogistic precau- tions require to be very rigid. In gunshot wounds, danger by inflammatory action is pre-eminently 1 Boston Med. and Surg. Journal, August, 1846, p. 53. 2 Larrey, Glinique Chirurgicale, torn. i. p. 140. 70 LODGEMENT OF FOREIGN BODIES. great. Not only is the wound of the contused and lacerated kind; there is also great probability of lodgement of the bullet, or portions of it, or of fragments of bone which have been displaced and driven in. And, it is well to remember, that the want of an apparently sufficient aperture of entrance is no sure proof of the ball having not penetrated and lodged; for, in the young more especially, the inherent elasticity of the osseous tissue may be so great as to diminish the space of entrance- wound very considerably. Contusion and laceration of the cerebral tissue and its investments, render a certain amount of inflammation inevitable ; and the lodgement of foreign matter determines the amount and intensity of such action to be great and hazardous. Farther; for- eign substances, penetrating deeply, are not unlikely to interfere with the most important portions of the organ, at its lower and posterior part; producing death, either instantly or at no protracted period, by direct interference with function. Lodgement of Foreign Bodies. When foreign bodies penetrate the brain, and their site of lodgement can be ascertained through the wound, the surgeon naturally becomes desirous of effecting removal of so palpable an exciting cause of the coming inflammatory action, the results of which he so much dreads, and not without good cause. If extraction can be effected easily, by forceps, probe, or hook, without much additional injury being inflicted on the cerebral tissue, it should certainly be attempted with as little delay as possible. If, however, the site of lodgement is unknown, or if the foreign body, of no great size, is found both difficult of access and firmly imbedded, it is better to abstain from the infliction of exploratory and evulsive violence, which would be certain to kindle an amount of inflammation quite uncontrollable. It is better to withhold all direct interference, contenting ourselves with busy antiphlogistics, to meet that amount of inflammatory action, perhaps amenable to control, which the infliction of the wound and the lodgement of foreign matter cannot fail to induce. We may happily succeed, though the general prognosis is, doubtless, unfavorable. There are instances on record of bullets, lodged deeply in the brain, remaining there harmless for years, incased in adventitious cysts, as happens in other textures (Principles, 3d Am. Ed. p. 628). Such fortunate patients, however, require ever to be most careful in avoiding all inordinate excitement of the cerebral functions and of the general circulation, for it has happened, again and again, that, after years of immunity, a debauch, or violent emotion, has induced a sudden and fatal coma. The rule of practice then is: That, while it is very desirable, at as early a period as possible, to remove foreign substances which have lodged in the brain, in order that we may hope to contend more suc- cessfully with the coming inflammation, such removal is not to be attempted at the expense of farther and serious injury to the cerebral tissue. Such additional injury will render the inordinate action uncon- trollable, and the patient must perish thereby. Leave the part undis- turbed, and trust to general antiphlogistics; for it is possible that the HERNIA CEREBRI. 71 inflammatory action may be kept within moderate limits and the patient saved. Sometimes they make wonderful escapes, as in the recent instance of recovery after an iron bar had completely traversed a large portion of the brain.1 Hernia Cerebri. By this term is meant protrusion of the cerebral substance through cranial deficiency. To constitute this morbid state, three things usually conspire; deficient space in the cranium; a corresponding aperture in the membranes of the brain, by wound, ulceration, or sloughing; and disorganization of the corresponding portion of cerebral substance by inflammation. It is most likely to follow on compound and comminuted fractures of the skull, with depression of the fragments, and laceration of both brain and membranes. The pouting prominence of brain at first merely fills the cranial orifice; it then shoots above it; and, in no long time, it may attain to a considerable size. Now, probably, its neck becomes impacted in the cranial aperture, is strangulated there, and sloughs; a fresh protrusion, however, takes place, and the progress is as before. Portion after portion of the upper part of the brain may be lost in this manner, without apparent and direct injury to the cerebral functions ;2 but, sooner or later, the formidable constitutional irritation which accompanies will prove fatal; and there is, besides, a risk of the disorganizing inflammation extending widely and fatally from the original site. Prevention may be in our power. When the brain has been exposed by compound and comminuted fracture; and when there is a deficiency of the cranium, by removal of the fragments, with or without use of the trephine, the occurrence of cerebral protrusion, in consequence of inflam- matory accession, is always to be apprehended; and two indications fall to be fulfilled : 1. To atone for the cranial deficiency, by affording uniform, steady, yet gentle support to the part, by compress and bandage; renewing the dressing as often as cleanliness and propriety of management require. 2. By antiphlogistics, timeous and efficient, to prevent or control the otherwise disorganizing inflammatory action. An attempt to cure comprises greater difficulty. The obvious indica- tions are, to restrain the inflammatory action, and to repress the exu- berant growth. The former is to be fulfilled by antiphlogistic treatment; but this must be most warily conducted, inasmuch as by this time there is no tolerance in the system of severe remedies of that character. To fulfil the second, three means may be considered effectual; pressure, ablation, escharotics. Pressure is to be preferred; direct, accurate, steady, firm, but not severe; otherwise symptoms of compressed brain might be induced, with, not improbably, aggravation of the inflamma- tory action. The hydrostatic pressure, as recommended by Dr. Arnott, may be found highly available. Ablation of the cerebral protrusion is 1 Bigelow; Brit, and For. Rev. Oct. 1850, p. 543. 2 It has been supposed that the lost portions of cerebral substance are regenerated by a reparative effort on the part of the brain; and that thus the non-impairment of cerebral function may be accounted for.—I^ancet, No. 1399, p. 7G0. 72 HERNIA CEREBRI. not expedient, unless-the protruded part be in a sloughy condition, and must ultimately be lost; or unless pressure alone have been duly tried and found ineffectual. In either case, the protruding portion may be shaved smoothly off, by a knife, on a level with the cranial aperture; and then restraining pressure is to be resumed. The use of escharotics is, in no case, advisable. The true hernia cerebri consists of cerebral substance more or less disorganized, often mixed with grumous blood, and other inflammatory products. Its formation is always a most unfavorable sign, and the ultimate issue is seldom but unfortunate. The affection is sometimes simulated, however, by coagulum. A mass of clotted blood, mixed with inflammatory exudation, but containing little or no cerebral substance, may protrude, presenting almost the same appearance as the genuine tumor. This is amenable to more summary treatment, and bespeaks a more hopeful issue, although usually a sign of active inflammatory action having seized on the part, and calling for a proportionate activity in antiphlogistics. The projection is at once removed by knife or fingers, and firm occupying pressure is applied to the cranial aperture. [Hernia cerebri may be occasioned either by disease occurring within the cranium independently of external injury, or it may result from violence which has produced a fracture of the skull, usually compound, complicated or not with rupture of the membranes of the brain and laceration of its substance. When dependent upon spontaneous intra-cranial disease, it is in the majority of cases a congenital affection, or comes on soon after birth, before ossification of the fontanelles; in either case the term encepha- locele is applied to it. The protrusion ordinarily takes place at one of the fontanelles, most commonly the posterior; sometimes, though very rarely, the brain protrudes into the nostrils or sphenoidal sinuses, and forms a tumor at the root of the nose or in the pharynx.1 In the Illustrirte Medizinische Zeitung, vol. i. No. 3, is an account of three cases of congenital encephalocele, in which the protrusion oc- curred at about the junction of the nasal and frontal bones, through original deficiencies of the parietes of the cranium at this part. In two of these cases an error in diagnosis was committed, and the nature of the tumors was not ascertained until after operations were undertaken upon them. In size, the tumor varies very much, being sometimes as large as a child's head. It is more or less rounded in shape, and occasionally pediculated, owing to the comparatively small dimensions of the aper- ture of escape. It is covered externally by the scalp, which is more or less thin and distended, according to the magnitude of the protruded mass; the pericranium and dura mater are closely adherent to each other, while the internal membranes are attached to the extruded brain. The cause of this form of encephalocele is great increase of the volume of the brain beyond the capacity of the cranium; and this enlargement is almost always due to hydrocephalus. The structure of the organ, as well as of the membranes, is generally more or less decidedly altered, 1 Rokitansky, Pathol. Anat. vol. iii. p. 372, Sydenham Soc. Ed. HERNIA CEREBRI. 73 as in hydrocephalus, and frequently important portions of it are wanting; the protrusion then consisting of the integuments and membranes filled with serum, while the partially developed brain lies at the bottom.of the sac. The symptoms of encephalocele need no especial mention here, the physical appearance and phenomena of the tumor being the most cha- racteristic. These should be carefully investigated, in order that this affection may not be mistaken for cephalhsematoma, a mere saccular protrusion of the arachnoid, vascular growths from the brain or dura mater, etc. The treatment of this affection is the same as that of hydrocephalus; in addition, the tumor should be carefully supported, and moderate pres- sure may be tried. Occasionally, a spontaneous effort is made to cure it by free diuresis, of which an exceedingly interesting example is recorded by Dr. Baron, in the 8th vol. of the MeJ.-Chir. Transactions ; or rupture of the membranes of the brain may take place, permitting the fluid to escape upon the exterior of the cranium, or even through the cribriform plate of the ethmoid bone, and downwards into the nos- trils, both of which curious phenomena occurred in the case of Dr. Baron. But a cure is not to be expected. The other variety of hernia cerebri is, as we have already said, the result of an injury which has fractured the cranium, with or without laceration of the dura mater and the brain; if the dura mater be not torn, it sloughs sooner or later from the pressure of the tumor. The immediate cause of the external protrusion is, as in the other form just described, a sufficient pressure from within to extrude through the accidental opening in the skull that portion of the brain which lies imme- diately beneath it, and which is now deprived of its accustomed pressure and support. It may also be, in some cases, that the tumor consists merely of a mass of fungous granulations, which have been produced upon the surface of the lacerated brain or its membranes; but this is not the usual condition. The protruding cause may be supposed to be the vascular turgescence and the oedema of the cerebral tissue, which ordinarily accompanies active congestion and inflammation ; but this can scarcely be admitted to be a sufficient cause to account for the magnitude which is often attained by the tumor; and, moreover, as Mr. Stanley remarks, in his paper on this subject (Mcd.-Cltir. Trans, vol. viii. p. 29), the protrusion usually commences at a period when the condition of the patient indi- cates that the inflammation has subsided, or even ceased; or the injury inflicted may occasion an attack of meningitis, with consequent hydro- cephalus, which, in turn, is sufficient for the production of the hernia. In some of the recorded cases the cause of the protrusion was undoubtedly an accumulation of serous fluid in the ventricles, as in several of the instances adduced by Mr. Stanley; the connection between the liquid thus situated and the external swelling is not always directly traceable, although its influence in effecting the extrusion of the portion of the brain implicated in the tumor is perfectly intelligible; but, in other cases, the tissue intervening between the ventricles and the tumor is ruptured, and the fluid even escapes externally (Mr. Stanley's paper, op. 74 HERNIA CEREBRI. cit. p. 34). In another group of cases, again, pus is generated within the cranium, and the pressure which it occasions forces out the brain through the accidental opening. The amount and seat of the purulent matter, of course, vary in different circumstances. It may be exterior to the brain and arachnoid membrane, as in Dr. Bright's 76th case (Medical Reports, part i. p. 161), in which a collection of pus was found upon the same side as the tumor, lodged upon the arachnoid, and forming a depression upon the surface of the brain a quarter of an inch deep in some parts. " A section was made perpendicularly through the fungus," (i. e. the protruding mass, which was On the right side of the forehead,) "into the ventricle, and through the corpus striatum of the right side, and a drawing made. The broken mass of red, brown, and curd color, with which the fungus was connected, extended to the surface of the ventricle, but had not opened into it. Around the broken mass several red points were visible in the substance of the brain, like small ecchy- moses, such as are usually seen around a portion of brain broken by an apoplectic clot. In the posterior cornu of the right ventricle pus was deposited, and the surface appeared rough and softened ; but as this was not examined until two days after the removal of the brain, the appearances were not very satisfactorily made out; a considerable quantity of pus lay between the arachnoid and the brain at the base, over the upper surface of the cerebellum, and at the under surface of the middle lobe of the cerebrum." In other instances, pus is accumulated in considerable quantity in the substance of the brain, beneath the external tumor. Thus, in one of the cases quoted by Mr. Stanley (op. cit. p. 49), "the tumor was evidently continuous with the anterior lobe of the right hemisphere of the brain. Both the lateral ventricles contained some ounces of a bloody fluid. An abscess was found in the anterior lobe of the right hemisphere, containing between two and three ounces of pus. This cavity extended from the anterior part of the corpus striatum to the base of the tumor, but it had no apparent communication with either of the ventricles. The other parts of the brain exhibited no morbid appearance." In another case, recorded by Dr. Bright (op. cit. p. 163), the lesions were equally significant. The opening through which the brain was extended was in the frontal bone, just anterior to its junction with the parietal. " On dissecting back the scalp, the edges of the external wound were slightly adhering to the pericranium, winch was detached for about'a quarter of an inch from the opening in the bone. The projecting portion of brain had entirely receded. On ele- vating the cranium, the edges of the opening in the dura mater adhered to the bone, and the pressure exerted in elevating the bone pressed out a portion of the brain, from which a small quantity of purulent matter exuded, which was contained in a cyst, and did not communicate with the right lateral ventricle, or the abscess opening into it. The convo- lutions of the right hemisphere were very much unfolded, as is seen in hydrocephalus internus. On cutting into the right part of the centrum ovale, an abscess was discovered occupying a large space of the ante- rior and middle portions of the cerebrum ; and communicating freely with the right lateral ventricle, a small portion of bone was found HERNIA CEREBRI. 75 deeply imbedded in the anterior lobe, and sero-purulent fluid was found with flakes in the lateral ventricles. The plexus choroides was not more vascular than usual. The quantity of fluid was from ten to twelve ounces; the piece of bone was connected with the larger abscess." A case of hernia cerebri recently fell under my own observation, the prominent features of which may be briefly stated. A lad, about ten years old, was struck upon the left temporal region by a brick; com- pound fracture of the skull was produced, with laceration of the dura mater and of the brain. At the first dressing, portions of the brain escaped when the depressed bone was elevated, and from time to time, subsequently, similar losses of cerebral substance occurred. During the first few days after the injury, the boy was treated at home ; afterwards, he was removed to the Pennsylvania Hospital, where he remained many weeks. While in the hospital, his general condition was remarkably favorable, and his mind usually clear; occasionally, he was a little feverish and soporose, but these symptoms were dispelled by mild pur- gative medicines. Soon after his admission into this establishment, a tumor appeared from the opening in the cranium, and gradually in- creased in size; pressure was first resorted to, to control its growth; but this means, as well as the application of caustics, failed to arrest or retard it. He was now removed from the hospital by his parents, and was under my care during the last month of his life. During this time, his mind was perfectly clear, he was quiet, not impatient, slept well, his appetite and digestion were good, and his nutrition was satisfactory. At this time, the tumor, which considerably overlapped the margin of the bony orifice, measured seven and a half inches around its base, and its perpendicular height was about two inches. Soon, a superficial slough, three or four lines in thickness, formed upon its summit, which gradually involved the whole superficies; a portion of it became detached, but large granulations rapidly made up for the loss of substance, the surface suppurating very freely and healthily. Compression and caustics having been fairly tried in the hospital, without benefit, I removed the tumor, with a knife, nearly to the level of the cranium; the boy expe- rienced no pain, but little blood flowed, and no unpleasant symptoms followed. The tumor, however, was being gradually reproduced. On the morning of the tenth day after the excision, the condition of the patient was as favorable as possible ; he ate for dinner, upon his mother's responsibility, an unusually large piece of meat, with potatoes in pro- portion ; at about ten o'clock that night he was attacked with convul- sions and fever, which continued unceasingly until the afternoon of the next day; no physician was sent for, and at my visit on the following morning I found the boy dead, and learned the above circumstances connected with his decease. No post-mortem examination was per- mitted; I was scarcely allowed to examine the injured part of the head with my finger; but from this hasty mode, I found that the edges of the bony aperture were smooth and rounded; the tumor had entirely disappeared, as in the case last cited from Dr. Bright; and instead of it, there was a depression beneath the level of the skull, and the surface of what was the tumor could be raised up like a sac which had been emptied of its contents; while beneath the brain, as it seemed, could be 76 PARACENTESIS CAPITIS. felt resisting pressure. My inference was that an abscess had existed here, and that its eccentric pressure had caused the protrusion; but as to what had become of the fluid, whether it had escaped externally or not, I could gain no information. It is to be regretted that there are so few carefully recorded cases of traumatic hernia cerebri to be found in our books. But the editor thinks that the causes above enumerated will prove more satisfactory in accounting for the protrusion than those ordinarily advanced, viz., vascular turgescence, and the presence of inflammatory exudations; though it is most likely that these are present in every case, and con- tribute, though not chiefly, to the production of the tumor. And if the causes which he has suggested, as inferences drawn mainly from the cases published by Mr. Stanley and Dr. Bright, be the most efficient ones, they point strongly to a mode of treatment which is not advised in the books, viz., to puncture of the tumor and evacuation of the super- abundant fluid, if any such collection have formed, together with the judicious employment of pressure.—Ed.] Paracentesis Capitis. The operation of tapping the brain in chronic hydrocephalus, known to Hippocrates, and practised by the surgeons of the Middle Ages,1 enjoys in the present day no great repute. Of modern practitioners, Dr. Conquest has shown the greatest favor to the procedure; and his experience of it has been by far the most favored by success.2 Of nineteen cases in which the operation was performed, ten were " living when last heard of."3 Dr. West has collected, from various sources, fifty-six cases ;4 of which forty died, sixteen only recovering. Of the fatal cases, six died within four days ; six within fourteen days ; three within one month; nine within three months ; only one survived the puncture six months ; and none survived the last puncture more than thirty-five days. Death took place either by exhaustion or under cerebral symptoms. In many cases, in addition to the presence of much fluid, the substance of the brain was found softened; and, besides, " there existed, in sixteen of the cases, serious organic disease or malformation of the brain itself." The serous accumulation usually takes place in the ventricles ; and the brain, if not congenitally deficient, is spread out and attenuated, with its convolutions smoothed away ; the ventricles ultimately consti- tuting one large cavity covered by a thin layer of cerebral substance, which lies immediately beneath its own membranes. Sometimes, on the other hand—though comparatively rarely—the liquid is immediately within the dura mater ; and the brain, which in these cases is usually partially deficient in its commissures, lies at the bottom of the serous cavity. 1 Philosoph. Transact, vol. xlvii. Ann. 1751. 2 Medical Gazette, March, 1838. 3' In Dr. Conquest's cases, the greatest quantity of fluid drawn off at one time was g20£; the largest total quantity ^57, or ^58; the greatest number of operations in any one case, five; performed at intervals of from two to six weeks. 4 Medical Gazette, April 15, 1842. PARACENTESIS CAPITIS. 77 Remedial means in chronic hydrocephalus consist of purgatives and mercurials, assisted by gentle and uniform pressure on the head. Fail- ing these, the question arises whether the patient is to be abandoned to his fate, or an attempt made to save him by tapping. Some, acting on the principle "anceps remedium melius quam nullum," operate ; the majority decline interference. Statistics, in the aggregate, as we have seen, hold out no flattering prospect of success. At the same time, in an otherwise hopeless case, if the parents, on a fair and full representa- tion of every circumstance having been made to them, are willing and desirous to undertake the risk, there seems to be no insuperable reason against the operation being then performed. One of three events may occur; death may ensue speedily; or matters may be left much as they were, the head refilling ; or a cure may be effected. Hoping for the last, the surgeon proceeds thus :— A small trocar is introduced perpendicularly through the bregma, or in the coronal suture, at a safe distance from the longitudinal sinus and its feeding veins ; and it is seldom necessary to penetrate farther than about two inches. Withdrawing the trocar, clear serum flows through the canula, and the more gradually it escapes the better; com- pensating pressure being at the same time made on the head, by the hands of an assistant. Should the pulse become quick, the pupils con- tract, and the face suddenly change its expression, the flow is stopped for a time. Faintness occurring, the child is laid horizontal, and a few drops of ammonia given in water. Sometimes blood comes through the canula, a sign that a vein has been punctured ;* sometimes the flow becomes obstructed by a portion of brain, and the canula requires to be cleared by a probe. After enough has been drained away, the wound is shut by means of collodion, and the whole head is carefully and uniformly supported by elastic strapping. Should slight cerebral excitement follow, it is well; for success is most probable in such cases ; a healthful action being in- duced by the excitement, as after injection of hydrocele (Principles, p. 193). But in general, mild doses of the hydrargyrum c. creta" are use- ful, as a check against over action. And when this does occur, our main reliance will be placed on mercurial influence, with topical depletion by leeches. In the most favorable cases, we can scarcely expect a successful issue but by repetition of the tapping ; and the amount of interval must be regulated by circumstances. In but one case have I ventured to operate. The first tapping proved highly satisfactory; the second terminated fatally by convulsions. In connection with this chapter, besides the foot-note references, see Dease on Wounds of the Head, Dub. 1760; Pott, on Injuries of the Head, Lond. 1760; Pott's Surgery, by Earle, Lond. 1790; Desault, Oeuvres Chirurgicales, Paris, 1812; Abernethy's Surgery, vol. ii. Lond. 1815 ; Brodie, on Injuries of the Brain, Med. Chir. Trans, vol. xiv. part ii. p. 325; Gama, Traite" des Plaies de Tete, Paris, 1835; A. Cooper, Lectures on Surgery, Lond. 1835 ; Sharp, on Injuries of the Head, 1841; Guthrie, on Injuries of the Head. Lond. 1842. 1 Watson's Lectures, Medical Gazette, March, 1841. CHAPTER IV. DISEASES OF THE SCALP AND CRANIUM. Erysipelas of the Scalp. This disease may be idiopathic, and then it is usually of a mild character, so far as intensity of the local action, and its effect on tex- ture, are concerned. It is very apt, however, to supervene on wounds; more especially if numerous dragging stitches have been unwisely used to effect approximation ; and still more especially, if these stitches have been allowed to work their own way out by inflammation and ulcera- tion. Such untoward accession to scalp wounds is also much favored by ungenial conditions of the atmosphere at certain seasons, as well as by previous derangement of the primge vise, or habits of intemperance on the part of the patient (Principles, 3d Am. Ed. p. 366). If the phlegmonous form occur, danger to texture is great, by diffuse infiltra- tion, both above and beneath the tendinous expansion of the occipito- frontalis, and the constitutional symptoms are proportionally urgent. The chief peculiarities of erysipelas of the scalp, in a practical point of view, may be considered to be: the unfavorable nature of the parts for suitable treatment of the milder examples, on account of the pre- sence of hair; the unfavorable nature of the parts on account of the presence of a large amount of tendinous expansion, for safe progress of the more grave forms of the disease, and the dangerous propinquity of the affected part to an organ of the greatest importance, which is ever liable to suffer, either by extension of the inflammatory action or by metastasis. Treatment.—When erysipelas threatens to seize upon the scalp, either directly or by extension from the face, it is our first duty to have clean abrasion of the hair effected, so that the necessary measures may be fully in our power when the accession does occur. In the case of extension from the face, the disease is usually of the simple charac- ter, and limited to the skin. And it is well to attempt to turn it from its upward course, by placing a guard by means of nitrate of silver (Principles, 3d Am. Ed. p. 178), while time and space still permit. For cure, hot fomentations, with or without punctures, usually suffice, in addition to the ordinary constitutional management. Cold, or other repellents, must never be employed ; they may be grateful to the sensa- tions of the patient at the time, but the risk by metastasis is overwhelming. Even the direct application of nitrate of silver to the erysipelatous part is not advisable, for a similar reason. Especial regard must be had to the TUMORS OF THE SCALP. 79 interior of the head, both during the progress of the disease, and for some days after its apparent decline. For, it has not unfrequently happened that convalescence has been suddenly and perhaps ruinously interrupted by inflammatory reaccession, not in the part originally affected, but in the membranes of the brain. Throughout the treat- ment, the head is kept high, the patient being almost in a sitting posture. If the phlegmonous form declare itself in the scalp, and dangerous infiltration have already begun, we cannot too soon make the requisite incisions (Principles, 3d Am. Ed. p. 372) in those parts which plainly demand them. At first, the knife need not pass beyond the subintegu- mental adipose tissue, for the action has as yet gone no deeper; but if, from neglect or otherwise, infiltration be already subtendinous, the knife must pierce tendon too, otherwise the invariably aggravating tension cannot be relieved, pain will increase greatly, and the inflammatory fever will rise higher, matter will burrow rapidly over the pericranium, and probably beneath it also, and the action will extend widely, per- haps involving the cranial contents, in at least a minor form. Timeous incision through the tendinous expansion is the only means whereby such extreme mischief may be mitigated; but it is surely better prac- tice, by an earlier and less extensive wound, to prevent all such casual- ties, effecting recedence of the action while it is yet limited to its ori- ginal site, the skin and subintegumental tissues. When burrowing of matter has taken place beneath the tendinous expansion, it is not necessary to lay the track open throughout the whole extent, but only, by the formation of a dependent opening, with a suitable counter-opening, if need be, to prevent purulent accumulation, and to afford the parts an opportunity of effecting reunion by granula- tion. To assist in this indication, uniform support by bandaging is very useful, after the acute stage has passed by (p. 28.) When the scalp has been undermined by pus, even extensively, it does not follow that it must necessarily slough in any part of the under- mined portion. Its vascular supply is not so dependent on the subjacent areolar tissue as is that of ordinary integument, the course of the rami- fications of the occipital and temporal arteries being rather cutaneous than subcutaneous, and the isolated skin, bearing its own vessels, con- sequently retaining its supply of blood but little impaired. Aware of the dangers of erysipelas of the scalp, it is plainly our duty in the management of all wounds of the head, however trivial they may at first seem to be, to avoid everything, in part or system, calculated to induce an undue amount and kind of inflammatory action, more espe- cially if by previous indisposition, or sinister atmospheric influence, the patient seem to be predisposed to erysipelatous accession. Tumors of the Scalp. Encysted tumors, commonly called Wens, are found more frequently on the scalp than in any other situation; and they are seldom single. In general, they are regarded mainly as deformities; but, when they inflame and open, they may become both troublesome and dangerous. 80 TUMORS OF THE SCALP. In some cases danger has arisen from the progress of mere growth; the calvarium having become absorbed, and consequently deficient, by the inward pressure of the tumor. The only advisable mode of treatment is removal by the knife. The main danger to be encountered is inflam- matory action, assuming the erysipelatous character; and this must accordingly be provided against by suitable constitutional treatment, as well before as after the operation, and by gentle and careful manage- ment of the wound. If the tumor be of large size, it is removed by regular dissection. By two elliptical incisions, of merely subcutaneous depth, the redundant integument is detached; and then the cyst, carefully preserved entire and tense, is leisurely dissected from its connections, and taken away along with the portion of sacrificed integument. The flaps of saved skin are then replaced ; and, on oozing of blood having ceased, they are brought into accurate contact, the wound being treated with the hope of adhesion. Approximation is effected by strips of isinglass plaster, or by collodion and lint; and, to facilitate the application of these retentive means, the surrounding scalp has been previously shaved. If oozing of blood have not wholly ceased, it is advisable to maintain ac- curate pressure on the whole wound for an hour or two, so as to prevent inward accumulation of coagulum, an event necessarily fatal to adhesion (Principles, 3d Am. Ed. p. 195). Stitches are neither necessary nor advisable. If the tumor be no larger than a nut or small egg, it is unnecessary to remove any integument, and regular dissection is therefore not re- quired. A more summary process suffices ; that by incision, extrusion of the contents, and evulsion of the cyst (Principles, 3d Am. Ed. p. 333). If an encysted tumor, in a patient advanced in years, have inflamed and suppurated, and be in process of intractable ulceration, it is well to destroy the part effectually, either by escharotics or by excision ; the latter method the preferable, for malignancy of action is otherwise apt to be assumed. Solid tumors, of various kinds, are occasionally found in this locality. Of these, the most common is the adipose, seldom of large size, and amenable to the ordinary treatment, excision. Of whatever nature the tumor be, its removal should be early, ere incorporation has taken place, either with the scalp above, or with the fibrous textures beneath (Prin- ciples, 3d Am. Ed. p. 300). Erectile tumors very frequently occur in the scalp. They are best treated by deligation, with or without previous reflection of the integu- ment, according as this happens to be involved or not in the morbid structure (Principles, 3d Am. Ed. p. 562). The very large tumors of this class, sometimes met with on the side of the head, need not be tied all at once, but may be dealt with in portions; different parts being strangulated at different periods. Experience has proved that, in such cases, attempted excision is fraught with the utmost danger to life, and that deligation of the main arterial trunk or trunks, is an insufficient remedial means; cases may occur, however, in which, as part of the cure, the principal arteries may be obliterated as they enter the tumor; PERICRANITIS. 81 the twisted suture being employed for this purpose, as in the case of veins1 (Principles, 3d Am. Ed. p. 575). Malignant tumors occasionally form in the scalp ; following the usual course, and amenable to the ordinary treatment. Benefit is to be expected only by free excision, and FiS- 10- that can be practised with expediency only at an early period. Medullary tumors may commence in the soft tissues, and involve the hard seconda- rily, fully as often they originate in the bone. Malignant ulcer of the scalp is not uncommon, beginning as a warty excrescence, or the result either of an originally simple sore, or of an open and degenerate encysted tumor. Early and free removal is had recourse to, if the lvmphatics as ,. . ■/ r Cancerous Ulcer from the yet present no contraindication. Scalp. Pericranitis. The pericranium becomes the seat of an inflammatory process, with or without external injury having been applied. Acute action may be the result of wound or bruise, following the ordinary course of such action in fibrous tissues; or acute and suppurative action may extend from the surface, as in erysipelas of the phlegmonous form. The usual antiphlogistic indications require to be fulfilled. Idiopathic pericranitis is more frequently chronic than acute, and seldom occurs but in the adult, who is saturated with the rheumatic diathesis, or who has sustained injury of the system by mercury and syphilis; one or other, or both. The ordinary symptoms are present; pain, swelling, heat, tightness; and the nocturnal exacerbations are peculiarly marked (Principles, 3d Am. Ed. p. 394). The affection may resolve, leaving little or no structural change; or the resolution is incomplete, an enlargement of bone remaining, resembling a diffused node; or true inflammation is established, and the bone suffers, to a greater or less extent, by ulceration, caries, or necrosis. Usually, the periosteum of other parts of the skeleton is at the same time and simi- larly affected; and the bones most likely to suffer along with the cranium, are the clavicles, sternum, tibiae, and ulnse. Treatment is mainly constitutional. The primae vise having been brought into a tolerably satisfactory condition, a sustained exhibition of the alteratives well known to be suitable to such cases is proceeded with; sarsaparilla and iodide of potassium, either together or alter- nately. The latter, especially, is found most beneficial. Locally, leeches and fomentations are applied at first, then counter-irritation. The inflammatory process having been removed, and its results only remaining, nothing is more effectual than the endermic use of a strong solution of iodine. Throughout the whole period of cure, the hair is kept either shaved or short. Atmospheric exposure is carefully avoided, and regimen is rigidly non-stimulant. If matter form acutely, it must 1 Dr. Warren, American Journal of Medical Science, April, 1846.- 6 82 AFFECTIONS OF THE CRANIUM, be evacuated, freely and early. If the abscess be chronic, opening is delayed, and discussion by iodine attempted. Even when rough and spongy bone can be plainly felt through the chronic collection of pus, iodine should still be persevered with, along with the internal use of iodide of potassium, when the affection is dependent on a constitutional cause; for, in such cases, discussion is not unlikely to follow patient perseverance, even under circumstances by no means promising. Should acute or subacute accession supervene, however, the abscess becoming tense and crescent, let incision be no longer delayed. In obstinate examples of pericranitis, causing mere change of struc- ture, with slight swelling, but great pain, the general health is apt to give way greatly from want of sleep, and consequent exhaustion. In such cases it is essential to give opiates ; and, if the more proper altera- tives have proved ineffectual, mercury may be given in guarded doses (Principles, 3d Am. Ed. p. 398). Affections of the Cranium. Abscess and ulcer of the cranium occur from ordinary causes, and are amenable to ordinary treatment (Principles, 3d Am. Ed. p. 411). Caries of the skull is preceded and accompanied by interstitial absorp- tion (Principles, 3d Am. Ed. p. 281), and seldom occurs but with a vice Fig. 11. Fig. 12. •..;• ■■•Jz&'&'Jvr •''•'■' :';; •' ' ■ .-"•" <;->^ SJf '■, f Fig. 11. Interstitial Absorption in progress, in the Fig. 12. Different portions of the same Skull as cranium; at a, just begun; at 6, more advanced. It Tig. 11; at c, ulceration established, surrounded by may stop here, producing a merely cancellous state insterstitial absorption; at d, caries, with necrosis of the tissue; or it may advance, becoming merged in the centre; interstitial absorption still accoin- in ulceration, and producing caries, as in Fig. 12. panying. AFFECTIONS OF THE CRANIUM. 83 of system; seeming to be rather a symptom and sign of this than to constitute a disease in itself. And the predisposing vices of system are scrofula in the young, syphilis, mercurio-syphilis, or the ill effects of mercury alone in the adult. Treatment, accordingly, is chiefly con- stitutional. Locally, the diseased structure is exposed, and removal of the carious surface is effected by the gouge, or by escharotics, chloride of zinc, or red oxide of mercury (Principles, 3d Am. Ed. p. 416). Sometimes nature is provident in this matter, and herself effects the necessary clearance; the useless parts coming away spontaneously, as small sequestra. If the whole thickness of the cranium be involved, there is of course additional danger by dura-matral involvement; and precaution requires to be exercised accordingly. Sometimes, unfortu- nately, a triumvirate of scrofula, syphilis, and mercurialism reigns in the system of the miserable patient; and then, as can readily be under- stood, the local affection proves particularly intractable. Necrosis may involve the whole* thickness of the skull, the result of wound or not—usually the former. Then, as already stated, there is Fig. 13. Mercuric-Syphilitic Caries of the Skull, a. A portion detached, in the form of sequestrum. risk to life by purulent accumulation between the bone and dura mater; and, if no external aperture already exists, as by fracture, the use of the trephine is demanded (p. 54). Exfoliation, or death of the external portion, is more frequent than complete necrosis ; the result either of external injury, or of chronic idiopathic pericranitis. The usual course of superficial necrosis is fol- lowed here as elsewhere. Ordinarily, we await patiently spontaneous separation, and then remove the sequestrum. Sometimes, when detach- ment is tedious, acceleration may be effected by the application of es- charotics (Principles, 3d Am. Ed. p. 436). And sometimes it is ne- cessary to interfere and forcibly elevate the dead portion, which, though 84 AFFECTIONS OF THE CRANIUM. Ulcer of Cranium, healed. The margins bevelled off, and sloping down. The surface studded with imperfect granulation. From the same cranium as Figs. 11, 12. separated from the hard textures, is yet confined by soft granulating structures around (Principles, 3d Am. Ed. p. 436). In no form of necrosis of the cranium does the ordinary formation of cortical and substitute bone occur. And how fortunate such an ar- rangement is at once becomes apparent, when we consider what would be the inevitable con- sequence of new bone bulging inwards on the dura mater. If the sequestrum have been superficial, healing is effected by a depressed cicatrix, as after simple ulcer of bone (Prin- ciples, 3d Am. Ed. p. 411). When the whole thickness has perished, atonement is made for the deficiency, as after the operation of tre- phining (p. 68). As in the case of caries, many examples of exfoliation «of the cranium are dependent on the mercurio-syphilitic vice of system ; and require constitutional treatment accordingly. In connection with the traumatic form, it is well to remember that detachment of the periosteum—even rudely, and with some bruis- ing of the bone itself—does not render the occurrence of exfoliation inevitable (Principles, 3d Am. Ed. p. 421). The part may, and frequently does, recover. And the treatment, in the first instance, is to be conducted with a view to such a result; the flap of integument being carefully replaced, the wound approximated, and speedy healing sought for. Exostosis of the cranium is not uncommon, of a dense, ivory cha- racter, and usually of small FiS-15- size. Fortunately, the site of growth is on the external as- pect of the bone. Xo treat- ment is required. The affec- tion is a mere deformity; and not even that, unless apparent from want of covering by hair. Spiculated exostosis some- times grows from the interior of the calvarium, inducing in- tense neuralgia, or epilepsy. As already stated, there are some few cases so plainly marked, as to admit of the offending body being removed by the tre- phine (pp. 68, 69). [Large exostoses, as well as the spiculated form, do sometimes grow from the inner face of the cranium, and produce compression of the brain and qther alterations of its functions, in proportion to their size, rapidity of growth, &c. The accompanying illustrations, taken from the work of M. Vidal de Cassis (vol. iii. pp. 115-116), afford very good examples of the kind ; in one, the growth is both external and internal; in the other, it is exclusively internal. These developments are usually Several Ivory Exostoses clustered on the Os frontis. AFFECTIONS OF THE CRANIUM. 85 the offspring of syphilis; they are generally accompanied by fixed pain in the affected part, and gradually occasion more or less disturbance in Fig. 16. Large Exostoses of the Cranium projecting both internally and externally at a and 6. the functions of the brain. The diagnosis of the affection must be somewhat doubtful. Constitutional treatment, such as is applicable to tertiary syphilis generally, should be resorted to ; uncertainty as to Fig. 17. the precise seat, and especially the dimensions of the tumor, even if its existence could be substantiated, must be regarded as opposing seri- ous objections to the employment of the trephine.—Ed.] Tumors of the calvarium—osteo- sarcoma and OSteOCephaloma--are Large Internal Exostoses. rare; more especially the true os- teosarcoma. When they do form, no treatment save mere palliation is advisable. The site and connections of the affected part forbid opera- tive interference. Polypus of the frontal sinus is a rare affection; and, in its first stages, of difficult diagnosis. When detected, cure may be obtained by removing the bone to such an extent as will permit, evulsion of the growth, with subsequent cauterization of its site.1 [Fungous tumors of the dura mater deserve mention in this connec- tion. Attention was first particularly called to them, in 1774, by Louis, then Secretary of the Royal Academy of Surgery of France.2 Since then this subject has been investigated by Sandifort, Siebold, Lassus, the Wenzels, Chelius, Velpeau, Lebert, and some others. Fungous tumors of the dura mater are usually regarded as of cancerous nature, more frequently of the encephaloid than of the scirrhous variety ; but M. Lebert found, in several cases which he examined, that the microscopic elements of the tumors belonged rather to the fibro-plastic than to the cancerous class (Physiol. Patholog. t. ii.). They grow ordinarily from the dura mater, most commonly from its external sur- ' Brit, and For. Med. Rev. Jan. 1846, p. 186. 2 Memoirs of the Academy of Surgery, Sydenham Soc. Trans. 86 AFFECTIONS OF THE CRANIUM. face; occasionally, similar tumors appear to proceed from the pia mater; they more frequently correspond with the vault of the cranium than with any other portion. They are usually single ; though, as in several of the cases cited by Louis, more than one may exist in the same sub- ject. The base of the tumor is in most instances larger than the free portion ; sometimes, however, the growth is more or less pediculated, the external portion being larger than the aperture in the bone, through which it escaped from the cranial cavity. After a time, the excrescence, by constant pressure upon the inner surface of the cranium at some point, produces absorption of the bone, and shows itself externally—the margin of the bony orifice being usually rough and irregular, but thin. Before complete perforation of the bone has taken place, the patient generally complains of a fixed pain, more or less severe, together with functional disturbance of the brain, or of some nerve, if any be implicated by the tumor, as occasionally has happened with the nerves of the special senses. After the bone over the tumor has become much thinned, it yields to the pressure of the latter, and allows the swelling to be detected by manipulation; and if now the prominence be pressed upon, a crackling may perhaps be elicited, as if from a piece of parchment, from the yielding of the delicate osse- ous covering; such was the case in the celebrated instance of Le Gallois, quoted by Louis (op. cit. p. 85), in which the tumor was first detected by a barber who was shaving the patient's head. When protrusion has actually taken place, the outgrowth is rounded, elastic, firm at first, but usually becoming somewhat softer; it pulsates synchronously with the heart and brain, unless it be constricted by the bony aperture through which it has escaped ; but the pulsation is different from the special and universal expansion of an aneurismal tumor ; the mass is usually susceptible of being returned into the interior of the cranium, and when this is done, symptoms of compression of the brain, or para- lysis, or other disturbance of function of some nerve are induced, out a less amount of pressure than is requisite to accomplish this, has been found to relieve the pain of which the tumor is the seat, sometimes to a very great degree; if, as is sometimes the case, the free portion of the tumor be larger in circumference than the aperture in the bone, of course reduction cannot be accomplished. The progress, rapidity of growth, duration, and size of these tumors are subject to no uniform or definite rules. The duration varies from several months to forty years (Desnon- villiers, Compendium). The positive diagnosis of this affection, before protrusion has taken place, is impossible; afterwards, it may generally be recognized, great care being employed to distinguish it from ordinary solid tumors and abscesses of the scalp, also from cephalhsematoma, hernia cerebri, erectile tumor, aneurism, &c. The result of this disease, if left to itself, is pretty certainly fatal, nor is the prognosis much more favorable when surgical aid has been resorted to. Previous to the external appearance of the tumor, the internal administration of narcotics is ordinarily all that can be done • occa- sionally, the application of a trephine directly over the seat of the pain may be justifiable, and has afforded temporary relief. After the growth AFFECTIONS OF THE CRANIUM. 87 has appeared externally, the application of caustic, or of the ligature, to the presenting portion, or the removal of this by the knife, has fre- quently been tried, and has undoubtedly, in most cases, produced a speedier death than if the mass had been left to itself. M. Boyer pro- posed that the trephine should be applied sufficiently often to the bone, to expose freely the whole base of the tumor, and that the latter, to- gether with the contiguous dura mater, should be removed. But this formidable operation, though performed by him and by others since, has been successful in so few instances, that its repetition seems hardly warrantable, especially if, as may be pretty certainly determined, the turner be cancerous. In the 3d vol. of the Transactions of the American Medical Associ- ation, p. 403, Dr. J. C. Warren, of Boston, describes an operation which he performed upon a tumor of this kind. He made four flaps of the ulcerated skin covering the tumor, which was situated on the right side of the forehead and right temple, and dissected them as accurately as possible from the soft cerebriform fungous mass; he then removed the latter piece-meal, traced it to its origin in the dura mater, upon the sur- face of which he freely applied the actual cautery. The hemorrhage was great, but was suppressed by two or three ligatures and the actual cautery. The subsequent symptoms were favorable. The wound healed very slowly, but was entirely closed at the end of some months, and has remained so up to the present time (three years after the operation). " She has now no unpleasant feelings in her head, nor any other symp- toms of disease." Dr. Warren had on a previous occasion operated upon a similar tumor, in a more advanced stage of the disease, but it returned and the patient died.—Ed.] [For information on the subject of Fungous Tumors of the dura mater, See Louis, Me- moirs of the French Academy of Surgery; Lebert, Physiol. Pathol. ; Boyer, (Euvres Chirurg. t. iv. ; Nelaton, Patholog. CLirurg.; Desnonvilliers, Compendium, t. ii.; Vel- peau, Diet, de Medecine, t. x.—Ed.] CHAPTER V. AFFECTIONS OF THE ORBIT, AND ITS CONTENTS. I. Affections of the Orbit. Orbital Inflammation Is usually the result of injury, when primary. Sometimes it is of a secondary character, and unconnected with violence done to the part, an extension of inflammatory action from a neighboring part, from the eyeball, or from the scalp. Most frequently it follows injury, and the action is usually intense, suppuration being certainly and soon attained. Pain is great and increasing, tension is great, for swelling is hindered by the unyielding process of the periosteal lining of the orbit, termed orbital ligament, which confines the orbital contents in front; vision is more or less impaired by compression of the eyeball, and this organ, according to the amount of deep swelling, is more or less protruded; the eyelids are red and oedematous, inflammatory fever is intense, and the cerebral functions are often prominently disordered. Treatment comprises the ordinary antiphlogistic indications. When a wound exists, careful examination is expedient to ascertain whether or not any foreign substance, as straw, wood, iron, has penetrated and lodged, and if such an obvious exciting cause of inflammation be de- tected it is forthwith removed. Leeches are applied in numbers; in some cases, general bloodletting may also be found advisable, and the antiphlogistic accessaries to bloodletting, aconite or antimony, purga- tives, quietude, &c, will not be neglected, vomiting being avoided, for obvious reasons. The part is diligently fomented, and as soon as indi- cations exist, however faint, of matter having formed, an evacuating incision is practised, it being obviously of the greatest importance to penetrate the orbital ligament at an early period of the suppuration. On evacuation of matter, the symptoms are speedily mitigated, the tension, throbbing, and intense pain almost immediately. If incision be delayed, spontaneous evacuation takes place, but not till after much suffering, considerable destruction of texture, and dangerous impair- ment of function in the eyeball. Wounds of the Orbit. These are usually of the punctured kind. As just stated, they are liable to prove the exciting cause of intense inflammation, more especially when there is lodgement of foreign matter. And the probability of the TUMORS OF THE ORBIT. 89 latter circumstance must always be regarded in practice. The wound having been ascertained to be clean and free, is carefully approximated, and cold is continuously applied, with much care, in order to avert in- flammation, if possible, and secure union by adhesion (Principles, 3d Am. Ed. p. 593). If inflammation supervene, antiphlogistic treatment must be early and active; a suppurating wound is then inevitable, but we hope to avert deep and confined abscess, which is prone to form by extension of the inflammatory action beyond the wound's track. But such injuries acquire a still higher importance in reference to the parietes of the orbit. A penetrating wound of the orbit, as by a bayo- net, pike, or pitchfork, is not unlikely to produce fracture of, the orbi- tal plate, and the fragments of the broken bone, driven inwards, are certain to penetrate or otherwise injure the brain or its membranes, en- dangering life, perhaps immediately, by extravasation of blood—more probably by the results of inflammation at a more remote period. Such wounds, therefore, require to be treated with the greatest caution. The extent of injury done to the bone is ascertained as soon, as accurately, and yet as gently as possible. If loose fragments are found to exist, these it is well to remove, the external wound being dilated, if need be, for this purpose. And when the spicula are certainly displaced inwards, in- juring the important parts in that direction, an attempt should be made to take them away, whether they seem detached or firm. The indication is as paramount as in punctured fracture of any other part of the cranium (p. 63). This important part of the treatment having been satisfactorily ac- complished, by dilatation of the external wound, and the suitable use of fingers, forceps, and probe, the patient is placed on his face, with the wound unapproximated, until bleeding cease, internal extravasation being thus rendered less likely to occur. Then the parts are brought together, and antiphlogistics are diligently employed, both locally and generally, in order to avert, if possible, an untoward amount and extent of the inflam- matory process. Tumors of the Orbit. Hard tumors of the orbital parietes are uncommon. The dense ivory exostosis produces little inconvenience, is usually of inconsider- able size, and requires no treatment. The cancellated exostosis, of a pedunculated character and larger dimensions, may incommode the eye- ball. If so, the nature of the case being plain, an incision may be made on the origin of the growth, its neck may be cut by the bone- pliers, and, by careful dissection, the offending substance may then be removed (Principles, 3d Am. Ed. p. 450). Soft tumors are of more frequent occurrence. And they may be practically divided into three classes. 1. The simple and sarcomatous; amenable to excision. 2. The erectile; capable of cure, but not by direct operation. 3. The malignant; usually forbidding operation, and admitting only of palliation. 1. The simple tumors—simply sarcomatous, fibrous, fatty, cystic— may form in the orbital areolar tissue, unconnected with either the bone or its periosteum; and the growth may be either of idiopathic origin, or a remote consequence of slight injury. Enlargement is slow, gradual, 90 TUMORS OF THE ORBIT. comparatively painless, and unattended with inflammatory signs; not likely therefore to be mistaken for orbital abscess. As in the latter affection, however, outward growth is prevented by the orbital ligament; compression of the eyeball follows; and this organ may be more or less protruded from its socket. At first, sight is not lost, and scarcely even impaired; for stretching of the optic nerve is gradual, and nervous as well as cerebral tissue has a very considerable power of accommodating itself to displacing agencies gradually applied. Ultimately, however, the stretching and displacement are attended with more or less impair- ment of vision. By careful inquiry into the history of the case, we satisfy ourselves that the tumor is of the simple kind. Of what exact species it may be, it is not easy to determine ; for the tense orbital ligament stretched over the swelling obscures tactile examination. Generally, however, we are able to satisfy ourselves on another point; whether or not the tumor is movable—connected or not with the bone and periosteum—consequently removable or not, entire, by operation. When convinced that the tumor is simple and movable, we do not hesitate to attempt its extirpation. A wound is made of sufficient extent, in a line parallel to the fibres of the orbicularis muscle. By cautious dissection, the tumor is reached and exposed. It is then laid hold of by a volsella, or hooked forceps; and evulsion outwards being steadily yet gently maintained, extirpation is rendered both easy and safe. The point of the knife is moved very warily, when near or in contact with the orbital parietes ; for these, by the pressure of the tumor, may have been much attenuated; and a care- less movement of the instrument might cause penetration. The eyeball and optic nerve are also carefully avoided. After removal of the tumor, the former is carefully readjusted in its proper place; and restoration of its functions usually ensues. The wound is brought together, and treated for adhesion. Partial removal even of the simplest tumor, in this situation, is obvi- ously inexpedient. For, reproduction will almost certainly occur from the portion which remains; and such second formations are very apt to prove of an unfavorable kind. 2. The erectile tumor is occasionally found occupying the orbit. It is seldom congenital, but occurs suddenly, in after life; and its origin is usually attended with a considerable amount of pain. At first an obscure deep swelling is found, causing more or less inconvenience; but as it en- larges and approaches the surface, the ordinary characteristics of erec- tile tissue become sufficiently apparent. Often the cheek is covered with large veins—recipients of the blood from the more active vessels within. This tumor cannot be treated directly; neither knife nor ligature are advisable. Yet, if no remedial means be adopted, the probable issue will be unfortunate; by enlargement, ulceration, hemorrhage; by in- volvement of the orbital parietes, and subsequent pressure on the brain; or by mere constitutional irritation. Experience has shown that deliga- tion of the corresponding carotid, is capable of effecting a cure, not by obtaining consolidation and obliteration of the dilated vessels, but, probably, by diminishing their supply of blood, removing the impulse of the heart's action, and so favoring resumption of the normal caliber. INJURIES OF THE EYELIDS. 91 And free bloodletting, after the operation, would seem to contribute materially towards this result (Principles, 3d Am. Ed. p. 563). 3. Tumors of a malignant kind—medullary—are no unfrequent oc- cupants of the orbital cavity. Generally, they originate in the eyeball; but occasionally this is involved only secondarily—the origin being in the orbital areolar tissue, in the periosteum, or in the bone. The sole hope of cure is by extirpation of the whole orbital contents. And this is expedient only when the disease is recent, apparently limited to the soft parts, and capable of entire removal. II. Affections of the Eyelids. Injuries. Ecchymosis is of frequent occurrence in the eyelids ; the areolar tissue being lax and delicate. Ordinarily, it is the result of a bruise or blow; but it may follow a wound, more especially if oblique or subintegu- mental; the application of leeches is almost certain to produce it, to a greater or less extent. It is important as a deformity. A patient hav- ing received an injury likely to be followed by ecchymosis, is anxious that this should be prevented ; and the escape of blood having occurred, he is equally anxious that the discoloration should be removed. Many remedies are popularly in vogue for both of these ends. For the former, the continuous application of cold by wetted lint, with quietude and abstraction of all stimuli, is both suitable and easily obtained ; if begun immediately on receipt of the injury, and properly maintained, the natural hemostatics will be much favored, and very probably little or no blood will escape from the torn vessels. Ecchymosis having occurred, the nature of the application must vary according to the presence or not of inflammatory action in the part; in the one case, fomentation is em- ployed, subjugation of the morbid vascular action being the paramount indication; in the other, a solution of the muriate of ammonia, or other sorbefacient, is applied, in order to hasten removal of the extravasated blood by absorption. Wounds of the eyelids, if contused, are treated by the water-dressing. If incised, approximation is effected by fine sutures ; other retentive means being plainly inapplicable to this locality. Great care should be taken to restore the normal relative position with accuracy, lest deformity ensue. In the case of burns, much precaution is required during the process of healing, lest by contraction ectropion supervene; and the careful dressing and bandaging necessary for this purpose is continued even for some time after the parts have healed. Foreign Bodies. Foreign bodies of small size, as particles of sand, dust, glass, coal, very frequently lodge in the eyelids, on their conjunctival lining. The patient, suffering much pain and irritation, with the eye already red, intolerant of light, and profusely lachrymating, applies for our aid on account of " something in his eye." Gently opening the eyelids, before a steady light, we scrutinize the eyeball in the first place; directing the 92 FOREIGN BODIES IN THE EYELIDS. patient to roll the organ in various directions, in order to facilitate such examination. If particles are found adherent, they are, in general, easily removed, by a curette, or flat end of a probe ; by a hair-pencil, or by a fold of a soft handkerchief. If fine dust only have lodged, fomentation and ablution will ordinarily suffice, assisting the lachryma- tion in its spontaneous cleansing effort. Sometimes it may be necessary to inject a gentle stream of tepid water, by means of a small syringe. In other cases, it is enough to shut the eye, or keep it shut, for a few minutes, occasionally blowing the nose; thus favoring the natural washing away of the foreign particles, by increased lachrymal and con- junctival secretion. The eyeball having been duly scanned, the lower eyelid is next examined; its conjunctival lining being readily exposed to a sufficient extent, by simple depression of the part. But the upper eyelid is the site most frequently occupied by the foreign substance, and it cannot be sufficiently exposed without eversion. This is effected by placing a probe horizontally across the lid, above its cartilage; taking hold of the eyelashes with the finger and thumb, and bending the eyelid backwards over the probe. If the foreign matter be loose, it is removed by any of the means already mentioned. If it be firmly lodged, the point of a toothpick, or of a couching-needle, will most conveniently effect its dislodgement. In certain occupations, particles of steel or iron are apt to get between the eyelids, and often become impacted in the cornea. When loose, they may sometimes be brought to the surface and removed by means of a magnet of strong power, but, generally, the point of a couching- needle is required to effect their detachment. When no assistance is at hand, the patient may, himself, in many cases, get rid of the irritating matter, by elevating the upper eyelid with the fingers of one hand, and pulling it downwards, while he at the same time closes the lower, and pushes it upwards. Having pressed gently over the globe, the finger is then withdrawn, and the lids allowed to separate. The eyelashes of the lower lid are thus made to sweep the conjunctival lining of the upper; and, it is in the latter situation, as already stated, that foreign bodies of small size usually lodge. The foreign body having been removed, the eye is closed; light is excluded; and antiphlogistics are employed according to circumstances. It is plain that if the foreign substance be not removed, inflammatory action will certainly be established, and probably prove untoward and intractable. Cases are not wanting in which complete destruction of vision has been the ultimate result of but a small particle of foreign matter lodging in the conjunctival lining of an eyelid; perhaps with much injury done to the system by severe and sustained treatment directed against the inflammatory action and its results.1 Blepharitis. The inflammatory process, attacking the eyelids, is so named. It may follow injury; assuming the ordinary character and course, and amenable to the ordinary treatment. 1 Lancet, No. 1061, p. 435. One among many. SWELLINGS OF THE EYELIDS. 93 In ^ erysipelas of the face, affection of the eyelids is usually a most prominent symptom ; the laxity of their areolar tissue admitting of much and unseemly swelling. Punctures are usually necessary, not so much to abstract blood as to evacuate serous effusion. After recession of the primary symptoms, this part must be closely watched ; for, during con- valescence, reaccession of inflammatory action is very apt to occur, advancing rapidly to suppuration (Principles, 3d Am. Ed. p. 210); and, unless an early incision be made here, the abscess will be large, and the integument will probably slough. Ophthalmia Tarsi. By this is meant a congestion, or chronic inflammatory process, affecting the eyelids, more especially at their margins. The Meibomian follicles are prominently affected, and a viscous, disordered secretion adheres to the parts, tending to cause cohesion of the ciliary margins. More or less lachrymation, in general, exists. The eyelashes are stunted, or deficient. Itching, heat, and intolerance of light are usually present, and the general expression is bleared and unpleasant. The disease will usually be found coexistent with some vitiated con- dition of the general system, and to that the treatment must be mainly directed. Not unfrequently, the constitutional vice will be found of the scrofulous character. If pain, heat, redness, and other ordinary cha- racteristics of the inflammatory process exist at all prominently, blood is to be taken sparingly from the part, by scarification of the conjunctiva or by leeches at the inner canthus. For a few days afterwards, foment- ations, medicated or not, are to be applied. Then stimulants are used, such as solutions of zinc, or nitrate of silver, or the ung. nitratis hydrar- gyri diluted. In obstinate cases, counter-irritation is sometimes useful, and this is best effected by the application of blisters behind the ears. In children, the state of the gums and teeth must be looked to. An advanced form of this chronic affection of the eyelids is some- times termed Lippitudo. The ciliary margins are red, thickened, everted, and denuded of hair, and the eye seems to be surrounded by an angry red circle. The general expression is consequently very un- pleasing, and the patient's discomfort is also great. Local and general alteratives are pre-eminently required, but they often fail to prove quite satisfactory. Stimulants applied to the parts are useful, such as pen- cilling the lids with a solution of nitrate of silver, and the like. Not unfrequently, ophthalmia tarsi is but a part of a more general affection of the eye, of a strumous character. Hordeolum, and other Swellings. By Hordeolum, or Stye, is meant a circumscribed inflammatory swell- ing, which may either remain of an indolent and indurated character or advance to suppuration. In the latter case, discharge of matter takes place, and discussion slowly follows. Very frequently the affection originates in a Meibomian follicle, and resembles an ordinary pimple. The follicle is obstructed, and its contents accumulate; an inflamma- tory process is then kindled in the perverted part, suppuration takes 94 ENCYSTED TUMORS OF THE EYELIDS. place, and the enlarged follicle becomes the seat of a small acute abscess. Here, too, the general health will be found amiss, and purgatives, alteratives, with regulation of diet will probably be required. While the swelling is nascent, fomentation and light poultices, or water-dress- ing are suitable. When matter has formed, a puncture should be made at the apex of the swelling for efficient discharge, and then water-dress- ing is again applied. If a chronic hardness should threaten to remain, discussion of this will be promoted by pencilling the part lightly over with a solution of iodine or nitrate of silver. An inflammatory swelling, similar to the true hordeolum, may form in the ordinary areolar tissue of the eyelid, resembling a small furuncu- lus. It is amenable to ordinary treatment. Small, hard swellings, of a whitish color, very superficial, painless, and almost stationary, occasionally form beneath the integument of the eyelid. According to their size, they are termed either Grando or Milium, according as they most resemble a piece of hail or a millet- seed. Causing deformity, they require removal. A scratch is made through the thin skin stretched over them, and the white pearly-looking substance is squeezed out. No escharotic is necessary. The wound scarcely bleeds, and heals simply. Warts sometimes form on the eyelids. They may be taken away by scissors, ligature, or caustic. Encysted Tumors of the Eyelids. Encysted tumors are of frequent occurrence in this situation, more especially in the upper lid. They are usually of small size, the con- tents are white and glairy, the cyst is extremely delicate. Their site may be either subcutaneous or submucous, on the conjunctival or on the external aspect of the tarsal cartilage. The majority of the pa- tients are of the female sex. Removal by regular dissection need not be attempted, the cyst is too delicate. And for the same reason, incision, with evulsion of the cyst, is inapplicable. It is sufficient, in many cases, to incise the part, to squeeze out the contents, and with the point of a probe to dis- Encysted Tumor of the Lower turD an(l break up the tender cyst. But, in Eyelid. The lid inverted. some cases, it is well to apply an escharotic, so as to insure the cyst's destruction, and conse- quent non-reproduction of the tumor. The nitrate of silver is very suitable, escharotic enough to annihilate the cyst, and not likely to cause such loss of substance as would delay the cure, extend the cica- trix unnecessarily, or risk the occurrence of either inversion or eversion of the lid by contraction of the cicatrix. Incision is facilitated by effect- ing previous tension of the part. This is done by simply stretching the skin over the swelling, and cutting through the attenuated integument, taking care to make the incision in a direction parallel to the fibres of the orbicularis muscle, or by everting the lid (p. 92), and then cutting CANCER OF THE EYELIDS. 95 through the stretched and prominent mucous membrane. Either form of procedure is the preferable, according as the site of the tumor hap- pens to be subcutaneous or subconjunctival. Hypertrophy of the Upper Eyelid. The upper eyelid is occasionally affected by hypertrophy of both its integument and mucous membrane. The swelling is considerable, and causes deformity ; it also obstructs vision, and there is an unpleasant puriform discharge. By two elliptical incisions, a sufficiency of the diseased integumental texture is removed, and the wound is approximated by suture. The conjunctival change is subsequently remedied by scarification, followed by the use of sorbefacients. Or, should the conjunctiva resist this gentler means, partial ablation of it may be practised, as in the case of the integument.1 Cancer of the Eyelids. Malignant ulceration is usually preceded in the eyelids, by warty formation. The only cure is by excision, early and free. If the disease be limited, sufficient removal may be effected, yet without de- formity or exposure of the eyeball, the wound being so shaped as to come well together by suture. But when the disease is extensive, and an operation warrantable, the prevention of deformity need not enter into our thoughts. One paramount indication is present, removal of all the diseased part. That must be effected, at whatever sacrifice of tex- ture. When it is found necessary to remove the whole or greater part of the eyelids, more especially the upper, on account of malignant ulcer, it comes to be a question whether or not it be politic to spare the eye- ball, supposing it to be apparently sound. Some writers recommend its removal at once, considering that the organ, being deprived of its natural protection, will be destroyed by inflammation. This, however, is not always the case. It is better to wait till this event has actually taken place, and then to induce collapse of the globe, by puncturing the cornea, and allowing the humors to escape ; this is more safe and simple than immediate extirpation, and equally efficient. Intractable ulcers of the eyelids, not malignant, are best treated by regard to the state of the system, more especially of the digestive organs, and by occasionally touching the parts with the fluid nitrate of mercury or nitric acid. Sometimes they are of a syphilitic character, obviously dependent mainly for cure on constitutional treatment. Closure of the Eyelids. By the term Ankyloblepharon, is understood union of the eyelids at their tarsal margins, congenital, or accidental, the result of cicatrization after burn or scald. When congenital, the cohesion is seldom to a great extent, occupying only the angles. No interference may be deemed 1 Liston, Lancet, No. 1089, p. 489. 96 LAGOPHTHALMOS. necessary. When more extensive, causing not only an unseemly de- formity, but likewise interfering with vision, separation of the preter- naturally united parts may be readily effected by incision. Afterwards, all necessary means should be taken to prevent reunion, each lip of the wound being made to cicatrize separately by granulation. When the closure is complete, a circumstance of rare occurrence, a fold of the parts should be first raised from the ball, and cut through in a horizon- tal direction; through this aperture a director is carefully introduced, and on it the subsequent division of the angles is safely effected. The accidental form is amenable to similar treatment. But greater care is necessary, in the after management, to avoid reunion. This is pre- vented by the interposition of dressing, frequent movement of the parts, and if necessary by forcible separation of the lids by plaster, and the application of some gently astringent lotion. By Symblepharon, is meant adhesion of the eyelids to the eyeball, seldom congenital, usually the result of cicatrization after injury. In some cases, the cicatrix is dense and contracted, admitting of no attempt at cure. In others, the adhesions are comparatively slight, and there is sufficient laxity of texture. In these latter, the lids are to be libe- rated by careful dissection, their separate cicatrization being afterwards carefully attended to. Reunion is much more liable to take place in symblepharon than in anchyloblepharon, and is best prevented by fre- quent motion of the eye, by proper dressing, and by the occasional introduction of a probe to separate the new adhesions. The temporary insertion of an artificial eye has been suggested, but even the most per- severing exertions have often proved unsuccessful. [Probably the most successful plan of operating will be found to be that of Von Ammon. He surrounds the base of the connecting band, at the point of its attachment to the lid, by an elliptical incision which penetrates through the lid; the sides of the incision converge towards the skin, so that the band is thereby cut loose from the lid, and rests be- tween the latter and the globe of the eye. The edges of the wound are now approximated by means of fine sutures; and after union of the gap has taken place, the band is severed by scissors from its attachment to the conjunctiva of the eyeball. Mr. Walton, in his recent publication on Operative Ophthalmic Surgery, reports two successful cases treated by incisions upon the lid and the conjunctiva of the globe, made in the same way, and treated subsequently, as in Von Ammon's operation just described.—Ed.] Lagophthalmos. Lagophthalmos, or Hare-eye, means an inability to close the eye- lids ; and the eye, being deprived of its natural protection, is exposed to the action of the air and other external irritants, which may cause inflammation of the conjunctiva, eventually terminating in opacity of the cornea. The disease often results from paralysis of the orbicularis muscle; more frequently it is caused by retraction or shortening of the lid, arising from contraction following abscess, or burns and other inju- ries. Sometimes it proceeds from cold or other causes acting upon the facial nerve in its transit or distribution. TRICHIASIS, AND DISTICHIASIS. 97 The treatment varies according to the cause. When the affection arises from paralysis, blisters, friction, electricity and strychnia are appropriate; when from retraction of the lid, division of the cicatrix may be of use; and when from affection of the facial nerve, leeches, blisters, and stimulants in the course of the nerve are to be employed. When it is caused by cerebral congestion, antiphlogistic remedies are to be had recourse to. Ptosis. Ptosis is a falling downwards of the upper eyelid, producing no in- considerable deformity, and seriously interfering with vision. It may constitute a disease of itself; or it may be but a symptom of serious affection of the brain. When original, it may depend on debility of the elevating muscle, or on superfluity or thickening of the integument; or it may be connected with both of these circumstances. Redundancy of integument is easily got rid of by removing a sufficient portion, either by knife or by scissors. Atony of the muscle may be overcome by stimulant frictions, the passing of electricity or the ender- mic use of strychnia. Ordinary means having failed, an operation may be had recourse to. A large portion of integument is removed from the eyelid, and also from a corresponding portion of the eyebrow; the two raw surfaces are then brought into apposition by suture, and when union has taken place the lid will be elevated by the action of the occipito-frontalis muscle, to such an extent as to admit of useful vision. In the secondary form, dependent on affection of the brain, treatment must of course be directed to the cerebral disease. Trichiasis, and Distichiasis. Trichiasis denotes inversion of the eyelashes, whereby much irritation is induced on the surface of the eyeball. The inversion may implicate the whole cilia, or only a few. It may occur in either lid, but is most frequent in the upper. The position of the eyelid itself is not altered. At first, there is merely inconvenience ; but, sooner or later, an inflam- matory process is established on the surface of the eyeball, and conse- quent danger to vision may prove great. Treatment is either palliative or radical. The former consists in evulsion of the erring cilia, from time to time, and mitigation of the irritation and inflammatory action which they may have occasioned. For evulsion, a pair of broad-pointed forceps, with their opposing sur- faces in accurate contact, are required, for the hairs are usually both slender and light-colored, and the assistance of a lens is often necessary. This method is, on the whole, unsatisfactory, and is only applicable to those cases in which but a few of the cilia are in fault. To effect a radical cure, it is essential that the lashes be not only removed, but that their non-reproduction shall be insured. One of two methods may be followed. The errant cilia may be plucked out, and their bulbs destroyed; or the bulbs and cilia both may be removed by cutting instruments. The former method is applicable to the partial 98 ENTROPION. trichiasis; the latter to the complete. If the former be chosen, an in- cision is made with the point of a lancet, on the free margin of the lid, down to the roots of the inverted cilia; into this little opening, a needle, or another lancet, coated with powdered tartrate of antimony, is inserted, allowing it to remain so that its coating may dissolve there; and the hairs are then pulled out. A small pustule forms, and the bulbs are destroyed.1 When it is our object to remove not only the cilia, but their bulbs, a horn spatula is introduced beneath the lid, an incision is made down to the tarsus along the whole length of the inverted portion, parallel to, and about a line from the ciliary margin, to which it is to be connected at each extremity; the ciliary edge is then to be laid hold of with the forceps, and the integuments carefully dissected from the cartilage, so as to include the bulbs without interfering with the mucous edge of the lid. When the part cicatrizes, little deformity will result. Or, the margin of the lid is laid hold of, and stretched by the fingers of the left hand, or by forceps; and, by the stroke of scissors, or the sweep of a fine bistoury, the requisite amount is taken away. By operating in this way, more deformity will be produced than by the former plan ; but, by either, the eyeball will be freed from a continual source of irritation. By Distichiasis, is understood a row of supernumerary cilia, growing inwards, and causing the same unpleasant and untoward results as the foregoing affection. The same treatment is required as for trichiasis. But more careful examination is expedient, inasmuch as the observer is apt to be deceived by seeing the ordinary eyelashes of their normal character; and, even when the lid is raised and scrutinized, the paucity, slimness, and paleness of the stray lashes may often cause them to be overlooked—a serious matter—for, unless they be noticed and removed, inflammatory action will not only become established, but will prove uncontrollable. To detect them readily, the lid should be inspected laterally, as well as in front, and the patient should be desired to turn his eye in different directions, so as to form a dark background of the iris and pupil. Entropion. This is a turning in, not only of the eyelashes, but of the margin of the eyelid itself, attended with all the unpleasant consequences of trichiasis, in an aggravated form. It may Fls 19- be temporary or permanent. In the former ^^^s^^ case, it is the result of inflammatory swell- _J0m^ silt *nS °*" tne eyehd > " the tumefied conjunc- ^■BNf^^iLi t^Va Press^nS out tne orbital edge of the ■ wKSU ^'Wj^t tarsus, while its ciliary margin is turned ^^^^^USB^1 inwards by the action of the orbicularis."2 Jp'''' When permanent, it may depend on relaxa- tion of the integument of the lid, whereby Entropion, affecting both eyelids. displacement inwards of the ciliary margin 1 Edinburgh Monthly Journal, April, 1841, p. 259. 2 Littell, on Diseases of the Eye, p. 95. ENTROPION. 99 is both permitted and favored; or on contraction of a cicatrix on the conjunctival aspect of the lid, whereby the ciliary margin is directly pulled inwards ; or on a perverted form having been assumed by the tarsal cartilage itself, in consequence of ophthalmia tarsi, psorophthal- mia, or other chronic disease, [or in the case of the upper lid, on a con- tracted state of the folds of the conjunctiva forming the external and internal tarsal ligaments, whereby the levator palpebrae acts on the lower portion of the cartilage, and inverts it, as suggested by Mr. Crampton; or on a faulty action of the orbicularis muscle.—Ed.] Either eyelid, or both, may be affected. It is evident that treatment must be both early and suitable, if we wish to save the eyeball from serious injury. In the temporary form, it will be sufficient to oppose inversion by the application of retracting plasters, frequently renewed, until the cause of displacement has been removed by treatment directed towards subjugation of the inflammatory process and dispersion of its swelling. [Very little reliance can be placed upon adhesive plaster to maintain eversion of the margin of the lid, in consequence of the difficulty of obtaining for the strip a sufficient surface of attachment to the lid, and of preventing its detachment by the moisture which constantly escapes from the eye, and by the frequent rubbing of the inflamed organ by the patient. A much more efficacious means is recommended by Mr. Lawrence, in inversion of the lower lid; it consists in wearing a piece of strong wire, bent like a pair of specta- cles, and so arranged as that it shall rest upon the nose, and at the same time press with sufficient firmness upon the lid to evert its margin (Am. Ed. p. 150). Still better is the expedient advised by Mr. Whar- ton Jones : " A bit of firm wire, so twisted and bent as to fit on the back of the head by its middle, and press by its rounded extremities against the orbital portion of the lower eyelids." (Am. Ed. p. 401.) A similar contrivance might be applied, probably, to the upper lid.—Ed.] In the permanent form, operative interference is essential. If the in- tegument be redundant, a portion is to be removed. And it is necessary that, in the first instance, a very careful examination be made, to de- termine how much is to be taken away, so as to insure rectification of the position of the eyelid; while yet we avoid removing an unnecessary amount, and so causing an opposite condition of the parts—ectropion. A horizontal fold is pinched up by suitable forceps, or by the fingers, and is removed by either knife or scissors. The edges of the wound are then united by sutures, and adhesion follows. Escharotics may be employed for the same purpose; but they are inferior to the cutting instruments, being possessed of no exactitude as to the amount of tex- ture to be destroyed. Sulphuric acid is the most effectual, not only destroying skin, but consolidating the areolar tissue, and producing eversion by contraction of the granulations. When acid is used, a piece of round hard wood is dipped into it, and applied behind the tarsal cartilage in a line extending the whole length of the inverted portion. Cold water-dressing is applied, and in a few days the slough separates, the granulations contract, and the lid is restored to its proper position. The eye, however, must.be carefully guarded from the acid during its application, by a piece of wetted lint introduced between the 100 ENTROPION. lid and the globe. This action of sulphuric acid causes, in general, exquisite pain, and is only applicable to cases where the patient will not submit to an operation by sharp instruments. When the disease is dependent on a perverted state of the ciliary margin and tarsal cartilage, one of two methods may be adopted. The cilia and their bulbs may be removed, as for trichiasis; care being taken to leave the puncta lachrymalia intact. Or, by such an operation as the following, an attempt may be made, retaining the eyelashes, to liberate and restore them to their normal position. " The patient hav- ing been placed in a sitting posture, and the head supported by an as- sistant, the inverted lid is separated from the globe of the eye by means of the finger or a sharp hook ; and then, Avith a pair of strong scissors, two perpendicular incisions are made through the tarsal cartilage, each about a quarter of an inch in length, the one upon the temporal, the other upon the nasal side, avoiding the punctum, and including the whole inverted portion of the lid. This part being now everted, and held in that position, the two perpendicular incisions are connected by a hori- zontal incision upon the conjunctival surface, close to the ciliary margin, by means of a scalpel; cutting through the conjunctiva and tarsal car- tilage, and leaving the inverted portion of the margin united to the rest of the lid merely by the integument. And especial care is taken that the knife does not penetrate through the skin." Water-dressino- is applied. And " the success of this operation depends in a great mea- sure on the edges of the incision being prevented from uniting by the first intention, particularly the horizontal incision upon the conjunctival surface. This is effected by everting the lid occasionally during the first few days, and by touching the edges immediately after the opera- tion with the sulphate of copper, so as to cause them to suppurate and heal by granulation.1 Mr. Crampton's operation for entropion consists in making a perpendicular section of the lid, with scissors, at each can- thus, from a quarter to half an inch long ; taking care not to wound the punctum. An elliptical portion of skin is then removed from the outer surface of the lid. Two or three ligatures having been introduced through the skin at the tarsal margin, the eyelid is everted by means of them, and drawn up towards the eyebrow; in which position it is retained for a few days, by the ligatures being fixed to the forehead with a strip of adhesive plaster. In the mean time, the exposed mucous membrane is covered with a piece of wetted lint; and as the perpendicular incisions heal by granulation, a sufficient degree of eversion will be produced. [Mr. Crampton's operation and that of Mr. Guthrie are here con- founded and blended. The former consists in dividing the tarsal carti- lage by two perpendicular incisions, each about three lines long, in the manner described in the text; next, to overcome the supposed con- tracted state of the conjunctiva, a transverse division of this membrane is to be made, uniting the extremities of the first sections; and the lid, now easily everted, is to be maintained in this rectified position by a suspensonum palpebrarum, until union of the edges of the wounds has taken place. 1 Dublin Medical Press, July 27, 1842, p. 54. ENTROPION. 101 Mr. Guthrie, finding that this method did not always succeed, modi- fied it as follows: He made the perpendicular incisions as did Mr. Crampton, but rather more freely, from a quarter to a half inch, " until that part of the eyelid containing the tarsal cartilage is perfectly free, and is evidently not acted upon by the fibres of the orbicularis muscle, which lie upon it." If any vicious curvature of the tarsal cartilage can be detected, by which the everting effect of the first incisions is coun- teracted, it must now be divided in its length, exactly at the place where it is bent, which is generally at its inner part. The portion thus slit is only connected with the common integuments of the lid; this incision need not exceed one-eighth of an inch at each extremity, and is usually requisite only at the inner. The next step consists in removing a fold of the skin from the length of the eyelid, as close as possible to its margin, between the perpendicular incisions, and in uniting the edges of this wound carefully by three or four fine sutures, which are noAV also passed through the edge of the lid and finally secured upon the forehead by strips of sticking-plaster. The perpendicular incisions are not to be permitted to close by first intention, but lunar caustic or sul- phate of copper is to be applied J;o them from time to time, so that they may be made to granulate. Mr. Guthrie objects to the transverse in- cision of Mr. Crampton, as being not only unnecessary but injurious. In entropium of the lower lid, Mr. Guthrie generally finds it neces- sary to divide the tarsal cartilage only at its outer angle, and to evert the lid as in the case of the upper; in very inveterate cases, how- ever, a similar division is made at the inner extremity also, avoiding the punctum ; union by granulation is insisted upon, as in the operation on the upper lid.1 Fig. 20. [Mr. Guthrie's operation.—a, b. The perpendicular incisions, c. The ligatures supporting the lids. d. The confining strips, e. Line of incision in a case of inversion of the lower lid. (From Lawrence, Am. Ed.)—Ed.] 1 [Operative Surgery of the Eye, p. 30, &c] 102 ECTROPION. The accompanying figure, copied from Mr. Guthrie's book, exhibits a view of this operation. In a very interesting paper on Entropium, published in the Dublin Medical Journal, for March, 1844, Mr. Wilde recommends an operation for it, which differs from that advised by Professor Miller for trichiasis, only in the fact that, after the excision of the cilia and their bulbs, the edge of the mucous membrane, which has been carefully preserved un- touched by the knife, is nicely united by fine sutures with that of the skin, so that union by first intention, instead of by granulation, is secured. Mr. Haynes Walton, in a very recent work on " Operate Ophthal- mic Surgery," in which he appears to have diligently investigated the causes of this troublesome affection, contends with good reasons that it is due not to any faulty condition of the skin, conjunctiva, or tarsal cartilage, but to vitiated action of the orbicularis muscle ; and his indi- cations of treatment are, " to overcome the means of the inversion by dissecting away the thick marginal portions of the orbicularis, supposing that part of the muscle to be entirely or nearly all that is at fault; and also to remove as much of the skin of the lid as may be necessary to produce such tension as shall overcome the deformity which other tissues of the lid may have acquired, from the irregular position into Avhich they have been thrown by the muscles, and Avhich has been made more or less permanent by the changes induced by inflammation," (p. 164.) Accord- ingly, he dissects from the tarsal margin of the lid an elliptical portion of the integument and orbicular muscle, extending along the entire length of the lid, from as close as possible to its edge as far backwards as may be necessary, and then unites the edges of the wound by three or four fine sutures, applying subsequently the cold water-dressing. Mr. Walton's chapter on this subject is a very instructive one; the text is elucidated by numerous draAvings.—Ed.] Mr. Tyrrell recommended that the lid should be merely divided at its centre by a single perpendicular incision. The pressure caused by the contracted cartilage was thus relieved; and as the wound, shaped like an inverted f\, became filled by granulations, very little deformity would result. Both this and Mr. Crampton's operation are only applicable to cases where the disease arises from a contracted state of the cartilage. Ectropion. Ectropion denotes an opposite condition of the eyelid—its eversion: and is more frequently met with in the lower, than in the upper lid. The conjunctival lining is exposed, the eyeball is partially denuded, and much deformity is produced. After a time, the exposed palpebral conjunctiva loses much of its mem- branous character; the surface of the eyeball becomes irritable, in- flames, and undergoes change of „ , ff .- „, ,.., ., ± structure—probably fatal to vision; Ectropion, affecting the upper eyelid: the result , r / , ' of exfoliation. and a degree of epiphora invariably ECTROPION. 103 exists, in consequence of the natural course of the lachrymal secretion towards the puncta being interrupted. The malposition most frequently results from contraction of cicatrices of the integument; and these may exist in the eyelid or its immediate vicinity, in the corresponding cheek, or extensiA-ely on the face and neck as after severe burns (Principles, 3d Am. Ed. p. 642). The lower eyelid is the more frequently affected. The cicatrix may follow a burn, wound, sloughing abscess, or exfoliation; the first and last are the most unfavorable. Ectropion, however, arises from other causes than the contraction of sores. Simple relaxation of the lower lid will produce it; and this may depend on flabbiness and redundancy of all the component textures, or on atony only of the fibres of the orbicularis. The last circumstance is no uncommon occurrence in old people. Frequently, ectropion is caused by a faulty condition of the conjunctival lining of the lid, which is the seat of swelling, of either an acute or chronic kind. And it is well to remember, how general inflammatory swelling of the lid is able to cause either inversion or eversion, according to the accident of displacement; just as a similar condition of the prepuce may be the cause either of phymosis or of paraphymosis. Evasion is no uncommon attendant on purulent ophthalmia; from the acute and great swelling of the lid, more especially of its conjunctival lining. It also results from an indo- lent enlargement and thickening of that mem- brane. The accidental division of either can- Fig- 22- thus, too, may cause it; the lid becoming loose and pendulous. Or it may arise from an elon- gated and irregular state of the tarsal carti- lage. Treatment necessarily varies according to the nature of the cause. « Acute SAvelling of the eye- lid and its lining is subdued by the usual means. Chronic enlargement of the membrane is first treated by scarification, and astringents. If , i.ii -it i Ectropion, affecting the lower these be resisted, the redundancy may be re- eyelid moved, either by curved scissors or by caustic; the former obviously to be preferred; great care being taken lest, by the removal of too much, entropion be produced. Atony or paralysis of the fibres of the orbicularis may be combated by the usual means ; but, generally, this form of the affection, occurring in those of advanced years, may be regarded simply as one of the many signs of decay, and irremediable. When there is elongation of the tarsal cartilage, or re- dundancy of the whole lid, abbreviation, sufficient to restore normal position, is effected by a simple operation. Towards the centre of the lid, a triangular portion of its whole thickness is to be removed in the form of the letter V; the margins of the wound are brought together by suture, a proper compress is applied, and when the parts heal the lid will be in close apposition to the globe. (See Fig. 23.) In the case of faulty cicatrices, the procedure is more difficult and less promising. Occasion- ally, the simple division of a tight adhesion may suffice for liberation and replacement. But generally, there is loss of substance connected with the cicatrix, and consequently simple incision proves inadequate. 104 BLEPHARO PLASTICS. In the case of a moderate cicatrix, at some distance from the ciliary margin, amendment, if not complete restoration, may be effected as fol- lows : Supposing the lower eyelid to be affected, a V wound is made, through the integument only, the apex FiS- 23- pointing to the cheek. By means of the knife's point, the included skin is freed Fig. 24. [Plan of this operation. (From Lawrence, Am. Ed.;—Ed.] Plan of this operation; the dotted line marking the original wound; the plain line representing the flap of skin in its new and elevated position. a little from its areolar connections ; and resilience upwards is favored by the ne- cessary manipulation. Displacement up- wards is then definitely secured by bringing together laterally the Avound that remains beneath, by means of sutures. In not a few cases there is not sufficient laxity of parts to admit of this. Under such circum- stances, something may be done by incising the eyelid, and replacing its ciliary margin; then filling up the chasm beneath, which necessarily results, by a flap of integument borrowed from the adjoining cheek. When ectropion has resulted from accidental wound at the canthus, rectification is easily obtained by reunion of the diA'ided parts; the margins of the cicatrized wound being made raw* by paring, and re- tained in accurate apposition by suture. . [So many operations have been devised to suit particular cases of Ectropium, that it would be out of place to describe them all in a gene- ral treatise like this. The reader is, therefore, referred to special works on diseases of the eye, and particularly to the American edition of Mr. Lawrence's book, where a great variety of proceedings are enume- rated and illustrated.—Ed.] Blepharoplastics. When either eyelid has been partially or totally destroyed, by injury, or by disease not of a malignant kind, an attempt may be made not without good prospect of success, to supply the deficiency by a suitable flap brought from the immediate vicinity. No precise rules can be -iven for such an operation; the details must necessarily vary in each case * 1 London and Edinburgh Monthly Journal, 1843, p 359 Surgery. Sub voce. Cyclopaedia of Practical AFFECTIONS OF THE LACHRYMAL SAC. 105 III. Affections of the Lachrymal Apparatus. Epiphora. Stillicidium. Epiphora consists in an increased secretion of tears, Avhich Aoav over the cheek. Stillicidium lachrymarum depends on some affection of the excreting lachrymatory apparatus, which prevents them from taking up the tears as they are secreted. The watery eye may be either congenital, or the result of injury or disease. It is best treated by means of astringent collyria; by Aveak solutions of nitrate of silver, or wine of opium, dropped upon the eye once a day; or by exposing the eye to the vapor of laudanum; and by using at the same time some weak red precipitate ointment to the edges of the lids at night, when there is any derangement of the Meibomian secretion. In all cases, not prominently connected with some more important affection of the eye, the state of the general system must be carefully looked to; for it is extremely probable that no slight declension from health will be found; and, unless this be remedied, all local treatment will prove of comparatively little avail. When a watery eye results from a contracted state of the puncta, these are to be dilated by means of fine probes, or a stiff bristle. When there is relaxation or atony of the lachrymal sac, then stimulating injections or collyria are to be used. These are thrown into the sac by means of Anel's syringe, through the punctum. Occasionally, a small blister applied over the sac is of use. When the nasal duct is obstructed, measures must be taken to effect its clearance. Often, the watery eye is but a symptom of general ophthal- mia, and is only to be cured by its subjugation. Xeroma denotes an opposite condition; a dryness of the eye, depend- ent on deficiency of the lachrymal secretion. Frequently, it is a tem- porary prelude to graver affections of the eye, of an inflammatory nature. When it occurs singly, and persists—as is but seldom—restor- ation of the secretion is to be courted by ordinary stimulant means. Inflammatory Affections of the Lachrymal Sac. The areolar tissue over the lachrymal sac sometimes is the seat of an inflammatory process ; while, in the first instance, the sac itself is free." A red, itchy, painful swelling exists at the corner of the eye ; and the system sympathizes slightly. The cause usually is exposure to cold. Purging, and antimonials internally, with low diet, and pencilling of the affected part with nitrate of silver, or tincture of iodine, will ordi- narily suffice to obtain resolution. If they fail, then local depletion by leeching must be had recourse to; the leeches being applied over the part itself. It is obviously of much importance to be early and active in such treatment; so as, if possible, to prevent involvement of the lachrymal sac. If suppuration should occur, a very early incision should be practised, lest perforation of the sac take place. Not unfrequently, notwithstanding every precaution, the sac is involved, and suppurates 106 affections of the lachrymal sac. acutely. The same treatment is necessary; an early evacuating inci- sion, or enlargement of the spontaneous opening, and light water-dress- ing afterwards. The opening granulates and heals; and usually the breach in the sac closes, leaving its cavity unoccluded. The lachrymal sac may itself be the primary seat of acute inflamma- tion. This may occur idiopathically in those of weak system, or in any one, after exposure to cold. A small, hard, circumscribed, and very painful swelling is formed below the tendon of the orbicularis muscle; the superimposed integuments soon become red, the eyelids are more or or less oedematous, the corresponding side of the nostril is dry; and the system sympathizes considerably. The swelling increases, often almost obscuring the eye; and severe headache usually is complained of. The course of the tears is obstructed, by the tumid state of the duct's lining membrane—inflammation having extended to it—and.they find their way over the cheeks. Suppuration occurs, and, sooner or later, the matter is discharged externally. Then a slow recovery may ensue, the nasal duct becomes again open, the tears resume their proper course, the suppurated aperture granulates and heals. Or the obstruction in the nasal duct remains, the tears do not reach their wonted outlet, the aperture contracts but does not heal, and the condition of fistula lachry- malis is established. In severe and neglected cases—more especially if occurring in a debilitated frame—the subjacent periosteum may be de- structively involved, and tedious exfoliation ensue. Antiphlogistics are obviously demanded here ; leeches over the in- flamed sac, warm anodyne fomentations, and a full dose of morphia at night, to allay pain and procure rest. These ought to be used early to avert suppuration if possible. When matter has formed, it must be evacuated at once. This is done by introducing a bistoury into the sac, below the tendon of the orbicularis, which ought to be rendered promi- nent by drawing the lids outward. After evacuation, light water-dressing or poultice is applied; and the sac, after a time, may be occasionally syringed with warm water. We hope that the membrane of the duct will duly recover from its tumid state, that the natural course of the lachrymal fluids will be restored, and that the outward opening in the sac Avill close. A chronic affection of the lachrymal sac is not uncommon; the vas- cular process reaching no higher than congestion, and limited almost . entirely to the lining membranes. An indolent swelling occurs beneath the tendon of the orbicularis, soft, fluctuating, comparatively painless, and capable of being emptied by pressure; for the puncta remain open, and through them the puriform secretion escapes upAvards. The passage downwards is obstructed; and, indeed, this circumstance seems, in most cases, to be the origin of the malady. Sometimes this chronic distension of the sac is the result of an acute or subacute attack. In other cases, it is chronic from the first; and, in these, the state of the general system is usually unsatisfactory. There is a constant liability to acute accession from but slight causes ; and, when such an aggravation does occur, the progress is likely to be rapid and untoward. Suppuration and outward discharge take place, and fistula lachrymalis is established, perhaps with necrosis of the os unguis. fistula lachrymalis. 107 Treatment consists in prophylactic care, so as to avert such untoward events ; in attention to the general health; in maintaining a compara- tively empty state of the sac, by occasional pressure; and in the use of stimulant injections, collyria, or ointments. Sometimes vesication over the .sac, by nitrate of silver, or tincture of iodine, is of use; at other times, the application of a feAV leeches will prove serviceable. It is in such cases that Anel's syringe is of most use; to clear out accumulated discharge, and to convey alterative and stimulating fluids to the congested membrane. For overcoming structural obstruction in the nasal duct, any such injection is quite inadequate. Fistula Lachrymalis. How this condition is produced, has already been explained. Ob- struction takes place in the nasal duct; the lachrymal sac inflames, suppurates, and ulcerates—the ulcerated aperture discharg- ing externally; and the wound, only con- tracting, does not heal. This train of events may originate in the lachrymal passages, and usually does so. But the origin may be in the subcutaneous areolar tissue, as already stated; or in the bone and perios- teum, in those with a mercurio-syphilitic Flstula Lachrymalis. The chronic stage taint Of System. The greater number of established; and the aperture small. cases, hoAvever, are of a simple nature ; originating in the lachrymal passages, and involving the deeper parts secondarily, if at all. The essential parts of the disease are, obstruction in the nasal duct, and an external opening in the lachrymal sac. In treatment, it is our Fig. 26. [View of operation for fistula lachrymalis, from Lawrence, Am. Edit.—Ed.] 108 fistula lachrymalis. object to close the latter; and that can be done only by removing the former. To this end, an operation is necessary. The patient having been seen seated on a chair, with the head supported, a narrow, sharp- pointed, straight bistoury is inserted into the fistulous opening beneath the orbicularis tendon; and is not only lodged in the sac, but pushed into the osseous nasal canal as well. To accomplish this dexterously, reference to the anatomy of the parts is necessary, in order that the penetrating instrument may receive the requisite direction ; downwards, a little backwards, and a very little inwards. By the side of the bis- toury a stout probe is passed down; and, as the former is slowly with- drawn, the latter is pushed steadily onwards, until it has overcome the obstruction, and is felt to touch the floor of the nostril. To effect this perforation, a little force is sometimes necessary. A few drops of blood, escaping by the nostril, prove re-establishment of the duct complete; also, if the patient be made to expire forcibly, while the nostrils are shut, air and bloody mucus will be ejected upwards through the duct, if the probe have been withdrawn. (See Fig. 26.) But it is not enough that the knife and probe procure a temporary re-establishment of the canal. This must be kept permanently open; and, to accomplish this, styles, or small bougies, are employed, of various sizes, and made of silver. One, about the thickness of an ordinary probe, and sufficiently long to reach from the upper wound to the nasal aper- ture of the duct, is lodged in the canal; its flattened head resting on the integument. No fixed size can be defined as generally Fig. 27. suitable for the commencement of the treatment. It is 1 enough if the style pass easily after withdrawal of the ordi- nary probe. Having been lodged, it is allowed to remain. After some hours, the usual resenting of the presence of a foreign body is evinced. The part becomes hot, painful, and swollen; still, the exciting cause is not to be removed; the style is left untouched. Fomentation, or a poultice, and the minor general antiphlogistics are employed: and, usually, after a day or two, the inflammatory signs subside, the style feels loose again in its site, and a purulent dis- charge escapes freely by it. After a few days of quietude, style for the La- tne original style is withdrawn, and one a size larger gently chrymai Duct, substituted. This, in its turn, gives place to a third; and so on, until one is passed of sufficient bulk completely to occupy the canal; the passage being syringed once a day with tepid water, to keep it clean. This last style is worn for some considerable time, until there is good reason to suppose that the normal caliber of the passage is fully restored, and that its lining membrane has returned to a tolerably sound condition. Then the instrument, which had only been taken out occasionally, for the purpose of being cleaned and re- placed, is withdrawn, and a smaller substituted. This, after having been worn for some days, is succeeded by a less ; and by this gradual abstraction of the stimulus, relapse is rendered improbable. Then, if the tears continue to flow naturally, and all else seem favorable, the use of the instrument may be wholly abandoned; and the external aperture, now much contracted, may be permitted and encouraged to obstruction of the nasal duct. 109 close entirely. Frequently, no aid is necessary to secure this latter eA7ent. But, should a small fistula threaten to prove obstinate, the touch of a heated wire, or point of caustic, will usually effect its contraction and closure. At one time, tubes were employed instead of styles. Experience, however, has declared them to be inferior. They create the same dis- turbance in the part, are apt to become obstructed, equally require occasional removal; and, in some cases, their attempted removal has been attended with the utmost difficulty. At one time, also, it was no uncommon practice to seek a more direct road to the nasal outlet, than through the obstructed lachrymal duct, by perforation of the os unguis. This destruction of unimplicated texture, however, is in the present day very properly deemed unwar- rantable. If necrosis accompany the condition of fistula lachrymalis, exfoliation must be patiently awaited; for not until the dead portion of bone has been thrown off, can the soft parts be expected to heal. At the same time constitutional treatment will certainly be necessary. It is well to remember that fistula lachrymalis may be simulated, tolerably closely, by malignant disease. A medullary tumor, or a malignant polypus, formed in connection with the nasal passages, may project towards the surface at the inner angle of the eye; and its first prominence, yet covered by the stretched and attenuated integument, may occupy the exact locality of the lachrymal sac. But a touch of the part will evince elasticity instead of fluctuation; a glance at the nostrils will show the true seat of the disease; and the cachectic face and general appearance will sufficiently testify to the malignant character. Obstruction of the Nasal Duct. We can readily understand how this should be a not unfrequent result of an inflammatory process in the lining membrane. The mem- brane is at first turgid by soft exudation; and this narrows, and may obstruct, the canal. Such obstruction is temporary in its nature, and capable of yielding to ordinary treatment, whereby cessation of undue action and absorption of extraneous deposit may be obtained. If the process continue, exudation becomes more and more dense, and more enduring; partly mucous in its site, but chiefly submucous; and by continuance or aggravation of such structural change, diminution and obstruction of the canal are rendered plainly inevitable. For the minor form of obstruction, rectification of the general health, counter-irritation applied over the part, and the use of sorbefacient collyria or injections, will ordinarily suffice. In the more advanced form the stimulus of the lodgement of a foreign substance in the part is essential to efficient restoration by absorption. In some instances, this indication may be fulfilled without incision, by passing a probe upwards, from the nasal orifice of the duct. The probe, GensouVs, bent nearly to a right angle, at about three-fourths of an inch from its point, is 110 AFFECTIONS of the lachrymal gland. passed carefully along the floor of the nostril, until it arrives below the anterior extremity of the inferior turbinated bone; then its point is directed upwards into the canal. This manipulation is always doubtful in the first instance, on account of the valvular protection by which the nasal orifice of the duct is guarded, and which must be forcibly broken up; often it proves most difficult to the surgeon, and both teazing and painful to the patient; not unfrequently it fails altogether. It should never be attempted, unless after repeated practice on the dead body. And, even when the introduction can be effected with tolerable facility, it is not unlikely that such means will in the end be found quite inadequate to remove the disease. In all serious cases, therefore, of obstruction in the nasal duct, it is better at once to have recourse to the same treat- ment as for fistula lachrymalis; to puncture the sac, and proceed with gradual dilatation by styles. Obliteration and Absence of the Nasal Duct. 1. The nasal duct may be obliterated by change of structure in the membrane. Restoration by perforation may be attempted. 2. It may be shut up entirely by change of structure in the bone. Then restora- tion in the original site is hopeless; and if anything remedial is at- tempted, it can only be by perforating the os unguis, and rendering the unnatural aperture permanent. A case is related by M. BeVard, of congenital absence of the nasal duct; from which there had resulted a congenital fistula, which con- tinued open and discharging at the age of twenty-one. An artificial outlet was formed for the secretion, by perforation of the os unguis.1 Dacryolites. Concretions are sometimes found in the lachrymal passages; mainlv lodged in the sac; and consisting chiefly of carbonate of lime, cemented by concrete mucous and albuminous matter. The foreign substance produces swelling and lachrymation, and may ultimately cause fistula, Its presence is easily detected by manipulation, and by the introduction of a probe through one of the puncta. The remedy is simple; incision and removal. The wound may be expected to heal kindly, and without any fistulous tendency. In minor cases, mere expression, without wound, may prove sufficient. Affections of the Lachrymal Gland. Dacryadenitis.—The lachrymal gland may be the seat of an inflam- matory action, chronic or acute; but either form of attack is rare. The secretion is first increased, afterwards arrested, and then restored in a perverted form. A painful swelling forms in the region of the organ; the eyeball is displaced, and inconvenienced in function and movements. 1 British and Foreign Review, No. 24, p. 541. encanthis. Ill The eyelids are cedematous; and the conjunctiva is apt to sympathize, and take part in the action. In the acute form, the system suffers severely; the pain grows intense, and shoots through the head; anu suppuration may take place. If the matter be discharged spon- taneously, a fistulous aperture may remain. The treatment is according to general antiphlogistic principles ; when matter forms, an early and free opening is to be made. Atrophy of the Lachrymal Gland may take place, but this is very rare; the organ ultimately becoming almost effaced. Then either xeroma results; or the conjunctival secretion is augmented, to atone for the glandular deficiency. Tumors of various kinds may form in the substance of the gland. It is liable to simple hypertrophy, amenable to discutients. Sometimes it is the seat of cystic formation, remediable by simple puncture; or, if that fails, by excision. Carcinoma may attack the gland. Then there is obviously no hope but from early removal. And, in extirpation of the eyeball on account of malignant disease, it is well always at the same time to remove the lachrymal gland—its occupation now gone— whether involved or not; lest, by its continued presence, return and reproduction of the tumor should be favored. Encanthis. By this term is meant an enlargement of the caruncula lachrymalis. The enlargement may be a simple and somewhat acute engorgement of the part, the result of an inflammatory process resident therein. This will readily give way to Fig. 28. ordinary treatment—scarification, or leeching, fomentation, and sorbefacients. A chronic swelling, of the nature of hyper- trophy or simple tumor, may occur; less amena- ble to discussion, and often resistful of it. It slowly increases; producing deformity by its prominence and bulk ; displacing and obstruct- ing the puncta and lachrymal canals, whence Encanthis troublesome lachrymation results; preventing due closure of the eyelids; and favoring the occurrence of ophthalmia, If discutients fail, under such circumstances, excision is to be practised; care being taken to leave the puncta canaliculi, and lachrymal sac un- injured. Sometimes the caruncle is the seat of tumor of a malignant, or at least suspicious character. In such a case, discussion is hopeless ; and palliatives of any kind are not employed, if excision be practicable. By early as well as free removal only, can immunity from return be hoped for. It is very rarely, however, that excision of this texture, on any account, is required. 112 SIMPLE CONJUNCTIVITIS. IV. Affections of the Eyeball. Ophthalmia. Fig. 29. Diagram showing the characteristic yascularity of external and internal Ophthalmia, a. External. 6. Internal. (W. Jones.) In such a work as this, it is not to be expected that so wide a sub- ject as the affections of the eye- ball—so important, varied, and numerous — should be fully dis- cussed in all its details. The lead- ing points only can be overtaken; the student being referred for far- ther information to the many excel- lent monographs in this department of Surgery. Ophthalmia is the general term in which all affections of the eye- ball of an inflammatory nature are comprehended; and, according as the superficial or more deeply seated textures are involved, the ophthal- mia is said to be External or In- ternal. Affections of the Conjunctiva. The inflammatory process, in all its grades, is very frequently found established in the conjunctiva; and the affection varies materially not only according to the intensity of the action itself, but also according to the cause which induced it, and the state of the system in which it has occurred. Different varieties of the disease may, in consequence, be enumerated. The most prominent of these are the Simple Purulent and Strumous. ' ' Simple Conjunctivitis. t The eye becomes the seat of pain, heat, and lachrymation; there is intolerance of light, and consequent shutting of the eyelids-more or less spasmodic; frequently, there is a sensation as if sand or other foreign matter were lodged in the part. On separating the eyelids the membrane is seen to present an appearance of unusual vascularity; not from formation of new vessels, but from enlargement of those already there. It is important to remember that these vessels have a peculiar character, whereby affection of this membrane may be distinguished from the affections of more deeply seated parts. The vessels are of considerable size, they seem to advance from the periphery of the globe where the membrane is reflected from off the palpebral, are tortuous in heir course, freely inosculate with each .other, and terminate gradually at the margin of the cornea; they are also observed to follow the move- SIMPLE CONJUNCTIVITIS. 113 Fig. 30. External Ophthalmia; Catarrhal Conjunc- tivitis. ments of the membrane; sometimes they are distinct and separate, because not very numerous; sometimes they are numberless, consti- tuting one mass of angry red; and the redness is usually of a bright scarlet hue (Fig. 29, a). Whereas, in sclerotitis, the vessels are small, straight, not affected by the movements of the eyeball, appear first near the margin of the cornea, become paler towards the periphery of the globe, do not inosculate, plainly occupy a deeper plane, and cause a redness of a pink or purplish hue (Fig. 29, b). In what is strictly termed Simple Con- junctiATitis, the range of the inflammatory process does not reach higher than active congestion. Effusion takes place copious- ly ; partly beneath the conjunctiva, but chiefly external to it. If the crisis of true inflammation be approached, a temporary drying up of the discharge, with aggrava- tion of all the symptoms, marks the untoward advance. The system is sympathetically involved; but, in general, its disorder is neither prominent nor severe. The disease may occur per se, or be but a part of a more general inflammatory attack. Not unfrequently, it is merely a symptom of eruptive fever, as in measles and smallpox. The predisposing causes are numerous; over-exertion of the organ in many ways; derangement of the general health; a glaring, sunny, or dusty season. The exciting causes are equally numerous ; exposure to cold, heat, wind, or light; the application of all chemical and mechanical irritants, directly; and the indirect influence of irritant causes, more remotely. The most obstinate forms of the disease are to be expected, when the exciting cause is by a direct irritant which remains in constant operation; as when a particle of sand, dust, or glass, lodges in the membrane, or when it is constantly rubbed or fretted by stray eye- lashes. In the treatment, our first care is to remove the cause. Then anti- phlogistics are to be used; but these need not be of the highest class. If the cause—as a foreign substance lodged in the membrane—have been removed at once, nothing may be required in addition to rest of both body and part, low diet, abstraction of light, and continuous application of cold over the shut eyelids by means.of wetted lint. The inflam- matory process may be entirely averted; or, if just begun, it may very speedily resolve. If not, then blood is to be abstracted locally, and transition made gradually from cold cloths to warm fomentations. The blood may be drawn from the temple, or by cupping at the nape of the neck; or by the application of leeches in the neighborhood of the eye itself. The last method and locality are generally preferred ; and care should be taken that all the animals fasten near the inner angle only, immediately beneath the tendon of the orbicularis; for there less pain 114 SIMPLE CONJUNCTIVITIS. will be occasioned, more blood will be drawn, and less risk both of ecchymosis and of erysipelas will be incurred, than when application is carelessly and diffusely made along the eyelids. The amount of local depletion will of course vary according to the intensity and duration of the disease, and the age and constitution of the patient. The action may simply and steadily resolve ; or may pass from the acute to the chronic condition, and there tend to remain. It is to be borne in mind that, in all cases of this affection, not of a traumatic origin, and not occurring in a robust and vigorous frame, the chronic condition, a state differing little from that of mere passive congestion, is very apt to be assumed at an early period—after the lapse of but a few days. Then, continuance of antiphlogistics would but aggravate the morbid state. A change has to be made. It may be advisable to unburden the distended vessels; and this will be best done, by scarifica- tion of the conjunctiva on the lower lid. By fomentation, the flow of blood is encouraged; and after this has ceased, gently stimulating collyria are employed, to restore tone to the vessels; solutions of zinc, alum, or of nitrate of silver, are the best; or a dilution of vinum opii begun very weak, and gradually increased in strength. Also, the ordi- nary stimulus of light is again gradually admitted. In those cases in which amendment is tardy or fluctuating, it is well to adopt the aid of counter-irritation; which is best applied by blistering, behind the ear. Constitutional treatment is not to be neglected during any period of thecase; first moderately antiphlogistic, then alterative" and ultimately tonic. If the occurrence of the attack have been connected with the drying up of any habitual or normal discharge, return of this should be sought for and secured. When one eye only is affected, it is well to remember the close sym- pathy which exists between the two organs. The unaffected eye there- fore, should, during the acute stage, be kept equally quiet and shaded from the light, and otherwise treated with prophylactic care. Confine- ment to a dark room is not generally necessary however, and when the case is chronic, free exposure of the organ to the open air will often prove beneficial. In the obstinately chronic cases, beneficial change of action may often be obtained by the application of nitrate of silver in solution or very lightly in substance, to the inner surface of the lower lid immediate!? after scarification. J A common variety of simple conjunctivitis is termed the Catarrhal: whose prominent characteristics are—in addition to those of the simple form-a profuse secretion of vitiated muco-purulent fluid from the mem- brane, oedema of the eyelids irritation of the tarsal margins, less in- tolerance of light more marked remissions, and the presence of the usual indications of catarrh. [It is also well to bear in mind that this variety of conjunctivitis, besides being sometimes epidemic, is probably, like the more severe puru- lent ophthalmia, contagious. Such, at least, seems to be proved bv the rapid manner in which it spreads over communities of persons, as child- ren in orphan asylums, after the accidental introduction of a single case Consequently, the same care should be used against contact of the" PURULENT CONJUNCTIVITIS. 115 purulent or mucorpurulent secretion, from eye to eye, as in the case of purulent ophthalmia. The most efficacious treatment is unquestionably the application to the inflamed conjunctiva of a solution of nitrate of silver, 5 to 10 grs. to the ounce of distilled water, repeated at first every day; mild purg- ing and stimulating pediluvia are also serviceable adjuvants; in ordinary cases, local bleeding is unnecessary.—Ed.] Purulent Conjunctivitis. Purulent ophthalmia seems to be merely an aggravated form of catar- rhal conjunctivitis, running its course, however, much more rapidly, and mainly distinguished from the latter, in its mild form, by the discharge being purulent instead of muco-purulent. But when purulent discharge occurs in the simple form, an aggravation of the inflammatory process having been somehow induced, such a circumstance is to be regarded as an accidental intensity in acute simple conjunctiA'itis, rather than as an example of true purulent ophthalmia. Usually, action is from the first intense, and suppuration is very speedily attained. The first symp- toms are pain and itching in the palpebral conjunctiva, and often there is a sensation as if foreign matter were lodged there. Then the ordi- nary characters of conjunctivitis appear, in an aggravated form. The pain is not confined to the eye, but shoots through the head, and not unfrequently extends to the face also. The eyeball becomes quickly covered with meshes of enlarged conjunctival vessels; the membrane itself is infiltrated and tumid ; a profuse purulent secretion is poured out; the eyelids are swollen and cedematous, often to a great extent; ordinarily, the eyeball is concealed by the tumid lids; on opening them forcibly, purulent matter escapes in increased quantity, and eversion is apt to ensue—the engorged and red conjunctiva becoming exposed. As the disease advances, the conjunctival lining of the eyelids, more especially of the upper, changes from the uniform, vascular, and villous appearance, to one of more irregularity, as if granulating. The con- junctiva is then said to be granular. This term, however, does not imply that the membrane becomes actually studded with true granula- tions ; the fleshy elevations being mere enlargements of the natural papillae. These continue to furnish a profuse discharge; and the friction of them over the ocular conjunctiva doubtless maintains the general morbid action. The ocular conjunctiva, it has been already said, undergoes change of structure. Exudation and extravasation take place both intersti- tially and beneath it. Serum, or fibrine, if the disease be very acute, is effused between it and the sclerotic, causing it to bulge considerably over the margin of the cornea, and leaving that texture in the relative position of a depression or dimple. This state is termed Chemosis; the result of true inflammation in the conjunctiva. When the action is acute, and the chenaosis great, the cornea is in danger of sloughing; partly from over-action, and partly by the strangulating effect of the surrounding swelling, checking the supply of blood to the cornea, and causing it to die from want of nutrition. 116 PURULENT CONJUNCTIVITIS. The system sympathizes to a great extent. At first inflammatory fever is developed. Afterwards, the form of Constitutional Irritation is often assumed. Vision is in imminent danger, by change of structure in the cornea, and also by disorganization of the entire globe; for to the latter result this affection may advance, under circumstances of either neglect or severity. In Egypt, the disease prevails as an epidemic, and has done so for ages; of the most virulent and intractable form; very fatal to sight; originally induced by sun and sand, propagated, also, by direct con- tagion ; and in effecting reproduction by the latter mode, the flies are said to be active agents—passing from one eye to another, tainted with the contagious matter. In this country, it is happily both less frequent and less severe. It may follow injury; and then the purulent discharge is to be looked on as the mere consequence of a high amount of inflam- matory action induced by a powerful exciting cause. Want of cleanli- ness, and of ventilation, and the overcrowding of inmates—as in schools and barracks, and on board of ship—predispose to the production of this form of disease, under the influence of a comparatively slight excitino- cause. ^ Thus occasioned, it is undoubtedly contagious; the matter of one patient, applied to the sound conjunctiva of another, being capable of inducing a similar affection. And when many patients happen to be crowded together, without due cleanliness and ventilation, there is good reason to believe that the infectious character is also acquired. Treatment, in energy and promptitude, requires to be proportioned to the rapidity and intensity of the disease. It is only by active and early, as well as suitable measures,-that we can hope to avert change of structure and impairment of function. When the patient is robust and plethoric, and there is intense supraorbital pain, headache, chemosis, and a feeling of tension and throbbing in the eye, blood is to be drawn not only from the part, but from the system; with a full antiphlogistic effect in view. The bowels are to be well acted on. Regimen should be most sparing; with quiet, and seclusion from all stimuli—light more especially. If not strongly contraindicated, by constitutional or other causes, calomel and opium are to be freely administered, to excite gentle ptyalism; for the action is intense, the texture delicate, and the func- tion important (Principles, 3d Am. Ed. p. 169). The eye is to be diligently fomented with an anodyne fomentation. If the case be not seen till the disease has made progress, and lost much of its acute type, both locally and constitutionally, such severe measures are of course unwarrantable. And a like reservation will be required in the case of the puny adolescent, perhaps scrofulous as well as sickly, who may happen unfortunately to become a victim. When the second stage has set in, we cease from constitutional antiphlogistics—though still maintaining the most guarded regimen; the local, too are proceeded with differently. The swollen conjunctiva is to be freely scarified, in order to empty its sanguineous contents, and at the same time to afford ample space and* opportunity for the interstitial and subconjunctival exudation to escape. The palpebral conjunctiva is divided with a lancet or scarificator, in a horizontal direction; the eyelids being freely everted for this purpose; and sepa- PURULENT CONJUNCTIVITIS. 117 ration of the lids ought to be maintained for some time, so as to favor the escape of blood. The chemosed ocular conjunctiva is to be divided also in a horizontal direction; otherwise, the cornea, already in a critical condition, will have its sloughing accelerated and made certain by inter- ruption of the vascular supply. Or, rather, the incisions are begun at the corneal margin, and made to radiate outwards to the circumference, as recommended by Mr. Tyrrell; there being thus less risk of cutting across the vascular supply of the cornea, than in any other form of incision. This incision of the chemosis is not always to be reserved for the second stage ; but is often highly expedient at an early period, when the action is yet acute; in order to save, if possible, the threatened cornea, as well as to obtain a general resolutive effect upon the inflam- mation. Fomentation is to be used for some hours after the scarifica- tion, so as to favor the flow of blood; and then the nitrate of silver is advisable. Probably, the best way of employing this remedy is to apply it, either in substance or in solution, to the eyelids; on these it exerts a direct and powerful remedial effect, opposing the congested and granular state; and from these it is gradully diffused over the globe, with an effect more gentle but equally beneficial. The application is made daily, or every second day, according to circumstances. Through- out the whole treatment, it is essential that matter be not allowed to accumulate beneath the SAvollen and shut lids; these are to be gently opened from time to time, and the pus washed away by warm water, or by some gently astringent fluid—anodyne or stimulant, according to the stage of the disease. For general use, there is nothing better than a weak solution of nitrate of silver dropped into the eye once or twice a day. It ought to be borne in mind, throughout the whole period of treat- ment, that the discharge is of a contagious nature; and the patient, practitioner, and attendants, should guard accordingly against direct propagation of the disease. If the morbid state still persist, and become more and more chronic in character, the nitrate of silver may be well superseded by some more purely stimulating remedy ; as the sulphates of zinc and copper. Or some of the preparations of mercury may be employed ; in form either of ointment or of solution. At this period, too, counter-irritation, by blistering behind the ears, or on the nape of the neck, will not be with- out its use. The state of the system, throughout the whole course of the disease, must be well considered; often a combination of tonics \vith alteratives will probably be required. When a swollen and altered state of the palpebral conjunctiva obsti- nately remains, after comparative disappearance of the other symptoms, this lingering one must be attacked with more energy. The sulphate of copper or nitrate of silver is applied lightly over the parts. Or the enlarged granulations may be at once removed, either by knife or scis- sors. The surface which remains is then made the subject of ordinary treatment. Of course, care must be taken that the removal of texture be not excessive ; otherwise entropion is likely to ensue. 118 PURULENT CONJUNCTIVITIS. _ Such is the nature of the ordinary Purulent Ophthalmia. Two varie- ties of the disease require a separate though brief notice. Ophthalmia Neonatorum.—By this term is understood Purulent Conjunctivitis, occurring in the recently born child. It may be in- duced by mere want of cleanliness, by imprudent exposure of the deli- cate organs of sight to intense light, or by the direct application of other stimuli. But frequently it owes its origin to direct contamination of the conjunctiva by vaginal secretion, during parturition. The disease presents its ordinary characters; and there is much risk of permanent loss of sight by pearly opacity of the cornea. Children have been born with opaque corneas, apparently the result ot purulent conjunctivitis. It has been inferred, therefore, that this disease may occur in utero. Such opacity, however, may be the result of mere arrest in development. The treatment is founded on antiphlogistic principles, proportioned to the age and condition of the sufferer. But much depends on an early commencement being made. Then mild measures suffice; bleeding will seldom be required, either by leeches or by scarifications; and counter- irritation, also, will rarely be necessary. It is enough to employ simple ablution, frequently repeated, perhaps every second hour; soon gently medicating the collyrium by means of alum, decoction of oak-bark or other astringent; the proportion of which is gradually increased. A weak solution of nitrate of silver dropped into the eye, once a day, is of much benefit Great attention to cleanliness is to be always maintained, and the eyelids should be prevented from adhering together, by apply! mg a little red precipitate ointment to their edges at night. Attention is at the same time paid to the prim* viae and general system. Jf^orrhval Ophthalmia.-The application of recent gonorrhoea! matter from the urethra to the conjunctiva, produces the most intense form of purulent conjunctivitis. One eye ordinarily is affected for It is seldom that both are at once inoculated; and, in^his re^k her is a difference from the ordinary purulent conjunctivitis. In the latter also the morbid action usually commences in the palpebral coniunctva' resides there chiefly, and extends only Becbndaril/Jth^aS^S of the membrane. But, m the gonorrheal form, the reverse is he case; the disease would seem, in most cases, to commence In the ocula ntlTe 2 The h°,"T ^ t0 *" PalpebraL Action^™ intense, ana the hazard to vision is o-rpar • fn>. +l« „„ i i by a firm fibrinous chemosis, isfn a ZT^ZtZTTJZ0^ quently perishes by sloughing; „r the JtFon^^V^jtTllr- minate in genera] disorganization of the iriohe Th« tJ™7 .* • way peculiar; only proportioned in Zttjtott*7Tto££ General bleeding ought seldom to be omitted at the outset* and this merits ^^^7^ ZT^Y^ his d.sease ,s more aeute, and runs its course more rapidlyTan Z GRANULAR CONJUNCTIVA. 119 Strumous Conjunctivitis. This affection of the membrane, in addition to the ordinary traits of the strumous cachexy, is characterized chiefly by remarkable photopho- bia, or intolerance of light; often, with comparatively little pain and vascularity ; though sometimes the vascularity is considerable ; by tend- ency of the enlarged vessels to collect into fasciculi, Avhich stretch towards the corneal margin, terminating there in pustules or phlyc- tenule ; by exacerbations occurring in the morning, while there are remissions at night; the opposite of what obtains in other ophthalmite. Corneal change of structure, as ulcer, is extremely apt to ensue. The affection seldom occurs after puberty; and prevails chiefly during child- hood. At that age, the intolerance of light, with spasmodic closure of the eyelids and copious lachrymation, is certainly the most prominent symptom. The child " keeps its hands pressed on the shut eyelids, and turns its face on the nurse's shoulder, or, if in bed, on the pillow, even in comparative darkness. In chronic cases, the edges of the lids are kept in this manner in an almost inverted condition, and the eyelashes get under, and are there retained, augmenting the distress." The cheeks are scalded by the discharge which almost constantly wets them, and become covered with an angry eruption. The features are con- torted ; and a confirmed expression of pain and discontent is assumed. On attempting to open the lids, much suffering is occasioned; the lachry- mation increases, the lids become more inverted, and the eyeball is rotated upwards and outwards so as to conceal the cornea. The treatment consists in constitutional management, suited to this particular cachexy conjoined with an inflammatory process in an im- portant part; in slight local depletion by leeches ; in applying nitrate of silver to the integument of the lids, lightly, so as to blacken merely; in the use of a weak solution of this substance as a collyrium, and in counter-irritation by blistering behind the ear. The last remedial means, however, is to be used with caution; otherwise, it is apt to excite troublesome scrofulous enlargement of the cervical glands. Sometimes benefit is obtained by the local use of belladonna, smeared over the eyelids, which seems to act as a sedative in such cases. Or, it may pro- bably afford relief by temporarily paralyzing the iris, and so placing that contractile texture in a condition of repose. In the early stage of the disease, an emetic is generally of much service. No medicine, however, seems to act so beneficially as quinia, which often displays a decided influence in allaying the morbid sensibility, relieving the intol- erance of light, and removing the inflammation. For bathing the eyes, warm water is used, simple or medicated with opium. The child should have a solid and nutritious diet, and should not be confined to the house, unless during cold and wet weather. Granular Conjunctiva. The granular condition, dependent on a hypertrophied state of the mucous papillse of the palpebral conjunctiva, has been already noticed 120 GRANULAR CONJUNCTIVA. —as constituting an important integral part of purulent conjunctivitis. But a similar change of structure may occur, quite independently of this latter disease. It may be the re- Fig. 31. suit of a chronic inflammatory process resident in the palpebral membrane. At first, doubtless, there is mere enlarge- ment of the normal structure; but after a time, this is more or less altered by continuance of plastic deposit; the sur- face becoming dense as well as pro- minent, rough, irregular, and sometimes fissured. The upper eyelid is more prone to suffer than the lower. It can be readily understood how such a structure, at each movement of the lid, must greatly fret the ocular conjunctiva, causing an irritation there sufficient to light up inflammatory action, and more Granular conjunctiva. The eyelid everted, than sufficient to maintain an action which has been already established. To remove the alteration of structure, therefore, becomes a most important therapeutic indication. In the first instance, scarification of the eye- lid is to be employed; followed by the application of nitrate of silver, used either lightly in substance on the part or in strong solution. If the nitrate prove unsatisfactory, other astringents may be employed instead. Failing these, the altered part is to be removed by knife or caustic. The nitrate of silver or sulphate of copper may be applied firmly to the surface, so as to have a destructive effect. But in general, it is better to remove at once, by knife or scissors, the enlarged granules; great care as usual being observed, lest by excessive ablation entropion be established on cicatrization. The general health ought in all cases to be attended to, as the disease frequently occurs in lymphatic or stru- mous individuals. Bepose of the eye ought to be enjoined, with due attention to diet, exercise, and change of air. [A decided objection to the removal of granulations of the eyelids by the knife or scissors, and even to the free scarification of the lids, exists in the fact that permanent thickening, induration, and irregularity of the mucous surface of the lid, is usually the result of all such proceed- ings. It is much better to trust to the local applications advised by the author—nitrate of silver in substance or in strong solution (9j or 3ss to the ounce of fluid), or a smooth crystal of sulphate of copper—and to the administration of proper alteratives, of which one of the best, as has been found at the Wills Hospital, is cod-liver oil. This method will not procure the removal of the granulations so speedily as excision; but the cure will be more permanent, and will not be attended by the unpleasant consequences alluded to. The applications should be made every second or third day, according to their effect. The altered condition of the ocular conjunctiva and cornea, induced by the state of the lids, generally demands appropriate treatment also. —Ed.] CORNEITIS. 121 Pterygium. Pterygium denotes a vascular and fleshy thickening of the ocular conjunctiva. The formation is of a triangular form; the base resting on the internal or external canthus, and the apex stretching towards the cornea. When of moderate size, and not advanced farther than the corneal margin, vision is not interfered with ; but when it begins to encroach on the cornea, the affection then ceases to be a mere deformity or inconvenience ; sight is in danger, and remedial measures are required. Sometimes the web is thin and membranous; consisting chiefly of varicose vessels held together by fine areolar tissue. Sometimes the structure is dense, firm, and fleshy ; sometimes it contains a large proportion of adi- pose substance. The term Pannus is applied only to those cases in which the cornea is completely covered with red vessels, presenting the appearance of a piece of red cloth^ and very materially interfering with vision. In the milder cases of pterygium, a cure may be attempted by scari- fication and astringents ; the scarifications being made across the dilated vessels, in the sclerotic conjunctiva. In those cases in which the cornea is en- croached upon, excision of the sclerotic portion is to be.had recourse to, if the milder measures fail, as they are likely to do. The membrane is elevated by a fine hook, and carefully removed by knife or scissors. The corneal covering is then usually found to disappear. When, in pannus, the whole cornea is covered, a cure is said to have been effected by in- oculation of the morbid tissue with the discharge of purulent conjunctivitis; the inflammatory action which thence results having the effect of breaking up the morbid tissue, and rendering it amenable to removal by absorption. This, however, is a very dangerous mode of treatment; the eye may be lost in consequence of the violent inflammation which is induced, and the patient's health may be much injured by the severe measures which may be requisite to subdue that inflammation. Such procedure, therefore, is plainly inapplicable, except to those extreme cases in which the cornea presents no sound part, but is completely and thickly covered; and in which, consequently, the condition of the eye can scarcely be made worse. Affections of the Cornea. Corneitis. The inflammatory process, affecting the cornea, may be either an ori- ginal affection, or merely an extension from previously existing conjunc- tivitis. It may originate either from injury done directly to the part Fig. 32. Pterygium, double. 122 CORNEITIS. itself, or from an exciting cause applied to some other part of the surface of the eye. The conjunctival investment only may be involved; and this is most likely to occur when the affection is a* mere extension from conjunctivitis; or the action may be mainly and originally resident in the proper substance of the cornea. All forms of conjunctivitis, when of any duration, are apt to implicate the cornea; but the strumous form more especially. A red zone of dilated vessels encircles the corneal margin, generally at the upper part; and between the two there is no intervening clear space of white sclerotic, as in affections of Fig. 33. the deeper parts of the eye. When the conjunctival covering is involved, small hair-like vessels are seen ramifying on it, in greater or less number, continuous with those constituting the outer zone. When the proper substance alone is affected, such vascularity is, in the first instance, not dis- / cernible, unless by the aid of a magnifying / glass. There is pain in the eye, and in the orbit generally; lachrymation and in- tolerance of light. By and by, the cornea loses its transparency, becoming turbid, and of a bluish-white appearance. The various results of the inflammatory process may then ensue—varying according to the intensity of the action; deposit of plastic lymph, pro- ducing thickening and opacity; formation of pus between the corneal layers, afterwards absorbed, or making its way either externally or into the anterior chamber; chronic ulceration, commencing superficially with mere abrasion, in which case the surface of the cornea is more or less rough, and bears some resemblance to a piece of ground glass, but which appearance, on close inspection, is found to consist of a crowd of minute ulcers ; or, there may be a large ulcer, originating in the giving way of a pustular formation; lastly, sloughing, either of the whole or of a part, seldom occurring in the case of simple corneitis alone, but only when this is part of an extensive and severe ophthalmia. If a foreign body be left imbedded in the cornea, it is very evident that inflammation, suppuration, and ulceration must ensue; in obedience to the general law, whereby natural extrusion of foreign matter is effected in all living textures. In the treatment, general depletion is not often necessary; local abstraction of blood, however, by leeches, is of much service. Counter- irritants, by means of blisters behind the ears, are of use. Purgatives, antimony, and mercury are the most appropriate remedies for arresting the progress and removing the effects of the disease. But, of these, mercury seems to act more beneficially than any other. When a debili- tated condition of the system causes protraction of the malady, the eye continuing irritable and intolerant of light, quinia and an improved diet will be required. At first, the local applications should consist of opiate fomentations; but as the disease becomes more chronic, weak stimulants, as vinum opii, or a solution of nitrate of silver (four grains to the ounce) are to be employed. ABSCESS OF THE CORNEA. 123 Strumous Corneitis is of very frequent occurrence in the young; it is more chronic than the simple form, and usually mainly resident in the conjunctival covering. The vascularity is less, and more diffuse; and the zonular arrangement at the corneal margin is less distinctly marked. Opacity is the ordinary result; and pustules, ending in troublesome ulcers, are not uncommon. The treatment is such as is calculated to subdue chronic conjunctivitis, with an especial reference to the depraved state of system. Mild mercurials should be given to check the deposition of opaque matter in the cornea ; and, combined with these, quinia is useful to improve the general state of the system. ' In general, the affection proves of rather an intractable nature. Aquo-Capsulitis.—This term denotes the inflammatory process resi- dent in the serous membrane of the aqueous humor, including the inter- nal layer of the cornea. It may occur per se ; or it may form an integral part of the preceding affection. It is characterized by " a pale, deeply-seated opacity, which is unequally distributed, imparting to the cornea a mottled appearance; and by a turbid or cloudy state of the aqueous humor." Sometimes lymph is exuded, and coats the membrane.. This disease is very apt to run on to inflammation of the iris. The treatment is as for corneitis, or iritis. Abscess of the Cornea. Matter, as we have seen, may form between the layers of the cornea ; a result of corneitis. If it collect at the lower part, the accumulation usually assumes a crescentic form, resembling the Avhite semilunar mark at the root of the nail; and hence such an appearance is termed Onyx. But it may be deposited elsewhere, in the form of dots or points, which may either remain separate, or may unite with each other by increase and extension. The fluid seems to be purulent. It may, however, be a less advanced inflammatory exudation. Antiphlogistics Avill plainly be the most likely means whereby the secretion may be arrested, and its disappearance by absorption favored. And in order to effect these two indications rapidly, in time to save structure and function, the systemic influence of mercury is highly available—obtained as soon after local bloodletting as possible. Failing absorption, one of three events may occur. The small collection may spontaneously discharge itself internally into the aqueous humor, form- ing an hypopion ; or it may assume the pustular form, and escape exter- nally, when an ulcer will be the result; or an artificial opening may be made for its external evacuation. In the greater number of cases, the artificial opening is withheld, in the hope that disappearance by absorp- tion may take place; and the frequency with which this result does occur, would lead to a suspicion that the fluid is not truly purulent. If, however, the fluid be of considerable quantity, causing tension in the part, and painful symptoms of an aggravated character, the apex of the abscess may sometimes be touched beneficially, with a fine point of the nitrate of silver. A small slough is thrown off, the matter is discharged, and an ulcer remains, which heals readily. The only application to the eye should be opiate fomentations. 124 ULCER OF THE CORNEA. Ulcer of the Cornea. Ulcers are often the result of corneitis. Their origin may be from without, when the conjunctival covering of the cornea is chiefly affected, and then the commencement is with superficial abrasion, sometimes extensive ; or a pustule forms, elevating the conjunctival layer ; and, on the giving way of this, ulceration follows, still superficial. Or the origin may be from within; matter collects between the true corneal layers, and is discharged externally, leaving an ulcerated aperture; or foreign matter has lodged in the cornea, and is extruded by suppuration and ulceration. In either of these latter cases, the ulcer is deeply seated and serious. The ulcer here, as elsewhere, presents different characters under dif- ferent circumstances. Sometimes it is acute ; the inflammatory action is still in progress, loss of substance is advancing, and there is no attempt at repair. * In this state, the ulcer looks as if a portion of the corneal substance had been dug out mechanically ; the edges are abrupt, or they may be thickened and swollen, and in and around them are the usual signs of inordinate action. Very frequently, a distinct plexus of vessels is found leading to the ulcer. The pain, lachrymation, and pho- tophobia are most distressing. Or the ulcer degenerates into the irri- table form; the loss of substance growing neither larger nor less ; the margins and surface showing an angry and vascular appearance, often as if covered with a layer of wetted chalk ; and the symptoms all under- going intense aggravation. Or the sore may be of a healthy and healing disposition. Then the edges are less abrupt, and as if bevelled off; the chasm is diminishing; a white haziness surrounds the margins, and invests the surface, denoting the deposit of plastic exudation ; and the unpleasant symptoms are all very much diminished. Or the ulcer may stop short in the progress towards cicatrization, and assume the indolent character; becoming stationary, and causing comparatively little incon- venience. This last phase, however, is certainly not the one of most frequent occurrence. In the case of the acute ulcer, it is obvious that the only suitable treatment is antiphlogistic, with mercury given, if necessary, in small quantity, in order to change the perverted condition of the capillaries; and this is to be continued, along with an especial regard to the general health, until the overaction is subdued, and symptoms of repair succeed those of destruction of texture. Then, in the healing sore, we must con- tent ourselves with watching the natural progress of cure, and carefully guarding against reaccession of inflammatory action, by exclusion of light and other stimuli, by regulation of diet, and by the use of tepid soothing applications. In the irritable sore, nothing is so useful as the nitrate of silver, applied either lightly in substance to the ulcer, or in solution by means of a hair-pencil. It acts probably in two ways ; by its escharotic power destroying the sentient extremities of the nervous tissue; by its coagulating power forming a protecting film for the raw surface. The application is repeated every second or third day, until the irritability cease; or the interval is shortened or increased, as cir- MVOCEPHALON. 125 cumstances may seem to require. When either the irritable or inflamed condition threatens to prove obstinate, great benefit often is derived from counter-irritation by blistering behind the ears. For the indolent sore, the various stimulant collyria are suitable. When the strumous habit is strongly declared, as it too often is in ulcerated cornea, little permanent good will be done by any local management, unless constitutional treat- ment be at the same time duly employed. As a general rule, the preparations of lead should never be employed as collyria, in the case of ulcer of the cornea. An insoluble chloride of lead will be formed; and this, becoming entangled in the cicatrix, will render it more irremediably opaque than it otherAvise would have been. The sustained use of nitrate of silver, also, should be conducted with caution, lest an olive-colored stain ensue. When the ulcer is deep, acute, and situate near the centre of the cornea, there is great risk of perforation of the inner layer, escape of the aqueous humor, and protrusion of the free margin of the iris, to a greater or less extent. To obviate this last accident as much as pos- sible, belladonna is employed to maintain a dilated state of the pupil; so that the margin of the iris may be retracted out of harm's way. If, however, the site of ulcer be towards the circumference, the use of bel- ladonna would probably be prejudicial. Previously to completion of the perforated aperture, the membrane of the aqueous humor sometimes protrudes in the form of a small trans- parent vesicle; this condition is termed Hernia of the Cornea. It ought to be touched occasionally with a solution of nitrate of silver, and the iris should be kept fully dilated by belladonna to prevent its being pro- lapsed, in the event of complete perforation taking place. Sometimes the perforating ulcer heals only in part, contracts, but does not close, becoming a fistulous aperture, through which the aqueous humor continues to escape. This is remedied by the occasional appli- cation of nitrate of silver, finely pointed, to the part, and by a tonic system of treatment constitutionally. The iris, protruding through the perforated cornea, forms a black tumor, usually of no great size; bearing a slight resemblance to the head of a fly; and, therefore, termed Myocephalon. Sometimes the iris does not protrude, but simply rests upon the aperture, and closes it up ; and in this abnormal position it may become adherent. In either case, the pupil will be deformed, and vision may be seriously impaired. The indica- tions of cure are to restore the iris to its normal position, and to hasten cicatrization of the aper- ture. In recent cases the protrusion, when slight, may be overcome by placing the patient on his back and applying belladonna; and anti- phlogistics are to be employed, to avert or moderate the inflammatory action which is to be expected to ensue. When, however, protrusion is considerable, the aperture being capacious, immediate replacement is not desirable; temporary and partial protrusion being the salutary means whereby Nature prevents complete escape of the aqueous humor, 126 OPACITIES OF THE CORNEA. and consequent collapse of the eye. Under such circumstances, we content ourselves with rest, exclusion of light, supine posture, use of belladonna, and occasional application of the nitrate of silver; thus pro- moting healing of the sore, removing irritability of the texture involved, and favoring gradual replacement of the iris. In cases in which the displaced portion of the iris has contracted permanent adhesions with the cornea, replacement cannot be effected; removal of the protruded part is had recourse to, either by cutting instruments or by caustic; and then cicatrization of the remaining sore is attended to. Opacities of the Cornea. Nebula is the thin cloudy opacity which follows inflammatory affec- tion of the conjunctival covering of the cornea. It arises from slight structural change remaining in that tissue, and is the form of opacity most likely to be removed, so as to leave the part altogether of its healthy character. The indications of treatment are—to obtain final extinction of any inflammatory excitement which may remain; and, afterwards, to favor disappearance of the structural change, by absorp- tion. The former indication is fulfilled by the usual means ; the latter, by the guarded use of various stimulant applications. The nitrate of silver, sulphate of zinc, or other substances, may be applied in solution; or fine powders—as calomel, oxide of zinc, alum, &c.—may be blown on the part through a quill; great care being always taken that this part of the treatment is not overdone, and inflammatory reaccession, Avith probable extension of the opacity, consequently re-established. In the more obstinate cases, iodine is said to be advisable, both externally and internally. And of late, the local use of hydrocyanic acid has been found of considerable avail. The state of the ^eyelids should, in all cases, be carefully attended to; for, not unfrequently, a granular condition of the palpebral conjunctiva is the cause of the opacity's continuance, if not of its first formation. The curative process is neces- sarily gradual; and patient perseverance in the use of remedial means is consequently required. Albugo denotes the more deeply seated opacity which results from plastic exudation between the layers of the cornea. It, too, is amena- ble to absorption ; but not so favorably as the conjunctival deposit. The treatment is conducted on the same principles ; but with a certainty of longer perseverance being required, and Avith a less sanguine expec- tation of an altogether successful issue. If the changed part be seen traversed by bloodvessels, the prospect of complete cure may be re- garded as especially unpromising. Leucoma is the dense pearly opacity which results from cicatrization of a granulating wound or ulcer of the cornea; it is, in short, a corneal cicatrix—thick, opaque, and little amenable to change. Some- times there is a black point in the otherwise white opacity ; denoting entanglement, at that part, of a portion of the iris. Treatment, with the hope of discussion, is of little or no avail. Remaining overaction is subdued, and stimulants employed. But the latter are not used with the hope of altering the cicatrix itself; but only in order to dissipate STAPHYLOMA OF THE CORNEA. 127 the nebulous or the albuginous halo, with which the leucoma is usually surrounded. If the opacity be central and small, vision will be greatly improved by habitual dilatation of the pupil by means of belladonna ; if it be both central and large, the only hope of amendment is by the formation of an artificial pupil. It has been proposed to dissect off opacities of the cornea; but, ob- viously, success can never follow any such procedure; inasmuch as the loss of substance, caused by the dissection, must heal in the ordinary way, and so healing must produce at least an equally opaque and ex- tensive cicatrix. It has been proposed, however, to operate in one class of cases, with a rational and fair prospect of ultimate benefit. The opacity which follows injury of the cornea by sulphuric acid, would seem, occasionally at least, to be a chemical incrustation on the cornea, rather than a vital change of and in its structure ; sulphoproteic acid is said to be produced, and adheres to the external layer of the cornea ; and this may be scraped away, immediately after receipt of the injury, by the edge of a fine knife, leaving the rest of the part clear and free.1 [In his " Lectures on the Parts concerned in the Operations on the Eye," London, 1849, Mr. Bowman gives an account of two cases in which this operation was performed with complete success on both eyes of each patient. The opacity came on gradually, and without contact of acid, or any other special cause. The opaque patches were brown- ish in color, mottled with dark dots, and stretched horizontally across the cornea, so as completely to obscure the pupils, unless these were much dilated; they seemed to be superficially situated, as if in the anterior elastic lamina of the cornea. Ordinary treatment having been entirely unavailing, the point of a knife was applied, the epithelium first removed, and then the hard opacity which came off in flakes, leav- ing the pupil perfectly transparent. The operations were painful, but no inflammation folloAved of any consequence ; in a few days new and healthy epithelium was reproduced, without any return of opacity, and vision was very much improved ; in one eye, in fact, the sight was so good, that the smallest "pearl type" could be read with it. The opacity consisted of salts of lime and magnesia, principally phosphates.—Op. cit. pp. 117-121.—Ed.] In advanced years, and sometimes even in the comparatively young adult, the corneal periphery gradually becomes opaque, and of a gray color. The affection is termed Arcus senilis ; a mere deformity ; and not amenable to remedial treatment. [This circumferential opacity has been demonstrated by Mr. Canton, to depend upon & fatty degeneration of the margin of the cornea. It frequently coincides with the same abnormal condition of other organs, as of the heart.—Ed.] Staphyloma of the Cornea. Staphyloma of the cornea is an opaque projection of a part, or of the whole of this membrane. 1 Lancet, No. 1010, p. 537. 128 STAPHYLOMA OF THE CORNEA. Fig. 35. Staphyloma. Partial staphyloma is usually situated at the lower or lateral part of the cornea. The iris is adherent to the whole inner surface of the pro- jection, and, consequently, the anterior cham- ber is much diminished in size; generally, the pupil itself is more or less involved, and vision rendered very imperfect. The affection is caused by an ulcer penetrating the cornea, and allowing the iris to become prolapsed through the opening. When a considerable portion of the iris has protruded, it does not shrink when the inflammation subsides, but remains, and forms a. projection at that part of the cornea. After a time, the exposed projection of the iris is covered by an opaque firm tissue, of the nature of cicatrix, the edges of which become incorporated at the base with the sound cornea. It is generally the consequence of strumous, catarrhal, or purulent oph- thalmia. Total staphyloma is formed exactly in the same way ; it differs only in degree. When, as is often the case in purulent ophthalmia, the whole or greater part of the cornea is destroyed, the iris falls forwards, the pupil closes, and the aqueous humor, accumulating in the posterior chamber, keeps the iris distended in the form of a tumor in the front of the eye. The surface of this tumor, as in the partial staphyloma, be- comes gradually covered with a firm opaque cicatrix-like tissue of more or less thickness ; and a total staphyloma results. This pseudo-cornea, or staphyloma, has the form and appearance of a small globe stuck on the front of the eye, with sometimes a ring of the proper cornea sur- rounding its base. It is often so large as to project considerably from between the eyelids, and prevent them from closing. When the staphyloma is large, the iris, being unable to expand to the same exent*as the pseudo-cornea, is torn and separated from the choroid; and when the staphyloma has been removed, the iris is found in contact with its posterior surface, broken up and in shreds. This does not occur in a small or partial staphyloma. Vision in total staphyloma is com- pletely destroyed. For the treatment of a small partial staphyloma, the less that is done the better; except to guard against any tendency to inflammatory action. If it be large and implicate the pupil, the projection may be diminished, by touching it from time to time with some caustic—as the caustic po- tass—in order to produce condensation and contraction; which it does by exciting a slow inflammatory process. In the total staphyloma, relief is sometimes obtained by puncturing it from time to time with a large cataract-needle, and allowing the aqueous humor to escape, when the projection collapses. As the aqueous humor, however, becomes almost invariably reproduced in the same or even greater quantity, and as the staphyloma is a great deformity, besides keeping up a constant state of irritation which is apt to extend to the other eye, its removal should be recommended, so that an artificial eye may be worn. In removing a staphyloma, the eyelids being properly fixed, and a hook passed through the projection in order to command OVER-DISTENSION OF THE CORNEA. 129 the globe, the base of the tumor is transfixed with a cataract-knife from its temporal to the nasal side, a little below its transverse diameter; the knife is then pushed on, and a flap is formed as it cuts itself out. This flap is seized Avith a pair of beaked forceps, and that part of the base of the staphyloma which remains uncut is divided with curved scissors, and the Avhole removed. The lens and some of the vitreous humor often escape; but generally sufficient remains to form a good stump for an artificial eye. After the operation, a pledget of lint, soaked in cold Avater, should be kept applied upon the eyelids, as a preventive of in- flammatory action. If severe reaction supervene, it is to be treated by active antiphlogistics. When bleeding folloAvs the operation, it is checked by cold Avet compresses, or by ice applied over the eye.1 Conical Cornea. Sometimes the cornea, " retaining its transparency, gradually assumes a conical or pyramidal form; and when viewed from certain positions, reflects the light so strongly as to exhibit a peculiarly brilliant and sparkling appearance, characteristic of the disease. It generally affects both eyes, though not in an equal degree; has been observed at all periods of life, but more commonly about the age of puberty; and is said to be most preAralent among females."2 On the Avhole, it is a rare affection, and fortunately so, being but little capable of amendment. If the apex protrude from between the lids, it is liable to become opaque. Or ulceration Fi 36 may take place ; and then staphyloma is not unlikely to supervene. In the clear conical cornea, palliation may be obtained by adapting concave spectacles provided with a small central transparency. Lately, it has been said that amendment, if not cure, has followed perseverance in the use of purgatives and emetics ;3 but how the bene- ficial result is so obtained, it is not easy to un- Conical cornea. derstand or say. When the apex is opaque, temporary amelioration of sight may be secured, by transferring the pupil to a point of the circumference which is as yet clear. Over-distension of the Cornea. Simple over-distension of the cornea, by an unwonted accumulation of the aqueous humor, produces both dimness and prominence. If this state be the concomitant of an existing inflammatory process pervading the eye, as corneitis, by subjugation of this the cornea will sometimes be restored. If, on the other hand, the morbid state is not so connected, but of a passive and indolent nature, antiphlogistics Avill do no good, and are likely to do harm. From the internal use of the iodide of 1 Vide Wharton Jones's Manual, p. 186, et seq. 2 Littell, p. 188. 3 Dublin Journal of Medical Science, January 1844, p. 357. 9 130 STAPHYLOMA OF THE SCLEROTIC. potassium, or—failing this—from a cautiously given alterative course of mercury, more benefit is to be expected; a diminution being thus made in the aqueous humor, on whose plethora the over-distension de- pends. Repeated evacuation of the aqueous humor, by means of a needle, is often of service. Affections of the Sclerotic Coat. Sclerotitis. This may occur as part of a general inflammatory process, however excited. Not unfrequently, it exists per se, and then almost uniformly is of rheumatic origin; exposure to cold, probably, having proved the exciting cause. It is most frequent in the adult, and about the middle period of life, and is often limited to one eye. Pain is complained of, of a dull, aching kind; increased by pressure, and by movement of the globe; partly resident in the eye, but mainly in the forehead and tem- ple ; and marked exacerbation occurs at night. At the commencement of the disease, the eye feels hot and dry; but this state is soon suc- ceeded by an increased secretion of tears. There is generally, how- ever*, little lachrymation or intolerance of light. The minute sclerotic vessels are seen enlarged, radiating in straight lines, to form a vascular plexus or zone of a pink hue, around the circumference of the cornea (Fig. 29); and a narrow white line often encircles the cornea, between that membrane and the pink zone. Not unfrequently, the pupil is con- tracted, and incapable of its wonted activity of motion; this denotes that the iris has participated in the morbid action. The conjunctiva, too, frequently sympathizes more or less ; and by its large, florid, tortu- ous vessels, the sclerotic characters may be in part obscured. There are often rheumatic pains in other parts of the body. Antiphlogistic treatment is to be had recourse to, with an activity and continuance proportioned to the intensity of the symptoms. The iris ought to be placed and kept under the influence of belladonna. Mercurial and anodyne frictions should be made on the temple and brow. And the system is to be put under the influence of colchicum, iodide of potassium, guaiac, salines, or other remedies of antirheumatic virtue. Cinchona and soda, five grains of each, given three times a day, sometimes cut this disease short when exhibited at its commence- ment. Counter-irritation, by blisters behind the ears, is also of ser- vice. The only local application should be tepid fomentation, either simple or medicated. Occasionally, the affection is found associated with ague, and then a combination of quinia with colchicum is found of much service. Should the iris become involved, the systemic in- fluence of mercury is to be unhesitatingly employed, conjoined with the ordinary antiphlogistic treatment proper for the cure of that affection. Staphyloma of the Sclerotic. This is much less frequent than staphyloma of the cornea. Gene- rally, it is the result of inflammatory action in the choroid and change CHOROIDITIS. 131 of structure so induced. The sclerotic becomes attenuated, and yield- ing ; the choroid coat, engorged, shines through it, and irregular bulging forwards takes place, constituting several swellings of a bluish or leaden hue. The external vessels are usually enlarged and tortuous. The bulging is often to a great extent, and consequently demands surgical interference. When protrusion takes place from between the lids, then diminution by either puncture or incision is expedient, as in the analo- gous affection of the cornea (p. 128). Puncturing the staphylomatous swelling from time to time, and allowing the fluid within to drain off, sometimes diminishes the size of the globe; but, if this be not effectual, Fig- S7. Fig. 38. Fi^. 37 Staphyloma of the Sclerotic Coat, Fii;. 3S. The same disease, seen in front. Staphyloma Been in profile. racemosum. the humors ought to be discharged through an incision in the cornea, or the cornea itself may be altogether removed, and then the globe will collapse, and the eye shrink to a small size. In the early stage, internal use of the arsenical solution seems to exert a beneficial influence in preventing or checking the bulgings of the sclerotic. Affections of the Choroid Coat. Choroiditis. Choroiditis, though a frequent associate of iritis, sometimes evinces an independent existence. It is generally confined to one eye, and is most common in females of a strumous tendency. The early symptoms are often gradual and insidious, because chronic. Musca; volitantes and an impaired state of vision usually first attract the attention of the patient. These slowly increase, and terminate eventually in more or less complete amaurosis. Sclerotic vascularity is exhibited, in a faint and imperfect degree, at an early period of the disease; it soon becomes aggravated, however, and is generally more distinct at one or two points than at others. It is accompanied with a feeling of tension and deep-seated pain, often severe, and extending to the surrounding parts; the eyeball is tense and hard to the touch, and by pressure the pain is aggravated; some- times there is intolerance of light and photopsia. 132 MUSCiE VOLITANTES. The sclerotic now becomes attenuated by absorption, assuming a dull blue or leaden hue from the dark choroid shining through it; it also becomes irregularly prominent at certain points. The pupil is dilated, irregular, and of impaired mobility; it is frequently dragged and displaced in the direction of the prominences on the sclerotic; vision is more or less impaired. Ultimately, the whole globe becomes enlarged, and staphyloma of the sclerotic takes place, the thinned coat having been pushed forwards, either by the swelling caused by the enlarged and tortuous vessels of the choroid, or by the exudation which has taken place from them. By the inward pressure, too, the retina has become more and more affected, being pressed towards the centre of the eye, where occasionally it may be seen through the pupil, in the form of a glistening or whitish cord; loss of vision is at length com- plete. General internal ophthalmia is not unlikely to supervene. Treatment should consist in the abstraction of blood, both generally and locally, but more particularly in the latter way; in the early stage of the disease, the extreme vascularity of the choroid being more de- cidedly influenced by abstraction of blood than by almost any other remedy. In the subacute form, blood is to be withdrawn with more caution; and, in both forms of the disease, counter-irritation is of good service. Purgatives also are useful. Mercury, given so as slightly to affect the system, seems in many cases to arrest the untoward progress; but, when the malady is connected with a strumous habit, it requires to be given with great caution, and generally should be combined with quinia, iron, iodine, and the like. In such cases, nutritious diet, good air, and exercise are also beneficial. The arseniate of potash given in small doses, three times a day, has often proved beneficial in the ad- vanced stage, when other remedies have failed. If staphyloma of the sclerotic have occurred, puncture or incision may become "necessary, as already explained. Muscse Volitantes. Weak vision, rendered imperfect and interrupted by opaque bodies seeming to float before the eye, is generally understood to depend on congestion of the choroid coat. The ordinary cause is over exertion of the organ, combined with sedentary habits ; it is also often symptomatic of derangement of the stomach. The remedial treatment "consists of moderate depletion from the neighborhood of the part, gentle purging, alteratives, careful diet, repose of the organ, bodily exercise, and ulti- mately tonics. Affections of the Iris. Iritis. Inflammatory action in the iris may be the result of injury, or it may be of idiopathic origin; it may occur primarily, itself constituting a disease, or it may be but a part of general deep ophthalmia; it is often connected with the syphilitic and mercurio-syphilitic taints of system; and, not unfrequently, it is of a rheumatic character. IRITIS. 133 Fig. 39. A pink or brick-red vascular zone is seen on the sclerotic, formed by the minute subdivisions of the anterior ciliary arteries. This zone is most distinct near the edge of the cornea, and becomes gradually shaded off toAvards the circumference of the globe; it is more or less marked, according to the extent and stage of the inflammatory action. There is at first a distinct interspace of white be- tAveen the vascular zone and the corneal margin ; ultimately, this white line becomes obscured by involvement of the conjunctival vessels in the inflammation. The pupil is contracted, and much less movable than in health, under the ordinary stimulus of light. Indeed, returning mobility of this part is one of the first and surest signs of amendment having fairly begun.1 The iris changes its hue; if of a light color natu- rally, it becomes greenish ; if dark, it as- sumes a reddish-brown appearance. It is also perceptibly swollen, or thickened at Iritis; showing the characteristic -vas- cularity of the globe, the iris clogged with lymph, the pupil contracted and irre- gular. 1 Gromelli, from the observation of successful injection, concludes the iris to be an erectile tissue. He supposes that contraction of the pupil, during the inflammatory pro- cess, depends simply on engorgement of the radiating vessels, which are fixed at the cir- cumference, and free at the pupillary margin ; and that return of the blood, in resolution, allows the iris to shrink, and the pupil consequently to expand.—Brit, and For. Rev. No. ■J.-K p. 233. [The existence of muscular fibres in the human iris, as the cause of the contraction and dilatation of the pupil, long suspected, has been recently satisfactorily proved by Mr. Lister, of England. An interesting account of his investigations upon this subject is con- tained in the first No. of the Quarterly Journal of Microscopical Science. Mr. Lister has shown that a distinct sphincter and also a dilator muscle may be recog- nized. Their structure belongs to the unstriped variety of muscular tissue, consisting of elongated fibre-cells containing elongated nuclei, and collected in bundles. After stating the mode of examination, and the dimensions, and other physical properties of these ele- ments, Mr. Lister remarks that "the sphincter muscle is readily seen, while the dilator is that whose investigation alone presents very serious difficulty. In the first iris that I ex- amined with a view to the distribution of the muscular tissue, I was struck, after removing the usual pigment,' with the appearance of a band on the posterior surface of the iris, near the pupil, and parallel to its margin, quite evident to the naked eye, elastic, and highly extensible. This proved to be the thickest part of the sphincter pupilhc. I havte examined six human irides with reference to the distribution of the muscular tissue, but in none have I had any difficulty in recognizing the sphincter, which I have also found equally distinct in some lower animals, viz., in the rabbit, the guinea-pig, and the horse. In man I find it about l-30th of an inch in width, thickest towards its outer part, where it lies nearer the posterior surface of the iris than the anterior, and thinning off towards the pupil, where it forms a sharp margin, covered apparently on its anterior aspect only by some vessels and nervous threads and a delicate epitheliated membrane, which is thrown into beautiful folds when the pupil is contracted. The fibres of the sphincter are not absolutely parallel, and this deviation is probably produced in part by the dilating fasci- culi sweeping in at various parts in a curved manner, and becoming blended with the sphincter. By teasing out under the microscope a portion of the actual pupillary margin, I found the sphincter to consist at this part of apparently unmixed muscular fibre-cells, without any connecting cellular tissue," &c. {op. cit. p. 13.) "On teasing out portions of the outer part of the human iris, I have found long delicate fasciculi, whose faint out- line, absence of fibrous character, and possession of well-marked elongated nuclei parallel to the direction of the fasciculus, left no doubt in my mind that they were plain muscular 134 IRITIS. its pupillary margin; sometimes it is seen of increased vascularity, and bulging forwards in the anterior chamber. The eye is painful, intole- rant of light, and there is increased lachrymation; pain is felt in the brow, temple, and head, and undergoes marked nocturnal exacerbation. Sight is greatly impaired. As the disease advances, these symptoms increase. The aqueous humor becomes turbid. Plastic deposition takes place from the surface of the iris; sometimes coating it with a thin layer, sometimes studding it with nodulated points; sometimes diffused in the anterior chamber ; often and most frequently situate at the free margin of the iris, hanging pendulous in fringes from the circumference, forming a delicate network stretched across, or perhaps completely blocking up the already con- tracted pupil. And at this stage, if not before, the contracted pupil is found to be irregular in form, in consequence of adhesions having taken place between it and the capsule of the lens ; an irregularity, which becomes especially distinct when partial dilatation has been effected by belladonna. Extravasation of blood from the surface of the iris may occur; small clots are sometimes to be seen resting on it; or the blood may gravitate to the bottom of the anterior chamber, and accumulate there, constituting the state termed Hyposema. Or effusion of pus into either chamber may take place. The pus forms small abscesses on the iris, which soon give way and discharge their contents ; and, gravitating to the bottom of the anterior chamber, it collects there, constituting Hypopion. Such events indicate an intense action ; not only likely to prove most prejudicial to the delicate texture involved, but also almost certain to extend to those adjoining. The result of fibrinous exudation is denoted by various terms, accord- ing to its extent and site. When fibrine blocks up the pupil permanently, the case is termed one of False Cataract. When adhesion has formed between the posterior surface of the iris and the capsule of the lens, it is termed Synechia posterior. When the iris, bulging forwards, has reached the posterior layer of the cornea, and become adherent thereto, the term Synechia anterior is applied. After a time, the vascularity of the organized fibrine can often be distinctly seen, when a strong light is thrown upon the part. During active advance of the inflammatory action the system sym- pathizes to a considerable extent; there is often a marked form of inflam- matory fever. Treatment.—Our principal object is to arrest the progress of the « tissue." (p. 14.) This is more clearly demonstrated in some of the lower animals, par- ticularly in the horse; in which "the dilating fasciculi appear to consist of precisely the same tissue as the sphincter, and to blend with it in their insertion." (p. 15.) "In the human iris I have seen a muscular fasciculus, as it appeared from the nuclei it contained, crossing the sphincter at right angles for a short distance : this observation, so far as it goes, seems to imply that the same mode of insertion of the dilator occurs in man as in the horse. The fibre-cells of the dilator appear to be held together much more closely than those of the sphincter, at least in the outer part of the iris; for I have never been able to define the individual fibre-cells in a perfectly satisfactory manner in the dilator, though 1 have often traced out portions of the outer part of the iris. The dilating mus- cular tissue is also probably less abundant than the muscular tissue of the sphincter; and this, if the fact, will help to account for the comparative difficulty in discovering it," &c. (p. 1G.)-Ed.] iritis. 135 disease at an early period, ere exudation or structural change has taken place, in order to avert all hazard to the important part, if possible. Our remedies ought to be early, active, and powerful. Blood should be abstracted freely, both generally and locally. The eye is kept dark or shaded, and should be frequently fomented. The bowels are freely moved; and then, as rapidly as possible, the system is brought under the full influence of mercury—unless there be some pre-existing and undeniable contraindication; for in general it is not till the mouth is affected mercurially, that the disease begins to amend. If the system, howlver, be strumous, and consequently intolerant of mercury—or when there is a known idiosyncrasy rendering all exhibition of the mineral dangerous by the induction of erethismus—then a substitute must be sought, likely to aid general antiphlogistics in preventing exudation, or in causing its absorption. Turpentine is often a valuable remedy for this purpose, when giAren in full and continued doses j1 but it is not always to be trusted to alone; it seems to act better when a small quantity of mercury has been previously given, and then its use frequently proves beneficial, not only at the time, but also in preventing relapse of the disease. From the first, belladonna is applied, so as to oppose the tendency to contraction in the pupil, and effect dilatation if possible. The semifluid extract is smeared on the eyebrow and temple, or an aqueous solution may be dropped between the eyelids; but the former method of application is usually preferred, at least in the first instance. In those cases in which mercury is not contraindicated, mercurial fric- tion on the temple and forehead is advisable, to maintain the constitu- tional effect which internal exhibition of the mineral has produced. In the more chronic form of the disease, counter-irritation may take the place of the direct antiphlogistics. And, ultimately, when traces of the affection still linger, the internal administration of tonics, especially of quinia, proves beneficial by dissipating the state of passive conges- tion which threatens to remain. When Hypopion has formed rapidly, and when the purulent accumu- lation is considerable, it has been proposed to make an opening at the lower part of the cornea, by means of a cataract-knife, so as to effect evacuation. This, however, is dangerous; it is better to trust to the sorbefacient powers of mercury, than to encounter the risk of aggravated inflammatory action. The extravasated blood of Ilyposema should receive the same treat- ment. Active antiphlogistics are had recourse to ; and these having told favorably on the action, the extravasated blood may be expected to disappear gradually by absorption. The occurrence of Ilyposema, however, as indicating a high degree of inflammation, is always of bad omen. The adhesions, or Synechise, are superable in the recent state. By perseverance in the local use of belladonna, the imperfectly organized ' Mr. Carmichael's Formula is as follows: Recipe, 01. Terebinth, rect. unc. imam; Vitel. unius ovi; Tere simul, et adde gradatim, Emuls. Amygd. unc. quatuor; Syrup, cort. aurantii unc. duas; Spir. Lavend. comp. drachmam, c. semisse; Olei Cinnamomi, guttas quatuor. M.-----Dosis, unc. un. ter in die. 136 CHANGES IN THE PUPIL AND IRIS. fibrine is extended or torn, and the iris recovers its normal play. At the same time, absorption of the deposit is to be favored, by moderate continuance of the mercurial friction. Syphilitic Iritis is a frequent variety of the affection, occurring as part of the secondary train of venereal symptoms. Its characteristics are : the accession along with other venereal symptoms; marked noc- turnal exacerbations; a dark hue of the vascular zone; fibrinous deposit occurring in nodules of a broAvnish hue, studded on the margin or the pupil as Avell as on the surface of the iris; and the margin of the pupil often observed to be thickened, and corrugated. This form generally is more severe, and runs its course more quickly, than the idiopathic variety of iritis. Treatment is as for ordinary examples of the disease. The Rheumatic and Arthritic Iritis is not of such frequent occurrence. It is characterized by: accession taking place along with other symp- toms of a rheumatic or gouty character; the vascular zone is of a pur- plish hue, and not a little obscured by early involvement of the con- junctival vessels; the whitish ring surrounding the cornea is more perceptible in this species of iritis than in any other; the pupil, con- tracting, inclines to assume an oAralform; and there is peculiar proneness to relapse. Treatment consists of the ordinary antiphlogistic remedies directed against acute and inflammatory rheumatism. Mercury should be given cautiously, and often requires to be combined with quinia as a tonic; in many cases its place may be advantageously taken by col- chicum, guaiac, or iodide of potassium. Strumous Iritis frequently results from extension of the inflamma- tory process inwards, in cases of strumous corneitis, and is the form of iritis most generally met Avith in childhood. The previously existing opacity of the cornea is very liable to mask the internal and more im- portant action; deceiving the practitioner as to its existence, until the opportunity for successful treatment has passed. Mercury should be used very sparingly; and, at a comparatively early period, the admini- stration of quinia, iron, iodine, &c, with a tonic regimen, is required. Changes in the Pupil and Iris. Unusual dilatation of the pupil is termed Mydriasis. It may be of idiopathic origin; or it may be connected with disorder in the cerebral functions; it is a common symptom of Amaurosis; and frequently it is caused by contusions; often it is sympathetic of intestinal irritation. The admission of an excess of light to the retina is found to be a serious inconvenience; and vision is confused and impaired accordingly. The remedial treatment consists in detection of the cause; removal"of this, if possible; and subsequent stimulation of the part, by frictions on the temple and brow, and by exposure of the eye itself to ammoniacal vapor. Electricity and galvanism are also sometimes useful. In the idiopathic forms of paralysis of the iris, M. Serres recommends cauterization of the corneal margin by nitrate of silver. In other cases, palliation results from contracting the space for admission of light, by spectacles OCCLUSION OF THE PUPIL. 137 darkened except at a small opening in the centre, as in the case of conical cornea (p. 129). *\S hen dilatation of the pupil accompanies amaurosis, of course it can- not be expected to disappear, unless the amaurotic condition have been previously removed. Myosis denotes unusual contraction of the pupil. This is one of the consequences of iritis, as we have already seen; it may also attend on disorder of the cerebral functions ; sometimes it is induced by habitual straining of the eye on small objects—as in microscopists, engravers, watchmakers, &c. Ordinary and useful vision is necessarily impaired. The means of cure consist in removal of the cause. In the artificers just enumerated, temporary abstinence from the usual aVocations Avill often suffice to restore the normal state. Tremulous Iris.—A trembling, or oscillatory movement of the iris, not unfrequently accompanies amaurotic affections; and seems also, in most cases, to be connected with softening of the vitreous humor. It is but little amenable to treatment; and is chiefly notable as a sufficient contraindication of operative interference, in connection with cataract and artificial pupil. Adhesions of the Iris—Synechise—have been already considered (p. 135). They may be the result of wound, of corneitis, or of iritis. In synechia anterior, complete, and accompanied with opaque cornea, cure is manifestly hopeless. When incomplete, and the cornea clear, amend- ment by the formation of an artificial pupil is within our power. When the adhesion is partial and recent, it may sometimes be remedied by mercurials, and the use of belladonna. Similar treatment will avail in synechia posterior, when recent and partial. But, when complete, it is usually accompanied with opacity of the crystalline capsule, and it may be of the lens itself; under such circumstances, amendment of vision can be effected only by an operation directed against the cataract. Occlusion of the Pupil. The pupil may be closed in various ways, llemaining itself in a normal state, it may be obscured by the cornea which has become simply opaque, or opaque and staphylomatous. Or, the cornea remaining clear, the iris may contract during inflammatory action, and the pupil may become occupied by organized fibrinous deposit. Or both iris and cornea may undergo serious structural change; as when complete synechia anterior takes place in staphyloma. In the last-mentioned case, restoration of sight is manifestly impossible. But in the other examples, something may be done by forming an Artificial Pupil. Before proceeding to any such operation, however, certain circum- stances are invariably to be taken into consideration. It must be ascer- tained—that the adhesions of the iris are irremediable by the influence of mercury and belladonna; that the opacity of the cornea is perma- nent; that the other parts of the visual apparatus—especially the retina and vitreous humor—are in a sound and healthy condition ; that the eye has not only ceased to be the seat of all inflammatory action, but, also, that it is not prone to resume such action on the application of a fresh 138 OPERATIONS FOR ARTIFICIAL PUPIL. exciting cause. An operation is also very properly held to be inexpe- dient, so long as the patient enjoys a tolerable degree of vision with the other eye; and it is plainly contraindicated, when one eye only is affected. Three distinct modes of operation are practised ; all implying division of the iris—so as to make a sufficient gap in it—opposite a clear por- tion of the cornea. The desired space in the iris may be obtained by incision, excision, or laceration. Accordingly, the operation is said to be by Coretomia, Corectomia, or Coredialysis. The situation of the proposed new pupil requires consideration. The centre of the iris is the best position; but when this is impracticable from central opacity of the cornea or other cause, the nasal side is to be preferred'; or it may be made on the temporal or lower sides. When made above the centre, it is apt to be covered by the upper eyelid. The patient, by previous preparation, should be placed in a condition favorable to the avoidance of inflammatory action. Fig. 40. Coretomia, or incision, is performed in cases where J the greater portion of the cornea is clear, and the iris is apparently in a state of tension, with the pupil Fig. 41. [The Iris-Knives of Sir AVilliam Adams, c. One loss than a line in width. d. One still narrower 1. Coretomia through the sclerotic. The knife introduced—rather far back. 2. Ccfretomia through the cornea, showing the lines of the incisions. 3. The same- after the operation. 4. Coredialysis, or separation. (From AATiarton Jones.) closed. It may be performed either through the scle- rotic or through the cornea. In operating through the sclerotic, an iris-knife is introduced through this mem- brane about a line from its junction with the cornea, as in the operation for cataract, and the point of the knife is made to pierce the iris at about a line from its temporal margin ; the instrument is then carried across the front of the iris in the anterior chamber, to the na- sal side of the cornea (Fig. 41, 1); and, while it is withdrawn again, gentle pressure should be made with its edge upon the iris, the tense fibres of which when divided will separate, and an elliptical or ovoid pupil will be the result. The fibres of the iris should be divided for about a half of the diameter of the mem- brane. When the lens is opaque, as is generally the (From Lawrence.)-Ei>.] case, it should be broken up at the same time. OPERATIONS FOR ARTIFICIAL PUPIL. 139 In operating through the cornea, a method practised by Maunoir, an opening is made in this membrane by a cataract-knife, involving about a third of its circumference ; into this aperture a pair of fine scissors is introduced, the pointed blade of Avhich is thrust through the Fig. 4: Fig. 43. /&* piaunoir's Scissors; so delicate that the thickness of the two blades united does not exceed that of an ordinary probe. (From Lawrence.)—Ed.] iris, while the blunt one is carried between that membrane and the cornea. The scissors are pushed on, till their farther pro- gress is arrested by the junction of the cornea with the sclerotic, when their blades are brought together, and the iris is divided as in the former instance. Or, another incision may be made with them, diverging from the first, and including a triangular portion, the apex of which is near the centre of the iris. The flap so formed Avill shrivel up in the direction of its base, and leave a sufficient opening for the admission of light (Fig. 41, 2 and 3). Corectomia, or excision, is performed through the cornea, in cases where a portion of that membrane is opaque. When the pupil is non-adherent, and only the centre of the cornea opaque, abroad Fig. 44. fiat needle, or the point of a cata- ract-knife, is passed into the ante- rior chamber at the lower or outer side of the cornea; through this aperture Mr. Tyrrell's fine blunt- hook is introduced, and having been entangled over 'the free mar- gin of the pupil, is withdrawn through the opening ; the included portion of iris being either excised with scissors, or allowed to rub off with the friction of the lids, after having become strangu- lated in the wound of the cornea. When the pupil is adherent either to the capsule of the lens, or to the cornea, a larger incision than in the former case should be made, near the junction of the cornea with Tyrrell's Blunt Iris Hook. Extensive Opacity of the Cornea. A portion left clear, suitable for an arti- ficial opening in the iris, by corectomia. Fig. 4.r». 140 OPERATIONS FOR ARTIFICIAL PUPIL. Fig. 46. the sclerotic, and through a clear portion of the cornea. The aqueous humor escapes, and is generally followed by a protrusion of the iris, which should be increased by gentle pressure on the globe; or a portion of it may be dragged out of the opening by a small hook; and when a sufficiency has been protruded, it should be excised with the curved scissors. Sometimes it is necessary to separate the adhesions with a needle, before the iris will prolapse. A portion of the pupillary margin should, if possible, be included in the excised part. Coredialysis, or separation, is performed when the cornea is opaque, except a small part at its circumference. Having made an opening about two lines in length through the opaque membrane, a fine sharp hook is introduced, which is fixed in the iris close to its ciliary border, and behind the clear portion of the cornea. When the hook is withdrawn, the iris is torn away from its ciliary attachment till an open- ing of sufficient size is obtained (Fig. 40, 4). The portion of the iris which is drawn out of the anterior chamber, may either be allowed to become strangulated in the edges of the incision, or it may be excised. This operation may also be performed by introducing a curved cataract-needle through the sclerotic, and carrying it across the posterior chamber, till it reaches that portion of the iris which it is wished to separate from its ciliary attach- ment ; here it is made to perforate the iris, and separation is effected by pressing the point dowmvards and outwards. [Dr. Hays, of this city, performed, in 1841, an operation which differed from those above described. The cornea was densely opaque in the centre, but perfectly clear beloAV, ex- cepting a few very minute points where it had been burned by grains of gunpowder ; the upper edge of the pupil ad- hered firmly to the cornea. The operation consisted in incising with a cataract-knife the cornea near its junction with the sclerotica, commencing a little below the middle, and extending the incision so as to divide nearly one-fourth of the circumference of the cornea. The knife was carried steadily and quickly forward, so that the aqueous humor should escape with a gush, and carry the iris before it to the incision, and that subsequent adhesion should take place be- tween the iris and the latter—all of which did occur, and excellent vision Avas secured to the patient. If the iris should not prolapse readily, it may be drawn down by a hook, as done by Himly, or pressure may be made upon the eyes from above.—Lawrence, Am. Ed. pp. 455-7.—Ed.] There is generally a considerable quantity of blood effused into the anterior chamber after all of these operations, and more or less inflam- matory action follows. Strict antiphlogistic treatment should be pursued, Avith confinement in a dark room. It is to be remembered that the new pupil, on its first formation, should seem rather too large than otherAvise; there being ahvays a decided tendency to subsequent contraction. [Sharp Iris- hook. (From Lawrence.)— Ed.] AMAUROSIS. 141 Affections of the Retina. Retinitis. The acute form of this affection may follow direct injury by wound, or the pressure of a depressed lens, or exposure to intense light or heat, or undue and continued exertion of the eye; or it may be of idiopathic origin. It is accompanied with agonizing pain, deep-seated, shooting through the head, aggravated by the slightest motion, and often with delirium. There is very great intolerance of light, Avith lachrymation ; luminous bodies seem to pass before the eyes; vision is greatly im- paired from the commencement; the pupil is at first much contracted, but afterwards becomes dilated, and remains motionless. Then the in- tolerance of light abates, and blindness becomes complete—the retina being no longer capable of obeying the accustomed stimulus. The sys- tem is involved in marked inflammatory fever. At first, the outward indications of increased vascularity are not very apparent; but, ulti- mately, as the action extends to the other deep textures of the eye, the usual signs of internal ophthalmia become developed. Treatment, which should be decidedly antiphlogistic, consists in seclu- sion from all stimulus of both the eye and system; bleeding, both local and general, repeated if need be; purgatives ; counter-irritants ; and free exhibition of mercury, so as to exert its full influence on the sys- tem. Mere abatement of the acute symptoms is not sufficient; there- fore, the remedies ought to be persisted in till a perfect cure is esta- blished ; due regard being paid to the safety of the patient. If the disease be allowed to degenerate into a chronic form, it will ultimately proAre injurious to the function of sight. Amaurosis. By this term is understood impairment of vision, more or less com- plete, dependent on change in the retina, optic nerve, or brain ; and that change may be either structural or functional. In the latter case, there is good hope of cure by suitable treatment; in the former, even palliation is often hardly within our power. The causes are : change in the retina, optic nerve, or brain, by the inflammatory process, acute or chronic ; compression of these parts in any way—as by extravasated blood, inflammatory effusion, or formation of a tumor ; a congested state of these parts, induced by over-exertion of the eye or brain, by irregularity of bowels, by habitual exposure to much light and heat, by intemperance, by gout—by, in short, whatever tends to cause determination of blood to the head. Sometimes, on the contrary, amaurosis is caused by want of the circulating fluid in the eye or in the head; as in cases of anaemia from prolonged lactation, pro- fuse uterine discharge, or the like. Wounds of the supraorbital branches of the fifth nerve have often been folloAved by amaurosis. The symptoms are : impairment of vision, gradual and increasing ; at first there is, perhaps, mere obscuration of sight, but this soon gives place to thorough perversion of that function; objects are often seen of 142 AMAUROSIS. erroneous proportion and color. In the congestive and inflammatory forms, more or less pain is complained of. At first, there may be in- tolerance of light; but, ultimately, a glare is borne with impunity, or is rather desired than otherwise. Ocular spectra are seen, either con- stantly, or from time to time, especially after exertion of the eye; they may be dark or luminous, massy or scintillated, steady or flickering. The pupil is dilated; the iris is sluggish, and ultimately motionless ; the eye has a vacant, staring expression ; and the patient acquires a pecu- liar, uncertain gait. Often, there is no fixed or decided pain in the part; but rather a sensation of tension and uneasiness. Sometimes the eyeball has a tremulous or oscillatory motion. On the whole, the ordi- nary and characteristic symptoms are, the painful sensations, the im- pairment and perversion of vision, the ocular spectra, and the state of the pupil. In applying the catoptrical test (p. 144), the three images of the candle are seen as in the healthy eye—a sufficient distinction from both glaucoma and cataract. From the latter, it is farther dis- tinguished by vision being improved in strong light, and impaired by belladonna; by the state of the pupil; by the absence of crystalline opacity; by perversion of sight existing—not mere impairment; and by the characteristic stare and gait of the patient. But there is no uniformity as to symptoms. In most examples, pain ceases on full establishment of the disease; in others, it continues un- abated. In most, the symptoms gradually advance to complete loss of sight; in others, independently of treatment, the symptoms reach a certain point, and then remain stationary. One patient may continue to have intolerance of light throughout; the majority of advanced amaurotics, on the contrary, seek a strong light, finding their vision improved thereby. Some see objects double ; this variety is called Diplopia. Others see but the half of an object; and this is termed Hemiopia. In many, the pupil is at first contracted, there being an originating inflammatory process present; in most, ultimate and perma- nent dilatation exists ; but, in a feAV cases, the iris seems natural in both form and hue, and is perfectly obedient to the stimulus of light. The untoward progress is very \rarious. Sometimes vision is lost at once, as when extravasation takes place by sudden congestion. Some- times months elapse, or even years may be occupied in the gradual decay. The affection is most common in the middle period of life; and while it seldom attacks both eyes at once, both are ultimately involved in the great majority of cases. In the inflammatory form, the mode of treatment is plain; the ordi- nary antiphlogistics are demanded in cases which are at all acute ; and the system ought to be brought, and maintained for some time, under the influence of mercury, which often evinces a striking control over the disease. In the chronic examples, moderate depletion, followed by an alterative course of mercury, is most likely to prove useful; and counter-irritation is at the same time advisable. When congestion is suspected, moderate depletion should be practised with purgation ; and then the ordinary means are to be taken for preventing local determina- tion of blood. If the affection have followed disappearance of an accus- tomed discharge, normal or not, return of that discharge is to be sought. CATARACT. 143 If an atonic state of the system exist, a stimulating plan of constitu- tional treatment is plainly indicated. If the disease be apparently but a secondary symptom, as it Avere, of some constitutional malady, as jaundice or hysteria, that malady is to be thoroughly eradicated from the system, if possible. If intestinal irritation exists, or be suspected, it is to be treated by the ordinary means. In short, the predisposing and exciting causes should, if possible, be ascertained and removed. And this paramount indication having been more or less perfectly ful- filled, certain means are sometimes in our poAver whereby to rouse the retina to a resumption of its function. Stimulants, when applied directly to the eye, or to its neighborhood, are sometimes useful for this purpose; or the endermic application of strychnia may be made on the temple or forehead. A blister having been applied, a quarter of a grain of the powder is sprinkled on the part, once or twice a day. The dose is gradually increased, until a bitter taste is felt in the mouth, and then temporary discontinuance of the remedy is expedient. Failing strychnia, electricity may be employed, but its use is seldom attended with much benefit. Affections of the Crystalline Lens and Capsule. Cataract. The term Cataract is applied to opacity of the crystalline lens. It is said to be lenticular, when the disease is situated in the lens itself; capsular, when the capsule only is opaque; and capsulo-lenticular, when both the lens and its capsule are affected. The affection may occur at any age, and is said to be owing to " defective nutrition from the changes Avhich are going on in the vascular or lymphatic system." Or it may be induced by external injury of the part. Sometimes it is a congenital defect. Most frequently, it occurs in advanced years; one sign, among many, of the frame's gradual decay. The prominent symptom is impairment of vision. At first, objects are seen as if obscured by a gauze or mist; this obscuration gradually increases ; and ultimately vision is almost, but not entirely, lost. Some- times uneasy sensations are complained of in the eye and forehead ; more frequently the part is the seat of no abnormal sensation. Sight is improved by a diminution of light; it is better at twilight than at noon, and also better when the patient is seated with his back to the light than when facing the window; for the pupil, then dilating, per- mits the rays of light to pass to the retina through the margin of the lens, which is as yet unobscured. For a like reason, the use of bella- donna materially improves the sight. On looking into the eye, an opacity is discernible, occupying the pupil, and situate immediately behind it. Whenever deliberate examination is contemplated, bella- donna should be previously applied, to dilate the pupil, so as to afford every facility for ascertaining the extent, and character of the opacity. In proportion as sight is impaired, the opacity is found to have in- creased. It is greatest at the centre; when complete, it is of a gray, white, bluish, or amber hue; and this is not unfrequently contrasted 144 CATARACT. with a dark annulus or ring on its exterior—the shadow of the iris falling on the periphery of the cataract. In the most advanced cases, the patient is still able to distinguish light from darkness. The iris is not necessarily impaired in its functions. Both eyes are seldom attacked at once; but usually both are ultimately involved. What is termed the catoptrical test of cataract is conducted thus: The pupil having been dilated by belladonna, the patient is seated with his back to the light, and the surgeon holds a lighted taper in front of the eye. In a sound organ, the depth of the clear pupil exhibits three reflections, or images, of the light; one superficial, bright, and distinct, caused by reflection from the cornea; one deep-seated, pale, and indis- tinct, caused by reflection from the anterior portion of the lens; and one in the mesial plane, or between the two former, small and obscure, caused by reflection from the posterior portion of the lens ; the first tAvo, erect, move consentaneously with the lighted taper ; the last mentioned, inverted, moves sloAAdy, and in an opposite direction. . In the case of cataract, the middle inverted image is first extinguished; and, after- wards, the deep erect one also becomes im'isible. Or, to speak more accurately, " opacity of the posterior capsule prevents the production of the middle inverted image; and opacity of the anterior capsule de- stroys the two posterior ones. In other words, in posterior capsular cataract, the middle or inverted image is not seen; in cataract of the anterior capsule, and in capsulo-lenticular cataract, the anterior straight one only is visible." In amaurosis, the three images are always dis- tinct, as in the sound eye. " Glaucoma, only when much advanced, obliterates the inverted image; while, in all its stages, it renders the deep erect one more evident than it is in the healthy eye." [In order that the catoptrical test shall be successfully applied, the room should be darkened, the only light in the apartment being that of the candle in the surgeon's hand; and, moreover, his own eyes should be screened, so that the glare from this shall not interfere with his examination of the eye.—Ed.] From glaucoma and amaurosis cataract is farther distinguished by the state of the pupil, the site and character of the opacity, the nature of the vision, and the expression and gait of the patient. Spurious Cataract is said to exist Avhen organized fibrine occupies the pupil. This is distinguished from true cataract by being of a yel- low or whitish color, and by the lens being adherent to the iris, which is puckered, altered in hue, and irregular in its pupillary maro-in. [The term Spurious Cataract must also include such "opacities as are produced by disease or injury, causing the exudation of pus or blood into the chambers of the aqueous humor, or turbidity of this fluid ; also, the deposition of the uvea pigment upon the capsule of the lens. But the expression is a bad one, as it conveys false ideas of the actual pathological state, and should not be applied to the conditions just enumerated; the latter, on the contrary, should be designated each by its proper name.—Ed.] Cataracts vary as to density. Hard cataract is most frequent in the old, and is characterized by its brownish or amber tint. The lens is apparently shrunk in its dimensions, and the greatest amount of opacity CATARACT. 145 is central. The iris is free and movable; the dark ring surrounding the cataract is remarkably distinct, and in the tAvilight, as also after the use of belladonna, objects may often be discerned Avith tolerable accuracy. Soft cataract, of fluid or semifluid consistency, is large and bulging, and completely occupies the pupil. It is most common in the young and middle aged, and is characterized by its bluish-Avhite or milky color. The iris is clogged in its movements, from the increased size of the lens, and the impairment of vision is great. The opacity is not always homogeneous, dots or streaks are occasionally observed on it, and these may change their form and site from time to time. In Avhat is termed the Radiated Cataract, the opacity is formed in streaks, and not unfre- quently commences at the circumference, thence extending towards the centre. This peculiarity is readily observed on inspection, and, as can be easily understood, vision will for some time prove better with a con. tracted than with a dilated pupil. [The term Morgagnian Cataract is sometimes employed to designate an opacity of the lens, supposed to be caused by an increase in the quantity and an alteration in the quality of the aqua Morgagni. But it has been satisfactorily determined, by recent capable observers, that the fluid of Morgagni does not normally exist between the lens and the capsule. Mr. Bowman states in his Lectures, already quoted from, that "when this fluid exists in the cataractous lens, betAveen the body and the capsule, or when it is found there after death, it is to be re- garded as a morbid or false condition, indicative of the destruction of the layer of cells which exist immediately within the capsule, separat- ing the latter from the superficial fibres of the lens, but forming an organic union between the two, and constituting the medium through which the nutrition of the fibrous part is conducted. It is therefore to be regarded as a variety of the Soft Cataract. It is of rare occurrence; it sometimes forms rapidly, as stated by Beer, who belieA*ed that it results only from the immediate influence of mineral acid or other irritative vapors on the eye (Lawrence, Am. Ed. p. 621); it does, however, form more slowly, and without any such cause. Mr. Dalrymple, in his recent work on the Pathology of the Human Eye (description of plate 26), gives the following excellent account of this affection: " Fluid cataract is met with at all ages, but is a some- what rare species. It appears to consist of disintegration of the lens, and when it occurs in elderly persons, the nucleus of a hard lens is often found in the interior of the capsule. This latter investment may or may not be also opaque. When the capsule is entirely transparent, it will generally be seen on dilating the pupil; and if the eye has been a short time at rest, the color is not wholly uniform; that at the lowest part the opacity is dense, while a certain degree of milky trans- lucency is apparent at the upper part. If the eye be suddenly rolled about or rubbed, the opacity becomes general and uniform, but clears in the upper part by rest and subsidence of the more opaque materials of which it will be found to be composed. It is by this means that we distinguish a fluid from an ordinary soft cataract. On examining the contents of the capsule, when we have the someAyhat rare opportunity 146 CATARACT. of doing so, we find the fluid semi-opaque, containing the debris of the lens, which may easily be distinguished by the microscope; also many oil-globules and some plates of cholesterine. In old subjects, as I have before said, the hard yellow nucleus will be found, having resisted the disintegrating process or softening of the lens." A curious peculiarity connected with this variety of cataract, noticed by Mr. Dalrymple, Mr. Wilde, and others, is, that if the capsule be opened and the morbid fluid be allowed to remain in the chambers of the eye, the patient is soon seized with violent pain, nausea, and vomiting, and, if the fluid be not evacuated, severe inflammation comes on speedily. An interesting paper on this subject by Mr. Wilde, may be consulted with advantage (Med. Times and Gaz. Oct. 2, 1852). Capsular cataract may be anterior or posterior, or both. In texture and structure the capsule is so different from the lens, that opacity of the former can generally be easily distinguished from this condition of the latter. In the capsular, the opacity may commence at any part of the membrane, not in the centre, as in the lenticular cataract; it is not uniform, but spotted or striated, and of a chalky or pearly color, and more or less glistening, instead of being of an amber hue. The position, too, of the opacity is different, being nearer to the pupil in the capsular than in the lenticular. Posterior capsular cataract may be distinguished from the anterior by the position of the opacity, by the color being more yellowish and less glistening, in consequence of being seen through the lens, and by the application of the catoptric test. Very commonly the capsular and the lenticular opacities are com- bined, the symptoms being a blending or combination of the two.—Ed.] Treatment.—Unfortunately, our art has as yet provTed impotent in attempting to stay the progress of advancing cataract, and, when it has fairly formed, no faith need be reposed in any attempts at simple dis- cussion of the opaque structure. By operation only can amendment be obtained. The obstructing body may be wholly extracted from the eye, or it may be pushed out of the axis of vision, or it may be broken up into fragments, which are expected to be afterwards absorbed, or it may be simply drilled, or it may have its capsule opened, so as to admit the aqueous humor, and thus favor absorption of the crystalline sub- stance. Before any operation, however, is undertaken, certain pre- liminaries require to be adjusted, as in the case of Artificial Pupil (p. 137). We must first be satisfied that the eye is in other respects sound, so that when the obstruction to light is removed there may be a fair prospect of vision being restored. There must be no amaurosis, glau- coma, change in the vitreous humor, ophthalmia, or affection of the eyelids. The patient must be free from any marked constitutional ail- ment. The state of the atmosphere should be mild and favorable. While there is a tolerably useful amount of vision enjoyed by either eye, it is more prudent to refrain from operation, the results of opera- tion being found most favorable in cases well matured. One eye only should be operated on at a time. Finally, by careful regimen, and medicinal treatment if necessary, the system is brought into a favorable state, and is rendered not morbidly susceptible of inflammation. CATARACT. 147 In the congenital variety an operation should be performed early, otherwise the unsteady rolling motion which the eyeball is so prone to assume, will prove an impediment to subsequent interference, and to the successful result of operation. Extraction.—In the operation by extraction, the opaque lens is removed from the eye through an aperture in the cornea, an operation necessarily comprehending a considerable extent of wound, and no slight amount of injury done to the parts. If inflammatory action can be pre\Tented, the result is often most successful. But if inflammation supervene, or an accident happen to the vitreous humor during the operation, sight is lost irretrievably. Many favorable circumstances require to be present to warrant an attempt at extraction. The cornea should be sound, the anterior chamber of proper size, the iris mobile and non-adherent, the globe prominent and steady, the cataract lenti- cular and hard. The patient should be in good health, neither plethoric and inflammatory, nor weak and incapable of plastic exudation, capable of self-control, and of maintaining the supine posture, not troubled with cough, sneezing, or asthmatic ailments. And this series of qualifications necessarily limits the operation by extraction to a minority of the cases of cataract. The pupil should not be dilated, otherwise escape of the vitreous humor is favored. The patient is placed before a steady light, but with his head slightly inclined from it, and either seated or recumbent; the sound eye may be covered by a bandage. The surgeon, holding the knife in his right hand, should be placed either in front or behind, ac- cording to the eye which is to be operated on. An assistant now opens one lid, with his fore and middle finger, at the same time steadying the eyeball by a little gentle pressure; the surgeon opens the other eyelid, and assists in steadying the globe, by the fingers of his left hand. If the patient sits, his head is secured against the lower part of the assist- ant's chest. The flap may be made superiorly or inferiorly, according as it is the right or left eye which is to be operated on. It is usually made superiorly when it is the right eye, the surgeon standing behind, and elevating the upper lid himself; when it is the left eye, the flap is made inferiorly, the surgeon being seated before his patient, and depress- ing the lower lid, while the assistant raises the upper. The knife used is the triangular one, known as Beer's. It should be held lightly between the thumb and points of the fore and middle fingers, Fig. 47. Extraction. The knife cutting through. the ring and little fingers resting upon the cheek. The flat edge of the point is first made to touch the cornea gently, in order to reassure the patient, and secure steadiness of the organ; it is then entered at about 148 CATARACT. a line from the corneal margin, and passed into the anterior chamber in a perpendicular direction, lest separation of the corneal laminae should take place from the knife getting between them. Penetration having been effected, the direction is changed, and made parallel to the surface of the iris ; the knife is then pushed steadily across the anterior cham- ber, the point emerging at a spot directly corresponding to that of its entrance; and the steady advance of the instrument is continued, until section of the. cornea is complete. All pressure is now to be removed from the eyeball. If the aqueous humor escape prematurely, the iris falls forward, and is consequently brought into contact with the edge of the knife. In this case a stop is made, and gentle pressure must be applied to the cornea yet uncut, without however withdrawing the knife. This may succeed in replacing the iris, and then section is continued. If not, the knife is withdrawn, and probe-pointed scissors are substituted, with Avhich the wound is finished.1 [Mr. Tyrrell has suggested an improvement upon Beer's knife, which consists in shortening the blade, while the same depth is retained at the shoulder. Beer's knife (Fig. 48) measures If inch along the cutting edge; Mr. Tyrrell's (Fig. 49), only 1 inch. The advantage of the latter instrument is, that by it "the section of the cornea can generally be completed by a single thrust, before the point of the knife reaches the nose; whereas, in using Beer's knife, when the point has been carried as far as the nose will permit, a considerable portion of the cornea still remains to be divided, beneath the edge of the instrument, and it is difficult to complete the division of the part."—(Tyrrell, vol. ii. p. 392.) The incision in the cornea may sometimes be more readily enlarged by using one of the small curved knives, of which the accompanying drawings (Figs. 50-51) are illustrations; in one the cutting edge is upon the concavity, in the other on the convexity.—Ed.] The corneal section having been completed, the eyelids are permitted to close, the eye to rest, and the pupil to dilate. Then, the lids having been gently reopened, the sharp end of a curette (Fig. 52), is cau- tiously introduced beneath the flap, and as gently as possible made to divide the capsule. The slightest possible pressure is then made on the upper eyelid—over the anterior part of the globe, just behind the corneal margin—so as to dislodge the lens—and nothing more. On escape of the opaque body, the corneal flap is properly adjusted, and the eyelids are permitted finally to close. Should the iris have prolapsed, sudden exposure to a bright light will probably suffice for its reduction, by caus- ing contraction of the tissue; if not, the protruded portion may be re- placed by gentle use of the blunt extremity of the curette. The eye is covered with a light pledget of lint, and a bandage. The patient should be laid on his back, with the -head elevated; light and all other stimuli are to be rigidly excluded; the most sparing regimen is to be enjoined, the act of mastication even being interdicted; precautions are to be taken against coughing, vomiting, and sneezing; and, if need be, in- voluntary rubbing of the eye is to be provided against also. If possi- 1 Or, according to the method of Sichel, and others, the operation may he interrupted and postponed till the humor is reproduced. CATARACT. 149 ble, the eye should not be uncovered, and exposed to the stimulus of light, for at least three or four days. The symptoms of inflammatory Fig. 48. Fie. 49. Fig. 50. Fig. 61. Fig. 52. [Fig. 48—Beer's Knife. Fig. 49.—Mr. Tyrrell's Knife. (From Lawrence.)—Ed.J [Figs. 50 and 51.—Curved Knives for extending the incision in the cornea. (From Lawrence.)—En.] [Fig. hi.—The Curette, a narrow, sharp-pointed, and slightly curved steel instrument; at the other end of the handle, Daviell's Scoop, or Spoon, a small silver instrument, Sometimes used to remove the lens, if it do not readily engage in the opening. (From Lawrence.)—Ed.] action must be carefully watched, and treated when they occur; by bleeding, purging, and abstinence — but obviously not by nauseants. Mercury, too, is inexpedient, lest it prevent such exudation as is necessary 150 CATARACT. Fig. 53. Depression. (From Jones.) Wharton Fig. 54. A I A for the healing of the cornea. The period of inflammatory action hav- ing passed, the eye is gently and gradually ac- customed to its wonted stimulus; but exercise of its full function is to be very slowly resumed. Depression, or Couching, implies downward displacement of a solid cataract, which it is not found expedient to extract. The pupil having been dilated by belladonna, the position of the patient is arranged as for extraction. The needle used for this purpose is the one known as Scarpa's, and which is curved at its point. It is pushed through the sclerotic, on the external side of the cornea, in the transverse axis of the eye, at the distance of a line from the corneal margin; this point being selected in order to avoid the two di- visions of the long ciliary artery, which vessel usually bifurcates at a distance of two or three lines from the corneal margin; also to avoid wounding the retina and the ciliary body. The needle having entered, is pushed steadily forwards into the anterior chamber, between the iris and the lens. By depressing the hand a very little, its point is brought into contact with the upper part of the lens, the concavity of the instrument being opposed to that body. By now elevating the hand, the lens is depressed towards the bottom of the eye, gently and steadily, and the instrument, having been allowed to rest there for a few moments—detaining the displaced body, till the vitreous humor closes over it—is gently extricated and withdrawn. The eye is now closed, a piece of wetted lint, with a light bandage is applied, and the ordinary precautions against inflammation are to be adopted, as after extraction. Comparative facility of performance is in favor of depression. But the manifest objections are: danger of chronic inflammatory action, in consequence of the displaced body pressing upon or irritating the retina and ciliary processes; disorganization of "the vitreous humor ; and the possibility of future escape of the lens upwards—again to obstruct the transmission of light. Reclination is a modification of depression. The instrument used, and the manner of intro- ducing it, are the same as in the operation for depression ; but the lens, instead of being completely dislocated and pushed down- wards, is simply made to revolve partially, so as to turn its supe- Front view. 2. Side Reclination. (From AVharton rior margin backwards into the view. Jones.) vitreous humor; while its anterior CATARACT. 151 surface is directed upwards, and remains nearly on a level with the lower edge of the pupil. Less injury is done to the retina than in de- pression : but reobstruction of the pupil is at least equally probable. The operation to promote absorption, or dissolution, is practised when the lens is of fluid or semifluid consistence. The procedure is simple, and easily performed, but requires repetition ; and the result is tardy, and may be uncertain. The object is, to admit the aqueous humor to a free and general contact with the substance of the lens—a circumstance which experience has shown to be conducive to absorption or solution of the latter. When breaking up is intended, the needle is introduced as for depression. Its point, having reached the pupil, in front of the lens, is made to divide the capsule by a slight rotating motion, and also to break up the lens into fragments. If the lens be fluid, no division of its substance is necessary; it escapes at once into the aqueous humor, on its capsule being opened. When of soft consistence, a few of the fragments often find their "own way into the anterior chamber; if not, they are gently placed there by the needle ; for, in that locality, absorp- tion or solution seems to advance more rapidly than behind the iris. Care must be taken, however, not to dislodge the lens forward in a mass, or in bulky fragments; otherwise untoward inflammatory action may be induced, in the iris and other parts, by*pressure of the lens upon them. At the first operation, the lens is diA'ided but slightly. Many deem it sufficient to divide the capsule only; and certainly it is well not to attempt any displacement; when the operation, however, requires to be repeated, the lens may be more freely broken up. A few weeks are allowed to intervene between the operations; and, after each, ordinary antiphlogistic precautions are to be adopted. The operation by drilling is performed through the cornea. A straight needle is entered near the corneal margin, and passed through the pupil into the substance of the lens. Having penetrated into this, to the extent of about a sixteenth of an inch, it is rotated freely, and carefully withdrawn. The proceeding is repeated from time to time, as in the breaking up; on each occasion a fresh part of the lens being chosen as the site of puncture. The object is to admit the aqueous humor ; and, by its agency on the lens, gradual absorption of that body takes place. After removal of the lens, in any way, a convex glass requires to be adjusted to the eye, in order fully to restore vision. This is the duty of the optician. Only let it be the surgeon's care not to permit any such adjustment, and resumption of the full exercise of the organ, until at least two months have elapsed after the operation; and more espe- cially if that operation have been by extraction ; for not until then will the eye be safe from accession of inflammatory action. If, after removal of the lens by operation, the capsule become opaque, and, occupying the pupil, obstruct vision, it may be got rid of in one of three ways. It may be extracted, through a minute aperture in the cornea, by a hook, or by small forceps. It may be detached at its 152 CATARACT. ciliary margin, by a needle, and depressed, like a lens. Or it may be crucially divided by the needle; and the flaps, shrinking from the centre, may leave the pupil patent and sufficiently free to admit light. Dislocation of the Lens. [Dislocation of the lens may take place, either spontaneously or in consequence of violence inflicted upon the eye. The injury may have been inflicted by a thorn, or other sharp body, which has penetrated through the external tunics, wounded the capsule of the lens more or less extensively, and caused the lens itself to fall through the latter rupture. Violent inflammation speedily ensues, Avhich may involve all the textures of the eye, and even cause the com- plete disorganization of the organ. The dislocated lens may fall into the posterior chamber, pressing the iris forwards, and obliterating, to a greater or less extent, the anterior chamber; or it may engage in the pupil, projecting into both chambers ; or, it may pass through the pupil into the anferior chamber, and remain impacted between the iris and cornea; or, after having occupied one of these situations, it may undergo a gradual diminution in size, so as to pass from one to the other on changing the position of the n*ead, constituting a floating cataract. Generally, after the inflammation which immediately succeeds the in- jury has been overcome, the lens becomes opaque, undergoes a gradual absorption, and may, at length, be entirely removed; the opaque and thickened capsule remaining permanently undissolved. Similar changes—rupture of the capsule and dislocation of the lens— may follow a simple blow upon the eye, without any external wound. And Mr. Mackenzie suggests that,'in many cases where loss of vision has folloAved a blow or other injury upon the orbit, involving the supra- orbital nerAre, and has been attributed to the latter alone, the violence really implicated the ball of the eye also, occasioning dislocation of the lens, and consequently the blindness. It may also happen occasionally that, after a blow has been inflicted upon the eye, the patient having even forgotten the circumstance, the lens, diminished in size, and loosened from its natural attachments, drops through the pupil into the anterior chamber (Mackenzie, Treatise, p. 340). Such cases have been sometimes considered as instances of spontaneous dislocation. The lens, inclosed within its capsule, the latter being Avounded or entire, may be detached from its connections by a blow, and fall into the aqueous humor. If the capsule has been opened, absorption of the lens may take place pretty rapidly; but the opaque capsule, remaining unabsorbed, floats like a sac in the aqueous fluid (eataracta cystica). It is possible, perhaps, that even Avhen the capsule is entire, the lens may be absorbed, and the bag-like capsule be left (Mackenzie, p. 340); but Mr. Lawrence says that a patient occasionally visited the London Ophthalmic Infirmary, with the lens, surrounded by its capsule, in the anterior chamber, Avhere it had been twenty-eight years ; and Beer mentions a case in Avhich the lens had been in the anterior chamber twenty-six years, without any reduction in its size (op. cit. p. 183); in such circumstances the lens may even retain its transparency. CATARACT. 153 The lens may be forced into the vitreous humor; or through the choroid and sclerotica, so as to present, as a solid tumor, beneath the conjunctiAra, of which several examples have been seen by Mr. Mac- kenzie, Mr. Middlemore, and others.1 Spontaneous dislocation of the lens may also occur, usually from loosening of the suspensory ligament, as in the cases cited by Mr. Bow- man, in the Appendix to his Lectures. This condition of the liga- ment generally exists only as one of a number of lesions, of which the eye is, in such instances, the subject; e. g. cataract, a fluid condition of the vitreous body, etc. But spontaneous displacement of the lens may take place without any apparent cause or complication of this kind (Lawrence, p. 488). For the correct diagnosis of this injury, in all its phases, a careful examination of the eye in various positions, the pupil being dilated, if necessary, by means of belladonna, and the employment of the catop- trical test are essential, whether the case be seen soon after the acci- dent, or not until after some time has elapsed. The treatment must vary according to circumstances. In all cases it is necessary to subdue existing inflammation by the appropriate means, and thus prevent destructive changes from taking place ; operative interference, too, is often necessary. If the dislocated lens be in either chamber, or engaged in the pupil, and if the evidences of inflammation do not disappear promptly and satisfactorily under proper general and local treatment, the lens should be looked upon as a foreign and offend- ing body, and should be remoAred by extraction. If the inflammation be overcome, it will be proper to wait, observing the changes which may occur in the lens, and deferring any operation which may eventually seem expedient, until a favorable opportunity. It must also be borne in mind that the uninjured eye is liable to suffer from the deranged con- dition of the other, if an operation be too long delayed. If the lens be forced beneath the conjunctiva, it is easily extracted by making a simple incision over it; in the cases seen by Mr. Macken- zie, the aperture in the choroid and sclerotic had closed before division of the conjunctiva was made. It happens, sometimes, that traumatic cataract, without dislocation of the lens, follows a blow, or a punctured wound of the cornea and cap- sule, or a blow without any solution of continuity. The wounding body may be very minute, as a needle, or a grain of wheat (case by Dr. Hays, Lawrence, p. 184). Opacity of the lens and capsule speedily ensues, accompanied by severe inflammation, and followed, of course, by loss of vision. After a time, absorption of the lens takes place, and may be wholly accomplished Avhen the surgeon is consulted. In such cases, the pupil should be dilated, if possible, and a catoptrioal examination be instituted, when the nature of the case will generally be detected (see cases by Dr. Hays, op. cit.). The treatment is to be governed by the same indications as if dislocation of the lens had taken place; if the inflammation is not readily subdued, the lens should be extracted, the patient being thus afforded a better prospect of recovery of sight than 1 Mackenzie, Lond. Med. Gaz. vol. ix.; Lawrence, op. cit. p. 182. 154 HYDROPHTHALMIA. if the lens be allowed .to remain; if the inflammation has been happily overcome, and sight is lost, a suitable opportunity may be taken for a subsequent operation.1] Affections of the Humors of the Eye. Hydr ophthalmia. Dropsy of the eye may depend on excess of the aqueous humor, of the vitreous humor, or of both. In the first case there is tension, prominence, change of form, and increasing nebulosity of the cornea; the iris is changed in color, and impaired in mobility ; the pupil is dilated; vision is much affected; there is a sense of fulness in the eye: and more or less headache is complained of. When the vitreous humor is increased in quantity, enlargement and tension of the whole eye occur ; the iris is motionless, and arched for- wards ; the sclerotica is attenuated, and has a bluish or brown appear- ance ; vision is wholly lost; and the pain is deep seated and severe. Ultimately, the eyeball protrudes between the lids, inflames, and ulce- rates ; or rupture takes place, with partial evacuation of the humors. Palliation is in our power, by evacuation of the redundant fluid—by puncture of the cornea or sclerotica, or by incision of the former tex- ture. Sometimes the progress of the disease may be delayed, if not arrested, by counter-irritation and constitutional treatment. Synchysis Oculi. The term Synchysis denotes a deficiency, and unnatural fluidity, of the vitreous humor. The eye is shrunk and flaccid ; the iris is tremu- lous; the pupil is motionless, and vision is either impaired or lost. Not unfrequently the lens becomes opaque. The disease is usually regarded as incurable. Glaucoma. By Glaucoma is understood an amaurotic state of the eye ; with a greenish opacity, behind the pupil, concave, and deeply seated. Ac- cording to some, this state is mainly attributable to affection of the retina; according to others, the choroid coat is chiefly implicated; while a third class are of opinion that change in the lens and vitreous humor is the principal cause of the disorder. It is probable that all these textures are more or less involved. The prominent and charac- teristic symptoms are, impairment or loss of sight, permanent dilatation of the pupil, green discoloration of the vitreous humor, and in the ad- vanced stage of the disease opacity of the lens. Diagnosis from cata- ract is made easy, by observing that the opacity is more deeply seated than the lens ; and that it becomes indistinct or even invisible when viewed laterally. The catoptrical test shows the three images of the 1 [See Lawrence; Mackenzie, in Lond. Med. Gaz. vol. ix.; Barton, ditto, vol. v., etc.—Ed.] OPHTHALMITIS. 155 candle at first ;by and by, the middle inverted one is extinguished ; but the deep-seated erect image generally remains throughout. At the commencement of the disease, amendment may sometimes be obtained by local depletion, counter-irritation, alteratives, and a mild mercurial course, or exhibition of the iodide of potassium. If gouty or rheumatic symptoms exist—as is not unfrequently the case—the ordinary appropriate treatment is directed against that particular state of system. The adA*anced form is incurable. The disease seldom occurs, except in those of mature age. Ophthalmitis. This term, in its correct acceptation, deno.tes involvement of the entire globe of the eye in inflammatory action—an affection of much danger to structure and function, as can be readily understood ; and one which demands the most careful and active treatment. The ordi- nary results of this inflammatory process are opacity, ulceration, or staphyloma of the cornea ; adhesions of the iris, with contraction of the pupil; cataract; and often complete destruction of the organ of A^sion. A very severe form of this disease occurs in puerperal women—some- times in connection with the malignant childbed fever—sometimes in- dependently of this. The symptoms are generally of the highest in- tensity, vision is rapidly impaired, and often there is great chemosis. Cases occasionally occur where the inflammation goes on to suppuration; the eye becoming a phlegmon. In such circumstances, great relief is experienced by opening the abscess. Wounds of the Eyeball. These are very common causes of acute ophthalmitis. And, accord- ingly, their treatment must be carefully conducted in order to avert disastrous results. If foreign matter lodge in the interior of the eye, antiphlogistics will avail but little, so long as the foreign body remains; the globe will suppurate, burst, and collapse. It is an important indica- tion, therefore, to ascertain the presence and site of a foreign body, and to effect its removal. But the same difficulty is encountered as in the case of the brain (p. 70). It is difficult to ascertain either the site or presence of the foreign matter; and, even when these are plain, it is often very difficult to effect its removal without most serious injury to the organ. In regard to prognosis, it is important to bear in mind, that there may be foreign matter in the interior of the eye, without any apparent solu- tion of continuity in either the cornea or sclerotic. For the elasticity of texture may at once close the chasm in the tunic, and conceal it from even minute inspection. Entozoa. The Filaria medinensis has been found beneath the conjunctiva; the Filaria oculi humani in the lens. In the latter texture, also, have 156 TUMORS OF THE EYEBALL. been found the Monostoma lentis, and the Distoma oculi. _ The Cysti- cercus tehs cellulosse has more than once occupied the anterior chamber; it may be removed by section of the cornea. Tumors. The eyeball is liable to be the seat of two kinds of tumor; both malig- nant—the medullary, and the melanotic. Carcinoma is rare. The medullary tumor is most common at an early age, and seems usually to originate in connection with the retina; growing from the bottom of the eye, occupying the chamber of the vitreous humor, and rapidly making its way externally. Loss of vision is early and complete; the tumor in its first stage can be seen dimly, through the pupil; and the pain, cachexy, and other signs of the medullary tumor are present to testify its character (Principles, 3d Am. Ed. p. 322). When the coats of the eye have given way, the tumor increases more rapidly than before ; a fungus is thrown out; and this may assume the hemorrhagic tendency. The end is death. Cure can be attempted in but one way—by extirpation of the eyeball; and that only at an early period, when the disease is confined to the interior of the globe; and even after removal of the globe, the disease frequently returns again in the optic nerve ; eventually destroying life. In the advanced stage, all operative interference is contraindicated; reproduction is certain ; and the progress of the disease, instead of be- ing'arrested or retarded, is likely to become accelerated. Indeed, the cases are very feAv in which the operation has proved thoroughly success- ful. Lately, however, I had occasion, on account of false aneurism at the bend of the arm, to tie the humeral artery of a gentleman aged thirty-three, who, at the age of nine, had undergone extirpation of the eyeball on account of medullary tumor ;l and in him there has never been the slightest symptom of return. The melanotic tumor generally occurs after the middle period,of life; it slowly fills up the interior of the eye ; is seen dim, black, and bulging, through the pupil; ultimately thinning the coats, and forming dark colored external projections of the sclerotic; attended with pain, tension, and early loss of vision. In some cases, care is required not to mistake the disease for simple staphyloma of the sclerotic (p. 131). The only cure is extirpation of the eyeball, and this should be done at as early a period as possible. Extirpation of the Eyeball. This operation may be required on account of tumor of the eyeball; tumor of the orbit, involving the globe secondarily ; cancerous ulceration of the eyelids, involving the globe, or destroying the whole of the eye- lids—as formerly explained (p. 95). The commissure of the eyelids having been divided, at the outer angle, so as to afford space, the globe is laid hold of by a volsella; and by this instrument is steadied and directed, throughout the remainder of the procedure. A straight bis- 1 Edinburgh Medical and Surgical Journal, vol. xix. p. 51. CONGENITAL DEFICIENCY OF THE EYEBALL. 157 toury is entered at the margin of the orbit, and made to move round, so as to detach the muscles and other parts from the bone ; the point, however, being used very carefully at the bottom of the orbit lest per- foration of the thin orbital plate should occur. The optic nerve is then cut across, and the tumor Avithdrawn. If there be reason to suspect unusual attenuation of the bone—perhaps partial deficiency—it were no unwise precaution to effect the deeper dissection by the handle of the scalpel. If the lachrymal gland have escaped the general removal, it may be seized by a hook, and dissected aAvay ; but this is not absolutely necessary. Having become satisfied of the entire removal of the dis- eased structure, the cavity is sponged clear of blood ; dossils of dry lint or charpie are placed so as to fill the orbit and project somewhat beyond the margin, and a retaining bandage is passed around, with sufficient firmness to arrest bleeding from the ophthalmic A'essels. After a few days, the dressing is gradually undone and removed; suppuration is established ; granulation succeeds ; and the granulating wound is to be treated in the ordinary way. After cicatrization, an artificial eye may be adapted to the socket. Congenital Deficiency of the Eyeball. An interesting example of this occurred to me some years ago. A girl, strumous, and of strumous parentage, labored under conjunctivitis, which proved very obstinate, and had already produced considerable opacity of both cornese. The mother, naturally of an anxious tempera- ment, had her every thought engrossed by the state of this child—then an only one. She again became pregnant; and still persevered in her watchful nursing unweariedly, and, if possible, with an increased solici- tude. The second child was born at the full time. It proved a male, well-formed, and seemingly perfect in every way. But, on opening the eyelids, not a vestige of either eyeball could be found. The lids were perfectly normal in both form and size, but gave no sign of globular projection beneath; and on opening them, red, fleshy, mucous-looking membrane, flat and loose, was found to be the apparently sole occupant of the orbits. As the child grew, the congenital deficiency remained un- altered. Strabismus. Squinting may affect one eye, or both. Very frequently both are implicated ; but one only in a minor degree. The immediate cause ob- viously depends on inharmonious action of the recti muscles. One may act excessively, while its antagonist retains quite its normal character ; and displacement is effected by the former. Or—as there is good reason to believe frequently happens—one retains its normal condition, while the other is enfeebled, or altogether paralyzed ; and displacement is caused by the former. The ordinary varieties of squinting are the Con- vergent, looking inwards; the Divergent, looking outwards. The former is by much the more frequent. A great advance has been made in the treatment of this deformity, 158 STRABISMUS. by having recourse to division of the muscle on the side towards which there is displacement—an operation suggested by Stromeyer, and first performed by the late Dr. Dieffenbach of Berlin. The patient is placed as for other ophthalmic operations. The eye which is not the subject of treatment is closed; and the patient is made to turn the affected organ in the direction opposite to that of the squint. A fold of conjunc- tiva, between the cornea and the angle of the eye, but nearer to the latter than to the former, is then seized and elevated, by means of com- mon dissecting forceps; and is divided by a stroke of the scissors. By one or two touches of the scissors, aided by the forceps, the sub- conjunctival areolar tissue is cut, and the mus- cle exposed—at that point where it ceases to be fleshy and begins to be tendinous. It may either be gathered up by the forceps, or ele- vated on a blunt-hook passed beneath. It is plan of the Eye, showing the line then divided completely. And it is well to of incision in the conjunctiva. make, at the same time, a clean dissection of the sclerotic, for some little distance on either aspect of the muscle; so as to divide any bands of fibrous or areolar tissue, which might otherwise act retentively on the malposition of the eye. If the organ prove unsteady during the operation, it may be ex- pedient to control its motions by means of a sharp, short, double hook, inserted into the sclerotic conjunctiva at a safe distance from the corneal margin. The operation over, and all instruments withdrawn, the patient is directed to look as he formerly squinted. If he finds a difficulty in re-effecting the displacement, the immediate result of the operation may be considered as fully attained. But otherwise, it is necessary to make a more free division of the textures implicated; in all cases, however, taking care not to occasion an unseemly exophthalmos, by carrying such division to an undue extent. The eye is covered up for a day or two; and moderate antiphlogistics are used. Untoward inflammatory action seldom occurs. The Avound may unite by adhesion. More fre- quently, it heals by the second intention. Sometimes a fungous granu- lation forms; this is removed by the scissors, and is subsequently kept down by gentle escharotics. After a feAV days, the functions of the eye are to be resumed, and they should be so arranged as to give the organ an habitual movement in the direction opposite to that whereto it was formerly directed. Indeed, this exercise or training of the eye, subse- quently to the operation, is a very essential part of the treatment; and should be begun at an early period after the operation—almost immedi- ately; otherAvise an improper reunion of the divided muscle may take place, and maladjustment of the eyeball be restored. Occasionally the cure is more than complete; squinting in the oppo- site direction being threatened. And were the other rectus muscle now to be divided, unseemly projection of the eyeball could not fail to be produced. Fortunately, it is often sufficient to excise merely a por- tion of the conjunctiva near the cicatrix of the wound; the contraction of this new sore, in healing, tending to restore the normal position. STRABISMUS. 159 [The instruments illustrated by the accompanying drawings, are those recommended for this operation by Dr. Hays, of this city, in his edition of Mr. Lawrence's Treatise on the Eye; they will be found Fig. 57. very serviceable.—Ed.] Sometimes it is sufficient to operate on one eye only. At other times we are compelled to operate on both. For, when both eyes are implicated in squinting—though in very unequal degrees—it will be found quite impossible to re- store parallelism in position and motion, if the myotomy be limited to that organ which is most prominently affected— let the division be as extensive as it may. When operation proves in all respects successful, not only is deformity removed, the func- tion of sight is also materially benefited. But all SquintS do [An clastic steel-wireSpeculum for separating the Eyelids— Ed.] not require myotomy. Accord- ing to the cause and circumstance, the treatment varies. Strabismus may be congenital. During early adolescence, attempts are to be made to remedy the evil by due exercise or training of the organ, when one only is affected. The sound eye is to be covered up for some hours in the day; and the other, employed exclusively, may in time be compelled, as it were, to look straight upon the objects of sight. But care must at the same time be taken, that the sound eye do not Fig. 58. [A pair of small Toothed-Forceps, for pinching up a fold of the Conjunctiva.—Ed.] suffer from undue confinement and disuse. Or a pair of spectacles, or goggles, may be worn occasionally, through which the patient cannot see with both eyes, unless they are directed in a parallel manner. When such means fail, myotomy may be had recourse to. Squinting not unfrequently is the result of imitation. This must be corrected by breaking off the habit, and removing the patient from cir- cumstances likely to induce its repetition; also by the remedial exercise of the organ just noticed. The like treatment is available, when squint- ing has been induced by the presence of marks on the nose or cheek, to which the eyes are from time to time diropted; when it has followed 160 STRABISMUS. on a long confinement of the patient to one posture, perhaps constrained; when it is the result of using one eye habitually and painfully directed on small objects, as in certain mechanical professions. . Fig. 59. Fig. 60. Fig. 61. [Fig. 59. A pair of small Scissors, one blade probe-pointed, for dividing the Conjunctiva. Fig. 60. A small Iris-Knife, which may be used instead of the Scissors, if preferred. Fig. 61. A blunt silver Hook to be passed under the muscle previous to dividing it.—Ed.] In children, squinting is not unfrequently connected with gastric and intestinal irritation; and is remediable by purgatives, alteratives, or STRABISMUS. 161 anthelmintics. In such cases the strabismus is almost invariably con- vergent; as can be readily understood, when it is remembered how closely the sixth pair of nerves is connected with the sympathetic. Sometimes squinting is but a sign of general disorder in the system; and disappears, along with the other symptoms, under appropriate con: stitutional treatment. At any age, it may be the concomitant of im- portant cerebral disorder. Not unfrequently, squinting occurs as a sequela of some infantile disease. In such cases, the affection is of an atonic character; and may be mitigated, perhaps removed, by a general tonic system of treat- ment, by the application of strychnia to the temple and forehead, or by the passing of electro magnetism through the part. As a general rule, the operation should not be performed, until other means likely to prove remedial, have been found insufficient. And in the case of the female near the age of puberty, the operation should always be withheld, until the catamenia haAre appeared; inasmuch as, on this occurrence, rapid amendment and removal of the deformity is, by no means, unlikely to occur. English.—J. C. Saunders, Treatise on some Practical Points relating to the Diseases of the Eye, 2d ed. London, 1816.—J. Wardrop, The Morbid Anatomy of the Human Eye, vol. i. Edinburgh, 1808; vol. ii. London, 1818.—B. Travers, A Synopsis of the Diseases of the Eye and their Treatment, 3d ed. London, 1823.— G. J. Guthrie, Lectures on the Operative Surgery of the Eye, London, 1823.—A. Watson, A Compendium of the Diseases of the Human Eye, 2d ed. Edinburgh, 1828.—R. Middlemore, A Treatise on the Diseases of the Eye, 2 vols. London, 1835.—F. Tyrrell, A Practical Work on the Diseases of the Eye, &c. 2 vols. London, 1840.— W. Mackenzie, A Practical Treatise on the Diseases of the Eye, 3d ed. London, 1840.— W. Lawrence, A Treatise on the Diseases of the Eye, 2d ed. London, 1841.—S. Littell, A Manual of the Diseases of the Eye, 2d ed. Philadelphia, 1846.—T. Wharton Jones, A Manual of Ophthalmic Medicine and Surgery, London, 1847.—A. Jacob, A Treatise on Inflammations of the Eyeball, &c. Dublin, 1849.—J. Dalrymple, Pathology of the Human Eye, London, 1852. French.—A. P. Demours, Traite" des Maladies des Yeux, 4 vols. Paris, 1818.—J. Sichel, Traite" de l'ophthalmie, &c. Paris, 1837.—Carron du Villards, Guide Pratique pour l'Etude et le Traitement des Maladies des Yeux, 2 vols. Paris, 1838.— Velpeau, Manuel Pratique des Maladies des Yeux, &c. Paris, 1840.—M. F. Rognetta, Traite" Philosophique et Clinique d'ophthalmologic, &c. Paris, 1844.—Deval, Chirurgie Oculaire, Paris, 1844.— Desmarres, Traite des Maladies des Yeux, Paris, 1847.—[Sichel, Iconographie Ophthal- mologique, Paris, now being published in numbers.—Ed.] German.—Beer, Lehre von den Augenkrankheiten, 2 vols. Vienna, 1813-1817.—C. II. Wetter, Die Krankheiten des Menschlichen Auges, 4th ed. Berlin, 1830.—F. A. Von Ammon, Zeitschrift fur ophthalmologic, Dresden and Heidelberg, 1830-1837.—A. Rosas, Lehre von den Augenkrankheiten, Vienna, 1834.—J. C. Juengken, Die Lehre von den Augenkrankheiten, 3d ed. Berlin, 1842. Italian.—A. Scarpa, Saggio di Osservazioni sulle Principali Malattie degli Occhi, Pavia, 1801; or Translation by Briggs, 1818.—G. Quadri, Annotazioni Pratiche sulle Malattie degli Occhi, 4 vols. Naples, 1818-1830. 11 CHAPTER VI. AFFECTIONS OF THE NOSE. Fracture of the Nasal Bones. Fracture of the nasal bones is the result of external violence, di- rectly applied. It may be either simple or comminuted; and the latter form is of frequent occurrence. It may be either simple or compound; and the latter form may be constituted by wound of the integument, or by laceration of the internal mucous membrane, or by a combination of both circumstances. Deformity, by displacement, is a very prominent feature of the injury; the slightest manipulation suffices to detect de- crepitation ; and this sensation is often greatly extended, by an emphy- sematous condition of the areolar tissue, in those cases in Avhich the mucous membrane has sustained greater injury than the skin. SAvelling and discoloration occur, to a greater or less extent; and usually pass laterally and downwards, to the eyelids and cheek. Replacement is easily effected, by passing a pair of small dressing- forceps, or the ordinary polypus-forceps, shut—or a goose-quill, bloAv- pipe, director, or female catheter—into the upper part of the nostril; pressing outwards with the instrument, so as to restore the normal position of the.fragments ; and at the same time modelling them into their proper place by the fingers of the other hand applied externally. Sometimes, indeed, it may be in our power to improve on the original elevation, and to impart to the organ a more pleasing contour than it originally possessed. If any small fragments be completely detached and exposed, they should be at once remo\red. No retentive apparatus is necessary; for redisplacement is not likely to occur, unless under reapplication of external violence. But if bleeding prove troublesome from the membrane, it may be necessary to plug the nares gently with lint. If there be wound of the soft parts, it is treated according to ordinary principles. And, in all cases, the requisite precautions are put in force against the accession of overaction, and the risk of erysipelas. Lipoma of the Nose. By this term is understood a hypertrophied condition of the integu- ment and subcutaneous adipose tissue of the apex and alae ; seldom occur- ring but in the male, of advanced years, Avho has lived freely. When the enlargement is partial and of no great bulk, no operative interfer- ence is required. It is sufficient to attend to regimen, and to the state of the general system, so as to prevent, if possible, farther growth; and POLYPUS OF THE NOSE. 163 direct medical treatment may be applied to the organ itself, with a view towards restoring it to a normal state. But when the growth is large, it proves a serious inconvenience; interrupting Adsion, and interfering Lipoma of the Nose. unpleasantly with the spoon and the wineglass ; and, in consequence, surgical aid may be asked and granted. The redundant growth is to be carefully pared away. A finger having been placed in the nostril, so as to distend the part, and facilitate dissection—while, at the same time, division of the cartilage is provided against—the scalpel and for- ceps are carefully used, so as to remove the whole of the changed in- teguments. The bleeding is considerable ; but is quite amenable to arrest by cold, pressure, and ligature. Sometimes the parts are so dense as to preclude ordinary use of the ligature ; in which case, if pressure fail, the curved needle is to be employed (Principles, 3d Am. Ed. p. 350). Cicatrization is tardy; but, Avhen obtained, is satisfactory. Apparent reproduction may take place by groAvth from the surrounding integument, formerly unaffected; but the cicatrix itself usually remains firm and depressed. Polypus of the Nose. Nasal polypi are of various kinds; simple-mucous, and cysto-mucous; fibrous, and medullary (Principles, 3d Am. Ed. p. 390). The first are, fortunately, of most frequent occurrence; and usually are found adherent to the investing membrane of the superior turbinated bones. The symptoms of the common mucous polypus are sufficiently charac- teristic. The patient feels that something unusual, and apparently fleshy, is occupying the nostril; calls to blow the nose are unusually 164 POLYPUS OF THE NOSE. Fig. 63. Simple Mucous Polypi, seen growin in the nasal passages. frequent, and can be but imperfectly obeyed—passage of air through that nostril being found to be much obstructed; there is a preternatural amount of mucous discharge from the part; on attempting to blow the nose, a great portion of the mucous secretion is thrown into the pharynx; there is a constant feeling as if there existed "a cold in the head ;" very frequently, there is lachry- mation, the extremity of the nasal duct being compressed by the growth, or the lining membrane of the duct being sym- pathizingly involved in congestion; and these uncomfortable circumstances are all aggravated in damp and variable weather. On looking into the nostril the tumor is seen ; and, when the speculum is used, a very distinct exploration of its bulk and form may in most instances be effected. When the mass has attained to some considerable size, it renders itself appa- rent by projecting on the upper lip. As it enlarges backwards, deaf- ness may be produced by pressure on the Eustachian tube; and giddiness may be occasioned by compression of the jugular. The sense of smell is necessarily much impaired; and so in many cases is that of taste. Speech is indistinct, and snuffling. In sleep, the patient is an habitual and sonorous snorer. After a time, the countenance may undergo a formidable change ; the nasal bones becoming gradually disjoined and expanded; giving a very unpleasant breadth to this part, and establish- ing the condition which is ordinarily termed "Frog-face." (Fig. 64.) Then—and often, also, at an early period of the case—pain is com- plained of in the head, especially in the forehead. In the minor cases, it is essential that diagnosis be accurate. Symp- toms are not trusted to alone. The speculum must be employed, so as to expose the nasal cavity ; enabling us to ascertain whether the obstruc- tion depends on nascent polypus or not. For the disease is apt to be simulated. There may be merely a general congestion of tlie lining membrane. Or there may be a bulging of the septum to one side, with or without congestion of the membrane on the convexity of the bulge. There may be abscess forming between the septum and its investing membrane. Or there may be a hypertrophied condition of the spongy bone. Any of these circumstances may produce more or less occlusion of the nostril, increase of discharge, snuffling of speech, and most of the ordinary symptoms of polypus. By use of the speculum only can the true condition of parts be determined. If there be no polypus, no forceps are required. For congestion, abstraction of blood and astringent lotions are sufficient, with roborant treatment constitutionally. Abscess of the septum may be prevented by leeching ; when formed, it requires evacuation. Displacement of the septum, and enlargement of bone, call for no interference. Removal of the common polypus is effected by twisting and evulsion {Principles, 3d Am. Ed. p. 391). Care is taken to apply the forceps POLYPUS OF THE NOSE. 165 Fig. 64. Frog-face; the polypi causing much deformity by expansion of the bones, and change of relative position in the soft parts. accurately to the neck of the tumor, so as to insure removal of the entire mass ; and gentleness is used, so as not to endanger evulsion of bone. The forceps are well toothed, firmly jointed—and secured by a pin betAveen the blades, so as to prevent them passing each other during the twisting movement; strong, yet not so bulky as those commonly in use — less than the "dressing-forceps" of the ordinary pocket-case. Sometimes, forceps considerably curved are useful in reaching small soft polypi, which not unfrequently grow from the upper and front part of the nares, and which the ordinary instrument passes by. The tumors being generally numerous, more than one operation is usually required to effect eradication of the whole ; and of this the patient should be warned in the first instance, to prevent disappointment. After tempo- rary clearance of the nostril has been effected, the cavity is plugged with lint; to arrest bleeding, and prevent the access of cold air to the raw surface. A second operation is not attempted until the inflammatory results of the former have completely subsided ; nor until examination by the speculum has revealed the fresh crop of tumors, somewhat advanced to mature development. This may be after weeks or months. After the nostril has been finally cleared, the use of an astringent is 166 POLYPUS OF THE NOSE. advisable—such as a solution of zinc, nitrate of silver, alum, matico— with a view to prevent reproduction, and restore the mucous membrane to a sound state. The following form is often found very suitable: sulphate of zinc half a drachm, tincture of Galls one drachm, water eight ounces. If evulsion be found to cause inordinate pain, with inflammatory symptoms, the attachments of the polypi, in the repeated operation, may be severed by probe-pointed scissors or knife. The dense fibrous polypus, when originating from the posterior part of the nasal cavity, projects backwards, is of a somewhat pyriform shape, and hangs pendulous in the fauces. For removal of such a tumor, the use of ligature is most suitable. A long double loop of wire, catgut, or strong cord, is passed through the affected nostril. The noose is caught, as it appears in the posterior fauces, by forceps intro- duced through the mouth. And. then, by fingers or forceps, the loop may be carried over the fundus of the tumor; so that on drawing the ends hanging out of the nostril, the noose may be run tight upon the upper part of the growth. This having been done, the nasal ends are passed separately through a double silver canula, which is then pushed into the nostril until its extremity rests on the polypus. By pulling the ends, the noose is now completely tightened, so as to strangulate the mass at its attachment. And the ends, drawn tightly, are secured through rings placed for this purpose at the anterior extremity of the canula. From time to time, a renewal of the tightening may be had recourse to. The tumor at last drops away ; and is either swallowed, or coughed up and discharged by the mouth. Sometimes, however, the noosing of the mass cannot be so easily accomplished. The double ligature having been passed as before, the loop hanging out of the mouth is divided, so as to constitute two single ligatures. The oral end of one is passed through a long single canula, and is carried carefully under the base of the tumor on one side. In the same way the corresponding end of the other ligature is managed, so that this ligature passes round the tumor on the opposite side. The directing canula having been then withdrawn, the double form of liga- ture is restored by uniting the oral ends in a firm knot. The nasal ends are now drawn, and the noose is run tight on the tumor, at its upper part, as before, tightening of the noose being effected by means of the double canula passed through the nose.1 But a dense and firm polypus may occupy the anterior part of the nares, broad in its attachment, and firmly united with both periosteum and bone. Such tumors experience has declared to be prone to de- generation, early becoming vascular, softening, and ultimately assuming the medullary character. Removal therefore is highly expedient, and, to be effectual, it must be both early and complete. Ligature will not suffice. The morbid structure must be cut out, along with the parts from which it springs, and with which it is intimately incorporated. The operation is formidable and severe, but not the less expedient. No fixed rules can be given to guide the operative procedure. It may be 1 Brodie, Lancet, No. 1058, p. 316. epistaxis. 167 possible to disclose the tumor and its site sufficiently by simple incision of the nostril. Or it may be necessary to remove a portion of the superior maxilla.1 The medullary and malignant nasal polypi may be regarded as incurable. By the time the case has been submitted to the surgeon, the morbid structure has so extended as to render its entire removal, by any feasible operation, impracticable, and we content ourselves with palliation. If much distress be occasioned by occlusion of the nostril, the soft obstructing mass may from time to time be pushed away by the finger or probe; but even this interference must be very carefully practised, lest troublesome hemorrhage ensue. Also, let us beware of mistaking protrusion and pointing of the tumor, at the internal canthus, for fistula lachrymalis about to form (p. 107). The erectile tumor has been found growing from the anterior nares, not merely an inconATenience, but dangerous by tendency to hemorrhage. Cure has been obtained by destructive application of the actual cautery to the diseased tissue.2 Rhinolithes. Rhinolithes, or calculi of the nasal fossae, are composed of mucus, phosphate of lime, and the carbonates of lime and magnesia, and are most frequently found in the inferior meatus. In volume they vary from a pea to a pigeon's egg; in color, black, gray, or white; of rough surface, and often containing a foreign body, or the root of an incisor tooth, as a mulens. Sometimes they create but little disturbance; in other cases, chronic inflammatory action is lit up ; in some, suppuration occurs, with profuse fetid discharge, and the septum may ultimately give way by ulceration, the whole organ becoming seriously deformed. The eye too may sympathize, and that seriously. Treatment is by extraction of the offending substance, and this is to be effected either by forceps or by scoop, as may seem most convenient, antiphlogistics being afterwards employed to subdue excitement.3 Epistaxis. By this term is understood, an inordinate hemorrhage from one or both nostrils. It may be the immediate result of an operation for polypus; it may follow external injury, with or without fracture of the nasal bones ; it may be one of the untoward results of medullary forma- tion, within the nasal cavity, or connected with it; it may be a critical depletion, of natural occurrence, tending towards resolution of an inflam- matory process, or it may be the consequence of a passively congested and hemorrhagic state of the Schneiderian membrane. The common bleedings of the nose in adolescents, caused by plethora, and tending to 1 Syme, London and Edinburgh Monthly Journal, 1842, p. 791. 2 Dublin Quarterly Journal, Feb. 1847, p. 31. [See a very good paper on nasal polypus, by Dr. Watson, of New York, in Am. Journal of Med. Sci. 1843.—Ed.] 3 Demarquay, Annales de la Chirurgie, July, 1845, and Ranking's Retrospect, vol. ii. p. 106. 168 EPISTAXIS. relieve the system from that unsafe condition, scarcely come under the designation of epistaxis; usually, the bleeding is not inordinate, is in all respects safe and beneficial, and certainly requires the adoption of no means for its arrest. Our first duty, when called to a case of alarming hemorrhage from the nose, is not at once to attempt to check it, but to determine whether such an attempt be advisable or not. If the bleeding be habitual, in a robust and plethoric patient, not very far advanced in years—if it be at all critical in its history as connected with an inflammatory attack advancing in some adjacent part—if we are told that the patient has been subject to giddiness, or other affections of the head—we are cer- tainly not to interfere, unless evident signs exist that a greater amount of blood has already flowed than the system can well bear, and that farther loss would probably be attended with hazardous consequences. Then, but not till then, we endeavor to prevent continuance. The patient's head is elevated, and cold is applied to the nose, forehead, and back of the neck. All stimuli are forbidden, and absolute rest and quietude enjoined. This treatment failing, astringents may be taken into the nostril, and applied to the bleeding surface, by injection or by insufflation, Ruspini's styptic, a solution of zinc or alum, turpentine dilute, powdered gall-nuts, matico, &c. And this method of arrest may be assisted by obstruction of the anterior nares, either by compression, or by stuffing the cavity firmly with lint, after the styptic has been sufficiently applied. Lately, it has been proposed to elevate the arm, or arms, and to retain them raised above the head, and certainly this proceeding would seem occasionally to contribute, at least, towards the successful result, perhaps in consequence of greater power being required to propel the arterial blood upwards in the arm, and less consequently being expended on the carotid circulation, as the originator,1 Dr. Negrier, imagines, or perhaps in consequence of the increased facility of venous Fig. 65. The arresting of Hemorrhage by plugging. A plug, about to be lodged firmly in the posterior nares, by means of the ligature. This having been done, and a plug afterwards placed in the front nares, the bleed- ing from that nostril is fairly commanded. 1 Archives G6ne"rales de Medecine, June, 1842. EPISTAXIS. 169 return in the subclavian vein " hurrying the return-blood in the jugu- lars, and thus deriving from the bleeding vessels of the nose." When such minor means fail, it is necessary to plug the nares, both anteriorly and posteriorly. A long stout ligature is passed through the nostril into the mouth ; by means of a flexible bougie, a loop of wire or catgut, or a springed instrument made for the express purpose. To the upper part of the oral extremity of this ligature, a portion of sponge or a dossil of lint is attached, of sufficient size to occlude the posterior opening of the nostril; and by pulling the nasal extremity of the liga- ture, this obstructing substance is firmly impacted; the extremity of the oral portion of the ligature remaining still pendent from the mouth. [Belloe's Instrument for plugging the nostrils. (From Fergusson.)—Ed.] The anterior nostril is then filled with lint, pushed firmly from the front. After three or four days have elapsed, the apparatus is removed gently. The anterior plug is withdrawn by means of forceps; the posterior is extracted by pulling the oral extremity of the ligature, previous dis- lodgement, if need be, being effected by the cautious pushing of a probe passed through the nostril. Sometimes it is necessary to plug both nostrils ; but, generally, the hemorrhage proceeds from one only. Constitutional treatment is not forgotten ; more especially if there be reason to suppose that a hemorrhagic tendency exists in the system (Principles, 3d Am. Ed. p. 359). Another method of plugging the nares has been lately proposed ; by inserting a tube of vulcanized caoutchouc, and distending this either by air or water.1 When syncope has occurred from epistaxis, in an elderly patient predisposed to head affection, we should be very careful not to excite premature and excessive reaction, otherwise extravasation Avithin the cranium is not unlikely to folloAV. The head is not to be placed Ioav, as 1 Lancet, No. 1370, p. 579; also Cyclop, of Pract. Surgery, p. 142. 170 CONGESTION OF THE SCHNEIDERIAN MEMBRANE. in restoration from ordinary syncope, but should be kept elevated; and stimuli should, if possible, be avoided. The passing of Nasal Tubes. Flexible tubes may be readily enough passed along the floor of the nostrils into the posterior fauces ; and thence they may be directed into either the larynx or cesophagus, as circumstances may require. The former destination is necessary in attempts to restore breathing, in cases of suspended animation ; the latter, in order to introduce nutri- tive ingesta into the stomach—as in cut throat. If, in the latter case, the tube is to be left permanently inserted, the passage by the nose is plainly preferable to that by the mouth ; avoiding profuse salivation, and much discomfort. Foreign Bodies in the Nostrils. Foreign bodies may lodge accidentally in the nasal cavities ; more frequently they are introduced wilfully, by the young and inconsiderate; peas, beads, portions of pencil, and such like substances are very com- monly inserted by the thoughtless child. On the foreign body de- cidedly disappearing inwards, the patient is alarmed ; and probably makes desperate efforts to extrude it by the fingers, but with the effect only of pushing it farther into the nostril. The parent or nurse is now made aware of the circumstance, and by them similar efforts at dislodge- ment are made, again with the effect of causing a deeper lodgement. By this time, the foreign substance is beyond the reach of the eye ; and its site is farther obscured by the slight bleeding which has probably taken place during the,abortive efforts at extrusion. And in this condi- tion the surgeon finds the case. It is well, in the first instance, to inject a stream of warm water into the nostril; it clears away coagula, loosens the foreign body, and may effect its expulsion. If not, the probe is to be used, the patient's head having been firmly secured; and the best way of accomplishing this, in the child, is to place the head firmly between the knees of the operator—unless, indeed, anaesthesia be employed, as in most cases it should be. By the probe, used gently, we first ascertain the presence and site of the foreign substance—for it may have passed outwards by the mouth, or downwards by the pharynx. Having discovered the foreign body, the flat end of the probe, slightly bent, or the scooped end of a director, or a curette made for the pur- pose, is passed down upon it, and insinuated past it; then, by raising the handle of the instrument, and bringing the point to bear upon the posterior aspect of the foreign substance, the latter is dislodged forwards, and may be readily removed. Forceps, hoAvever slim, are very likely to fail. They seize the anterior part of the body only ; and, slipping, have the effect of causing a firmer and deeper impaction. Congestion of the Schneiderian Membrane. The lining membrane of the nostrils is liable to become the seat of a minor inflammatory action, chronic and unimportant as regards struc- ULCERS OF THE NOSTRILS. 171 tural change, but troublesome and inconvenient by its continuance. There are redundancy of secretion (often fetid), uneasy sensation, and a fe'eling of stuffing in the part; not unfrequently the tone of voice is considerably impaired, and the sense of smell may also be rendered imperfect. Many of the symptoms of mucous polypus are present, and careful exploration by the nasal speculum is necessary to insure accuracy of diagnosis. If the action be at all of an acute nature, a few leeches may be required, more than once, applied directly to the membrane by means of a suitable glass tube; and in the passive form of congestion, leeching may also be expedient, once, to unload the vessels of the part. Then astringents are employed, solutions of nitrate of silver, sulphate of zinc, chloride of soda, alum, matico, &c, and these are patiently persevered with, either singly or combined. But in all cases an especial regard must be had to the state of the general system. Usually an atonic condition is found, and the greatest benefit is derived from sus- tained exhibition of the chalybeates. In very many cases, indeed, with- out this tonic general treatment, all local care Avould prove of but little avail. Abscess of the Septum Narium. Abscess may form beneath the mucous covering of the septum, and, when acute, the inflammatory action which causes it is usually the result of external violence. The chronic form may be independent of all ap- parent exciting cause, occurring in a patient of broken-down system, probably a victim of the mercurio-syphilitic taint. The bulging swell- ing is apt to simulate the growth of polypus. During the nascent stage, leeches are to be applied to the part, and other suitable anti- phlogistics employed, to prevent suppuration if possible. When matter has formed, an evacuating incision cannot be made too soon, in order to save the cartilage, otherwise great deformity may ensue, by a falling in and shrinking of the most prominent part of this important feature. Ulcers of the Nostrils. 1. Simple ulceration of the Schneiderian membrane is liable to occur from the ordinary exciting causes of ulceration of mucous tissue (Prin- ciples, 3d Am. Ed. p. 389), exposure to cold, contact of acrid matter, irritation communicated from diseased teeth, &c. The treatment accord- ingly consists, first, in taking away the exciting cause, seclusion from atmospheric exposure, discontinuance of snuff-taking, removal of diseased teeth or stumps in the upper jaw. And then, according as the ulcer manifests the inflamed, irritable, or weak characters, the applications are bland and soothing, or nitrate of silver in substance or solution, or various gently stimulant lotions (Principles, 3d Am. Ed. p. 229, &c). 2. Mercurio-Syphilitic ulcers not unfrequently form in this situation, of a secondary, or more commonly of a tertiary character (Principles, 3d Am. Ed. p. 74). They are obstinate, and likely to resist all mere local treatment. The more important remedial agents are those which affect the system, especially the iodide of potassium and sarsaparilla. 172 ULCERS OF THE NOSTRILS. 3. Ozaena.—By this term is understood an unhealthy ulceration of the lining membrane of the nose, with affection of the subjacent bone, caries, necrosis, or both combined. Discharge is profuse and offensive, the ulceration tends rather to spread than to heal, portions of bone from time to time come away, the nose sinks inwards, and is more or less deformed, both articulation and respiration are interfered with, and ultimately the general health may seriously give way. The nasal bones themselves may perish and exfoliate, and then the deformity is not only great but almost irremediable. The peculiarity of this ulcer is', that the ulceration is of a spreading character, simply acute, or slowly pha- gedaenic, and that the bones are more or less extensively involved. In the adult, few examples will be found in which the abuse of mercury, for syphilitic or other ailments, cannot be traced out as the paramount cause. In children, the affection would seem to be connected with the strumous cachexy. Treatment is mainly constitutional, as in the simple mercurio-syphilitic sores, without affection of bone. Besides the iodide of potassium, and sarsaparilla, arsenic is found a very useful internal remedy, steadily persevered with, in small doses. In obstinate cases, benefit has often resulted from exhibition of the liquor hydriodatis arsenici et hydrargyri, a powerful alterative.1 The local applications are necessarily varied. At first bland and tepid injections are advisable, afterwards those Avhich are stimulant and alterative. A weak solution of arsenic, solutions of the nitrate of silver, sulphate of zinc, &c, may be employed, as circum- stances seem to indicate. Throughout the cure, the chlorides should be used, at least occasionally, as correctives of fcetor. By some, the fol- lowing combination is held in high repute: an injection composed of from one to two drachms of chloride of lime, rubbed up with thirteen ounces of decoction of rhatany root, strained after standing half an hour. In scrofulous cases, ordinary antistrumous constitutional treat- ment will, of course, not be neglected. 4. Lupus, or Noli me tangere, is a confirmed phagedaenic ulcer, com- mencing usually in the upper lip, or at the exterior of the nasal cavity, spreading upwards, inwards, and around, but more in breadth than in depth, often healing at one part, while it extends at another, ultimately involving the bones, denuding them, and inducing, by caries or necrosis, such deforming results as at an earlier period follow on ozama. In advanced cases, the soft parts of the nose, and not a little of the hard, may be wholly destroyed, Avhile an unseemly chasm has also been made in one or both cheeks. The destructive action may proceed still more extensively, producing deformities more and more hideous, and ulti- mately proving fatal by hectic exhaustion. The disease is most com- mon in adults, of the poorer sort, ill-fed, ill-clothed, scrofulous, or tainted in system by mercury, and too probably also given to habits of intemperance. Sometimes, however, it attacks the most careful and correct. As in other phagedaenic ulcers, the action may be either chronic or acute (Principles, 3d Am. Ed. p. 248). Treatment is partly constitutional, such as recommended in ozaena, 1 Dublin Journal of Medical Science, September, 1840, p. 98. RHIN OPLASTICS. 173 partly local, consisting of such applications as are found most suitable for arrest of phagedaena (Principles, 3d Am. Ed. p. 249). An escha- rotic, such as chloride of zinc, nitric acid, or nitrate of mercury, is first employed, and then the sore is subsequently treated according to the characters which it presents. When it threatens to become irritable, and verges again towards phagedaena, a weak solution of arsenic is found of much service. Of escharotics, the chloride of zinc is perhaps most employed, in the form of paste, and is especially useful when bone has become affected, for it seems to hasten exfoliation. Occasional use of the simpler chlorides is as essential as in ozaena. Sometimes repeated leeching is useful. After arrest and cicatrization, the greatest consti- tutional care is still required, othenvise reaccession of the disease is extremely probable. 5. Cayicerous ulcer may implicate the nose, by extension from the face, or may originate in the former site. It is amenable to but one treatment, early removal by knife or escharotic, or by both. Rhinoplasties. When the soft parts of the nose have been destroyed, partially or wholly, by wound, ulceration, or sloughing, they may be restored in some measure by transplanting a compensating amount of cutaneous and subcutaneous tissues, borrowed from an adjoining part. When ulceration has been the destroying agent, no restorative operation is ever to be attempted, until satisfactory evidence have been afforded that all ulceration has ceased, and is not very likely to return on the application of a common exciting cause of inflammatory action. Under any circumstances, it is plain that the sequela of lupus presents a much less favorable prognosis than when the cicatrix is the result of wound, or any other simple casualty. When almost the entire organ has been removed, its restoration is attempted as follows: A piece of card or leather is shaped of the required dimensions, to constitute new alae and apex, the columna being left for an after proceeding. And this outline of the new struc- ture should always be rather too large than otherwise, there being great tendency to shrivel by absorption, after the flap has become fixed in its new locality. The edges of the cicatrized sore, on which the bor- rowed flap is to be adjusted, are made raAV by the knife. The outline of the flap is then laid flat on the forehead, the fundus pointing upwards, the neck resting between the eyebrows. It is there steadily held by an assistant, while the surgeon, with ink, or at once with the knife's point, draws its boundaries. Thus defined, it is carefully dissected down, of uniform thickness, until the narrow part is reached, and then the incisions are carried to a greater depth, to insure an abundance of vascular sup- ply. In no part of the wound is the pericranium interfered with, and, if possible, the flap should not be made to encroach upon the hairy scalp, for obvious reasons. The neck of the flap is made sufficiently long to admit of its being twisted, without serious interruption to the circulation, and to facilitate this movement the knife is carried lower down on that side to which the twist is to be made. A little time is 174 RIIINOPLASTICS. allowed for the oozing of blood to cease, then the flap, having been twisted so as to bring the integument upwards, is adjusted to the rudi- ments of the old feature, carefully and accurately, by the requisite num- ber of points of interrupted suture, and support is afforded to the flap beneath, by the lodgement of dossils of lint, so as to give that prominence and character which seem best suited to its new office of repair and imita- Fig. 67. Fig. 68. Fig. 67. Plan of Flap for a new Nose, according Fig. 68. Plan of Flap for a new Xose, as modified to the original Indian method, columna, apex, and by Mr. Listen. The apex and alae provided for; alae being all made at once. the columna to be brought, subsequently, from the upper lip. tion. The lower part of the wound in the forehead is brought together by suture, and may unite by the first intention ; the rest is covered with water-dressing, and left to granulate. The flap adheres, in part by adhesion, in part by granulation; the stitches are cut away at the ordi- nary period; and the interior stuffing is changed from time to time— medicated, if necessary. Ultimately—in twelve or fourteen days, usually—the borrowed substance becomes firmly seated in its new abode ; and then attention is directed to the connecting slip. If the ossa nasi have been left entire, with their integument, the apex and alae only having been destroyed, the connecting slip may be divided and removed. A wedge-shaped portion is taken avray by means of a nar- row bistoury ; and adjustment is effected Avith the integument beneath, made raw by the knife for reception. But if the ossa nasi have been lost, it is well to leave the medium of attachment uninterfered with; only securing its incorporation with the subjacent surface; for, by its continued presence, the want of prominence which the loss of the nasal bones could not fail othenvise to produce, will be very much compensat- ed. Besides, continued nutrition of the transplanted flap will be fully secured, and its shrivelling by atrophy may be, in a great measure, prevented. If the prominence should threaten to be excessive, it may be reduced by compression suitably applied. RHINOPLASTICS. 175 Certain precautions are always to be attended to in such proceedings. As already stated, the flap should at first seem too large; if neatly fitting at the time, it is sure to prove insufficient afterwards. TAvisting is effected very gently and carefully, lest strangulation ensue. Should engorgement occur, relief is to be obtained for the passively congested vessels, by punctures, or by draAving blood from the still raw edges. Erysipelas may supervene; if it does, the transplanted part need not be exempted from puncture or incision, if these be deemed necessary; for experience declares it to possess at least an equal tolerance of such remedial treatment as the original textures. When peculiar circumstances render the ordinary operation imprac- ticable, the flap may be taken from the hairy scalp, as practised by Dieffenbach; the hair having been previously removed by means of the bichloride of mercury in solution; and the flap being connected with a long narroAV strip of the integuments of the forehead. When consolidation of the neAv alae and apex has been duly effected, formation of the columna is then proceeded with, according to the method first proposed by Mr. Liston.1 The centre of the upper lip is found tumid and elongated ; in consequence, removal of a portion of the redundancy would of itself be a considerable improvement; and when the portion so removed can be converted to the useful purpose of con- stituting a most efficient new columna, the expediency of the proceeding becomes very apparent. " The inner surface of the apex is first pared. A sharp-pointed bis- toury is then passed through the upper lip—previously stretched and raised by an assistant—close to the ruins of the former columna, and about an eighth of an inch on one side of the mesial line. The incision is continued down, in a straight direction, to the free margin of the lip ; and a similar one, parallel to the former, is made on the opposite side of the mesial line, so as to insulate a flap about a quarter of an inch in breadth, and composed of skin, mucous membrane, and interposed sub- stance. The fraenulum is then divided, and the prolabium of the flap removed. In order to fix the new columna firmly and with accuracy in its proper place, a sewing-needle—its head being covered with sealing- Avax to facilitate its introduction—is passed from without through the apex of the nose, and obliquely through the extremity of the elevated flap; a few turns of thread over this suffice to approximate and retain the surfaces. The flap is not twisted round as in the operation already detailed, but simply elevated, so as to do away with the risk of failure. Twisting is here unnecessary; for the mucous lining of the lip, forming the outer surface of the columna, readily assumes the color and appear- ance of integument, after exposure for some time, as is well known. The fixing of the columna having been accomplished, the edges of the lip must be neatly brought together by the twisted suture. Two needles will be found sufficient, one being passed close to the edge of the lip ; and they should be introduced deeply through its substance—two-thirds, at least, of its thickness being made superficial to them. Should troublesome bleeding take place from the coronary artery, a needle is to be passed ' Practical Surgery, p. 253. 176 PARTIAL RESTORATION OF THE NOSE. so as to transfix its extremities. The whole surface is thus approximat- ed ; the vessels being compressed, bleeding is prevented; and firm union of the whole wound is secured. The ligature of silk or linen, which is twisted round the needles, should be thick and waxed; and care must be taken that it is applied smoothly. After some turns are made around the lower needle, the ends should be secured by a double knot; a second thread is then used for the other needle, and likewise secured. With the view of compressing and coaptating the edges of the interposed part of the wound, the thread may be carried from one needle to the other, and twisted around them several times ; but, in doing this, care must be taken not to pull them towards each other, else the object of their application will be frustrated, and the wound rendered puckered and unequal. Last of all, the points of the needles are to be cut off with pliers. No farther dressing is required. The needles may be removed on the third day; their ends are cleaned of coagulated blood, and, after being turned gently round on their axis, they are cau- tiously withdrawn, without disturbing the threads or the crust which has been formed about them by the serous and bloody discharge. This crust often remains attached for some days after removal of the needles ; and, besides forming a bond of union, is a good protection to the tender parts. Some care is afterwards required, from both surgeon and patient, in raising up the alae, by filling them with lint—thus compressing the pillar, so as to diminish the cedematous swelling which takes place.in it, to a greater or less degree, and repressing the granulations. It is, besides, necessary to push upwards the lower part of the column, so that it may come into its proper situation ; and this is done by the applica- tion of a small round roll of linen, supported by a narrow bandage passed over it, and secured behind the vertex." Partial Restoration of the Nose. When a portion of either ala is destroyed, the deficiency may be readily supplied from the adjoining cheek; if there be the ordinary ful- ness there. The flap is raised, transplanted, and has its vascular supply maintained, by conducting the operation in the same way as for restora- tion of the whole organ. The wound in the cheek may, generally, be approximated entirely ; and, in consequence, may be expected to unite by the first intention. The entire ala may be restored in a similar way. But if the cheek be either naturally spare, or already occupied by cicatrices, the flap must be brought from the forehead. An operation is performed, similar to that for restoration of the whole organ, but on a minor scale. When the ridge of the nose is long, it is well to make a suitable furrow in its centre—by incision—for reception of the long connecting slip ; which, otherwise, finding itself but indifferently supported on the exterior of the nasal integument, might fail to afford due nourishment to the flap, and induce its sphacelation. After union has occurred throughout the whole wound, the connecting slip may be raised from its temporary bed, and the raw edges of its site approximated; or it may be left undis- turbed, according as circumstances may seem to indicate. PARTIAL RESTORATION OF THE NOSE. 177 Loss of the apex and both alae is supplied by a frontal flap ; with or without lodgement of the connecting slip, according to the length of the nasal ridge. The ridge itself, when deficient, may be restored by a frontal flap, Fig. 69. " The Alae of the Xose; deficiencies in the upper, anterior, or lateral parts of the organ, in the forehead, Ac, may be supplied from the neighboring integument, on the same principle as the preceding repairs. In many of these operations the flap can be so contrived and cut out, as that it can be applied without its attachment being twisted. The form of such flaps is here given." (Listen.) very readily and efficiently; either by adapting a suitable portion to its surface, made raw; or by inserting a slip into a sulcus made for its reception. By cutting out the depressed portion, and approximating the margins of the wound by suture, depression may be removed, in some cases satisfactorily ; but, in most, such an attempt would be fol- lowed by an elevation of the apex causing a deformity little less unseemly than the original. When the columna alone is deficient, the operation for its restoration is performed, as detailed at p. 175. Not unfrequently, the columna, and the integumental part of the alae and apex, remain entire, while the cartilaginous texture has suffered more or less dilapidation; and the nose, in consequence, shrinks, falls inwards, and is much deformed. Autoplasty is not required to remedy this case. In some examples, it is sufficient to divide carefully the ab- normal adhesions within, to elevate the nostrils then to their normal level, and to maintain this elevation subsequently by suitable stuffing of the cavities. In other cases, however, such manipulation is found in- sufficient ; and then it is expedient to approximate the cheeks, so as to force the nose into increased prominency; the original insertions of the alae on the cheek having been previously detached, by subcutaneous in- cision. The organ, thus rendered movable, is transfixed at its base horizontally, by silver needles, which are made to perforate a piece of leather, or wood, after emerging from the nose; and by twisting the 178 PARTIAL RESTORATION OF THE NOSE. extremities of the needles, on this exterior foreign substance, the due amount of approximation is effected and maintained.1 When there is both depression of the alae and apex, and loss of the columna, the depression is first to be removed; and then a new columna is to be constructed in the ordinary way. But, in truth, no exact details can be established for any autoplastic or simply restorative operation on this organ ; the proceedings must vary, in almost every case, according to its peculiar circumstances. It is right farther to state that the majority of such operations come under the category of those of "complaisance,"—undertaken under no absolute necessity, but rather to please the patient—proverbially prone to untoward casualties in the after treatment. The flap may shrink or slough; ulceration may recur; erysipelas, phlebitis, pyaemia, may peril existence. And, at the same time, it is to be remembered that a very passable substitute for the lost organ may be adapted by the mechanic, Avithout pain or danger. For farther information on Rhinoplasties, the student is referred to the Practical Sur- gery of Mr. Liston, and the writings of Dieffenbach—who, in this department, bid fair to rival the fame even of Tagliacotius. [See also reports of operations by J. M. Warren, M. D., Boston Med. and Surg. Journal, vols, xvi., xxii., and xxviii., and Am. Journal, vol. xx.; by Dr. Mutter, Am. Journal, vol. xxii., and in Am. Ed. of Liston's Practical Surgejy; by Dr. Pancoast, Operative Surgery.—Ed.] 1 Fergusson's Practical Surgery, Am. Ed. 1853. CHAPTER VII. AFFECTIONS OF THE SUPERIOR MAXILLA. Collection of Fluid in the Antrum. The antrum is liable to become the seat of a chronic collection of fluid, Avhereby its parietes are expanded and attenuated, and its cavity much enlarged. The. condition is ordinarily termed abscess ; but it seems very doubtful if this appellation be accurately applied. The fluid may be puriform, but is seldom purulent. It is more like what is usu- ally found in serous cysts; sometimes thin and serous, sometimes glairy, sometimes sanguinolent, sometimes puriform, not unfrequently mingled with more or less of solid curdy matter. The parietes of the cavity are not thickened by fresh osseous deposit, as in chronic abscess; on the contrary, they are simply expanded, becoming thin, and in some places perhaps deficient—the loss being supplied by membranous structure, contributed probably by the periosteum. In short, the morbid condition more resembles that of osteo-cystoma, than that of chronic abscess of bone (Principles, 3d Am. Ed. p. 408). The symptoms are uneasy sensation in the part; swelling of the cheek, which ultimately crackles on pressure, and may be felt to fluctuate— the parietes having become much attenuated; the palate may bulge con- siderably downwards; sometimes there is increased secretion from the corresponding nostril; and from the hanging and stiffness of the lip on that side, articulation may be interfered with. The change may be attributed to a slight and remote injury; or to the presence of decayed teeth in the corresponding maxilla; but very frequently, there is no as- signable exciting cause. The remedy is by evacuation ; and the aperture must be both free and dependent. An aperture sufficiently dependent may be formed in the corresponding alveoli of the canine or first molar teeth ; and sometimes a communication is found already established there, on removal of the decayed teeth or stumps. But such an opening is seldom if ever suf- ficiently free, when of spontaneous formation; indeed, sufficient space is not readily obtained at this part, even by operation. And it is es- sential that the opening shall be of some considerable size; otherwise the fluid will not escape by it; but will be retained by atmospheric pres- sure—as in the case of the narroAv-necked bottle, which, when filled with water, is suspended in an inverted position for barometric purposes. It is better to make an opening through the most dependent part of the attenuated parietes, above the first molars. The membrane of the cheek is incised there; and, by means of the same instrument—a strong 180 POLYPUS OF THE ANTRUM. bistoury—the parietes of the cavity may also be perforated, in the greater number of cases. If the bone, however, prove thick and resist- ing, a pointed lever, as used for the extraction of decayed teeth, may be employed. An aperture having been made of sufficient dimensions to admit the point of the little finger, through this the contents readily drain away. Besides, reaccumulation is effectually prevented ; and, by pressure from without, return to the normal state by contraction is favored. Abscess of the Antrum. The lining membrane may undergo inflammatory action, with or with- out the application of external violence; and suppuration may ensue. The action may be either chronic or acute. In the former event, the case will very much resemble the cystic enlargement just detailed. This, however, is of rare occurrence, and is usually unconnected with ex- ternal injury. Acute abscess generally results from violence applied, or from irrita- tion communicated by decayed teeth or other affections of the gums. The symptoms are severe. With a considerable amount of constitu- tional disturbance, there are deep-seated and great pain, tension and throbbing, and swelling of the superimposed soft parts. Usually, partial evacuation takes place, spontaneously, by the side-of a tooth; with relief from the more prominent symptoms. Such imperfect evacuation and relief, how- ever, are not enough ; the operation, above the bicuspid teeth, as for emptying the in- dolent fluid collection, must be had recourse to. But, of course, in the first instance, attempts are made to forego the necessity of all operative interference, by timeously arresting the inflammatory process, if possi- ble, ere matter has at all formed. When purulent accumulation has taken place, the artificial opening cannot be too soon esta- blished. For, from the turgid state of the membrane, it is very obvious that no partial relief can be expected from spontaneous evacuation through the nasal aperture—as sometimes happens in the indolent collection of fluid. Fig. 70. Enlargement of the Antrum, by accu" mulation of fluid within. Polypus of the Antrum. _ The lining membrane of this cavity, like that of the nostrils, may give origin to polypous formations. But the occurrence of benign polypi here is comparatively rare. The medullary formation is not uncommon; constituting the origin of osteocephaloma, as affecting this bone ; and amenable to the ordinary rules of treatment (Principles, 3d Am. Ed. p. 457). Did plain indications exist of the presence of a benign polypus— TUMORS OF THE SUPERIOR MAXILLA. 181 mucous or fibrous—within the antrum, it would certainly be our duty to expose the cavity, by suitable incision, from the mouth ; Avith or without division of the lip ; and to eradicate the morbid growth thoroughly. Such cases, hoAvever, are extremely rare. Tumors of the Superior Maxilla. Two forms of tumor are liable to occur in this bone : Osteosarcoma Fig. 71. Large Osteosarcoma of Upper Jaw; macerated, showing the osseous stroma. Still limited to the superior maxilla, in which it originated. (Howship.) and Osteocephaloma; tumors very different in themselves, and re- quiring very different treatment. The one, early irremediable ; the other, capable of cure at an advanced date, and after a large or even enormous size has been attained (Principles, 3d Am. Ed. p. 457). The osteosarcoma may reach a large size by external bulging, and by expansion of the bone ; but, unless it degenerate in structure, it remains limited within the confines of the superior maxilla; and, consequently, by removal of that bone alone, the whole of the diseased formation may be taken away. The swelling projects into the fauces, into the mouth, and outwards on the cheek; the main protuberance is in the last-named direction, interfering with articulation, mastication, and vision ; a thin serous discharge escapes by the mouth, seldom bloody, and seldom of- fensive ; and the general health may be hale in all respects. The remedy is excision of the superior maxilla ; and this, though a severe and some- what difficult operation, may be fearlessly undertaken, even in the most advanced cases of this disease—if genuine; experience having proved that the issue of such operations is almost invariably prosperous. The osteocephaloma may be of original formation, or may be the 182 EXTIRPATION OF THE SUPERIOR MAXILLA. result of osteosarcoma degenerated. When of the former character, the diseased formation has extended beyond the limits of the superior maxilla, ere any considerable prominence has appeared externally. The outward tumor may be yet trifling, while the mouth and fauces are completely occupied, and the base of the cranium hopelessly involved. The system, too, is already worn by malignant hectic. In such cases, we cannot—by excision of the superior maxilla, the palatine bones, and the malar—hope to take away the whole of the tumor ; a portion re- mains, deep-seated and inaccessible ; from this, reproduction of a tumor, soft, fungated, and bleeding, takes place; and a most disastrous issue is precipitated. Or, not improbably, the already much enfeebled system speedily sinks under the immediate effects of the operation, ere ever a new production has had time to form. In short, while we may perform excision of the upper jaw with the best prospect of success, even at a late period of the case, in osteosarcoma, we ought to refrain from opera- tion in all examples of osteocephaloma, excepting those in which we are satisfied that the disease is yet recent, and limited to the bone in which it began—and such cases are very rare. Fig. 72. Extirpation of the Superior Maxilla. The patient is seated firmly on a chair, or reclines on a table with the head and shoulders considerably elevated ; for so the manipulations of the surgeon are facilitated, and the outward escape of blood is favored. As elsewhere stated (Principles, 3d Am. Ed. p. 730), my own impres- sion is, that anaesthesia by chloroform is at least of doubtful propriety here. ^ The experience of others, howeATer, among whom I may place the high authority of Mr. Lawrence, testifies that this important agent may be employed, under due precaution, even here, with perfect safety. If used, every care must be taken to prevent the main risk, namely, asphyxia, by accumulation of blood in the air-passages. • The jaw haAdng been made clear of teeth at the point where section is intended to be made, a strong bis- toury is inserted near the inner cor- ner of the eye, over the nasal pro- cess of the superior maxilla, and is brought down to the mouth; cutting the lip in the mesial line, and dis- secting the ala of the nose from its basis. The knife is again entered over the external angular process of the frontal bone, and carried oblique- ly downwards to the angle of the mouth ; dividing the whole thickness of soft parts. The flap, indicated by these two incisions, is then dis- sected upwards off the tumor; and Tumor of the Upper Jaw; showing the lines of incision for Removal. EXTIRPATION OF THE SUPERIOR MAXILLA. 183 is held raised by an assistant. The orbital contents are separated from the bone, on their lower aspect; and are gently elevated and protected by a flat copper spatula, which is also retained by the assistant. The soft palate is'incised in the mesial line, correspondingly with the wound of the lip ; and, by cross cutting, the pendulous velum of the palate is separated from the doomed parts—now isolated, so far as the soft tex- tures are concerned. By a small saw—stronger and longer than what is ordinarily sold as Hey's—the union between the maxilla' and malar bone is severed. By the same instrument the alveolar process is cut through, at the part exposed by the labial wound ; and a groove is also made in the palatine process, at the part incised. A pair of stout and long bone-pliers may then be used to complete the section at this part; one blade resting in the palatine and alveolar groove, the other passed into the corresponding nostril. If such an instrument be not at hand, however, the section may be completed readily enough by means of the saw alone. The nasal process is severed by the ordinary cutting pliers. And, now, by pressing the tumor downwards, it is dislodged from its connections ; while complete separation is readily effected by touching with the knife those soft parts which require its edge. The velum of the palate, formerly separated, is carefully preserved—and, if possible, also the palatine plate of the palate bone. One or two vessels, hang- ing in the deep wound, will probably require ligature ; and the facial Fig. 73. Portrait after removal of the Upper Jaw, for Osteosarcoma. An example of how little deformity may in some cases remain. vessels, which during the operation were restrained by the fingers of an assistant, are also secured. The amount of deep bleeding is often but slight; the vessels being torn, not cut, during evulsion of the tumor. 184 EXTIRPATION OF THE SUPERIOR MAXILLA. The vacant space, having been cleared of coagulum, is filled with lint; and over this the flap is replaced. Both incisions are then brought together with great accuracy, by means of the twisted and interrupted forms of suture ; treatment is conducted for adhesion ; aricl, generally, this does not fail to occur, in almost the entire extent of the facial wound. The deep cavity of course inflames and suppurates. The lint loosens, and is brought aAvay. A less amount of dressing is daily re- newed, medicated with a weak solution of the chlorides; granulation advances, and cicatrization is in due time obtained. In some cases, a marked deficiency remains ; and this may be remedied by the skill of the dentist. But in other cases, the deficiency is wonderfully atoned for, by nature's effort alone; partly by the formation of new matter, partly by contraction and accommodation of the old. When the tumor is of large size, the malar bone is encroached upon, and has to be taken away along with the maxilla. In such a case, a third incision is made along the zygoma, terminating in the upper part of that which passes from the outer corner of the eye to the angle of the mouth ; the zygomatic and orbital processes being divided by the bone- pliers. If the tumor be small, one incision may suffice—that from the outer corner of the eye to the angle of the mouth; it being quite possible to expose the parts sufficiently, by raising the triangular flap while the lip and front-face are retained entire. Dieffenbach's mode of procedure is as follows: Having made the central incision by the side of the nose, the knife is carried across be- neath the eye to the temple; and the flap, thus indicated, is dissected off. This admits of a thorough exposure of the tumor ; subsequent deformity by the cicatrix is comparatively slight; and paralysis from division of the facial nen'es will probably be avoided. [In a case of scirrhus of the antrum, Dr. Horner, of this city, re- moved the whole of the upper maxillary bone of the left side without making any external division of the cheek; the patient being thereby saved the unsightly scar which is left after the ordinary operation. For an account of this operation, and of several others performed by Ame- rican surgeons, see Smith's Operative Surgery, Philadelphia, 1853. In removing the upper maxillary bone, it is obviously a matter of great importance to preserve, if possible, the floor of the orbit intact, in order that the eyeball and lower lid may be sufficiently supported. This can best be accomplished by the plan recommended by Dr. Mussey, of Cincinnati. It consists in separating the maxillary from the malar bone by running a narrow saw downwards and outwards from the orbit, through the latter bone, just outside of the malo-maxillary suture, nearly parallel with that suture, and extending the cut to the sphenomaxil- lary fissure. The nasal process is to be sawn at its base, downwards and inwards, from the orbit to the nostril, in order to disturb as little as possible the lachrymal canal (Trans. Am. Med. Association, vol. iii n. 364).—Ed.] ' P If any doubt should occur to the surgeon as to the solidity of the growth, an exploratory puncture should be made in the direction of the EXTIRPATION OF THE SUPERIOR MAXILLA. 185 antrum, previous to operation ; for excision of the upper jaw is rather too severe a remedy in the case of mere distension of the antrum by accumulation of fluid. See Bibliography of Diseases of Bones, in Principles of Surgery ; also Lizars, London Medical Gazette, vol. v. p. 92; and System of Anatomical Plates, part. ix. Edin. 182(i (where excision of the superior maxilla is first proposed); Blandin, (iazotte M_ brane are brought together by points of in- """"-------"""' terrupted suture. When the disease is more extensive, and the lip lax, it is yet possi- ble both to remove the diseased part satisfactorily, and to prevent any great deformity. The including incisions are made in the form of the let- 194 ULCERS OF THE LIPS. ter V, the apex pointing downwards ; and with care taken that the good general rule is not transgressed, of taking away a border of apparently sound texture along with the truly carcinomatous formation (Principles, 3d Am. Ed. p. 317). The wound is approximated and secured by twisted suture, as for harelip. In not a few cases, however, almost the whole surface of the lip is involved, the disease at the same time extending deeply towards the chin. Under such circumstances, we have but one paramount indica- tion to fulfil; namely, complete excision of the diseased part; and this is uncompromisingly effected by a free sweep of the knife. Approxi- mation is not attempted. But the part is left to granulate and heal, as ordinary suppurating wounds do. And sometimes the ultimate defi- ciency of lip, after such an operation, proves much less than might have been anticipated; partly on account of formation of new matter, but mainly by resilience and centripetal movement of the old textures. The lower lip, when destroyed by carcinoma, may sometimes be re- stored in great measure by incision and elevation of the adjacent parts, without transplantation of flaps; as has been practised by Blasius, Dief- fenbach, Serre, Syme, Lawrence, and others.1 The operation is thus described by Mr. Syme, in a case in which removal of the cancer and restoration of the lip was done at the same time: " Two incisions were made from the angles of the mouth, so as to meet at the chin, and re- move the whole of the morbid part in a triangular form. The line a b and b c being supposed to represent these incisions, I cut from the point b outwards and downwards, on each side, to d and e, in a straight direc- tion, and then, with a slight curve outwards and upwards, to/ and g. Fig 81- Fig 82. The flaps abdf zndcbeg were next detached from their subjacent connections, and raised upwards, so that the edges a b and cd came into a horizontal line; while those represented by b d and b e met together in a vertical direction, and the lateral extensions to/ and g allowed suffi- cient freedom to prevent any puckering or overstraining. The respective surfaces were lastly retained in contact by the twisted and interrupted suture; four points of the former being inserted in the middle line from 'See Blasius, Klinischen Zeitschrift Halle, 1836. Dieffenbach, Handbuch der Plas- hschen Chtrurgie Berlin, 1838. Serre, Traite" sur l'Art de Restaurer les DeTormiSs de la Face, Pans, 1842. Syme, Monthly Journal, March, 1847, p. 642. «*m«es ae ia CHEILOPLASTICS. 195 the lip downwards, and the same number of the latter in the curved por- tion on each side. The wound then presented the appearance shown by Figure 82. It healed entirely by the first intention." Cancrum Oris. This is an example of Sloughing Phagedaena (Principles, 3d Am. Ed. p. 248). It originates in the mucous membrane of the lip or cheek, and extends sometimes both rapidly and far, presenting the usual characters of that class of sore. It is almost exclusively met with in the ill-fed, ill-clothed and ill-housed children of the poor in densely populated towns. But in any child of weakly habit it may be induced by imprudent mer- curialism. The constitution sympathizes greatly; in the form of irri- tative fever, tending to the typhoid character. Treatment consists in amending the outward condition of the patient, if possible, by change of air, ventilation, &c.; rectifying the primae viae, but studiously avoid- ing all mercurial medicines ; carrying out the -active local treatment suitable to this form of sore (Principles, 3d Am. Ed. p. 249); and ad- ministering internally the chlorate of potass—found to be a very ap- propriate alterative, in the dose of from one scruple to tAvo scruples in the course of twelve hours. In the worst form, nourishment, tonics, and even stimuli may be imperiously demanded, to prevent sinking. And if the patient survive, the loss of substance will probably be such as can be remedied only by a determined autoplastic operation. Cheiloplastics. When the lip has been lost, either entirely, or in its greater part, in a patient otherwise of tolerable health, and not far advanced years, re- storation by autoplasty may be contemplated. The part may have been destroyed by wound, sloughing, or intractable ulceration. In the last- mentioned case, we must be very careful not to attempt the engrafting of a substitute, until all ulcerative tendency has for some time wholly ceased—for very obvious reasons. After removal of truly cancerous disease, restorative interference is seldom expedient; unless by the pecu- liar arrangement of incision already spoken of (p. 194). The autoplastic operation is conducted on the same principles as for restoration of the nose. A flap, of suitable form and dimensions, is brought from beneath the chin. A connecting slip is left at the sym- physis ; there gentle twisting is made, so as to bring integument to the surface; the part is secured in its new site by suture ; and, by the like means, a portion of the submental wound is approximated—the rest being left to heal by granulation. After adhesion of the flap is com- pleted, the mental slip of attachment is divided, and smoothed down, by the bistoury. See Dieffenbach, &c, as in the foot-note of the former page. Liston's Practical Surgery. On Cancrum Oris, see Marshall Hall, Lancet, 1839-40, p. 409. Cycl. of Pract. Surgery, sub voce. Hunt, Med.-Chir. Trans, vol. xxvi. Also Lancet, No. 1023, p. 60. CHAPTER X. AFFECTIONS OF THE PALATE. Congenital Deficiency. Extensive deficiency of the hard palate is with difficulty remediable. Mitigation of the deformity and inconvenience may be effected by the dentist; a metallic plate being fitted into the chasm, on completion of the part's development. Also, something may be done by surgery; as recommended by Dr. J. M. Warren. The soft parts, having been care- fully dissected off the bony arch, are brought together by suture, after the edges of the gap have been made raw. What filled the arch will probably meet readily on a plane surface; but should difficulty be ex- perienced, farther relaxation may be obtained by dividing the anterior pillars of the soft velum.1 A mere fissure of the hard palate may disappear spontaneously, dur- ing the progressive development in adolescence. And if the mucous membrane should be slow in closing over, this process may be expedited by occasionally applying a heated wire, or by raising and approximat- ing the raw edges. ^ The soft palate may be fissured, alone. Then, if the want of sub- stance be not great, we have it in our power to attempt remedy by operation. Three circumstances, however, are essential, as prelimi- naries to the attempt. There must be no great deficiency, otherwise traction in approximation Avill be considerable, and adhesion will almost certainly fail. The patient must be of adult age, or nearly so; great steadiness and self-control being indispensable on his part, both during the operation and afterwards. The patient should also be of sound system, and in good health ; so as to afford every possible facility to the occurrence of adhesion in the wound. And unless a concurrence of these circumstances can be obtained, the prudent surgeon will refrain from interference. The operation is termed Staphyloraphe, or Velosynthesis. It con- sists of three distinct parts; preparation of the velum, paring of the edges, and approximation of the fissure by suture. The first part re- quires some considerable time for its completion. For weeks before the actual operation, the patient accustoms himself to open his mouth wide, and to retain it so, steadily and enduringly—with no effort at deglutition of saliva; and he also seeks to reduce the irritability of the parts, by 1 New England Quarterly Journal of Medicine and Surgery, April, 1843. STAPHYLORAPHE. 197 frequently touching them with his finger, or otherwise. The nature of the operation is fully and candidly explained to him, and his willing co- operation secured. Then he is seated before a good light, with the mouth widely opened, and the edges of the fissure are made raw, by a narrow sharp-pointed bistoury, used as in harelip ; a volsella being em- Fig. 83. Fig. 84. [Volsellum. (From Fergusson.)—Ed.] ployed to seize the uvular extremity, and so to make the part tense during incision. This completes the second part of the operation. Some hours are now allowed to intervene; and it is well to give some simple nourishment at this time—it being obviously important to avoid the effort and movement of deglutition for some time after approxima- tion has been effected. The third part of the procedure consists in bringing the wound into accurate apposition at every point; diminishing the strain on the sutures, by lateral and parallel incision of the mucous membrane; and keeping the part in a state of as complete quietude as circumstances will possibly allow. Approximation is not made immedi- ately after incision, because it is expedient to allow all oozing of blood to cease in the first instance; so as to avoid the irritation* and involuntary movements of the palate, which its trickling does not fail to pro- duce. But bleeding having wholly ceased, there is no necessity for farther delay. The necessary num- ber of sutures are passed; and may be secured either by the ordinary knot, or by passing the oral ends through a soft metallic bead, running this up to the line of wound, and clasping it on the threads there by means of firmly-pointed forceps. Not a few instru- ments have been contrived for facilitating the sewing department in this operation—undoubtedly one of The double ligature in the great difficulty; but it is probable that the curved «*of bGing drawn. The needle in a fixed handle—as used for deligation of dotted lincs murk thc libe- i / Tt • • i oja -ni Fnr-rr racing incisions of the mu- vascular tumors (Frinciples, 3d Am. Ed. p. 595, Fig. ^^ membrane. 209, b)—will be found quite suitable in experienced hands ; or a short needle, very much curved, may be conveniently enough passed by means of a porte-aiguille. When approximation has been completed, a longitudinal incision is made on either side of the palate, through the anterior mucous mem- brane ; so as, by permitting expansion at the cut part, to diminish trac- tion on the line of union. Absolute starvation is not desirable. But 198 STAPHYLORAPHE. simple farinaceous food is sparingly and carefully administered from time to time; the patient being as passive as possible in the act of swal- lowing. And the ordinary constitutional treatment, favorable to the occurrence of adhesion, is of course rigidly enforced. Not a little self- denial is necessary, on the part of the patient, to avoid the oft-occurring excitements to coughing, hawking, and swallowing; compliance with which would have a manifestly unfavorable effect upon the wound. Mr. Fergusson has introduced a very ingenious modification of the ordinary operation; obtaining steadiness and quietude of the parts ope- rated on by means of myotomy. Looking on a split palate, from the mouth, the parts are seen hanging quiet in the fauces, with a distinct central gap in the velum. If the flaps be touched, they will be raised upwards, by the action of the levatores palati muscles. If a stronger stimulus be applied, as by the rude touch of a finger, " each flap is for- cibly drawn upwards and outwards, and can scarcely be distinguished from the rest of the parts forming the sides of the nostrils and throat;" and this is done by the action of the palato-pharyngei muscles, added to that of the levatores palati. On exciting the parts situated more posteriorly, "as in the second act of deglutition, the margins of the fissure are forced together, by the action of the superior constrictor muscle of the pharynx." The main opponents of approximation in staphyloraphe are thus shown to be the levatores palati and palato- pharyngei. And Mr. Fergusson's operation is planned so as to divide Fig. 85. Fig. 86. r Fig. 87. [Figs. 85, 86. Knives employed by Mr. Fergusson.—Ed.] [This drawing represents the Posterior Nares and upper surface of the Soft Palate, a. The levator pa- lati; the dark line shows where it should be cut across; the inner bundle of fibres of the palato-pha- ryngeus forming the posterior pillar of the fauces; the black line indicates the place for division, c. The palatoglossus with the place for incision, if one should be deemed necessary. The tonsil lies between these two muscles, d. The tensor palati, the cartilaginous extremity of the Eustachian tube is in front of this letter, e. The posterior extremity of the inferior tur- binated bone. /. The septum, gg. The uvula on each side stretched apart. (From Fergusson.)—Ed.] ULCER AND EXFOLIATION OF THE PALATE. 199 and temporarily paralyze these muscles. "With a knife, whose blade is somewhat like the point of a lancet, the cutting-edge being about a quarter of an inch in extent, and the flat surface being bent semicir- cularly, an incision is made about half an inch long, en each side of the posterior nares, a little above and parallel Avith the palatine flaps, and across a line straight downwards from the lower opening of the Eusta- chian tube. By this incision, placed about midway between the hard palate and the posterior margin of the soft flap, just above the thickest and most prominent part of the margin of the cleft, the levator palati muscle on each side is divided, just above its attachment to the palate. Next, the edges of the fissure are pared with a straight blunt-pointed bistoury, removing little more than the mucous membrane. Then, with a pair of long blunt-pointed curved scissors, the posterior pillar of the fauces is diATided, immediately behind the tonsil; and, if it seems neces- sary, the anterior pillar is cut across too; the wound in each part being about a quarter of an inch in extent. Lastly, the stitches are intro- duced. . . . Or, it may be found more convenient to divide the palato-pharyngeus first, next the levator palati, and then to pare the edges when the muscular action has been taken off." When the pared edges look thin, it may be well to increase their breadth by applying the curA'ed knife, so as to split the margins to a slight depth; so render- ing the occurrence of satisfactory union more probable. Ulcer and Exfoliation of the Palate. The lining membrane of both the hard and soft palates is liable to ulceration, from ordinary or specific causes. The most intractable, and not least frequent examples, are those which are connected with the mercurio-syphilitic taint of system. In such, constitutional treatment is all-important; the local applications varying, according to the cha- racters of the sore. Exfoliation of the hard palate, not unfrequently complicated with caries, and necessarily accompanied with ulceration of the corresponding mucous membrane, is seldom, if ever, found to occur, except Avhen mer- cury has been freely administered. Again, treatment is mainly consti- tutional. Locally, separation is patiently awaited; and, when this has been completed, removal of the sequestrum is duly effected, if neces- sary. If the whole thickness of bone have perished, an aperture of communication necessarily results between the nasal and buccal cavities. If this be large, the deficiency can be supplied only by mechanical con- trivance. If, however, it resemble a merely fistulous opening, closure of the mucous membrane may be obtained by the occasional application of a heated wire. Med.-Chir. Transact, vol. xxviii. p. 291. Also, Fergusson's Pract. Surgery. For Dief- fenbach's procedure in this operation, see his Operative Chiruigie, 1845, p. HW. [The reader will find very good papers on this subject of fissures of the hard and soft palate, by Dr. Mettaiier, Am. Journal, vol. xxi. ; Dr. Mutter, ditto, vol. ii. N. S. ; Dr. Warren, ditto, vols. vi. and xv. N. S.; Dr. Pancoast, ditto, vol. vi. N. S. Also, Smith's Operative Surgery.—Ed.] CHAPTER XI. AFFECTIONS OF THE TEETH. It is unnecessary here to enter fully on the various and important topics connected with the subject of this chapter. A few leading sur- gical points may be stated; reference being made, on other matters, to the various separate works which treat of Dentistry in detail. First, it is well that the student remember how affections of the teeth are connected not only with the convenience, comfort, and good looks of a patient—but with his health and very existence. The causes— sometimes remote, sometimes tolerably direct—of many affections im- plicating the general frame, as well as important parts of it, proceed entirely from the contents of the alveoli. Bad teeth "are frequently the cause—and the sole cause—of violent and continued headache; of glandular swellings in the neck, terminating in, or combined with ab- scess ; of inflammation and enlargement of the tonsils, either chronic or acute; of ulcerations of the tongue or lips, often assuming a malig- nant action from continued irritation; of painful feelings in the face, tic douloureux, pains in the tongue, jaws, &c.;" of abscess and sinus of the cheek; of enlargement and change of structure in the gum, which may lead to dangerous tumor of the bone; " of disordered stomach, from affection of the nerves, or from imperfect mastication; and of continued constitutional irritation, which may give rise to serious constitutional disease." Crowded Teeth Are important in a surgical point of view. Behind, the irritation so caused may induce swelling, vascularity, and ulceration of the mucous membrane; probably with repeated attacks of troublesome and even dangerous cynanche. In front, croAvded incisors are very apt to cause abscess ; not confined to the soft parts, but implicating the bone also. The remedy is plain; early to prevent mischief, by removal of one or more of the redundant organs; or, at a later period, to retrieve disaster by the same procedure—removal of the cause. Caries of the Teeth Is the term usually employed to denote decay of the osseous matter; which usually commences on the surface, at one or more points, and proceeds inwardly until the pulp is exposed—the enamel also giving TOOTHACHE. 201 way at an early period. When the disease is yet recent Fig. 88. and limited, its progress may be arrested; by clearing away the disorganized substance, and llstoppingv the cavity, either with gold or with cement. But after the pulp has been fairly exposed, and pain established, it may be stated, as a general rule—not to be rashly or often de- viated from—that under such circumstances "stopping" is not advisable, and extraction of the offending part is highly expedient. Long to retain a decayed tooth, or por- tion of a tooth, in the hope of by various means quelling the pain of toothache, and so avoiding the pain of extraction, is to court the accession of some of the more important evils already enumerated as likely to spring from such a source of irri- tation. Hopeless De- struction of the Tooth. Toothache, It is important to remember, may proceed from different causes; and so requires different treatment in different cases. It may be an example of neuralgia, with or without any connection with diseased teeth or gums, requiring the ordinary anti-neuralgic treatment, local and general (Principles, 3d Am. Ed. p. 587). It may be caused by caries of the tooth, advanced so as to expose the pulp; and then may be palliated by anodynes; temporarily arrested, painfully, by escharotics, or entirely quenched by extraction of .the tooth; and the last, as already stated, is in most cases the preferable proceeding. It may arise from inflamma- tory action in or around the tooth—in the interior of the tooth's cavity, or in the alveolar investing parts—not necessarily connected with decay of the tooth at any part; and this form is plainly to be assuaged by antiphlogistics, local and general; locally, leeches and fomentation to the gum; constitutionally, purgatives, antimony, and low diet; the pa- tient at the same time affording as much rest as possible to the affected part, especially avoiding all irritation of it by tongue, finger, or toothpick. Also, severe pain may be felt in the teeth, apparently sound, quite of a rheumatic origin and character; and this is to be got rid of by anti-rheumatic remedies, mainly constitutional in their operation. Change of structure in the fang of the tooth—it becoming coated by rough osseous deposit—may induce intense pain, though the organ be in other respects sound; by such hypertro- phy, it is probable, the nerves are incommoded and com- pressed; and the only remedy is extraction. And, lastly, the fang or fangs, of a tooth may become necrosed, the croAvn and cervix remaining apparently sound; chronic abscess forms around the affected part, the matter accumulating in a distinct membranous pouch ; and much pain is likely to be thus occasioned, until either the tooth is extracted, or becomes loose and permits spontaneous evacuation and discharge. Fig. 89. Purulent Cyst at the fang of a decayed Tooth; often the simple origin of most serious mischief- 202 EXTRACTION OF TEETH. Extraction of Teeth. Extraction of a tooth is.demanded, not unfrequently, of the surgeon, as an operation of itself; or as a means towards the cure of another, Fig. 90. Fig. 91. Fig. 90. Diagram showing the Fig. 91. Forceps for the upper jaw; constructed so as to adapt them- application of the tooth-key. selves closely to the form of the tooth. In a, the tooth, sawn across, shown embraced. and, perhaps, distant affection—such as neuralgia; or as part of a more serious operative procedure—as in extirpation of a portion of the jaw. Fig. 92. Forceps for the Lower Jaw. In a, the tooth embraced. Forceps and the tooth-key are the instruments usually employed. The former, in general estimation, is by much the preferable; equally certain to effect the object in view, and possessing the great recommendation of exerting all the force on the doomed part, and leaving the alveolus and gum comparatively, or absolutely, uninjured. Practice is, no doubt essential to the skilful and efficient use of forceps; and many instru- ments are required in the well-equipped armamentarium, adapted to the configuration and lodgement of the tooth to be removed. HEMORRHAGE AFTER EXTRACTION OF TEETH. 203 Stumps are removed either by means of sharp forceps, introduced beneath the gum; or by a lever passed between the offending part and its alveolus, making use of a neighboring sound tooth, if possible, as a fulcrum. Hemorrhage after Extraction. Troublesome bleeding may follow the ordinary extraction of a tooth, and may proceed from one of two causes. An arterial branch, of some size and actiA'ity, may have been implicated in the injury inflicted on the alveolus. Or the patient may be one of those unfortunates afflicted with the hemorrhagic diathesis. The former case is usually manageable enough. The cavity is sponged dry, and an escharotic applied—nitrate of silver, probably the preferable—so as temporarily to arrest the flow, and afford a dry bed for the compress. Then, with all convenient speed, strips of lint, steeped in a strong tincture of matico, are inserted firmly into the cavity, by means of a stout probe or director; and the jaws,. having been brought together with a compress interposed at the injured part, are made to exert and maintain a sufficiency of pressure on the bleeding point. In the other case, the same local treatment is advisable, with the means suitable to the hemorrhagic diathesis (Principles, 3d Am. Ed. p. 360). Tartar on the Teeth. Accumulation of salivary deposit is to be prevented, for obvious rea- sons ; its presence being prejudicial to the teeth themselves, to the gums, to the mucous membrane of the cheek and lips, and to the tongue. The teeth are apt to loosen and decay, the gums to become congested, the mucous membrane to become the seat of obstinate and painful ulcera- tion. In effecting removal, care must be taken to leave the enamel uninjured. Recession of the Gums. In advanced years, and sometimes even in middle age, the gums recede from the cervices of the teeth, especially in front, exposing the fangs; occasioning looseness, pain, irritation, and final decadence ; though, in other respects, the organs may be quite entire. In the senile cases, but little can be done by remedial treatment; the occurrence ia only a part of the general decay, and is, in all respects, to be regarded as such. A similar result may follow the accumulation of tartar; it is to be averted by removal of the offending matter. Congestion of the gums may induce it; and this cause is met by local abstraction of blood, by leeches or scarification, and by the subsequent use of astringent dentifrices. At the same time it is very necessary to look to the state of the primae viae, and to correct the irregularities which will probably be found there. 204 INJURIES OF THE TEETH. Lnjuries of the Teeth. A tooth struck smartly may be deprived of a part of its compact structure, without any serious injury to the integrity of the rest. If, however, it have been displaced, and its vascular connection broken up, necrosis is the result. Sometimes simple dislocation occurs, without fracture. By replacing a dislocated tooth, an imperfect union with the alveolus may take place; but the tooth will eventually lose its color, and induce an unhealthy action in the gums. C. Delabarre, Traite" de la Seconde Dentition, Paris, 1819. F. Maury, Traite" Complete de l'Art du Dentiste, Paris, 1833. Thomas Bell, Anatomy and Physiology of the Teeth, London, 1835. William Robertson, Practical Treatise on the Human Teeth, London, 1839. Chitty Clendon, On Extraction of the Teeth, London, 1844. Goddard and Parker, Anatomy, Physiology, and Pathology of Human Teeth, Philadelphia, 1844. John Tomes, Lectures on Dental Physiology and Surgery, London, 1848. Chapin Harris, Principles and Practice of Dental Surgery, Philadelphia, 1850. CHAPTER XII. AFFECTIONS OF THE JAWS. Parulis. The term Parulis denotes the condition of Gumboil; inflammation of the gum, usually connected with a decayed tooth or portion of a tooth. The swelling causes much pain and discomfort, sometimes with smart constitutional disturbance. On suppuration taking place, relief is obtained by evacuation of the matter; but so long as the decayed tooth remains, a certain discharge, with swelling and pain, continues to prove the source of no slight annoyance. Treatment varies according to the stage of advancement. At first, the affection just originating, the decayed tooth should be removed at once, and bleeding from the wound encouraged; and afterwards, if need be, blood may be farther withdrawn by leeching the affected part—the animals being most con- veniently applied through a glass tube. When matter has formed, it should be early and fully evacuated ; and after the excitement followinc incision has abated, under ordinary antiphlogistic means, the offending tooth or stump should be gently extracted. To perform extraction earlier, might be to aggravate the inflammatory action unnecessarily. When the matter has formed and been discharged, extraction of the tooth will ordinarily suffice for effecting contraction and closure of the discharging aperture, with subsidence of the swelling and pain. If not, some of the many suitable astringent solutions may be applied to the part. Epulis. Epulis denotes a solid tumor of the gum, of non-inflammatory origin; but, like parulis^often, if not usually, connected with the presence of a decayed tooth, or portion of alveolus. It may be either simple or malignant. The simple form is a sarcomatous growth, at first seated in the soft parts of the gum, but tending soon to involve the subjacent bone ; in short, the tumor, at what may be termed its period of ma- turity, may be truly considered an example of osteosarcoma, on a small scale. It spreads slowly. Teeth loosen, and are surrounded by the fleshy growth ; and the body of the bone becomes more and more in- volved. 206 TUMORS OF THE LOWER JAW. In the early condition, it is sufficient to remove the offending tooth, or piece of bone, and, with a bistoury, to excise the altered portion of gum, repressing subsequent tendency to growth, if need be, by the application of an escharotic. When the bone has become involved, it is essential that the affected portion shall be taken away, early and freely, for obvious reasons, and this is readily effected by knife, saw, and cutting pliers (Principles, 3d Am. Ed. p. 458). The malignant form is, fortunately, by much the more rare. Very early the bone is affected, and the tumor is a true specimen of osteo- cephaloma. Soon the surface ulcerates and fungates, with bloody loath- some discharge, and the spread is rapid in all directions. Obviously, the only remedy is by ablation, and that at a comparatively early period. Sometimes, malignant disease commences in the upper jaw, not with the formation of tumor, but at once by ulceration, osteocancer (Prin- ciples, 3d Am. Ed. p. 460). The loss of substance speedily wastes the alveoli, and, opening into the antrum, discloses a foul and hideous sore, at a very early period beyond the reach of the most active surgery. Tumors of the Lower Jaw. The lower jaw, like the upper, is liable to be the seat of a chronic collection of fluid, here usually termed Spina ventosa, as well as to be occupied by both osteosarcoma and osteocephaloma. Spina ventosa of the lower jaw, as formerly explained (Principles, 3d Am. Ed. p. 408), is an example of octeocystoma. Fig. 93. ^he remedy is by puncture and evacuation, gradual contraction and consolidation of the cavity being sought for, by pressure from without, and by main- taining a certain amount of inflammatory action within, as by a seton, or stimulant injections. The solid tumors require the same treatment as in the upper jaw. But, with this difference, that in consequence of the relative anatomy of the parts, complete ablation of an osteocephaloma is within our power at a much more advanced period, than cyst at the root of a in the case of the superior maxilla, inasmuch as stXrirantand the. ^ di^ased structure can be included in the filled with puriform fluid, incisions, and taken away. chronic, supposed to be The simple Osteoma (Principles, 3d Am. Ed. p. ofUeSyrmr^^8' J52) has occurred in the lower jaw. At first, to be treated by attempts at arrest of growth, and subsequent discussion; this failing, ablation of the affected part is to be had recourse to, for even this simple structure has been known to degenerate. EXTIRPATION OF THE LOWER JAW. Fig. 94 . Fig. 95. 207 Fig. 94. Osteosarcoma of Lower Jaw. Hard, smooth, non-ulcerating; slow in growth. Fig. 95. Osteocephaloma, contrasted with the pre- ceding. Soft, fungous, ulcerous, rapidly enlarging, and involving all textures. Extirpation of the Lower Jaw. Amputation of the whole bone has been practised, on account of tumor, but with such a result as scarcely to warrant repetition of the operation. The dangers to life are many and almost insuperable. Besides those by loss of blood, and con- stitutional shock, there is an immediate Fig- 96- risk of suffocation by the uncontrolled condition of the tongue and fauces. In- flammatory action, causing oedema, is, at a more advanced period, certain to cause laryngeal obstruction, threatening asphyxia. And, supposing these dangers past, another remains, by Jaronchitic or pneumonic seizure, cold air being at once and constantly admitted to the larynx; whereas, for a long time previously, at- mospheric access had been by a most circuitous and gradual route, in conse- quence of the presence of the large obstructing tumor. Partial removal of the lower jaw is a very feasible operation; and, as formerly stated, when undertaken on account of genuine osteosarcoma, is seldom followed but by a fortunate issue. Not unfrequently the jaw is so occupied by the tumor, as to render removal of the entire half necessary; by disarticulation, and division at or near the .symphysis. An incision is begun opposite the articu- lation, and continued downwards and forwards, along the posterior and inferior borders of the bone, first on its ramus and then on the body. Opposite to where it is intended to saw the bone in front, the forward Osteosarcoma of the Lo\ vening on osteocystoma. Kltments, p. 420.) r Jaw, super- (Liston. Vide 208 EXTIRPATION OF THE LOWER JAW. course of the knife is arrested, and the instrument is directed upwards to divide the lip—leaving, however, the prolabial portion entire. The flap, thus indicated, is dissected upwards; including all the soft parts, and fully exposing the tumor. Then the anterior portion of the bone, where section is to be made—wide of the tumor—is fully cleared of soft parts, on every aspect; a tooth, if necessary, is extracted; the ex- ternal surface is notched by Hey's saw, and section is completed by stout cutting-pliers. Now the internal attachments of the tumor and implicated bone are divided by the bistoury. And as the articulation is approached, the anterior portion of the bone is depressed by the operator's left hand, so as to facilitate disarticulation; yet avoiding such an amount of pressure as may occasion fracture of the altered structure. Depression being made by the surgeon, and an assistant now compressing the common carotid, the muscular attachments to the coronoid process are cut across, and afterwards disarticulation is effect- ed ; this part of the operation being completed as rapidly as possible, from before backwards, opening the joint in front, and with the knife's point moving closely to the bone, so as to avoid an unnecessary loss of blood. The bidding vessels are then tied at the upper angle of the wound, either singly, or by deligation of the common trunk of the tem- poral and internal maxillary arteries—which may happen to be exposed —by means of an aneurism needle. The facial, temporarily commanded by the fingers of an assistant, is last secured. And then the flap is replaced, and retained by suture; the entireness of the prolabium in front obviously contributing much to the facility of accurate adjustment. The wound, in its major part, is likely to heal by adhesion; a portion suppurates and gapes, not inopportunely, to permit suitable discharge of the purulent secretion from within. Dressing of the interior is con- ducted as in the case of the upper jaw; and consolidation, Avith repara- tion, in like manner results. During the process of cure, material benefit will sometimes accrue from the use of a mechanical contriATance, adapted to the teeth, whereby overlapping and displacement of the mutilated part is prevented. " Metallic caps are fitted to the teeth of the upper and lower jaws of the sound side, and are riveted and soldered together at their bases, so that, when applied, they shall have the effect of preventing the dragging of the remaining portion of the bone and chin to the opposite side by the external pterygoid, mylo-hyoid, and digastric muscles, and by the elasticity of the soft parts. This appa- ratus should be worn for many weeks after the operation."1 ContriA'- ances may also be temporarily worn, on the injured side, to prevent undue shrinking of the cheek during granulation. A tumor implicating the body of the bone only, on one side, mar be removed by a similar but less extensive incision; section of the bono being made at the angle and symphysis. But the propriety of such a proceeding is very questionable. Experience has sIioavii that, in such cases, return of the disease is very apt to take place in the truncated ramus ; and when this happens, difficulty of disarticulation is found to be great, from want of power in depressing the coronoid process, and 1 Liston's Practical Surgery, p. 318. EXTIRPATION OF THE LOWER JAAV. 209 consequently in dividing the insertion of the temporal muscle. It is expedient, therefore, in all such cases, to anticipate return of the tumor, and the difficulties of a second operation, by at once perform- ing disarticulation. Besides, this is a principle of operation quite analo- gous to what determines excision of a long bone, affected by tumor. rather than its partial removal; preferring, for example, amputation at the shoulder-joint to an operation Avith section of the bone, on account of tumor of the humerus (Principles, 3d Am. Ed. p. 457). Sometimes, though rarely, osteosarcoma originates in the ramus. Then it is necessary to effect disarticulation, after performing section at or near the angle of the bone. In such a case, it is expedient to grasp the ramus, after section, by means of firm and sharp-pointed for- ceps, so that the requisite lever-power may be obtained for depression. Also, it may be possible to effect this operation, without opening the caA-ity of the mouth.1 The symphysis may be removed on account of tumor; a horizontal wound being made along the lower border of the bone, with a perpen- dicular incision at each extremity, leaving the prolabial surface entire. Section of the bone is made partly by the saw, partly by cutting-pliers; the requisite teeth having been previously extracted. After excision has been effected, some care of the tongue is necessary; lest, after divi- sion of its anterior attachments, it should be unduly retracted, and threaten asphyxia. To obviate this, the organ may be temporarily restrained, either by ligature or by forceps. Sometimes it is necessary to remove the symphysis along with one half of the jaw, the tumor being so extensive. This is effected by such a form of incision as recommended for disarticulation with section at the symphysis. Sometimes it is expedient to remove a portion of the jaw, on account of ulcer or tumor of the soft parts, which has implicated the osseous tissue secondarily. One paramount indication must in all cases be ful- filled ; to remove the whole of the morbid structure, and to cut wide of the disease. [Dupuytren has generally received the credit of having first per- formed partial extirpation of the lower jaw; but the honor of the opera- tion unquestionably belongs to Dr. Deadrick, of Tennessee; Dr. Deadrick operated in 1810, and Dupuytren in 1812. Since then, the operation has been often repeated, Velpeau enumerating about 160 cases, of which 40 terminated fatally. The entire lower jaw has been removed several times, recently by Dr. Carnochan, of New York.2 In the American Journal of Medical Science, vol. vii. 18'>1, Dr. Bar- ton published an account of an operation by which he excised a large part of the lower jaw, extending on each side of the symphysis, without removing the base of the bone, thus leaving the attachments of the tongue and muscles of the neck untouched. The patient had a very 1 Syme, London and Edinburgh Medical Journal, 1843, p. 904. 2 American Medical Recorder, July, 1823 ; South's translation of Chelius, Am. Ed. vol. iii.; Carnochan, New York Journal of Medicine, January, 1852, and May, 18-32; Blaekman, ibid. February, 1852; Smith's Operative Surgery; Velpeau, Operative .Surgery, Am. Ed. vol. ii. 14 210 CARIES AND NECROSIS OF THE LOWER JAW. large tumor, which filled the cavity of the mouth, separated the jaws, and formed a large swelling on their exterior. In a month after the operation the man was well, and able to masticate his food with the remaining molars. (See Smith's Operative Surgery.) In the last edi- tion of his Practical Surgery (Am. Reprint, 1853), Mr. Fergusson de- scribes a similar operation successfully performed by himself, since Dr. Barton's. The importance of saving the base of the jaw, if possible, is very evident. In these operations upon the lower jaw, the surgeon should bear in mind the importance of avoiding the duct of Steno and the facial nerve. In a case in which Dr. Mussey, of Cincinnati, was obliged to remove the left half of the jaw, he accomplished the operation without dividing the above-mentioned organs, by commencing his incision of the integuments below the point of their transit, and by dissecting the soft parts from the bone, in the process of disarticulating and separating the latter, as closely as possible. By this means, the symmetry of the mouth was perfectly preserved; and, after an artificial jaw was adapted to the side operated on, the beauty of the lady's face was but little marred. (Trans. of the Am. Med. Association, vol. iii. p. 364).—Ed.] During these operations on the mouth, it is plain, for reasons formerly assigned, that chloroform, if employed at all, must be used warily (p. 182). Caries and Necrosis of the Lower Jaw. The lower jaw is liable, like other bones, to these common affections. But, in the present day, it suffers much less frequently and extensively in this way, than it did when mercu- rialization was more in vogue for vene- real affections — real and suspected. Many teeth, large portions of the jaw, and eAren the greater part of the entire bone, not unfrequently were tediously and painfully discharged, as worm- eaten sequestra; causing much dis- turbance, both local and general, at the time, and great subsequent de- formity. When either of these affec- tions do occur, the general principles of surgery are brought to bear on them ; by treatment partly local, part- ly directed to the system. Necrosis of the jaws, from the agency of phosphorous acid generated in the manufacture of lucifer matches, has been already alluded to (Principles, 3d Am. Ed. p. 421).1 Fracture of the Lower Jaw. The lower jaw may be broken by violence applied either directly or indirectly. Fracture near the middle of the body of the bone may be Fig. 97. Ulcerative destruction of the Coronoid Pro- cess of the Lower Jaw, caused by " the awkward position of the wisdom tooth." The patient " perished in consequence of the extensive ab- scesses of the mouth and neck." (Liston.) 1 Vide also Lancet, No. 1367, p. 498. DISLOCATION OF THE LOWER JAW. 211 Fie. 98. the result either of a blow delivered on the symphysis, or of injury directly sustained by the part fractured. The body of the bone is most frequently injured, but all parts are liable. The ramus has been fissured, the condyle has been broken off, the coronoid process has been snapped through, and the symphysis itself has given way. The fracture may be either simple or compound. Almost always, there is laceration of the mucous membrane, with consequent hemorrhage into the mouth, and exposure of the fractured ends in that direction. The signs of the oc- currence are sufficiently plain; by deformity, crepitus, loss of power, and evident displacement. The mental portion is usually displaced down- wards, by muscular action. Reduction is easily effected ; and, usually, retention is not difficult. Supposing the fracture to be at its ordinary site, near the middle of the body of the bone, the fragments are carefully adjusted, with the teeth in a line ; and two wedges of cork, sloping gently backwards, with their upper and under surfaces grooved for the reception of the upper and lower teeth, are inserted on each side of the mouth; the jaws having been firmly closed on them, a pasteboard splint is adapted to the exterior sur- face ; and the whole is retained by suitable bandaging. The object of the wedgves is twofold, and obviously beneficial; namely, to secure accurate apposition of the fragments, and to leave a vacant space in front, suitable for the passage of fluid nourishment without movement of the parts. The objection to their use is, that, as foreign bodies, they may cause saliva- tion or other inconvenience; if this should happen, they can readily be removed; and meanwhile, by their temporary presence, considerable benefit may have been obtained. Some- times, if firm teeth occupy the verge of each fractured portion, it may be well to secure these in apposition by silk ligature. Teeth quite detached should be removed at once; and so ought fragments of bone, similarly circumstanced—in cases of comminution. For some time, the patient must be content with such articles of food as require no mastica- tion ; and all movement of the fractured part must be avoided. Four-tailed Bandage, applied to secure the lower jaw. Dislocation of the Lower Jaw. Dislocation of the jaw is forwards ; the condyles in front of the base of the zygomatic process, and the coronoid processes resting on the edge of the malar bone.1 The accident may be complete or partial; according as one or both condyles are displaced. And it may be the 1 Nelaton, Me"moires de la Socie'te' de Chirurgie de Paris, 1849. 212 ANCHYLOSIS OF THE JAW. result of mere muscular action, as in yawning; or of force applied to the symphysis, with the mouth more or less open. The mouth gapes, and cannot be shut; the chin is depressed, and saliva trickles over it; the condyloid space is vacant, and prominence is felt beneath the zygo- matic process; considerable pain is experienced, and articulation is very indistinct—perhaps altogether obstructed. Reduction is effected by a combined movement; depression of the angle, elevation of the symphysis, backAvard pressure on the coronoid processes, and traction forwards of the Avhole bone. Thus the bone is extricated from its entanglement; and, brought within the uncontrolled play of the muscles, is by them pulled back into its normal position. The thumbs placed over the last grinders, within the mouth, effect the first movement; the rest of the hand makes the extension, with elevation of the symphysis; and an assistant presses back the coronoid processes from their rest on the cheek bone. It is not necessary to protect the thumbs, by a towel or otherwise. As the jaw is felt to yield, they are made to slide on to the alveoli on the outer side; and the snap, which accompanies and denotes replacement, finds nothing interposed between the teeth. For some days afterwards, the motions of the jaw should be very limited; and in most cases it is well to restrain them by a bandao-e. Anchylosis of the Jaw. This may be spurious or real (Principles, 3d Am. Ed. p. 503); the result of change in the soft parts or in the hard. Mastication, degluti- tion, and speech are seriously interfered with; and the patient anxiously seeks relief. This may be afforded by the knife alone, when cicatrices are in fault; dividing adhesions, and preventing reunion by careful dressing subsequently. Sometimes, in addition, subcutaneous section of the masseter is advisable.1 When rigidity is extreme, and depends on true anchylosis, it may be necessary to operate on the jaw itself, in order to prevent death from inanition; sawing the bone through, so' as to make a false joint; or removing a central portion entirely, for the admission of food. [The operation will be very much facilitated, either with or without previous division of the muscles and adventitious bands, by the employ- ment of mechanical means for separating the jaws. For this purpose the lever of Heister, a similar instrument contrived by Dr. Mott or the screw dilator of Dr. Barton, will be found available. The instrument of Dr. Mott is represented in the 3d vol. p. 1142, of his edition of Velpeau's Operative Surgery, where also the reader will find detailed remarks concerning anchylosis of the jaw ; the dilator of Dr. Barton is figured in Smith's Operative Surgery, where, in like manner, operations for the relief of the difficulty are described and illustrated—Ed.] On removal of the jaw, see Koeckcr on Diseases of the Jaws, &c. London 18°8 Boyer, Memoire sur 1'Amputation de l'os maxillaire inferieur, in Journal Coroptem du Diet, des Sciences MSdicales. Dupuytren, Lecons Orales. Mott, American Medical'Re corder, vol. 1. Cusack, Dublin Hospital Reports, vol. iv. 1 Fergusson, Practical Surgery. CHAPTER XIII. AFFECTIONS OF THE TONGUE. Glossitis. The inflammatory process in the tongue may be variously induced; by wounds, stings, or other injuries; by ptyalism ; by acrid applications. Or it may occur spontaneously. The symptoms are—pain, swelling, salivation, intense thirst, impairment of the ordinary functions of the organ. In extreme cases, the swelling may occlude the fauces, and threaten asphyxia. The treatment is by abstraction or counteraction of the cause; leeches to the part, or the opening of a ranine vein ; and the ordinary antiphlogistics internally. In cases of urgency, we need not hesitate to make longi- tudinal incisions, freely, as if for phlegmonous erysipelas; the escape of blood is copious, the exuded fluids also find a ready exit, usually the swelling rapidly abates, and the wounds, which at first were gaping and deep, dwindle down to mere scarifications. The antiphlogistic result is satisfactory, and no important lesion of structure is inflicted on the part. Should a case present .. -i« , n -i, i •, n •, • i- ii Tongue, swollen by Glossitis. itself too advanced to admit of waiting tor the effects of incision, life must be saved at all hazards—by bronchotomy. Wounds of the Tongue. Wounds of the tongue bleed copiously. Hemorrhage is to be com- manded by ligature and styptics; if need be, the cautery may be applied. In uniting the wound, after bleeding has ceased, it is plain that we can avail ourselves only of the common interrupted suture—other retentive means being inapplicable to the part. In the slighter cases, the use of sutures may effect not only approximation but also a hemostatic result. Ulcers of the Tongue. Ulcers of the tongue, like those of the lips, may be either simple or malignant. The former may depend on local irritation, as from tartar or decayed teeth; or on gastric irritation; or on a general febrile con- 214 INDURATION OF THE TONGUE. Fie. 100. Excavated Malignant Ulcer of the Root of the Tongue. (Edema glottidis has supervened secondarily. dition; or on a mercurio-syphilitic state of system. And the treatment, it is obvious, will vary accordingly. The preferable local applications are—nitrate of silver, either in substance or in solution; and, in obstinate cases, the fluid pernitrate of mercury; the former applied frequently, the latter at long intervals. The malignant ulcers are to be got rid of, by knife, ligature, or cautery. The first two methods are usually to be preferred; and due care must ever be taken that the whole of the apparently diseased part, with a border of apparently sound texture, is removed (Prin- ciples, 3d Am. Ed. p. 317). Persons of advanced years should be very careful to avoid all continued irritation of the tongue, as by tartar, false teeth, &c, lest troublesome and ultimately malignant ulcera- tion be induced. Hypertrophy of the Tongue. The tongue is occasionally the seat of simple enlargement—congeni- tal or acquired. The normal texture is gradually expanded and the papillae become greatly enlarged. Much inconvenience necessarily results, even though, as usually happens, the jaw, in some proportion, accommodates itself to the altered interior. Ultimately, the tongue protrudes, and a wasting discharge of saliva necessarily results. De- glutition, articulation, and even breathing are more or less interfered with. The treatment is by rectification of the primae vise, usually very prominently disordered, by repeated leeching of the part, and by inter- nal administration of the iodide of potassium. Should such means fail it may be expedient to remove a portion at the apex, of a wedo-e shape' and of such a size as to restore the organ to something like iS normal bulk, on approximation of the wound's edges, at least rendering the organ capable of residence within the mouth, so removing the principal deformity and inconvenience—protrusion, and reducing the risk of excessive inflammation in the wound. Lnduration of the Tongue. The tongue, instead of undergoing a general hypertrophy, may be affected by partial enlargement, certain portions becoming elevated hard, and painful, being the seat of a chronic inflammatory process of low grade. The swellings may remain of an indolent nature, slowly enlarging, or altogether stationary. Or they may slowly suppurate • the matter imperfectly discharging itself by a ragged and somewhat REMOVAL OF PORTIONS OF THE TONGUE. 215 sinuous aperture ; the general appearance of the part closely simulating malignant disease. The treatment is as for hypertrophy, by leeching, alteratives, and attention to the primae A'ise. In many cases, the internal use of arsenic has been found of signal benefit. And, Avhen sarsaparilla, iodide of potassium, arsenic, fail, a cautious course of mercury may be adminis- tered. The combination in Donovan's liquor often proves useful. The unhealthy cavities made by suppuration are to be exposed by potass, freely applied ; and then sound cicatrization may be expected. Erectile Tumor of the Tongue. The erectile tumor may form in this organ. A few examples are on record. If the diseased structure be limited and accessible, it is to be re- moved by inclusion in ligature. If it involve the whole organ, or be other- Fig- 101. wise not amenable to deligation, at- tempts may be made to induce a reme- dial change of structure, either by ulceration or by plastic exudation (Principles, 3d Am. Ed. p. 563). Fail- ing this, the disease must be regarded as beyond the reach of our art. Deli- gation of both lingual arteries has been practised, but Avith a result which does Expansion of the Lower Jaw; the result of not hmte repetition; fatal Sloughing pressure by the tongue, enlarged by erectile of the Orffan ensued l tissue. (Liston. Vide his Elements of Surgery, ° " p. 410.) Removal of Portions of the Tongue. On account of malignant disease, occult, or open, as well as on account of erectile tumor, it may be necessary to remove a part of the tongue. Malignant disease, involving the whole organ, may be regarded as irre- mediable. Carcinoma and Cancer show their ordinary characteristics here, and follow their usual course. A detailed statement of the symptoms and progress of such affections is therefore unnecessary (Principles, 3d Am. Ed. pp. 310, 313). Removal may be effected either by knife or by ligature. The former is employed when the doomed part is situate anteriorly, and not exten- siAre; hemorrhage, under such circumstances, being readily under con- trol. By a volsella, the part is seized, stretched, and made to project outwardly; and by a bistoury satisfactory ablation is leisurely and care- fully effected. Hemorrhage having been arrested, the wound is approxi- mated by suture, if its size and form permit. In other cases the ligature is preferred. A stout cord is passed on the proximal aspect of the diseased part, in sound texture, by means of a large needle in a fixed handle, as recommended for erectile tumors 1 Liston's Elements of Surgery, p. 409. 216 RANULA. (Principles, 3d Am. Ed. p. 562); the noose of the ligature having been divided, each half is draAvn tight separately, so as completely to isolate and strangulate the diseased portion ; and it is well to notch with a knife the line of constriction, previously, so that strangulation may be at once complete. By whatever mode removal is effected, the prognosis must be but gloomy ; for it can be readily understood, that return of malignant disease is but too probable, in an organ which has been only in part taken away. Sometimes it may be Avarrantable, even in avowedly hopeless circum- stances, to remove a malignant ulcer of the tongue by operation, solely with the view of palliation (Principles, 3d Am. Ed. p. 319).1 Division of the Frsenum. In the child, the frsenum linguae may be so short as greatly to incom- mode the organ ; at first impeding suction, afterwards embarrassing articulation. Or the defect may be more accurately expressed, perhaps, as an abnormal prolongation forwards of the fraenum, tying down the apex of the tongue. The faulty texture is readily divided, by means of probe-pointed scissors—the point of the tongue being elevated, so as to stretch the part, by the finger, or by means of a split card; and, cut- ting rather on the jaw than on the tongue, troublesome bleeding by wound of the ranine vessels is avoided. During healing, the tongue should be exercised so as to preArent recontraction. In the adult, a someAvhat similar condition may supervene, in conse- quence of troublesome suppuration beneath the tongue. During cica- trization, the apex of the organ is drawn down, and becomes confined by a dense band of adventitious formation. This spurious fraenum may be dissected through ; and, by dint of careful dressing, a more favor- able cicatrix may be obtained. Ranula. Ranula denotes a tumor, formed beneath the tongue, in consequence of obstruction in one or both of the salivary ducts. It consists of a cyst, produced by expansion of the duct, and condensation of the sur- rounding parts ; and of clear contents—perverted secretion of the cyst, and of the corresponding salivary gland. Inconvenience is felt in mas- tication, deglutition, and articulation ; indeed, the term ranula has been applied on account of the croaking change of voice. The tumor is distinctly seen on elevating the apex of the tongue ; and but slight manipulation is necessary to ascertain its cystic and salivary nature. [There is no doubt that the tumors to which the term Ranula is ap- plied, are in some instances formed by the dilation of the ducts of the sublingual, and less frequently of the submaxillary gland, caused by obstruction from salivary calculi, or from inflammatory exudations.2 In most cases of this kind, the formation of the tumor takes place 1 See also Bennett on Cancerous and Cancroid Growths, p. 129. 2 See Abeille, Traite des Hydropisies et des Kystes, p. 501. RANULA. 217 gradually; sometimes, however, after having attained a certain size, a sudden increase of volume occurs in consequence of rupture of the dis- tended duct, and the contents of the swelling are thrown into the loose cellular tissue exterior to it. But in many, and probably in most cases, the pathology of ranula is different. This is evident from many circumstances. 1. The size to which the tumor not unfrequently arrives is so large as to render its origin from distension of a duct, so small as that of the excretory ducts, exceedingly improbable. Thus Petit saw a ranula, which was three times as large as a hen's egg; it displaced the genio-glossus and genio- hyoid muscles, and formed an enormous tumor between the chin and the hyoid bone. Clerc describes one from which he evacuated a pound of fluid; Wilmer removed 12 ounces from another. Boinet operated upon one which threatened the patient with suffocation ; it filled the whole buccal cavity, and projected half its volume out of the mouth; the teeth had impressed themselves deeply into its substance. Malcolmson describes one which surrounded the front of the neck, and extended downwards to the chest.1 2. In many cases of ranula, the ducts have been found perfectly pervious when examined with a probe, and free from any calculous concretion after death; and even when such concre- tions existed, it by no means follows that they obstructed the ducts, or that they produced the swelling—for similar concretions are not at all rare in ordinary cysts.2 3. If the tumor were due to the cause stated in the text, its contents would be uniformly similar to, or identical with, the saliva, or its component elements would resemble those of the latter. But the fluid found in ranula is very variable in consistence, color, and microscopical ingredients. It is, moreover, entirely different from saliva in chemical composition, containing no sulphocyanates, and but a trace of salivin, but chiefly albumen.3 The character of the fluid has also been carefully investigated by Besanez; he found in it water, traces of fat and chloride of sodium, aqueous extractive matter, and albumi- nate of soda; under the microscope, blood-corpuscles and inflammatory exudation corpuscles, but none of the ordinary characters of saliva.4 4. If incision be practised upon an excretory duct, it remains fistulous ; whereas, if ranula be thus treated, the sac closes by granulation; hence the success of this mode of treatment as recommended by many sur- geons.5 5. The sac constituting the tumor has been removed by dissec- tion, and found to have no connection with the ducts of the gland.6 (i. The cyst in ranula is often multilocular, of Avhich Dupuytren gives an example (Clinique, torn. iii. p. 318); a condition which is much more readily explained upon the supposition that it is a cyst of new formation than upon any other. Like other true cystic tumors, ranula is not unfrequently congenital ;7 and it is also not unfrequently accompanied 1 Wernher, die Augeborenen Kysten Hygrome, fyc, p. 53. 2 Wernher; Schuh, uber die Erkentniss der Fseudoplasmen; Sir C. Bell, Institutes of Surgery, &c. 3 Gmelin, in Brit, and For. Med. Rev. vol. xv. p. 2'!G. 4 Cyclopaed. Anat. and Physiol, art. Saliva, p. 420. 5 See Syme, Principles of Surgery, p. 474. 6 Brit, and For. Med. Rev. vol. xx. p. I'.'A. i Von Ammon, die Angeborenen Chirurgischen Krankheiten des Menschen, tab. viii. 218 TUMORS BENEATH THE TONGUE. by cystic tumors in other parts, as noted in the reports of many of the cases of hydrocele of the neck. From these circumstances, it is necessary to conclude that, in very many cases, at least, of ranula, the tumor is not owing to obstruction and gradual distension of the gland ducts, but that it is a cyst of new formation, developed in the same manner as other cysts—from one of the gland-cells, or from the areolar tissue (see Principles, 3d Am. Ed. p. 303). Others again suppose that ranula is very commonly an enlargement of a normal bursal sac which exists behind the fraenum of the tongue, called sometimes Fleischman's bursa, from its discoverer.1—Ed.] Two modes of treatment are applicable—restoration of the normal opening, or the making of an artificial substitute. In recent cases, the former method may succeed. The occluded original orifice is dilated by probes of suitable dimensions; and the due degree of patency and caliber is subsequently maintained, by the occasional passage of a bougie or probe for some time afterwards. In most cases, however—as in the somewhat analogous circumstances of subcutaneous encysted tumor (Principles, 3d Am. Ed. p. 333)—the normal orifice cannot be detected and restored. An artificial opening is made, at an anterior and dependent part. The contents readily escape; but they soon re- accumulate ; and the difficulty in the case consists in keeping this arti- ficial opening so patent as to allow of constant discharge, and conse- quent contraction of the secreting cyst to the capacity and character of the original duct. To effect our object, it is well to touch the aperture occasionally Avith the potassa fusa, as if to compel cicatrization of the margins without closure. And this object may be farther facilitated, by the occasional use of a large probe or bougie, after the caustic has been disused. Failing in our attempts thus, a seton is passed through the cyst, and retained until the requisite contraction is obtained. A piece of silver wire—retained by twisting the ends—may sometimes be found more suitable than the caoutchouc tape, or skein of silk or cotton. Tumors beneath the Tongue. Encysted tumors are not unfrequently found in this situation ; simu- lating the condition of ranula very closely. The cyst is thin ; the con- tents are clear and glairy ; the size may be considerable. The remedy is by incision and cauterization. The cyst is opened anteriorly by a free puncture; the contents are allowed wholly to escape; and then to the lining membrane is applied either the nitrate of silver firmly, or the potassa fusa lightly; care being taken to confine escharotic action to the part intended. After the use of potass, rinsing of the mouth re- peatedly Avith vinegar and Avater, is a safe and prudent precaution. Fatty tumors beneath the tongue have also simulated ranula (Prin- ciples, 3d Am. Ed. p. 299, Fig. 61). The attachments are delicate and loose; and, for extirpation, little more than mere incision of the invest- ' [See Schuh; Jobert, in Brit, and For. Med.-Chir. Rev. No. 18, p. 277.__Ed.] SALIVARY CONCRETIONS. 219 ing membrane is sufficient. For obvious reasons, remoAral by the knife cannot be practised too early. In the after-treatment of suppurating wounds in this locality, it has already been stated that care must be taken, lest, by cicatrization, the condition of tong-ue-tie become established. Salivary Concretions. Concretions form in the extremities of the Whartonian ducts, more frequently than in connection with the parotid gland; with or without obstruction of the saliva's course. Inconvenience is considerable, by the bulk and irritation of the foreign substance. By manipulation and use of the probe, the presence of the concretions can, in most cases, be very readily detected. "When of large size, they become fully exposed in the progress of working their way out by ulceration, after the manner of a sequestrum, or any other foreign substance. The operation for removal is then simple; after suitable incision, the calculus is laid hold of by forceps and extracted. But when the foreign body is small in a large containing caA'ity, it may retreat, and elude the attempts at seizure. In such a case, let the patient masticate any agree- able article of food; and by the outward current of saliva the concretion will be either washed away, or at least made prominent and superficial. Fig. 102. Salivary Calculus, of con- siderable size; removed by operation. On enlargement of the tongue, see Percy, article Langue, in Diet, des Sciences Me*dicales, vol. xvii. Van Doeveren, Dissert, de Macroglossa, Lugd. Batav. 1824. Clanny, Edin. Med. and Surg. Journ. vol. i. p. 317. On affections of the tongue in general, see Brodie, Lan- cet, No. 1059, p. 346. CHAPTER XIV. AFFECTIONS OF THE UVULA AND TOXSILS. (Edema of the Uvula. (Edema of the Uvula, with a relaxed state of the neighboring soft palate, may occur singly; but more frequently it is the result of an im- perfectly resolved inflammatory affection of the whole fauces. There is a feeling of very considerable discomfort in the part; the quality of the voice is altered; articulation is impeded; and not unfrequently a tickling and annoying cough exists. The various astringent gargles are of service, with attention to the general system. Failing these, stimulants and astringents may be applied directly to the part, in solu- tion or in powder; as alum, capsicum, tannin, &c. Or the part may be touched occasionally with the nitrate of silver, or sulphate of copper, in substance or solution. In obstinate cases, it is well that scarification precede the last-named remedies. Elongation of the Uvula. Relaxation of the uvula, with elongation, is of no unfrequent occur- rence ; the extremity of the organ passing downwards, and by titillation of the glottis causing a very unpleasant and sometimes distressing cough. Sometimes the extremity is cedematous and bulbous; sometimes it is thin and fimbriated. In the slighter cases, ordinary astringents and stimu- lants may be tried. But when elongation is considerable, as regards both extent and duration, there is no suitable remedy but by cutting off the redundant part; an operation which has never yet been followed by any untoward consequences. The patient, seated before a good light, is directed to cough, so as to bring the pendulous uvula on the dorsum of the tongue. Then a suitable portion may be at once cut off by the stroke of sharp-cutting scissors—probe-pointed, lest the patient should prove unsteady. Or—better—by a volsella the apex is laid hold of; and then, by stretching the part, section will be facilitated as well as rendered more accurate; care being taken not to stretch until at the instant of cutting, otherwise troublesome retching is apt to ensue. Com- plete extirpation of the uvula has been recommended in such cases, on the plea that relapse is otherwise probable. But, even supposing the fear to be justly founded, such a ruthless proceeding is scarcely warrant- able; the organ being doubtless endowed with some useful function in the general economy. ABSCESS OF THE TONSIL. 221 Tonsillitis, or Cynanche Tonsillaris. This term denotes an inflammatory affection of the fauces, chiefly resident in and around the tonsils, ordinarily the result of atmospheric exposure, and characterized by swelling, redness, heat, and pain of the part, impeded and painful deglutition, inability to separate the jaws, difficult articulation, marked alteration of the voice, and the ordinary constitutional accompaniments according to the intensity and advance- ment of the action. Treatment is by ordinary antiphlogistics, local and general. Scarification of the part is sometimes advisable, with the view of abstracting blood, controlling SAvelling, and rendering suppura- tion less likely to supervene. Sometimes large doses of guaiac, half a drachm of the powder thrice daily, have a resolutory and almost specific influence; Dover's powder, too, is often useful in a similar way. The affection may prove formidable by assuming the erysipelatous type, and spreading downwards into the air-passages. Abscess of the Tonsil. An acute abscess, of some size, in the tonsil, requires active surgical interference. If allowed to follow its own course, much distress is likely to be occasioned by pain and swelling ere evacuation and sub- sidence take place; indeed, the swelling may be such as not only to prevent deglutition wholly, but also to impede respiration and threaten asphyxia. Besides, spontaneous bursting of the abscess may take place during sleep, and a considerable quantity of pus and blood passing sud- denly into the glottis unexpectedly may induce spasmodic dyspnoea of the most formidable character, not improbably suffocating the patient. To avert such pains and perils, the general principles of surgery should be fully carried out, by artificially evacuating the pus, so soon as it has been formed. This may be readily and safely effected thus: The patient, placed before a strong light, is exhorted to great steadiness. With the forefinger of the left hand the tongue is depressed, and the mouth opened so as to expose the red and prominent tonsil, perhaps already occupying the middle of the fauces, and displacing the uvula, the ordinary occupant of that space. A straight sharp-pointed bistoury, with its back resting on the tongue, is passed into the mouth and entered into the centre of the swelling, with the point directed straight back- wards, as if with the intention of impinging upon the anterior surface of the cervical vertebrae; and a puncture having thus been made, a sufficient aperture is then established by moving the instrument with a slight sawing motion. The pus escapes upon the tongue, and is dis- charged externally. Lateral movement of the knife, outwards and backwards, is especially to be avoided, otherwise important bloodvessels are in danger, the internal carotid artery and the internal jugular vein posteriorly, and the common trunk of the temporal and internal maxil- lary arteries on the external aspect. A chronic stage is not unfrequent, in which the tonsil remains swollen, painful, and stationary, affording no sign either of recession, by resolu- 222 ULCERS OF THE TONSILS. tion, or of advancement by suppuration. Such uncertainty is best dis- pelled, and usually at once, by the application of a blister over the part, beneath the angle of the jaw. It is of use to remember that a patient once affected by tonsillary abscess is extremely liable to return of the affection, on the application of comparatively slight causes, until the first period of adult age has passed, and then the attacks become less frequent and severe, at length altogether disappearing. Ulcers of the Tonsils. The tonsils are liable to ulceration from ordinary causes; from exposure to cold or wet, from the irritation of decayed teeth, or from the " cutting" of the last grinders. Treatment is by touching the part occasionally with nitrate of silver, after removal or mitigation of the cause, extraction of the decayed teeth, or scarification of the tense gum. Other ulcers of the tonsils are of constitutional origin, connected with taint of system, venereal, mercurial, or both; sometimes of second- ary, sometimes of tertiary accession, the local characters of the sore varying according to circumstances—simple, weak, indolent, irritable, inflamed, sloughing, or phagedaenic. Treatment, in such cases, is mainly constitutional. Hypertrophy of the Tonsils. In adolescents of weak habit, chronic enlargement of the tonsils is very apt to occur, connected with a minor inflammatory affection of the fauces, the swollen part partially and slowly subsiding between the inflammatory attacks, which are of frequent occurrence and induced by slight causes. In such cases, it is not uncommon for the tonsils to become permanently enlarged, by simple hypertrophy. Both are in general affected, projecting as fleshy eminences into the fauces, inter- fering considerably with deglutition, somewhat with respiration, and greatly with articulation; often causing deafness, by pressure on the Eustachian tubes, and rendering the patient very liable to acute inflam- matory affections of the fauces, on the slightest exposure to atmospheric inclemency or vicissitude. In the state of excitement, mild antiphlogistics are necessary for a few days; low diet, aperients, gentle diaphoretics, sinapisms, or other light counter-irritation! In the indolent state, it is our object to amend the general health by a tonic system of general treatment; to obtain gradual subsidence of the swellings by discussion; or, this failing, to remove the redundant texture. As discutients, nitrate of silver, alum, and iodide of zinc are most in use; the first two rubbed on the parts in substance; the last applied in strong solution, by means of a hair- pencil or a piece of sponge. The constitutional treatment is as for the strumous cachexy—a condition very similar to, if not identical with the state of system found to prevail in such patients (Principles, 3d Am. Ed. p. 68). When discussion fails, the knife's use is expedient; not to HYPERTROPHY OF THE TONSILS. 223 extirpate the glands, but merely to take away the redundant and pro- jecting parts. The mouth being opened before a strong light, the promi- Fig. 103. Fig. 104. Excision of the Tonsils; the knife turned the wrong way. nence of the swelling is seized firmly by a volsella; and, by means of this instrument, the part is made tense and steady, and brought more into the central space. A probe-pointed bistoury is passed into the mouth, with its back resting on the tongue; and its edge having been brought in contact with the lower part of the base of the swelling, section upwards is effected by a slight sawing motion. A similar pro- cedure is repeated on the opposite side. Bleeding and pain are generally inconsiderable. The raw surfaces granulate and heal; occasional applica- tion of the nitrate of silver being made lightly, if need be. It is seldom that reproduction is even threatened. Objections have been taken to such operations, on the ground that dryness of the fauces is apt to fol- low, with imperfect articulation; and that, sometimes, also, there has seemed to be a certain amount of sexual impotence induced. The experience of most surgeons does not tend to sustain such objections; at the same time there is no doubt that most cases of chronic enlargement of the tonsil, in adolescents can be got rid of by local discutients and constitutional alteratives, and hat, therefore, operative interference should be reserved wholly for those cases which have been found to resist milder means. *f [Fahncstock's Instru- ment for removal of the Tonsils. Of all the instru- ments specially contrived for this object, this is pro- bably the best; and, for operating upon young or timid persons, it is much more available than the knife or scissors.—Kd.J 224 MALIGNANT DISEASE OF THE TONSILS. Extirpation of the entire tonsil, by ligature, or by knife—the one operation very hazardous, the other accomplished with great difficulty— is, in the present day, never contemplated, being well superseded by the partial removal just described. Malignant Disease of the Tonsils. Cancerous ulceration may extend to the tonsil from the tongue, or may originate in the gland itself. The latter event is rare. Carcinomatous or medullary tumor may occupy the tonsil, as a pri- mary disease ; but more frequently such enlargement of this part is but an extension of malignant disease from the lip or lymphatic glands. All such affections are incurable; and operative interference is out of the question—unless, .indeed, at an advanced period of the case, temporary relief by bronchotomy be deemed advisable, on account of impending asphyxia. Le Cat, Me"moire sur l'extirpation des amygdales squirrheuses, Journal de Me"decine, vol. ii. 1755. Louis, sur la resection des amygdales, M6m. de l'Academie de Chir. vol. v. p. 423. Lisfranc, Considerations, &c. sur la Luette, Revue M6dicale, July, 1823. Wat- son, Lectures on Practice of Medicine, vol. i. London, 1843; Allan Burns, Surgical Ana- tomy of Head and Neck, Edinburgh, 1811; Harvey on Excision of the Enlarged Tonsil, London, 1850. CHAPTER XV. AFFECTIONS OF THE PHARYNX. Pharyngitis. The inflammatory process, affecting the pharynx, pre-eminently or solely, is of comparatively rare occurrence. Most frequently it is the result of a direct exciting cause; as the lodgement of foreign bodies, or the contact of acrid substances. The membrane becomes red and swollen, at first dry, afterwards affording an increased and perverted se- cretion ; deglutition is difficult and painful; pain is felt on pressure from without; and the ordinary constitutional symptoms attend. The action may simply resolve ; or ulceration may take place in the membrane, with copious purulent discharge; or the submucous tissue may become the seat of abscess; or by submucous deposit of plastic matter, and change of structure in the membrane itself, contraction of the pharyn- geal space may result. Pharyngeal Abscess. When matter has formed beneath the mucous membrane, a fluctuating, yet tense swelling may be perceived ; and deglutition becomes more and more impeded, according to the increase of the tumor. In children, the affection is apt to simulate croup.1 Treatment is by early and free evacuation. The ordinary site of abscess is on the posterior aspect of the pharynx, in front of the cervical vertebrae and their coverings; and here cutting instruments may be used in all security. If the abscess be large, it is well to use a trocar and canula, lest the pus, suddenly escaping in quantity, might endanger suffocation by passing into the windpipe. If opening be delayed, not only are risk and inconvenience great by the large size of the tumor ; there is also the same danger from sudden spontaneous discharge, as in abscess of the tonsil; besides, the bones may be involved by a burrowing of the matter; and, in the ulti- mate cicatrization of a large cavity, contraction and stricture of the pharynx may result. Stricture of the Pharynx. Simple stricture may be the result of simple pharyngitis, causinc structural change in the mucous membrane, with accumulation of plastic 1 Vide Monthly Journal of Medical Science, August, 1846, p. 146. Ibid October 1847, p. 220. 15 226 SPASM OF THE PHARYNX. deposit in the submucous tissue; and, on the latter occurrence, the contraction mainly depends. Or it may be the consequence of ulceration of the membrane, with or without suppuration in the parts beneath. The prominent and characteristic symptom is difficulty of swallowing, more especially of solid and imperfectly masticated food. And certainty of the existence of the change is determined by the use of a probang or tube, whose passage downwards is resisted by the contracted part. The ordinary site of contraction is at that part of the cavity which is natu- rally most narrow—the lowest. Malignant contraction is produced by carcinomatous formation in the mucous and submucous tissues; the surface speedily assumes the open condition, and much unhealthy matter is discharged. The symptoms are, great pain in the affected part, increased by motion and pressure ; expectoration of fetid, copious, bloody discharge; great and increasing difficulty in swallowing; gradual wasting of the frame, partly by inani- tion, partly by progress of the usual malignant cachexy. The simple stricture is treated by dilatation. A probang—a rounded piece of whalebone, Avith a bulbous extremity made of ivory—is passed gently down to the obstruction ; or a gum-elastic bougie may be used for the same purpose. One having been selected of such a size as will pass without the use of force, it is lodged in the contracted part, and retained there for some time, according to the sensations of the patient. After a day or two, the irritation caused by the former instrument having subsided, another, a size larger, is similarly employed. And thus, gradually, the normal caliber is restored. An instrument of full size should be passed occasionally, however, for some time afterwards, to obviate the tendency to recontraction, which exists in all mucous canals so affected. The object of the passing of instruments is, not to excite inflammation or ulceration in the contracted part, for this would plainly tend to ultimate aggravation of the morbid state; but to excite absorp- tion of the submucous deposit, and a resolutory action, with discharge, in the membrane itself. At the same time, some benefit is also obtained by mechanical dilatation. The malignant stricture admits only of palliation. Great attention is paid to the administration of nutritiAre ingesta, so as to husband the failing strength; while pain and discomfort are assuaged by opiates. Direct interference with the part, by means of bougies, or othenvise, with dilatation in vieAV, cannot but do harm. Often, however, the pain of the ulcerated surface may be relieved, by occasionally touching it with a solution of the nitrate of silver. Spasm of the Pharynx. In patients of nervous temperament, prone to hysteria, with stomach and bowels disordered, spasm of the muscles of the pharynx is not an unfrequent occurrence; causing pain in the part, with an uneasy and apprehensive feeling of tightness, and materially interfering with de- glutition. The attacks are only occasional, sudden in accession, and gradual in remission. The treatment is mainly constitutional; of an alterative, tonic, and antispasmodic character. Locally, external FOREIGN BODIES IN THE PHARYNX. 227 counter-irritation of a slight grade, or opiate friction, or a belladonna plaster over the nape of the neck, may be of service. Sometimes even the passing of the probang will not convince the hysterical patient that the affection is merely nervous. Paralysis of the Pharynx. This, occurring in the sequel of any disease, is usually of very un- favorable import; denoting affection of the brain, probably by effusion, which is likely to prove fatal. It may occur singly, however, as after external injury of the head or neck, and then the prognosis may be someAvhat more hopeful. The prominent symptom is simple dysphagia, without obstruction to instruments, or any other sign of stricture in the passage. Treatment is to be directed mainly to the head and neck, by counter-irritation, and such internal remedies as may seem advisable; while life is meanwhile sustained by supplying the stomach with nutri- tive fluids, by means of a tube passed into the oesophagus. Sacculated Pharynx. Sometimes the lower part of the pharynx becomes dilated into a pouch, of greater or less size, situate immediately behind the oesopha- geal orifice. Food lodges there, sometimes for many hours, coming up again in a kind of rumination. Deglutition is difficult and imperfect; often accompanied, especially when liquids are taken, with a churning noise. Frequently, too, there is a copious secretion of glairy mucus; sometimes accumulating spontaneously in the mouth, more commonly brought up by hawking. The affection plainly admits of no direct treatment; and care must be taken in using the probang—should that be thought necessary for an exact diagnosis—lest it should enter the pouch, and be forcibly impelled thence through the parietes. Tumors of the Pharynx. Tumors occasionally, though rarely, form in the pharynx. They are troublesome by the dysphagia which their bulk necessarily occasions, and dangerous by the tendency which all tumors have to enlargement and degeneration. They may be simple, and of the polypous character, and these may be detached by ligature, applied to their base by means of a double canula. Or they are medullary; and then irremediable. Foreign Bodies in the Pharynx. Portions of food, and other articles held in the mouth, not unfre- quently become arrested in their passage downwards ; even though no abnormal contraction exist at any part of the canal. Substances of some size and solidity are likely to rest at the narrowest—the lowest— part of the pharynx. Those of a slim and spiculated character, on the contrary—as needles, pins, fish bones, pigeon bones, &c.—are more fre- quently entangled in the folds of the soft palate. In both situations, 228 THE PASSING OF INSTRUMENTS BY THE PHARYNX. the foreign matter is within reach of the finger ; and this is the best instrument by which to ascertain the exact site and nature of the lodge- ment—as well as the best guide to the forceps in extraction. Even a minute substance entangled in the fauces causes much discomfort; and besides, if not removed, will probably induce a certain amount of in- flammatory action. But the larger and solid substances, lodged lower down, call more urgently for our aid; inasmuch as by their bulk and pressure, and by the spasmodic movements which their irritation induces in the larynx, they threaten suffocation. The patient is seated firmly on a chair; the fore-finger is thrust determinedly into the fauces, and its point is moved about in every direction, until either the foreign sub- stance is discovered, or the surgeon is satisfied that there is no foreign body there. Much retching will be occasioned in all probability; but this must be unheeded by the examiner, and endured by the patient; perquisition of the soft palate being got over as speedily as possible, the extremities of the nerves concerned in the production of vomiting being chiefly situated there. The presence and site of the foreign body having been ascertained, it is seized by forceps, and gently withdrawn. For pins and small bones in the arches of the velum, the ordinary dressing-forceps, or merely the finger-nail, will suffice. For solid matter lodged lower down, longer forceps, gently curved at the extremity, are more suitable. It is.important to remember that very frequently the painful sensa- tion of a foreign body lodged in the pharynx remains, after the sub- stance itself has passed doAvn into the stomach. When, therefore, we have made a careful examination of the parts, and satisfied ourselves that no foreign body is there, Ave treat such abnormal sensation by leeching, followed by counter-irritation, or by anodyne embrocation. The passing of Instruments by the Pharynx. The surgeon is not unfrequently called upon to pass instruments into the pharynx and cesophagus; curved forceps for the extraction of foreign bodies; probangs and bougies for the propulsion of impacted articles of food, or for the relief of simple organic stricture; hollow tubes for the conveyance of nourishment into the stomach, in cases of wound of the pharynx or oesophagus—as in cut throat; and the tube of the stomach- pump, in cases of poisoning. The points to be attended to are—to use all gentleness, so as to avoid lesion of the lining membrane of the canal; and to take especial care, particularly Avhen it is our object to throw in ingesta, that the tube does not pass into the air-passage. If the patient be sensible, he is seated on a chair, with the head thrown much back, so as to bring the upper part of the alimentary canal into as straight a line as possible. The mouth having been opened wide, and the tongue depressed with the left fore-finger, the tube is moved rapidly past the soft palate, so as to avoid retching; and its extremity is then gently propelled, resting on the posterior part of the pharynx and made to glide, as it were, on the anterior surfaces of the vertebrae in its passage downwards. When the instrument's point is opposite the rima glottidis, the patient is directed to make an effort to swallow his saliva; or, with THE PASSING OF INSTRUMENTS BY THE PHARYNX. 229 the left hand, the surgeon raises the box of the larynx, and at the same time pulls it gently forwards from the cesophagus; such movement being plainly conducive to the free passage of the instrument into the latter canal. When insensibility exists, the operation is in one way facilitated; inasmuch as there is no resistance on the part of the patient. But, in such cases, it is plain that our care to insure a right passage for the instrument must be doubly exerted; the patient having no power to warn us of a threatened deviation from the proper track. In most cases, it is well to assure ourselves fully that the tube is in the cesophagus, and not in the larynx, before fluids are passed downwards to the stomach. For this purpose, a sheet of paper may be placed over the face, with the extremity of the tube projecting through it; while in front of the tube a lighted taper is put, which by the paper is effectually screened from the flatus of the nostrils in expiration. If, on expiration, the flame remain steady, no air impinging on it, we may proceed with injection; the tube is certainly in its right place. If the'flame be extinguished, or even made to bend considerably, it is equally plain that an error has been made; and that injection would almost certainly occasion fatal asphyxia. It is possible, however, that the flame may be affected a little in expiration, although the tube be quite in its right track. For, it is probable that in inspiration a certain amount of air may pass down- wards by the tube, which during expiration may be again extruded. It is well to remember that a large instrument is preferable, in such cases, to one of small size; being much less likely to enter the windpipe. And it is also worthy of note, that, in emergencies, a syringe is not essential to effect clearance of the stomach; a tube having been passed, the fluid contents of the stomach may be made to flow out by it, on merely bending the body, and bringing the mouth to a lower level than that of the epigastrium. When a syringe is employed, it should always be with caution; otherwise, ecchymosis and laceration of the gastric mucous membrane are not improbable. Also, unless previously aware that the stomach contains much fluid, it is prudent to begin the operation by injecting tepid water, Avhich is afterwards pumped out along with the previous contents; and this in- jecting and ejecting may be repeated as often as may seem necessary, with the double view of Avashing out the viscus thoroughly, and at the same time avoiding injury to the lining membrane. Watson, Clinical Lecture, Med. Gazette, vol. xvii. Kunze, Commentatio Pathologica de Dysphagia, Lips. 1820. Monro, on the Morbid Anatomy of the Gullet, Edin. 1830. C. Bell, Institutes of Surgery, vol. i. Appia, de Stricturis CEsophagi, Ileidelb. 1842. CHAPTER XVI. AFFECTIONS OF THE (ESOPHAGUS. Fig. 105. Stricture of the (Esophagus. Oesophagitis, of a most intense character, is occasionally induced by the swallowing of acrid fluids, as scalding water, the nitric or sul- phuric acids, soap lees, caustic alkalies, &c. A more moderate action may be induced by slighter causes, or may occur when no cause can readily be assigned, and its probable result will be contraction of the canal, partly by change of the mucous membrane, partly and mainly by submucous deposit. But contraction of the cesophagus may be of three kinds, as in the case of the pharynx. It may depend on spasm, of sudden accession, and only occasional; removable by general treatment. Or it may be the result of a chronic inflammatory process, of gradual ap- proach, constant, and curable only by a cau- tious use of the simple probang or bougie. Or it may be caused by structural change of a malignant kind, followed speedily by ulceration, and capable only of palliation. The simple organic stricture is of most fre- quent occurrence. Its ordinary site is at the narrowest part of the canal, opposite the cricoid cartilage. When tight and of considerable duration, the tube is prone to become dilated above the strictured part, forming a pouch in which food inconAreniently accumulates. The constrictors of the pharynx are usually hyper- trophied, and the upper cornua of the thyroid cartilage may become closely approximated.1 Above the stricture, too, ulceration is apt to take place, Avhich, though not malignant, is nevertheless vary intractable, and most incon- veniently complicates the case. Besides, in consequence of obstruction to deglutition, the system is apt to suffer more or less by an ap- proach to inanition, and therefore it is obviously our duty to commence the suitable remedial interference at as early a Stricture of the Gullet, at its most ordinary site. A bougie shown introduced by the mouth. 1 Lancet, No. 1209, p. 483. FOREIGN BODIES IN THE GLSOPHAGUS. 231 period as possible. In using the bougie, even more gentleness and care, if possible, are expedient, than in the case of strictured pharynx, force being more likely to produce lesion of the membrane, and even to cause perforation of the tube. It has happened that the head of a pro- bang, supposed to have passed on to the stomach after having overcome the stricture, has been found, after death—at no distant date, and not unconnected with the event—to have lodged in the mediastinum ! An- other precaution is equally necessary, namely, to beware that there is no error in our diagnosis, to be certain that the contraction is really caused by structural change in the cesophagus itself, and not dependent on the pressure of an aneurismal or other tumor. It is easy to under- stand how the thrust and pressure of a probang or tube, acting on the parietes of an advancing aneurism, may fearfully accelerate the fatal issue. Foreign Bodies in the (Esophagus. Foreign bodies, whether obtuse and globular, or sharp and angular, portions of meat, or bones, pins, &c, become arrested usually at the narrowest part of the canal, nearly opposite the cricoid cartilage. Or. lodging there in the first instance, they become displaced either upwards or downwards, usually in the latter direction, by the efforts either of the patient or of those whom he calls to his.aid. The result varies, according to circumstances. There may be simply an irritation pro- duced by the presence of a foreign body, Avith more or less dysphagia, or an inflammatory process is kindled, and advances perhaps to sup- puration and ulceration, or by the pressure and irritation of a bulky substance life may be immediately perilled by impending asphyxia. Or, as very frequently happens, the foreign body slips down into the stomach, leaving, however, a marked sensation of its presence at the site of its temporary arrest. The presence of foreign matter is ascertained by the bent forceps or by the probang, passed carefully down and moved gently. According to the nature of the substance, either extraction or propulsion is prac- tised. If the obstructing body be a piece of meat, or other article of food, not likely to injure the canal in a forced passage, and capable of being subsequently digested in the stomach, it is the simpler practice, and perfectly warrantable, to push the foreign substance gently down- wards by means of the probang. When, however, the circumstances are of an opposite character, as usually happens—when we are satisfied that the cesophagus cannot fail to sustain lesion in attempts at pro- pulsion, and that the stomach will be unable to make any satisfactory impression on the substance, should it be received there, extraction is invariably to be preferred. Long, curved forceps are the most gene- rally available instrument, the surgeon being provided with two pairs, of opposite movements in the blades. The one having missed the foreign substance, when this is narrow or flat, the other can scarcely fail to seize it. Seizure having been made, dislodgement from the parietes of the canal is to be effected by a cautious wriggling movement of the hand, before extractive power is applied, to avoid unnecessary 232 FOREIGN BODIES IN THE G5SOPHAGUS. injury of the parts. Needles or pins may be entangled in loops of thread attached to the end of a piece of whalebone, passed down to the Fie. 106. Fig. 107. Fig. 106. Forceps for extracting foreign bodies from the pharynx and oesophagus. Fig. 107. The companion Forceps to Fig. 106, open- ing in the opposite direction. site of lodgement and moved gently about. Flat substances, such as coins, presenting their edges to the operator, may be brought up by a flat and broad blunt-hook. When no instrument is at hand, and the case is urgent, extrusion of the foreign substance may be effected by exciting vomiting, and this may be done either by administration of the ordinary emetics, if swallowing be at all practicable, or by mechanicallv tickling the fauces. J When indigestible substances have passed into the stomach they usually find their way to the surface, by the natural outlet—per anum • passing off with the feculent matter—often but little changed—after the CESOPHAQOTOMY. 233 lapse of some time. To assist the downward movement, purgatives are often employed. If the foreign body be solid and obtuse, no harm is done, and extrusion will probably be expedited. But if the substance be sharp and spiculated, the practice cannot but be mischievous ; tend- ing to produce entanglement in the mucous membrane, probably with perforation of the bowel; and also tending to kindle inflammation in the affected part. In such cases, therefore, it is more prudent to aAvait the working of nature. Needles and pins usually do perforate the in- testinal canal; but, if left to themselves, the process is gradual, accom- panied by protective plastic exudation, and consequently harmless. In due time, the foreign body appears at the surface, as if soliciting ex- traction—perhaps months after the date of its entrance, and after hav- ing traversed a most circuitous route. Fish-bones, and bones of rabbits or other small animals, are not unfrequently arrested by the sphincter of the anus, after having safely made the passage above ; and may re- quire the use of both knife and forceps for their removal. Cherry- stones, and such like substances, may lodge in the vermiform process of the caput caecum, and excite either abscess there or general peritonitis. Occasionally, though rarely, it happens that the foreign body will move neither up nor down in the oesophagus. Extrusion and propulsion having both failed, excision is the only other resource. The substance is cut down upon from without, and extracted through the wound. (Esophagolomy. The neck is stretched, by elevating and throwing back the head; and, by the fingers of an assistant, the foreign substance is made to project as much as possible on the left side of the trachea; [or, a stout probang may be passed down to the obstruction, and its point be pressed against the side of the gullet, so as to make the latter prominent.—Ed.] A free incision is made over the swelling, through the skin and platysma my- oides; and then, by a cautious and more limited use of the knife, the cesophagus is exposed in its most projecting part. Here it is penetrated by the knife; and the opening thus formed is afterwards dilated to a suffi- cient extent, partly by the finger, partly by slight touches of the knife's edge. The offending matter is laid hold of by the finger, or by forceps, and removed. Hemorrhage having been arrested, the Avound is brought accurately into apposition, and treated for adhesion. For some days a tube is worn, passed by the mouth; and through this the necessary nourishment is conveyed, clear of the wound. It may be imagined that foreign substances may be safely left to loosen themselves by suppuration, and so to facilitate, if not effect, their own extrusion. But experience declares that it is not so. The obstruction to deglutition, and impediment to breathing, are themselves circumstances sufficiently untoward to demand prompt interference. The inflammatory process, too, which is sure to follow, is fraught with both disadvantage and danger; it may lay the foundation of a formida- ble organic stricture ; it may cause a troublesome abscess, resulting perhaps in a fistulous opening in the canal; or, in a low site, ulceration may open into the arch of the aorta, and prove speedily fatal. 234 PALSY OF THE CESOPHAGUS. [03sophagotomy has been performed also in a few instances of aggra- vated organic stricture of the oesophagus, in which other means had been long tried in vain, and in which death from inanition was immi- nent. But the incurable nature of the disease which generally pro- duces the stricture, the dangers, difficulties, and ultimate fruitlessness of the operation, the possibility of nourishing the patient per rectum for a considerable time—these and other considerations must render the operation an unadvisable one. The reader will find an interesting paper on this subject, together with the report of a case of cesophagotomy, by Dr. Watson, of New York, in the Am. Journal, vol. viii. N. S. The difficulties and obstacles to be overcome are therein narrated ; they are so great, that Dr. Wat- son suggests that gastrotomy might be preferable. But, although the latter operation is easy enough of accomplishment, and although an abundance of nutriment might be readily introduced thereby, it can scarcely be called a more eligible proceeding than the other.—Ed.] Palsy of the (Esophagus. This, like the corresponding affection of the pharynx, is usually of evil import; betokening disease of the nervous centres. Inability to swallow may be complete ; but the probang meets no obstruction. In some cases, benefit may be derived from counter-irritation and use of galvanism; but in most we must be contented with palliation—sus- taining life by matters introduced by means of the stomach-pump, as well as by nutrient enemata. Kunze, Commentatio Pathologica de Dysphagia, Lips. 1820. Monro, on the Morbid Anatomy of the Gullet, Edin. 1830. C. Bell, Institutes of Surgery, vol. i. Arnott, on OEsophagotomy, Med.-Chir. Trans, vol. xx. Appia. de Stricturis'CEsophagi, Heidelb. 1842. [Smith's Operative Surgery, p. 277 ; Mott's Velpeau, vol. iii. p. 4t»6 ; Fergusson's Pract. Surgery.—Ed.] CHAPTER XVII. AFFECTIONS OF THE EAR. Foreign Bodies. Children are apt to insert foreign matter into the meatus auditoriu3, as well as into the nostrils. Dislodgement and extrusion are effected by the same means ; by the stream of water injected ; or by the use of a flat and bent probe, or curette. Forceps are a still more reprehensible instrument here, than in the case of the nostril; for impaction is hot only more probable, but likely to be followed by much more serious results. Abortive attempts to dislodge, by forceps, have occasioned deeper entrance, disruption of the internal ear, intense otitis, and death.1 Larvae have lodged in the ear ; causing severe inflammation there, with much local suffering, and grave constitutional disturbance. White Precipitate, suspended in milk, is found successful in killing the animals, when injected ; and they may be subsequently removed by forceps, curette, or a stream of water.2 Polypus of the Ear. Two forms of polypi may form on the lining membrane of the meatus externus—usually from that middle part of the meatus which furnishes the cerumen ; one soft and pulpy, analogous to the common mucous polypus of the nose ; the other more firm and fleshy, resembling rather the solid polypi of the uterus ; both simple in structure and tendency. Deafness is occasioned, along with uncomfortable sensations in the part; and more or less discharge escapes, of a puriform and offensive charac- ter. Treatment is by evulsion ; slim forceps being employed for this purpose, as in the case of nasal polypus. By the use of the ear-specu- lum, cautiously introduced—an instrument similar to the nasal speculum, only of a more tubular extremity, suited to the cavity which it is in- tended to explore—the site of growth is ascertained ; there the seizure by forceps is made ; and, by slight torsion combined with evulsion, extirpation is effected. Or the attachment may be divided by means of blunt-pointed scissors. When the growth springs from near the mcm- brana tympani, however, evulsion is not safe ; and it is better to destroy it by caustic—such as the potassa cum calce.3 When bleeding has ceased and pain subsided—after the use of forceps or scissors—it is ' Lancet, No. 1062, p. 458. 2 Ibid. No. 1341, p. 588. 3 Toynbee, Medical Times and Gazette, Jan. 3, 1852. 236 OTITIS. Fie. 108. well to touch the part with nitrate of silver, so as to diminish the chance of reproduction. And if the morbid structure should not have been entirely removed, such cauteriza- tion may require repetition from time to time. During the healing process, relaxation of the membrane, with copious discharge, is apt to prove troublesome ; demanding the daily and repeated use of gently stimulating and astrin- gent injections. Fungoid granulations, of a polypous character, not unfrequently spring from the membrane of the meatus, in cases of long-continued otorrhoea. They grow from the lower part of the tube, or from the membrana tympani itself; and, when of large size, may simulate polypus. They are got rid of by nitrate of silver, used escharotically, and by the subsequent employment of astringent injections. [A more simple and equally useful Speculum for the Ear, recommended by Mr. AVilde, of Dublin. It is made of silver, highly polished on the in- side ; various sizes should be made, for ears of different dimensions. (From Druitt.)—Ed.] Otitis. The inflammatory process may attack the mucous membrane of the ear, and textures connected therewith, either on the exterior or on the internal aspect of the membrana tympani. In the one case, the affection is said to be external; in the other, internal. External Otitis.—This most frequently occurs in the young; the result of exposure to cold, with or without irritation, caused by affections of the teeth or gums. It constitutes the common earache, from cold; the pain being that which attends on the ordinary inflammatory process, occurring in a part of extreme sensitiAreness. The action may simply resolve; or it may cause a puriform exhalation from the mem- brane ; or abscess may form beneath the membrane, pointing, discharg- ing, and causing much aggravation of distress. Treatment is simply antiphlogistic; leeching behind the ear, fomentation, hot poultices, purges, and antimony. When abscess forms, activity in the application of heat and moisture is redoubled; and, as soon as the appearance of matter is presented, evacuation is effected by puncture. Internal Otitis is a more serious affection, and may be variously induced, by injury, exposure to cold, or extension of a more outward attack. Pain may not be more acute, but is deeper seated, and more intolerable; attended with throbbing, and confusion of the head; the system sympathizing in well-marked inflammatory fever. If the action proceed to suppuration, disruption of the internal ear, with loss of hearing, is all but inevitable; and, very probably, a still more serious result may ensue, namely, affection of the interior of the cranium. Treatment is actively antiphlogistic. When certain that acute internal otitis exists, we will not content ourselves Avith leeching behind the ear, but may take blood both from the part and from the system. Calomel and opium, too, will be administered; the invasion of an organ of deli- cate texture, of important function, and in near connection with the brain, being sufficient warrant for such procedure (Principles, 3d Am. OTORRHCEA. 237 Ed. p. 169). In short, the best efforts will be made early and satis- factorily to subdue the rising process, so as to prevent suppuration, if possible. When matter has formed in the cavity of the tympanum, the membrana tympani acts injuriously, by repressing outward discharge of the abscess; occasioning tension, Avith aggravation of the symptoms. Here the general rules of surgery are to be fulfilled, by incising the tense, resisting membrane—which is seen Avhite and prominent—so soon as we are satisfied, by its change of color and form, and the course of the general symptoms, that intra-tympanal suppuration has taken place. The membrane must yield, ultimately, by ulceration or sloughing; pro- bably too late to saA*e the delicate and complicated apparatus of hearing from irreparable injury'; perhaps too late to prevent extension of aggra- vated inflammatory action to the brain or its membranes. Chronic internal otitis is common; less formidable than the acute form at the time of invasion, but prone, if unchecked, to lead to equally serious consequences. The membrane may be simply changed in struc- ture ; thick, rough, and vascular; clogging and enveloping the ossicula auditus. Or suppuration may take place, with perforation of the mem- brana, and probably with ultimate necrosis, and discharge of the ossicula. Treatment consists in attention to the general health, alteratives, and patient counter-irritation. Otorrhcea. By this term is understood a puriform or purulent discharge from the ear; the result of chronic inflammatory action. Usually it is preceded by the ordinary signs of an attack of otitis, acute, or subacute in cha- racter. Children are most liable to this affection; and especially those of strumous habit. Often it is one of the sequelae of scarlatina. It is well to examine the meatus atfentively, by means of the speculum, dis- charge having been previously removed by gentle ablution. For if the membrana tympani be found entire, and tolerably sound, the affection is so declared to be comparatively simple; whereas, if that membrane be found imperfect, denoting an internal origin of the suppuration, prognosis is rendered more guarded and unfavorable. It must never be forgotten that the term Otorrhcea, in truth, compre- hends many affections; inflammation of the external ear, of the cavity of the tympanum, or of the mastoid cells. And it is equally important to observe that inflammation begun in the external meatus may at any time extend to the other parts, and thence to the contents of the cranium, from the tympanum to the cerebrum, and from the mastoid cells to the cerebellum.1 Treatment is mainly palliative and expectant, as regards the part, restorative as regards the system. The constitutional cachexy is to be ' " No person suffering from chronic catarrhal inflammation of the dermoid layer of the meatus, the membrana tympani, or of the mucous membrane of the tympanum, can be assured that disease is not being prolonged to the temporal bone, the brain, and its mem- branes ; and that any ordinary exciting cause, as an attack of fever or influenza, a blow on the head, &c, may not induce the appearance of acute symptoms, which, as a general rule, are speedily fatal."—Toynbee, Med.-Chir. Trans, vol. xxxiv. 238 ABSCESS OF THE MASTOID CELLS. combated by the usual means. The ear is kept clean by frequent and careful use of tepid water, without and within the meatus. The state of the mouth is looked to, and, if need be, amended. Reaccessions of inflammatory action are averted or subdued by occasional leeching and fomentation, as circumstances may require. The chronic action, which is maintaining the structural and functional disorder of the mucous membrane, is sought to be overcome by careful counter-irritation, such as blistering behind the ear; this, however, being proceeded with cau- tiously, lest enlargement of the glands of the neck, which frequently is an accompaniment of otorrhcea, should be either induced or aggravated. When nearly all the symptoms of inflammatory action in the part have subsided, and when the general system has decidedly improved, weak astringents may be employed to favor recovery of the membrane, and consequent cessation of the discharge. This part of the treatment however, must always be conducted with the greatest possible care' lest, by sudden arrest of the discharge, return of the inflammatory attack in a deeper site, and in an aggravated form, should unhappily ensue. Such risk is in all cases great when sudden arrest of discharge has occurred from any cause, but especially in those cases in which implication of the internal ear is indicated by imperfection of the mem- brana tympani, and perhaps previous discharge of the ossicula auditus J Otorrhcea m the adult may be connected with the lodo-ement of foreign matter in the meatus, long overlooked. A grass-see°d, or such like substance may be extruded after many years, otorrhcea, occasional or constant, having been maintained during the whole period of its residence. r Otorrhcea is occasionally connected with a degenerated condition of the pars petrosa of the temporal bone, which has softened and become converted into a medullary mass. The symptoms are cerebral and obscure. The issue is hopeless. And it is very plain that the fatal event would certainly be much accelerated by a successful attempt to arrest the aural discharge. F Abscess of the 3Iastoid Cells. Inflammatory action may originate in the cancellated texture of that part of the temporal bone which constitutes the mastoid process. It may be the result of external injury; more frequently it occurwithout any appreciable exciting cause in systems of the strumous character and is most especially liable to invade those whose oS^rf system has been aggravated by imprudent exhibition of Sh Like the preceding affection, it is most frequent in the you B very often this disease is but the extension of an originalh mire out ward affection, namely, long-continued inflammatio/ofi eternal maThard vTiHoT VnT? t0' f » ^^ P™baMe?c^ may hardly fail to be established, and is usually complicated with ta^te the nose. Purulent discharge has symptoms, and on dissection ^X^^l^Jr^ ^T' ^ head with corresponding affection of the brain. CnDrit0rm pIate of the ethm<^l bone is found, DEAFNESS. 239 necrosis, portions of the osseous texture separating in the form of sequestra. From the near connection of the posterior surface of the cells with the dura mater of the cerebellar cavity, it can easily be understood how readily in advanced cases the latter texture may be involved. The lateral sinus, too, is in close contact, and perforation of this vessel gives rise to two formidable dangers, hemorrhage and pyaemia. Supposing the affection to be primary, treatment in the first instance will be directed to aArerting suppuration and caries, if possible, by the ordinary means. When there is reason to believe that matter has formed, we shall be very anxious to obtain an early and sufficient open- ing externally, and thus to limit the mischief already done. OtheiAvisc there is great danger by extension. The internal car having been involved, hopeless deafness will ensue ; paralysis of that side of the face is not unlikely, from implication of the portio dura; nay, it is possible that the contents of the calvarium may be attacked, as already stated, directly and imminently perilling existence. But, independently of such aggravations, life may be hazarded by the hectic of a continued and wasting discharge. From local treatment alone but little good need be expected; consti- tutional means must be at the same time and sedulously employed. When employing counter-irritation, the blister should not be placed over the part affected, otherwise the morbid action might be increased, but at a distance, as on the nucha, or between the shoulders. Otalgia. This constitutes true earache, a neuralgic affection, unconnected directly with the inflammatory process. Very frequently it is con- nected with irritation in the mouth. The pain is very distressing, and has all the characters of neuralgia. It is amenable to the same treat- ment (Principles, 3d Am. Ed. p. 587), search for a dental cause or connection never being neglected. Among the anodynes suitable for application to the part, aconite and belladonna deserve a prominent place. Deafness. Deafness may proceed from the affections already mentioned, and from many causes beside. In order to arrive at a true diagnosis, careful examination of the external meatus and of the membrana tympani is essential, and to effect this the well-made speculum is of great service. Deafness is very frequently occasioned by accumulation of inspis- sated cerumen within the meatus. Or, perhaps, obstruction to the vibrations of sound is rendered still more effectual by commixture of wool or cotton with the cerumen, the patient having been in the habit of negligently stopping his ears, besides forgetting to practise requi- site cleanliness. The presence of obstruction will be at once declared by use of the speculum; and often that is not necessary, tension and 240 DEAFNESS. straightening of the tube by pulling the lobe, before a clear light, being sufficient. Remedy consists in removing the offending mass. And this is best effected by washing out the meatus with warm water by means of a stout syringe. Instruments, such as are employed for gonorrhoea or for the injection of sinuses, are wholly inefficient; the syringe should be of metal, well valved, and of considerable power. And the injection is persevered in, either at one or at repeated sittings, until the membrana tympani is disclosed clear, on the use of the speculum. When the cerumen is unusually hard and tenacious, it may be loosened, previously to syringing, by the careful use of a curette, or by moistening it with bland oil for a day or two. Deficiency of ceruminous secretion is an occasional but much less fre- quent cause of deafness. The meatus is found dry and empty, and the membrana tympani is seen clear and glistening. Stimulants are of use in restoring the secretion, as the essential oils, more or less diluted, and their action may be farther assisted by stimulant friction around the auricle. Exhaustion of the cavity is said also to have a beneficial effect, by means of a syringe, fitted with a soft nozzle which completely oc- cludes the meatus. Until the normal secretion returns, glycerine, applied by means of a hair pencil, will be found a ATaluable substitute.1 Thickening of the lining membrane of the meatus is a cause of deaf- ness, the result of chronic inflammatory action. It is to be treated by the application of gentle stimuli, such as solutions of nitrate of silver, sulphate of zinc, &c, which are best administered by means of a hair pencil. Rectification of the general health, and counter-irritation behind the ear, are often useful auxiliaries. The membrana tympani may be changed in structure, thickened, and congested, the result of inflammatory action. Similar treatment is advisable, the stimulants being applied by means of injection, except when the membrane is imperfect, and then again the hair pencil becomes preferable, lest undue excitement be caused in the internal ear. Imperfection of the membrane, by ulceration or by rupture in conse- quence of external injury, may be repaired by nature's effort. If not, hearing may be much quickened by applying a small shred of lint, or cotton wool moistened in glycerine, over the aperture.2 By hypertrophy of bone, the osseous meatus may be so contracted and changed as to produce a considerable amount of deafness, an affection obviously but little amenable to treatment. The internal ear may be disordered, and on this cause the great ma- jority of cases of deafness are found to depend.3 The change may be in the lining membrane, in the osseous texture, or in the nerves. For- tunately, modern research has declared the most usual site of disorder to be the texture first named, the one most amenable to successful treat- ment. This mainly consists in attention to the general health, and patient perseverance in the use of counter-irritation, the latter preceded by moderate local depletion. 1 AVakley, Lancet, No. 1346, p. 631. 2 Lancet, No. 1296, p. 10, and No. 1298, p. 64. 3 Toynbee, Med.-Chir. Transact, vol. xxiv. DEAFNESS. 241 The extremity of the Eustachian tube may be obstructed in various ways, and deafness ensue. It may be shut up and compressed by enlarged tonsils, or by nasal polypus hanging Ioav from the posterior nares. In such cases, deafness will disappear on removal of the tonsil or polypus. Congestive swelling and relaxation of the fauces may cause obstruction of the tube, to be removed by astringent applications, counter-irritation, and attention to the general health.1 Ulceration of the fauces, implicating the extremity of the Eustachian tube, may cause more serious obstruction by the contraction which oc- curs on cicatrization. This is to be obviated by speedily healing the ulcer, while yet superficial and of slight extent ; and is to be remedied —if possible—by the introduction of probes, or catgut bougies, whereby to effect gradual dilatation of the canal. The probe, or bougie, about six inches long, and sufficiently curved, is introduced along the floor of the nostril, with the convexity upAvards ; and, just before the pharynx is reached, it is gently turned so as to bring the point outwards and a little upwards—the mouth of the Eustachian tube being above the level of the floor of the nostrils. If the tube is open, the instrument will be plainly felt entering it. When obstruction or obliteration exists, pres- sure is to be made where the normal aperture ought to be; in the hope that thus the obstruction may be overcome. Sometimes the operation is at least partially successful. But in too many cases, this as well as the other operations on the Eustachian tube, are found to be not only difficult in performance, but also nugatory in their result. By catheterism, as it is termed, it is proposed to rid the tube of a redundancy of mucus—another cause of deafness; but that will pro- bably be as easily and certainly more safely accomplished, in most cases, by general treatment, gargles, and counter-irritation. In chronic affections of the membrane of the middle ear, it is possible that benefit may sometimes follow the careful injection of water, air, or medicated vapor, into that cavity; and this is accomplished by means of the me- tallic Eustachian catheter—introduced in the same way as the probe, and fitted with a suitable syringe. All such operations, hoAvever, must be conducted with the greatest caution ; seeing that it requires but little morbid change in the bony walls of the tympanum to produce an al- most direct communication between that cavity and the interior of the cranium.2 Organic change in the brain, or in the auditory nerve, is not an un- frequent cause of deafness ; and seldom admits of successful treatment. Hopes of amendment will mainly rest on counter-irritation, and on mer- curialism moderately employed. Functional disorder of the nerve is fortunately a more frequent, as 1 Clearness of the tube is ascertained by directing the patient to shut his mouth and nostrils, and then to expire forcibly, as if blowing his nose. He will be sensible of a click in the ear, produced by the shock of air acting on the membrana tympani, sup- posing this to be entire, and the sound will be very plainly heard by the surgeon, through a stethoscope placed on the mastoid process. If the tube be open, but clogged with mucus, the noise is of a gurgling or crackling kind. 2 Toynbee, Medico-Chir. Transact vol. xxxiv. 1851. 16 242 PERFORATION OF THE MEMBRANA TYMPANI. well as more hopeful cause ; variously induced—as by blows, falls, loud noises, disorder of the general health, &c. Besides obviating the induc- ing cause, employing counter-irritation, and perhaps venturing on mer- curialism, benefit may be obtained from the endermic use of strychnia —as in the analogous case of functional amaurosis (p. 143). Or a few drops of an alcoholic solution of strychnia may be dropped into the ear, from time to time. Determination of blood to the head, in consequence of suppression of normal or habitual discharge, or hoAvever induced, is not unlikely to produce a certain degree of deafness, along with noises and other un- pleasant sensations in the head. Treatment is by leeching or cupping, purging, and other means ordinarily found available to overcome local plethora. Perforation of the Membrana Tympani. This little operation is not frequently required. It is deemed advisa- ble, when, by insuperable obstruction of the Eustachian tube, access of atmospheric air is denied to the cavity of the tympanum; and also when that cavity has become obstructed by extravasation of blood. The ex- pediency of simple puncture, in the case of abscess of the tympanum, has been already noticed. In cases of deafness, caused by obstruction of the Eustachian tube, it is our object not merely to make an aperture in the membrane, but to keep that pervious ; and so permanently to atone for want of the accustomed atmospheric supply in the middle ear. This may be accom- plished by using the instrument of Fabricci. "It consists of a canula, into which slides a spiral wire, somewhat resembling that of a corkscrew. It is to be used in the following manner: Pass the canula with the spiral wire down upon the inferior part of the membrana tympani (so as not to interfere with the manubrium of the malleus), retain it there with the left hand, being careful not to press too firmly on the mem- brane ; then, with the right hand, take hold of the small handle which revolves the spiral Avire, and turn it from right to left, being what is usually called turning the wrong ivay. The instant at which the mem- brane is perforated is sensibly felt by the operator. The Avire is now no longer to be turned; but by its handle the instrument is to be re- tained in its situation; then gently revolve the canula, Avhich has a cut- ting edge, from left to right, when a circular portion of the membrana tympani, corresponding to the diameter of the canula, will be cut out, and at the same time drawn into the canula and held fast by the spiral wire."1 Or, instead of this instrument, a trocar, volute and sharp in the sides, may be employed; turning it quickly in the membrane, so as to excise the punctured portion. Hemorrhage from the Ear. Blood, escaping by the ear, may proceed from various sources, and requires different treatment accordingly. 1. One of the most prominent 1 Williams on the Ear, p. 204. CONGENITAL OCCLUSION OF THE MEATUS. 243 symptoms of fracture at the base of the cranium is bleeding from the ear; amenable to no direct treatment; and usually an unfavorable omen (p. 58). 2. Mere laceration of the lining membrane of the meatus may furnish a copious discharge of blood ; independent of any injury done to the cranium, or elsewhere. It, too, requires no direct treatment— not being likely to prove excessive. And it is not a sign of an unto- ward character. It may be the result of a blow, fall, or direct injury done to the part. 3. Passive hemorrhage may take place from this, as from mucous surfaces ; amenable to the ordinary treatment, local and constitutional, suitable in such cases. 4. The internal carotid may have been opened into by ulceration. The hemorrhage is constant, copious, and of the arterial character. Pressure may be tried, Avith styptics, but may fail. The only sure remedy is ligature of the common carotid artery. 5. The lateral sinus, opened by ulceration, may be the source of bleeding—dark, and venous. In this case, while ligature of the carotid would prove wholly nugatory, moderate pressure is found to be quite effectual. Hypertrophy of the Auricle. Hypertrophy of the whole auricle is an occasional, though rare, occurrence. Partial hypertrophy, affecting the lobe only, is more fre- quently met with, and chiefly in women. If excessive and irksome to the patient from its unseemliness, the redundancy may be removed by the knife. This deformity, hoAvevcr, may be artificially and intentionally pro- duced, as by the native Indians, who wear a dagger suspended from the lobe of the ear. Otoplasties. Deficiencies of the auricle, by wound, ulceration, or sloughing, may be repaired by autoplasty. Restoration of the entire organ is scarcely to be attempted; but a portion may be readily replaced, Avhen laxity of the surrounding integument is favorable, by an operation conducted on the same principle as rhinoplasty (p. 173). Congenital Occlusion of the Meatus. The meatus may be congenitally imperforate. It may be fully de- veloped in all respects, but covered by integument. In such a case, simple incision of the«kin, and careful dressing of the wound, so as to prevent contraction, will suffice to establish the normal state. Or a thick fleshy covering may conceal the cartilaginous tube, which is only partially developed. And, in this case, a more careful and regular dissection may obtain a similar result, but, perhaps, more imperfectly. Or, the external apparatus of hearing may be altogether deficient; the bone itself being imperforate. Such cases are wholly beyond the reach of our art; yet it does not follow that hearing is denied, or even 244 CONGENITAL OCCLUSION OF THE MEATUS. very imperfect. And of this a striking example occurred to me some years ago. A boy, aged fourteen, came from a distance, desirous of having an aperture made in each auricle; and each of these organs was found very imperfectly developed, of a shrivelled appearance, and Avholly imperforate. On making a very careful dissection down to the bone, in search of an external meatus, it became apparent not only that no such tube existed, however imperfect, but that, also, there was no aperture in the temporal bone. Yet, the patient heard ordinary con- versation, if distinct and rather loud ; he had gone to school at the same age as other boys, and had made equal proficiency in the ordinary branches of education, although no unusual means of teaching had ever been applied to him; and he assisted his father in the occupation of a butcher, with much smartness and intelligence. A series of experi- ments, conducted by my colleagues, Professors Forbes and Thomson, seemed to show that he heard mainly by conduction of sound through the bones of the cranium to internal ears very perfectly constructed.1 Itard, Trait6 des Maladies de l'Oreille, Paris, 1821. Abercrombie on Diseases of the Brain, &c. Edin. 1828. Bright, Hospital Reports, vol. ii. part i. London, 1831. Kramer, on Diseases of the Ear, Berlin, 1836, translated by Bennett. Pilcher, on the Structure and Diseases of the Ear, London, 1838. Williams, on the Ear,-London, 1840. AA'ilde, on Otorrhcea, Dublin Journal of Med. Science, Jan. 1844. AAarden, Edin. Phil. Journ. Oct. 1844. Yearsley, Lancet, 1848, vol. ii. pp. 10, 64, &c. And Mr. Toynbee's various papers, Medico-Chir. Transactions, vols. xxiv. and xxxiv. Med. Gazette, July, 1843. Monthly Journal, Feb. 1849. [Also, some very good papers by Mr. AA'ilde, in the Dublin Journal; and a Treatise by the same gentleman, Philada. 1853.—Ed.] 1 Monthly Journal, Dec. 1846, pp. 420 and 729. CHAPTER XVIII. AFFECTIONS OF THE NECK. Glandular Enlargement and Abscess. In scrofulous adolescents, the glands of the neck are very liable to enlargement, by a chronic inflammatory process ; and frequently, not- Avithstanding every effort to the contrary, suppuration is attained to— causing more or less deformity by unseemly cicatrization. In the nascent stage, we endeavor to arrest progress ; by constitutional treat- ment suited to the strumous diathesis ; by leeching and fomentation ; and subsequently, by the application of iodine, or other discutients, or by slight counter-irritation. When matter has formed, an early evacua- tion is practised by incision ; the wound being made as minute as possi- ble, and in the direction of the folds of the neck, so that its cicatrix may escape observation. A common lancet is the preferable instrument. Sometimes, however, the use of potass is demanded; the integuments having been much undermined, and the gland requiring disintegration (Principles, 3d Am. Ed. p. 213). In the after-treatment of suppurations in the neck, cure is often de- layed by over-dressing the part—covering it Avith too many em'elops— especially when the patient is not confined to the house. The object of such dressing is to conceal the state of matters from public observation, and to guard against exposure to cold; but the result often is, to main- tain a degree of congestion in the part, favorable to continued suppura- tion, and unsuited to contraction and consolidation of the abscess. When abscess has formed at all deeply in the neck, whether connected or not with glandular enlargement, evacuation by incision cannot be too soon had recourse to, otherwise serious mischief can scarcely fail to ensue. Fascia is made to slough ; areolar tissue is broken down ; the trachea and oesophagus are each liable to be opened into by ulceration; the jugular tvein may communicate with the abscess; or, still more disastrously, by communication with the carotid artery the cyst of the abscess may be converted into the sac of a false aneurism. And then, when the wound for evacuation—too long delayed—is at length made, the most serious consequences are ineA'itable (Principles, 3d Am. Ed. pp. 207, 208). Hydrocele of the Neck. This affection is not uncommon, and might in most cases be termed more appropriately Hematocele; originating in lesion of a superficial 246 HYDROCELE OF THE NECK. vein, and the contents of the cyst being more or less sanguinolent. The cyst is thin, superficial, and seldom of very large size. Usually, the production of the swelling is sudden ; and its progress in growth may be rapid; after a time, however, becoming stationary, and proving in- convenient mainly by its bulk. Treatment consists in tapping and in- jecting iodine, as in the more ordinary serous accumulations. Should this fail, a small seton may be inserted ; or free incision may be prac- tised, with subsequent granulation from the bottom of the wound. In the necks of" young children similar swellings are not unfrequently obserA'ed, altogether unconnected with blood or bloodvessels; the con- tents clear and albuminous. [The term Hydrocele of the Neck, was originally applied by Mau- noir1 to certain tumors on the front and sides of the neck, which con- tain a watery fluid, bearing more or less resemblance to that found in hydrocele of the tunica vaginalis testis. This designation is not a for- tunate one, for it seems to suppose an analogy or similarity of charac- ter between the two affections, when no such resemblance exists. In one case, a morbid collection of fluid, varying very much in physical properties in different instances, is formed in an abnormally developed sac; in the other, serous or sero-fibrinous fluid is effused into a normal serous cavity. A better name for the first, would be Hygromatous Cyst of the neck, as suggested by Von Ammon ; it has also been called Struma cystica, Hygroma cellulosum colli, &c, &c. The affection may be either congenital or acquired. Numerous in- stances of each variety have been witnessed and described ; they resem- ble each other in all essential features. Tumors precisely analogous to those about to be described, occur in other situations upon the exterior of the body; they have been observed as congenital affections, on the posterior part of the neck, in the axilla, and about the sacrum and perineum ; they are also found in various internal organs.2 Symptoms.—The Hygromatous cyst of the neck, or Hydrocele of the neck, may appear upon either side, seeming to have no preference for one rather than the other; or it may grow upon the middle of the neck, and extend laterally. When in the former situation it is found about the angle of the jaw, and extends, in proportion to its dimensions, from this point upwards toAvards the zygomatic arch, outwards towards the mastoid process, downwards in the direction of the shoulder and the sternum, and towards the middle of the neck. The size of the tumor varies from that of a nut to that of the child's head, or even beyond the latter, so as to occupy all the space indicated above. When upon the median part of the neck, it is usually symmetrical in its develop- ment, extending pretty equally on both sides. The median tumors are generally larger than the lateral in infants, but the reverse is the case in adults.3 Thus Von Ammon describes and figures one upon the ante- rior face of the neck of an infant fourteen days old, which extended from ear to ear, covered the whole front of the neck, and reposed upon ' Sur les Amputations, l'Hydrocele du cou, et l'organisation de l'Iris. Geneve, 1825. 2 Wernher, die Angeborenen Kystcn-IIygrome, und die ihnen verwandten Geschwulste Giessen, 1843, p. 2. 3 Fleury et Marchessaux, Archives Gales de Me"decine, p. 285. HYDROCELE OF THE NECK. 247 the chest ; the mass was so enormous, as to induce the belief that it contained a foetus.1 In other instances, the prominence of the tumor above the surface may be comparatively small, Avhile it extends deeply beneath the fascia and superficial muscles of the neck. The boundaries of the tumor are well defined externally. Its connections Avith the neigh- boring tissues may be quite close and firm, so as to allow of but little mobility : or, on the other hand, it may be susceptible of being moved from side to side, and even raised up from its bed Avith comparative freedom. The shape may be more or less regularly globular, pyriform, or fusi- form. The tumor may be single or multiple ; or, if it be single, the fluid may be contained in more than one sac, and the compartments may be so much distended as to present the appearance of many almost distinct tumors. The surface is sometimes smooth and uniform, and tense from the amount of fluid beneath; or it may present irregularities corresponding with the lobulated structure of the mass. If the integu- ments are sufficiently relaxed to permit a careful examination, the septa which divide the interior into separate compartments may often be dis- tinguished, varying in number and in thickness. The skin covering the tumor may be normal in appearance, or of a red color with varying shades of blue ; in some cases, particularly in the congenital variety, it presents abundant ramifications of small blood- vessels, which become distended when the child cries, like a nsevus; but, in such instances, there is no,pulsation to be detected, unless from an artery beneath or near the cyst, nor is it possible to trace any vas- cular trunk running into the tumor, nor does the latter diminish in size under pressure. Sometimes the integuments are so much thinned from distension, and the contained fluid is so transparent, that the whole tumor, or parts of it, are translucent when viewed against a strong light, like a hydrocele of the tunica vaginalis testis. Fluctuation can almost always be elicited by proper manipulation. It may be felt through the entire cavity, from side to side ; or it may be limited in extent, and be developed only by palpation as upon an ab- scess, thus showing that the cavity is divided into loculi more or less distinct from each other. On the other hand, this sign may be entirely wanting, either in particular parts, or throughout the Avhole of the tumor ; in consequence of the smallness of the individual cysts, and the consequent comparative predominance of the solid tissue composing their walls and septa, or of the absolute thickness of the latter, or of the semi-solid character of the contents of the sac. The tumor is not, unless it be accidentally inflamed, painful, or tender on pressure; nor does it necessarily produce any constitutional disturbance. Its growth is usually slow; patients commonly state that it began as a small, circumscribed, hard swelling, and progressed slowly, until excited to more rapid progress, by some accidental exciting cause, as a blow, or pressure ; or by some violent and continued straining, as in labor. But, occasionally, its appearance is sudden, and its development rapid. The amount of suffering, inconvenience, or danger induced by 1 Die Angeborenen Chirurgischen Krankheiten, p. 13, pi. 53, of the text. 248 HYDROCELE OF THE NECK. these growths, depends upon their size, situation, and rapidity of pro- gress. If small, they produce little or no trouble; but, if large, or situated beneath the fascia and cervical muscles, they occasion pressure upon subjacent parts, interfering with deglutition and respiration, and with the circulation of blood to and from the head. Death, in fact, ordinarily results from one or all of these causes, or from intercurrent inflammation of the tumor, at varying periods, from a few days to several months after birth (Wernher, p. 45). And when the pressure is not sufficient to produce these effects so decidedly, it may displace the larynx, the tongue, and the cervical vessels, occupy a part of the buccal cavity, alter the voice, induce wasting of muscles, &c. &c. Anatomical Peculiarities.—The tumor, as has been intimated, is a multilocular cyst, composed of one cavity, but subdivided by traversing septa, forming chambers, sometimes entirely closed, sometimes commu- nicating ; or it may be a compound cyst—cyst developed within cyst; or, instead of having a common involucrum, the individual cysts Avhich form the mass, may be entirely distinct from each other, and either connected or not, externally one to another. Of the latter arrangement, a remarkable example is reported by Mr. Hawkins, who found many hundreds of such cysts in the case of a child (Med.-Chir. Trans, vol. xxii. p. 238). The fluid contained within the cavity varies in different cases ; it is similar to that found in other cysts of the same kind. It is very fre- quently a pure, limpid serum; sometimes it is gelatinous, thick and viscid, or in flakes; it may be colorless, or nearly so, or dark brown; it is frequently reddish from contained blood, and sometimes coagula of blood are found in it. Microscopically examined, it contains epithelial scales, blood-globules, pus-corpuscles, molecules and globules of fat, exudation granules and corpuscles, cholesterine scales; or all these may be wanting, and the fluid be perfectly homogeneous (Wernher, p. 32), Hydatids are also met with in the fluid. Chemically, it consists of water holding in solution albumen, osmazome, salts of soda, lime, and magnesia (Wernher). The cyst-Avail varies in thickness and density somewhat according to the size and age of the tumor, being most thin and delicate in those which are of most recent development, but acquiring additional thick- ness and capability of resistance as the amount of fluid increases. Stu- dencky supposed that he could distinguish three separate laminae; an external, composed of fibrous tissue; a middle, and an internal serous lamina (Wernher). Bruch carefully examined the wall of such a cyst, and found that it was formed of the integuments, entirely unaltered, either histologically or anatomically. The inner lamina is more or less vascular, sometimes very much so ; thus explaining how it so often hap- pens that th% fluid found within the sac is bloody, and even contains coagula of blood; its free surface frequently presents a trabeculated appearance, like a network, the striae being perceptible to the touch as well as the sight. In the case examined by Bruch, this arrangement was so marked that the interior of the cavity looked like the inner sur- face of one of the ventricles of the heart. These trabecule were com- posed of fibres of areolar tissue, with fine nuclear fibres of fibrous tissue, HYDROCELE OF THE NECK. 249 such as the normal areolar tissue consists of.1 Sometimes the surface of the lining membrane has a flocculent or shaggy appearance, compared to the cotyledons of the placenta (Wernher, p. 24). Pathological Relations, Progress, §c.—The congenital hydrocele of the neck occurs sometimes in children otherwise perfectly formed and developed ; in other instances, more or less important imperfections and deformities coexist with it. Wernher has studied the relations which existed between the development of the tumor and the period of utero-gestation at Avhich birth took place, in many cases; but Ave need not cite the results of his investigations. After birth, these tumors haAre been met Avith at all ages, from sixteen to sixty years.2 They affect the sexes about equally. The progress of the case, and the changes which occur, vary in differ- ent instances. An opening may form spontaneously, particularly in the congenital variety, at one or more points of the sac, through which the fluid will escape slowly, until the cyst is completely emptied; the cavity may thus contract, and become permanently obliterated; the vestiges of its former existence will become less and less apparent; and, finally, but little eA-idence of it will remain. This may be true of a portion or of the whole of the tumor; the latter was the case in one of the in- stances reported by Wernher. A similar occurrence may take place before birth, judging from the appearance of the tumor or of some por- tions of it at the time of birth. The cyst, having once emptied, may refill again and again. If the sac be punctured, the same process of cure may ensue ; or inflammation may follow, with varying results ; or it may become inflamed without any apparent exciting cause. Again, the volume of the cyst may remain unaltered; or it may increase more or less rapidly, or diminish spontaneously. Occasionally, spontaneous opening has taken place into the cavity of the chest, and into the trachea, and oesophagus.3 The parietes of the sac are liable to the same changes as those of other cysts; to cartilaginous, calcareous, or osseous transformation. Nature, Sec.—As regards the starting-point of hygromatous tumors of the neck, it may be from one of the glandular bodies of that region, or be entirely distinct from these. Mr. Hawkins saw them growing from the submaxillary and parotid glands ; Redtenbacher found, in one case, the submaxillary and sublingual glands wanting, and in their place a multitude of small cysts. With regard to the connection of the congenital cyst with the thyroid gland, but little satisfactory is known; most writers on this kind of tumor, make no mention of this point; some others found the gland perfectly healthy. Bednar is the only one whom we have consulted; who states that the cyst, in the con- genital form, is sometimes developed from the parenchyma of this body. He reports two cases of the kind ;4 in one, cited in the last-mentioned reference, a portion of the thyroid gland was removed to make room 1 Zeitschrift fur Rationelle Medizin, vol. viii. p. 114. 2 Fleury et Marchessaux, Archives Guti^rales de M6decine, vol. v. 3d series, p. 284. 3 Fleury et Marchessaux, p. 287. 4 Die Krankheiten der Neugebornen und Sauglinge, part iii. p. 80, and part iv. pp. 80-82. 250 HYDROCELE OF THE. NECK. for the corresponding part of the abnormal growth. But numerous instances are recorded in which, in adults, the cyst was developed from the thyroid gland; several examples are adduced in the valuable essay of Fleury and Marchessaux; and of the five instances originally cited by Maunoir, two are stated to have had their nidus in this organ. Considerable discussion has been held as to whether the cysts ori- ginate in the areolar tissue exterior to the parenchyma of the gland (the thyroid, or one of the salivary glands, as the case may be), in that which connects together the different portions of the gland structure, or by modification of the cells forming the true parenchyma. Probably, any one of these starting-points may be the true one in different cases (Principles, 3d Am. Ed. pp. 301-304). However this may be, the cyst, when developed in the thyroid gland, constitutes one of the varie- ties of goitre—the cystic, as this disease is ordinarily described. In other cases they seem to originate in the areolar tissue of the neck, by enlargement of one or more of the areolar spaces with gradual accu- mulation of fluid, and modification of the tissue inclosing the cavity or cavities; or by some abnormal cell development. But an error may be committed with reference to this point; for, as M. Bednar remarks, small bodies, varying in size, and possessing a structure identical with that of the thyroid gland, but distinct, and more or less removed from it, are found on each side of it in the cellular tissue, beneath the pla- tysma myoid muscle; so that the cyst may spring from one of these, and not from the cellular tissue itself (op. cit. part. iii. p. 80). In other instances, again, they form in the bursa between the hyoid bone and the thyroid cartilage, behind the platysma myoides, and the thyro- hyoid muscles, as pointed out by Boyer.l Again, from the investigations of M. Lebert, on the intimate structure of the lymphatic glands, and from his having seen some instances in which cysts had formed within these bodies ; and, moreover, from the fact that the hygromatous cysts of the neck have often been observed in the usual positions occupied by the lymphatic ganglia, so called, it seems not impossible that, occa- sionally, these may have been transformed into the cysts in question.3 The diagnosis of this affection is, in general, not difficult. It is to be distinguished from Ranula, Parotid tumor, chronic Abscess of the neck, affecting either the areolar tissue or the lymphatic glands; from Aneurismatic and other Avascular groAvths ; from Goitre, of which, how- ever, it is generally made to constitute one of the forms ; from Hernia bronchalis; and from the other simple and malignant tumors which appear in this, region. From these it is distinguishable, by a careful investigation into the history of the case, and the determination of the presence or absence of the phenomena which characterize this and the other diseases enumerated, as detailed in this volume, or in the Prin- ciples. In cases of doubtful nature, the employment of a fine trocar, or an acupuncture needle, will generally settle the question. The most reliable methods of treatment have been mentioned by Professor Miller.—Ed. ' Essay of Fleury and Marchessaux, p. 280. 2 See Report of M. Lebert, on the details of a case of Hydrocele of the Neck, in Memoires de I'Academie de Chirurgie, vol. iii. p. 45. TUMORS OF THE NECK". 251 [The following works may be consulted on this subject: Weruher's Essay, already quoted by its title, in which is a very complete account of the congenital hydrocele of the neck, and an enumeration of authorities; Mr. Hawkins's paper, in the 22d vol. of the Med.- Chir. Transactions, in which seven cases of the same form are described; Mr. Lawrence's paper, in the 17th vol. and Mr. Phillips's, in the 25th vol. of the last-mentioned publica- tion; Mr. Bransby Cooper, in the 1st vol. of Guy's Hospital Reports; Gooch's Surgical Works, 2d vol.; Clinical Lecture, by Dr. Mutter, in Philada. Medical Examiner, May, 1850; O'Beirne, Dublin Medical Journal, vol. vi.; and the valuable Essay, by r'leury and Marchessaux, Archives G6n6rales de MOdccine, vol. v. 3d series, which is, with reference to the acquired hydrocele of the neck, what Weruher's Memoir is to the congenital affec- tion.—Ed.] Tumors of the Neck. Solid tumors, when of such a nature as not to be amenable to discus- sion, call loudly for an early use of the knife, otherwise each day will Fig. 109. Large Fibrous Tumor growing from the Nock. AVim BuccesBfully removed. but add to the difficulty and danger of the operation ; and when at last matters are found to brook no farther delay, it is not impossible, but the hazard may be found so much increased, as to render any attempt at extirpation quite unwarrantable. In connection with this subject, it is well to remember, that in con- sequence of a tumor being bound firmly down by the deep and strong cervical fascia, it may seem to be less deeply seated than it is; and that consequently, much caution is always expedient in conducting the dis- section, it being not at all improbable that the common sheath of the large vessels may be fully exposed—perhaps to some extent. 252 TORTICOLLIS. Opening of the External Jugular Vein. Occasionally, it is deemed expedient to abstract blood by opening this vein at its lower part. By pressure of the thumb, applied immediately above the clavicle, prominent bulging of the vein is produced; and then an inci- sion is made, as in venesection at the bend of the arm. The thumb's pressure is maintain- ed, so long as the flow of blood is desired; it is then with- drawn ; and this circumstance, of itself, is usually sufficient to arrest the bleeding. But, be- sides, it is well to place a small compress on the wound : retain- ing it by means of a long strip of adhesive plaster, or by a band- age very lightly applied. Dur- ing the blood's Aoaa-, precaution is advisable to avoid entrance of air into the vein (Principles, 3d Am. Ed. p. 577). Venesection in the Neck. The external jugular shown distended by pressure of the thumb, previously to inser- tion of the lancet. Torticollis. By this term is understood a distortion of the neck, dependent on muscular disorder—spasm, paralysis, or change of structure. The muscle usually to blame is the sterno-cleidomastoid. One, acting with the undue energy of spasm, overpowers its fellow, and displaces the neck accordingly; or one, affected with a loss of contractility, fails to afford the usual counteracting power to its fellow; or, by inflammatory action and its results, abbreviation and condensation of one or other muscle may occur, causing distortion of a very unpromising character; or the malformation is congenital. Children, shortly after birth, are not unfrequently found to labor under a certain amount of torticollis, from the second cause; one of the muscles seeming either to have been inadequately developed, or some- how to have become partially paralyzed. Friction over the spine, and on the muscle which is weak—with care, on the part of the nurse, to exercise the faulty muscle by position of the head, yet without'fa- tiguing the extensors—usually suffices to effect gradual but satisfactory amendment. In a similar state of matters, in the adolescent or adult, the ender- mic use of strychnia, or the electro-magnetic stimulus, may be had recourse to. Spasm of the muscle may be either temporary or permanent. The former most frequently occurs in children ; and i's to be treated by pur- TORTICOLLIS. 253 gatives and alteratives, followed by antispasmodics internally; locally by fomentation, leeching, and counter-irritation. Permanent spastic rigidity of the muscle is more common in the adolescent and adult; per- haps a remote consequence of the former affection. Mercurial friction and active counter-irritation may be tried ; but Avith no sanguine hope of success. Sooner or later, tenotomy has to be employed; and that not merely on account of the deformity, but to avoid a more serious evil —curvature of the spine—Avhich often supervenes, and which may, if unchecked, become both extensive and confirmed. The needle is in- serted obliquely, at the origin of the muscle from the sternum and clavicle ; and division is effected by cutting either from Avithout inwards, or in the opposite direction, as circumstances may seem to require; great care being of course taken not to injure the important parts Avhich lie immediately behind that part of the muscle. To insure safety in this respect, it may be well, in some cases, to puncture with the ordinary tenotomy-needle, or knife; and then, withdrawing this, to substitute an instrument with a probe-point wherewith to effect the muscle's section. Sometimes it may be sufficient to cut only one origin ; but, usually, divi- sion of both heads is essential. By resilience of the severed extremities, restoration of the normal state is at once produced; and this is main- tained by suitable bandaging, if need be, until consolidation of the divided parts occur, with the due amount of elongation. [If sufficient force and steadiness cannot be gained by simple bandag- ing, Jorg's apparatus may be used. It consists of a pair of leather corsets for the chest, and a firm band to encircle the head—the two Fig. 111. Professor Jorg's Apparatus for Torticollis. 254 WOUNDS OF THE THROAT. being connected by a steel rod; the rod is moved by a ratchet-wheel, so that the head may be inclined towards either side; the wheel is turned by a key, a.—Ed.] A similar operation is the only means whereby we may expect to cure the third form of the affection; that proceeding from structural change by inflammation and its results. Twisting of the neck is caused also by tumors—glandular and others; as well as by the contraction of extensive burns. The principles of treatment in these cases are obvious. Wounds of the Throat. Wounds of the throat are of two classes, those inflicted by the hand of the suicide or the murderer, and those made by the surgeon. The former now engage our attention. They are usually made in a trans- verse direction, and high in the neck—near or at the thyroid cartilage, the latter circumstance being probably connected with the popular idea that, to effect extinction of life, it is sufficient to open the air-passage, and so cause suffocation. The extent and consequent importance of such injuries vary very much; from mere scratches, penetrating no deeper than the subcutaneous areolar tissue, to the most ghastly sever- ing of all textures—almost to decapitation. Sometimes the incision is made immediately beneath the chin. Not unfrequently it is placed betAveen the hyoid bone and thyroid cartilage; the mouth being opened into, and the air-passage left intact. Sometimes the weapon is drawn across, a little above the clavicle; and then, if any considerable depth be attained to, death is certain and immediate. Sometimes the knife, held as a dagger, is plunged into the lower part of the neck, to the imminent risk of the larger bloodvessels. But the region of the larynx is that Avhich is most frequently involved. The first danger is by hemorrhage. If the carotid and jugular have been reached, death is very speedy, and may scarcely be prevented. Such extreme wounds, however, are of comparatively rare occurrence; the vessels being protected, high in their course, by the depth of their situation in reference to the front of the neck, and by the density of the parts Avhich have to be divided ere the sweep of the sharp edge can reach them. When, however, the deed is attempted, with a truer skill and deliberation, not by a horizontal gash, but by a puncture in the direc- tion of the vessels, the escape of these is likely to prove rather the ex- ception than the rule. A more limited transverse wound, leaving the carotid and jugular intact, may still cause death by hemorrhage, di- rectly, and withm a brief period; by implication of the thyroid Vessels —arteries and veins. And again, a comparatively slight bleedino- may prove fatal, more remotely; blood trickling into the larynx, and accumu- lating within the air-passage, so as to induce asphyxia ; such accumu- lation being permitted by the insensibility of the patient, or by his inability, through faintness, to make the requisite efforts for expectora- tion. r The second danger is by inflammatory changes at the wounded part; occluding the laryngeal aperture, or canal, or otherwise interfering with WOUNDS OF THE THROAT. 255 respiration. And this is all the more likely to occur, if the wound have been brought together tightly, with an imprudent haste. The mucous membrane, as well as the rest of the wound, becomes the seat of an acute inflammatory process; and the consequent SAvelling may be such as to cause* rapid and great occlusion. At the same time, mucous secre- tion is both increased in quantity and vitiated in quality—becoming more viscid and tenacious. This accumulating in the already narrowed canal, renders suffocative hazard all the more imminent. And the risk is farther contributed to, by the diminished poAYer of expectoration which a patient so situated necessarily possesses. A third danger, liable to occur along Avith, and to aggravate that which has just been considered, is—that during the movements of the part—voluntary and involuntary—one portion of the wound is not un- likely to overlap the other, and thus, by suddenly producing a mechani- cal obstruction to the passage of air, at once to bring life into the greatest peril. A fourth danger is by the occurrence of inflammatory action in the trachea and lungs; the inflammatory process extending downwards from the wound, or the unwonted direct access of cold air proving an excit- ing cause of original morbid action. Bronchitis, indeed, more or less severe, is almost an invariable consequence of such injuries. A fifth danger arises from inanition, in those cases in which the gullet has suffered; and when, consequently, it is not easy to maintain a due supply of nourishment. Hectic, also, may ensue, in the case of an extensive, profusely suppurating, and sloAvly healing wound; more espe- cially if much blood have been lost at the time of the infliction of the injury. And lastly, the mental condition is, in all cases, likely to exert an untoward influence on the bodily frame. In not a feAv examples, when dissipation has led to the rash and guilty act, life is perilled at an early period by the occurrence of delirium tremens. Or this, indeed, may have been some time in progress, and may have caused the suicidal attempt. And in those cases which have been preceded by gloomy, brooding despondency, a continuance of low mania, accompanied with typhoid symptoms, will usually paralyze our best remedial efforts, and determine a fatal issue by sinking. Thus it can be readily understood, how feAv cases in Surgery present more obstacles to satisfactory treatment than do those of cut throat. We overpass one difficulty and danger only to meet another. And, too frequently, after the most prominent evils have been skilfully counter- acted, the patient slowly yet surely sinks under obscure typhoid symp- toms, intimately connected with mental alienation. Treatment.—When called to a case of cut throat, it is obviously our first duty to arrest the hemorrhage. And this is done by ligature of the arterial orifices; pressure being applied, if need be, to venous points. Then the wound is to be approximated by suture, not wholly, but in part. The angles are drawn and kept together, but the centre of the wound is left free, approximation there being effected solely by attention to position of the head, keeping the chin, by bandaging if necessary, depressed towards the sternum; and even this is not done until all 256 WOUNDS OF THE THROAT. bleeding from the wound has ceased. If the chasm be at once drawn tightly together, immediate risk is greatly enhanced, as already stated; and yet this is an error very frequently committed, in the hurry of actual practice. Blood, oozing from the cut parts, does not find a ready escape externally, but either trickles into the air-passage, ami accumu- lates stealthily there, or is infiltrated around the line of wound, causing compression of the windpipe by the increasing coagulum; in either way threatening suffocation. The viscid mucus, too, is more likely to en- tangle itself in the shut wound, and inflammatory turgescence is more prone to prove untoward. Air, also, is likely to be infiltrated into the areolar tissue during expiration, causing troublesome and dangerous emphysema. When, on the contrary, the wound is left entirely free, these latter risks are not only less likely to occur, but also, in the event of their occurrence, untoward tendency can be much more readily and effectually counteracted. It need scarcely be added that the dressing of the wound should be most simple; consisting, not of a complication of plaster, compress, and bandaging, but of a mere strip of lint, moistened in water, and loosely and lightly retained upon the part. The main bleeding having been secured, and the wound partially approximated, the patient is laid on his side so as to favor outward escape of the continued oozing. And the cut part is protected from unfavorable atmospheric impression, by a covering of loose gauze, or of woollen texture, thrown lightly over the neck, attention being at the same time paid to maintain an equable and genial temperature in the apartment. Duly qualified attendants are at hand, not only to guard against repetition of the suicidal attempt, but also prepared to separate and clear the wound, should swelling and entanglement of mucus render such a proceeding necessary to prevent suffocation. And the patient should be instructed to facilitate his expectoration, by completely shut- ting or very much diminishing the wound, by means of his fingers at, the time of the effort being made. It is hoped that the wound will granulate, contract, and cicatrize, in the ordinary way, and the local treatment is conducted with that object in view. Constitu- tionally, we have to guard against favoring inflammatory action in the wound, and in the air-passages, by neglect of antiphlogistic measures; and on the other hand we must beware of aggravating the tendency to sinking which sooner or later becomes apparent in the majority of cases. As a general rule, bloodletting from the system is seldom if ever warrantable. Should the pharynx or cesophagus have been wounded, the use of a tube becomes necessary to convey nourishment to the stomach. In the ordinary effort of deglutition, the ingesta would necessarily escape more or less copiously by the wound, and so do harm in many ways. The feeding-tube cannot be inserted from the wound, although the facility of such a proceeding may invite the attempt, otherwise closure of the wound must be seriously interfered with. If intended to be intro- duced and worn permanently, until the pharyngeal or oesophageal aper- ture shall have closed, it is to be passed by the nostril. But it is found to be more expedient to introduce the tube only occasionally, by the mouth, twice or thrice daily, as circumstances may seem to require. It WOUXDS OF THE THROAT. 257 is not necessary to pass the instrument com- pletely down to the stomach; it is enough that its extremity is placed fairly beyond the wound. And of course the precaution is not neglected of ascertaining that lodge- ment is rightly accomplished ere fluid nou- rishment is begun to be introduced. One very obvious objection to the permanent retention of a tube, whether passed by the mouth or by the nose, is that its extremity, pressing against the posterior part of the windpipe, is apt to occasion ulceration there, which may perforate, complicating the case untowardly, by the establishment of tracheal fistula. Should this occur, as has happened, the ordinary test of the tube being rightly placed will probably fail; air, in expiration, escaping by the tube in the oesophagus, as well as by the natural outlet (p. 228). Throughout the whole cure, the state of respiration must be sedulously watched. And should threatening of suffocation supervene, as is not unlikely, and prove of such a nature as not to be removed by attention to the state of the wound, tracheotomy is to be had re- course to unhesitatingly. Then, the canula being retained in the tracheal wound, the transverse aperture may be brought to- gether, and treated so as to favor rapid union, there being no longer any risk from internal swelling or other change at that site. I have often thought that in extensive transverse wounds of the neck, implicating the windpipe, however inflicted, tracheotomy may be regarded as expedient at an earlier period, that is, shortly after arrest of the hemorrhage, and partial approximation of the wound ; so soon, in fact, as the patient has rallied sufficiently to bear the immediate effects of the operation. For then we should have it in our power to place and maintain the whole track of the wound in perfect apposi- tion, and perhaps to procure union almost by the first intention. So soon as the chasm had fairly closed, the canula might be withdrawn, and the tracheal opening cautiously and gradually closed. And thus, also, should we be more likely to avoid the occurrence of fistulous tend- ency in the suicidal wound, which, in the ordinary progress of cure, is not unlikely to prove troublesome. In performing the operation, it will be expedient to raise and steady the windpipe, by means of a hook fixed in the lower margin of the transverse wound. In those cases which recover, there is a risk of the larynx becoming 17 Fig. 112. " A view from behind of the larynx of a patient who some weeks pre- viously attempted suicide, by wound- ing the forepart of the neck. By some mismanagement, the edges of the incision were kept asunder, and they cicatrized. The patient was seized with difficult breathing, the inspirations were rare, long, and laborious, and he had threatening of suffocation during his disturbed sleep. These symptoms were disre- garded, lie started up suddenly in the night, caught hold of the patient in the next bed, and fell down in a state of asphyxia, from which he could not be recovered. The cede- matous swelling of the rima glottidis is remarkable; beyond that, i.s seen the rounded opening betwixt the thyroid cartilage and epiglottis, which last is in a normal state." (Liston, Elements, p. 432.) 258 FOREIGN BODIES IN THE WINDPIPE. contracted in its caliber, so as seriously to interfere with normal respi- ration, and all the more probably if there be at the same time a fistulous opening established by imperfect closure of the wound. Such cases are doubtless unpromising, yet are capable of being brought to a prosperous issue. The contracted passage may be dilated by bougies passed from the mouth, and the normal capacity of the larynx having been restored, the fistulous opening may be made raw, and approximated by suture. A successful case of this nature occurred in the practice of Mr. Liston.1 Bronchotomy. Under this general term are comprehended the surgical wounds of the throat, Laryngotomy and Tracheotomy, made in a longitudinal direction, artificially opening the windpipe, with some important reme- dial object in view. But before treating of these operations, it may be well to consider briefly the various circumstances which may demand their performance. Foreign Bodies in the Windpipe. Foreign bodies, held in the mouth, are apt to pass into the windpipe, during sudden inspiration, as in speaking, crying, or laughing. During inspiration the glottis is opened wide, and a foreign substance, even of considerable size, may pass readily inwards. For expiration, however, a comparatively narrow opening of the rima suffices, an aperture quite insufficient for the backward escape of the intruding substance; and, indeed, such escape is still farther opposed by the effort to produce it, which, impinging the foreign substance on the tracheal aspect of the rima, stimulates that part to spasmodic contraction. The foreign substance may remain loose within the windpipe, moving from part to part, according to the circumstances of displacement. Or it may lodge at a particular site: 1. In the larynx, becoming entangled in the ventricles, or being of such form and size as to be impacted in the general cavity. 2. It may be similarly fixed across the trachea; pins, portions of glass, and other sharp substances, for example, have been thus impacted. 3. In either bronchus. And the right being the more directly continuous with the trachea, in that the impaction is most likely to occur. 4. Or the body, of small size, may gravitate still lower, and take up a lodgement in one or other of the bronchke. 5. Or it may be impacted in the very rima glottidis. Thus: a man, much intoxicated, becomes almost insensible, and is sick. The contents of the stomach are lazily evacuated upwards, and a portion of the ingesta may enter the rima and remain there, causing suffocation. A piece of potato-skin has thus proved fatal. Or again, large substances held in the mouth and forced downwards in sudden inspiration, may prove too bulky to pass through the rima, and become impacted there, inevitably causing suffocation, unless instant relief be obtained, either at the hand of surgery, or by the patient's own expulsive efforts. And in such a 1 Liston's Elements, p. 435. FOREIGN BODIES IN THE WINDPIPE. 259 case, unless the tightness of impaction be great, success is more likely to follow the instinctive throes, than in the case of smaller bodies within the larynx, spasm of the glottis being mechanically preA'ented, and con- sequently proving no obstruction. The symptoms denoting the occurrence of such accidents are, in general, tolerably distinct. If impaction haAre taken place in the rima, the symptoms are those of rapid asphyxia ; the patient suddenly exhi- biting the greatest distress, becoming livid and swollen in the counte- nance, staring with bursting eyeballs, gasping anxiously, struggling for breath, and speedily becoming insensible. When the foreign body has passed within the rima, the symptoms vary according to the site and nature of the lodgement; but, in all cases, they evince two leading characteristics—denoting obstruction to respiration, and irritation pro- duced in the part with which the substance is in contact. If it be loose in the windpipe, or lodged in the larynx or upper part of the trachea, the following are the ordinary symptoms. A violent fit of suffocative cough immediately succeeds the entrance of the foreign body—seeming to cease, it is probable, only on Xature haAring been Avholly exhausted. And, at short intervals, such paroxysms are reneAved ; more particu- larly, if any new movement of the foreign body have occurred. Inspi- ration is loud, strained, and of a harsh, croupy, or sawing sound. The voice is changed. Pain is complained of in the part. A more or less copious expectoration of mucus takes place ; and sometimes of blood. The countenance is suffused, and expressive of great anxiety—an ex- pression almost pathognomonic, especially in the young. And the neck is stretched, with the head eleA^ated and throAvn back, in the position of orthopncea. Often, all the auxiliary muscles of respiration are found in full play. It is right to remember, however, that in some cases—more especially Avhen a considerable period has elapsed since the occurrence of the accident—the intervals betAveen the paroxysms may be passed in comparative quiet, with an almost total absence of symptoms at that time. When impaction has taken place in a bronchus, a characteristic sign is indicated by auscultation—suppres- sion of respiratory sound on that side, with puerile respiration in the opposite organ. The respiratory movements of the parietes of the chest, too, are diminished or arrested in the obstructed part. Or a still more plain indication may be afforded, if the substance happen to be of musical capability, hoAvever rude, and so situated that the air passing by it in respiration may evoke its powers of sound. Rough substances soon occasion purulent discharge, which possesses great and characteristic fetor. Sometimes the foreign body, when smooth and loose, may be felt distinctly impinging against the upper part of the larynx, during a convulsive effort at extrusion. The affection with which this accident is most apt to be confounded, is rapid obstruction of the upper part of the Avindpipe by inflammatorv action. But the history of the two cases must necessarily be very different; urgent symptoms being in the one case immediate, unaccom- panied with febrile excitement of the system, and often most intense at first; while in the other they are more or less gradual in their accession, of a crescent character, and invariably attended with inflammatory 260 FOREIGN BODIES IN THE WINDPIPE. fever. Also, in the accident, expiration is difficult, while inspiration is comparatively easy ; whereas, in the disease, the precisely opposite condition obtains. That in all cases there is a necessity for the speedy adoption of mea- sures calculated to effect removal of the foreign body, is tolerably plain. Otherwise, the risks to life will be neither few nor slight. 1. Sudden suffocation may occur, at a very early period, by impaction of the sub- stance in the upper part of the larynx—as already shown. 2. Imper- fect respiration may more gradually induce a fatal issue; in consequence of partial obstruction caused by the foreign body, and accunaulation of mucus at the incommoded part. 3. Laryngitis or tracheitis may be excited, of formidable character. 4. Congestion may take place in the lungs ; followed perhaps by apoplectic disruption of the pulmonary tis- sue, or by pneumonia, or by bronchitis. 5. A foreign body of small size may perforate a bronchus or bronchial tube, and lodge in the pul- monary tissue ; and acting untowardly there, as all foreign substances must, may cause abscess, or lay the foundation for tubercular deposit and fatal phthisis. 6. Or the passage outwards may be more advanced. The lungs may be passed through, and the cavity of the pleura reached; and empyema may be the result. No doubt it has happened that yet another step has been taken ; the foreign substance has perforated the walls of the chest by tedious ulceration, and been discharged externally. And it has also happened that a foreign body has been expectorated by the mouth, along with purulent matter, at a long date from its introduc- tion. But such occurrences are much too rare to warrant their use as precedents in determining the appropriate treatment. If the violent efforts of the patient fail to dislodge and extrude the foreign body—as is not unlikely—recourse must be had to broncho- tomy ;. and through the artificial opening in the windpipe the foreign body is sought to be extracted. Before proceeding to this operation, however, it is well, in cases of comparative obscurity, to explore the pharynx and gullet, in the first instance. Urgent symptoms of dysp- noea, we have already seen, may be caused by foreign substances lodged in either of these passages ; thence compressing, irritating, and ob- structing the air-passage. And experience has shown that a foreign body, not bulky enough to cause dangerous compression, may lodge near the rima, and exterior to it; may cause many of the ordinary symptoms of a foreign body within the windpipe ; and that in such a case, while bronchotomy must necessarily fail, expulsive efforts, duly aided by the surgeon, are most likely to succeed.1 When the foreign body is of small size, and plainly indicated by the symptoms to be either loose in the air-passage or fixed in the upper part of the larynx, laryngotomy may be had recourse to. It is of easy performance ; and, though an aperture through the crico-thyroid space be necessarily of limited dimensions, it is probable that through that space such a foreign body may be readily enough removed. In all other cases, however, tracheotomy, though a more troublesome operation, is, for obvious reasons, to be preferred ; the aperture is more free, and 1 Lancet, 1069, p. 729. FOREIGN BODIES IN THE WINDPIPE. 261 the facilities for extraction, both from below and from above the open- ing, are manifestly greater. When the foreign substance is loose, it is usually expelled forcibly by the outward current of air, so soon as the operation is completed. But if fixed, it must be sought for, and removed artificially. If lodged above the opening, a common probe is the most convenient instrument for exploration. By it the site is detected; by it the foreign body may be pushed through the rima—to be coughed up; or loosening is effected. with subsequent expulsion through the tracheal Avound. When the site of lodgement is in the bronchus, long-curved forceps—such as recom- mended for extraction of foreign matter from the pharynx and ceso- phagus (p. 232)—are very suitable for both exploration and extraction. Auscultation and percussion having preAdously imparted to the operator a shrewd suspicion of the site of lodgement, the instrument is passed down shut, and made if possible to impinge on the foreign substance : then, slightly withdrawn, the blades are opened ; and, pushing on again gently, the object is probably grasped; if not, the other forceps—open- ing in an opposite direction—is similarly employed, with almost a cer- tainty of success. The wound is kept open until bleeding has ceased ; it is then brought accurately together by adhesive plaster, and adhesion hoped for. But the air-passage may prove intolerant of the forceps ; and perse- verance in their use, searching for a foreign body, might peril life by violent paroxysms of dyspnoea.1 In such cases, modern experience has pointed out a safer mode of procedure2—more especially if the foreign body be of some weight, as a stone, coin, or any piece of metal. The tracheal wound being kept open, let the patient's body be inverted, so as to make the head dependent; and, if need be, let succussion of the frame be had recourse to, so as to favor dislodgement of the offending substance, and its descent towards the larynx by gravitation. Arrived at the rima, it will not find its outward passage there obstructed by spasm, nor will a paroxysm of dyspnoea be induced; for, the opening in the trachea has the effect of obviating this difficulty and danger. Escape is made readily into the mouth, and thus extrusion is effected with both ease and safety. It has been proposed to supersede bronchotomy altogether, by the preceding manoeuvre. But such a proposal does not seem to be a pru- dent one. In most cases the attempt would probably fail, and life be imminently perilled, the foreign body being obstructed by spasm at the rima, and, perhaps, becoming impacted there. The proceeding is suit- able only when the foreign body is small, smooth, and of high specific gravity; and seems to be in all respects safe, only when a tracheal aperture has previously been established; and when, in consequence. irritability of the rima has been assuaged, and accident by impaction 1 In using the forceps, anaesthesia is obviously calculated to prove of much service: rendering exploration both easy and safe. In applying the chloroform, it will be neces- sary to place it over the wound as well as on the mouth. See a case by Dr. Johnston, of Montrose, Lancet, No. 1478, p. 600. 2 Lancet, 1063, p. 502. 262 ASPHYXIA. there fully provided against. A case or two of accidental success,1 will not suffice to overthrow the general principle here inculcated. It may happen that some considerable time—weeks or months—has elapsed since introduction of the foreign body, before aid* is requested. Such lapse of time need not deter the surgeon from operating, if other circumstances prove favorable; for experience has shown that removal of the offending matter, even at a distant date, may be sufficient to avert all serious ulterior consequences.2 Asphyxia. In attempting resuscitation from asphyxia, it is necessary to main- tain artificial respiration; and this is effected, in ordinary cases, by insufflation of air through the mouth or nostrils (Principles, 3d Am. Ed. p. 694). But were the rima glottidis spasmodically closed, such ordinary means would be likely to inflate the stomach only, leaving the lungs unaffected. Under such circumstances, therefore, one of two pro- ceedings is necessary; to pass a tube into the windpipe from the mouth, or to perform bronchotomy. The operation of passing a tracheal tube is always difficult, and becomes especially so, even in an insensible patient, if the rima be closely shut, as in the case of suffocation by car- bonic acid. It can readily be understood, therefore, how, in many cases, such an attempt is well superseded by the operation. Usually, laryn- gotomy will suffice. One caution must be particularly attended to, namely, to prevent blood from entering by the wound, and accumulating in the air-passages. And should such entrance have been effected, means should be taken, by suction applied to the wound, to accomplish its expulsion. In cases of suspension by the neck, it is plain that bronchotomy cannot avert a serious result, and may, probably, fail in the attempt at resuscitation; for the cause of death is not from constriction of the windpipe only, but by concussion of the brain and spinal cord, and by interference with the jugular circulation. And these latter circum- stances may, of themselves, be sufficient to produce a fatal issue, inde- pendently of direct interference with respiration. Seldom does any displacement occur in the cervical vertebrse. Injuries of the Larynx. A blow on the larynx may directly peril life by arresting respiration. The rima glottidis may be wholly shut, either by spasm of the occluding muscles, or by paralysis of their antagonists—more probably by pa- ralysis of all the muscles concerned ; or it may be but partially occluded, yet Avith such a tumult and difficulty of respiration as to render the case one of great and immediate hazard. And, under such circumstances, it is plain that the only prospect of relief is by tracheotomy—opening 1 Northern Journal, Feb. 1845, p. 220. 2 London and Edinburgh Medical Journal, August, 1842, p. 722; and Liston's Practi- cal Surgery, p. 371. ACCIDENTAL SWALLOWING OF BOILING WATER, ETC. 263 the windpipe below the injured part; the aperture being kept patulous, until the organ has recovered, and is able to resume its wonted functions in normal respiration. Rupture of the trachea, by external injury, may prove fatal, by rapid and extensive emphysema; the pressure of this producing asphyxia more or less rapidly. By making many and early punctures in the affected part—or by incision—we may give an outAvard escape to the air, and so avert the threatened disaster. Apoplexy of the larynx may occur; blood being infiltrated copiously beneath the mucous membrane. Symptoms may be urgent, simulating croup or oedema glottidis, and so threatening asphyxia as to render relief by bronchotomy inevitable.1 The thyroid cartilage, ossified, may be fractured by external violence, and serious consequences ensue ; requiring active antiphlogistics, and perhaps tracheotomy eventually. The accidental swallowing of Boiling Water, Acids, or other Irritant Fluids. It is common among the poorer classes, in some localities, to have but one vessel, a large kettle, to hold water for culinary purposes— sometimes cold, at other times hot, according to circumstances. A child, accustomed to have its thirst assuaged from such a source, is likely to help itself, when no one else is near; and, in doing so, may unhappily fill its mouth with fluid of a boiling temperature. Instantly an attempt is made by the little sufferer to eject the fluid ; and in the backward movement of the hot water, partial entrance into the open rima glottidis is not unlikely to occur, during the expulsive paroxysm. The result is a scalding of the air-passage, as well as of the pharynx and upper part of the oesophagus ; and by swelling in the former situation, during the subsequent inflammatory process, the most serious results may ensue. Adults may swallow acids or other acrid fluids, either by accident, or intentionally. In the latter case, the air-passage is seldom injured. The determination to the act of swallowing shuts the glottis, and the fluid passes downwards in the gullet alone. But if a patient accident- ally attempt to swallow a fluid of this kind, mistaking it for some other of a harmless nature, the expulsive effort is instantly made—as in the case of the child with hot water; the glottis is opened in the paroxysm, and the noxious fluid effects a partial entrance there. The treatment of such cases requires to be conducted with an energy proportioned to the urgency of their nature. The inflammatory process may not be prevented ; but it should be our anxious endeavor to mode- rate and delay its onset, and to effect its speedy retrocession. The most active antiphlogistics are employed—immediately ; bleeding from both part and system ; outward fomentation; antimony. It may be that, by such means, the progress of inflammatory tumescence may be re- strained, so as not to affect respiration urgently, and that extension of 1 Monthly Journal, August, 1847, p. 126. 264 SPASM OF THE GLOTTIS. inflammatory action from the parts first involved to the air-passages in general, may be prevented. If, however, antiphlogistics fail, and as- phyxia threaten by obstruction in the larynx, tracheotomy is to be had recourse to at once; not reserving the operation, especially in the child, until by extreme urgency of the symptoms it cannot possibly be longer delayed, and when recovery is rendered more than proble- matical by congestion in the brain, in the lungs, or in both. Laryngo- tomy is plainly unsuitable ; to practise that would be to cut into the affected part, and to fulfil very imperfectly, if at all, the object of the operation. The wound of tracheotomy, on the other hand, is below the seat of disease, the affected part is put at rest, life is saved from as- phyxia, and the inflaming larynx, by being allowed quietude, is power- fully aided in the resolutory effort. On decadence of the inflammatory process, and when absorption, clearing away all swelling, has restored the normal state of the organ, the tube is withdrawn, and the wound permitted to close. Spasm of the Glottis. It has been already stated how bronchotomy may be highly available in the case of spasmodic closure of the glottis, threatening asphyxia; as in poisoning by carbonic acid. Laryngismus stridulus, a spasmodic affection of the windpipe, not uncommon in children, and occasionally met with in the adult, may, in its paroxysms, threaten suffocation ; and, in such circumstances, the question of the expediency of bronchotomy comes to be entertained. In general, the operation is to be withheld, unless the circumstances prove extremely urgent; and it is then employed as a means of pallia- tion and protraction, rather than of cure. And more especially will the prognosis be guarded and unfavorable, if there be reason to believe that the spasmodic attacks are dependent on irritation produced by structural change at a low part of the windpipe ; as by enlargement of the thymus gland, affection of the bronchial glands, aneurism, or forma- tion of other tumor. In one form of aortic aneurism, when the tumor is small, and does not compress and contract the air-passage, but acts on the larynx irritatingly by implication of the recurrent nerve, causing suffocative paroxysms of spasm in the glottis, it seems very proper to have recourse to tracheotomy early, with a certain hope of relief, and a prospect of even something more than mere palliation. But when the tumor is large, compressing and contracting the air-passage, and causing continuous dyspnoea, the prospect is not so favorable, and the grounds for operation are scarcely sufficient, probably, to warrant its performance.1 It were out of place, in such a work as this, to enter fully into the various interesting and important affections of the Avindpipe. But it is right to notice them briefly, in connection with the operation of bron- chotomy ; the leading features only being stated. 1 Monthly Journal, Aug. 1851, p. 185. LARYNGITIS. 265 Fiff. 113. Laryngitis. The inflammatory process, occurring in the larynx, may be either chronic or acute. I. Acute Laryngitis, a. Laryngitis simplex.—There is, in this affection, more or less turgescence of the mucous membrane, Avith the accustomed change of secretion—the results of a minor amount of the inflammatory process ; but the swelling is diffused uniformly, and not at any part great, and the secretion is not liable to be retained and accumulated ; no paroxysm of dyspnoea threatening suffocation is likely to be caused by such changes ; and, consequently, in this affection the direct interference of surgery, by bronchotomy, is not required. Medi- cal treatment suffices. b. Laryngitis cedematosa.—This is the acute oedema glottidis ; an inflammatory process attacking the larynx and rapidly causing much bulging of the lining membrane by serous and fibrinous infiltration of the submucous tissue; active congestion being rapidly reached, and persisting of high intensity (Principles, 3d Am. Ed. pp. Ill and 119). In consequence of such change, the characteristic symptoms are soon developed ; increasing dyspnoea, liable to paroxysmal ex- acerbation ; inspiration protracted, labored, stridulous; expiration comparatively easy and silent; anxiety of countenance, &c. And, be- sides, there is ultimately afforded to the sur- geon a more plain indication ; inasmuch as the oedematous swelling may be felt, on the epi- glottis and glottis, by the finger introduced from the mouth ; and may even be seen, on depressing the tongue forcibly by the specu- lum. Practically, the disease may be divided into three stages: 1. There is the condition of laryngitis simplex ; while % action has not proceeded beyond turges- cence, and when there is no obstruction to breathing. But this state is quickly overpassed, in most cases. 2. The characteristic oedematous swelling is forming; not diffused and uniform, but mainly affecting the glottis and its immediate neighborhood, and causing prominent bulging there. Inspiration is now more or less impeded ; and obstruction is on the increase. 3. Breathing having been for some time seriously inter- fered with, and aeration of the blood imperfectly performed, untoward results begin to manifest themselves in both lungs and brain—congestion, followed by serous effusion ; the threatening of asphyxia is aggravated by threatened supervention of coma. Most frequently the obvious cause of death is by the former event; obstruction by mucous swelling becom- ing greatly augmented by accumulation of viscid mucous secretion, a paroxysm of dyspnoea is induced ; in the tumultuous disorder of respira- tion that ensues, it is not improbable that the patient may drop as- Acute (Edema (Jlnttidis ; exposed from behind. 266 (EDEMA GLOTTIDIS. phyxiated; and recovery from that state will be seriously affected by the cerebral change already in progress. In other cases, the fatal issue is more gradual; asphyxia steadily advancing, without paroxysmal ag- gravation. The suitable treatment is active throughout. At first, ordinary anti- phlogistics are plied industriously ; bloodletting, antimony, calomel, and opium. These may arrest the affection in its first stage. If not, let them be persevered with ; for they may yet mitigate the swelling, pre- vent the occurrence of urgent symptoms, and procure a favorable reso- lution from the second or characteristic stage, without life having been ever seriously endangered by threatened asphyxia. In this stage, how- ever, be it remembered, bloodletting must be had recourse to with very considerable caution; it being well known, from experience, that there is an intolerance of this remedy, heroically employed, in all cases in which respiration is seriously obstructed. Let mercury take the place of loss of blood; and by it, judiciously employed, let us hope to limit deposit and promote absorption successfully, and thus to make a satis- factory impression on the oedematous bulging. Not seldom, marked benefit will follow free scarification of the epiglottis and lips of the glot- tis, by means of a curved knife; the tongue being fully depressed by the mouth-speculum, so as to render these parts accessible to such pro- cedure. Should, however, resolution fail to follow on the use of such means—the symptoms proving both crescent and grave—let broncho- tomy be at once had recourse to ; regarding the operation as truly a part of the remedial treatment, whereby the peril of extreme urgency may be avoided, not as a last resource whereby a life half lost may only perhaps be regained. Tracheotomy is plainly to be preferred; for thus only can we place the artificial opening beneath the seat of obstruction so as to effectually avert the immediate danger by impending asphyxia; and thus only can we fulfil the very important indication of placing the affected part in the state of comparative quietude and repose, so suited for facilitating resolution and recovery. The medical treatment is not interrupted meanwhile. In due time it tells favorably on the swelling. This begins to subside ; and then the use of the tube may be begun to be discontinued, introducing it only occasionally. Ultimately the part recovers itself wholly as to swelling ; anfl then, the tube having been finally withdrawn, the wound is approximated and encouraged to heal. During the first hours of the tube's use, great care is necessary in keep- ing the aperture clear; viscid mucus is being copiously secreted; the power of expectoration being very weak, occlusion of the artificial rima is apt to ensue ; and such risk by sudden asphyxia is all the more likely to occur, if the patient have fallen asleep shortly after performance of the operation—as often happens. More than one day and night may have been passed in sleepless anxiety, pain, and distress ; and the relief at once experienced, after the first effects of the tube's introduction have passed away, is apt to lull the relieved sufferer into a deep and uncon- scious slumber—from which it were hard to be awakened, abruptly, only to perish by suffocation. The attention of a qualified attendant must be constant, to maintain clearness of the tube, until the excessive secretion of mucus has diminished, and the power of expectoration been regained. CROUP. 267 114. t\ In this affection, then, let tracheotomy be had recourse to, so soon as it is plain that medical treatment has failed to effect timeous resolution. Do not delay, until both lungs and brain have been so far involved as to render recovery under any treatment at that stage more than doubtful. c. Laryngitis fibrinosa is usually combined with a corresponding morbid state of the trachea—tracheitis fibrinosa—constituting croup. This, too, may be conveniently divided into three stages: 1. Again the laryngitis simplex, but of greater intensity than in the previous case, and with a marked tendency to spread along the mucous mem- brane downwards. 2. The fibrinous exudation begun ; aggravating all the symptoms, and affording serious obstruction to breathing. 3. The lungs and brain implicated, as in the former case, by reason of the con- tinuance of impeded respiration. The former organs, however, in this case, are exposed to an additional source of danger. The inflammatory action, by continuous extension, may have reached the bronchial rami- fications ; and to the oppression of the lungs' play, otherwise occasioned, the additional and serious complication of bronchitis may be added. In the first stage, medical treatment is practised, as in the correspond- ing period of the previous affection. There is no demand for bronchotomy, on account of urgency of symptoms connected with respiration; and the spread- ing acute inflammatory action is not likely to be limited, in either its extent or intensity, by the in- fliction of a tracheal wound, and retention of a foreign body therein. In the second stage, the symptoms are sufficiently urgent to call for any aid which our art can afford. Tracheotomy will give a more direct and free entrance for air passing tOAvards the lungs, than through the affected larynx; and the larynx will be placed in a state of comparative rest, favor- able to recovery. But the same good result does not follow as in the case of acute oedema glottidis. The disease is not limited to the larynx, but has passed the site of tracheal wound, and is already established too, probably, in the bronchial tubes; the wound is made—not in a comparatively sound part, to afford rest to the superior portion of the canal—but in the midst of the disease, affording rest to but a part, and a minor part, of the disorder's seat, and inducing, by its additional stimulus, an aggravation of the whole. Air is let in towards the lungs, but with only a doubt- ful chance of reaching them; for, by this time, the bronchial tubes are clogged with viscid mucus, the bronchial membrane is itself swollen and infiltrated, the trachea is more or less obstructed by false membrane, and, perhaps, indeed, pseudo-membranous exudation has extended throughout almost the whole bronchial ramifications. Thus, the salu- tary indications are not fulfilled, and the operation fails of its expected issue. In the third stage, surgical interference must prove still more manifestly hopeless. In this disease, therefore, the practical inference Example of False Mem- brane in Croup. Its evil consequences very appa- rent. 268 CROUP. from such considerations will be, that our principal confidence must be placed in medical treatment; that the operation of tracheotomy— laryngotomy being, in all respects, obviously unsuitable—cannot be expected to prove of either great or frequent service; but that if it be had recourse to, it should be during the second stage, when plainly medical treatment has failed to arrest or mitigate, and before the third stage has set in; rendering recovery, under any circumstances, all but absolutely hopeless. Becourse to the operation may be regarded, therefore, as the exception rather than the general rule.1 An operation of a simpler kind, and sometimes productive of benefit, has lately been advocated by Dr. Green, of New York, and others, namely, the direct application of nitrate of silver, in strong solution, to the affected part. By means of a powerful spatula, the tongue is de- pressed and brought forwards; a bent piece of whalebone, tipped with sponge, and soaked in the solution (from two to four scruples of the salt to the ounce of distilled water) is passed behind the epiglottis, and then Fig. 115. End of the Sponge-Probang, for the Larynx; the sponge always carefully affixed to whalebone not made brittle by the caustic. suddenly forced on into the larnyx. The effect is twofold ; mechanical clearance of the canal, the sponge withdrawing much mucus and exuda- tion, and the nitrate exciting a curatiAfe influence on the affected mem- brane. At first, the presence of the foreign body is resented by unpleasant spasm and irritation; but these soon subside, and the opera- tion may be repeated at such intervals as circumstances may seem to require. But there are cases of true laryngitis fibrinosa, in which the action is 1 I am quite aware that authority is not wanting to enforce an opposite practice; Trousseau and Bretonneau, for example, warmly advocating the performance of tracheo- tomy in croup, and supporting their doctrine by an array of successful cases [Brit, and For. Rev. No. 23, p. 110). But, on this point, the question always obtrudes itself: Were these cases all examples of true croup ? for it is well known how loosely medical nomen- clature is often applied; and as, by some, all sores on the penis are called chancres, all hard swellings on the breast dignified by the appellation of scirrhus, every bleeding fungus called fungus hematodes, so may all acute affections of the larynx be arranged under the general denomination of croup. CHRONIC LARYNGITIS. 269 mainly limited, and the pseudo-membranous exudation entirely confined to the larynx itself. These are few, certainly, compared with the ordi- nary examples of croup; still they do occur, and may be diagnosed by the absence of tracheal and pulmonary symptoms, and by the apparent concentration of laryngeal disorder. In such cases, if other treatment fail in the second stage, and symptoms are urgent, tracheotomy should be unhesitatingly practised, on precisely the same grounds as in acute oedema, and, probably, with the same fortunate result. Diphtheritis, or cynanche membranacea, may be said to be a variety of laryngitis fibrinosa. The aphthous exudation, hoAvever, and the action which causes it, do not originate in the larynx, but in the mouth and fauces, thence spreading rapidly doAvmvards. The lungs, through the bronchial ramifications, are early involved, and cannot possibly be relieved by a tracheal wound. Bronchotomy, therefore, is, in this affection, inadmissible. d. Laryngitis purulenta.1—In this, the inflammatory process is more advanced than in any of the preceding forms of acute laryngitis; true inflammation is reached, and its characteristic product exhibited. For- tunately, such a result is of comparatively rare occurrence; and, fortu- nately, also, when it does occur, the action is usually confined to the upper part of the larynx, and corresponding portion of the fauces. The matter is not limited in the form of abscess, but is diffusely infiltrated into the submucous areolar tissue. The membrane gives way, the mat- ter is discharged, and an ulcerated surface remains. The symptoms and progress are very similar to those of acute oedema. And the treat- ment is to be guided by precisely the same principles. By medical treatment, we hope to arrest the action in time to avert peril to life. If not, and dyspnoea increase threateningly, tracheotomy is to be per- formed, early, in the second stage, as a part of the remedial treatment. The prognosis is favorable—as in oedema, when timeously relieved. Acute ulceration of the larynx may result from this affection, as already stated; almost certain to be attended Avith more or less swelling; and, consequently, requiring the same surgical aid as the acute oedema glottidis. II. Chroxic Laryngitis.—This may be the result of an acute or subacute attack; more frequently it is chronic from the first. But, however originating, it is ever liable to sudden and acute aggravation, from comparatively slight causes; bringing life into peril,- all the more imminently on account of the insidious and comparatively mild nature of the previous symptoms. a. Thickening of the Mucous Membrane, resulting from what may be termed simple chronic laryngitis, usually gives way to remedial treat- ment alone; leeches, counter-irritation, mercury, and other alteratives. Should an acute accession supervene—and to such the patient is con- stantly liable—obstruction to respiration may be speedily induced, threatening the most serious consequences. Under such circumstances, proportional augmentation of the medical treatment may fail to relieve; and then tracheotomy comes to be required. 1 London Medical Gazette, January 12, '1833. 270 CHRONIC CEDEMA GLOTTIDIS. As a general rule, when counter-irritation is employed in any affec- tion of the larynx, it should be applied either laterally, or on the back of the neck, not in front; for the remedial effect is the same ; and it is obviously expedient to leave the site of tracheotomy clear and available, in the event of recourse to that operation becoming necessary. b. Follicular disease of the larynx is an affection of great frequency, the morbid action being resident and in most cases originating in the mucous follicles. These are seen on the back of the pharynx, in various stages and forms of alteration by disease, hypertrophied, vesicular, pus- tular, ulcerated, and the presence of similar change Avithin the larynx is marked by characteristic symptoms, cough, expectoration, hoarseness of voice, &c. If permitted to advance, the consequences are serious; loss of voice, increase of structural change in the air-passages, and impairment of the general health. Treatment consists in rest of the parts, application of the nitrate of silver, in the manner already described (p. 268), both to the fauces and within the larynx, and alteratiAres in- ternally, according to circumstances, arsenic, iodide of iron, Donovan's liquor, &c. c. Chronic (Edema glottidis.—This affection is more gradual and less marked than the acute form, but is not less dangerous, being liable to sudden and great exacerbation. The oedema is gradually formed, of more solid consistence, and more uniformly diffused. But from slight exposure to cold, error in diet, or other casualty, acute accession is very prone to supervene, speedily blocking up the passage, and causing the most distressing and dangerous dyspnoea, partly by acute swelling, partly by entanglement of viscid mucus, partly by spasmodic or other- wise disordered action of the muscles of the larynx. Sometimes, with- out any apparent source of aggravation, a fit of dyspnoea suddenly occurs, dependent, probably, on the last-mentioned cause, spasm. Such a patient is never secure. One moment he may be walking abroad, conversing, or otherwise enjoying life with tolerable comfort, the next he may be prostrate, livid, and struggling for existence. A fatal result, however, seldom follows the first of such seizures. Minor attacks usually precede the fatal event. The duty of the practitioner is, by suitable treatment, to arrest the sluggish action, to undo the change of structure, and to restore tone to the enfeebled system, and by every care to provide against the application of such causes as are likely to induce aggravation. Should such aggravation occur, he must be on the alert. Medical treatment is continued, with redoubled care and anxiety, and the patient is closely watched. If the treatment prove unsatisfactory, fits of dyspnoea con- tinuing to recur, tracheotomy is certainly to be performed. Thus only can the tenure of life be rendered at all secure in such cases ; and then, too, the other remedial means may be expected to have a more salutary effect on the original disease, as in the case of simple thickening. After some time, the tube may be withdrawn, and the wound closed. How- ever, prognosis as to discontinuance of the tube is not so favorable as in the acute form. Resolution may be slow and imperfect, the part may never wholly regain its normal state; perhaps respiration cannot ULCERATION OF THE LARYNX. 271 be restored through the normal passages, and the tube consequently may require to be Avorn during the remainder of life. d. Ulceration of the Larynx.—The larynx is liable to ulceration of different kinds, the result usually of chronic inflammatory action: 1. Simple ulceration may occur as a direct result of chronic laryngitis, or of follicular disease; or the larynx may be implicated secondarily by extension of ulceration from the fauces, as is not unlikely to happen in patients who have the misfortune to labor under an aggravated form of mercurio-syphilis. The ulceration is very liable to be surrounded by oedematous swelling, which, by obstructing respiration, seriously com- plicates the case, and may demand both instant and energetic measures to save life. And such complication is especially apt to occur, if by exposure or other cause an inflammatory aggravation have supervened on the previously chronic form. Or the amount of oedema may be slight, respiration may never be seriously impeded, the ulcer may heal, and the normal caliber and function of the larynx may be almost wholly restored. Or, on cicatrization, long delayed, contraction and displace- ment of the parts are such as permanently to interfere most seriously with both voice and respiration. Treatment consists in constitutional alteratives, suitable regimen, careful protection from all sources of aggravation, patient continuance of moderate counter-irritation, and regulated use of nitrate of silver to the affected part; and thus we hope to effect cicatrization ere dangerous loss of substance has occurred—to effect, in short, something like actual resolution. If oedema supervene, and life be threatened by paroxysmal dyspnoea, tracheotomy is imperatively demanded, and must be performed. At this juncture, it is indispensable to the preservation of life. But it comes to be a question, whether its earlier employment may not be expedient, not to save life directly, but to save structure, by placing the larynx at rest, and so facilitating the action of remedial means, accelerating cicatrization while ulceration is yet both limited and super- ficial, and thus preserving unimpaired the important function of the organ. I would incline to the opinion that it is expedient to have recourse to tracheotomy, and temporary use of the tube, in those cases of simple ulcer of the larynx which threaten to resist ordinary remedial means, and which, by loss of substance, endanger the function of the part, operating before life has been threatened by intercurrent oedema, when there is soreness on pressure of the thyroid cartilage, when pain is felt acutely, on the box of the larynx being rubbed laterally across the spine, when there is a sensation of rawness and soreness in the part complained of by the patient; when there is decided and peculiar fetor in the breath, with pain and difficulty in SAvallowing, cough, and puru- lent sputa—occasionally streaked with blood ; and Avhen these symptoms persist unsubdued. By the operation, the diseased part is put at rest; counter-irritation, and alterative treatment will have a much more powerful and salutary influence; and besides, an additional opportunity is afforded of applying remedial means directly to the ulcerated surface. From the tracheal wound, the nitrate of silver may be applied freely to the diseased surface, more readily and accurately than through the glot- *tis. And thus, healing may be obtained at an earlier period than other- 272 PHTHISIS LARYNGEA. wise could have been possible ; the part recovers without loss of sub- stance ; and after a time, the tube may be finally withdrawn, leaving the cure complete. When, however, tracheotomy has been performed at an advanced period of the case, on account of emergency caused by oedema, the tube's discontinuance is very uncertain ; a falling in of the box of the larynx is too probable, as the result of cicatrization ; and in consequence, permanency of the artificial opening may be rendered indispensable. 2. Tubercular Ulceration not unfrequently attacks the windpipe; constituting the true Phthisis Laryngea. There is first submucous or mucous deposit of tubercle, which softens, disintegrates, and opens up the membrane in patchy chronic ulceration. The scrofulous cachexy attends ; and too frequently, also, phthisis pulmonalis is coexistent. Although by no means likely to make a satisfactory impression on such a constitutional malady, still, the ordinary treatment is to be patiently employed. Tracheotomy is certainly not advisable, as a means towards cicatrization and cure ; but it may be had recourse to as a mere pallia- tive—a means of protracting existence—when, by the occurrence of oedema, life is threatened from suffocation. 3. A diseased state of the cartilage is not unfrequent, in broken-down mercurio-syphilitic habits ; associated with chronic abscess and ulcera- tion. In advanced age, the cartilages become ossified, and may necrose. But this which we now allude to is a different affection ; bearing the same analogy to senile degeneration of cartilage, as atheromatous de- posit in the arterial tissue, favorable to aneurism, does to the senile calcareous condition of arteries. The cartilage is thickened, indurated, changed in hue, and partially ossified ; portions die ; suppuration takes place around ; the matter bursts into the windpipe, and is expectorated; a ragged ulcerated aperture remains ; the diseased portion of cartilage loosens, protrudes, and, having been wholly detached, is expectorated; the cavity which held it may then contract and close, along with the ulcerated aperture through which it made its escape; or additional sup- puration takes place, fresh portions become necrosed, and the disease is both aggravated and protracted. In the most favorable point of view, prognosis is unsatisfactory ; for cicatrization cannot take place, without entailing such contraction and change of the canal as must seriously and permanently interfere with respiration. Sometimes a dead portion of ossified cartilage, having been detached, falls downwards ; and be- coming impacted in a bronchial ramification, leads to a fatal issue, either suddenly by asphyxia, or more remotely through pulmonary disease. Treatment is as in ordinary ulceration of this part, Avith especial at- tention to the constitutional vice. And when an emergency, perilling life, does occur, by intercurrent oedema of the larynx, tracheotomy is certainly advisable ; not with the hope of thorough cure, but in order to avert immediate danger, and perhaps to accelerate cicatrization. If life continue, the tube must be permanently worn ; for, under the most favorable circumstances, it is not to be expected, in this affection, that normal caliber and function can be regained. Tracheal Fistula is apt to result from the preceding affection. The abscess connected with the necrosed portion of cartilage may discharge STRICTURE OF THE WINDPIPE. 273 itself externally, as well as into the windpipe, and a fistulous aperture is not unlikely to remain. This may be brought to heal, by the occa- sional use, at long intervals, of heated Avire (Principles, 3d Am. Ed. p. 221). But let no attempt at closure be made, until we are certain that the necrosed portion has been fairly ex- truded, and that no fresh sequestrum is in pro- gress there ; otherwise, by confining the matter, and so causing swelling and obstruction, serious consequences to respiration may ensue. Warts of the Larynx. Warty excrescences have sometimes been found growing from the lining membrane of the larynx, at its upper part; and solid enlargements of structure, pendulous, pyriform, and of the nature of polypus, haATe also, though still more rarely, occurred. They necessarily impede respiration; and, by leading to an inflammatory accession, with its attendant oedema, they may bring life into sudden and imminent jeopardy. The voice is hoarse, and ultimately lost; a hard cough, like that of croup, is troublesome ; and during deglutition and expectoration, the sensation is felt of a foreign body in the larynx; but the most characteristic evidences are the expulsion of small portions of the tumor by coughing, and the seeing and feeling its upper part by careful and deep exploration of the fauces. When an emergency by dyspnoea occurs, tracheotomy is plainly required. Through the wound—made more free than usual—the growth is re- moved, by evulsion or knife. And for some days, at least, the use of the tracheotomy tube will be expedient, lest inflammatory swelling occur at the injured part.1 Warts in the Larynx; growing in the situation of the vocal chprds. Stricture of the Windpipe. Contraction of this tube is liable to occur, at various points, and from various causes; by contraction of the wound after cut throat; by con- traction after cicatrization of ulcers; by change of structure following on chronic laryngitis, independent of ulceration; by necrosis and dis^ charge of portions of cartilage, and consequent narrowing of the pas- sage after closure of the ulcerated cavities. It is doubtful whether our art may be able to restore the normal caliber and function in such cases, by dilatation, as in similar affections of other mucous canals. The ex- periment has been made;3 but the present voice of experience is as yet scarcely in favor of the measure—except in the case of contraction 1 Vide Monthly Journal, Dec. 1846, p. 458. 2 Liston, Elements, p. 453. 18 274 STRICTURE OF THE WINDPIPE. after wound (p. 258). Life may often be protracted, however, and suffering alleviated, by continued use of the tracheotomy tube, of full Fig. 117. Double Stricture of the Trachea: the canal decidedly dilated on the lower aspect of the second contraction. •; The patient had worn a small silver tube in an opening in his windpipe for many years. It was originally introduced on account of long-continued disease of the larynx, with dreadful suffering and constant sense of impending suffocation. He could not be made to dispense with the tube entirely, as he felt, immediately on the wound closing, a threatening of return of his painful and dangerous symptoms. A small one was substi- tuted for that at first used. He led a very irregular life, used a vast quantity of opium, and no small amount of spirituous liquors. He used to be out in the open air occasionally all night, and suffered repeatedly under attacks of bronchitis. He was under treatment again and again in the hospital, on account of rheumatic affection and deranged digestive organs. He used occasionally to present himself, complaining of difficult breathing, and stating that his silver tube was too short. He could articulate tolerably well when he stopped with his finger the orifice of the silver tube; at all times a part of the respired air passing through the natural channel. Latterly, he used to suffer from threatening of suffocation, and he used to relieve himself of the '■ause of this, viz., the inspissated and ropy mucus which got entangled in the trachea, then not suspected to be in a diseased state, by pushing through the opening in his neck and into the bronchi, long turkeys' fea- thers ; of these he carried a good store, and some are now in my possession. This feat he performed without causing the slightest excitement or coughing. Ultimately, and about twelve years after the operation had been performed, he died, principally from diseased viscera." (Liston, Vide Elements of Surgery, p. 451.) size; and by unremitting attention to keep both tube and trachea free from accumulation of viscid mucus. The latter indication may become of easy fulfilment, in consequence of the tracheal and bronchial mem- brane losing much of its sensibility—becoming almost cutaneous in this respect, and not resenting a tolerably free use of probe, feather, sponge, or other means employed for clearing the passage. Formation of Matter near the Larynx. Diffuse infiltration of purulent matter may take place, deeply, in the neck; and the consequent swelling and tension may seriously impede respiration, by encroaching on the canal of the windpipe. The proper remedy is free incision of the infiltrated part, whereby both cause and CASES REQUIRING BRONCHOTOMY. 275 effect are at once removed. Should this fail, or should the symptoms prove obscure, so as not to warrant or even indicate incision, tracheotomy is certafnly advisable. Circumscribed abscess may form in the vicinity of the larynx. And the rules of practice are the same; an early evacuating incision, if possi- ble; otherwise, tracheotomy. Bronchotomy, then, is available in the following cases: 1. In the case of foreign bodies lodged in, or otherwise obstructing, the air-pas- sages. Extrusion, independently of this operation, may be expected to be the exception to the general rule. 2. In suspended animation; when we cannot otherwise effect, with certainty, artificial inflation of the lungs—as will rarely be the case. 3. In spasm of the glottis. Threat- ened asphyxia from external injury may perhaps depend on this cause— perhaps on a precisely opposite condition; in either case, the operation is demanded to save life. And there is a like necessity, in the spasmo- dic occlusion of the glottis which attends poisoning by carbonic acid. In laryngismus stridulus, we withhold the operation, if possible, and trust to general treatment; yet we are aware that urgent circumstances may arise to demand the tracheal wound, at least with the hope of palliation, and perhaps with the effect of affording time for the effectual working of other remedies. In certain cases of thoracic aneurism, too, when laryngeal distress is occasioned by irritation of the recurrent nerve and threatens immediate death, tracheotomy is advisable—in some few cases, it may be, with more than the hope of mere palliation (p. 263). 4. In oedema glottidis, chronic and acute, there is no safety but by operation, so soon as the symptoms have become at all urgent. And, in the acute cases, there is good hope of speedy discontinuance of the tube, closure of the artificial aperture, and complete restoration of normal respira- tion. 5. In laryngitis fibrinosa, the operation is as warrantable as in urgent oedema, when the disease is limited to the larynx. But in most cases of true c»oup, in which the whole windpipe with its ramifications is involved, operation may rather be regarded as an exception to the general rule of non-interference; in the early stage, it is inexpedient, while mechanical obstruction to respiration is not yet threatened; in the more advanced period, it is likely to prove ineffectual. 6. In purulent laryngitis, there may be the same necessity for operation, and the same prospect of a good result, as in acute oedema. 7. In chronic laryngitis with thickening, the supervention of oedema, through inflammatory accession, may render operation indispensable to the preservation of life. 8. In simple ulceration, the same event may occur as that just mentioned in connection with mere thickening of the membrane. Or, independently of such an accidental crisis, operation may be deemed expedient, to assist the action of other remedial means, and by effecting early cicatrization to save structure and function. 9. In ulceration, with disease of cartilage, operation is likely to be required to save life from immediate danger by threatened asphyxia; but with little or no prospect of discontinuance of the tube's use. 10. In phthisis laryngea, 276 LARYNGOTOMY. it may be similarly demanded for a temporary object; scarcely with a hope of contributing to cure; but rather as a means of protraction and palliation. 11. In pressure on the windpipe, caused by the formation of tumor or abscess, or by impaction of food in the oesophagus or pha- rynx—operation may be necessary, if the obstruction to respiration cannot be otherwise relieved, namely, by removal of the cause; by evacuation of the matter, extirpation or diminution of the tumor, or ex- trusion of the impacted substance. 12. In cut throat, tracheotomy is not unfrequently demanded to save life from impending asphyxia; and it maybe expedient, at an early period of the case, to avert all such hazard, and to favor as well as permit immediate and entire closure of the wound. 13. In glossitis, in tonsillitis, and in extreme cases of pharyngitis, it is required, when swelling is so great, rapid, and uncontrollable as otherwise to render fatal asphyxia all but inevitable. 14. In carotid aneurism of large size—when, by circumstances, we are precluded from speedy recourse to deligation of the artery—life may be suddenly brought into peril, by supervention of the diffuse form on the circum- scribed (Principles, 3d Am. Ed. p. 521), and consequent compression of the windpipe. Bronchotomy then is essential; and the tube will require to be worn, until by deligation of the artery we have effected such diminution in the bulk of the tumor as altogether to free the respi- ratory canal. 15. Thoracic aneurisms, by compressing and narrowing the air-passages, may simulate the results of inflammatory disease in the larynx; and, in such circumstances, little good can be expected from bronchotomy. In those cases, however, in which the tumor is small, and causes dangerous paroxysms of dyspnoea by spasm of the larynx arising from irritation of the recurrent nerve, the operation, as already stated, is certainly expedient (p. 264). In the great majority of cases, tracheotomy is preferable to laryn- gotomy, for obvious reasons. The passing of tubes into the windpipe, by the nose or mouth, has been proposed as a means of superseding bronchotomy. But modern experience limits their use to cases of suspended animation, unconnected with laryngeal or tracheal disease ; and even then, their superiority may come to be a matter of question and doubt. Laryngotomy. The performance of this operation having been determined on, the patient is seated on a chair, with the head thrown back and steadied. A longitudinal incision is made over the box of the larynx, in the mesial space; by dissection, the crico-thyroid membrane is exposed; and through this an opening is then made by the knife—as free as the car- tilaginous boundaries of the space will alloAV. There will seldom be any trouble by hemorrhage. TRACHEOTOMY. 277 Tracheotomy. Excepting the case of artificial respiration on account of asphyxia unconnected with laryngeal disease, the case of a foreign body impacted in the rima, and the case of a loose foreign body of small size within the windpipe, tracheotomy is certainly preferable to laryngotomy. [It would seem, as the result of careful investigations, that the choice of laryngotomy or tracheotomy may, in most cases for which either operation is performed, be decided by the comparative facility Avith which, in any particular instance, either may be accomplished. Mr. Prescott Hewett, in an interesting paper, published in the London Journal of Medicine, Feb. 1849, states, as the result of post-mortem examinations, that in all cases of acute inflammation of the larynx in adults, and in those cases that occur in children from swallowing boiling water or other irritating fluids, the obstruction is seated above the infe- rior vocal chords ; the mucous membrane covering them, or that below them, not being in the slightest degree thickened; and that, conse- quently, as laryngotomy is a much simpler and safer operation than tracheotomy, it ought in such cases to be preferred. This statement is confirmed by Mr. Erichsen, who says that he has examined many recent specimens of inflamed and obstructed larynx, and those preparations of laryngeal disease which are preserved in several of the London collections, without meeting with one in which an opening in the crico-thyroid membrane would not have relieved the asphyxia equally as well as one in the trachea. This examination de- termined him in future to have recourse to laryngotomy rather than to tracheotomy in acute obstructions of the glottis, whether primary, or supervening on chronic ulceration, or disease of the part. This de- termination was strengthened by the result of the post-mortem exami- nation of two cases in which he had performed tracheotomy—the one, of old syphilitic disease of the larynx, followed by acute oedema; the other of erysipelas of the glottis, in both of which the obstruction was found to be situated above the inferior vocal chords.—American Journal, Oct. 1850, p. 515.—Ed.] The patient having been placed as for tracheotomy, an incision is made in the mesial line of the lower part of the neck, from an inch and a half to two inches in length, the upper portion terminating a little above the cricoid cartilage. Skin, fat, and fascia having been divided, the commissure of the sterno-hyoid muscles is exposed ; and this is carefully separated by the handle of the knife. The tracheal rings are made bare; detachment of the areolar investment being effected by either the point or handle of the knife, according to circum- stances. Then the patient, if adult and conscious, is directed to swal- low saliva. While the windpipe is rendered tense and elongated in the act of deglutition, the scalpel is made to penetrate at the lower part of the wound, with its back to the sternum ; and, by a sawing movement of the instrument upwards, the necessary extent of tracheal wound is completed; the isthmus of the thyroid gland being pushed out of harm's way, by the finger—upwards. [In the last edition of his Practical 278 TRACHEOTOMY. Surgery, Mr. Fergusson has described an instrument which was exposed at the Great Exhibition, in 1851. It is the contrivance of a M. Garin, of Lyons. It resembles a pair of common forceps in shape and appear- ance, excepting that the extremity of one blade is bent, as shown in the figure. The blades, when closed, are about the size of a small scalpel, and one is so sharp at the point and on the side, that it will readily pierce and cut the trachea—whereupon they may be allowed to sepa- rate, when they will hold the sides of the incision asunder, for the pur- poses of the operation.—Ed.] If the operation have been undertaken on account of the lodgement of a foreign body, no tube is necessary. The wound having been made, the foreign substance, if loose, will be expelled at once ; if not, it is to be sought for by probe and forceps, as formerly stated. In the case of disease, it is our object to establish a con- stant and sufficient aperture for respiration, at the site of [Fig. 118.] the wound ; accordingly, a curved silver canula is intro- duced ; and this is retained by tapes passing from a ring on each side of the canula, to be secured behind the neck. The canula is of sufficient size to atone, completely, for the temporarily occluded rima; varying, consequently, according to age; and, generally, of not much less diame- ter than the trachea which receives it. Yet it should not be so large as to press harshly on the lining membrane of the passage, lest ulceration be induced. The wound should be of size sufficient to receive the canula, without force, and yet not too freely ; the cut margins should be compressed by the canula, internal escape of blood being so prevented; and this object is farther contributed to by the conical form of the instrument. To facilitate intro- duction, the canula may- be provided with a plug, the bulbous end projecting—as in the vaginal speculum ; an Fig. 119. [Instrument of M. (iiirin for open- ing the Trachea. (From Fergusson.) —Ed.] Ordinary Canula. a. In profile; b. Transverse section of orifice. idea for which Ave are indebted to Dr. W. T. Gairdner. The patient is laid on his side, so as to render the wound dependent and favorable to the outward escape of blood and mucus. After a time, Avhen the coni- cal form of the tube is no longer an advantage, on account of hemor- TRACHEOTOMY. 279 rhage, an instrument of uniform caliber may be substituted, as more suitable for respiration. And in cases of old standing—more especially Fig. 120. d a Canula, as recommended by Dr. Gairdner. From a to 6 the canula. c. The end of the plug, projected, d. The handle of the plug. The plug is of course withdrawn, so soon as the canula has entered the windpipe. those in which the tube is permanently retained—a double canula may be used; one portion being removed from time to time, for the purpose of being cleaned, while the other remains, keeping the canal constantly free. To the orifice of such an instrument, too, it is well to attach a valve, which, opening to the full in inspiration, leaves the whole space free, but, shutting in expiration, forms a smaller aperture suitable for expectoration. The circumstance of the canula's introduction being itself an efficient hemostatic means, materially facilitates performance of the operation.1 It is not necessary to wait for entire cessation of bleeding before open- ing the windpipe ; no valuable time need be lost in stemming oozing; main jets of blood, if any, having been secured, the tracheal Avound is at once made, and the tube as speedily introduced. At first, the pre- sence of the foreign body, and of the small quantity of blood which has necessarily entered along with it, is much resented; a violent fit of spasmodic cough, threatening suffocation, ensues; but the blood having been thrown back, through the tube, this fit of irritation passes off, and comparatively calm respiration is speedily established through the arti- ficial opening. For many hours—but more especially during the first few—the patient must be carefully Avatched, lest the tube become ob- structed by mucus; and this is from time to time to be cleared away, by a probe, armed with lint or sponge, or by a feather; or the double canula may be used from the first, admitting of one portion remaining in the wound, while the other is withdrawn and cleaned occasionally. Such attention is particularly necessary, as formerly stated, if the pa- tient have fallen asleep after the operation (p. 200). When expectora- tion is attempted, it is necessary to diminish the aperture of the ordinary tube ATery considerably, by temporary application of the finger, so that the expired air may be expelled forcibly. At first, this narroAving is made by the surgeon; but soon the patient becomes an adept in the simple manipulation. Should he grow too weak to expectorate, it is well to attempt extraction of the mucus by suction; by the adaptation of a syringe, or by the mouth of an assistant, if possible. 1 The tube is a hemostatic, not only by its pressure on the edges of the wound, but, also, and very importantly, by freeing the venous return in the neck, which, during dyspnoea, is necessarily much retarded. 280 TRACHEOTOMY. As already seen, in some cases the tube may be withdraAvn, and the wound permanently closed, after a few days or weeks; in other cases, normal respiration can neA^er be restored, and the tube must be worn during the remainder of life. And, in these latter, it is truly surprising hoAV little inconvenience is sustained; respiration becomes easy and silent, and even the voice may be regained, so far as to admit of the patient fulfilling the ordinary duties and customs of society. The prominent danger of the operation is by hemorrhage. During the incisions, this is to be guarded against by caution in the placing and making of them; more especially avoiding the large veins which are often to be found in the lower and front part of the neck; and if any stray vessel be encountered, it should be held carefully out of the way by an assistant. Arterial branches, which spring, are to be secured by ligature; to venous orifices, temporary pressure may be applied. On account of mere venous bleeding, however, no delay should take place; more especially when the operation is being performed on account of dyspnoea ; for the most likely means of freeing respiration, favoring venous return, and obtaining a comparatively quiescent and empty state of the veins implicated, is by lodging the tube in the tracheal wound. It has been often proposed, with a view to render the operation both more simple and safe, to perforate the trachea by means of a trocar and canula, discarding the knife. The proposal looks well in theory, but has found no favor with the practical surgeon, for reasons too obvious to require their formal statement. In all cases, it is obviously of much importance to keep the patient in an equable and genial temperature, to cover the wound with some cloth of loose texture, and to take every other means which may sug- gest itself, as likely to ward off the accession of inflammatory action by the stimulus of cold air directly applied to the membrane, as in the case of cut throat (p. 255). In the child, operation may be rendered extremely difficult, by the restlessness of the patient, the crying and struggling which engorge the veins, the small size of the trachea, the limited space of the neck, the number of veins likely to be encountered, and the intolerance of loss of blood on the part of the system. The dissection must be conducted with unusual caution; and it is well, after exposure of the trachea, to fix it by means of a sharp hook, so as at once to facilitate and render more safe the performance of the tracheal Avound. So soon as this has been effected, the child should be instantly turned upon its face, so as to prevent, as far as possible, escape of blood into the trachea. On cessation of the hemorrhage, the ordinary position may be resumed, should the circumstances of the case render this expedient. In most cases, anaesthesia will be considered inexpedient, except during exploration by forceps after the operation has been performed on account of the lodgement of a foreign body (p. 261). [The danger of hemorrhage from the necessary division of the parts may, to a great extent, be obviated by attention to the mode in which this division is effected. Dr. Pancoast, of this city, who has performed this operation repeatedly, advises that the tissue which connects the sterno-thyroid muscles be torn by means of the handle of the scalpel BRONCHOCELE, OR GOITRE. 281 instead of cut with its blade; and that the isthmus of the thyroid gland, if it descend Ioav enough to interfere with the opening of the trachea, be first tied on each side of the median line, and then divided between the two ligatures. It is well, also, to remove the tracheal fascia, of Mr. Porter, from around the proposed line of incision of the tube, before opening the lat- ter, lest emphysema of the surrounding parts should subsequently occur. The tracheal tube recommended in the text is itself a source of irritation to the tracheal mucous membrane, when introduced through the Avound; and, as mentioned by the author, it will require frequent cleaning, Avhich will add to the disturbance it produces. To obviate or avoid this dis- advantage, an elliptical piece of the trachea may be excised, large enough to permit free ingress and egress of air, and the expulsion and removal of blood and mucus. This plan was recommended by Mr. Porter, and is generally practised by Dr. Pancoast, of this city. A very simple means of preventing the integuments from falling over the tracheal wound has been suggested by Dr. Pancoast. It consists in passing a blunt-hook, or a piece of lead or pewter, properly bent, under each flap of the incision, and tying them around the neck suffi- ciently tight to insure the requisite separation of the margins of the wound. After a few days, this apparatus may be dispensed with, as the integuments will have retracted. A more elegant, and perhaps more efficient contrivance than the hooks is recommended by Dr. Smith [Operative Surgery, p. 254, and Plate xxx. Fig. 12). It is made of tAvo pieces of broad watch-spring, each being properly bent at one end, to draw aside the flaps; the other ends are connected to each other, so as to slide one upon the other, and thus to increase or diminish the length of the band which is intended to pass around the neck, from behind, forwards; the necessary length of the spring can be secured by turning a screw which fixes the slide. The after-treatment, particularly in croup, is a matter of great im- portance. The air inspired should be not only of the proper tempera- ture, but of the proper degree of moisture, so as to resemble that inhaled in health; the patient should be carefully watched for several days and nights, so that no obstruction of the tracheal wound shall occur; a few drops of nitrate of silver, of the proper strength (di to 3ss in ,?j of water), may be introduced into the wound from time to time, or some medicated vapor may be inhaled, as shall be deemed expedient. The reader may consult with advantage two papers, by Dr. J. F. Meigs, published in the American Journal, for April, 1847, and April, 1849, respectively ; one by Dr. Pepper, in the Transactions of the College of Physicians, of Philadelphia, in the volume for 1851; also a pamphlet by Dr. AVare, of Boston, on the Diagnosis of the Different Forms of Croup, Boston, 1852.—Ed.] Bronchocele, or Goitre. The term _ denotes swelling of the thyroid gland, and this may be of various kinds. 1. Mere hypertrophy is common, the enlargement being essentially chronic and very gradual, and ultimately making a transition into the state of simple tumor (Principles, 3d Am. Ed. pp. 282 BRONCHOCELE, OR GOITRE. 278 and 292). The whole gland may be equally involved, or the isth- mus also may enlarge, while the lobes remain of a normal character; more frequently one or other lobe is the seat of the partial affection, and sometimes both lobes are involved while the central portion remains free. And, indeed, the same remarks, as to the partial or general character of the swelling, apply to the other varieties of the affection. 2. The swelling may be of a cystic nature, the stroma being analogous to the structure of simple tumor, the cysts either numerous and small, or few and capacious, delicate, and filled Avith a glairy fluid. This pro- bably is the most frequent form of the disease. 3. The simple stroma may contain a greater or less amount of calcareous matter, giving much density to the tumor, Avhich is seldom then of large size. 5. The tumor may be malignant. Carcinoma is rare. Cephaloma, which is not so, folloAvs its ordinary course, and presents its usual characters. [Fig. 122.] [Fig. 121. Bronchocele, from a specimen in Kind's Fig. 122. Drawing from a preparation in the College Collection. The cesophagus pushed to the Middlesex Hospital. The cystojd appearance of a right by the tumor. (From Druitt.) section. (From Druitt.)—Ed.] Bronchocele is, in certain localities, an endemic disorder. In the Tyrol, and in the valley of the Rhone, it is especially so, and there almost invariably associated with a sadly deteriorated condition of the frame, to Avhich the term Cretinism has been applied. In this country, the disease is comparatively rare, and happily such an unfortunate com- bination but seldom exists. In Derbyshire, and some other counties, both in Scotland and England, however, it merits the appellation of endemic. The majority of the patients are female, and the ordinary period of invasion is about the time of puberty. The most prominent symptom is inconvenience, with deformity, occasioned by the bulky swelling. Growth is gradual and painless, unless in the malignant variety. The indications by touch vary according to the nature of the interior. As the tumor enlarges, the head becomes disordered, in con- sequence of venous return thence being interfered with, and respiration also is more or less seriously impeded, by pressure on the Avindpipe, [Fig. 121.] BRONCHOCELE. 283 especially Avhen the central portion of the gland is affected. Partial enlargement, affecting but one lobe, is apt to simulate carotid aneurism, receiving a decided impulse from the adjacent vessel, and careful mani- pulation is necessary to arrive at a correct diagnosis. In addition to the ordinary diagnostics (Principles, 3d Am. Ed. p. 529), it is to be borne in mind that, on deglutition being performed, a bronchocele Avill be found to move upwards with the larynx, while an aneurism remains unaffected. The causes of the disease are scarcely yet evolved from obscurity. Where endemic, it seems certainly connected with habitual use of un- wholesome water as an article of food, and habitual exposure to a humid atmosphere; and this circumstance necessarily possesses an important bearing on the question of cure. Treatment.—In reference to treatment, the examples of this disease may be conAreniently divided into two classes—those which are merely deformities, unseemly and somewhat troublesome by their bulk, and those which bring life into peril, directly or indirectly, by interference with the brain and the air-passages. For the latter, the most deter- mined remedial means may be Avith all propriety resorted to; for the former, heroics are not warrantable. And, fortunately, the majority of cases, in this country, demand only the milder form of treatment. Iodine has long been regarded as the most poAverful remedy, and justly. Internally, it is administered in the form of iodide of potassium, or com- bined, as with iron. Externally, it is applied in the form of solution, painted frequently on the swelling ; or ointment, or liniment, rubbed in ; moderate leeching having been premised, in those cases in Avhich con- tinuance of nutritive excitement may seem to render such a measure expedient; our object being to arrest growth, as well as to discuss bulk already attained. At the same time, habitual exposure to a dry and otherwise salubrious atmosphere, with habitual use of sound Avater, chalybeate if possible, are curative indications by no means to be neglected. And such treatment will be carefully maintained, so as to prevent a tumor, originally of the first class, from becoming of the second, and seriously perilling life by interfering with both breath- ing and circulation. Central tumors, pressing on the windpipe, may be removed by opera- tion, Avhen of no great size; partly by excision, partly by deligation. By the scalpel, the integuments are freely divided and turned aside; the tumor is laterally separated from its connections, care being taken to secure each arterial orifice by ligature, so soon as divided, and each venous orifice, as far as possible, by pressure of the fingers of an assist- ant ; and having proceeded as far with the knife, in the work of detach- ment, as prudence will allow, the remainder of the connections are to be included tightly in ligature. A strong needle is passed beneath the base of the tumor, the double ligature is divided, and each portion is tied separately, so as to strangulate the mass (Principles, 3d Am. Ed. p. 562, Fig. 199). Tumors of the isthmus have been thus removed suc- cessfully ; and it is probable that the same principle of operation may sometimes be extended to other swellings not limited to that part of the gland. 284 BRONCHOCELE. Large, solid bronchoceles, involving the whole gland, and of greatest bulk laterally, are not amenable to such radical cure. Their size, site, and attachments preclude the use of ligature; and attempted removal by the knife could scarcely fail to prove fatal by hemorrhage. Of late, however, an ingenious mode of operation has been devised by M. Porta, founded on observing that the large arteries which supply the thyroid gland, do not enter the interior of it, but break up into numerous small branches at the circumference, and that, consequently, hemorrhage need be dreaded only when the exterior part of the tumor is interfered with. Besides, the majority of simple bronchoceles he found to consist of nu- merous cellular or cystic developments, which push aside the proper texture of the gland, reducing that to the condition of a simple en- velop, on dividing which the neAv products are exposed, or may be extracted without difficulty, injuring only small vessels, and leaving behind a fleshy sac which collapses, leaving no trace of the tumor. Ac- cordingly, the operation is performed thus : the integuments of the neck, and usually, also, the omo-hyoid muscle, are divided by incision; the tumor is cut into, avoiding the trunks of the thyroid arteries; if any of these spring, they are tied or twisted; the exposed cysts are removed by forceps, or the handle of the knife; more solid structure, if it exist, is broken down and extruded by the same means; and, bleeding having been arrested, the wound is closed.1 In hopeless cases life may be protracted, and great relief afforded, by subcutaneous section of one or both sterno-mastoid muscles, so as to diminish tension, favor outAvard growth, and relieve the trachea and jugular from compression. In some cases, also, protraction .and pallia- tion may be obtained by tracheotomy, when the circumstances of the case are such as to render the performance of that operation practicable. For the purely cystic bronchocele, simpler means may supersede the more formidable operation of M. Porta. Iodine may be injected as in hydrocele (and to such affections some apply the term hydrocele of the neck, p. 246), or a seton may be used. The cyst having been punc- tured, and its contents evacuated, a few threads of silk may be passed through the substance of the swelling and retained. It is probable that the inflammatory result will lead to obliteration of the cystic formation; but much care is necessary in Avatching the action, lest it prove exces- sive, and threaten asphyxia through sudden and great enlargement of the swelling. For the solid tumors, the seton is not well adapted; it not only fails to discuss, but is also exceedingly prone to accelerate growth. The malignant bronchoceles, fortunately rare, are incurable. [The reader will find a valuable paper on Goitre, in Henle and Pfeufer's Zeitschrift fiir Rationelle Medizin, vol. vi. p. 123; in which the author, Professor Ecker, of Basle, deduces all the various forms of the affection from two primitive ones. These he designates struma vasculosa, and struma glandulosa, corresponding with the two important anatomical elements of the thyroid gland, the vascular and the secreting. His 1 Brit, and For. Med.-Chir. Rev. Jan. 1851, p. 106. DISEASE OF THE CERVICAL VERTEBRAE. 285 paper is based upon careful im^estigations of the normal and morbid anatomy of the organ, and will be found very interesting and instructive. It may be well, also, to refer to the chapter on diseases of the thyroid gland, in Hasse's Pathological Anatomy, and in Bokitansky's fourth volume, the Sydenham Society's edition.—-Ed.] Tumors over the Thyroid Gland. Not unfrequently cystic formations are found, not in the substance of the thyroid gland, but between this and the integument. If of small size and circumscribed, they may be dissected out. Those which are large may be treated by seton or injection. Enlargement of the Thyro-hyoid Bursa. Like other bursae, that which is situated between the hyoid bone and thyroid cartilage is liable to enlargement, chronic or acute; causing more or less swelling, with pain and obstruction to the movements of the neck. The acute form is met by repeated leeching and fomentation; the chronic is appropriately treated by the local application of Iodine in solution, or by other discutients. Hernia Bronchalis. A rare affection, so called, has been observed in those who habitually strain the throat in loud and sustained calling. A fold of the lining membrane is protruded outwards between two tracheal cartilages ; and thus a greater or less tumor, soft and compressible, is formed, according to the extent of protrusion. The only remedial means advisable are such outward applications as are likely, by affording external support, to oppose farther enlargement. And the exciting cause—straining of the throat—is, of course, to be discontinued. Disease of the Cervical Vertebrae. The chain of cervical vertebrae, like other bones with their articulating surfaces, is liable to disease of various kinds: 1. The bodies of the ver- tebrae may be interstitially absorbed. Then a greater or less degree of curvature is likely to ensue; the head usually bending forwards, with deviation to one or other side; and, not unfrequently, there is thicken- ing of the soft parts exteriorly, in consequence of a chronic inflamma- tory process slowly advancing there. 2. Or the bodies of the vertebrae are affected by the results of true inflammation. At first, there are thickening, hardness, and tenderness on pressure ; indicating the ostitic and periostitic stage. Afterwards matter forms, the bones are eroded by ulceration, and portions may be detached in the form of sequestra. There are pain, swelling, tenderness on pressure,- and the other usual signs of an advancing action of disorganization. More or less deformity, by curvature, necessarily ensues ; partly from change in the bones, partly from a wasted and paralyzed state of the extensor muscles. As 286 DISEASE OF THE CERVICAL VERTEBRAE. can be readily understood, deglutition is early and much interfered with; and by encroachment on, and inA'olvement of, the cervical nerves, serious results are likely to occur, as regards respiration. The functions of the superior extremities, too, may be perilled, by affection of the brachial plexus. The disease is generally connected, in the patient's narrative, with external injury; and the persons most likely to be affected are the young and strumous. 3. Or the disease may originate in the articulating textures; ultimately inducing similarly destructive results. 4. There is good reason to believe that, not unfrequently, such affections follow in regular succession; the diseased action commencing in interstitial absorption of the bones, advancing from absorption to true inflammation, and ultimately disorganizing both bone and joint. The obvious treatment of such disease is, to endeavor to arrest its course by leeching and counter-irritation—the latter of the graver sort (moxa, or actual cautery), and patiently continued; to exhibit iodide of potassium internally, more especially when taint of the system is sus- pected ; to keep the part at rest; and, in the advanced cases, to relieve the affected bones from the weight of the head, as much as possible, by mechanical means. A firm iron rod, fixed in a circular girth on the trunk, passes upwards, excurvating to receivre the posterior part of the head, and terminating over the forehead; and by a bandage or strap attached to the extremity of the rod, and passed under the chin, the required support is afforded. All suddenness of motion in the neck is especially to be aAroided; but, indeed, in most cases, the patient has an instinctiA'e dread of such risk, and carefully guards against it; turning the head slowly, and with the chin supported on the hand. In the case of disease affecting the atlas and dentata, such precaution is particularly necessary; lest, by sudden rupture of the ligamentous apparatus, dis- placement should occur, causing fatal compression of the medulla. Should matter form in considerable quantity, and seek to approach the surface, at the lateral or posterior part of the neck, a free and earlv incision is to be made for evacuation. In ad\*anced cases, the only hope of cure is by anchylosis. Cheyne, The Pathology of the Larynx and Bronchia, Edin. 1810. Burns, Surgical Anatomy of the Head and Neck, Edin. 1824. Lawrence, Med.-Chir. Trans, vol. vi. p. 221. Bretonneau, des Inflammations Spe"ciales du Tissu Muqueux, et en particulier de la DiphthMte, Paris, 1826. Cheyne, Cycl. of Pract. Med. (art. Laryngitis), vol. iii. London, 1833. Dupuytren, Clinique Chir. torn. iii. Paris, 1833. Tweedie, Cycl. of Praet. Med. (art. Throat, diseases of) vol. iv. London, 1834. Porter, The Surgical Pathology of the Larynx and Trachea, Dublin, 1837. Trousseau et Belloc, Traite de la Phthisie LaryngSe, Paris. 1837. Trousseau de la Tracheotomie, L'Experience, Nov. 5, 1840. Ley, on Laryngismus Stridulus; Henderson, on Laryngismus Stridulus, Monthly Journal' Jan 1841 p 10 Brodie, Case of Mr. Brunei, Med. Gazette, July 7, 1843. Watson, Lectures on the Prac- tice of Physic, London, 1848. Green, Treatise on Diseases of the Air-rassases, New York, 1849. Copland, art. Bronchocele, Diet, of Pract. Medicine. Porta, Delle^Malattie e dejle Operazioni della Ghiandola Tiroidea, Milano, 1849. Todd, Cvcl. of \nat. and Physiology, art. Thyroid gland, London, 1850. [For the treatment of oedema of the olottis by scarification, see papers by Dr. Gurclon Buck, in vols. i. and iv. of the Transactions of Am. Med. Association.] CHAPTER XIX. AFFECTIONS OF THE ARTERIES OF THE NECK AND SUPERIOR EXTREMITY. Deligation of the Carotid. The common carotid artery may require deligation on account of aneurism, hemorrhage by ulcer or wound, or erectile tumor in the orbit. Carotid aneurism is usually situated at the upper part of the vessel, near the angle of the jaw ; forming a tumor there of the ordinary characters, which, should it become diffuse, might seriously interfere with respiration. It possesses a peculiarity of being ill surrounded by repressing tissues ; it grows chiefly towards the pharynx, and may im- perfectly consolidate after operation (Principles, 3d Am. Ed. p. 541). Sometimes—but fortunately comparatively seldom—the disease affects the origin of the artery ; and then its interference with respiration is more early and serious. From sudden increase of the tumor—by diffu- sion or otherwise—immediate performance of tracheotomy may be de- manded to save from urgent threatening of asphyxia. The artery may be secured at one of two points; above or below where it is crossed by the omo-hyoid muscle. The former situation is the more easy of access, and is to be preferred when circumstances are favorable ; but in cases of aneurism, the tumor will generally be found to have encroached too far on the upper triangular space. The superior operation is performed thus : tThe patient having been placed recumbent, with the head thrown back and turned slightly to the opposite side, an incision is made through the integuments, platysma myoides, and superficial fascia, extending in the direction of the inner border of the sterno-mastoid muscle, from near the angle of the jaAv to the level of the cricoid cartilage. The deep fascia is carefully divided, with the use of forceps; cross Areins are looked for, and avoided ; the margins of the wound are held asunder by means of bent copper spatula?; and it may be useful to relax the parts somewhat, by changing the posi- tion of the head. The descendens noni is pushed aside ; the common sheath of the vessels having been pinched up by forceps, is opened to the requisite extent; and cautious isolation of the artery is proceeded with, so as to afford clear space for passage of the aneurism needle— and no more. The needle is passed from the outside ; the jugular vein being repressed, if necessary; and thus risk is avoided of injuring the 288 DELIGATION OF THE CAROTID. vein, or including the par vagum.1 Before securing the knot, especial care should be taken to ascertain that nothing but the arterial coats is included. The inferior operation is more generally suitable in the case of aneur- ism, as already explained. The patient having been placed as before, an incision of about three inches in length, parallel to the inner border of the sterno-mastoid, is begun a little above the level of the cricoid cartilage. The inner border of the muscle, having been exposed, is cautiously turned outwards ; while the sterno-hyoid and sterno-thyroid muscles are displaced in the opposite direction. The deep fascia is divided below the crossing of the omo-hyoid muscle ; and, the sheath having been opened, the operation is completed as before. The descend- ens noni, in the former case in front of the sheath, is here found in- clining to the tracheal side of the artery. On the left side, the jugular vein is very apt to prove troublesome by overlapping ; on the right side, it recedes from the carotid, to meet the subclavian vein. After the operation, congestion of the lungs, with its baneful conse- quences, must be guarded against by use of the lancet. And, in the case of aneurism at the angle of the jaw, external pressure is to be made on the tumor, so as to atone for the deficiency of repressive textures, formerly alluded to. It is well, also, to keep the neck bent so as to relax the artery. The artery at its inferior part has been secured by a transverse wound ; cutting the sterno-mastoid across, upon a director, and then opening the sheath in the ordinary way.2 In the case of aneurism at the root of the common carotid, deligation of the artery at its upper part may be practised, with a reasonable hope of cure. For, as formerly stated (Principles, 3d Am. Ed. p. 542), the common carotid is favorably adapted for Brasdor's operation. Deligation of the external carotid, and its branches, is required only in the case of hemorrhage ; and chiefly on account of wound. Xo defi- nite rules need be given as to the operative procedure ; this must be guided by the general principles formerly inculcated (Principles, 3d Am. Ed. pp. 349 and 533), and modified by the particular circumstances of the case. Deligation of the Arteria Anonyma is an operation now considered hopeless ; and in all probability, Avill never be repeated by any judicious surgeon; circumstances seeming to be insuperably hostile to satisfactory occlusion of the artery at the deligated point. Deligation of the Subclavian. This artery requires ligature, on account of axillary aneurism. Hemorrhage by wound or ulcer is likely to call for the operation bur rarely. i From inattention to this rule, at an early period of my professional life, I had the misfortune to include the par vagum in the noose of the ligature. But it is some consola- tion to know that the accident was, in all probability, unconnected with the fatal issue of the case. I willingly record the circumstance here ; that it may be of use, as a beacon, to deter and warn others from similar inattention and mishap. 2 Ilargrave, Dublin Quarterly Journal, Aug. 1849. DELIGATION OF THE SUBCLAVIAN. 289 Surgically, the vessel is conveniently divided into three portions; internal, from its origin to the inner border of the scaleni; middle, where overlaid by the anterior scalenus ; external, between the outer border of this muscle and the passage over the first rib. On the right side, it is possible to secure the artery at any of these parts of its Fig. 123. Plan of the relative position of the Subclavian Artery, in its outer third. course ; on the left, the last two only are practicable, the internal third being not only very deeply seated, but in close contact with most im- portant parts, which can scarcely fail to sustain serious injury in the attempt. On either side, the middle third is not desirable ; there being risk of serious injury to the phrenic nerve, as well as a probability of unsatisfactory occlusion on account of the near propinquity of large collateral branches at the deligated point. The external third is pre- ferred. But if, in performing the ordinary operation on this part of the vessel, the coats appear unsound, we are fully warranted in cautiously turning aside the scalenus muscle, and seeking upwards for a more healthy portion. Deligation of the external third is accomplished thus : The patient having been placed recumbent, on rather a high table, and the elevated shoulder having been forcibly depressed as much as possible, an incision is made over the clavicle, through the skin and platysma myoides ; ex- tending from the anterior border of the trapezius, to a little beyond the posterior border of the sterno-mastoid. And it is well to pull the skin downwards before using the knife, so that, on resilience, the wound may be more directly correspondent with the course of the vessel. A minor incision is made to fall into the first, passing along the posterior border of the sterno-mastoid ; and the flap thus indicated is slightly reflected. The cervical fascia is divided; the external jugular vein is looked for, and turned aside; the posterior belly of the omo-hyoid may be disclosed; and then we know that in the triangular space between that and the clavicle, is contained the object of our search. The outer edge of the 290 DELIGATION OF THE SUBCLAVIAN. scalenus muscle is sought for ; at the same time a part of the brachial plexus is brought into view; and now the field of search is farther limited ; the artery will be found by tracing the border of the muscle downwards, on a lower and more anterior plane than the portion of the plexus exposed. Placing our finger on the tubercle of the first rib, the artery is felt pulsating between ; and the knife is guided accordingly. The vessel having been reached, is cautiously isolated to the requisite extent; and the needle is passed from the clavicular aspect, so as to avoid injury of the vein. Before securing the noose, pressure should be made by the finger on the included texture, so as to make sure that it is the artery. In making the downward dissection, caution is neces- sary near the clavicle; lest, first, the supra-scapular artery be wounded; and, afterwards, lest the vein should sustain injury. The artery, if cut, proves troublesome by hemorrhage; and, besides, the vessel is important as a means of collateral circulation after obstruction of the main trunk. In the great depth which has sometimes to be encountered in this situa- tion, assistance may be derived from one or other of the auxiliary needles which have been invented; but it has so happened, hitherto, that the ordinary instrument, in skilful hands, has been found quite sufficient. In all cases, however, difficulty is to be contemplated; and in the dis- section allowance must always be made for the increased depth of the vessel's site, resulting from displacement of the shoulder upwards by the axillary tumor. To secure the middle third, a plan of incision very similar to that just described will suffice. The fibres of the scalenus are cut across with the greatest possible caution, so as to avoid injury of the phrenic nerve, which may be expected towards the inner margin ; and the noose is applied with equal caution, to avoid, as far as possible, the arterial branches of this part of the vessel. To expose the internal third, on the right side, let an incision be made a little above the clavicle, more anteriorly than in the former operations ; and into this a second incision is made to fall, along the inner border of the sterno-mastoid. The sternal attachment of this muscle is then divided and turned aside, outwards. The sterno-hyoid and sterno-thyroid muscles, having been exposed, are divided cautiously from their outer border, and displaced forwards. The lower part of the carotid may then come into view; this is traced downwards, until the subclavian is reached; and this vessel is to be secured, neatly and accurately, as near as possible to the origin of the vertebral, so as to afford space enough between the ligature and the origin of the carotid. Ihe textures to be avoided are the par vagum, and its recurrent branch, the cardiac branches of the sympathetic, the pleura, and the vein. The needle is passed from below upwards, to avoid wounding the pleura and right vena innommata. The operation is one of great difficulty, and not auspicious of a prosperous issue. The varieties of distribution to which the arteries of the neck are liable bear an important relation to the operations just described, and should ever be remembered and calculated upon by the surgeon.1 i Vide Quain on the « Arteries," with special reference to this subject. For the statis- tics of ligature of the subclavian, see Norris, American Journal of Med. Sclent^, July, 1845. DELIGATION OF THE AXILLARY. 291 Deligation of the Axillary. Modern surgeons seem to have almost agreed, that this vessel should not be made the subject of operation, unless in the case of wound of itself; when the general principles of surgery are to be fulfilled, by cutting down upon the bleeding point, and placing a ligature above and below the aperture. In the case of aneurism high in the arm, encroach- ing so far upwards as to render deligation of the humeral either unad- visable or impracticable, the axillary, no doubt, may be secured; but it is an easier, more feasible, and altogether preferable operation, to tie the subclavian in its external third. Like the subclavian, the axillary artery is surgically divided into three portions ; an upper, middle, and lower. And supposing that we have determined on deligation of the axillary, in preference to the sub- clavian—as, probably, will very seldom be the case—either the lower or the upper third will be selected, seeing that the middle is so covered and mixed up with other textures, as to be almost inaccessible—with safety. The operation, accordingly, is said to be either superior or inferior. The superior operation is performed thus: The patient haAring been placed recumbent, with an assistant ready to compress the subclavian in case of accident, an incision is made, about three inches in length, and of a semilunar form—with its convexity downwards ; commencing about an inch from the sternal extremity of the clavicle, and extending towards the acromion. Or a similar extent of wound may be made, with its convexity upwards, terminating at the anterior margin of the deltoid. In the one case, the clavicular portion of the pectoralis major is at once cut across in the deep dissection ; in*fche other, the intermus- cular space is dilated. Care must be taken to avoid the cephalic vein and thoracico-acromialis artery. To expose the latter vessel, however, is scarcely an untoward occurrence, as it may happen to prove a conve- nient guide to the vessel of which we are in search. The deep fascia and fat are carefully cut through ; and it may be necessary to turn down the upper border of the pectoralis minor. The vein, probably, will then be first disclosed ; this is pressed inwards towards the ribs ; and, the artery having been carefully isolated to the requisite extent, the needle is passed from the thoracic to the acromial aspect. For the inferior operation, the arm is raised from the side, with the hand supinated. In the lower part of the axilla, thus exposed, the head of the humerus is felt; and over this an incision is made of about two inches in length, rather more to the posterior than to the anterior border of the axilla. Then, on dissecting through fascia and areolar tissue. the axillary vein and median nerve are likely to be exposed; the latter having been displaced outwards, and the former inwards, the artery will be brought into view. The needle is passed from the ulnar aspect. In the latter part of the operation, it is useful to relax the textures, by bending the forearm. 292 DELIGATION OF THE HUMERAL. Deligation of the Humeral. The brachial or humeral artery may be secured at any part of its course ; on account of aneurism, true or false; on account of wound of the vessel itself; or on account of an otherwise uncontrollable hemor- rhage from either the hand or the forearm. The arm having been steadied on a convenient table with the hand supinated, the operation is conducted thus :— In the upper part of the arm, an incision of about two inches in length is placed over the vessel—felt pulsating—along the inrier border of the coraco-brachialis muscle ; and care is taken to avoid the basilic vein and internal cutaneous nerve, which may lie in the way. The fascia having been divided, the ulnar and internal cutaneous nerves, on the inside—the external cutaneous and median nerves, on the outside— the brachial veins close on each side—are avoided; the arm being bent, for the purpose of relaxing these tissues, if necessary. And the vessel having been isolated, the needle is passed from the ulnar aspect. Some- times the median nerve is superficial to the artery. At the middle of the arm, the incision is made along the inner border of the biceps muscle, which, overlapping the vessel, may require to be raised slightly. The median nerve is to be expected, superficial to the bloodvessels ; and while this nerve is displaced inwards, and the muscle held outwards, the artery may be separated from its veins and secured. It is right to remember, however, that, in this situation, the inferior profunda may be mistaken for the main trunk, and also that, if there be a high division of th^ humeral, one of the two vessels only may have been tied. Not until the surgeon has been fully satisfied on both of these points, should the operation be completed by approximation of the wound. In the case of high division, the second trunk, if not close to the other, will be found either along the inner intermuscular septum, in a line with the inner condyle of the humerus; or near its usual situa- tion, but deeply placed, and covered by fibres of the brachialis anticus muscle. In the lower part of the arm, the median nerve is to be expected on the ulnar side of the artery; but it is seldom that we are called upon to operate in this situation ; not, indeed, unless for wound of that part of the vessel. At the bend of the arm, false aneurism of the humeral is proverbially common. Its nature and progress have been already described (Prin- ciples, 3d Am. Ed. p. 523). If prevention by methodical pressure have failed, the sac is to be cut into, and the vessel secured by ligature above and below the aperture, in recent cases. In tumors of old stand- ing, deligation of the humeral, near its middle, is a simpler and equally effectual operation (Principles, 3d Am. Ed. p. 557). Varicose aneurism, occurring at this site, requires the same treatment as the ordinary form of tumor. For aneurismal varix, support by careful bandaging is usu- ally sufficient (Principles, 3d Am. Ed. p. 559). DELIGATION OF THE ARTERIES OF THE FOREARM. 293 Deligation of the Arteries of the Forearm. Deligation here is seldom if ever required, except in the case of he- morrhage from injury of the arteries themselves ; and then it is suffi- cient to dilate the existing wound, and to secure the bleeding point, or Fig. 124. • Deligation of the Humeral, Radial, and Ulnar Arteries; also of the Palmar Vessels. points, in the usual way. For secondary bleeding in the palm, ligature of both ulnar and radial would not suffice; the interosseous must also be secured. And, instead of this threefold and difficult operation, it is infinitely better at once to perform that which, while much simpler, is equally effectual—deligation of the humeral a little below its middle. The radial and ulnar arteries are most easily reached at the lower part of the forearm. For the radial, an incision is made on the radial side of the flexor carpi radialis. For the ulnar—made more superficial by bending back the hand and fingers1—the wound is placed on the radial side of the flexor carpi ulnaris. Near the elbow joint, the vessels 1 Malgaigne, Brit, and For. Med.-Chir. Rev. July 1848, p. 2G5. 294 DELIGATION OF THE ARTERIES OF THE FOREARM. can be exposed only through a great thickness of muscular tissue. The prolongation of the radial, between the metacarpal bones of the thumb and forefinger, may be exposed by an incision on the ulnar aspect of the extensor secundi internodii pollicis. Wounds of the Palmar Arch are apt to be troublesome by bleeding, both primarily and secondarily. In recent wounds, all bleeding points should be secured by ligature; dilatation being practised, if necessary, and moderate pressure afterwards applied. For bleeding occurring after the lapse of some days, exposure of the wound, with application of energetic pressure (Principles, 3d Am. Ed. p. 341), should be had recourse to; and if this fail, then deligation of the humeral should be practised. Ramsden, Practical Observations, &c. London, 1811. Liston, Ed. Med. and Surg. Journal, vol. xvi. p. 348. A. Burns on the Surgical Anatomy of the Head and Neck, Edin. 1824. Dietrich, Das Aufsuchen, &c. Nurnberg, 1831. Manec on Ligature of Arteries, Paris, 1832. Harrison, Surgical Anatomy of the Arteries, Dublin, 1833. A Cooper, Guy's Hospital Reports, vol. i. p. 53, 1836. R. Quain, Anatomy of the Arteries with large plates, Lond. 1840. CHAPTER XX. AFFECTIONS OF THE BEND OF THE ARM. Venesection. This little operation—at one time, it is to be feared, too frequently performed—is conducted thus: The patient having been placed erect semierect, or recumbent, according as it is wished to withdraw much blood or otherwise (Principles, 3d Am. Ed. p. 159), a ligature—-a ribbon, or bandage, or small tourniquet—is placed on the upper part of the arm, and secured with sufficient tightness to arrest the venous return, yet not so tightly as to interfere with the arterial influx—as indicated by the pulse at the wrist. The veins at the bend of the arm, thus made tense and bulging, are scrutinized with a view to selection. A branch which is superficial, and large enough to emit freely, is to be preferred, for obvious reasons; and, if possible, the median cephalic is chosen; for then we are less likely to interfere with the brachial artery, the fascia of the forearm, or the cutaneous nerves; and thus are avoided the risks of aneurism, diffuse inflammatory infiltra- tion, and neuralgic pain. But if no vessel ex- cept that over the brachial is found suitable— as not unfrequently happens—then the opera- tion must be conducted there with especial cau- tion ; care being taken merely to open, not to transfix the vein. The arm is placed nearly in a middle posture between pronation and supina- tion ; and precautions are taken to secure its being retained in that position unmoved. By the fingers or thumb of one hand—and it is well that the surgeon be ambidextrous in this pro- ceeding—the vein is steadied; and, pressure being made at the same time on the distal aspect, spirting from the puncture is prevented. The lancet—neither too spear-pointed nor too rounded in its blade—held between the finger and thumb of the other hand, is introduced obliquely across the track of the vessel; and by gentle movement of it a sufficient aperture is made—the instrument being made to cut more with the shoulder than with the point, so as to insure the superficial part of the wound being considerably more free than the venous orifice. Then the Illustration of Venesection at the bend of the arm. 296 ACCIDENTS OF VENESECTION. blood is allowed to flow. If the stream grow sluggish, movement of the fingers will tend to its increase by forcing the contents of the inter- muscular veins to the surface, and accelerating the general venous ^ re- turn ; but care must be taken to avoid any deviation from the original position of the limb, otherwise an overlapping of the wound by integu- ment will necessarily follow. The desired effect having been obtained, the ligature on the arm is slackened and removed ; a thumb is placed on the wound; the arm is sponged and made clean; a neatly fitting graduated compress is applied; by a bandage passed in the form of the figure 8, all is secured; and the limb is placed comfortably in a bent posture, supported if need be by a sling. Within forty-eight hours, the bandage may be safely withdrawn; but it is well to avoid use of the arm for some days. Accidents of Venesection. 1. Thrombus.—By this term is understood an accumulation of co- agulated blood in the areolar tissue between the vein and integument; caused probably by overlapping of the latter ; interfering with, and per- haps arresting, the flow of blood at the time of the operation; produc- ing an inconvenient swelling afterwards, and not unfrequently inducing troublesome suppuration in and around the wound. The accident is to be avoided, by a suitably free opening being made at once, and by maintenance of one position of the arm throughout the whole proceed- ing. When thrombus has formed, the coagulum should be carefully removed, an enlargement of the wound being had recourse to, if neces- sary, and then a suitable compress is accurately applied, so as to keep the tissues in close contact. 2. Neuralgic pains may invade the limb ; dependent, probably, on puncture of a cutaneous nerve. To avoid such accident, place the wound where this texture is least likely to be impli- cated ; to cure it, dilate the wound by incision, and apply an anodyne epithem. 3. Simple erysipelas may follow, and the ordinary treatment is required (Principles, 3d Am. Ed. p. 367). 4. Angeioleucitis may occur per se, or in conjunction with the preceding affection. There is no peculiarity in the treatment (Principles, 3d Am. Ed. p. 581). 5. Not unfrequently, diffuse inflammatory action occurs beneath the fascia, which has probably been injured by puncture. Free incision is impera- tively necessary; otherwise serious results, both local and constitutional, are almost certain to ensue. 6. Sometimes this last accident is associ- ated with a superficial and simple erysipelas, or erythema. 7. Aneuris- mal formations have been already considered. And in reference to these it is well to remember, that the arteries of the forearm, following an unusual course, may be found quite superficial, and not unlike the ordinary veins. Hence a careful examination of the part should uni- formly precede the performance of phlebotomy.1 1 Lately, a new variety of the aneurismal lesion has been observed ; the artery project- ing its contents through the wounded vein, and forming an aneurismal sac by condensation of the areolar tissue exterior to the vein. The deep wound of the vein is closely incor- porated with that of the artery ; and the superficial venous aperture is continuous with the arterial sac.—Brit, and For. Med.-Chir. Rev. April, 18o0, p. 338. Sometimes, too, the aneurismal communication is not with the superficial, but with a deep vein.—Ibid. p. 349. AFFECTIONS OF THE BURSA OVER THE OLECRANON. 297 Affections of the Bursa over the Olecranon. From habitual pressure, as in the miner, this bursa is liable to chronic enlargement, and the affection is to be treated in the ordinary way, by abstraction of pressure, and the application of discutients (Principles, 3d Am. Ed. p. 511). Acute bursitis is a frequent consequence of blows on the elbow, and is usually associated with an erysipelatous affection of the surface. Treatment is by puncture and general antiphlogistics, and if matter form within the bursa, it should be early evacuated by free incision. Lisfranc, Nouvelles Considerations sur la Saignee du Bras, Paris, 1813. Abernethy on 111 Effects of Bloodletting, Surgical AVorks, vol. ii. p. 133, Lond. 1815. AVardrop on Bloodletting, &c. Lond. 1825. Marshall Hall on the Eifects of Bloodletting, Lond. 1836. CHAPTER XXI. AFFECTIONS OF THE WRIST AND HAND. Ganglia and Thecal Collections. Ganglia frequently form on the wrist and back of the hand. When troublesome as well as unseemly, they may be got rid of, either by pressure, or by puncture of the cyst (Principles, 3d Am. Ed. p. 513). Collections of glairy fluid often occur in the thecse of the flexor tendons in the lower part of the forearm, with or without loose bodies contained, forming a soft bulging swelling, which usually extends also to the palm, and more or less seriously interfering with the functions as well as with the symmetry of the limb. In the worst cases, it has lat- terly been the practice to make a free evacuating incision, dividing the annular ligament at the wrist completely through, in the belief that thus tension during subsequent inflammatory accession will be avoided. But experience has yet to show that the deformity and loss of power which result from condensation and deposit among the tendons by such cure, are less than those which attended the previously existing state of parts (Principles, 3d Am. Ed. p. 512). According to M. Velpeau, it is most safe and effectual to evacuate the contents by a trocar's puncture, and then to inject iodine, as in the cure of hydrocele. Paronychia. No affection is more common than paronychia, or Whitlow, more especially among washerwomen, cooks, nurses, and others, whose fingers, by the nature of their avocations, are not only kept prone to the assumption of inflammatory action, but also much exposed to the application of its exciting causes. The disease varies both in site and intensity. 1. There is a mild form, limited to the very surface. The finger, at its point, and perhaps in its whole extent, is intensely hot and painful, red, and somewhat swollen, and vesications may be in process of form- ing. Treatment consists in leeching, fomentation, and general anti- phlogistics. Or, as is more frequently practised, the part is rubbed lightly over with nitrate of silver, so as to blacken and desiccate the sur- face (Principles, Z& Am. Ed. p. 178). Resolution is usually effected, but often not without the formation of one or more vesicles, which sometimes degenerate into superficial ulcers of an irritable character. PARONYCHIA. 299 Fig. 126. The disease usually commences at the root of the nail, a hot and pain- ful blush of redness surrounding this, and hence the term. In conse- quence of the matrix of the nail, in many cases, being primarily and permanently affected, shedding of the nail need be no unlooked-for event. 2. A somewhat more serious action is found to pervade the subcuta- neous areolar tissue, as well as the skin; bearing the same analogy to the former affection, as phlegmonous erysipelas does to erythema. It is usually caused by a puncture, laceration, or other wound; with or without inoculation of irritant matter. The swelling, heat, redness, tension, and pain are greater; and there is a proneness towards acute suppuration. Treatment must be proportionally active; copious leech- ing, at the sides of the finger ; or free puncturing of the affected parts ; active constitutional antiphlogistics; fomentation and poultice; early incision, if need be, as in phlegmonous erysipelas—not waiting till diffuse suppuration has formed (Principles, 3d Am. Ed. p. 372). 3. The Avorst form is the most deeply seated; and, unfortunately, not the least frequent in occurrence. The action originates in the deep fibrous textures ; sometimes, there is every reason to believe, in the peri- osteum, or immediately exterior to it. Pain is excruciating from the first. For days and nights the patient may enjoy not a moment's sleep, or respite from suffering. Ten- sion and throbbing are early and intense; so are the swelling, heat, and redness. The back of the hand, and sometimes part of the forearm, are red and greatly engorged with serous effusion. Matter forms early in the finger; deep and confined, and consequently with aggravation. The constitution labors under inflammatory fever, often severe. At the out- set, active antiphlogistics, locally and generally, are to be employed— copious leeching, fomentation and poultice, purging and antimony— Fig. 127. with the hope of averting suppu- ration. Failing these, there is no relief to suffering, and no means of averting SerioUS de- The illustration carried farther; after maceration. struction of texture, but by early and free incision. It seems harsh practice to lay a finger open through- out almost its whole extent, on the palmar aspect; but, soon after the infliction of such a wound, pain will rapidly abate, and in a short time the patient will probably be in a deep unconscious slumber. Free out- ward suppuration takes place; the swelling abates; bones, joints, and tendons are saved; and the finger recovers, tediously it may be, but well. Withhold the incision, and there comes no relief but on sponta- neous evacuation of the matter; and then bones are found carious or necrosed, joints are opened into, tendons are sloughing or have sloughed; Danger of delaying incision, in the worst form of paronychia, exemplified. Thumb lost in conse- quence. 300 ONYXIS. the fingers may recover, in some sense, but are stiff and useless; more frequently, amputation is demanded sooner or later. In both of the more severe forms, extension to the palm is by no means unfrequent. The same principles of treatment are to be fulfilled there as in the finger. But in incising, care must be taken to avoid, if possible, wound of the palmar arch. Sometimes the virulent form of paronychia is limited to the distal joint of the finger. Then exfoliation of the corresponding phalanx is extremely probable. But, fortunately, the whole bone seldom comes away; a portion at the articulation remains; and, from this, regene- ration may take place, with but little ultimate deformity. Onychia. This term denotes a diseased condition of the matrix of the nail; the result of a chronic inflammatory process, inducing intractable ulceration. The first indications are pain, swelling, and redness around the root of the nail; and, on pressure being applied, an ichorous discharge oozes from beneath the cuticle at this part. The nail separates more and more, and is ultimately detached; disclosing an angry ulcer, of irregular margin and tawny surface, surrounded by dusky redness, emitting a thin fetid discharge, and the seat of intense pain. Usually, an aborted re- production of the nail protrudes from the upper part of the sore. The indications of treatment are simple. To pluck away the stunted nail; by an escharotic—as the potassa fusa or nitric acid—to destroy the morbid texture; and, on separation of the slough, to make such appli- cation to the sore as its varying state may seem to require. In almost all cases, however, local treatment is not alone sufficient. The general health will be found greatly disordered. Alteratives and tonics are necessary; and, in some cases, a mild mercurial course is followed by the best effects. Certain cases are very obstinate, and to such the term Onychia ma- ligna has been applied; inappropriately, however, inasmuch as the sore, however unmanageable, possesses none of the characters of true malig- nancy ; in such cases, the escharotic application must be made with un- usual intensity; or, under chloroform, the diseased parts may be shaved off with a knife; and if, by this means, a satisfactory granulating surface cannot be obtained, it is well at once to perform amputation of the phalanx. This summary procedure is still more especially indicated, in those examples of the inveterate form in which the bone has become involved. Onyxis. Onychia occurs in both toes and fingers. Onyxis is usually confined to the former. By this term is understood a faulty condition of the margin of the nail, original or secondary; causing, or connected with, an irritable fungous sore of the soft parts. The root of the nail not unfrequently is surrounded by a red and swollen integument. The TUMORS OF THE METACARPAL BONES. 301 general matrix is sound; but, occasionally, onychia follows on the minor affection. Whether the nail have been originally to blame, or not, it is very important to remove its injurious contact with the angry sore beneath. For this purpose, either mild or rude measures may be employed; the former in the first instance. The nail is softened, and, having been scraped thin, has its edge gradually and gently elevated above the fungous granulations; and then there is interposed a layer of soft lint, or other suitable substance. The nail haA'ing been thus permanently elevated, the freed sore abandons its irritable character, and may be brought to heal under the ordinary applications. But, failing such measures, partial evulsion of the nail is to be had recourse to; a harsh seeming remedy, but very effectual. The nail having been softened and thinned, as before, the blade of a strong sharp-pointed scissors is run up from the point to the root; the nail is severed at that part by one stroke; the isolated portion of nail, usually about a quarter of the whole, is then laid hold of by strong dissecting forceps, one blade of which is pushed beneath, and, by a sudden wrench, evulsion is effected. Unless under chloroform, the pain is great, though momentary. Hot poultice or water-dressing is applied. A healthy character of sore, generally, soon appears, and healing is not long delayed. Contraction of the Palmar Fascia. The whole aponeurosis may be rigidly contracted; or a portion only, connected with one or more fingers. When the whole is involved, all the fingers are rigidly bent, and the hand consequently is not only much deformed, but almost entirely useless. The disease is most frequent in those who use the fingers much, and is but little amenable to treatment. Obviously, the change depends on a chronic inflammatory process affect- ing the aponeurosis; and is to be met in its early stage with leeching, mercurial friction, local use of iodine, &c. The partial form is common in those of the better ranks, who are much given to horseback exercise and other field sports. In some of these cases, amendment may follow subcutaneous division of the affected portion of fascia, the finger being subsequently straightened by the application of a splint and bandage. Spastic flexion of the thumb not unfrequently occurs during child- hood, in connection with intestinal irritation. It is treated by the application of splint and bandage, while, by purgatives and alteratives, the primae vise are rectified. Those who write much are liable to troublesome spasm of the thumb, sometimes called writers' cramp. Treatment consists in rest of the part, with tonics constitutionally and locally. Tumors of the Metacarpal Bones and Phalanges. Exostosis may occur, but is rare. Treatment is seldom, if ever, re- quired, the affection proving but little troublesome. Osteo-cystoma [Principles, 3d Am. Ed. p. 454) is more common. Its treatment depends upon the bulk. If small, it is incised; and, on pressure being subsequently 302 OTHER DISEASES OF THE METACARPAL BONES. Fig. 128. applied, contraction and healing will probably ensue. Or, if need be, a seton is passed, and temporarily retained; and thus the desired ob- literation is effected. Those of large size, involv- ing the whole periphery of the bone, warrant amputation of the affected part. Enchondromata (Principles, 3d Am. Ed. p. 453) have here their most frequent site. If small and external, the tumor is dissected off, and the bone left uninjured. Those which affect the whole bone require ampu- tation. Generally, the tumors are not single; yet, usually, we are able to save a part, and sometimes the greater part, of that most useful organ, the hand; the avowed non-malignancy of this tumor admitting of incisions being made very close to the morbid formation. Sometimes, how- ever, the size and connections of the tumor are such as to demand amputation of the whole hand. Lately, I had occasion to remove one of great size, weighing fourteen pounds. From the apex of the tumor, repeated and serious hemorrhage had taken place; and, it was satisfactory to find, on a careful exami- nation after injection, that the blood had escaped from ulcerated open- ings in large superficial veins, not from any degeneracy in the structure of the tumor itself. The Large Jinchondroma re- ferred to. a. A section made to show structure, b. The ulcer- ated surface, whence the bleed- ing came. For the microscopic characters, see Principles, Am. Ed. p. 305. Other Diseases of the Metacarpal Bones and Phalanges. These bones are especially liable to the inflammatory casualties__ ulcer, caries, and necrosis. The ordinary treatment is'to be put in force. When, as a last resource, amputation is unavoidable, one gene- ral rule should never be for- FiS- 129- gotten, viz.: that it is our duty to save as much as circumstances will possibly permit; a portion of the original hand being a much better organ of prehen- sion, than any artificial substi- tute, however ingeniously con- structed. Frequently, in consequence of whitlow, or inflammatory action trau- matically induced, it may be in our power to retain a finger, but not without complete anchylosis of all its articulations. And, under such circumstances, it comes to be a question whether it were not better to amputate such a member at once, before anchylosis and cicatrization have occurred; thereby not only shortening the cure, but also render- ing the hand much more useful, especially in the case of the laboring man, by whom a stiff finger is felt to be constantly in the way. I be° lieve that the question is to be answered in the affirmative—in favor of Scrofulous Necrosis of Finger ; macerated; after ampu- tation. CONGENITAL DEFORMITIES OF THE HAND. 303 amputation. The thumb, however, is in all circumstances to be pre- served, if possible. Rigid or not, it proves extremely serviceable. Another question arises in the case of a hopelessly diseased meta- carpal bone, whose corresponding finger is perfectly sound. May the metacarpal bone be removed alone, or must the finger be taken along with it ? The latter is the preferable practice. The finger left without its metacarpal bone is worse than useless. Two or eA7en three metacarpal bones, Avhen carious, may be removed, with their corresponding fingers. The operation is preferable to ampu- tation of the whole hand. For the paramount general rule of saving as much as possible, should ever be respected in such cases. Some years ago, in amputating a metacarpal bone, its base was found carious, and also the corresponding portion of the carpal range. The latter diseased part was removed by means of a gouge ; and a most satisfac- tory cure resulted. Hypertrophy of the Fingers. This rare departure from ordinary nature, has been occasionally noticed in young people; affecting one or more fingers; originating from no assignable exciting cause; consisting of true hypertrophy of all the textures—bones, joints, tendons, skin, and nails ; and accom- panied with more or less deformity, and loss of function. Firm and continued pressure may moderate the unnatural growth. If not, incon- venience may be mitigated by amputation—partial or complete. Congenital Deformities of the Hand. Supernumerary fingers are usually attached, not by articulating apparatus, but by ordinary integumentary tissues. Their amputation is accordingly very easily effected. Webbed fingers are often hereditary; and in some parts of the country are held in esteem. Should their amendment be wished, that is obtained by division of the abnormal band ; great care being taken, during cicatrization, to prevent reunion of the opposed parts. And, for this purpose, interposition of dressing is not enough ; it is essential, as in the case of burns (Principles, 3d Am. Ed. p. 645), to make con- stant and considerable pressure on the angle of union, at the knuckles; and this is done by means of a piece of cord or tape, placed and re- tained there. Club-hand, a condition of the hand analogous to club-foot, occasion- ally occurs. It is remediable, at an early age, with or Avithout the aid of tenotomy, by the wearing of suitable apparatus. And to the ma- chinist, the management of such cases is usually intrusted. It is also the province of that profession to 'atone, by mechanical substitutes, for deficient development of the hand or fingers. Vogt, de Paroncychia, Viteb. 1803. Wardrop, an Account of some Diseases of the Toes and Fingers, &c. Med.-Chir. Trans, vol. v. p. 129. Duteil, Dissertation sur la Panaris, Paris, 1815. Craigie, Pathological and Practical Observations on Whitlow, Ed. Med. and Surg. Journal, April, 1828, p. 255. Dupuytren, Clinique Chirurg. t. i. art. 1. CHAPTER XXII. DISEASES OF THE ARTICULATIONS OF THE SUPERIOR EXTREMITY. Disease of the Shoulder-Joint. This joint, like others, is liable to the ordinary affections of such parts. But it is, perhaps, especially liable to disorganizing disease, involving all textures ultimately, and usually originating in the cancel- lated tissue of the head of the humerus. To this the term Omalgia was formerly applied; very inappropriately, because apparently infer- ring that the disorder was of the nature of irritation, or neuralgic, not structural and inflammatory. It may occur at any age ; and very fre- quently its origin is connected with external injury. One of the first and most prominent symptoms is wasting of the deltoid; ultimately giving a prominence to the acromion. The arm is incapable of exertion ; and pain in the joint is increased by motion, especially when the arm is raised. Bending takes place at the elbow; and the limb projects awkwardly from the body, feeble and wasted, and apparently increased in length. The shoulder simulates luxation. And, at length, this result may actually occur; disorganization of the joint having become com- plete. The constitution does not fail to suffer in sympathy with the progress of this grave disorder. Swelling, as usual in primary affections of the hard tissues, is of secondary occurrence, and is seldom very great; evacuation, by external opening, being soon attained by nature's own effort. [Paralysis of the deltoid muscle, from a blow received upon it along the course of the musculo-spiral nerve, whereby the latter is injured, may simulate more serious organic disease. The muscles about the shoulder waste, the arm droops, motion is impaired and painful. A careful inquiry into the history of the case, and an attentive examina- tion of the local condition and of the state of health of the patient, will lead to a correct diagnosis. The prognosis depends very much upon the severity of the injury. The treatment consists in the use of the cold douche, stimulating frictions, blistering, the endermic employment of strychnia, electricity, &c.—Ed.] Treatment is to be conducted on the general principles formerly ex- plained (Principles, 3d Am. Ed. p. 515). But, true caries having been established, with an open condition of the joint, it becomes very impro- bable that spontaneous cure will take place; and usually the general health is then seriously and obviously on the decline. In such circum- RESECTION of the shoulder-joint. 305 stances, the diseased parts must be removed by operation, by amputation of the limb, or by resection of the joint. The latter operation is obviously preferable, when not contraindicated (Principles, 3d Am. Ed. p. 502). Resection of the Shoulder-Joint. To expose the articulation, a flap may be made from the outer and forepart of the deltojd; or a single incision may be placed longitudi- nally, over the outer aspect of the joint, the knife being entered below the aero- FiS- 130> mion, and pushed at once doAvn to the head of the humerus. In many cases, the latter mode is quite sufficient; and, being less severe, is to be preferred. The knife and finger having penetrated the joint, the remaining portions of the retaining apparatus are divided—more especially the muscles inserted into the tuberosities of the humerus, towards which the finger is the best guide—and the diseased head is then made to show itself, and project through the wound; the limb being with this view brought forcibly across the thorax. By a saw abbreviation is made to the required extent. The glenoid cavity is then examined; and, if found diseased, the affected part is taken away, by means of cross cutting pliers, or by a gouge. the parts are accurately reponed; the wound is brought together, and the limb is retained steadily in a convenient posture. Healing by granu- lation is to be expected ; with the formation of an artificial joint, more or less competent to assume the functions of the original. Often it proves, in all respects, an admirable substitute. And thus many useful limbs may be retained, under circumstances, which, but a few years since, would have called for nothing short of amputation. The operation may also be required, primarily, on account of injury done to the bone, as by gunshot wound. [It has seemed necessary, in some instances, to make much more extensive ablations from this part of the body, including even the whole scapula and clavicle, together with the arm, or subsequently to the removal of the latter. In 1837, Dr. Mussey, now of Cincinnati, removed the entire scapula and clavicle at one operation, having six years before removed the humerus of the same person at the glenoid cavity. In 1K3K, Dr. Geo. McClellan, of this city, amputated the whole of the upper extremity at one operation, including the arm, scapula, and clavicle; the latter being sawn through at its junction with the sternum—the stcrno-clavi- cular articulation not being opened. In 1841, Rigaud, of Strasbourg, removed an arm at the shoulder-joint; and, in the following year, the 20 Flap, placed in position, after resection of the shoulder-joint. Bleeding having been arrested, 306 RESECTION OF THE SHOULDER-JOINT. disease having implicated the scapula, he removed the whole of this bone, together with the outer extremity of the clavicle. In 1847, Mr. Fergusson removed the whole of the scapula and a part of the clavicle; three years after the arm had been taken off at the shoulder. These operations, with the exception of that of Rigaud, which was done for a gunshot injury, were performed for chronic diseases invoking the bones. Besides these, numerous smaller operations have been done in every country. It were hardly necessary to describe the mode of proceeding in such cases, the plan of operation being simple enough. In the case operated on by Dr. Mussey, the tumor which formed upon the shoulder was round and prominent, measuring horizontally over the summit, from the anterior to the posterior margin of its base, fourteen inches, and from the upper to the lower margin of its base, ten inches. The integuments were dissected from the clavicle, the bone disconnected from the ster- num ; its sternal end elevated and detached from the subclavius muscle, so as to admit of the finger of an assistant being passed under it to secure the subclavian artery. Having tied this vessel, Dr. M. divided the accompanying vein, when a bubble of air entered it, which caused the patient instantly to swoon, and he was roused with much difficulty. " The immense wound, with flaps of seven or eight inches in extent, united by adhesion, and became consolidated, literally without the form- ation of a teaspoonful of pus. In less than three weeks, the patient was dismissed, and he rode home in a stage-coach between thirty and forty miles," (Chelius, South's Ed. Philad., 1847, vol. iii. p. 765.) Mr. Fergusson's patient was suffering from caries of the scapula. His [Fig. 131.] [Fig. 132.] [Fig. 131. Flan of Mr. Ker^usson's Operation; the [Fig. 132. Appearance of the Scapula and Acromial black lines representing the incisions.] end of the Clavicle of Mr. Fergusson's patient.__Ed.] RESECTION OF THE ELBOW-JOINT. 307 operation is described in his Practical Surgery (Am. Ed. 1853); and is illustrated by the accompanying draAvings. (Figs. 131, 132.)—Ed. [See Chelius, vol. iii.; Fergusson's Practical Surgery; McClellan's Principles of Sur- gery; American Journal, vol. xxi. 1837.—Ed.] Resection of the Elbow-Jo int. Few affections are more common than articular disease at the elboAv; and, not unfrequently, it advances to disorganization, with or without strumous complication. To this joint, more than any other, the opera- tion of reseGtion is applicable. Care being always taken to select the case according to the ordinary tests (Principles, 3d Am. Ed. p. 502), lest, resection failing, amputation become necessary, and we discover, when too late, that the patient, who could have stood.one operation well, must inevitably sink under both. The patient having been placed prone on a table, or seated with his back to the surgeon, and with the arm ex- tended and held by an assistant, the joint is exposed from behind, by cut- ting, so as to form flaps: and the flap may be single, double, or quadruple; or thus I___. I In freeing the soft parts from the inner condyle, and reflecting them over it, care is necessary to keep the ulnar nerve free from harm. The Fig. 133. Incision marked for resection of the Elbow. r 308 RESECTION OF THE WRIST. insertion of the triceps having been cut across, on bending the arm the olecranon is made prominent; and this, having been separated from its connection with the soft parts, is removed by saw or pliers, to the requisite extent. The joint can now be very readily dislocated; the condyles of the humerus are isolated and sawed off; and the upper part of the radius, usually, is also removed—the saw being preferred, to avoid bruising of the soft- ened bone. Removal of the olecranon by pliers is mainly to facilitate disarticulation; afterwards it is usually necessary to saw away so much more of the ulna as may seem hopelessly diseased. Should any suspicious portions appear at or near the cut sur- faces, the gouge may be directed against them. Bleeding having been arrested, and the wound brought loosely together, the limb is secured in a slightly bent posture. Suppuration and granula- tion follow ; the wound slowly closes ; and an arti- ficial joint by ligamentous structure is ultimately constructed—often of remarkable usefulness. Caries of the Elbow; main- ly affecting the condyle of the humerus. The vegeta- tive effort around the carious surface well exemplified. Resection of the Wrist. It were easy enough to remove by operation the articulating ends of the radius and ulna, and to gouge out the affected parts of the corre- sponding surfaces of the carpal bones; but the proceeding is not found to succeed. And, consequently, when this joint is deemed irreclaimable, amputation is preferred. Fortunately, a vast proportion of the cases of scrofulous disease of this joint, in adolescents, recover under use of cod-liver oil, and general antistrumous treatment—with or without an- chylosis. Moreau, Resection des Articulations, &c. Paris, 1803. Roux, de la Resection des Portions d'Os, &c. Paris, 1812. Crampton, Dub. Hosp. Reports, vol. iv. 1827. Velpeau, Nouv. E16m. de Med. Operator, torn. i. Syme on Excision of Joints, Edin. 1831. CHAPTER XXIII. INJURIES OF THE SUPERIOR EXTREMITY. Fractures. Fracture of the Clavicle. The clavicle is frequently broken, and usually by violence applied to the acromial extremity, as by falls on the shoulder. The fracture is generally oblique, and near the centre of the bone. The limb is power- less, the part is pained and swollen, attempted movement aggravates the [Fig- 135.] pain, and the shoulder is both sunk and drawn towards the sternum. Dis- placement is caused by depression of the lower fragment, whereby the sternal portion is made very promi- nent, causing palpable deformity, and seeming to be out of place, though truly remaining nearly in situ, the action of the pectoral and sterno- mastoid muscles nearly neutralizing each other, and the bone being also steadied by the costo-clavicular liga- ment. The acromial portion is drag- ged downwards by the weight of the arm, and forwards and inwards by the action of the subclavius, the attachment of this muscle to the first rib being then the fixed point. [When the point of fracture is near the acromial extremity, where the bone is broad, there may be no displacement at first, and but little, perhaps, at any subsequent period. This is owing, partly to the breadth of the bone, and partly to the existence of ligamentous fibres, unruptured by the violence, which hold the fragments in apposition. Frequently, however, unless the accident is recognized and properly treated at first, some sudden movement, as in throwing a stone, or lifting any heavy article, separates the fragments and reveals the true nature of the acci- dent, at the expiration of a few days. When there is doubt, therefore, as to the existence of fracture, the patient should be carefully watched, or a fracture dressing be applied at once.—Ed.] The indications of treatment are plain, but unfortunately not very [The ordinary site of Fracture of the Clavicle (From Fergusson.)—Ed.] 310 FRACTURE OF THE CLAVICLE. Fig. 136. easily fulfilled. They are to raise the acromial portion to the same level with the sternal, to retain it there, and at the same time to keep the shoulder removed from the sternum, so as to prevent displacement inwards, and consequent "riding" of the ends of the bone. Many and complicated are the means devised for this end. The simplest, most easily obtained, and not the least efficient, are as follows: A wedge- shaped pad is placed in the axilla, sufficiently large to occupy that cavity completely. The best pad is made of horse-hair, covered with soft leather, but any temporary substitute may be taken at the first dressing. By means of a shawl or large handkerchief, within which it is placed, the pad is securely lodged in the axilla, and, by tying the ends over the opposite shoulder tightly, elevation of the shoulder, and consequently of the acromial portion of the clavicle, is effected; and the latter indication is farther contributed to, by placing the forearm in a short sling, well tightened over the elbow. To maintain extension of the bone is more difficult. Carry a bandage, handkerchief, or other ligature, across the chest, including the lower part of the arm on the injured side, arranging it so that the arm shall be both approximated to the chest, and carried well backwards, mak- ing the humerus a lever, which, acting on the pad as a fulcrum, forces the shoulder outwards. And, if need be, maintain approximation of both scapulae by means of a figure of 8 bandage, so as to complete and secure the read- justment. It is well also to relax the sterno-mastoid by attention to the posi- tion of the neck, for sometimes this muscle would seem to succeed in ele- vating the sternal portion slightly. Retention will be more easily effected in the erect or semi-erect than in the recumbent posture. The knot over the shoulder may gall the patient, and, to prevent this, the skin should be well protected by suitable padding. The application of pressure over the site of fracture can be productive only of evil. The integuments may be induced to slough, and an injury, originally simple, may be rendered compound. In females, for obvious reasons, the treatment is to be conducted with especial care. [We have seen no apparatus for the treatment of fracture, which answers the indications so well as that suggested by Dr. Fox, of this city. It is in common use here, and we have repeatedly seen cures effected by it without any perceptible deformity ; indeed, if proper care be exercised, the occurrence of deformity is the exception. The apparatus is composed of a ring, made of muslin, and pretty firmly stuffed with hair or cotton, to encircle the uninjured shoulder; a Simple Bandaging suitable for Fractured Clavicle. The sling omitted. FRACTURE OF THE BODY OF THE SCAPULA. 311 firm wedge-shaped pad, about half as long as the*humerus, having a piece of strong tape attached to each extremity of its base, for the pur- pose of securing it to the ring, after it has been placed in the axilla; and a sling, or pouch, of strong muslin, closed at one end and open at the other, in which the forearm is placed, the closed end receiving the elbow; this sling has sewed to each of its carpal flaps a piece of tape, and another piece to the humeral end, by which means it is secured to the ring. The accompanying figure will exhibit the modus operandi of this apparatus. A moment's inspection of the drawing shows hoAV well this appliance fulfils the indica- tions of treatment, and how readily [Fig. 137.] the acromial end of the fragment can be acted upon by tightening or loosening the tapes which secure the sling to the ring ; how exposed the broken bone is for the applica- tion of remedial agents and how comparati\*ely free and unincum- bered is the chest, and the mammse in females. Within the last few years, we have had the opportunity of test- ing a plan, recommended by a French gentleman, M. Guillou, and published by him in L'Abeille Medicate, October, 1847. The pieces composing the apparatus are numerous, but the plan con- sists essentially in fixing a pad in the axilla of the injured side, bringing the arm to the side, and securing the forearm behind the back, by suitable means. Fox's apparatus, applied somewhat differently from the ordinary way, would answer very well to accomplish the intention of M. Guillou's method. We have tried this in three cases of fracture of the clavicle, and have been perfectly satisfied with its operation. Our friend, Dr. Hollingsworth, has lately informed us that he has recently employed it, and with equal satisfaction. We believe that either of the methods now described is much superior to others in com- mon use. [Dr. Fox's Apparatus applied. Surgery.)- (From Sargent's Minor Ed.] For farther details concerning these apparatuses, see Sargent's Minor Surgery.—Ed.] Fracture of the Body of the Scapula. The body of the scapula may be broken across, by violence directly applied, or even by muscular force alone. There is but little displace- ment, or deformity. The part is pained, swollen, and limited in volun- tary motion, and, while movement is made, crepitus can be distinctly felt by the hand placed flatly on the part. In treatment, it is sufficient to restrain motion, by wearing the arm in a sling, and by having a 312 FRACTURE OF THE CORACOID PROCESS. [Fig. 138.] * broad flannel bandage passed tightly over the chest, including the fractured bone. Fracture of the Acromion. The acromion process may be detached from the spine of the scapula, by direct violence. There are pain, swelling, and loss of power, and a depression can be felt at the injured part, in consequence of the fractured portion being drawn downwards on the head of the humerus, by the action of the deltoid muscle. At the same time, the clavicle is drawn downwards and for- wards on the coracoid process, by the sub- clavius, and by the action of the deltoid and pectoralis major muscles overcoming that of the trapezius and sterno-cleido- mastoid. Crepitus is not felt on rotating the limb, until the arm has been raised, for then only can the fractured portions be brought into apposition. In treatment, it is sufficient to raise the arm fully by means of a sling, and to prevent motion by suit- able bandaging to the trunk. No pad should be placed in the axilla, otherwise the hiatus between the fractured portions will probably be increased. Union is generally by ligament. [The ordinary position of Fractures of the Body and Acromion process of the Scapula. (From Fergusson.)—Ed.] Fracture of the Coracoid Process. [Fig. 139.] This injury is also the result of direct violence. The fractured portion is displaced downwards, by the action of the coraco-brachialis, pectoralis minor, and biceps muscles. There are pain and swelling of the part, with loss of power in the limb; and crepitation is felt on rotating the limb, after the forearm has been flexed, and the arm carried across the chest, in order to relax the muscles connected with the process, and so to permit replacement of the fragment. In treatment, it is sufficient to make this relaxation permanent. The fin- gers of the injured limb are made to touch the shoulder of the opposite [Fracture of the Coracoid Process of the Sea- Slae, and that position is SCCUred by pula. (From Fergusson.)—Ed.] bandaging. FRACTURE OF THE NECK OF THE SCAPULA. 313 Fracture of the Neck of the Scapula. This accident, separation of the glenoid cavity and coracoid process from the body of the bone, is the result of great and direct violence, and, like the preceding, is of rare occurrence. Sometimes there is mere separation of the above-named parts; more frequently, the glenoid cavity is fissured and broken up. The detached portion of the scapula [Figs. 140 and 141.—Fractures of the Glenoid Cavity, and of the Neck of the Scapula in various directions. (From Fergusson.)—Ed.] is retained in close contact with the head of the humerus, by the long heads of the biceps and triceps muscles; and both the fragment and the head of the humerus are displaced downwards and forwards into the axilla, by the action of the subscapularis and pectoralis major, and of the other muscles connected with the upper part of the humerus. The appearances are very like those of dislocation ; there is the same flat- tening of the shoulder, with palpable prominence of the acromion, and vacancy beneath it; and the head of the bone may be felt plainly in the axilla; at first, too, there is no crepitation; and the limb is some- what lengthened. But, by very gentle effort, the head of the bone may be replaced—a thing very unusual, if not actually impracticable, in dislocation. Then crepitus may be plainly felt, on rotating the arm with one hand, while with the fingers and thumb of the other, pressure is made deep in the axilla and on the coracoid process ; then, too, flat- tening of the shoulder is made to disappear; but, on ceasing from manipulation, deformity and displacement are speedily reproduced. In treatment, a pad having been placed in the axilla, the shoulder is raised and the forearm supported by a sling. 314 FRACTURE OF THE NECK OF THE HUMERUS. Fracture of the Neck of the Humerus. 1. Fracture at the Anatomical Neck.—Occasionally, the bone gives way at this point, but not so frequently as beloAv the tubercles. The injury is the result of direct violence, and intracapsular. There is but little displacement or deformity ; the lower fragment being retained in its ordinary position by the muscles inserted into the tubercles. The chief signs are pain, impairment of motion, and crepitus. Sometimes impaction takes place, the upper fragment being driven into the cancel- lous tissue of the lower ; then the signs are unusually obscure ; but the circumstance is favorable to osseous and speedy reunion. When there is no impaction, the detached head of the bone may become necrosed; and in that event, inflammatory disorganization may be expected, for extrusion of the sequestrum. Treatment of this form of injury consists mainly in preserving quietude in the parts. 2. Fracture, by Separation of the Epiphysis.—This also is the result of direct violence. The head of the bone remains in its place; while the shaft is carried forwards on the coracoid process, by the action of the muscles inserted into the bicipital ridges. There is little or no flattening of the shoulder ; the head of the bone can be felt in situ, motionless on rotation ; the end of the shaft, directed obliquely upwards and inwards, is felt and seen projecting on the coracoid process; the arm is shortened, with the elbow awkwardly projecting from the side ; by slight extension and coaptation adjustment is readily effected, and then crepitus is emitted on rotation. The most characteristic sign is the remarkable prominence over the coracoid, produced by the resting of the end of the lower fragment there. Sometimes impaction, how- ever, occurs; the lower fragment being driven into the upper; and this necessarily obscures the signs of injury. In treating this form of fracture, a pad is placed in the axilla; by two splints of pasteboard, wood, or leather, placed one on the outside, the other on the inside of the limb, retention is secured ;l the forearm is supported by a sling ; but the elbow is left free and pendent. Were pressure to be made on the elbow, by adjustment of the sling in the ordinary way, displacement of the lower fragment would inevitably be reproduced; whereas, by following an opposite course, a certain degree of permanent extension is maintained on the humerus, which is of use in preserving apposition. 3. Fracture of the larger Tubercle.—This is the result of direct violence. The joint is preternaturally broad ; the acromion projects somewhat; the deltoid is slightly flattened; the arm is powerless as to elevation; and two hard swellings are to be felt—one, internal to the coracoid process, the head of the bone—the other, beneath the acro- mion, the detached tubercle. Treatment is as in the previous iniury; with the whole forearm supported. 4. Fracture at the Surgical Neck.—This is also the result of direct violence. The upper fragment remains nearly in its place, moved 1 Sometimes the internal splint may be dispensed with. FRACTURE OF THE SnAFT OF THE HUMERUS. 315 slightly upwards and outwards by the action of the muscles inserted into the tubercles. The upper end of the lower fragment, or shaft, is drawn upwards and close to the side by the muscles inserted into the bicipital ridges ; while its lower end, at the elbow, is abducted by the action of the deltoid on its point of insertion. The appearances conse- quently are—no flattening of the shoulder, on the contrary rather a fulness ; the head of the bone felt plainly in situ, motionless on rota- tion ; the upper end of the fragmental shaft felt displaced on the side, and a depression plainly perceived at a corresponding point in the ex- ternal outline of the limb ; the arm shortened and powerless; the elbow abducted; crepitus, on rotation after adjustment. In treat- ment, a full-sized wedge-shaped pad is placed in the axilla ; splints are applied along the limb, the outer one extending from the top of the shoulder to the external condyle, the inner from the internal condyle to the axilla; the forearm is supported by a sling ; and again the elbow is left free and pendent. 5. Fracture with Dislocation.—Fracture at either neck may occur, in consequence of great and direct violence, and be accompanied with dislocation of the head of the bone. Fortunately, the combination is of exceeding rarity. The symptoms are necessarily complicated. But the diagnostic mark is sufficiently plain ; the head of the bone is felt lodged in the axilla, not moving along Avith the shaft in rotation. On readjustment, too, characteristic crepitus may be detected. Treatment is difficult. An effort is to be made, by direct manipulation, to reduce the head of the bone if possible—of course, under chloroform ; and if this be accomplished, then the case, having been reduced to one of frac- ture, requires the ordinary retentive treatment after due coaptation. Or, failing in direct coaptation, the fracture may be reduced and ar- ranged tightly in splints, so as to admit of reduction of the dislocation by extension being'attempted in the ordinary way. But, if the luxa- tion remain, notwithstanding every warrantable effort to remove it, then it were well to adjust the end of the shaft into the vacated glenoid cavity, and to retain it there for a time by splints, bandaging, and a pad in the axilla. The broken end becomes rounded off, assuming an articular character and function ; and the new joint is likely to prove more useful, than if reunion had been effected upon the displaced frag- ment in the axilla. Fracture of the Shaft of the Humerus. 1. Below the Bicipital Ridges, and above the Insertion of the Deltoid. —Here the position of the fragments is the reverse of what results from solution of continuity at the surgical neck of the bone. The upper fragment is drawn inwards, to the side, by the muscles inserted into the bicipital ridges ; while the lower is displaced outwards and upwards by the action of the deltoid, causing an abnormal prominence at this part of the arm—immediately above the insertion of the mus- cle—with an inclination of the elbow to the side. The characteristic signs are, the prominence just .spoken of, shortening of the limb, cre- pitus on adjustment and rotation, and adduction of the elbow. Coapta- 316 FRACTURE AT THE CONDYLES OF THE HUMERUS. tion haAdng been effected, splints are applied, a pad is arranged so as to keep the upper fragment separate from the chest, the forearm is sup- ported, and the whole is steadied and retained by suitable bandaging. 2. At the Middle of the Shaft.—At this point the nature of the injury is at once made apparent, by deformity, shortening, and power- lessness of the limb, with distinct crepitus emitted on the slightest manipulation. Reduction is easily effected, by extension and coapta- tion ; and retention is maintained by splints ; the forearm being also supported by a sling. 3. At the Shaft above the Condyles.—Here the solution of continuity is generally oblique ; sloping down from behind forwards. And the appearances simulate those of dislocation of both bones of the forearm backwards. The lower fragment is drawn upwards and backwards by the action of the biceps, triceps, and brachialis anticus. The limb is shortened ; and there is much bulging posteriorly. On extending the forearm, passively, the deformity is removed ; but on resumption of the flexed posture, it is instantly reproduced; and by this test the accident is sufficiently distinguished from dislocation. Crepitus may be plainly perceived, on combining coaptation with rotation. When the line of fracture follows an opposite direction, passing obliquely upAvards from behind forwards, the displacement is reversed; the lower end of the upper fragment projecting behind, while the upper end of the lower fragment is drawn upwards in front. Reduction having been effected, rectangular splints are applied on the inside and outside of the limb, and are retained by bandaging ; the rectangular position of the forearm, being obviously advisable, in order to relax the displacing muscles—the biceps, triceps, and brachialis anticus. The splints, made of pasteboard, leather, or gutta-percha, should extend from near the middle of the arm quite to the wrist. Diastasis may occur; separation of the epiphysis, with or without rotation. Reduction having been effected, by extension and coaptation, retention will be maintained best in the bent position. Fracture at the Condyles of the Humerus. 1. Of the Internal Condyle.—The line of fracture is oblique to the shaft, detaching the internal condyle. During flexion of the forearm there is little or no displacement; but, on extension, the ulnar is drawn upwards and backwards, by the action of the triceps, there being no longer any efficient resistance to the coronoid process. The signs are —crepitus, on direct lateral movement of the injured part; obvious dis- placement of the ulnar in extension, and replacement of it by flexion of the forearm. In treatment, the limb is arranged in a rectangular position, as for fracture above the condyles. But from time to time it is expedient to undo the apparatus, and practise passive movement of the joint, lest stiffening should occur. 2. Of the External Condyle.—There may be little or no displacement in any position of the limb. But crepitus is to be felt; more especially during rotatory movement of the hand and radius. Treatment is as in the preceding case. FRACTURE OF THE ULNA. 317 [Fig. 142.] Fracture of the Ulna. 1. Of the Olecranon.—This may be the result of direct injury, by a fall on the elbow; or of muscular action only, in violent and sudden extension of the limb. Usually, ligament as Avell as bone is torn; and, consequently, the olecranon, detached from the shaft of the ulna, is displaced upwards by the action of the triceps; leaving a vacant space where prominence should have been, and placing the prominence an inch or more above its ordinary site. Voluntary extension is impracticable; flexion aggravates the signs of the injury. On extending the limb, the dis- placement is in a great measure removed ; the two fragments are brought sufficiently near for satisfac- tory ligamentous union ; and in treatment, therefore, it is enough to maintain the extended position, by the loose application of a splint on the palmar aspect of the elbow-joint. Very accurate approximation, indeed, is not desirable; a compact ligamentous bond of union being equally serviceable as an osseous one, and much less liable to a second disruption. Like- wise, the risk of excessiAre osseous deposit is avoided, whereby the fragment might become inconveniently anchylosed, on its articulating aspect, with the end of the humerus. Compound fracture of the olecranon follows di- rect injury; and is invariably to be regarded as an accident of serious import; inasmuch as intense in- flammation of the joint is very likely to supervene. And this tendency to serious evil we should never lose sight of, in treatment; endeavoring to prevent traumatic arthritis, if possible; and when it has occurred, doing our utmost to avert disorganization. Not unfrequently, with the best care, the joint suppurates, and is with diffi- culty saved by anchylosis. Sometimes even amputation is demanded. [In such cases the splint recommended by Mr. Mayo, will be found very serviceable. It consists of tAvo pieces of light wood or metal, grooved so as to afford a comfortable resting-place for the limb, and con- nected together by a firm rod on each side, as represented in the figure, leaving a space between them to receive the injured elbow. This con- nection may be movable, yet so arranged as to be fixable at any angle; but the elbow should be kept at least partially flexed, so that if anchy- losis takes place, as it probably will, the patient will still possess a very useful limb. In all cases where there seems to be a possibility of securing imme- diate union of the edges of the wound in the soft parts, this should be accurately closed by adhesive plaster, and a piece of lint wetted with white of egg or some other adhesive fluid, should be placed over the whole wound. This primary dressing should not be disturbed until it is [Drawing of a Specimen, exhibiting the usual site of fracture of the olecra- non, and the ligamentous union 'which most com- monly takes place. (From Fergusson.)—Ed.] 318 FRACTURE OF THE RADIUS. loosened by the discharge from beneath, or until evident signs of in- flammation, requiring other application, shall have arisen. [Fig. 143.] [Mr. Mayo's Splint for Compound Fracture at the Elbow. B. The part for the upper arm. C. That for the forearm. D. Horizontal piece for the hand to rest upon. A. An intervening space for the elbow; the con- necting bars curve outwards to afford more room. (From Lonsdale.)—Ed.] If the injury be too severe to admit of simple treatment of this kind, and operative interference be deemed necessary, resection of the bones should be preferred to amputation of the entire limb, whenever practi- cable, as in the cases recorded by Sir Astley Cooper.—Ed.] 2. Of the Coronoid Process.—This rare accident is more likely to follow inordinate muscular action than direct injury. The ulnar is dis- placed backwards, by the unresisted action of the triceps; and the tendon of the biceps is rendered tense and unusually prominent by the bulging forwards of the trochlea of the humerus. The coronoid frag- ment is drawn upwards by the brachialis anticus. In treatment, the forearm is placed in a state of extreme flexion, and retained so by band- aging, so as to relax the displacing brachialis. Ligamentous union is expected, as in the case of the olecranon. 3. Of the Shaft.—The weakest point of the shaft of the ulna is a little below its centre; and there fracture is most likely to occur, from violence applied indirectly. The lower fragment is drawn to the radius, by the action of the pronator quadratus muscle; and consequently a depression is made there in the outline of the bones, until obscured by sanguineous and inflammatory swelling. There is neither pronation nor supination of the hand. By coaptation and rotation crepitus is readily perceived. In treatment, splints are applied on the palmar and dorsal aspects ; each splint extending from the elbow to beyond the wrists, so as completely to command the latter articulation (Principles, 3d Am. Ed. p. 660). And, in order to prevent redisplacement by the pronator quadratus, a pad is placed on either aspect of the fractured part, of sufficient size to occupy the interosseous space fully, and so to offer a mechanical obstacle to undue approximation. 4. Of the Styloid Process.—This process may be chipped off, without other injury to the bone. There is little indication for treatment beyond rest of the part, until pain and swelling have subsided. Fracture of the Radius. In this injury, it is convenient to observe, as an aid in diagnosis, that there is invariably abnormal pronation of the hand; whether the bone have suffered alone, or in company with the ulna. FRACTURE OF THE RADIUS. 319 1. At its Neck.—This is an accident of rare occurrence, and difficult diagnosis. The fragments are but little displaced, and crepitus has to be detected through a thick cushion of muscular substance. The lower fragment is tilted forwards and inwards slightly, by the action of the biceps ; the upper is rotated somewhat outwards by the supinator radii brevis. Crepitus is to be sought for by firm pressure over the site of suspected fracture, while free rotation is made of the hand and forearm. In treatment, the forearm is flexed, and placed in the middle state be- tween pronation and supination; long splints being applied on either aspect of the limb. 2. Near the Centre.—The radius very commonly gives way near its centre, from violence indirectly applied, as by falls on the hand, or by twisting of the forearm. And sometimes the accident is the result of muscular action alone. The unnatural degree of pronation is very marked and characteristic, the hand hanging awkwardly with the thumb directed downwards. The upper fragment is draAvn upwards and in- wards, by the action of the biceps; and there is an apparent enlarge- ment of the upper half, with a diminution of the lower half of the fore- arm. The lower portion of the fractured bone is drawn towards the ulna, as well as completely pronated, by the action of the pronator quad- ratus. And the supinator radii longus assists powerfully, by tilting up the styloid process to which it is attached, in displacement towards the ulna. In treatment, the forearm is flexed, and placed in the middle state between pronation and supination; the interosseous pads are care- fully adjusted; the long splints are applied on either aspect, projecting beyond the knuckles ; the hand, bandaged separately to prevent con- gestion, is excluded from the retentive apparatus, and left pendent— so that by its weight it may counteract the displacing tendency of the long supinator, and separate the radius from the ulna at the point of fracture. 3. At the Distal Extremity.—This, too, is a very common result of falls on the hand. The radius being mainly concerned in the carpal articulation, to that bone the shock is chiefly and directly conveyed; and solution of continuity is extremely probable, more especially if any [Fig. 144.] [Illustration of the deformity produced by fracture of the distal extremity of the Radius. (From Fergus- son.)—Ed.] degree of twisting have been at the same time applied. The line of fracture may be either transverse or oblique. The upper fragment is displaced inwards by the pronator radii quadratus; causing an abnormal 320 FRACTURE OF THE RADIUS. prominence on the palmar aspect, with a corresponding depression on the dorsal. There is pronation; and, on coaptation and extension, crepi- tus may be detected. The hand, following displacement of the lower fragment of the radius outwards, leaves the end of the ulna unusually prominent—as if dislocated. Luxation of the carpus, indeed, is in not a few cases closely simulated. The diagnostic marks are—detection of crepitus, mobility at the injured part, and in general non-continuity of the bone as evinced on rotation. But the case becomes obscure when the line of fracture is oblique, and impaction has occurred (Principles, 3d Am. Ed. p. 652). The lower fragment having received the sharp end of the upper into its cancellated tissue, the two become locked, con- tinuity of the bone is apparently restored, and crepitus is felt but ob- scurely, if at all. When in doubt, let free extension be made, such as may undo the state of impaction, and then, if fracture exist, its ordi- nary signs will be evinced. In treatment, it is necessary to be very careful to effect accurate coaptation by reduction; then to apply the long splints on the dorsal and palmar aspects, securing the wrist and hand against every motion. The forearm is placed in the state of easy flexion. Lately, it has been proposed to treat this fracture without splints. The hand " having been brought into a position of strong flexion, the forearm is placed, pronated, on an oblique plane, with the carpus high- est, the hand being permitted to hang freely down the perpendicular end of the plane."1 [It may be well to remind our readers that two fractures of this part of the radius have been pointed out: Colles's Fracture, described by Mr. Colles, in the Edin. Med. and Surg. Journal, 1814; and Barton's Fracture, described by Dr. J. R. Barton, of this city, in the Philad. Med. Examiner, vol/i. 1838. In the former, the fracture is usually transverse, and its most common seat is from three-fourths of an inch to one inch above the radio-carpal articulation (Smith on Fractures, £c, Dublin, 1850). In Barton's injury, a fragment is broken off from the margin of the articular surface of the radius, the fracture extending through the cartilaginous face of the bone and into the joint (Med. Examiner, loc. cit.). The character of the deformity produced is the same in both cases, and the treatment is identical; but the prognosis, as to complete restora- tion of the motions of the radio-carpal joint is probably less favorable in Barton's than in Colles's Fracture, because inflammation of the joint is likely to be more severe in the former than in the latter. This incomplete recovery is an important matter for consideration in the history of this fracture. It is not commonly observed in young, or even middle-aged persons, if due attention is paid to the timeous and faithful performance of passive motion during the whole period of the treatment. But in elderly persons, and especially in such as suffer from chronic or subacute rheumatism, it is not at all unusual to find, at the end of the treatment, that the patient has little or no control over the wrist and finger-joints, and that this condition is permanent, with but 1 Lancet, 1236, p. 487. FRACTURE OF THE RADIUS. 321 comparatively slight improvement; and this, notwithstanding the utmost care on the part of the surgeon in preventing inflammation, making pas- sive motion from an early period, &c. In order to counteract this diffi- culty, Dr. Bond, of this city, has recently contrived a splint which allows the patient to bend the fingers and wrist pretty freely, while at the same time the fragments are kept securely in apposition and at rest, and the whole arm in a comfortable position. The splint is made of light wood, cut to the shape of the forearm, and extends from the elbow to the second joint of the fingers. To its palmar extremity is to be firmly attached, [Fig. 145.] Bond's Splint—the part for the forearm. by screws or nails, a carved and rounded block of wood of the size of the patient's hand, which the latter will grasp when the arm is extended on the splint. The splint may or may not be, according to fancy or convenience, covered with binders'-board, the edges of which shall pro- ject beyond the sides of the splint, and be turned up, so as to form a kind of box for the arm. If the binders'-board be not used, the splint [Fig. 146.] The same, with the carved block B, for the hand attached, and the binders'-board, A D, applied to the Splint and turned up at the edges. is wrapped, as usual, in a roller or in muslin, the arm is placed upon it, the fingers are allowed to rest comfortably, or to be moved at pleasure upon the carved block; a compress is to be placed under, the arm at the point of fracture, just large enough to fill up any vacuity which the shape of the part may occasion after the fracture is reduced; another compress is to be laid on the dorsal face of the liinflp opposite the first, and the arm is lightly secured to the splint by a roller.1 This splint is now constantly employed at the Pennsylvania Hospital, and by many surgeons in private practice, in this city, and meets with uniform approval. In the Am. Journal, Jan. 1853, Dr. Hays recommends a simplifica- 1 See the long and very interesting paper of Dr. Bond, in the American Journal, April, 1852. 21 322 FRACTURE OF BOTH RADIUS AND ULNA. tion of Dr. Bond's splint, which he has found satisfactory in practice. The splint, which was made extempore, was formed from the lid of a cigar-box (than which we may say, en passant, there is no better ma- terial !) by being carved somewhat to the shape of the forearm, extend- ing from the elbow to the distal end of the metacarpus; after having [Fig. 147.] Hays's Splint-Board. been well padded with cotton, a few turns of a roller were passed around it to secure the padding; the body of the roller Avas then attached to the face of the palmar end of the splint, corresponding to the carved [Fig. 148.] The same, ready for use. block of Dr. Bond's, and the apparatus was ready for use. The arm was laid upon the splint, as usual, an anterior and a posterior compress were properly arranged, and the whole was secured by a roller.—Ed.] Fracture of both Radius and Ulna. This is ordinarily the result of direct violence; and the fractures con- sequently are at corresponding points—usually near the middle of the forearm. By the action of the pronator quadratus the hand is pronated, and the lower fragments are approximated to each other; they are also drawn upward by the combined action of the extensor and flexor mus- cles in the forearm, and usually project on the dorsal aspect of the limb. On extension and rotation, crepitus may be very plainly perceived. The treatment is, as for single fracture, by long splints and interosseous pads. In young persons, both bones not unfrequently give way at their epi- physes; an accident which closely simulates luxation of the carpus. Like fracture of the radius alone, it is usually the result of indirect vio- lence, by a fall on the hand. The lower fragments, with the carpus, are displaced backwards; the upper project on the palmar aspect. The FRACTURE OF THE PHALANGES. 323 [Fig. 140.] latter are kept in close approximation by the pronator quadratus, while the forearm is pronated by the pronator radii teres. Considerable poAver is required, by extension, to undo the locking and displacement; and then crepitus is emitted on rotation. The hand usually remains in the middle state betAveen pronation and supination. In treatment, coaptation, by efficient ex- tension, having been accomplished, is maintained by long splints, as in the other fractures. \_Partial Fracture.—It happens occasionally that one or both of the bones of the forearm may be only par- tially broken, i. e., some of the fibres of the bone are ruptured, while others are merely bent. The result is a bending of the bones; no crepitus can be felt; the restoration of the proper shape of the bone is more difficult than in ordinary cases of complete fracture, but when this has been accomplished the deformity is less apt to recur. The treatment is the same as for the ordinary fracture.—Ed.] Fracture of the Metacarpal Bones. [Partial fracture with bending of the Radi- us—the patient being young, as indicated by the epiphysis having separated. (From Fer- gusson.)—Ed.] The Carpal bones are seldom fractured but by great and direct force ; and then the fracture is not only com- pound, but also generally accompanied with such injury to other parts as to call for amputation. The Meta- carpal bones, hoAvever, not unfrequently give way— simply, and remediably—by force either direct or indi- rect ; most frequently the latter, as in violent blows delivered on the knuckles. The fragments may be made to ride, by the force which occasioned solution of continuity; and lateral displacement may be sub- sequently caused by action of the interosseous muscles. The swelling, pain, and poAverlessness of the limb, with characteristic crepitus on manipulation, are sufficiently indicative of the nature of the injury. Coaptation is effected by extension, and is secured afterwards by splints, extending from aboA7e the wrist to beyond the tips of the fingers, on either aspect. Interosseous pads may be arranged on each side of the frac- tured bone, on the dorsal aspect; on the palmar, one large and suitable pad is placed, to occupy and maintain the hollow of the natural arch of the hand. In compound injuries of this part, amputation is to be had recourse to with reluctance. When it is inevitable, let it be as partial and limited as possible, for the obvious reasons formerly stated when treating of amputation on account of disease. Fracture of the Phalanges. Fractures of the phalanges are usually compound. But, whether compound or simple, their marks are so plain as to render mistake, under any circumstances, impossible. When preservation of the injured part is deemed practicable and expedient, reduction is carefully effected; 324 DISPLACEMENT OF THE ANGLE OF THE SCAPULA. and coaptation is maintained by slender splints of wood placed on the dorsal and palmar aspects. DISLOCATIONS. Dislocation of the Clavicle. 1. The sternal extremity may be displaced either backwards or for- wards, a. Forwards.—Dislocation forwards is by much the more fre- quent ; produced by force applied indirectly through the shoulder. The dislodged extremity is seen and felt plainly resting in front of the sternum. Replacement is effected by raising the shoulder, and by carrying it backwards so as to approximate the scapulae. Treatment is the same as for fracture of the bone, excepting the pad in the axilla, which is here unnecessary, b. Backwards.—Dislocation backwards is extremely rare. It has resulted from direct violence applied to the part, and also from the gradual displacement which attends on rotation and curvature of the spinal column. To effect reduction, let an assistant grasp both shoulders, and, placing his knee between, suddenly bend them backwards towards each other, while the surgeon in front pulls forward the end of the bone. For retention, it is necessary to remove the shoulder from the side; and this may be done by placing a large pad in the axilla, and binding down the lower end of the humerus. In an example dependent on spinal curvature, it was found impossible to retain the end of the bone in its proper place; and the distress occa- sioned by its backward pressure, proved so great as to lead to extirpation of the offending part.1 2. The scapular extremity is not unfrequently displaced upwards on the acromion, by falls on the shoulder; the amount of deformity and inconvenience being proportioned to the degree of laceration of the con- fining ligaments. The shoulder is depressed, and the end of the clavicle is seen and felt rising over the spine of the scapula. Reduction is effected by elevation and retraction of the shoulder; consequently, the same treatment is necessary as for fractured clavicle, but maintained with unusual accuracy, as well as for an unusual length of time, the bone being very liable to redisplacement, and consolidation of the ligamentous apparatus being apt to prove both tardy and imperfect. Displacement of the Angle of the Scapula. Young men, Avho use the arms violently in their habitual occupations, are liable to this accident. The latissimus dorsi passes beneath, instead of over the loAver angle of the scapula, causing unseemly projection of this, with pain and loss of function in the limb. Reduction is easily effected by direct manipulation, while the arm is much raised and-brought backwards, so as to relax the muscle; and, by bandaging and rest, the normal relation may be maintained. On resuming the use of the arm, 1 A. Cooper on Dislocations, last edition, p. 354. DISLOCATION OF THE SHOULDER. 325 redisplacement is very apt to occur; a circumstance of the less moment, however, as in time both power and extent of motion are almost com- pletely regained, independently of reduction. A more serious deformity is connected with paralysis of the rhomboid muscles, and occurs in young persons who follow constrained and seden- tary avocations. Displacement of the lower angle not only takes place ; but, besides, the base of the bone projects forwards, on moving the shoulder, to such an extent as almost to admit of the hand being placed between the subscapularis and the ribs. In this case, treatment must be mainly constitutional; but the attention is also directed towards restoration of tone in the faulty muscles, by galvanism, friction, and other means. Dislocation of the Humerus at the Shoulder. This is more likely to follow indirect than direct violence, as formerly explained (Principles, 3d Am. Ed. p. 675). There are varieties ; three complete luxations, and two partial displacements. 1. Dislocation downwards, into the axilla, is the most common— indeed, is regarded as the ordinary form of injury. In addition to the general signs of dislocation, there are the following: The shoulder is flattened, the deltoid having sunk inwards; an ample and evident space exists beneath the acromion, which process is unusually and strikingly prominent; the arm is slightly elongated, the elbow is abducted from the side; on elevating the limb, the head of the bone is plainly felt in Fig. 150. Dislocation of the Shoulder. The flattening shown at a. The right shoulder is normal. the axilla—and it is found to move with the shaft in rotation ; motion is greatly abridged, unless when the muscular system is unusually relaxed and flabby; there is no true crepitus; pressure of the bone's head on nerves and veins in the axilla is evinced, by tingling sensations and swelling of the limb ; paralysis may follow; not unfrequently the cir- cumflex nerve has been torn across, and permanent paralysis of the deltoid has resulted. Reduction may be effected, in a variety of ways ; pulleys being used or not, according to circumstances (Principles, 3d Am. Ed. p. 680, &c). 326 DISLOCATION OF THE SHOULDER. In all cases of difficulty, chloroform is of course employed (Principles, 3d Am. Ed. p. 735). a. By rectangular extension—the axis of exten- sion being intended to relax the deltoid, supra-spinatus, and infra-spi- natus muscles, which, according to Sir A. Cooper, are the principal opponents of reduction. And it is well to relax the biceps, also, by flexion of the forearm; the laque being attached, when required, above the elbow. The patient may be either seated or recumbent; and counter- extension is made by a broad sheet or belt passed round the chest— pressure being at the same time made on the top of the shoulder, so as to fix the scapula more completely. After extension has been duly sus- tained (Principles, 3d Am. Ed. p. 681), it is suddenly slacked, and a jerking, coaptating movement is made on the head of the bone upwards; the humerus being used as a lever. When the patient is seated on a chair, much power in this way is obtained by the knee placed in the axilla, on which the humerus is, as it were, suddenly and forcibly bent. Reduction may take place suddenly and with a snap; or gradually, and without a noise. Then the arm is secured to the side, by bandaging, and retained so for a few days. b. By extension parallel to the axis of the body.—Thus we may suc- ceed, single-handed, in recent or otherwise favorable cases. The patient is laid recumbent; and the surgeon places himself, sitting, by his side. Taking hold of the hand or wrist of the injured limb, the surgeon makes extension by pulling towards him; while, placing his unbooted heel in the axilla, on the head of the bone, and pushing from him, counter-extension is made, and at the same time direct reductive force is applied. Or, instead of pulling by the wrist, a laque may be fastened above the elbow; by a strap or towel attached to which, and passed behind the surgeon's back, extension may be made ; leaving the hands free to rotate the flexed forearm. Care must be taken, however, that the heel's force is neither excessive, nor unduly directed; for it has happened that, failing to reduce a dislocated humerus, the operator has caused fracture of the ribs. Rupture of the axillary artery, also, with subsequent formation of false aneurism, has been caused by the heel— booted, and used rashly. Failing with the heel, the strap for producing counter-extension is placed in the axilla, and extension made steadily with pulleys, with such rotation and manipulation as seem necessary (Principles, 3d Am. Ed. p. 681). c. By movement upwards.—This is the method of Malgaigne. The shoulder and chest are steadied, while the arm is forcibly raised above the head; and, if need be, extension is made in that direction, with subsequent manipulation directed against the head of the bone. It is expected, however, that these latter proceedings may not be required, the bone slipping into its place during the upward movement. Such details as to reduction apply mainly to those cases in which, from some cause or other, anaesthesia is not employed. With the full effect of chloroform the muscular frame is so relaxed, that in general little else than simple extension, Avith coaptation, is required; it being comparatively immaterial in what direction the extension is made. 2. Dislocation forwards, beneath the pectoral muscle.—The head of the bone is displaced to the inside of the coracoid process, and is locked DISLOCATION OF THE ELBOAV. 327 between that and the clavicle. There is the same flattening of the shoulder, Avith abnormal subacromial space, as in the preceding accident; but to a greater extent. There is less pain, the axillary plexus being free. Motion is more abridged. The elbow is abducted and throAvn back. The head of the bone may be both seen and felt in its abnormal site. The arm is somewhat shortened. In reduction, the extending force is to be made downwards and backwards, in a line with the body, not in a rectangular direction ; in order to avoid the resistance of the coracoid process. 3. Backwards on the dorsum of the scapula.—This is the rarest form of complete luxation. Palpable presence of the head of the bone, in its new locality, is sufficiently diagnostic. Reduction may be effected very simply, by merely elevating the arm, and carrying the hand behind the head. Failing this, the ordinary means are to be employed, as for dislocation downwards. 4. Subluxation on the coracoid process.—A partial displacement may take place in this direction. There is slight flattening of the shoulder, with a corresponding degree of vacancy beneath the acromion, and the head of the bone is felt and seen projecting on the coracoid process. Reduction is beset with no difficulty; in fact, the manipulation required for diagnosis generally succeeds in effecting replacement. The acci- dent is rare. 5. Subluxation upwards, with displacement of the long head of the biceps.—The long tendon of this muscle may be displaced from the bicipital groove, and laid over the lesser tubercle. In consequence, the head of the humerus escapes upwards, coming into immediate contact with the acromion. The accident is obscure, and probably rare. It is noted by loss of power in the biceps, by pain in the seat of injury, and by the peculiar deformity attendant on the upward displacement of the head of the bone. Reduction is effected by a coaptating manipulation, directed to the tendon, during flexion of the forearm. Dislocation of the Radius and Ulna at the Elbow. 1. Backwards.—Both bones of the forearm are not unfrequently displaced backwards, without fracture of any part, by falls on the' hand, Tig. 151. Dislocation of both Bones backwards. with the elbow in a state of semiflexion. The joint is much deformed, and has its motion greatly abridged. The hand and forearm are supine ; 328 DISLOCATION OF THE ULNA. Fig. 152. the joint is bent nearly at a right angle, and can be neither completely flexed nor extended. The ulna and radius form a very marked pro- jection posteriorly, and, on examination, the olecranon is found on a higher level than the external condyle of the humerus. The coronoid process of the ulna rests in the cavity which ought to receive the ole- cranon; and on each side of the olecranon a hollow is caused, by absence of the lower part of the triceps from its wonted locality. The trochlea of the humerus, projecting forwards, forms a hard swelling behind the tendon of the biceps. Reduction may be effected in two ways. a. By extension, with co- aptation, from behind. This is the preferable mode. The patient is placed with his back to the surgeon, and the chest having been fixed, extension is made with the arm directed completely backwards, in a rectangular rela- tion to the trunk, so as to relax the triceps muscle. Very frequently, in recent cases, the operator thus succeeds, single-handed, by extension alone. With the left hand he makes counter-extension on the scapula, Avhile with the right he extends from the wrist. In difficult cases, extension is intrusted to assistants, with or without pulleys, while the surgeon conducts the direct coaptating manipulations of the joint, the patient under chloroform, b. By forcibly bending the joint over the knee.—The patient having been seated on a chair, the surgeon places his knee in the hollow of the elbow. Pressing the radius and ulna down upon the knee, the coronoid process is freed from the humerus, by separation; and then, on forcible yet gradual flexion, reduction is effected. 2. Laterally.—Both bones may be displaced late- rally, as well as backwards, in two ways; to the in- side, or to the outside, a. Backwards and outwards. —The coronoid process rests on the back part of the external condyle. The ulna projects more backwards than in the ordinary dislocation. The radius forms a protuberance behind and on the outer side of the elbow, where its head may be felt plainly rotating. The inner condyle projects palpably, b. Backwards and inioards. —The external condyle projects. The ulna is promi- nent posteriorly, resting on the inner condyle, while the head of the radius is placed in the posterior fossa of the humerus. Reduction, in either case, may be effected as in ordinary dislocation. Dislocation of the Elbow; showing pre- ternatural fulness in front. Dislocation of the Ulna at the Elbow. The ulna may be displaced, singly, in two directions. 1. Back- wards.—The olecranon projects behind. The forearm is much twisted inwards, with pronation of the hand. The elbow is bent nearly at right angles, flexion can be but very slightly increased, and extension is quite impracticable. Reduction is effected by bending the elbow DISLOCATION OF THE ELBOW. 329 over the knee, and drawing the forearm downwards. The radius proves of use, in this movement, by pushing the external condyle back upon the ulna. 2. Backwards and inwards.—The olecranon projects much behind, the coronoid process rests on the inner condyle, and a finger may be placed in the sigmoid cavity. The forearm is semiflexed, the hand pronated. Extension may be performed readily by the surgeon, but complete flexion is impracticable. Much pain is experienced, on account of pressure on the ulnar nerve. Reduction is effected by direct efforts of coaptation, during powerful and sustained extension. The accident is rare. Dislocation of the Radius at the Elbow. Fig. 153. The radius may be displaced singly, also, in two directions. 1. Forwards.—The head of the bone rests in the hollow above the external condyle, and may be felt there. The forearm is slightly bent, and can be neither completely flexed nor extended. On attempting flexion, the head of the radius is felt to strike against the hu- merus, abruptly arresting the move- ment. The hand is inclined to prona- tion. Reduction is effected by grasping the hand firmly, performing supination, and extending the forearm steadily. 2. Backwards.—The head of the radius is displaced behind the external condyle and to its outside; and in this locality it can be both seen and felt very plainly, especially on extending the limb. Reduction is managed as in the preceding accident, but with the hand pronated, not supine. [Compound Dislocation of the Elbow. Compound dislocation of the elbow may occur, complicated, perhaps, with fracture of the upper part of the ulna or radius, or of the condyloid [Fig. 154.] Dislocation of the Radius forwards. Compound Fracture of Elbow. (From Fergusson.) 330 DISLOCATION OF THE WRIST. portion of the humerus. In this form of injury, if the soft parts are not too seriously damaged, and the bone not too much comminuted, and if the main artery has escaped, reduction may be attempted. If this cannot be accomplished, the propriety of resection of the bone or bones should be considered before amputation of the arm is determined on, as in the case of compound fracture of the elbow. In case of reduction, the wound in the soft parts should be closed as accurately as possible ; lint, saturated with some adhesive material, should be placed upon it, and every effort made to procure union by the first intention. During the treatment, the arm should be maintained partially flexed, upon a properly constructed splint.—Ed.] Dislocation of the Wrist. 1. Dislocation of the Radius and Ulna.—These bones may be dis- placed, together, either on the dorsal or on the palmar aspect of the [The Anterior Dislocation of the Badius and Ulna at the Wrist. (From Fergusson.)__Ed.] wrist. Falling on the palm, the two bones may be displaced forwards on the annular ligament; while, [pis- 156-] from a fall on the back of the hand, the reverse movement is likely to occur. In either case, the signs are plain; a dorsal and a palmar swelling exist, com- posed either of the carpal bones or of the ends of the radius and ulna, as the case may be; and, by rotation and manipulation, it is ascertained that continuity in the radius and ulna is un- broken. The accident is rare; fracture of the radius being a much more common result of the [The Posterior Dislocation of the Radius and Ulna at Same exciting CaUSC Reduction the AVrist. (from Fergusson.)—ed.] is readily effected by extension DISLOCATION OF THE THUMB. 331 and coaptation. And it is Avell to maintain retention for some time, by splints, as for fracture of the bones. Subluxation forwards is by no means an uncommon result of falls on the palm; the bones being not only displaced towards the palm, but also separated from each other. The nature of the accident is plain, and reduction is easy. But, unless splints be carefully Avorn for at least a fortnight, deformity by continuance of partial displacement may scarcely be averted. 2. Dislocation of the Radius at the Wrist.—The distal extremity of the radius may be displaced forwards, separately ; resting on the sca- phoid bone and trapezium. The styloid process is no longer situated opposite to the latter bone; and the end of the radius may be both felt and seen projecting on the forepart of the wrist. The hand is twisted. Reduction is effected by simple extension and coaptation. Splints are necessary for subsequent retention. 3. Dislocation of the Ulna.—Dislocation of the ulna, separately, may take place backwards ; the end of the bone projecting plainly, with twisting of the hand; and the line of the styloid process showing obvious alteration. Reduction and retention are managed as in the preceding accident. 4. Dislocation of the Carpus.—Complete luxation of any of the car- pal bones is rare. But subluxation of the os magnum and of the cunei- form bone is occasionally met with; weakening the joint, and causing projection on the back of the wrist during flexion. Treatment is by continued pressure and support from without, and by disuse of the part for some considerable time. Dislocation of the Fingers. By falls sustained on the tips of the fingers, dislocation of the pha- langes is sometimes produced; and the displacement is usually on the dorsal aspect. It is more common between the first and second pha- langes, than between the second and third. The nature of the injury is exceedingly plain; and replacement is effected by extension and coaptation. To render extension effective, it may be necessary to affix a laque, a piece of tape, or the end of a silk handkerchief, or a ribbon, to the distal phalanx, by means of the clove-hitch (Principles, 3d Am. Ed. p. 680). Sometimes the handle of a key may be used advantage- ously as an instrument of reduction. Splints are expedient for some days afterwards. Compound dislocations almost always are of such severity as to demand amputation. Dislocation of the Thumb. The first phalanx is not unfrequently dislocated backwards on the dorsum of the metacarpal bone ; and is reduced, in general, with diffi- culty, on account of the strong lateral ligaments which oppose the retro- grade movement; and also on account of the many strong muscles— 332 DISLOCATION OF THE THUMB. eight—which are connected with this part, and require to be overcome in the extension. Extension having been maintained for some time, [Fig. 157.] [Dislocation of the first phalanx of the Thumb, backwards, on the dorsum of the Metacarpus. (From Fergusson.)—Ed.] steadily, by means of a suitable laque attached to the first phalanx, flexion is made towards the palm ; and during this forced movement, slowly yet determinedly performed, reduction is usually accomplished. [Fig. 158.] [Noose, or laque, for the purpose of making extension upon the Bone. (From Fergusson.)—Ed.] It may be necessary, in extreme cases, to have recourse to subcutaneous section of one or other lateral ligament; but such necessity, with the use of chloroform, may scarcely be expected to arise. Hind, on Fractures, London, 1836. Lonsdale, on Fractures, London, 1838. A. Cooper, on Dislocations and Fractures, London, 1842. Dupuytren, on Diseases and Injuries of Bones, Sydenham Society, London, 1847. Smith, on Fractures in the Vicinity of Joints, &c, Dublin, 1847. Vincent, Observations on Surgical Practice, &c. London, 1847. [Callaway, Fractures in the Vicinity of the Shoulder-Joint, London, 1850. Malgaigne, Traite" des Fractures, Paris, 1850.—Ed.] CHAPTER XXIV. INJURIES AND DISEASES OF THE SPINE. Concussion of the Spinal Cord. By falls or blows, the spinal cord, like the brain, may sustain a greater or less degree of concussion; haA'ing its functions arrested or disordered, without actual lesion done to its structure. The concussion may be either general or partial. In the latter case, it is probable that the whole cord suffers, though unequally; the major effect being at and beneath the part struck—as denoted by paralysis, more or less complete, of the parts thence supplied by nerves. This paralysis is transient; passing off in a few hours—or days ; never of long duration when simple—that is, when not accompanied or followed by extravasation or effusion. As in the case of the brain, reaction may prove excessive, and inflammatory action may speedily supervene ; attacking the cord, its membranes, or both, and ushering in a completely new train of symptoms. Or—also as in the case of the brain—the immediate re- sults of the injury may all seem happily to pass away; and, at a remote period, an insidious chronic inflammatory process may occur, in the cord or in its membranes; causing, in the one case, thickening with effusion, in the other, purulent softening of slow progress. Treatment is guided by the same principles as in concussion of the brain (p. 38). Absolute quietude is enjoined ; and the period of re- action is carefully watched. If it threaten to prove excessive, antiphlo- gistic measures are adopted, according as circumstances may seem to demand. And, for a long period after receipt of the injury, the patient must be content to use all the precautions of a prudent invalid, so as to avert, if possible, the insidious and formidable remote results. These, having threatened, are best met by rest and patient counter-irritation— with appropriate constitutional treatment. Softening of the spinal cord, chronic, insidious, and intractable, is no unfrequent consequence of severe falls, or blows, upon the spine ; more especially in those in the better ranks of life, who have lived hard, and indulged much in venery. The lower limbs first begin to fail, the extensor muscles proving unequal to maintain the erect posture, and the knees consequently ever and anon threatening to give way. The feet are moved oddly, and are not planted on the ground firmly, or with certainty on the spot intended ; the legs are thrown outwards in step- ping, and bring the feet down with a slap. The body is stooped in walking; and the line of progress is seldom a straight one. The 334 FRACTURE OF THE SPINE. bowels get sluggish, and the abdomen enlarges. The urine is voided with difficulty. The arms are found to be weak; and the fingers seem to be gradually freeing themselves from control of the will; there being the same uncertainty and inefficiency in doing anything with the hands and fingers, as was first observed in the lower extremities. Not unfre- quently, the patient is much harassed by neuralgic pains, shooting down the back and limbs, and sometimes affecting the head also. Gradually, such symptoms increase ; urine and feces come to be passed involun- tarily, or almost so; the use of the limbs becomes more and more feeble and uncertain ; the brain at last is involved ; the mind grows imbecile, as well as the body ; and the patient dies, often with symptoms of slow compression. The spinal cord is often found more or less affected with ramollissement; sometimes, however, it presents no organic lesion. But little benefit can be expected from treatment. Of heroic remedies, there is no tolerance. Indeed, the prudent practitioner contents himself with enjoining great temperance in all things; while, by the employ- ment of ordinary and simple means, he seeks to palliate symptoms, and delay the fatal issue. Compression of the Spinal Cord. This may be caused, as in the brain, by extravasation of blood, on the surface or in the substance of the cord ; by fracture and displace- ment of the vertebrae, producing direct pressure on the cord, with or without laceration of its substance ; by inflammatory exudations and effusions exterior to the cord ; or by purulent disorganization of the cord itself, the result of inflammatory action. Very obviously, the direct interference of operative surgery is here of no avail; the tre- phine is not to be thought of. Treatment consists of expectant rest, in the first instance ; anxiously looking for the earliest appearance of inflammatory action; opposing this by the suitable means, yet not heroically—knoAving that in such cases actiA'e and extreme depletion is ill borne ; and mitigating the symptoms connected with the paralytic state, as far as the resources of our art will allow. In the case of extra- vasated blood, if the immediate risk be overpassed, we may reasonably entertain expectation of a fortunate result. On the other hand, few cases of displaced fracture are wholly recovered from. And the end of inflammatory disorganization, whether chronic or acute, is almost in- variably disastrous. Fracture of the Spine. Severe and direct violence is more likely to cause fracture than dis- location of the vertebrae; these bones being so intimately connected to each other by their articulating processes. The spinous processes alone may be broken. There is then little displacement; and the con- sequences are but trivial. But fracture traversing the body of the bone, making a complete solution of continuity in the spinal column at that part, is fraught with the utmost danger. Structural injury has proba- bly been inflicted, at the same time, on the spinal cord and its mem- FRACTURE OF THE SPINE. 335 159. Fractured Spine, bisected; Bhowing the formidable and fatal injury inflicted on the cord. branes ; extravasation of blood has taken place into the canal; pro- bably this is displacement of the fragments, and farther injury thereby done to the soft parts within. Ordinarily, there- fore, the most prominent sign of spinal fracture —besides pain, swelling, mobility, crepitus, and departure from normal outline at the injured part—is paralysis of those muscles Avhose nerv- ous supply proceeds from beneath the seat of injury. According to the seat of injury, the nature of the case materially varies. When the lumbar region has suffered, the more prominent symp- toms are—paralysis of the lower limbs, usually with loss of sensation; involuntary discharge of feces; retention of urine; and, frequently, priapism. When the injury has occurred in the upper dorsal, or lower cervical region, in addi- tion to these symptoms there are—paralysis of one or both arms, difficulty of breathing, slug- gishness of the bowels, with distension of the abdomen. If, again, the fracture be above the origin of the phrenic nerve—and compression there prove great—respiration will at once cease, causing death. An almost invariable result of spinal fracture, wherever situated, is a deteriorated condition of the urinary organs. The kidneys err in their function ; and the lining membrane of the bladder, becoming the seat of chronic congestion, assumes a most depraved action; copious, fetid, turbid, ammoniacal urine passes away, with sad aggravation of the general disorder of system. The bowels, too, are not merely dis- tended and sluggish, but become depraved in the function of their mucous membrane; the dejections evincing a very vitiated character. Bed-sores are apt to form. The symptoms, continuing and gravescent, may terminate in death, or, gradually mitigating, recovery may ensue, more or less complete. Obviously, the dangers to life are both many and formidable; inflam- matory action in the cord or membranes, effusion, exudation, disorgani- zation, secondary affections of the digestive and urinary organs, bed- sores, and general exhaustion. It need not excite surprise to find the average of recoveries extremely small. The treatment may be reduced to simple principles: Very careful movement of the patient, and adjustment on a hard mattress, lest far- ther displacement of the fragments occur. [The best bed for patients suffering with fracture of the spine, is the water-bed of Dr. Arnott. But this is accessible to but few; in hospitals, it should be provided for all such cases. The ordinary mattress may, perhaps, hasten the sloughing which always attends this injury, and the feather-bed has nothing to recommend it.—Ed.] An equally careful reduction of the displacement which is found to exist. Retention, by adaptation of a splint, of wood, pasteboard, gutta-percha, or padded iron, on each side of the spine, for some distance above and beloAv the site of injury. 336 DISLOCATION OF THE SPINE. Enforcement of absolute quietude, antiphlogistic regimen, and the other obvious prophylactic measures. Moderate antiphlogistics, should sym- toms of overaction exhibit themseh7es. Mitigation of the unpleasant results occurring in the digestive and urinary organs ; obtaining regular and better movements of the bowels; relieving the bladder by the cathe- ter, at stated and frequent intervals; and rectifying the state of the urine, by mineral acids and other medicinal means in ordinary use for that purpose. Ultimately, immediate danger having passed by, direct- ing attention to amendment of circulation in the paralytic parts; thus preventing shrinking by atrophy, and perhaps assisting in the recovery of function. The means usually employed to fulfil the last indication, are friction, shampooing, galvanism, and electricity, and the use of strychnia. Galvanism and electricity are to be used with caution, how- ever; it being the opinion of some, that although, by means of these agents, muscular contractility may for a time be roused, yet that the amendment is in general but temporary, and that the parts ultimately lapse into a worse degree of impotency. Counter-irritation is some- times of service. In the obviously displaced spinal fracture, with symptoms of com- pression of the cord, it has been proposed to employ the trephine, with the view of relieving the injured medullary matter. Reason and ex- perience, however, have decided against the procedure, inquiry having shown that the compressing agent is usually the fore part of the body of the vertebra, which cannot be reached and dealt with from without. Spinal fissure may occur, without displacement, and yet may prove fatal, from another cause than concussion. Into the cleft, a portion of the membranes may be received and retained; the constriction acts as an uninterrupted exciting cause of inflammatory action, and fatal exuda- tion or structural change ensue. The case is obscure in its course, and is likely to be unfortunate in its issue, all remedial means proATing of little avail to arrest an action, which is being ever fed and maintained by an influence which is inaccessible and consequently insuperable. Dislocation of the Spine. Luxation of the spine, without fracture of the processes, is a rare injury; yet has occurred, occasionally, in the cervical region, ordinarily between the fifth and sixth vertebrae. It has happened by muscular power alone; a maniac, for example, having so caused death by, as it were, forcibly throwing his head from him, during restraint in a paroxysm of excitement. More frequently it is the result of violence applied from without, as by falls on the head. Suspension sometimes causes it, but much more rarely than is generally supposed; usually, there is no displacement of the vertebrae whatever, even in criminal cases, death taking place from other causes (Principles 3d Am. Ed. p. 693). V F ' The displacement is easily recognizable on manipulation, and the concomitant symptoms of compressed or torn spinal cord are sufficiently explicit. If life, or the hope of life, remain, replacement is to be effected by careful extension and coaptation; afterwards, untoward results are LATERAL CURVATURE OF THE SPINE. 337 Fig. 160. Fig. 161. Fig. 160. Dislocation of the Spine, between the fourth and fifth cervical vertebrae. The patient fell backwards over a high paling, and alighted on his head. Cord torn. Complete paralysis. Is- sue fatal, within a few days. Fiir. 161. The same; seen laterally. to be obviated by such management as has been advised in the case of fracture. Subluxation, or partial displacement of the vertebrae, is by no means uncommon, and may take place at any part of the spinal column. It is probably of most frequent occurrence in the dorsal region, caused by falling on the breech, from a considerable height, with consequent forcible bending of the trunk forwards. The posterior ligamentous apparatus gives way, to a greater or less extent, and a hiatus between the spinous processes results. The symptoms, in addition to the marks of displacement, are those of severe spinal concussion, and the subse- quent dangers are also such as may be expected to follow that accident. By extension, replacement is gently effected. The same retentive ap- paratus is then applied as for fracture, and must be worn patiently for weeks; the patient resuming use of his lower limbs very gradually, and not till after many weeks have elapsed. Throughout the whole period of treatment, an anxious regard is paid to the spinal cord, and remedial measures are adopted, if necessary, to ward off morbid action there. Lateral Curvature of the Spine. Lateral curvature of the spine is usually held as contrasted with antero-posterior curvation; the latter the result of ulcerative lesion in the bodies of the vertebrae, the former originally unconnected with structural change. In the one, there is mere change of position ; in the other, there is change and loss of bone, by the results of inflammatory action which has originated there. It is right to remember, however that in some cases the antero-posterior curve is found to be of the same nature as the lateral displacement—originally unconnected with struc- tural change. Lateral curvation may arise from different causes. And it is import- ant to classify the cases accordingly, that the suitable treatment mav ' 22 J 338 LATERAL CURVATURE OF THE SPINE. be afforded to each. 1. Peculiar avocations are not unfrequently the cause. Those, for example, which entail an habitual use of the right arm, much disproportioned to that of the left; as in blacksmiths and dragoons. The muscles of the right side become largely developed, and powerful; and the trapezius and rhomboids, thus changed, acting on the spinal column so as to overpower their fellows of the opposite side, have the effect of gradually inducing distortion—it may be to a con- siderable extent. Of course, this is most likely to occur during ado- lescence. The remedy is simple; partial discontinuance of the use of the right side, with increased employment of the left. The displace- ment, if recent and slight, can be perfectly removed. 2. Bad habits, of standing, sitting, or reclining, in an awkward posi- tion, are very apt to cause a greater or less amount of lateral distortion in the young. The spinal column is habitually thrown off its normal line of erection ; and, in course of time, both muscles and bones, becom- ing accustomed to their abnormal position, may refuse to assume any other. And thus curvature, both great and confirmed, may become established, without any actual vice in the skeleton, the muscles, or the general system. Obviously, there is one class of human beings much more than any other exposed to this form of curvature ; namely, young girls occupied in the crowded details of an imprudently managed course of education. Young people of both sexes are also very liable, who are employed in sedentary occupations in trade; as in sewing, knitting, en- graving, coloring, &c. The indications of treatment are plain ; discon- tinuance of the hurtful habit or occupation; ample amount of exercise out of doors; and a voluntary use of such gymnastic or other exercises as are calculated to produce a healthful play of the general muscular sys- tem, and more especially of the muscles of the trunk and spine.1 And by means of light articles of dress, fashioned and worn so as to attract the patient's notice to the threatened deformity, while at the same time they warn of the negligence or awkwardness which has led to it, disuse of the habits in question may be greatly favored. By some, the in- fluence of a pulley and weight, horizontally extended on the opposite side, is made to act correctively on the curve.2 But all cumbrous ap- paratus—in the shape of stays, or other machinery—are plainly to be avoided, as likely to pro\re most hurtful. 3. Hitherto, we have spoken of simple deformity. Now, we have to do with disease. General Debility, however induced, in the young, is a frequent cause of lateral curvature; insufficient food and clothing, excess of confinement and Avork, febrile or other affections leaving thr system exhausted—are all causes of such debility, with its consequent injurious influence on the spine; and to these all ranks of life are sub- ject. The muscular system groAvs especially weak; the extensors of the trunk are unequal to the task of duly maintaining the erect posture; and deviation from the straight line results—at first occasional, after- wards habitual, and ultimately confirmed. In the previous examples of lateral curvature—unconnected with actual disease—the curvation begins 1 Sir B. Brodie, Lancet, No. 1218, p. 3, et seq. 2 Dr. Brown, of Boston, U. S. Lancet, No. 1329, p. 178. LATERAL CURVATURE OF THE SPINE. 339 usually in .the dorsal region, and is mainly situated there. But in this case, the beginning of curvation is more likely to take place in the lumbar region—at the basis of the pyramid of support. An inclination is made to either side; then, to atone for that, an opposite curve is made in the dorsal region. And, not unfrequently, there is a third ultimately established in the cervical, in a direction opposed to that of the dorsal. As the amount of bending increases, rotation at the same time generally takes place—the rotation being toAvards the same side as the curve; the height of the spinal column, too, greatly decreases ; and, in consequence, serious changes happen to the thoracic and abdo- minal viscera. The ribs expand on one side, while they are closed on the other ; and they fall inwards, narrowing the chest in its lateral di- rection, and producing prominence of the sternum and of the costal cartilages. The heart and lungs become incommoded, and labor in their function. The sternum, too—with its costal appendages—has approached unusually near to the pelvis; the abdominal space is nar- rowed in consequence, and its organs are injuriously affected. At first, the spinal change is chiefly in the intervertebral spaces ; and the de- formity, at that time, is capable of being undone, by appliances from without, or, partially at least, even by the efforts of the patient. But, by and by, the bones become consolidated in their new relation ; inter- stitial absorption taking place at the compressed points, while corre- sponding expansion or growth occurs at those which are free; and then the deformity has become fixed and irremediable—a circumstance of very important and obvious bearing on the question of treatment. The indications of treatment are directed fully more to the state of the general system than to the part affected. A tonic regimen is pa- tiently persevered in; at the same time, the deficient extensors are to be roused by friction and by suitable exercise; and from time to time, by manipulation, a restoration of the normal outline ofv the spine is to be attempted. To aid in the fulfilment of the last indication, a light mechanical contrivance may be occasionally employed, restorative yet not oppressive. But all cumbrous or confining apparatus, continuously worn, must prove prejudicial; the muscles, already weak, will be en- feebled more and more; and the original malady cannot fail to sustain aggravation. Good diet and clothing; regulation of the bowels ; expo- sure to good air; judicious use of medicinal tonics; friction of the back, acting more especially on those muscles which seem most deficient; healthful exercise, both of the general body and of the muscles of the trunk, short of fatigue; and occasional attempts at readjustment by mechanical appliances, constitute the most important means towards alleviation and cure. Myotomy has been practised, both in this and in other forms of spinal distortion, but with no good result. The experience and judgment of the profession are alike opposed to it. 4. A diseased condition of a muscle or bone, in another part, may cause curvature of the spine. Thus, a rigid and contracted state of the sterno-cleido-mastoid muscle of one side, producing the state called Torticollis, is very apt to cause spinal curvature, as has already been noticed. The remedy is simple; by division of the offending muscle. And, again, shortening of a lower limb, by morbus coxarius, or by ill- 340 LATERAL CURVATURE OF THE SPINE. united fracture, unless atoned for by suitable mechanical contrivance, can scarcely fail to cause more or less distortion of the vertebral column. 5. Rickets is certainly not the least common cause. And the curva- tures, so occasioned, are at once the most rapid and decided in their progress, and the least amenable to treatment. The peculiar character- istic is indication of the rickety state; strumous complexion and cha- racter, and distortion of other parts of the skeleton, as well as of the spinal column (Principles, 3d Am. Ed. p. 442). The results of extreme spinal curvature, usually with rotation, are rapidly developed; and, at Fig. 162. ^ Fig. 163. Figs. 162 and 163. Permanent Curvature of the Spine, with rotation, produced by Rickets. the same time, the pelvis and lower limbs, as well as the clavicles and the superior extremities, are more or less distorted. Usually, the direc- tion of the spinal curvature is lateral; but it may be antero-posterior The treatment—prophylactic and curative, is such as has been already considered (Principles, 3d Am. Ed. p. 446, &c). It is here that the use of mechanical aids, in the shape of stays and belts, is not only allowable but highly necessary, when the patient is in the erect or semi- erect posture, and especially when exercise is taken ; yet requiring much prudence and skill both in their first adjustment and subsequent use DISEASE OF THE BODIES OF THE VERTEBRA. 341 Disease of the Bodies of the Vertebrse. Interstitial absorption frequently occurs, in connection with simple curvature, as already stated; whereby a distortion, at first remediable, becomes ultimately confirmed and unalterable. It also occurs as a pri- mary affection, in the bodies of the vertebrae, as a prelude to carious ulceration (Principles, 3d Am. Ed. pp. 281 and 410). More rarely, it exists as a separate Fig. 104. and distinct disease, causing displacement by curvation forwards at the affected part; and deposit, following on absorption, after a time, confirms the curve by consolidation. Treat- ment is by rest and gentle counter-irritation. Continuous Absorption, and Simple Ulcera- tion occur in the bodies of the vertebrae, as the results of pressure; the former often is caused by the gradual action of an aneurismal tumor; the latter may result from the more speedy operation of the same cause, and is sure to be produced by the pressure of an ab- scess. Healing takes place, on removal of the cause—if that be in our power. Caries of the Vertebrse is a most formidable affection, and unfortunately not of rare oc- currence. It is the ordinary cause of sharp antero-posterior curvature usually termed "an- gular;" sometimes attributable in its origin to external injury, but often unconnected with any assignable exciting cause. The morbid action follows the ordinary course (Principles, 3d Am. Ed. p. 413); sometimes limited to one or two bones; often involving almost the whole chain. Its most frequent site is in the dorsal region. Usually, it is associated with, and probably dependent on, the strumous diathesis. Obscure spinal symptoms generally precede; pain, uneasiness, numb- ness, and weakness in the limbs; spasmodic twitchings; obstinate bowels; alkaline urine, with trouble in discharging it. In the part there is dull uneasiness, and ultimately pain, which is increased by pressure, and rendered intense by sharp percussion. The gait is tottering and un- certain ; with the back kept peculiarly rigid, so as to avoid motion of the diseased vertebrae. Often a distressing sense of constriction is felt m the chest, as if this were girded by a tight cord. The symptoms of paralysis manifest themselves gradually; affecting different parts according to the site of the vertebral disease; and usually motion is impaired before sensation—as can readily be understood on reference to the anatomical arrangement of the nerves given off from the spinal cord. Sharp curvature, forwards, advances more and more. The matter, in which the carious mass is bathed, accumulates ; and, seeking an out- Continuous absorption illustrated by the pressure of an Aortic Aneu- rism on the Bodies of the Vertebra?. a. The arch of the aorta. 6. The descending aorta, c. The vertebral column. Opposite d, the bodies of the vertebrae are seen excavated, with corresponding processes of the compressing clot; while the inter- vertebral substances, successfully resisting the pressure, project into corresponding depressions of the fibrine. 342 CARIES OF THE VERTEBRA. let, points at some part of the surface—directly, on the back; or at some distant point, as in the loins or groin. The ultimate result may be cure by anchylosis, in the slighter cases; the curve remaining per- Fig. 165. Fig. 166. Fig. 167. Fig. 165. Caries of the Vertebrae; macerated; the bodies extensively destroyed; marked curvation forwards. Fig. 166. The same during life. Angulation. manent. Much more frequently, the issue is fatal; occurring rapidly, by the effects on the spinal cord; or more gradually, by hectic and ex- haustion. Treatment consists in affording absolute rest to the part, by confine- ment to the recumbent posture ; with attention to the general health, and patient continuance of cod-liver oil. In the avowedly strumous cases there is usually an intolerance of all forms of active counter-irritation, which threaten to accele- rate the fatal issue by exhaustion; and, in such patients, we are to content ourselves with rest and general management, looking gloomily to the result. And in all cases, caustic issues are only serviceable at the commencement of the disease. The prone position is usually preferable to the supine; as relieving the spinal column more tho- roughly from the superimposed weight, and prov- ing favorable to venous return from the bodies of the vertebrae. And " the prone couch," employed almost constantly, day and night, Avill be found Caru>s of the vertebra; pre- jn most cases a nrreat assistance in the treatment; vlously to maceration. The i . /»; ° .. , ■, , . . . aorta overlays the cyst of the becoming, after a time, not only not irksome but abscess. absolutely agreeable to the patient; and of course LUMBAR AND PSOAS ABSCESS. 343 so managed as to avoid, as far as possible, even the very appearance of restraint. In all cases, mechanical adjustment of the distorted spine by force is manifestly at variance with both surgery and sense. Caries of the upper cervical vertebrae requires the most careful management, lest, by sudden motion, displacement should occur, causing fatal compression of the upper part of the cord. The patient seems to be instinctively aware of this hazard ; and, on moving his head, always supports the chin carefully on the hand, Avhile the whole body—as a pillar—is made to turn in obedience to the direction of its capital. Here, mechanical contrivance is most suitable and necessary ; in order to guard against sudden motion, and at the same time to relieve the diseased bones from the weight of the head (p. 286). By this and counter-irritation, with due attention to the general health, cure by anchylosis is to be sought for. And though in no case our hope need be sanguine, neither in any need it give place to despair; seeing that our museums show cures by anchylosis under circumstances the most unfavorable—the spinal cord having accommodated itself to great displacement, as well as loss of substance, affecting even the atlas and dentata. Lumbar and Psoas Abscess. By Lumbar Abscess is understood, a collection of matter pointing somewhere in the lumbar region. It may originate wholly in the soft parts. More frequently, it is the result of caries of the vertebrae. Treatment depends on the nature of the case. If there be no prospect of ultimate cure, no opening should be made ; the ordinary palliatives are to be administered, and every care is to be taken to keep the inte- guments entire. If the case present a favorable aspect, on the con- trary—the amount of disease in the spine seeming slight, and the sys- tem yet tolerably robust—a free evacuation should be made by punc- ture. By the inflammatory disintegration following on such opening, we are most likely to obtain such spontaneous change in the state of the bone, as will admit of the healing process (Principles, 3d Am. Ed. p. 418). But the action requires an anxious watchfulness, lest it involve the system in a dangerous amount of disturbance, and lest, also, by excess, it prove prejudicial to the affected part. If a case present itself, in all local respects promising, but with the system accidentally low, the opening should be delayed until, by time and suitable manage- ment, the constitutional powers have been somewhat restored, and a tolerance of the remedy regained. When the matter connected with vertebral disease points in the groin, having descended along the course of the psoas muscle, the affection is termed Psoas Abscess ; but it, too, may occasionally be found uncon- nected with disease of bone. Treatment is the same as in the former instance. Under care, cod-liver oil, and the prone couch, sometimes wonderful recoveries take place; even after long-continued discharge. 344 SPINA BIFIDA. Spina Bifida, or Hydrorachitis. This is a congenital malformation, usually situated in the lumbar region ; but it may be in the dorsal or sacral. The posterior part of one or more vertebrae is deficient; and, in consequence, the membranes of the cord protrude, constituting a tumor of greater or less size—com- posed of the ordinary integuments, the changed spinal membranes, and the spinal fluid secreted in excess. In other respects, the child may be fully and well formed. More frequently, it is otherwise defective ; the lower limbs, especially, being shrunk and paralytic. Usually, the tumor enlarges, fry accumulation of the contained fluid; the integument thins and ulcerates; the fluid contents escape, and the tumor collapses; an asthenic inflammatory action seizes on the spinal cord and its mem- branes ; and the patient perishes either directly in consequence, or by hectic. In the more favorable cases, the tumor may enlarge slowly, if at all; and the child's growth may advance uninterruptedly. Some- times, by spontaneous ulceration, a very minute aperture is formed, through which the fluid contents slowly drain away, the tumor gradually shrinking, and the parts becoming satisfactorily consolidated. Curative treatment is attempted only in those cases which afford a reasonable prospect of successful issue. In some cases, it is enough to palliate and prevent increase. In others, we get rid of the swelling, hoping that the fissure in the spinal column may close; or, at all events, that such consolidation shall take place as may effectually prevent recurrence of the protrusion. 1. By steady and uniform support and pressure from without, not only is increase preATented, absorption may also be occasioned ; and the tumor having become slowly discussed, an opportunity may be thus given for closure of the vertebral hiatus. 2. Along with the use of pressure, occasional puncturing of the cyst may be practised, so as to expedite the process. 3. The fluid may be at once drawn off with a trocar and canula. And it has been farther proposed subsequently to inject iodine, as for hydrocele. 4. By includ- ing the prominence of the tumor in two elliptical incisions, which pene- trate the whole thickness of its coverings, the fluid is at once eAracuated; and then, on bringing and retaining the margins of the wound in contact by means of suture, such a degree and kind of traction is made upon the parts beneath as may favor, very much, the desired closure of the spinal fissure.1 In dissecting away the part included in the elliptical incisions, care must be taken to injure the nervous expansions on its internal aspect as little as possible. The head, too, should not be kept high; otherwise the fluid of the sheath is apt to escape too suddenly. This last operation is warrantable only in those cases in which the fissure is slight, and other circumstances are favorable. After such a proceeding, as Avell as in the modes of treatment by puncture, obviously there is much danger by inflammatory seizure of the spinal contents— which has to be guarded against accordingly. ' Dubourg, Gazette Medicale de Paris, Juillet 31, 1841; and Brit, and For. Rev. No. 24, p. 547. MALIGNANT DISEASE. 345 Malignant Disease. The spinal column has occasionally been found affected by malignant tumor ;x an affection Avhich is fortunately rare, seeing that in all cases it must be quite incurable. Shaw on Distortions of the Spine, Lond. 1823 and 1825. C. Bell on Injuries of the Spine. Lond. 1824. Lawrence on Dislocations of the Vertebrse, Med.-Chir. Trans, vol. xiii. 1825. Teale on Neuralgic Diseases, Lond. 1829. Beale, a Treatise on Deformities, &c, Lond. 1830. Stafford on Injuries, Diseases, and Distortions of the Spine, Lond. 1832. Brodie on Injuries of the Spinal Cord, Med.-Chir. Trans, vol. xx. 1837. Gue"rin. Gazette Medicale, 1840, Nos. 14 and 15. Hewitt, Cases of Spina Bifida, Lond. Med. Gazette, vol. xxxiv. 1844. Lonsdale on Curvature of the Spine, Lond. 1847. Stanley on Diseases of the Bones, Lond. 1849. Bishop on Deformities of the Human Body, Lond. 1851. Tamplin on Lateral Curvature of the Spine, Lond. 1852. Pirrie, Principles and Practice of Surgery, Lond. 1852. Brodie on Injuries of the Spinal Cord, Med.-Chir. Trans, vol. xxi. Brodie on Curvatures of the Spine, Lancet, No. 1218, et seq. ' Medico- Chirurgical Transact, vol. vi. art. 6. CHAPTER XXV. INJURIES AND DISEASES OF THE CHEST. Fracture of the Ribs. The ribs are very liable to fracture; by a blow, or fall, or the appli- cation of crushing weight; and the ordinary site of injury is near the middle of the bones. The signs are, pain at the part, usually with dis- coloration and swelling; difficult breath- Fig. 168. ing; full inspiration impracticable, the attempt causing great aggravation of pain, with sudden catching of the breath; crepitus felt, when the palm is held over the part, during respiratory movement. Displacement is seldom great; and is almost always inwards. The injury may be compound, with corresponding wound of the integuments. More fre- quently it is in a manner compound, by wound of both pleurae, and consequent communication with the lung, the integu- ments remaining entire. Under such circumstances, emphysema can scarcely fail to occur, to a greater or less extent; air escaping outwardly from the lung, and becoming infiltrated into the sub- cutaneous areolar tissue—puffing up the surface of the chest, and probably also extending to the neck. Inflammatory affection of the pleura is not unlikely to supervene, as can readily be understood. The objects, of treatment are, to effect and maintain replacement, to prevent motion, and to avert inflammatory or other untoward consequences. A compress is laid along the sternum, so as to make that surface equally salient with the spinous ridge of the vertebrae; and then a broad flannel roller is applied tightly round the chest; the effect of such deligation being to arrest respiratory movement of the ribs, and to force outwards the fragments of the rib or ribs—not only placing them in more accu- rate contact than they otherwise would be, but also removing their sharp extremities from the pleura, which they might seriously injure. In se- General emphysema of the whole surface after wound of the right side of the chest (After Larrey.) FRACTURE OF THE RIBS AND STERNUM—PNEUMOCELE. 347 vere cases, when the cavity of the pleura contains much extravasated blood, bandaging must be conducted Avith great caution, lest it seriously aggravate the already existing dyspnoea. Rigid antiphlogistic regimen is enjoined; and active antiphlogistics are not delayed, if inflammatory accession threaten in the chest. Cough, sneezing, and other involun- tary movements of the part, should be avoided, if possible; and confine- ment to bed is expedient, during the first few days. The bandaging is likely to limit or prevent emphysema; but if this prove excessive and inconvenient, relief may be obtained by punctures. Ordinarily, it does not occur to a great extent, and gradually disappears, probably by ab- sorption. Dislocation of the Ribs. Sometimes, but rarely, the head of the rib is displaced from its con- nection with the spinal column, without fracture. Displacement is usu- ally slight. And the injury resembles fracture very closely, both in its history and treatment. Fracture of the Sternum. The sternum is sometimes broken by direct violence, and displaced inwards. The signs are plain; deformity by displacement being at once discernible, and crepitus taking place during respiratory movement. Treatment is as for broken ribs; but without any compress over the broken bone. And there is the same necessity for watchful anxiety as to the state of the thoracic contents. Caries and Necrosis of the Ribs and Sternum. These bones are liable to caries and necrosis, in connection with injury, and as results of mercurial poison—with or without syphilis. The ordinary treatment has to be put in force; except in those cases of chronic caries in which the disease is slight, and has been of very long duration, in a feeble system. Then, sudden suppression of the dis- charge, by healing, would be apt to prove injurious; and it is well to be contented with mere palliation. When operation on a diseased rib is necessary, freedom of manipula- tion is favored by the previous condensation and thickening of those parts which lie .between the bone and the pleural cavity. Hernia of the Lungs, or Pneumocele. This mal-position may be: 1. Congenital, from defective development of the thoracic parietes; 2. Traumatic, a wound having left a portion of the parietes open to protrusion; 3. Consecutive, following fracture of a rib, or perforation of the chest's wall by abscess; 4. Spontaneous, protrusion taking place through an intercostal space, during the exer- tion of coughing, or through the natural apertures at the root of the neck beside the large bloodvessels. The intercostal spaces most fre- 348 WOUNDS OF THE CHEST^, quently affected are the seventh, eighth, and ninth, at their anterior part. When slowly formed, the protruded part acquires a sac from the pleura costalis; and, from a small beginning, may come to be of great size—its dimensions greatest during forcible expiration. Auscultation reveals nothing in inspiration; but during forced expiration an intense vesicular murmur is heard, similar to that of normal inspiration, and sometimes accompanied by a kind of crepitant rdle. At the same time, too, an impulse is given to the hand, and the vesicular "rustling" may be felt as well as heard. In the traumatic form, reduction is to be effected, if the protruded portion of lung be in a fit state for replacement. Otherwise, it is to be removed by incision. If left to itself, the part will sphacelate, and spontaneous cure may result. No real strangulation, however, occurs; and on this account prognosis is more favorable than in abdominal hernia. In the other forms, the tumor is reduced, and a firm compress and bandage continuously worn.1 Wounds of the Chest. These may be inflicted by the thrust of a sharp instrument, by the penetration of obtuse bodies, by gunshot, or by fractured rib. Danger is great both at once and secondarily; immediately, by loss of blood, and by entrance of air into the pleural cavity ; subsequently, by inflam- matory action, and its results. The latter danger is the more serious. And the general statement may safely be made, that in the early treat- ment active antiphlogistics are mainly to be trusted to ; unless decidedly contraindicated by special circumstances of the case. Penetrating wounds by sharp instruments, affecting the lungs, are ahvays formidable by bleeding. But, in the case of an obtuse body penetrating, the elas- ticity of the lung saves that tissue from injury, which, from a sharp- pointed body, it could not fail to sustain. 1. Wounds of the Pleura Costalis.—If the intercostal artery have been wounded, bleeding is likely to be both troublesome and dangerous. The loss may be excessive through the external wound; or blood, accu- mulating within the pleural cavity, may compress the lung, and consti- tute a dangerous haematothorax. This point, therefore, should engage our first attention. And, to secure the vessel, one of two methods may be adopted. It and its accompanying rib may be included in the noose of a ligature. Or, a linen bandage having been placed over the part, a fold of it is pushed into the wound, between the ribs; and the linen pouch within the pleural cavity is crammed with charpie, by means of a probe or director; then, tightening the bandage, and securing it firmly round the chest, this internal plug is made to compress the vessel and occlude its orifice. But, indeed, the dangers by wound of this 1 Vide M. Merell-Lavallge, Me"m. de la Soc. de Chirurg. de Paris, 1847 : and Brit, and For. Med.-Chir. Rev. Jan. 1848, p. 133. WOUNDS OF THE CHEST. 349 vessel seem to have been somewhat overstated; and, in most cases, ordinary hemostatics, it is probable, will not be found to fail.1 Entrance of air by the wound, and accumulation of it within the chest, are to be aAoided by early and accurate closure of the Avound. Otherwise, the condition of pneumothorax becomes established; the lung is compressed, and made to collapse; respiration is consequently rendered imperfect ; and the other lung, having suddenly a great amount of additional duty thrown upon it, labors in its function, becomes dangerously congested, may prove apoplectic, or is attacked by violent inflammatory action. These immediate dangers having been surpassed, others remain. The wound, suppurating, may lead to inflammatory affection of the pleura or of the lungs, by extension of the inflammatory process; and this has to be guarded against by antiphlogistic regimen, in the first instance, followed, if need be, by venesection and antimony. 2. Wounds of both Pleurse and of the Lung.—The dangers are still by blood, air, and inflammatory action. There is now a third outlet for the first; by the bronchial tubes, as well as into the pleural cavity, and through the external wound. And the bleeding, coming from so vascu- lar an organ as the lung, is likely to prove formidable. The usual signs of wound of the lung are—a state of system bordering on collapse, dif- ficult breathing, great anxiety of countenance, and expectoration of florid arterial blood. Bleeding is dangerous, by direct loss, and by danger of haematothorax; and also by risk of accumulation in the bronchial tubes, or in the trachea, during the stage of collapse. After- wards comes the peril of intense inflammatory action in lung and pleura. And, lastly, by profuse and continued discharge from the suppurating wound, the patient may perish under the symptoms of phthisical hectic. The first danger is met by rest, quietude, and rigid antiphlogistic regi- men ; recourse being had also, if need be, to more direct means of con- trolling the hemorrhage, derivative venesection, nauseants, acetate of lead and opium, &c. (Principles, 3d Am. Ed. p. 351). Rallying and reaction having occurred, antiphlogistics come into use, and often not sparingly. Hectic having threatened or set in, a corresponding change must be made in the treatment. The local management is simple throughout. At first, careful examination of the wound is made, in order that no foreign matter may be permitted to remain. Then it is covered by tepid water-dressing, retained by light bandaging. And the patient is laid and directed to remain on the wounded side, so as to faA7or outward escape of discharge; while by this posture, also, adhe- sion is favored between the corresponding wounded portions of the two pleurae, so as to shut off the injured part from the general costal cavity.2 When contusion exists, as in gunshot injuries, great watchfulness is necessary at the time of the separation of sloughs, lest secondary he- morrhage occur. Small doses of aconite are of use in averting this ; by subduing the febrile excitement of the circulation which usually pre- cedes. Emphysema may occur in one of two ways, but is seldom such as to require direct treatment. Air, escaping from the pulmonic lesion, Guthrie on AVounds of the Chest, p. 104. 1 Ibid. p. «. 350 H.EJIATOTHORAX. may not be wholly discharged externally; or, in a valvular form of external wound, air may enter more readily in inspiration than it can escape during expiration; and, in either case, a portion is liable to be infiltrated into the subcutaneous areolar tissue. Hxmatothorax. This term denotes an accumulation of blood in the pleural cavity, causing compression of the corresponding lung, and the dangerous con- sequences of this, already noticed. It may be produced by spontaneous escape of blood, through ulceration, as in aneurism; much more fre- quently it is of traumatic origin, by wound of the lung, or of an inter- costal artery. It may be either simple or compound; the latter, if the result of a penetrating wound ; the former, if caused by puncture of the lung in a case of fractured rib, with much displacement of the sharp ends of the bone, the integument remaining entire. According to the extent of accumulation, respiration is more or less oppressed; there is dulness on percussion on that side, and no respiratory murmur can be heard; on the opposite side, respiration is puerile ; the patient lies only on the affected side, and the corresponding cheek has often been ob- served of a purple color ; the countenance is anxious; the general sur- face is cold, pale, and bedewed by clammy sweat; and there is feeble pulse, with cold extremities, and other signs of serious loss of blood (Principles, 3d Am. Ed. p. 356). [Valentin observed in several cases of hemorrhage into the thoracic cavity, that an ecchymosis occurred* at the angle of the false ribs, and spread towards the loins. The ecchymosis is described as of a clear purple hue, like the spots which sometimes appear on the abdomen shortly after death. (Cooper s Surgical Diet. 7th ed. p. 1494.) But this sign is not always present in intra-thoracic hemorrhage; and it cannot compare in point of value with the evidences elicited by ausculta- tion and percussion, taken in connection with those of the constitutional effects produced by considerable loss of blood.—Ed.] If the affection be not compound, and slight in other respects, treat- ment is analogous to that of sanguineous collections in the external parts of the body, following bruise. Wound of the surface is carefully ab- stained from, and gradual disappearance by absorption patiently awaited (Principles, 3d Am. Ed. p. 691). Venesection is advisable, unless when specially contraindicated; first, to arrest bleeding, and so to limit the accumulation; secondly, to diminish the amount of cfrculatino- fluid in the laboring sound lung, and at the same time to avert or mitigate in- flammatory action in all the injured parts. If, however, the accumula- tion be obviously great—as evidenced by the amount of dulness and fulness of the side, and by the oppression in breathing—it becomes necessary to afford the confined blood means of escape, by making a suitable opening in the parietes. In the compound form, the wound is kept open ; and means are taken to arrest the bleeding at its source, and at the same time to assist the respiration; and inflammatory symptoms are timeously opposed. [For the arrest of hemorrhage from a Avound of the lung, the same PNEUMOTHORAX. 351 principles of treatment, both general and local, are applicable as to bleeding from other sources. One of the most effective local haemo- statics is compression. We cannot directly bring this means to bear upon the lung ; but we can induce the lung to collapse, and thus effectu- ally compress its vessels. So long as the external wound is allowed to remain open, the blood which escapes from the lung will of course flow out of the chest, especially if the patient be directed to lie upon the wounded side, as advised in the last section, and the lung will continue to be expanded. But if the external orifice be closed, in addition to the other means recommended, the lung will be gradually compressed against the spine, the blood will slowly coagulate, and thus the bleeding will be stopped. We cannot but think, therefore, that the advice given in the text, to keep the wound open, is injudicious. Another mode by Avhich, in case of emergency, and where death from hemorrhage seems imminent, we may induce collapse of the lung and consequent compression of the pulmonary vessels, is to alloAV the air to enter freely through the external wound, which, indeed, would be the case in every instance of penetrating wound of the chest, if the ori- fice were large enough. But in many cases the wound is small, so that the presence of flowing blood in it, and of the lung in apposition to it behind, prevent the entrance of air. The remedy in such cases is mani- festly to enlarge the wound, taking care to avoid cutting the intercostal artery.—Ed.] Pneumothorax. This denotes accumulation of air in the pleural cavity. The case may be either medical or surgical; the latter dependent on wound of the lung; the former caused by perforating ulcer, connected with tuber- cular abscess. The traumatic form is the result of penetrating wound, oblique and valvular; or of fractured rib, displaced inwards. It has also resulted from mere bruise of the chest; the lung and pleura pulmonalis having giving way by rupture. Its signs are: absence of the respi- ratory murmur on the affected side, with a peculiarly clear resonance on percussion; the ribs are fixed; and, on the opposite side, respiration is puerile, as in the preceding affection. In the medical form, there is usually fluid as well as air in the chest; consequently, a splashing of this fluid is heard, on succussion; and coughing produces a ringing sound, termed metallic, or amphoric resonance. Treatment consists in affording ease to the working lung, and avert- ing inflammatory action. Judicious loss of blood, as already seen, con- duces powerfully to both objects. In urgent cases, an outward escape is to be afforded to the air, by acupuncture, or by the thrust of a small trocar and canula. Emphysema sometimes coexists with Pneumothorax. It has been already considered, incidentally. 352 PARACENTESIS THORACIS. Paracentesis Thoracis. Puncture of the thoracic parietes may be required, we have seen, on account of accumulated air or blood in the pleural cavity. It may also be called for in consequence of fluids having collected there—the result of inflammatory action—Hydrothorax and Empyema ; diseases which belong to the department of the physician, and which it is consequently unnecessary to consider here. In empyema, the side is found dull on percussion and swollen, and the ribs are unusually separate; there are dyspnoea, difficulty of lying on the sound side, and the other signs of pleural accumulation already noticed; the side enlarges more and more; fluctuation comes to be discernible in the intercostal spaces ; and, ulti- mately, by ulceration at the most prominent part, spontaneous evacua- tion may take place, as in ordinary abscess. For the discharge of purulent and sero-purulent fluids, an opening is made by means of a trocar and canula. This instrument may be em- ployed, subintegumentally, as in the case of chronic abscess (Principles, 3d Am. Ed. p. 216). Or the opening may be made direct, and left patulous and dependent. However made, the margins of the ribs should be carefully avoided, especially the lower, lest wound of the intercostal arteries occur. In the direct puncture, it is well to make an incision through the skin and muscular stratum, by means of a scalpel; merely completing perforation by the trocar. As to the most eligible point for making such a wound, authorities greatly differ. The opening must be dependent, and sufficient in all respects for evacuation; and yet it must not be so placed as to endanger the diaphragm, though this muscle, it is to be remembered, is usually displaced downwards very considerably by the accumulation, and is farther protected by the patient being di- rected to inspire during the act of puncture. The space between the fifth and sixth ribs is frequently chosen, midway between the spine and sternum. Some prefer that between the seventh and eighth; others ope- rate between the sixth and seventh. Some go as high as between the fourth and fifth ribs, having observed that natural pointing not unfre- quently takes place there. Of late, the space between the sixth and seventh, or that between the seventh and eighth has been opened, by cautious dissection and the thrust of a small trocar, at the most depend- ent part, below the loAver angle of the scapula. The patient is placed with the side prominent and dependent; and arrangements are made for turning him on his face, should oppressed respiration ensue. In the case of direct opening, permanency may seem preferable to closure and reopening; and this is secured by suitable dressing of the wound. To favor discharge, the patient remains recumbent on the affected side. If closure be attempted, the greatest care must be taken to avoid the en- trance of air; the patient is exhorted to shallow breathing; the canula is withdrawn before all the fluid has escaped; and the wound is instantly shut up. The physical signs of hydrothorax are not dissimilar from those of empyema. And often very marked benefit may be derived from para- centesis. Accumulation having proceeded so far as greatly to embarrass PARACENTESIS THORACIS. 353 breathing; the patient is arranged as already described, and by means of a small trocar the serum is cautiously withdraAvn ; the utmost care being taken to prevent entrance of air into the pleural cavity. Enough having been removed, the puncture is treated so as to secure immediate union. And, subsequently, the operation may be repeated, if neces- sary. Relief is certain, for the time; and in not a few cases this adaptation of surgery to medicine seems to have been instrumental towards a permanent cure. [The important pathological differences existing between Hydro- thorax, whether the result of inflammation or of passive transudation of serum, and Empyema, and the fact that the operation of para- centesis is more frequently called for in the latter than in the former affection, for the simple reason that this is more amenable to the ordi- nary medicinal treatment than that, render it expedient to set forth more clearly the means of diagnosis between the tAvo. Although there is a considerable degree of resemblance between the phenomena of these affections, yet, in empyema, the duration of the symptoms, and physical signs, is commonly longer than in hydrothorax, and the progress of the case is usually more slow and gradual; and in hydrothorax, from passiAre transudation, there is, in most cases, a lesion of the heart, or of some other important organ, sufficient to account for the collection of fluid in the chest, which is affected in common Avith other serous cavities and the areolar tissue generally. In empyema, the constitutional disturbance ordinarily assumes the form of hectic fever. The physical signs, too, are somewhat different in these tAvo affections, and, taken in connection with the general symptoms, will almost always determine the character of the complaint. In empyema, there is frequently much greater prominence of the diseased side of the chest, and of the lower intercostal spaces, than in hydrothorax. The reason of this is probably as suggested by Dr. Stokes (Diseases of the Chest), that these are more relaxed, and their tonicity and muscular con- tractility more impaired in empyema, in consequence of the more pro- tracted duration of the inflammation; and, moreover, the specific gravity of the fluid is greater, and consequently the pressure exercised upon the walls of the chest is more considerable. Again, the superficial veins of the chest are, more frequently distended and tortuous in empyema, be- cause the free return of venous blood to the heart through the ascending cava is interfered with, by the pressure of the fluid and the collapsed lung upon this vein—the pressure being greater in empyema than in hydrothorax, because the fluid is of greater density.1 Besides, the im- perfect decarbonization of the blood by the respiratory process, renders it necessary that the liver shall perform more than its ordinary task ; hence, this organ becomes more or less congested, and the portal circu- lation embarrassed, unless the redundant blood shall find its way back to the right auricle by the superficial .venous channels.2 In many cases of empyema, uncomplicated with any active disease of the lung, and in whi^h there was no fistulous communication between the pleural sac and 1 Pepper, Cases of Empyema, reported in the American Journal, for January, 1852. 2 McDonnell, Dublin Journal, March, 1844. 23 354 PARACENTESIS THORACIS. the bronchial tubes, purulent expectoration has been observed, which has not, so far as we know, been noticed in hydrothorax. This phenomenon may very probably be explained by the long-continued congestion of the bronchial mucous membrane, which seeks to relieve itself by the purulent discharge.1 But empyema may be confounded with other diseases than hydro- thorax; with encephaloid degeneration of the lung,vf'\th enlargement of the liver, with pulmonary phthisis. From the first, it may be dis- tinguished by the absence of symptoms which generally accompany encephaloid disease of the lung, e. g. the currant-jelly-like sputa, and the cancerous cachexia, with external cancerous tumors; and when the lungs are thus diseased, tumors of an analogous kind are apt to be pre- sent in the mediastinum, producing pain in the neck and shoulders, oedema of the face and integuments of the chest, pressure upon the cesophagus and trachea, &c. &c. From enlargement of the liver, it differs in the locality and character of the physical signs, and in con- stitutional symptoms; and in the absence, in the last disease, of the dislocation of the heart, and of the prominence of the intercostal spaces. The history of the case, the evidences of the tubercular cachexia, with its usual concomitant, enlargement of the cervical lymphatic glands, the commonly diseased condition of the lung of the other side, and the presence or absence of the physical signs of the existence of pleuritic purulent effusion, will ordinarily enable one to distinguish between pul- monary phthisis and empyema. But it is important to bear in mind that these two diseases may, and often do, coexist. If the surgeon is still in doubt as to the nature of the case, after having examined the patient in the ordinary manner, he may resort to an exploratory puncture, as recommended by Dr. Davies ;2 and having thus satisfied himself of the actual condition of things, complete the operation or not, according to the information he has gained by the puncture. The existence of fluid in the pleural sac haAring been determined, the treatment to be instituted for its removal becomes a matter for serious consideration. If the fluid be serum, or sero-albuminous, constituting hydrothorax, a reasonable hope may be indulged, under favorable cir- cumstances, that it will be removed by absorption, no matter how large the quantity may be. But this is not always accomplished, as is evi- dent from the fact that many persons die of hydrothorax. Thus, Dr. Boyd, in the course of three years, opened the bodies of tAventy-four persons, Avho died of this affection, in the St. Marylebone Infirmary, and of twelve others, in each of whom he found evidences of pleurisy and effusion.3 The patients may have been so much reduced by the pleurisy, or the fluid may so much interfere with respiration, and secondarily with other important functions, from its amount alone, or it may have so rapidly accumulated, that absorption cannot take place under the most favorable hygienic circumstances, and the most judicious 1 Pepper, op. cit.; also, McDonnell, op. cit. 2 Watson's Lectures, Philad. 1851, p. 598. 3 Roe, on Paracentesis Thoracis, Med.-Chir. Transac. vol. xxvii. p. 212. PARACENTESIS THORACIS. 355 medical treatment. In such cases, the operation of tapping the chest should be resorted to, to prevent suffocation. But when the fluid consists more or less entirely of pus, constituting empyema, there is much less probability that it will be removed by absorption. There is here a physical impediment to absorption, in the fact that the pus-globule is too large to be taken up by the vessels, unless it has previously undergone some change, Avhereby it becomes broken down, disintegrated, or otherwise modified (Principles, 3d Am. Ed. p. 145). The watery portion of the pus may be removed in this manner, and hence, we not unfrequently see in the pleural sac, after death from pleurisy, a semi-fluid matter, consisting almost wholly of pus-globules and masses of fibrine—the portion Avhich the absorbent ves- sels could not take up, even had the surrounding serous membrane been in a normal condition, much less when covered, as it commonly is in such cases, by an incompletely vitalized and imperfectly organized layer of adventitious matter effused by the inflammation. In common ab- scesses upon the surface of the body, every one knows how rarely pus is absorbed; so much so, that, so soon as the surgeon is convinced that suppuration has actually commenced, his plan of treatment changes, he ceases to endeavor to promote the absorption of the effused fibrine, but applies warmth to the part, favors the conversion of the fibrine into purulent matter, the approach of the latter to the surface, and evacuates it by an incision. The progress of internal suppuration is rarely dif- ferent. Dr. Pepper says (p. 49 of his paper): " When it is remembered that our therapeutic agents have but little influence in promoting the absorption of pus—that these agents, such as mercury, purgatives, kc., are contraindicated in the impoverished state of the system Avhich attends empyema, and that, even supposing the pus might be absorbed, nothing but the most disastrous effects could result, such as metastatic abscesses, and other consequences of purulent infection, it certainly does not appear reasonable to procrastinate, in the forlorn hope that the unaided efforts of nature may open some safe channel for its escape," through the walls of the chest, or by vicarious action of the bronchial or intestinal mucous membrane, as seems occasionally to have been observed. (Stokes, McDonnell, Pepper.) In the majority of cases, the operation of paracentesis thoracis has not been resorted to until no other hope seemed to be left; Avhen the lung had become more or less altered in structure, perhaps irremediably so, the patient's health and strength seriously if not permanently compro- mised, and his very existence endangered from suffocation. And yet, as we shall presently show, under these very unfavorable circumstances, the success of the expedient has been equal to that of most other im- portant surgical operations. Is it not reasonable to infer that, had it been earlier undertaken, before so much valuable time had been wasted, and so much injury inflicted upon the parts concerned, and upon the patient's constitution, its success would have been even greater ? Probably the most commonly accredited objection to the operation consists in the fact that air is admitted to the pleural sac, whereby the pus is supposed to undergo some change which diminishes very materially the prospect of recovery. But it is evident that too much importance 356 PARACENTESIS THORACIS. has been attached to this circumstance, for practical men have not found these bad consequences to ensue so commonly as has been predicted. Thus, Mr. Fergusson says (Practical Surgery, Philad. 1853): "What- ever care may be taken to prevent the ingress of air, the occurrence is extremely likely to happen. I must say, however, from my own experi- ence, when this has happened, that I have not seen any evil follow directly therefrom." The testimony of Dr. Roe is still more important; he refers to twenty-four cases, nine of which were instances of purulent effusion, and says: "In every case which has fallen under my observa- tion, a considerable quantity of air entered into the pleura during the operation, and in some of them so freely as to excite all the physical signs of pneumothorax; but in none of them did it produce any per- manently evil effect, a few hours being sufficient for its spontaneous removal; in one instance only did it cause even temporary inconvenience. (Op. cit. p. 204.) The success of the operation has been much greater than is com- monly supposed. Dr. Roe, in the paper just cited, has collected all the cases published in the English language between 1812 and 1832; they are thirty-nine in all, of which number eleven died; twenty were ex- amples of empyema, of which fourteen were cured, and six died; thirteen of hydrothorax, of which eight were cured, and five died; tAvo had hyda- tids, both of Avhich were cured; in four, the character of the fluid was not stated, but they all recovered. In none of the thirty-nine cases did the operation prove fatal; in one, however, the patient died on the day fol- lowing it from suffocation, owing to the accumulation of air in the pleura, which might have been removed, as Dr. Roe states, by pumping with a syringe, as was done in one of Dr. R.'s own patients. In another table, he records twenty-four cases operated on by himself, or his friends, since 1833; of these, eighteen recovered, and six died; nine were cases of empyema, of which eight recoA^ered, and one died; thirteen of inflam- matory hydrothorax, of which nine recoA-ered, and four died; one of mechanical hydrothorax, which Avas relieved; one of pneumothorax, which died. Taking the two tables together, the results of the opera- tion will stand thus: the whole number of patients operated upon was sixty-three, of whom forty-six recovered, sixteen died, and one was relieved ; of these, twenty-nine had empyema, of whom twenty-two were cured, and seven died; twenty-seven had hydrothorax, of whom seven- teen were cured, nine died, and one was relieved; two had hydatids, of whom both were cured; in four, the nature of the effusion was not de- scribed, but all recovered ; one had pneumothorax, Avho died. Dr. Roe likeAvise quotes a memorandum given him by Mr. B. Phillips, in which this distinguished surgeon says : " Among my notes of the result of this operation, I find a record of one hundred and twenty-two cases, of which eighty-eight were cured. I find particularized thirty-one cases of pyo- thorax, of which twenty-six were cured ; and nine cases of hydrothorax, of which six were cured." Dr. Davies reports sixteen cases of empyema operated on, of which twelve recovered. In three of the less fortunate cases, the lung could not expand after the evacuation of the fluid, in consequence of the thick- PARACENTESIS THORACIS. 357 ness of the false membranes covering it.1 It is possible that had the operation been performed earlier in these three unsuccessful cases, the results would have been more happy. In none of the cases cited did the operation prove fatal; it is not a painful one; and it is evident that its ultimate success is equal to that of most others of importance undertaken by the surgeon. Dr. Roe, in reviewing his twenty-four cases, concludes thus: " The total mortality proportioned to the whole number of cases, viz.: six in twenty-four, is less than that which occurs after most operations; and yet it is more than can be fairly laid to the charge of paracentesis thoracis, as one of the deaths was from phthisis, another from pneumothorax, and a third from mechanical hydrothorax; for none of which diseases have I advo- cated the operation as a curative measure. Deducting these three cases, the mortality will be three deaths out of twenty-one cases," (p. 234, op. Paracentesis thoracis may therefore be advised and performed, either as a curative or as a mere palliative operation. Curative, in cases of empyema and inflammatory hydrothorax, uncomplicated Avith chronic diseases of the lungs, or other important organ ; palliative, merely, when such disease does coexist with the pleural effusion, and in mechanical hydrothorax, where the effusion into the chest is a mere symptom of serious lesion of the heart, or of some other important organ, which causes the serous transudation into the pleural cavity, and which will ere long itself cause death, even though the accumulated fluid be re- moved by the operation under consideration. In these last cases, how- ever, this expedient may be properly resorted to, in order to prolong life; and even, in some cases, with the hope that when the depression induced by the pleural accumulation is removed, the system may over- come the local disease which occasioned it. The proper time for resorting to the operation is a very important point. In cases of inflammatory and mechanical hydrothorax, simple, or complicated with pneumothorax, tubercular disease of the lungs, or other pathological conditions, it may be postponed until it seems neces- sary to resort to it to relieve impending suffocation, or until proper remedial means, which commonly relieve curable cases, have been tried. But, in instances of empyema, " If it were done, when it is done, then it were well It were done quickly;" and we have shown, we think, that not only is the operation not attended Avith danger, but that it is highly successful. Not only does long delay very generally do no good, so far as spontaneous removal of the fluid is concerned, but it is productive of positive injury. The longer the pro- crastination, the greater the probability that the lung will become thoroughly carnified, firmly bound down to the spine, atrophied, and otherwise unfitted for resuming its duties as a respiratory organ, even after the fluid shall have been removed by operation, or othenvise ; the greater also the liability of thickening and degeneration of the pleura, 1 Watson's Practice, Philad. 1851, p. 600. 358 PARACENTESIS THORACIS. of necrosis or caries of the ribs, of tubercular deposition into the lungs;1 and the more exhausted and diseased will the patient become, from long-continued hectic, which, of itself alone, without the induction of incurable disease of any organ, will, in the majority of cases, unless the cause be removed, occasion premature death. Dr. Roe says that, in his experience, " the success of the operation was directly in proportion to the shortness of the time which intervened between the accumulation of the fluid and the performance of the operation; and that, when it Avas unsuccessful, the chief cause of its failure was its being postponed until too late a period. The very fact that, with the exception of one case of pneumothorax, death occurred only where the effusion had been of very long standing, suggests the opinion that the failure of the operation may be attributed to the duration of the disease; the contracted state of the lung, and other changes which the thoracic viscera are known to undergo from the long-continued pressure of the effused fluid, leads to the conclusion that we ought not unnecessarily to delay the operation a single day," (p. 235, op. cit.) On looking over Dr. Roe's tables, Ave find that the whole number of operations performed, the dates of which, from, the commencement of the disease, are recorded, exclusive of those performed in phthisical patients, and in those with pneumothorax, was forty-two; of these, thirty-two were successful, and ten unsuccessful. These cases may be arranged as follows :— TOTAL. CURED. DIEl Operations performed after a month or less 12 10 2 " " between one and two months . 9 9 0 " " " two and three " 2 2 0 " " " three and four " 6 4 0 " " " four and five " 4 2 0 " " " six and seven " 3 2 1 " " " eight and nine " 3 1* 0 " " after three years 1 1 0 " " " seven " 1 1 0 " " " "a long time" 1 0 1 32 10 Or, of twenty-three operations performed within the first three months of the duration of the effusion, tAventy-one were successful, and two un- successful ; while of the nineteen resorted to later than this, eleven only were successful, and eight unsuccessful. Dr. Roe advises that the opera- tion should not be postponed beyond three Aveeks, believing that, after this period, there will be great danger that changes will have taken place in the lung and pleura, which will render the complete cure of the patient doubtful. He says : "No case occurred in my practice in which, after the lapse of five or six Aveeks from the commencement of the effu- sion, a patient was perfectly cured;' i. e. in which his lung perfectly recovered its normal capacity, and healthy respiration was regained. And it is, of course, highly important that something more should be gained by the operation than the simple removal of the fluid. We have seen that the admission of" air to the pleura, during the ope- 1 Williams, Library of Pract. Medicine, Art. Empyema ; Pepper, in paper before quoted, &c PARACENTESIS PERICARDII. 359 ration, is productive of less injury than is usually feared. But, in order to prevent its entrance, it has been recommended to perform the opera- tion while the patient is in a bath, the chest being under water; various instruments have also been invented for this end. Of these, we Avould mention the contrivance of Dr. Wyman, of Cambridge, Mass., a drawing of which is exhibited in a valuable paper on " Pleuritic Effusions and on Paracentesis Thoracis," by Dr. Bowditch, of Boston, in the American Journal, for April, 1852. After the e\*acuation of the fluid, the operation for which may be re- peated, if necessary, a treatment suited to the condition of the patient must be instituted.—Ed.] Wounds of the Heart. These have been already alluded to (Principles, 3d Am. Ed. p. 339). They generally prove fatal; but are not necessarily so; and, therefore, are amenable to the general principles of treatment formerly detailed (Principles, 3d Am. Ed. p. 351). [Paracentesis Pericardii. M. Velpeau doubts that this operation has ever actually been per- formed (Operative Surgery, vol. iii. p. 520, Am. Ed.); but does not question the feasibility or even the propriety of the proceeding. It should, of course, be reserved for urgent cases only, and where proper treatment by ordinary means has failed. Mr. Walshe says : " Para- centesis of the pericardium becomes justifiable, as an ultima spes, pro- A'ided urgent suffocative symptoms exist. The patient is certainly not placed in a worse position by the operation than he was before it; the immediate relief is extreme, and a certain very small chance exists of at least a temporary recovery."1 The diagnosis of the condition of the pericardium can be determined upon with great certainty; so that an objection on that ground cannot now be maintained. The mode of opening the pericardial cavity is a point concerning which different opinions are entertained. It may be accomplished by trephining the sternum an inch above the xyphoid cartilage, as recom- mended by Riolan, Laennec, &c.; in this operation, the internal mammary artery is not endangered, and the distended sac is perfectly accessible. Others advise that the opening be made at various points on the left of the sternum, between certain of the intercostal spaces. M. Velpeau prefers the procedure of Riolan. The trephining having been effected, the left forefinger should be introduced into the opening to substantiate the existence of fluctuation, and to serve as a guide to the bistoury; the sac having been incised, the patient should be turned on his left side, and the fluid allowed to escape. (Velpeau, op. cit.) Mr. Walshe says: " Were the operation determined on, a trocar should be cautiously introduced, perpendicularly to the surface, at the loAver 1 Diseases of the Lungs and Heart, p. 452, London, 1851. 360 PARACENTESIS PERICARDII. angle of the left fourth interspace close to the sternum. The fluid which escapes by jets, corresponding to the ventricular systoles, should be evacuated as completely as possible before the wound is closed—a syringe may even be employed to insure this. But the orifice of the canula, before its removal, should occasionally be closed, lest too rapid removal of the fluid might produce evils of its own on the heart, ac- customed as this has been, for a greater or less time, to considerable pressure." (Op. cit.) Dr. Smith states, in his Operative Surgery, p. 381, on the authority of a manuscript letter from Dr. J. C. Warren, of Boston, that this gen- tleman has once successfully performed this operation. The mode of operating in this case is not described. Of course, the operation is expected to produce only temporary relief; the cure of the disease must be sought after by proper constitutional and topical treatment.—Ed.] Hennen, Military Surgery, Edin. 1820. Mayer, Tractatus de Vulneribus Pectoris, &c. Heidleb. 1823. Quesnay, Dissertatio de Hremorrhagia Arteriae Intercostalis Sistenda, Berol, 1823. Larrey, Me"moires de Chir. Militaire, vol. ii. and Memoires de l'Acad. Royale de Medecine, Paris, 1828. De Jong, Diss, de Vulneribus Cordis, Groning, 1838. Guthrie on Wounds and Injuries of the Chest, Lond. 1848. Richerand, Nosog. Chirurg. vol. iv. p. 3. Diet, des Sciences Me"d. vol. iv.'p. 217. Dupuytren, Lecons Orales, vol. ii. Cock and Hughes on Paracentesis Thoracis, Guys Hospital Reports, Second Series, No. iii. Lond. 1844. CHAPTER XXVI. AFFECTIONS OF THE MAMMA AND MAMMILLA. Irritable Mamma. The female breast is not unfrequently the seat of irritation (Prin- ciples, 3d Am. Ed. p. 89); giving rise to much local uneasiness, and tending also to involve the system in serious disorder. The gland is nowise altered in structure ; sometimes there is slight puffiness in the superficial areolar tissue. The pain is very considerable; not constant, liable to exacerbations—often periodic—and otherwise evincing the ordinary characters of neuralgia. Aggravation generally occurs at the menstrual period. The patient is young or of middle age ; and usually is pale, thin, and cachectic. The affection is to be considered as symptomatic of more serious dis- ease, and treated accordingly. In the majority of cases, the uterus is to blame—disordered either in structure or in function; and, until this source of evil be rectified, all other treatment will prove of little avail. In cases of functional derangement, the preparations of iron are indi- cated. Conium is of service in allaying the general irritation of system. Locally, the endermic use of nitrate of silver, so as merely to blacken, often affords relief; and belladonna, aconite, and prussic acid may be used in the form of ointment, liniment, or plaster. Change of air, ex- ercise, attention to diet, and the other ordinary correctives of chronic disease, are of great importance. In some cases the symptoms seem dependent on neuromatous formation in the neighborhood of the gland; and under such circumstances, cure may be readily effected by excision of the superficial tumor. Mammitis. 1. Acute.—Acute inflammatory action in the mamma may result from external injury, exposure to cold, or any of the other ordinary excitants; most commonly it is connected with lactation. The pain and other local signs are intense ; fever is proportionally severe ; and suppuration is from the first imminent. The secretion of milk is first perverted, and then arrested. Matter, when formed, is seldom limited to one part, pointing rapidly there; but rather tends to pervade the whole gland, pointing slowly; and the abscess, after having become open, is liable to degenerate into tke condition of sinus (Principles, 3d Am. Ed. p. 218). 362 MAMMITIS—CHRONIC ABSCESS. In the outset, leeches are applied in abundance, with hot fomentation; and the gland is carefully supported by a soft handkerchief or shawl, passed beneath it and around the neck. Small doses of sulphate of magnesia, in acidulated solution, assist antimony in subduing the febrile state, and, at the same time, have the salutary effect of opposing de- termination of blood and consequent hyper-secretion in the gland. When resolution is to take place, this may be accelerated by gentle friction. When matter has formed, early evacuation should be made; for thus only may future severities by incision be prevented. In seArere or neglected cases, the gland may be, as it were, dissected out by the matter separating its component parts ; or many sinuses may form, communicating with each other, intersecting the whole mamma, and mixed up with intercurrent abscess. Such sinuses do not require to be each incised throughout its Avhole extent—the knife following merci- lessly on the probe ; it is enough to secure satisfactory evacuation by suitable counter-opening, and then by pressure to favor contraction of the cavities. In this, we generally succeed ; and continuance of the pressure is farther useful, in promoting discussion of the morbid paren- chyma in Avhich the sinuses are placed. It may be applied by bandag- ing, by careful application of strips of adhesive plaster, or by means of air or water contained in caoutchouc tissue, as recommended by Mr. Arnott. 2. Chronic.—The mamma is subject to enlargement and induration, by reason of a slow, painless, and minor amount of the inflammatory process. The whole gland may be effected, or only a part. Young adults are most liable. The swelling is more diffuse than any form of genuine tumor ; and is little painful, even on manipulation ; it feels as if composed of numerous small granules, and has the negative charac- ter of wanting the local and constitutional signs of carcinoma. Treat- ment consists, locally, in light antiphlogistics, followed perseveringly by discutients ; constitutionally, in attention to the general health, and to the uterine functions, by alteratives, tonics, &c. Galactirrhoea.—By this term is understood a persistent and excessive secretion of milk; whereby emaciation, debility, and even hectic may be induced. To arrest and remove this condition, iodine given internally seems to possess almost a specific poAver; suckling being of course desisted from, and the uterine functions restored. Chronic Abscess. Chronic abscess is not unfrequently found of a somewhat peculiar character in connection with this gland ; consisting of a firm cyst, con- taining a small quantity of thick creamy-looking pus ; existing for months or years, and enlarging slowly if at all; situate sometimes in the gland, more frequently beneath it; firm, because tense, to the touch; and closely simulating a solid tumor. It may be treated either by subintegumental or by direct puncture ; or, an error of diagnosis having been committed, and a free incision having been made, the cyst may be dissected away—as if a tumor. LACTEAL AND OTHER SAVELLINGS. 363 Lacteal Tumor. One or more of the lacteal tubes are liable to distension, by occlu- sion of their orifices ; giving rise to a swelling analogous to ranula in its formation. The contents are milky during lactation; at other times serous and fluid, or caseous and solid—or partly so. The swelling has a fluctuating feel, and extends, radius-like, from the nipple outwards ; often it is of a conical form, the apex towards the centre. Treatment is by puncture, near the nipple; keeping the opening pervious. Should inflammatory action take place, inducing obliteration, the occurrence need not be greatly deplored.1 Sometimes abscess forms ; requiring the ordinary treatment. Hypertrophy. The mamma is liable to hypertrophy, at the period of puberty; usually, with an unsatisfactory condition of the menstrual secretion. Sometimes a state resembling nymphomania attends. The undue amount of development may usually be got rid of, by attention to the general health, and to the uterine functions—aided, if need be, locally, by gentle leeching, followed by discussives. Of these latter none are so effectual, locally, as pressure ; and this is very conveniently applied by means of the hydrostatic apparatus of Dr. Arnott. Pendulous Breast. The pendulous breast is an affection of advanced years ; being but an exaggeration of the ordinary dug-like condition which this organ so generally assumes, in those Avho have borne children, and who habitually neglect support of the part in dress. The only warrantable treatment is palliation by suspension and support. Partial Hypertrophy. This is the " chronic mammary tumor" of Cooper. A portion of the gland becomes hypertrophied, with ultimate change of structure— yet simple; and enlargement of the lobules takes place usually from the outward surface, constituting a soft unequal tumor. It is peculiar to the young adult, seldom, if ever, appearing after thirty years of age; and is almost always connected with disorder of the uterine system. Treatment is the same as for general hypertrophy. Marriage, folloAyed by pregnancy and suckling, sometimes proves a successful means of cure. The tumor, though originally most simple, is liable to degeneration. Consequently, when ordinary discussive means have failed, after due trial, it should be regarded as other tumors not amenable to discussion. " Common snakes are killed, because vipers are dangerous." 1 I have known this simple morbid condition prove the precursor of inveterate carci- noma in the gland. 364 VARIOUS TUMORS OF THE MAMMA. Various Tumors. The gland may be the seat of Simple sarcoma. The treatment is first by discussion ; and, if that fail, by excision. Fibrous tumors have a favorite site here. Though less liable to degeneration than any other morbid growth, they are certainly not exempt from that untoward occur- rence ; and, therefore, except in the aged, it is well to remove "by opera- tion, that which can never grow better and may grow worse (Principles, 3d Am. Ed. p. 309). Cystic sarcoma is very common. Like the sim- ple mammary tumor, it is most frequent under thirty years of age, and prevails chiefly among the better classes. The tumor is composed mainly of serous cysts, the parenchyma consisting of little more than the substance of the gland slightly altered. And there is some reason to believe that these cysts may sometimes originate in partial lacteal dilatation. By puncturing the cysts, and afterwards applying pressure, the tumor may diminish, consolidate, and gradually disappear, in the minor cases. But when the whole gland is involved, extirpation should be at once had recourse to ; not only because other treatment will prove unsuccessful, but because such tumors are well-known to be peculiarly prone to degenerate, more especially when irritated (Principles, 3d Am. Ed. p. 304). True Hydatids are also found, in the gland. When single, they may be got rid of by puncture. When numerous, ablation of the part is expedient. The Malignant tumors of the mamma are unfortunately of proverbial frequency; more especially carcinoma. Fig. 169. Fig. 170. Fig. 169.—Carcinoma of the Breast, bisected. The figure of the tumor, with its effect on the gland and nipple shown. \'' % "I ^W Fig. 170.—Carcinoma; secondary. An example of the numerous nodulated tumors, which often form in the cicatrix of the former growth. One is ulcerated in the site of the mammilla. The general description of this tumor (Principles, 3d Am. Ed n 310) is not departed from; the chief peculiarity being in the nipple, which, early involved is remarkably retracted and shrivelled in appearance! The glands of the axilla, too, are liable to be soon affected The dis- ease is known by the age of the patient, the hardness of the tumor the character of the pain, the rate and mode of growth, the involvement of EXTIRPATION OF THE MAMMA. 365 the skin and retraction of the nipple, the cachectic state of the system as evidenced by the countenance and general appearance. The only cure is by extirpation; but, as-.formerly explained (Principles, 3d Am. Fijr. 171. Fungus Ilcematodes of Mamma; fungoid, bleeding, and blood-like. Ed. p. 317), it is only a small number of the many cases which present themselves to the surgeon, which warrant operation; and it may be well to repeat here, that if the skin be much involved, if the nipple be much retracted, if there be a marked depression over the tumor, if the open condition be arrived at, if there be adhesion of the tumor to the pectoral muscle or to the ribs, if there be ominous signs of some ob- scure yet serious disorder proceeding within, and if there be glandular affection without—these, being all singly most unfavorable, and betoken- ing relapse, do most certainly, when coming together, contraindicate all operatiATe interference. Extirpation of the Mamma. The patient having been placed recumbent, and duly anaesthetized the arm on the affected side is raised and held by an assistant, so as to stretch the pectoralis major, and facilitate incision. The knife is entered on the axillary aspect of the tumor, in a line with the mammilla, and is moved in a semi-elliptical direction towards the opposite point; a simi- lar proceeding is adopted, above or below, as the case may be,' to com- plete the ellipse ; and the size of this space necessarily varies, according to the extent to which the integument seems to be involved, and accord- ing to the natural laxity of the parts. It is a fault to take away an undue amount of sound textures, so that difficulty is experienced in effecting and maintaining apposition of the wound; but it is a worse 366 AFFECTIONS OF THE MAMMILLA. error to leave tainted parts, whereby reproduction of the disease cannot fail speedily to ensue. It is well to make the lower incision first, other- wise its course and position are apt to be uncertain, under the irrigation of blood. Then, on each aspect, the knife is sloped through the subcu- taneous fat, and regular dissection is proceeded with from the axilla downwards, dividing the principal vessels and ner\'es at once, and so rendering the subsequent steps of the operation comparatively blood- less and free from pain (Principles, 3d Am. Ed. p. 329). The diseased mass, with its border of apparently sound tissue, in the case of malignant tumor (Principles, 3d Am. Ed. pp. 317 and 329), having been removed, is carefully examined on every aspect by both sight and touch; and, if need be, the knife is reapplied where thorough removal is not assuredly apparent. The vessels having been secured, the wound is brought to- gether, and treated in the ordinary way. Tumors external to the mamma, forming in its immediate vicinity, but not incorporated with it, are not uncommon. The simple are removed, leaving the gland undisturbed. In the case of the avowedly malignant, the entire gland, as well as the tumor, is taken away. Of this class of tumors, not in, but near the mamma, the majority are simple and fibrous. Affection of the Mammilla. The mammilla of the male is liable to hypertrophy and to malignant disease. In the one case discussives are expedient, the other demands free and early ablation. The nipple of the female is also liable to hypertrophy, and malignant disease. In the former case, no direct interference is required ; in the other, there is safety in nothing short of summary removal, not only of the nipple itself, but of the mamma also. There is one case, however, in which it is unnecessary to sacrifice more than the former—when the nipple has been hypertrophied many years, and begins to degenerate in structure. Such degeneration usually commences in, and is at first limited to, the apex; and, in such a case, to cut at the root of the nipple is to cut in sound parts. The fissured and excoriated nipple of the nurse is an affection as fre- quent as distressing. A bare enumeration of alleged cures would occupy much space. Suffice it here to say, that the same treatment is neces- sary as in inflamed and irritable sores, modified by regard to the uses of the part. During application of the child, the nipple is protected by a shield; and, in the interval, some of the many remedies are applied, Avhich are not likely to injure the child, while at the same time they tend to soothe and heal the affected part. Abernethy on Tumors, Lond. 1804. Cumin, a General View of Diseases of the Mamma. &c. Edin. Med. and Surg. Journal, vol. xxvii. art. 1, 1827. Cooper, Illustrations of Pi senses of the Breast, Lond. 1829. Jeanselme, Memoire sur les inflammations et les absces du sein chez la femme, Gazette Medicate, Jan. 1839. C. Bell on Carcinoma Mammae, Med.- Chir. Trans, vol. xii. p. 713. Brodie, Lectures on Pathology and Surgery, Lond. 1810. Birkett on Diseases of the Breast, Lond. 1850. Forget, Bulletin de Therapeutique, torn. xxvii. p. 355. [Lebert, Maladies Cancereuses; Walshe, Treatise on Cancer; A. Berard, Diaguostique Differentiel des Tumeurs du Sein, Paris, 1842.—Ed.] CHAPTER XXVII. AFFECTIONS OF THE ABDOMEN. Abscess of the Abdominal Parietes. xVbscess of the abdominal parietes sometimes occurs spontaneously; frequently, it is the result of external injury; and, in some systems, but a slight blow, or a strain, as in retching, may suffice. The site of the abscess is more frequently deep-seated than superficial. At first, there is a hard, tender, increasing tumor, which softens obscurely as it en- larges, and slowly points. Treatment varies according to the stage. At first, while the inflammatory process is but recent and slight, and the swelling consists of plastic exudation, resolution is in our power, by rest and antiphlogistics. Advancement of the tumor is arrested, and the hard swelling begins to disappear. This subsidence may be accele- rated by judiciously used discussives ; employed, however, always with the greatest caution, inasmuch as we know, by experience, that if they be used either too freely or too soon, there is here a great probability of inflammatory reaccession, in an aggravated form. So soon as the formation of matter has been at all indicated, a free e\7acuating incision should not, for an instant, be delayed; it being remembered that the pus is much nearer to the peritoneum than to the integument, and, moreover, bound down by strata of dense fibrous tissue. But it is surely advisable to go a step farther; and, whenever we feel convinced that reasonable hope of arrest and resolution is gone, make an incision in the most prominent part of the swelling, where we anticipate that matter is first and mainly to form, in order that, so soon as it docs form, it may find a ready drain for its outward escape; all the hazards of its pent-up accumulation, in any quantity, being thereby felicitously avoided. If artificial opening be withheld, one of two events is very likely to occur ; the pus, finding its way into the general cavity of the abdomen, excites a most hazardous peritonitis; or, on spontaneous evacuation taking place, the condition of fecal fistula is declared—the perforation inter- nally, surrounded by plastic exudation, having penetrated into an adherent fold of intestine. As already stated (p. 233), cherry stones, and such like substances, may be arrested in the vermiform process of the caecum, and cause abscess of the abdominal parietes; so effecting their OAvn escape. 368 BRUISE OF THE ABDOMEN. Tumors of the Abdominal Parietes. These demand, also, early attention, lest, by long continuance and enlargement, they become unfavorably connected with the deepest por- tion of the parietal layers. The adipose is, perhaps, more common than any other form of tumor in this situation. In dissecting it out, the pre- liminary incisions should penetrate quite into the substance of the fatty matter, thereby facilitating extraction, and avoiding unnecessary depth and extent of incision. Bruise of the Abdomen. This is always important, on account of risk of injury to the abdomi- nal contents. Dangerous hemorrhage may at once occur by lesion of these, or formidable inflammatory action may be kindled subsequently. And, in treatment, both of these contingencies must be regarded. Ab- solute rest and quietude are enjoined, and the simplest ingesta are given most sparingly. Thus, extravasation of blood from a torn part is not favored; neither is escape of contents from any ruptured viscus pro- mot9d, on the contrary. On the first rising of the pulse beyond the limits of moderate reaction, on the accession of increased pain, with vomiting, or other sign of disorder of the system; in other words, so soon as there is any indication of inflammatory action having begun, the lancet is em- ployed freely, and is followed by calomel and opium, as circumstances may demand. And here the opium may be administered in a larger proportion than usual (Principles, 3d Am. Ed. p. 170), it being the only available opponent of the intense and exhausting pain which attends on such action; and it besides being of good service, in injury of the intestines more especially, by exerting a sedative effect on the muscular coat of the boAA^els. Very obviously, purging is not to be dreamed of in the early treatment. Subsequently, when it is necessary to move the bowels, the gentlest remedies are to be selected, and even they are used with caution. The first effect of bruise, attended with serious injury of the internal organs, is to produce a marked state of shock, or depression in the system. And a very common error in practice is, at once to attempt removal of this. The same evil consequences follow, as in the analogous case of injury done to the cranial contents (p. 39). Let the patient alone; and ere reaction occurs, with its quickened and full circulation, a torn liver or spleen may have had its vessels closed by nature's hemo- statics, and a ruptured portion of intestine may be so circumstanced by position and exudation, as to render fatal escape of its contents into the peritoneal cavity at least less probable. But, stimulate unwisely, and then premature reaction is established; the returning blood finds the mouths of vessels still open, and intestinal extravasation is quite unop- posed. In one case only are we to interfere; and that is, when the shock is extreme in both intensity and duration, and threatens to prove directly fatal. Then we stimulate, to save life from immediate loss; WOUNDS OF THE ABDOMEN. 369 and yet we stimulate very cautiously, lest, saving from one hazard, we engender another at least as great. A remote consequence of abdominal bruise may be such atrophy of the muscles at the injured part as shall cause permanent weakness there, with consequent liability to hernial protrusion.1 Wounds of the Abdomen. Wounds penetrating the abdominal parietes, and implicating the viscera within, are necessarily fraught with much danger. From lesion of the liver, a formidable hemorrhage can hardly fail to occur; wound of the urinary bladder causes infiltration of the contents, almost invariably fatal: from wound of the gall-bladder, acrid bile will escape, kindling intense peritonitis; both acrid extravasation and dangerous loss of blood #re likely to follow wound of the kidneys; wounds of the spleen, like those of the liver, are dangerous mainly on account of the risk of hemorrhage; from injured intestines, fecal extravasation is likely to take place, causing an extent and amount of inflammatory action which is seldom if ever recovered from. Such severe injuries are invariably attended with a grave amount of shock, which serves the double purpose of warning the attendant of the importance of the case, and giving an opportunity for the completion of nature's measures for obviating hemorrhage and extravasation. This state, as formerly ob- served, is not to be rashly interfered with by the practitioner; its pro- gress is watched; reaction is rather delayed than hastened ; and when this, no longer repressible, advances to excess, antiphlogistics are employed actively. Wound of the Bowel, suspected when discharge of blood by the mouth or by the anus accompanies the attendant shock, is not neces- sarily followed by extravasation. A mere puncture is closed by nature's efforts. The mucous coat is protruded outwards, and plugs the orifice: the abdominal viscera exert a constant equable pressure on each other at every point, and this tends obviously to counteract escape of contents ; and these two temporary means of arrest are duly followed by another which is permanent, namely, exudation of plastic lymph on the exterior of the wound, whereby union of the opposed surfaces of peritoneum, and a safe circumvallation of the injured part, are effected. As in natural hemostatics (Principles, 3d Am. Ed. p. 336), the tem- porary means are by plug and pressure, the permanent by plastic exuda- tion. A moment's consideration of the nature of this process will explain how mischievous must be the imprudent exhibition of stimuli, or indeed of ingesta of any kind, at the outset of the case. Protrusion of the Bowel.—If through a penetrating parietal wound a portion of intestine, or other viscus, protrudes entire, it is to be simply replaced, with all gentleness, so as not to endanger an aggrava- tion of inflammatory accession; and yet with all accuracy, the finger following the retreating viscus closely, so as to insure its being replaced wholly within the abdominal cavity, and thus avoiding the serious risk 1 Guthrie, Lancet, No. 1441, p. 397. 24 370 WOUNDS OF THE ABDOMEN. Fig. 172. of obscure strangulation, which is so prone to follow partial reduction. The wound is carefully approximated, by suture, if need be, and by moderate bandaging such pressure is made without, as is calculated to prevent reprotrusion. In subsequent treatment an anxious prophylaxis is maintained, with a preparation for suitable antiphlogistics on the shortest notice. If the protruded part be found to have sustained mere puncture, it may be simply replaced, as if intact, trusting to nature's means of closure. If a larger wound exist, incised, of no great extent, and con- sequently deemed capable of adhesion, it is to be brought accurately together by the glovers' suture (Principles, 3d Am. Ed. p. 602). And, in applying this, it is well to turn in the edges of the wounded part gently, so that the ap- proximated surfaces shall be peritoneal, that structure being well known to be much more capable of the required plastic exudation than are the mucous or middle coats of the bowel. The punctures of the needle should not be more than a line apart, and the fingers of an assistant should accurately retain the inverted condition of the wound during the manipula- tion. It is well to take the first stitch from within outwards, and the placing of a large knot here is supposed to favor the inward escape of the thread, which in time ulcerates its way into the cavity of the bowel, and is thence discharged. The suture having been duly arranged, the part is gently replaced, in the hope that it may become safely covered up by plastic exudation. If the portion of bowel be bruised, or otherwise so extensively injured as to render the occurrence of adhesion obviously impossible, it were folly to effect mechanical union and replacement of the part. After such procedure, the wound must necessarily inflame and open, feculent extravasation is inevitable, and death is almost certain. The wounded part should be retained at the surface, and, with this view, the peritoneal coat is united with the integument, at the lip of the wound, at one or more points by suture, and then through the upper orifice of the wounded part the feculent contents discharge themselves innocuously. The condition of Artificial Anus is established; a state of much dis- comfort, and not altogether devoid of danger, but infinitely preferable to fatal peritonitis by feculent escape within the cavity of the abdomen. Thus, the local treatment differs according to the nature of each case. But in all, the constitutional treatment is the same; rest and quietude; starvation; free venesection or leeching, or both, on the first onset of overaction; then calomel and opium—the latter in large doses. The Glovers', or continued Suture, in wound of the Bowel. ARTIFICIAL ANUS. 371 Artificial Amis. By this term is meant an unnatural outAvard opening of the intestinal canal, whence fecal contents are more or less copiously discharged. It may be the result of wound, of abscess and ulceration, or of sloughing consequent on strangulated hernia. By plastic exudation, the open portion of bowel is retained in contact with the abdominal parietes ; and the following condition of parts becomes established. The orifice of the upper or gastric portion remains abundantly patent, and not unfre- quently, troublesome prolapsus of its lining membrane occurs ; the ori- fice of the loAver or rectal portion contracts, is not patulous, and recedes from the external surface; the two portions haAfe a dense septum inter- posed between them—composed mainly of the two contiguous portions of the coats of the bowel; and this becomes more and more solid, and more and more opposed to restoration of the normal flow of the intes- tinal contents. Outwardly, the abdominal parietes are usually distended into a funnel-shaped caATity, whose apex is at the integument, whose base surrounds the intestinal breach, and within Avhose cavity feculent matter tends to accumulate. The integumental opening is red, everted, prominent, and surrounded by excoriation. The dangers and difficulties of such cases depend very much on the site and extent of the intestinal opening. If this be large and near the upper part of the tube, death by inanition can scarcely fail to occur ; chyle running so much to waste. If, on the contrary, the opening be in the large bowel, nutrition may be sufficiently maintained, and the result will probably be one more of annoyance than of danger. Treatment is in the first instance palliative. Such food is taken as is easily digested; and the bowels, by diet, and medicine, if need be, are kept " soft and easy." By external support—by compress and bandage, or by the adaptation of a suitable truss—outward escape from the upper orifice is moderated, if not altogether prevented, and protru- sion of the mucous membrane is opposed. And the ordinary means are employed to obviate excoriation of the surrounding integument. The outer opening may contract and heal, the funnel-shaped cavity may close, and the normal flow may be restored. But much more frequently such is not the case ; and farther interference by our art is required. The two main obstacles to cure plainly are—projection of the septum, and retraction and contraction of the lower intestinal orifice. The latter state is to be opposed by the occasional introduction of tubes or tents, gradually enlarged, whereby the normal caliber may be restored. The septum is to be got rid of by the gradual process of ulceration. Dupuytren's forceps may be employed for this purpose ; one blade passed into each orifice, the instrument closed and locked, and the degree of pressure regulated by the screw at the handle. The pressure is at first applied lightly and temporarily ; lest overaction ensue, and the surrounding parts be implicated so as to establish either enteritis or peritonitis. And throughout the whole period of the instrument's use, the effects must be closely watched, lest at any time overaction threaten to occur. By thus gradually destroying the septum—inducing ulcera- 372 FECAL FISTULA. tion of it by pressure, and regulating that pressure so that the inflam- matory process it creates shall not go beyond ulceration in the part, nor extend thence to the neighboring textures—by dilating and bringing forward the lower orifice, and by maintaining the external pressure at all times when the forceps and tent are not in use, we hope to restore the normal flow, and effect permanent closure of the aperture. But not only must this use of the forceps be cautiously conducted, it must also be warily begun. Weeks or even months should elapse before it is employed. For an early application is plainly in favor of the occur- rence of the following risks; a fold of bowel interposed between the two orifices, on account of the septum not being yet fully developed, may be grasped by the instrument, and fatal enteritis may ensue ;• or the yet recent, tender, and imperfect adhesions of the bowel to the parietes may be broken up, the former may recede, feculent extravasation then takes place, and life is soon ended miserably by peritonitis ; or, simply on account of the still unquiet parts having no tolerance of a newly excited action, immature use of the forceps may be speedily followed by enteritis ; or the pressure may cause ulceration of an asthenic kind —not attended by plastic exudation around—the abdominal cavity may consequently become exposed, and feculent extravasation may occur therein. The projecting septum, or eperon, may be repressed simply by the pressure of tents ; or the ingenious, though somewhat complicated instru- ment of Mr. Trant,1 may be used instead of that of Dupuytren. Such pressure, causing replacement and absorption of the projecting obstacle, is obviously more safe than that which produces destructive ulceration. An artificial anus is sometimes established, designedly, by the sur- geon, when the natural anus is imperforate ; or when, from any cause, the rectum has become insuperably obstructed. These proceedings will be considered in connection with affections of the lower bowel. Fecal Fistula. When an artificial anus has contracted to a narrow sinus, with a papil- lary orifice through which intestinal contents occasionally escape, it is termed a Fecal Fistula. A similar state may also result from parietal abscess (p. 367), whose cavity has opened, by ulceration, into a portion of adherent bowel, either before or after external evacuation. The opening of communi- cation's usually small; the cavity of the abscess contracts; and the condition of fistula is soon established. The methods of treatment are simple. Accurate and firm pressure is applied to the part, so as to prevent feculent escape, and favor con- solidation of the entire track. This may succeed, after patient con- tinuance for some time, along with due attention-to the state of the bowels. _ If it fail, then the actual cautery may be applied, so as by contraction of the burn to obtain closure (Principles, 3d Am. Ed. p. 1 Dublin Med. Press, vol. xiii. p. 305; and Brit, and For. Med.-Chir. Rev. Jan. 1847, p. 28. PELVIC ABSCESS. 373 220). And if this do not succeed, then, by autoplasty, the chasm may be filled up and permanently consolidated ; a suitable portion of integu- ment being transplanted from a neighboring part. Pelvic Abscess. The sub-peritoneal areolar tissue, in the pelvic region, is liable to be the seat of suppurative inflammatory action ; sometimes in connection with the puerperal state, but often Avholly independent of this. Occa- sionally it is induced, on the right side, by irritation extended from the caput csecum, forming the perityphlitis of Burns and others ; on the left fcide it may originate in impaction, or other disorder of the lower bowel. It has followed operative interference with the uterus, or its appendages, as well as with the penis and bladder, not unfrequently ; sometimes it is traced by the patient to a chill: sometimes it can be connected with no assignable cause. The disease is more frequent in the female than in the male. Exudation may be both rapid and copious ; and, at first, is either serous or lymphous. In this state it is amenable to absorption; and, under suitable treatment, may disappear rapidly. When suppura- tion has fairly taken place, evacuation is to be looked for, either spon- taneously or by the hand of the surgeon. In the former case the point of exit varies ; at the hypogastrium, by pointing in the ordinary way ; in the groin, by the bowel, through the vagina, into the bladder; or into the general abdominal cavity. Fortunately, the last-mentioned casualty is comparatively rare; the peritoneum, from its fibrous nature, long resisting the ulcerative action of the accumulating pus (Principles, 3d Am. Ed. p. 204). Sometimes, instead of suppurating, the tissue becomes loaded with a dense plasma, partially incorporated and organized. The symptoms are often ushered in by rigor. There are pain and tenderness of the part, with dulness on percussion. The rectum and bladder, being compressed, and involved in sympathy, have their func- tions more or less disturbed; and the uterus, too, is liable to displace- ment. On examining by the vagina or rectum, a hard dense swelling is perceived; determined to be non-uterine, if need be, by the use of the probe ; and, unlike other pelvic tumors, having very firm connection and continuity with the bony walls of the pelvis. In doubt, an explora- tory thrust may be made by the small trocar, through the abdominal parietes, by the vagina, or by the rectum, according as the site of the swelling may determine. On outward pointing taking place, the nature of the case becomes abundantly plain. At an early period, the treatment consists of leeching, followed by counter-irritation, and mercury pushed to ptyalism. Iodine may be painted over the abdominal parietes; or it may be administered in the form of ointment, by the vagina. Under such treatment, with rest, and attention to the general health, many formidable effusions satisfactorily disappear; perhaps leading an inexperienced observer to suppose that an ovarian or other tumor has been discussed. When matter has formed, it should be early evacuated, by means of the bistoury or trocar, at the point which circumstances may indicate as most suitable; by the vagina, by the rectum, or through the abdominal walls. 374 OVARIAN DROPSY AND TUMORS. Retro-uterine Sanguineous Tumors. There is another class of swellings in this situation, which may be mistaken for the inflammatory pelvic tumor, in the female. They are caused by extravasation of blood into the sub-peritoneal areolar tissue of the cul-de-sac between the uterus and rectum; and in their pathology resemble the thrombus, which is not unfrequently found situated in the vagina or vulva. The affection may, in fact, be described as a thrombus of the roof of the vagina. Attention has been recently directed to this subject by some late discussions in the Surgical Society of Paris; and Dr. Montgomery, of Dublin, has published cases of thrombus in this situation, occurring during or after labor. The blood is infiltrated into the areolar tissue, around the cervix uteri, and may spread thence into the areolar tissue surrounding the rectum, or into that involved between the folds of the broad ligaments. These tumors are liable to occur chiefly in cases where there is much venous congestion, and especially if there is a varicose and diseased condition of the vessels. They are caused by powerful straining efforts, as in labor, venereal excesses, &c. They may also, as M. Huguier points out, be produced by the escape of blood from a uterus over-distended by retained menstrual secretion. On examination, the roof of the vagina will present a hard resisting surface, without pain on pressure; or, if recent, tender to the touch in a much less degree than the real inflammatory pelvic tumor. The uterus will be found generally somewhat elevated, and pressed to the pubes. If they are small, these tumors require no special treatment. Best in the recumbent position, and the antiphlogistic regimen, are necessary as precautionary measures. If the extravasation is very extensive, there will be constitutional disturbance ; and local excitement may be produced, perhaps terminating in true inflammation. In this case, treatment must be conducted as in the common inflammatory pelvic tumor. Ovarian Dropsy and Tumors. Of abdominal tumors, the ovarian are those which most attract the attention of the surgeon. Occasionally fibrous tumors, or masses of the different forms of the ordinary malignant tumor, are found affecting the ovary, either alone or in combination with the cystic disease of the organ —which latter very far surpasses all others in the frequency of its oc- currence, and is generally known as ovarian dropsy. These cystic tumors are multilocular more frequently than monolocular. They may occur only on one side, or on both at the same time; they may be attached by a narrow pedicle to the broad ligament, or by a broad base; they may be movable, or fixed in the cavity of the abdomen—this gene- rally depending on their size, Avhich varies extremely; they may be free, or more or less adherent to the surrounding organs, or connected Avith the abdominal walls. On dissection, the ovary of the affected side may be undiscoverable; or it may be either entire, or partly incorporated OVARIAN DROPSY AND TUMORS. 375 with the tumor. The disease is believed by numerous pathologists always to originate in the Graafian vesicles ; and there is good reason to attri- bute certain of these productions to this source ; but it is equally well ascertained that the multilocular formation does not always acknowledge such an origin. The disease may affect a woman at any time of her menstrual life, and is found occurring most frequently at that period Avhen the repro- ductive functions are in greatest actiA'ity—namely, betAveen the ages of twenty and forty. It attacks the virgin as well as the married woman. Of course, it is found more frequently in married than in unmarried women, but there is no evidence for a common statement of authors that the former are more liable to it than the latter. Many causes connected with menstruation, marriage, and parturition, have been assigned to ovarian dropsy, but this part of the history of the disease is necessarily very difficult of investigation. These affections. may be mere precedents, and not causes. The disease may attain a large development, without giving rise to any symptoms except such as are referable to the displacements effected by its bulk. It may be accompanied by irregularity of the menstrual function, by menorrhagia, or by amenorrhcea. At its commencement there may be much complaint of pain and tenderness in either side, or a deep-seated pelvic pain may exist, or there may be other modifications of pain and tenderness too varied to demand description. The tumor may press on the sacral nerves, and cause numbness and a feeling of poAverlessness in one limb; or venous congestion and oedema of it, by obstructing the circulation. There may be pain and difficulty in defe- cation. Piles, and a varicose state of the veins of the legs, are often found. In diagnosis, our reliance must be placed almost entirely on the physical signs. Much obscurity is often produced by distension of the abdomen, with flatulence, when the disease is in an early stage ; and the evidence of its nature is derived chiefly from the circumstances of its position, its mobility, or its connections. At a later period, Avhen it is distending the abdominal walls, Ave trust to its own physical characters, the nature of its contents, and the history of its origin and progress. Careful manipulation usually shows the swelling not to be so uniform or soft as in ascites, but more or less broken up in its outline, as well as of various hardness. Attention is also given to the following points : In ascites; the fluid always occupies the most dependent parts, Avhile the small intestines, floated by their contained air, correspond generally to the umbilical region ; and the arch of the colon and the stomach oc- cupy the epigastrium. Percussion, therefore, elicits a dull sound over the hypogastric and lumbar regions, and a clear one in the umbilical and gastric ; whereas, in a large encysted dropsy, no tympanitic sound exists in these regions. The intestines, pushed back by the cyst whieh is developed anteriorly, may, hoAvever, produce a resonance laterally and posteriorly. Fluctuation is generally more easily and distinctly detected in ascites. If the ovarian fluid is of great viscidity, or if the anterior cysts of the mass are numerous and small, fluctuation may be scarcely perceptible; while, on the other hand, if the disease be monolocular, flue- 376 OVARIAN DROPSY AND TUMORS. tuation may be very apparent. Sometimes, in the multilocular variety, the larger cysts can be made out separately by the facility and distinct- ness of the fluctuation, when both hands are over the same cyst; and by its indistinctness or absence when one hand is on one cyst, and the other on a different one. In encysted dropsy, the general health is often comparatively undisturbed, while in ascites the reverse is almost always found to be the case. Along with ascites, there is generally anasarca of the lower extremities, while in ovarian dropsy this is rarely observed. In the latter affection, however, we frequently find a varicose state of the vessels, and puffiness of the limbs. It is also to be remembered that ascites and ovarian disease frequently coexist; the ascitic fluid being of the ordinary kind; or, as has been observed by Dr. Bennett and others, derived from an ovarian cyst by passing through foramina in its walls. When these diseases coexist, fluctuation, if light and super- ficial, may deceive; but if the fingers are pressed more deeply, a pecu- liar diagnostic mark is obtained by the stroke of the fingers against the ovarian cyst—after displacing the overlying ascitic effusion. If there is still doubt, we may in some cases be justified in drawing off a few drops of the fluid by a small trocar, and ascertaining its nature by proper tests. Dulness on percussion over the hypogastric region is more decided in ovarian dropsy than in ascites. If, however, the pedicle be long, and the tumor only moderately large, and not distending the abdominal walls, but rather floating in the cavity, there may be some resonance above the pubes. In some rare cases this mark is of importance, in distinguishing the ovarian dropsy from pregnancy; in both cases we may find, on auscultation, a murmur resembling the placental souffle; and in ovarian disease, especially if recent, the equivocal signs of pregnancy may be present. From pregnancy it is farther distin- guished by absence of the foetal heart's pulsation, by the absence of ballottement,1 by the drawing up of the uterus and vagina, so that the cervix is with difficulty reached, by the hardness and length of the cervix, by the anteverted or retroverted state of the organ, by the com- mencement of the disease on one side, by more or less complete absence of the ordinary constitutional signs of the pregnant state, and by the duration and history of the complaint. Let the surgeon, however, never forget that with ovarian disease (at least of one side) there may coexist an impregnated womb. There is, occasionally, great difficulty in distinguishing a multilocular ovarian dropsy from fibrous or other tumor of the uterus. The tension of the cysts, their small size, and the viscidity of their contents, may be such as to destroy all signs of fluidity in the ovarian mass; and the uterus may be so fixed in the pelvis by compression between it and the tumor, or by adhesions, as to render the signs derivable from a vaginal examination also nugatory. The history of ovariotomy, too, truly shows that the diseases may be mistaken for one another by the most experi- enced and able physicians. The chief distinctive marks are the follow- 1 A modified ballottement may be discovered in a case of ovarian tumor, if it is of moderate size and floating in ascitic fluid. OVARIAN DROPSY AND TUMORS. 377 ing: A fibrous tumor is often observed first in the centre of the hypo- gastrium, an ovarian tumor generally at one side ; a fibrous tumor grows more slowly than an OArarian; it has no fluctuation, and is generally much less movable and harder than a diseased ovary; it is more fre- quently accompanied by monorrhagia and leucorrhcea; the uterus is generally somewhat prolapsed, especially if the tumor is not of great size; the uterus feels heavy, and cannot be moved without moving the tumor; the cavity of the uterus is also often elongated ; sometimes it is shortened; frequently, the shape and plurality of the tumors are distinctive. In illustration and proof of the great difficulties which attend the diagnosis of ovarian disease, and of the errors liable to be made, even when the growth is so developed as to appear to demand an operation, we may cite the following fact in regard to one hundred and sixty-two cases in which incision of the ovary was attempted. In sixty of these, there was either no ovarian disease at all, or its removal Avas found impracticable.1 The management of ovarian dropsy is either palliative or radical. Besides, the ordinary treatment for intercurrent attacks of inflammation, derangements of the functions of the stomach, bowels, kidneys, and bladder, the most important palliative measures are tapping and pres- sure. Recourse to the former has been recommended early in this affection; but it is a very questionable proceeding, and one, besides, which we rarely have an opportunity of trying, as women seldom com- plain till the disease is far advanced. Tapping is not advisable, except under rare circumstances, till the accumulation has become intolerable to the patient, from its large size impeding respiration and progression, and causing much local pain and suffering: perhaps producing vomiting, or suppression of urine, by pres- sure on the stomach or kidneys. It is a very simple operation, and the danger supposed to attend it in ordinary cases, has probably been exag- gerated in the statistical tables of Southam, Safford Lee, Atlee, and others; which, embracing all cases, do, no doubt, include many in which it was resorted to in despair, or as a mere palliative, the patient's strength being already worn out by the disease, or compromised by some other affection. The dangers chiefly to be apprehended are syncope, the lighting up of suppurative inflammation in the lining of the cyst or cysts, and the supervention of peritonitis. It is performed thus: The patient having been seated on the side of a bed, or on a chair, has the abdomen tightly girded by a sheet or flannel bandage; the ends of which are held by two assistants, directed to pull steadily and firmly as the fluid escapes—so as to maintain equable pressure on the abdominal contents, and obviate the sudden loss of support to these, which might otherwise occur, and from Avhich serious hemorrhage might ensue by the' giving way of one or more abdominal veins suddenly deprived of their ordinary support. Or, independently of rupture, alarming syncope might take place, from great or sudden accumulation of blood within the abdominal veins. It 1 Lancet, Dec. 6, 1851. 378 PARACENTESIS ABDOMINIS. is well to ascertain that the bladder is empty. An aperture having been made in the bandage, an incision is made through the skin and fascia by a lancet or scalpel ; and then perforation is completed by a large trocar and canula. The trocar having been withdrawn, the canula re- mains, and through this the fluid escapes ; thin and albuminous, or viscid, ropy, and variously discolored. Fluid having ceased to come, the canula is withdrawn, the wound is covered by a compress, and the general bandage of the abdomen is drawn tightly and secured. This cure by tapping is an excellent instance of the surgeon taking a lesson from the plans sometimes adopted spontaneously by Nature. Examples of the simple cyst, and more rarely of the multilocular, haAre been cured by spontaneous discharge of the contained fluid from openings through the umbilicus, or some other part of the abdominal wall, or by discharge of the fluid per vaginam or per rectum. The point usually selected for the opening is in the linea alba, about midAvay between the umbilicus and symphysis pubis. But it may be made in the linea semilunaris, if the bulging of the ovarian cyst render that locality preferable. By the use of pressure after tapping, the walls of the cyst are made to collapse, and the mass comes to form a comparatiA-elY small firm tumor in one side of the pelvis. When such pressure is resorted to, it should be kept up for some months ; as these tumors have been known to refill, after they have lain in the pelvic cavity for a long time col- lapsed and causing no inconvenience. The use of pressure, if it can be borne, and be regularly conducted, is decidedly of service in impeding groAvth of the tumor, and refilling of the sac after tapping. Some ATery interesting cases are recorded, where inflammatory action, attacking the cyst, and its serous investment, has induced such induration, and caused the formation of adhesions so strong, as to resist farther pro- gress of the tumor; curing the disease by mechanically arresting its progress. But the cysto-sarcomatous tumors, the fibrous, and the ma- lignant masses, which are not unfrequently found in this situation, either alone or along with the multilocular cyst, are, of course, not amenable to any method of discussion. As auxiliaries to tapping and pressure, the only remedies to be recom- mended are iodine and diuretics. The former may be used both exter- nally and internally. That they may be of some service, we have evi- dence in the fact occasionally observed, that the rapidity of the growth or refilling of an ovarian tumor keeps pace with the diminution of the urinary secretion. The remarkable increase of this secretion often observed for some days after tapping, is sometimes accompanied by progressive diminution of the tumor, which recommences to fill only when the urine again diminishes.1 In general, after tapping, the cyst speedily refills and the operation is repeated as before, the cvst usually filling more rapidly after every repetition of the operation. The second tapping may not be required till after several months ; but subsequently 1 Many authors of note entirely discredit the efficacy of all internal remedies. Burns Bays they have an equal effect " over the configuration of the patient's nose." Hamilton, as is well known, used the solution of muriate of lime internally as a discutieut and placed great confidence in it. OVARIOTOMY. 379 the interval may diminish to a few weeks. This process generally ex- hausts the patient after some years, or an intercurrent attack of inflam- mation in the cyst, or in the peritoneum, may prove speedily fatal. Sometimes, however, patients survive to have the tapping very often repeated, and almost incredible quantities of fluid have thus been drawn off from the same woman.1 These tumors may be dealt Avith heroically. Attempts may be made at extirpation. The operation is very simple. The patient haAdng been suitably arranged in a room of elevated temperature, a wound is made through the parietes of such an extent as may be necessary. There is no good reason for incising the Avhole abdomen in all cases, from the ensiform cartilage to the symphysis pubis. The external in- cision should be proportioned to the bulk of the tumor. The dissection is to be carefully conducted till the tumor be brought into view, attention being directed to arrest as far as possible all bleed- ing from the wound. The tumor, its state as to adhesions, and its pedicle, are now to be examined; and, if deemed advisable, the opera- tion is continued. LTniess the adhesions are very strong and extensive, they do not form an insuperable obstacle. The tumor is to be turned out of the abdomen ; the pedicle is tied, and then divided. The wound and the surrounding viscera are sponged clean, and the wound closed. If unfortunately the bowels cannot be kept Avithin the abdomen during the operation, means must be taken to maintain in them their natural heat till they are replaced; they may be immersed in water at blood heat, or in fine linen moistened with tepid water. The ligature of the pedicle is brought out at the loAvest part of the incision; and, last of all, the wound is closed by the interrupted suture, in such a manner as to expose as little as possible to the surface of the bowels beneath. This is effected by passing the needle close to the peritoneal surface of the wound. The interrupted quilled suture may sometimes be of service. In conducting the first step of the operation, the plan proposed by Dr. Frederick Bird, to avoid mischances, may be resorted to, namely, to make at first only a small wound into the peritoneum, and to explore the tumor with the finger and probe; so ascertaining, to some extent at least, the feasibility of completing the operation before the patient is compromised by farther proceedings. At present, great hostility to all such operations is declared by a large body of the profession. There are cases, however, which may certainly render a duly conducted attempt quite warrantable; when the tumor is non-malignant, single, movable, and connected with a narrow pedicle; when the patient is 1 Dr. Mead's patient, whose endurance is celebrated in the following epitaph, has noAV unfortunately been frequently surpassed. " Here lies Dame Mary Page, Relict of Sir Gregory l'age, Bart., AVho departed this MeMaroh 21st, 1728, In the 56th year of her a^e. In 07 months she was tapped 00 times, Hull taken away 240 gallons of water, AVithout ever repining at her ease, Or even fearing the operation." Dr. Martineau, of Norwich, tapped a patient 80 different times, and di^w off 6832 pints of fluid. 380 OVARIOTOMY. apparently free from other disease; when the effects of this tumor are such as to threaten death by exhaustion at no distant period, unless relief be obtained; when the ordinary palliative treatment, after due persistence, has failed to give relief; and when the patient, having been made fully aware of the risk, is resolved and wishful to undergo the operation. Modern experience has certainly demonstrated, that free incision of the abdomen, with exposure and manipulation of the peritoneum, is a less hazardous procedure than was generally supposed. But there are extreme dangers necessarily attendant upon this opera- tion, from its site and its nature, from the necessity of leaving in the wound a long cord attached to the pedicle, from the danger of the liga- tures bursting, or the wound in the parietes partially opening, in con- sequence of distension of the bowels or efforts in coughing, and from the risk of strangulation of the bowel either in the wound or by the puckering of deep cicatrices. And, besides, the following unavoidable difficulties at present stand in the way of a general recommendation of the operation, namely, the confessed difficulty of diagnosis, as to the existence of extensive adhesions, as to the presence of malignant disease in the tumor or in the pedicle, and as to the large size of the pedicle rendering deligation difficult. Sometimes cure is attempted by a minor proceeding, making an open- ing in the abdominal parietes, only a few inches in length, puncturing the cyst, and drawing it out as the contents escape, and then cutting off the attachment, after deligation. Such an operation, howeA'er, has not been found more successful than the more direct and open procedure, and certainly it is not more easy of performance. The danger of some fluid from the cyst escaping, and finding its way into the peritoneal cavity, the impossibility of cleaning out the wound with the necessary care, the imperfect deligation of the pedicle, &c, are obvious objections to this mode of treatment. The statistics of ovarian operation give a mortality of about one death in every three cases. Its dangers, then, are very great. On the other hand, hopes of relief from ordinary treatment of the tumor can- not be sanguine. Most women are carried off by the disease in less than four years. Very few have the good fortune to be cured, and only a small number live beyond the four years. But it will always be a difficult and anxious matter for the surgeon to propose that a woman, suffering, it may be, very little from this disease, should subject her- self to the risk of almost immediate death, in order to obtain the chance of getting rid of that which might possibly permit several years of com- fortable existence. The general treatment of ovarian disease is still an open question, and we entertain strong and confident hope that the great attention drawn towards it will, some day, attain to the discovery of a method of cure, or of a plan of palliation tantamount to cure. But we do not purpose to mention here any of the numerous methods now proposed for these objects. As yet, they have mostly proved even more fatal than ovariotomy, and have many additional objections. None have received the sanction of the profession. FIBROUS TUMORS OF THE UTERUS. 381 Fibrous Tumors of the Uterus May be found in any part of the organ. They may be single, but more frequently there are several present together. They may vary in size from a pea to a man's head. They rarely occur before the age of twenty, and are most frequently observed about the age of forty.1 They do not prevent conception, but cause great risk of abortion during pregnancy, and in delivery may obstruct the advance of the child, also favoring hemorrhage and subsequent inflammation. The tumors them- selves are liable to congestion, inflammation, and suppuration ; in course of time, they may become calcified in whole or in part, forming the uterine calculi of old authors. They may be developed in any part of the uterine wall; the nearer to the mucous membrane, the greater is the hypertrophy of the uterine tissue. When the tumor is situated near to the peritoneal or to the mucous surface of the uterus, it may be protruded from the Avail of the organ in a polypoid form, and, the pedicle gradually diminishing in size, the tumor may drop off into the peritoneal cavity in the one case, and in the other may be expelled per vaginam. When the tumor is near to the mucous surface, it is some- times spontaneously discharged in another way, as has been observed to occur even in large tumors; and not unfrequently this result has fol- lowed the irritation and pressure caused by the efforts of delivery, on the tissues interposed between the cavity of the uterus and the tumor. By ulceration or sloughing, an opening is formed in these textures, and the substance of the tumor is exposed, disorganization ensues in the loose areolar tissue connecting the tumor to the uterus, contractions of the hypertrophied uterine tissue supervene, and expulsion of the tumor, in mass, or more gradually in parts, is the fortunate result. This may be called spontaneous enucleation, a process which has been imitated by art in some cases. If the tumor becomes polypoid, dilating the cervix or lying in the vagina, it may be treated as an ordinary uterine polypus. But it is to be remarked that more danger of uterine phlebitis attends the removal of this form of tumor, than of the ordinary uterine polypus. The symptoms attending the presence of these tumors are neither constant nor diagnostic. Physical examination alone can detect their presence and decide upon their nature (p. 376). They are generally accompanied by feelings of weight, pain, or uneasiness in the hypogas- trium, and pain in the back, in the side, or in the thighs—disorder of the functions of urination and defecation, &c. ; but sometimes no symptoms at all exist. Often, there is an increased amount of vaginal secretion and discharge, which may be checked by a mild astringent injection. Menorrhagia not unfrequently occurs, and may require the ordinary treatment, if severe; it is generally a sign of proximity of the tumor to the mucous membrane. Occasionally, but rarely, there is amenorrhoea. If the tumors become congested and inflamed, ordinary 1 Bayle states that in women above thirty-five years of age, fibrous tumor.-* are found in one out of every five. 382 GASTROSTOMY AND GASTROTOMY. antiphlogistic treatment is necessary—especial attention being paid to maintenance of the recumbent position. If the tumors are large, prominent, heavy, or movable, an abdominal bandage or binder may be useful to support and fix them, and to afford the patient a feeling of security. Nothing can be done in the way of discussing these growths. Dis- cutient remedies, as iodine used externally and internally, counter-irri- tants, rest, the occasional local abstraction of small quantities of blood by leeching or cupping, have often a beneficial effect in removing dis- agreeable symptoms, and sometimes seem to arrest growth, or even cause a diminution in size—probably by removing the surrounding swelling and engorgement. Gastrostomy.1 In the case of insuperable obstruction of the pharynx, oesophagus, or cardia, it has been proposed to open the stomach by direct incision; attaching the edges of the opening in the stomach to the integumental wound ; and thus constituting a permanent aperture, for the introduc- tion of food, similar to what occurred accidentally in Alexis St. Martin. The operation is feasible in theory, and simple in performance. But its extension to cases of hopeless malignant disease seems scarcely expe- dient.2 Gastrotomy. When the bowels are obstructed from an internal cause, beyond reach from the outlet, a question arises as to the expediency of performing gastrotomy, with a hope of relieving the obstruction. If that depend on bands of lymph, or on intussusception, a simple manipulation might suffice to liberate the affected part. But the difficulty of diagnosis, and chance of failure, besides the danger of the operation, conspire to en- force great caution in resolving on such serious procedure. At the same time, when all ordinary means have failed, when several days have elapsed, and when the case is otherwise certainly hopeless, the doubtful chance of the operation may be afforded; more especially when pain, and other symptoms, point somewhat plainly to some part of the abdomen as the probable site of obstruction. At that part the incisi6ns are made; with the precautions already spoken of. It may be happily in our power simply to disentangle and relieve ; or, at the worst, the distended bowel may be evacuated by puncture, and an at- tempt made at establishing the condition of artificial anus. Of twenty- seven patients operated on, Mr. Phillips mentions thirteen whose lives have been preserved.3 [Mr. Phillips's paper, alluded to by Professor Miller, contains many very judicious observations, some of which may properly be quoted here. 1 From yaa-Tne, stomach; and a-To/ua, mouth. 2 Sedillot, Gazette Me"dicale de Paris, Jan. 1847; and Monthly Journal, April, 1848: Retrospect, p. (J8. 3 Phillips, Med.-Chir. Transact, vol. xxxi. Lond. 1848; also Brit, and For. Rev. April, 1849, p. 4;J3. GASTROTOMY. 383 His memoir is based upon the records, more or less complete, of 169 cases of obstruction of the bowels ; from this number, those which depended upon disease of the csecal appendix are excluded. Of the 169 cases, 63 were instances of invagination ; 16 Avere caused by the pressure of tumors from without; 19 by stricture from disease of the parietes; 11 by intra-intestinal tumors—hardened feces or concretions; 60 by constriction from bands, from adhesion, from the passage of the intestine through some abnormal opening, or from a tAvisting of the intestine upon itself. Mr. Phillips presents a sufficiently detailed account of the symptoms and post-mortem appearances, exhibited in nine authenticated cases of obstruction, depending upon as many different causes; these were ileus, the presence of a biliary calculus, the accumulation of fecal matter, an intra-intestinal tumor, malignant contraction of the colon, a malignant tumor pressing upon the colon from Avithout, invagination, constriction by bands, and the passage of the intestine through an abnormal opening in the mesentery. From a careful study of the symptoms presented in these cases and in the others, Mr. Phillips remarks that, " no matter what may be the cause of the obstruction, no certain remarkable difference is observed in the more prominent symptoms by which it is accompanied. There are in all abdominal pain, abdominal tension, obstinate constipation, and sickness; but in the mode of their occurrence it would be difficult to point out any distinct difference. Thus, constipation, abdominal pain, or uneasiness, with tension and sickness of the stomach, are present in greater or less intensity, in most cases ; but there is no certain and definite line to be drawn,'either as to the time at which they occur, or the severity with which they are ushered in, whether the obstacle be a biliary calculus, or a band of false membrane."—P. 15. The diagnosis of the seat of the obstruction is not much more certain or satisfactory. With many exceptions, vomiting and pain are more severe when the obstruction occurs in the small than in the large intes- tines ; and with the same qualification, if the urine be copious, the ob- stacle must be far from the stomach. So, too, valuable but not positive information may be gained from examining the abdomen, if this bo done before much general abdominal distension has occurred, in order that the commencement and course of the flatulent dilatation may bo ascertained. The introduction of the stomach tube, together Avith the injection of fluid, will frequently much facilitate the recognition of the site of the obstruction; it must be remembered, however, that the sur- geon may be led into error by the bending of the tube, Avhich is not at all unusual. Mr. Phillips's conclusion with reference to this point is, that "the history of the case; the particular seat of pain; the occasional existence of a tumor, which is now and then detected in cases of invagi- nation, and indeed in some other cases, before there is much abdominal tension; the distended convolutions; the long tube, and the injection will usually afford us most important assistance in coming to a conclu- sion as to the seat of the obstruction. At the same time, it is certain that, in the experience of the ablest men, they have failed."—P. 18. As to the success of treatment, it is not more satisfactory than the 384 GASTROTOMY. diagnosis. Of the 169 cases which were subjected to the various modes of treatment, 133 terminated fatally, or rather more than seven-ninths. —P. 19. With reference to the history of Surgical Operations, practised for the relief of obstruction, Mr. Phillips cites 53 cases; of these, 26 were performed upon infants for the purpose of establishing an artificial anus, the natural passage being imperforate ; 27 were upon adults, for various kinds of obstructions. Of the first 26 cases—the incision in each patient having been made in the left iliac fossa, or in the left lumbar region, and an artificial anus established—8 were successful; 12 died within a month ; and in 6 the result was doubtful, the history being defective. Of the second group of adult cases, 27 in all, an artificial anus was made in 19, for the relief of obstruction in or near the rectum. In 17 of these, an incision was made, either in the left iliac fossa, or the left lumbar region; and in two instances, the opening was made in the right iliac fossa. Of these operations nine were successful. In the re- maining eight cases the operation was performed at other points of the abdomen, and without the establishment of artificial anus ; and of these four appear to have been successful.—P. 30. At p. 34, Mr. Phillips says: "There are not more than two well-authenticated cases in which constricting bands have been severed; and with the exception of cases of invagination, not more than two cases in which the integrity of the intestine has been respected, and the obstacle successfully removed. From these sentences we infer that, in two of the four successful cases, without the formation of an artificial anus, the obstruction was owing to bands of false membrane, and in the remaining two to invagination. The inferences which Mr. Phillips deduces from his scrutiny of the cases, with reference to the proper time for the operation, the point to be selected for it, &c, are as follows:— " That the interference by surgical operation is justifiable when three or four days have passed without any relief from ordinary means (pro- vided the constipation be complete, and vomiting of fecal matter con- tinue), because it affords a greater chance for the preservation of life than ordinary means. " That, if the indications as to the seat of the obstruction be suffi- cient to satisfy the surgeon, it is at or near that point that the incision should be made ; but if there be much doubt, it is most prudent to make the incision on the median line. " That if it be found impracticable to remove the cause of the ob- struction, or imprudent to make any extended search for it, relief may be obtained by forming an artificial anus as near as may be prudent to the seat of the obstruction ; and that, if it be, as it frequently is, near the termination of the ilium, an incision on the median line admits of its accomplishment as near as may be to the termination of that intes- tine."—P. 35.—Ed.] AFFECTIONS OF THE DIAPHRAGM. 385 Affections of the Diaphragm. Surgically, the diaphragm may be affected by penetratiny wound. This may prove formidable by hemorrhage, or by inflammatory action, and has to be treated accordingly (p. 369); or, those dangers avoided, an imperfect closure or weak cicatrix may invite protrusion of the abdo- minal contents at the weak points,1 more especially Avhen that happens to be on the left side ; and this may be folloAved by a sudden crisis in- duced by strangulation of a diaphragmatic hernia; or, from simple mis- placement, the thoracic organs may suffer chronic disorder, not without a risk of ultimate asphyxia. Rupture of the diaphragm may be produced by external injury or violent muscular effort. The risks by consequent misplacement of the abdominal organs are as in the former case. Such malposition is usually indicated by an anxious expression of countenance, a sunk empty state of the abdomen, corresponding fulness in the chest, thoracic percussion unusually clear or unusually dull, auscultation affording borborygmi rather than respiratory murmur, with obscuration of the sounds of the heart. In treatment, but little is in our power. Should paralysis of the diaphragm coexist with ascites, obviously great care is specially necessary in withdrawing the fluid by paracentesis, lest dangerous collapse occur (p. 377).2 Travers, Inquiry into the Process of Nature in Repairing Injuries of the Intestines, &c. Lond. 1812. Scarpa, on Hernia, by AVishart, Edin. 1814. Lizars, Observations on Ex- traction of Diseased Ovaries, Edin. 1825. Fingerhuth, Dissertatio de Vulnerum in Intes- tinis Sutura, Bonn, 1827. Weber, de Curandis Intestinorum Vulneribus. Reybard, M6- moires sur le Traitement des Anus Artificiels, &c. Paris, 1827. Jobert, Traite" des Maladies Chirurgicales du Canal Intestinal, Paris, 1829. Velpeau, Memoire sur l'Anus Contre Nature, &c. Paris, 1836. Dupuytren, de l'Anus Contre Nature, &c. Lecons Orales, &c. vol. ii. p. 193. Lawrence on Ruptures, Lond. 1838. Teale, Cyclop, of Practical Surgery, article Intestinal Fistula, Lond. 1841. Phillips, Med.-Chir. Trans, vol. xxxi. Clay, Cases of Peritoneal Section for the Extirpation of Diseased Ovaria, &c. Medical Times, vol. vii. pp. 43, 59, 67, 83, 99, 139,153, 270. Phillips, Med.-Chir. Trans. vol. xxvii. p. 473, 1844. Lee, on Tumors of the Uterus and its Appendages, Lond. 1847. Bright, Guy's Hospital Reports. Boivin and Duges, Diseases of the Uterus, &c. Cru- veilhier, Anat. Pathol, livrais, 5, &c. Seymour, on Diseases of the Ovaria. Nauche, Malad. Propr. aux Femmes. Lee, Cyclop, of Pract. Medic, art. Diseases of the Ovary. Simpson, Library of Medicine, vol. iv. [See Lee, Medico-Chir. Trans. 1851; and Atlee, Transact. Am. Med. Assoc, vol. iv. for very full tables, with reference to the ovarian operation.—Ed.] 1 Mr. Guthrie is of opinion that a wound made in the diaphragm never heals by closing. 2 Von C. W. Mehliss, die Krankheiten der Zwerchfells des Menschen, Eisleben, 1845; also British and Foreign Med. Rev. July, 1847, p. 106. 25 CHAPTER XXVIII. HERNIA. By Hernia is understood a protrusion from within an internal cavity, of part of the contents of that cavity. But the term is usually limited to the most frequent form of such protrusion, namely, that from the cavity of the abdomen. And of this Hernia there are \rarieties, accord- ing to the site of the protrusion : Inguinal and Ventro-inguinal, Femoral, Umbilical, Ventral, Phrenic, Perineal, Vaginal, Labial, Obturatorial, Ischiatic. These, again, may vary according to the anatomical relation of their parts : Congenital, Infantile ; and according to the parts pro- truded : Enterocele, Epiplocele, Entero-epiplocele, Hernia Litrica. And, farther, other varieties depend on the pathological condition of parts: Reducible, Irreducible, Incarcerated, Strangulated. The Causes of Hernia are predisposing and exciting. Whatever weakens the abdominal parietes at any point, predisposes to protrusion at that point; natural want of closeness of development, as at the groin and navel; rupture of muscle and fascia, at any part, as in parturition; atrophy of muscle, following bruise; penetrating wound. Again, what- ever tends to propel the abdominal contents with unusual force against such weakened or predisposed parts, directly excites or causes the pro- trusion ; as violent coughing, straining at stool, or severe muscular ex- ertion of any kind. And, farther, the predisposing and exciting cause may be the same. Cough, straining, or habitual exertion of the abdo- minal muscles in any way, when long-continued, tend to weaken and enlarge the natural outlets of the cavity, by constantly propelling the abdominal contents against the parietes—and thus prove predisposing. And then some sudden cough or strain effects protrusion, and proves the exciting cause. Hence it is, that old men with coughs and urinary complaints, sailors, gymnasts, &c, are especially subject to the ordinary forms of this disease. The component parts of the tumor vary according to the nature of the protrusion. But, generally, they may be stated to consist of Cover- ings, Sac, and Contents. The Coverings are far from uniform ; differing in the varieties of Hernia, and being seldom exactly the same in any two cases. In in- guinal and femoral hernia, for example, the coverings differ widely; and in each of these affections, the density, thickness, and even number of the investing layers, depend very much on accidental circumstances. In operating, it is vain to look for an unvarying sameness in this part of the tumor. In all cases of ordinary hernia, however, there is first HERNIA. 387 the usual integument, and then one or more layers of fascia. These will be enumerated, in the separate consideration of the varieties of hernia. The sac is the portion of parietal peritoneum Avhich is pushed before the protruding viscus, and which forms its immediate envelop. Some- times it is wanting, as in hernia following directly upon wound, and in the congenital form of the disease. In the great majority of cases, we are to count upon its presence, adherent or not to the extra-abdominal parts with which it is in abnormal contact, according to the duration of its presence "there, and the occurrence or not of plastic exudation on its exterior. We ordinarily speak of the neck and body of the sac as we do of the neck and body of the general tumor; the neck being that portion, of smaller caliber, which is at and near the aperture of protru- sion, and the body being understood to be the more globular SAvelling beyond. If the tumor have been long protruded, without reduction, and otherwise but little altered in its circumstances, the neck of the sac is apt to become dense and unyielding in structure, and the caliber in con- sequence is at that part of a fixed nature. When, under the application of a fresh exciting cause, a new protrusion takes place, there is an extension in the sac, corresponding to the increased bulk of its contents; but, not improbably, the propelled original neck of the sac does not change, except in its position only; and, remaining of its contracted dimensions, it may become the seat of stricture in the case of strangula- tion, the new neck proving comparatively free and accommodating. This circumstance has obviously an important bearing on the operation for relief of strangulation. The hernial contents are various, inasmuch as every abdominal viscus is liable to protrusion; but the most frequently affected, by far, are the intestines and omentum; one or other, or both. If intestine alone is protruded, the tumor is said to be an enterocele; epiplocele, implying descent of omentum ; and entero-epiplocele, descent of" both. Sometimes only a redundant portion of bowel escapes, in the form of a diverticu- lum ; and this is termed a Hernia Litrica. The diagnosis of hernia is a practical subject, obviously of the highest importance. Ordinarily, a hernia is found to be a soft tumor, at the site of an abdominal aperture, receiving an impulse on coughing, and tending to enlargement under exertion of the abdominal muscles in any way, gurgling under pressure, if containing bowel, and capable of being replaced, by pressure, within the abdominal cavity. There are certain affections for which such tumors are especially liable to be mistaken. 1. Hydrocele simulates the oblique inguinal hernia, but is to be dis- tinguished thus: Hydrocele is generally more or less translucent, and hernia is almost always opaque; the exception being, when in a large hernia, invested by thin integument, a fold of bowel alone descends, capacious, and filled only with gaseous contents. Hydrocele is a con- stant tumor, unaffected by pressure; hernia is ever varying by accidental circumstances, and is usually capable of being diminished by pressure, if not made wholly to disappear. The apex of the pyriform swelling, 388 HERNIA. in hydrocele, simulates the neck of the hernia; but, on careful manipu- lation, it is found to terminate beneath the abdominal outlet, leaving always some part of the cord clear; and the cord is never at any part clear in unreduced hernia. The hydrocele, unless congenital, has no impulse, and evinces no tendency to enlargement, on coughing, or other exertion of the abdominal muscles. The testicle is felt obscurely, if at all, in hydrocele; in scrotal hernia it is usually found, distinct and separate, at the loAver part of the scrotum. The history of the case, too, is widely different; the hernial tumor appears suddenly, and pro- ceeds in development from above downwards; the hydrocele is of gradual formation, and its progress is from beloAV upwards. Not unfrequently, however, be it remembered, hydrocele and hernia coexist. 2. Hydro- cele of the cord.—This is usually a circumscribed swelling, leaving a portion of the cord clear, above and below, as may be ascertained by careful manipulation ; it is not reducible; and it evinces the ordinary negative signs on coughing, or other exertion. When the portion of cord within the inguinal canal is affected by circumscribed serous accu- mulation, however, the diagnosis may become of great difficulty, as can readily be understood, resting mainly on the reducibility or irreducibility of the tumor. 3. Cirsocele.—Ordinary varix of the spermatic veins, and veins of the scrotum, can scarcely be mistaken for hernia; the cord is comparatively clear, the feel of the veins is marked and characteristic. Like hernia, there is diminution of the swelling during recumbency and on pressure; but, unlike hernia, there is return of swelling on resump- tion of the erect posture, and on abdominal exertion, though the thumb be kept accurately and firmly placed on the abdominal outlet. When there is a SAvelling, however, at the upper part of the cord, partly within the inguinal canal, and consisting of enlarged Areins, perhaps with some serous accumulation, diagnosis is difficult; for the form and history of the tumor are \'ery like those of hernia, and there is an impulse on coughing. We trust to non-reducibility of the entire swelling, and its characteristic feel; on pinching it, the veins roll like earth-worms be- tween the finger and thumb, and the touch of the experienced is usually able to detect the absence of all abdominal descent. This swelling, however, often paves the way for hernia by dilating the canal, and thereby facilitating protrusion. 4. Bubo.—The history, progress, form, and feel of bubo must obviously differ very much from those of hernia. The two may be combined, however; a patient afflicted Avith inguinal hernia, or femoral hernia, may have enlargement of the inguinal glands. 5. Descent of the Testicle.—The testicle, descending at an unusually late period, may be arrested in the inguinal canal, causing a painful swelling ^ there very similar to hernia. It is knoAvn by absence of the testicle in that side of the scrotum, by the feel of the tumor, and by the characteristic pain which is experienced on pressure being made on the part. Like the high form of cirsocele, it may be the precursor of hernia; a portion of boAvel or omentum slipping down behind the tes- ticle, through the abnormally dilated canal. 6. Sareocele.—This is readily distinguished by the history and progress of the tumor, its feel and form, and its negative signs on coughing; the cord, too, is free, except in some cases of malignant disease. 7. Psoas abscess is distin- REDUCIBLE HERNIA. 389 guished from femoral hernia, by the evidences of spinal disease, by the history of the case, by distinct fluctuation in the swelling, and by the progress of " pointing;" and, most frequently, the site of the abscess is exterior to that of hernial protrusion. 8. Varix of the femoral vein.—A bulging varix of the femoral vein, projecting through the saphenic opening, may very readily be mistaken for femoral hernia. The test is simple. Reduce the swelling by pressure in the recumbent posture, and then press firmly on the abdominal outlet; if the case be one of hernia, there is no reproduction of tumor; if it be varix, the swelling quickly reappears. Reducible Hernia. At some part of the abdominal parietes, a swelling forms, painful, sudden, usually after some unwonted exertion ; at first slightly tense and tender, afterwards soft, compressible, and tolerant of manipulation, increased by the erect posture and by abdominal exertion; and then, too, sustaining an impulse, when held; capable of being reduced, by pressure made in the direction of the outlet through which it has come ; often disappearing spontaneously, on recumbency being assumed. An enterocele is smooth, elastic, and more or less globular in form; it gurgles on pressure, and flatulent noises may be emitted spontaneously; reduction, under pressure, is preceded by gurgling, and is often abrupt, taking place per saltum. Epiplocele is doughy, and more irregular in form, it emits no noise, and reduction is slow and gradual. The treatment of reducible hernia may be regarded as analogous to that of dislocation, consisting of prevention, reduction, and retention (Principles, 3d Am. Ed. p. 679). Not unfrequently there are premoni- tory symptoms of protrusion, and then prevention is in our power. Pain and slight fulness appear at an abdominal outlet, after unusual exertion. Hernia is about to form. In order to avert it, the exciting cause is removed, by discontinuing all abdominal exertion, as much as possible. And the predisposing cause is met by a well-fitted, lightly- springed truss being worn on the part, so as to strengthen what is Aveak in the parietes, while at the same time a mechanical obstacle is directly opposed to protrusion. Should hernia actually form, replacement, or Reduction, cannot be too soon effected, inasmuch as the parts protruded are ever liable, from apparently but slight causes, to the supervention of strangulation, a state fraught with the utmost danger to life. To leave a hernia unre- duced, and at the same time to continue any laborious avocation, or even to be exposed to but occasional abdominal exertion, is to convert a comparatively unimportant disease into one of a grave character, and to render a life, otherwise good, dependent on a very slender tenure. In life insurance, for example, an applicant affected with a slight but well-trussed hernia is admitted, if in other respects suitable, Avith only a trifling addition of premium; Avhile he who, with as simple a hernia, and of equally good health in other respects, neither wears a truss, nor otherwise provides against descent, is unhesitatingly rejected. Reduction is effected by placing the patient recumbent, slightly 390 REDUCIBLE HERNIA. elevating the trunk, removing all outward pressure from the abdomen, and in short taking every means to relax the abdominal parietes; then gentle and steady retropellent pressure is made with the hand, in the direction whence the descent has come. Such manipulation is termed the Taxis. Retention is effected by continued and suitable pressure at the site of protrusion; and this pressure is best made by means of a truss—a steel spring, with a compressing pad at the extremity. Of these instru- ments many varieties have been constructed, but of late opinion seems to have inclined, very justly, tOAvards a decided preference for the simple spring with its ordinary cork pad, provided that the instrument is accurately adapted to each individual case; the pad fitting nicely to the abdominal outlet, not too conical, lest permanency of dilatation should be so maintained, and yet not so flat as unnecessarily to diffuse the pressure ; the spring passing about two inches beneath the crest of the ilium, grasping there firmly, and terminating a little way beyond the spinous processes of the lumbar vertebrse ; the spring not so strong as to gall the parts by inordinate pressure, and yet strong enough to shut up the opening effectually; a thigh strap passing from the back part of the spring to the pad, so as to prevent that from being displaced upwards; and, to avoid chafing, a piece of folded lint or linen being interposed beneath the instrument, at the site or sites of pressure. At night, the truss may be removed, on the patient lying down in bed. In the morning it is the first article of dress to be adjusted, great care being always tak^en in regard to tAvo points: 1. That the pad fits accurately; and 2. That there is no descent, however slight or partial, during its application. Should at any time reprotrusion occur, the instrument must be instantly removed, and means as instantly taken for replacement and accurate readjustment. By careful and constant use of the truss, a radical cure is expected in the child. The predisposing cause is permanently removed; for, descent being prevented, farther dilatation of the outlet does not occur; and, during the general development of structure, the aperture or canal comes to acquire the normal proportion and capabilities. The period during which the truss requires to be worn, for attaining this end, is considerable ; from one to three, or more years. In the adult, so for- tunate an issue is not to be hoped for ; the outlet remains dilated, and predisposed to redescent, on application of but a slight exciting cause ; usually, the truss must be worn for life. And yet, a happy incident may occur, in favor of a better issue. Thus, we have seen a phleg- mon form under the pressure of a galling pad; the abscess discharged, contracted, and healed ; and, on cicatrization, it was found that the extent and site of plastic exudation had been such as to consolidate the outlet, and render farther use of the truss quite unnecessary. And even without such accidental aid, it sometimes, though rarely, happens that a slight hernia disappears under temporary use of the truss, and does not return. As, in the adult, the truss, however carefully and patiently Avorn, generally proves but a palliative, Radical Cures have naturally been sought for with some avidity. Of these, several have been applied to IRREDUCIBLE HERNIA. 391 the inguinal hernia. What seems the best method is, to adopt the principle of subcutaneous puncture ; making several scarifications in the neck of the sac—the cord carefully protected—and then applying accurate pressure over the canal, so as to favor occlusion of its unoccu- pied part by plastic exudation. Another method is by invagination ; pushing a fold of integument into the canal, after reduction of the tumor ; retaining the invagination by a suture, at the upper part; and obtaining afterwards adhesion of the invaginated portion of integument, by pressure, after excoriation by means of ammonia. This, hoAvever, is found to be both, more uncertain, and more unsafe, than the former mode. And neither should be attempted, unless in extreme cases, and at the express desire of the patient; seeing that neither is quite free from risk by excess of inflammatory action. The application of iodine to the neck of the sac has been tried, by puncture and injection ; but this method does not seem more promising of success than the other.1 Irreducible Hernia. A hernia is said to be irreducible, which cannot be reduced, and is permanently fixed in its extra-abdominal position. This state may be caused : 1. By adhesion of the sac, on its external aspect, to the parts into which it has been protruded ; and by adhesion of its internal sur- face to the hernial contents. In a neglected hernia of any considerable duration, the former event seldom fails to take place ; and to constitute the second, plastic exudation has only to occur on the opposed surfaces. 2. By the nature of the protrusion. The caput caecum coli is uncovered by peritoneum posteriorly. It may slide down through the parietes; and, presenting at the groin, it may constitute an irreducible tumor— as well as a hernia without a sac. The areolar adhesions of the dis- placed gut have been extended and shifted but not broken ; and they may present an insuperable obstacle to replacement. But it has hap- pened otherwise. The boAvel may have a more extensive peritoneal in- A'estment than usual; and, instead of merely descending with its fleshy connections, may acquire a complete mesentery—so becoming easily reducible.2 3. By contraction of the abdominal cavity. When a large hernia has been long unreduced, it may become permanently irreducible, although no adhesion form between the contents and the sac. The ab- dominal cavity, having parted with a large proportion of its ordinary contents, contracts upon the remainder; and then there is found to be no room for replacement of the extruded parts, even were circumstances quite favorable for such reduction. Irreducible herniae are predisposed to evil. The patient usually suf- fers from flatulence, indigestion, and constipation. The peristaltic movement of the protruded bowels is imperfect, and to other causes of incarceration and strangulation the part is constantly exposed. Such cases, therefore, require to be watched with unusual care. The bowels are to be carefully regulated ; all excitants of intestinal disorder are to be avoided, as well as unnecessary abdominal exertion ; and a bag truss 1 Bigelow, Boston Med. and Surg. Journal, Dec. 1850. 2 Lancet, 1235, p. 462. 392 STRANGULATED HERNIA. must be constantly worn, so as both to support the protruded parts, and prevent the occurrence of farther protrusion. No direct interference is warrantable, with a view to remove the obstacles to reduction. But, should strangulation occur, the ordinary operation is to be performed, for relief of the constriction. Incarcerated Hernia. This term denotes a temporary retention of the parts in their abnor- mal position, without obstruction to the fecal flow, and without the occurrence of inflammatory action. No urgent symptoms call for re- duction; but when this is attempted, it is found to be impracticable under existing circumstances. There may be: 1. An enlargement of the hernial contents. The gaseous matter may have become expanded; the fluid and solid contents may have accumulated in unusual quantity; or a portion of extruded omentum may have slowly expanded by increased deposit of adipose tissue; and the tumor, thus enlarged, is too bulky to repass the outlet. Or, 2. While the tumor may be but little changed, the aperture through which it came may be temporarily contracted— preventing replacement, yet not causing constriction and strangulation; and this state may depend on muscular spasm, or on swelling of the parts connected with one or other of the various stages of an advancing inflammatory process. Treatment depends plainly on the cause. Gaseous contents are di- minished by the continued application of cold; solid and fluid, as well as gaseous contents, may be favorably acted on by purgatives and enemata; a fatty omentum may be diminished by pressure and starva- tion; and, then, the reduced tumor may be pushed back within the abdomen. Spasm is overcome by the warm bath, opium, chloroform, or other antispasmodics; inflammatory exudation is got rid of by anti- phlogistics, followed by discutients ; and through the cleared outlet a comparatively unchanged protrusion may again be passed. Until this desirable event can be achieved, the part ought to be supported by a bag truss, or otherwise; and every precaution should be taken to avert the occurrence of strangulation—to which such tumors are especially liable. Strangulated Hernia. Strangulation is said to have taken place, when fecal flow is arrested in the hernial tumor by tightness of constriction at the neck ; and when, usually from the same cause, circulation has been disturbed in the pro- truded parts, and the inflammatory process is begun. Or the condition may be otherwise defined to be: incarceration, with interruption to both the fecal and the vascular Aoav, and Avith an inflammatory process in the protruded parts either following or preceding constriction. For this state of matters, the hernial contents are usually to blame. The con- striction may depend on spasm, or other alteration in the abdominal outlet; but much more frequently it is caused by sudden, or at least rapid and unusual enlargement of the protruded parts—in consequence STRANGULATED HERNIA. 393 of which, the neck of the tumor becomes, as it were, jammed at the aperture of descent. A fresh protrusion takes place; or feculent con- tents accumulate; or gaseous contents become increased ; or an inflam- matory process is begun in the protruded parts, causing both engorge- ment and serous effusion. Much more frequently, however, the inflam- matory action is consequent to constriction—indeed, caused by it. The symptoms of strangulation are very marked. The patient is annoyed by flatulence and general uneasiness. The bowels refuse to act; the contents of the lower bowel may be evacuated, but no dejec- tion can be obtained from above the seat of stricture; yet frequently there is ft troublesome and urgent desire to go to stool. The tumor is found incapable of reduction ; at first it may be flaccid, but it soon grows tense, and tension rapidly increases. Pain is felt in the part; on the increase, and extending towards the abdomen. Sickness comes on, with retching. Then the stomach is emptied; and, vomiting continuing, the upper bowels also eject their contents ; the peristaltic movement comes to be wholly reversed, and the Amounted matters are stercoraceous. At first, the pulse may have risen to the sthenic and inflammatory cha- racter ; but now it becomes of another type—denoting the state of Constitutional Irritation, and tending fast to lapse into the typhoid character. The tumor becomes more and more tense and painful— perhaps intolerant of eA7en the gentlest pressure. Great pain affects the whole abdomen, with aggravation and twisting at the umbilicus. Nausea and vomiting continue; the countenance is anxious, pale, pinched, and wet with clammy perspiration; there is great restlessness, and distress is constant; the pulse grows rapid and indistinct; hiccoughing sets in; the tumor becomes less intolerant of manipulation, less tense and pain- ful, and feels doughy and crepitant on being handled. Gangrene has taken place. Then vomiting may cease, and sudden cessation of pain and discomfort may be experienced; perhaps the bowels act imperfectly; and the patient may express himself not only relieved but confident of recovery. Sinking, hoAvever, continues; and the fatal issue is not long deferred. Such is the ordinarv course of a strangulated hernia, unrelieved. But there may be another and less formidable termination. In the progress of the case, the integument and other envelops of the tumor become involved in the inflammatory action; at first they are bright red, tense, and very painful; afterwards darker in hue; less painful and tense, cold, phlyctenulous—in fact, gangrened. The contents are in a similar condition. All slough. And, on separation of the mortified parts, copious feculent discharge takes place; relief follows immediately; the urgency of the symptoms is over; and gradual recovery may ensue, with the establishment of artificial anus. In the preceding enumeration of symptoms, we have first the signs of obstruction, and then those of inflammatory action, in the protruded parts. But this may be reversed. The inflammatory process may be the original affection; caused, perhaps, by a blow—though a less direct and palpable exciting cause may suffice. The tumor is painful and red and swollen, even for some time, while as yet the abdomen is free from ailment, and the boAvels are working naturally. The pain and tension 394 STRANGULATED HERNIA. are chiefly at the body of the tumor, in the first instance, instead of at the neck as in primary constriction. But, the inflammatory action con- tinuing, engorgement with effusion takes place, the bulk of the whole tumor is increased, in consequence constriction occurs; and then follow obstruction of the bowels, affection of the abdomen, and aggravation of the local disorder. The rate of progress varies according to circumstances. When the tumor is small and recent, constriction is usually tight; and, in a few hours, death of the parts, at least if unrelieved, is certain. Whereas, if the hernia be of some size and long standing, and if obstruction precede the inflammatory action, and neither prove urgent, days may efepse ere much mischief be done to either part or system. On the average, how- ever, it is not by days, but by hours and minutes, that the registration of time is made in cases of strangulated hernia. And, by the practical man, these minutes are invariably regarded as of vital importance. Many, if not all of these symptoms, may exist, independently of either hernia or strangulation. Whenever they do occur, however, hernia is invariably to be suspected, and the necessary inquiry and examination should be made under all circumstances. There may be no tumor found at the ordinary sites of protrusion, or at any other accessible part of the abdominal parietes ; then it is probable that the symptoms are independ- ent of hernia—purely abdominal. If a hernia is discovered, of old standing and considerable size, not very tense or painful; if the pain is not greater in the tumor than elsewhere, perhaps not so great; if the bowels are acting, though perhaps imperfectly; if, on inquiry, it is ascertained that the abdominal and general symptoms plainly, and by some consi- derable time, preceded change in the tumor, then the probability is, that the affection is enteritic or peritonitic, originating in the general abdo- men, affecting the tumor secondarily, and perhaps eA'en in a minor degree. When, however, the signs of strangulation are found marked and acute, and the history plainly indicates precedence of the local and extra-abdominal signs of disorder, there need be no doubt that the case is of the ordinary kind—the urgency essentially dependent on strangu- lation of the hernia. Treatment of strangulated hernia necessarily varies according to the nature of the case. In general, it may be said that our object is to effect reduction as speedily as possible; saving structure, by favoring decline of the inflammatory process; restoring the normal passage of the intestinal contents; and arresting the disastrous progress of consti- tutional disturbance. But it is not ahvays good practice to have recourse to the manipulations for reduction immediately; and, in regard to this practical point, the cases may be divided into two great classes; those Avhich are preceded by inflammatory action in the hernia, and those in which this action folloAvs on constriction otherwise produced. The latter, doubtless, are the majority. In the former, it is the natural and proper course of procedure to remove the cause of constriction, if possible, in the first instance, provided the case is chronic enough to admit of this; leeches are applied, and other suitable antiphlogistics are enforced; and when, by such means, the bulk of the tumor has diminished, and the parts have also acquired a better tolerance of manipulation, then TREATMENT OF STRANGULATED HERNIA. 395 reductive pressure is to be applied, without risk of doing harm, and Avith a good prospect of proving successful. The inflammatory action has caused constriction ; remove the cause, and the constriction is easily dealt with. But, in the other class of cases, the state of matters is reversed. The constriction has caused inflammatory action ; and only after removal of the former, can we expect to cope successfully with the latter. In employing leeches for the relief of hernia, it is well not to apply them to the* tumor itself, but to its immediate vicinity; otherwise, the slipperiness which is produced, by oozing of blood, may interfere seri- ously with the manipulations of the taxis. In applying the taxis, the patient is placed recumbent, and with the limbs and trunk so arranged as to relax the abdominal parietes to the full -,1 it is well, also, to see that the bladder is empty, and that no bandage, belt, or other outward constriction is affecting the abdomen. The tumor is then grasped with the hands, firmly, yet cautiously; and while with one hand general pressure is made on the bulk and body of the tumor, forcing it in upon itself, as it were, and at the same time push- ing it back in the direction whence it has been protruded, a kneading or pinching movement is made on the neck of the tumor by the fingers of the other hand, so as to disentangle and free the part most compacted and compressed. And this is steadily persevered in, for some time, provided the patient do not complain greatly of aggravation of pain and general uneasiness. Our wish is to push the hernial contents back, not in mass, but in detail; those going first which were last protruded. The patient, if not chloroformed, is kept in conversation, to prevent him from straining his abdominal muscles in involuntary opposition to the operator. There is energy, yet no violence of force in the pressure; and it is patiently and steadily maintained, yet not continued too long; that is, not after reasonable hope of its success has passed, and when its maintenance must inevitably tend to serious aggravation of the cres- cent inflammatory action.2 Sometimes it is not applicable at all; when, for example, the case is acute, and has made great progress ere assist- ance is called; when the parts are so obviously intolerant of pressure as to convey to the practised hand and mind the apprehension of texture giving way by rupture under an attempted taxis; also, Avhen we are satisfied that inflammatory action has already gone so far as to render loss of substance, either by ulceration or by sloughing, inevitable in the constricted parts. Sometimes benefit accrues from an opposite direction of gentle force, previous to the reductive application of it; bringing down the jammed neck from the abdominal aperture, and so favoring a clearance of the passage by an unravelling, as it were, of its contents ; causing, in fact, 1 By some, it is thought that much may be done by position alone ; flexing the thighs, rotating the limbs inwards (for inguinal and femoral liernia, especially the latter), raising the nates till the whole weight rests on the shoulders, retaining this position for a time, then lowering and raising again, the hand of the surgeon meanwhile making gentle pres- sure on the tumor. It is thought that the posturing tends to pull the contents out of their sac.—Brit, and For. Rev. April, 1850, p. 491. 2 For a sample of the injuries done by imprudent taxis, see Teale on Hernia, p. 96. 396 AUXILIARIES TO THE TAXIS. a slight increase of the descent, before the whole is attempted to be replaced. A bluff forcing of the fundus of the tumor on its neck is especially to be avoided, when replacement is intended; for the effect of this, in the case of protruded bowel, is not only to jam the parts yet more, but actually to favor formidable accession to the tumor's bulk by traction from the aperture downwards. Failing in the well-applied taxis, we naturally look for Auxiliaries to it; and we find a catalogue of these, analogous to the aids of reduction in dislocation (Principles, 3d Am. Ed. p. 681). Some act on the con- tents of the tumor, tending to reduce bulk; others affect the abdominal outlet, tending to enlarge space; and the latter act well, not only in those cases in which spasm of the abdominal parietes is the cause of constriction, but also in those in which the abdominal outlet may be of the ordinary dimensions, yet quite unfit for return of the impacted tex- tures Avhich it happens to contain; in other words, they are of use in relaxing muscular fibre, not only in a spastic but also in a normal state —making easy room, either way, for replacement of the dislocated parts. And here it may be stated, that though in many cases the ab- dominal outlet is in the first instance free from change, and constriction depends on alteration in the contents; yet, strangulation having occur- red, the abdominal parietes at the site of the hernia become involved in perverted action, and sooner or later are irritated into spasm. And hence it is, that the most useful auxiliaries are such as tend to abdominal relaxation. 1. Venesection is advisable in but a few cases; in the comparatively young and robust, of inflammatory tendency, tolerant of loss of blood; with a tight strangulation yet recent, marked signs of advancing acute action in the parts, and the constitutional symptoms still evincing a sthenic type. In such cases, bloodletting—one copious and rapid abstraction from the arm—is of use, by both combating this advancing action, and at the same time, tending to cause complete pros- tration of the muscular system—the abdominal parietes of course in- cluded. 2. The Warm bath has similar tendencies ; and is obviously more generally applicable, inducing temporary depression ; gaining the desired end, yet saving the system from actual loss. If there be time, this is one of the best means of assisting the taxis. The patient is placed recumbent in the bath, with the abdominal parietes relaxed by posture ; and, when faintness is beginning to be complained of, the taxis is resolutely applied. It may fail; but the opportunity by the bath is not yet over. Let the patient be replaced in bed; in a few minutes he will be found deluged in perspiration, with a muscular system more prostrate than before; and then the taxis is most likely to succeed. 3. Fomentation is inapplicable ; by rarefying the gaseous contents, and favoring exudation, it increases the bulk of the tumor ; and it is too feeble and limited in its relaxing effect, to act favorably on the abdo- men. 4. Antimony, as a nauseant and prostrating agent, is very infe- rior to the bath; adding greatly, and in a dangerous degree, to the irritability of the stomach, and to the downward tendency of the con- stitutional symptoms. It is inapplicable. 5. And, for a like reason, let Tobacco be used very warily, if at all. By other, less hazardous, and more manageable auxiliaries, our object may be as speedily ob- AUXILIARIES TO THE TAXIS. 397 tained. 6. Opium is deservedly in much higher repute; following bloodletting in the marked cases of an inflammatory nature, given singly in others; the dose a full one, not less than one or tAvo grains— for the adult. The beneficial effect is twofold. Constitutionally, the system is rendered more tolerant of the depressing effects of strangula- tion ; the remedy being, in fact, equally useful here as in the case of intense abdominal inflammation unconnected with hernia (Principles, 3d Am. Ed. p. 171). Locally, very great service is obtained by muscular prostration, so soon as the full narcotic effects of the drug have been established. This requires time, however; and consequently opium, like the warm bath, is not applicable to all cases—at least as an auxiliary of the taxis ; for, in all, there is not time to aAvait the operation of the remedy. 7. Chloroform, as has elsewhere been stated (Principles, 3d Am. Ed. p. 743), is almost equally serviceable here as in dislocation ; producing thorough relaxation, not aggravating collapse, quickly pass- ing off, and leaAdng no unpleasant trace behind. 8. Glysters of acetate of lead, each containing ten grains dissolved in about six ounces of water, have been employed with success ; repeated, if necessary, every two hours.1 9. Purgatives are in all cases of strangulation most un- warrantable. The bowel is locked; and the stimulus of purging, quite unable to undo the locking, acts but injuriously, in applying a stimulus which cannot be obeyed, and aggravating an already crescent inflamma- tory action. In the case of incarceration, the wary use of purgatiAres is often serviceable in unloading the protruded bowel; but in the tighter degree of constriction, causing strangulation, they are never to be thought of. 10. Enemata, however, have a different character. When simple and bland, however freely and largely administered, they have not the pernicious properties of purgatives—more especially, of those which are drastic and given by the mouth. Besides, they are positively of use, by disburdening the loAver bowels of their contents, both solid and gaseous ; and so making room within the abdominal cavity for re- ception of the extruded parts. And experiment would also lead us to suppose that they have a mechanical tendency to extricate, by exciting traction, from within, on the constricted and protruded bowel.2 11. The long elastic Rectum-tube is also both safe and useful, when passed high and cautiously, so as to reach the colon ; the object being to evacuate the gaseous contents of the lower bowels more thoroughly than enemata can do, and so to make room Avithin the abdomen. But, ob- viously, such a proceeding is only applicable to those cases in which distension of the lower bowels exists. 12. Some auxiliaries affect the tumor mainly. Certain cases, we have already seen, render it neces- sary that local bloodletting should precede the taxis. Fomentation has been thought of, but is found worse than useless. The application of Cold is sometimes of the greatest service. Applied indiscriminately, it will do harm; but limit its use to those cases which are chronic in their progress, in which the signs of obstruction plainly precede those of inflammatory action, and in which the inflammatory process affecting 1 Brit, and For. Rev. Jan. 1849, p. 271. *■ Lancet, No. 1035, p. 468. 398 AUXILIARIES TO THE TAXIS. the tumor is not only slight, but scarcely begun—then the effect is often most favorable. The gaseous contents being condensed, bulk is dimi- nished ; muscular energy is probably somewhat lowered, and space is gained; and, perhaps, by puckering the investments of the tumor, some little reductive pressure may be so exerted. But act as it may, there is no doubt that the local application of cold tends wonderfully to assist the taxis, in the class of cases just described. It may be applied by sprinkling the tumor and surrounding parts with ether, and keeping up a continuously rapid evaporation by directing a current of air upon the part. Should this fail, great care must be taken for some time not to apply heat suddenly to the part, by fomentation or bath, or other- wise to cause rapid exaltation of temperature, for very obvious reasons (Principles, 3d Am. Ed. pp. 155 and 272). Ice and freezing mixtures are less suitable ; being apt, by doing too much, to act injuriously on the hernia's contents. 13. Acupuncture has been proposed, when the constricted bowel is obviously distended by gaseous contents. But the use of cold is likely to obtain the same end, as effectually, and more safely. 14. Posture may be rather considered as a part of the taxis, than as auxiliary to it; so invariably is it to be attended to. It neces- sarily Araries, in details, according to the site of the protrusion. Its main object is ever the same ; to relax the parts through which reduction has to be made. In hernia at the groin, as already stated, it has been thought that elevation of the pelvis, with a hanging position of the recumbent body, has been of use in exerting an extricating traction on the strictured parts (p. 395). The most available, and most generally used of these auxiliaries are: bloodletting, local in all the inflammatory cases, and general in the few examples which admit of it, the warm bath, opium, chloroform, simple enemata, in large quantity, perhaps the long tube, in the chronic and uninflamed cases, ahvays the local application of cold. If the taxis is to succeed, a yielding of the tumor is felt beneath the hands, the con- tents are plainly shifting; then a gurgling noise is heard, denoting replacement of the gaseous contents, ahvays a welcome sound, and speedily thereafter the solid matters recede, sometimes very gradually, often as it were per saltum. A truss, or suitable compress and bandage, is instantly applied; the patient is confined to bed, recumbent; anti- phlogistic regimen is strictly enforced ; after some hours, an enema may be given, if the bowels have not acted spontaneously ; but not till after many hours should even the simplest purge be given by the mouth, it being well-ascertained that the loop of bowel included in the stricture remains long in a paralytic state, and incapable of obeying the peristaltic stimulus. There is, in short, the same serious objection to purgatives immediately after reduction, as during the existence of strangulation. Should peritonitic or enteritic symptoms threaten, the usual antiphlo- gistic treatment must be had recourse to, both early and with energy. Not unfrequently, after tight constriction, discharge of blood takes place per anum, this doubtless being furnished by the mucous coat of the lately strangled part. It may happen that under forcible application of the taxis, in a recent hernia, the tumor recedes suddenly, in mass. This is not desirable. THE OPERATION FOR STRANGULATED HERNIA. 399 For, it is not improbable that the untoward symptoms may continue quite unchanged, the reason being that the sac and its contents have been reduced together with their relations unaltered, and that the neck of the sac continues to constrict the omentum or bowel, as before. In such a case, treatment becomes embarrassed. But most surgeons are of opinion that we are required to expose the abdominal outlet by opera- tion, in search of the yet strangulated boAvel, aiding that search by making the patient cough, or otherwise exert himself, so as to favor re- descent of the hernia. An operation under such circumstances is much more promising of success than Gastrotomy, on account of an unde- fined internal obstruction (p. 382). For in this case the cause of strangulation is plainly in the sac, and that is within reach at a fixed point, the parietal relations of the sac being likely to detain the reduced mass close to the site of protrusion.1 The operation for strangulated hernia is unhesitatingly to be had re- course to, so soon as the taxis, with such auxiliary means as seem advis- able, has been fairly tried, without success. The great majority of experienced surgeons agree, that in regard to this operation error is more frequent on the side of delay than of precipitancy. Two circum- stances demand its instant performance; a conviction that by no other means, than by the edge of the knife directly applied, can the abdo- minal outlet be so enlarged as to relieve constriction and admit of replacement; also, a conviction that already inflammatory action has advanced so far, that either ulceration or sloughing is inevitable in the protruded parts. In the one case, we operate to relieve the stricture and effect replacement, hoping to arrest inflammatory action; in the other, we operate to relieve the stricture, and, leaving the hernia unre- duced, prevent fatal extravasation of intestinal contents within the abdomen—hoping also to limit inflammatory action to the directly im- plicated parts. The danger of strangulation is twofold; formidable disturbance of the system, and untoward inflammatory progress in the tumor. Both dangers advance, in most cases, with rapidity. And if we wish to meet them successfully, the measures of relief must be not only suitable but early; in other words, time, all valuable, must not be wasted in ineffectual attempts at the taxis, when the case at all partakes of an acute character. Large herniae are more hopeful of reduction than the small; the inguinal protrusions are more hopeful than the femoral. It has been proposed to relieve the stricture by means of subcutane- ous section. But this proceeding is obviously so beset with danger and uncertainty as to be quite inapplicable. The seat of stricture is exposed by careful and regular dissection; the incisions necessarily varying in their plan, according to the kind of tumor. Having cautiously divided the integuments and fascial envelops, the sac is exposed, clear and glistening, resembling very much the peri- toneal coat of the bowel; and there may be some difficulty in ascertain- ing whether it is the sac or bowel. By pinching it up, so as to show bowel separate beneath; or by observing serum, fat, or a portion of 1 Monthly Journal, Retrospect, Feb. 1849, p. 35. 400 THE OPERATION FOR STRANGULATED HERNIA. omentum between, we arrive at a sure diagnosis. But, this difficulty having been surpassed, another immediately arises. The sac having been exposed—or nearly so—are we to open it, examine the state of its contents, and divide the stricture from within; or are Ave to attempt division of this from without, leaving the peritoneum intact, and so escaping the danger of peritonitis? So long ago as 1720, Petit pro- posed this modification of the procedure—leaving the sac unopened; and the proposal has met with a varied reception since—inclining to distrust rather than otherwise. Lately, however, it has been revived under better auspices; and in suitable circumstances,it may be considered as the established and preferable practice. Were it applied indiscrimi- nately, nothing could Avell be conceived more pernicious; bowel or omentum might be reduced when they ought not; or, one stricture haAr- ing been relieved, another might be left—this second existing in the sac, perhaps beloAV its proper neck, and continuing to embrace the hernial contents with fatal tightness after reduction. But, limit it to those recent cases of strangulation in which we are certain that the hernial contents are sound and reducible, and in which we are also certain that the only stricture is that which we propose to divide—then, doubtless, the extra-peritoneal operation is by much to be preferred. It is also suitable in cases of irreducible hernia, which have become strangulated; and in which, from their large size, the exposure of peritoneum may reasonably be expected to prove especially hazardous.1 If the case appear favorable for extra-peritoneal division, the invest- ing textures are carefully divided at the neck of the tumor, so as to admit the point of the finger, or at least the finger's nail, within the tight orifice of the abdominal aperture; and then on the finger's point, so introduced a probe-pointed bistoury is passed, and by it the necessary enlargement is effected. If the stricture be in the neck of the sac itself, even that may perhaps be relieved extra-peritoneally, by carefully scratching the outer part by the knife's point.2 Then the taxis is ap- plied; the parts are reduced—the contents going first, and gradually, otherwise stricture might remain after reduction; if the unopened sac be non-adherent, it is pushed back also ; the wound is brought together; and by suitable adaptation of compress and bandage, and avoidance of the ordinary exciting causes, reprotrusion is prevented. But if it be deemed expedient to proceed in the ordinary way, the sac is pinched up by forceps; choosing a part where serum or fat inter- poses betAveen it and the bowel—and that will generally be towards the fundus of small hernine. By the knife's edge, held horizontally, the raised fold is divided. Through this aperture the point of the finger is introduced; and, on this, as the best director, dilatation of the opening is made to such an extent as may be deemed advisable. However large 1 Indiscriminate performance of the extra-peritoneal operation must often lead to serious and fatal error. Selection must ahvays be carefully made. For objections to the opera- tion, vide Hancock, Observations on the operation for Strangulated Hernia, Lond. 1850. 2 According to Mr. Luke, the site of stricture may be ascertained previously to ope- ration, by making impulse on the fundus of the tumor with one hand, while the other is placed on the neck. Wherever impulse stops, there is the stricture.—Med.-Chir. Trans. vol. xxxi. THE OPERATION FOR STRANGULATED HERNIA. 401 Fig. 173. a a. The portion of bowel which has been pro- truded ; constricted, dark, and engorged. At 6, the upper, or cardiac portion, dilated, and of dark color. At' c, the lower portion, comparatively empty, flaccid, and pale. the hernia, the opening of the sac need not be of greater extent than what is merely sufficient for ascertaining the state of the contents, and permitting the finger to reach the site of stricture. The point of the forefinger having been passed up to the abdominal aperture, the probe- pointed bistoury is slid flatly along it; and, by the point's edge, pressed upon the stricture; this is divided to the necessary extent. Then the hernial contents, if sound and re- ducible, are replaced gently, portion by portion—the last protruded first. Recent and tender adhesions may be gently broken up with the finger, or touched with the edge of the knife; but consolidated adhesions, if at all extensive, render the parts irreduci- ble—they should not be interfered with. When there is any consider- able portion of omentum in the sac, it should be carefully examined, to ascertain whether or not it conceals —perhaps strangles—a knuckle of intestine. If the sac be not adher- ent, it is replaced as well as its contents, but not along with them ; for, reduction is found to be facilitated by an assistant's finger steadying and stretching the sac, while the contents are pushed upwards on its smooth and slippery surface. Reduction having been accomplished, the wound is brought together, and suitable pressure applied. Approximation by suture should not be complete, however; for union by adhesion is not desirable, otherwise danger might accrue from the secretions in the deep wound finding their way into the peritoneal cavity. They should be allowed a free outward drain. When hernia is irreducible, we content ourselves with division of the stricture. If the contents are sound, the external wound is approxi- mated with a view to adhesion. If the contents are found gangrenous, or verging thereto, the wound is left open, to permit free discharge of the feculent contents. If, on exposing the contents of a reducible hernia, the bowel be found merely congested; ruby-colored, it may be ; perhaps spotted by points of ecchymosis, or showing one or more vesicles of the peritoneal coat, it is reduced unhesitatingly. If showing signs of plastic exudation on its surface, it may still be reduced; no structural change has taken place but what may be recovered from. But if the bowel be dark-purple at some part, greenish at another, and perhaps ash-colored at a third, friable, and evidently fast passing into gangrene, under no circumstances is it to be reduced, else fatal feculent extravasation must ensue. And if omentum be found dark-red, emphysematous, and with its venous blood coagulated, it too must be left to slough in its outward site; in either case, hoAvever, as much care being taken to free the neck of the tumor by division of the stricture as if the whole were fit for reduction. 26 402 THE OPERATION FOR STRANGULATED HERNIA. In the case of gangrened bowel, it is also well to incise the sloughing part, so as to relieve by immediate and copious feculent evacuation. Afterwards, the treatment is as already described for artificial anus (p. 371). In the case of gangrenous omentum, two modes of procedure are in our option. We may cut off the gangrened part, having previously satisfied ourselves that there is no portion of bowel within the mass, secure the vessels by fine ligatures, and return all within the abdomen. Or, having cut off the gangrened part, and secured the bleeding points, we may leave the rest still impacted in the abdominal outlet, Avith a view to its becoming permanently fixed there, and so preventing all future tendency to protrusion. The former method, though not free from risk by bleeding and inflammatory exudation within the abdominal cavity, is usually preferred; the latter being often followed by uneasy sensations in the part, and proneness to abdominal disorder. In all cases of doubt as to viability of the strangulated parts, reduc- tion should at least be delayed. It is never to be forgotten that, notwithstanding relief and replacement, inflammatory action may still advance in the bowel, so as to cause loss of continuity by ulceration. And if this take place within the abdomen, and be followed by feculent escape, the patient's doom is sealed. Sometimes, after opening the sac, stricture at the ordinary sites is sought for in vain. In such cases it is likely to be found in the hernial contents themselves; a portion of omentum, for example, may encircle a portion of bowel. This is detected by careful manipulation, and is to be gently undone by the fingers, perhaps aided by a touch of the knife. After successful reduction, by operation, the same treatment is re- quired as in the case of simple taxis ; rest; recumbency : antiphlogistic regimen; leeching, and other antiphlogistics,1 if inflammatory symptoms supervene; hydrocyanic acid or creosote, if the stomach continue irri- table ; bland enemata; but no purge by the mouth, howeA*er simple, until many hours have elapsed; otherwise, as already stated (p. 398), dilatation with obstruction will take place above the palsied portion of intestine, and the patient will probably sink under symptoms of ileus. If intestine previous to reduction have shown an advanced stage of the inflammatory process, antiphlogistics are especially necessary, both local and general, in order to avert, if possible, ulceration, or other dan- gerous structural change. When the case is of the obscure nature already described (p. 394), and it is difficult to say whether the hernia is to blame or not for occur- rence and persistence of the untoAvard symptoms—let the operation for relief of stricture be performed. When the tumor itself is Of an ambi- guous character, when we are not certain whether it is a hernia or not, and yet the ordinary symptoms of strangulated hernia are present, again let the surgeon operate. It is well that he should approach error on the safer side. After operation, the greatest attention must be paid, for some days, to prevent reproduction of descent, by keeping the compress accurately 1 Dieffenbach is afraid of calomel; supposing that it acts injuriously on the bowel, and is apt to induce an unhealthy state of the wound.— Vide his Operative Surgery, 1848. OBLIQUE INGUINAL HERNIA. 403 applied, and avoiding the ordinary exciting causes. Should repro- trusion take place, by coughing, restlessness, or imprudence of the patient, the dressing must instantly be undone, and replacement effected. When the sac remains unreduced, simulation of redescent is apt to take place, by serous accumulation within the sac, especially if the integu- mental incision be closed; but this state is at once detected and reme- died, on opening up the wound. After cicatrization, a well-made truss must be worn, as in ordinary cases, for it is seldom that the operation for relief of stricture effects a radical cure. Oblique Inguinal Hernia. This is by much the most common form of hernia, in the male. Descent takes place along the spermatic cord, through the inguinal canal; the tumor shows itself external to the parietes, at the lower aperture, and thence descends into the scrotum in the male, consti- tuting an oscheocele, or scrotal hernia; into the labium of the female, constituting labial hernia. The investments of the tumor are as fol- lows : externally, the integument; then the superficial fascia of the abdomen; then the proper fascia, or fascia propria of Camper, consist- ing of fibres from the tendon of the external oblique; then the fascia cremasterica, consisting of fibres from the cremaster muscle ; then the infundibuliform, or transversalis fascia, consisting of a prolongation of the fascia transversalis abdominis ; lastly, the sac. As the tumor is about to descend, a painful fulness is found opposite the upper abdominal aperture, increased by abdominal exertion, and sustaining an impulse upon coughing. Then is the time for applying a truss carefully, and avoiding exciting causes, Avith a view to prevention of the hernia. The pad of the truss should compress the superior ab- Plan of Inguinal Hernia; on the rightside oblique, on the left direct, a. The hernial sac. 1. The cpipi.'trir artery. (After Tiedemann.) dominal aperture, not the lower; otherwise there is room enough for hernia, and strangulated hernia too, within the abdominal parietes. 404 OBLIQUE INGUINAL HERNIA. To reduce this form of tumor, the pressure of the taxis is applied obliquely upwards and outwards, in the direction of the inguinal canal. In large tumors of old standing, however, it must be remembered that the canal becomes shortened as well as more direct, the two apertures coming to be almost opposite to each other; and this is attended to in the taxis. The patient is laid recumbent, with the trunk raised, and the thighs flexed and approximated. In the operation for strangulation, a simple straight incision is made along the neck of the tumor, beginning a little above the aperture of protrusion, and extending dowmvards on the tumor, as far as may be deemed necessary. The deep cut for relief of stricture, is made directly [Fig. 175.] [Representation of the appearance of a large inguinal Hernia, and of the direction of the incision to be made in the operation. (From Fergusson.)—Ed.] upwards, in order to avoid the epigastric artery, which courses behind and to the inside of the hernia's neck. The spermatic cord is usually behind, and out of harm's way, but sometimes it is split up and scat- tered over the neck of the hernia, and then caution is required to avoid the spermatic artery and duct. The stricture may exist at one of three points : in the margins of the lower abdominal aperture, in the superior abdominal aperture, in the neck of the sac itself. Sometimes a double stricture exists, each abdominal aperture being at fault. The ordinary site is at the lower outlet, but if, after free division of this, reduction is still opposed, the superior site is at once to be suspected, and explored accordingly. At this site, it is to be remembered, a small strangulated hernia may exist, with scarcely any perceptible swelling; a minute portion of bowel being tightly embraced by the margins of the superior abdominal aper- ture. The symptoms are likely to be mainly those of enteritis, and at- tention may not be directed to the groin. In such circumstances the patient has great risk of perishing ; unless, by sloughing and abscess, outward discharge occur, with establishment of artificial anus. There are sub-varieties of inguinal hernia: 1. The intermuscular Hernia.—This is more liable to occur in females than in males; the bowel meeting with obstruction in its ordinary descent. Having passed CONGENITAL AND INFANTILE HERNIA. 405 Fis. 176. the internal aperture, it turns towards the ilium, and lodges between the abdominal muscular layers, above and exteriorly to its point of exit. On account of this unusual site, diagnosis may be somewhat ob- scure.1 2. The Congenital Hernia.—This is a very simple deviation from the normal state of parts ; dependent on imperfect development. It is not likely to take place till after birth; for not until after inflation of the lungs are the exciting causes applied. But so soon as the child is born, the exertion of crying brings down a portion of bowel or omentum along the open process of peritoneum, which exists in consequence of that which constitutes the tunica vaginalis testis having not been occluded. There is no sac, unless the tunica vaginalis be considered as such ; the bowel or omentum lies within the cavity of that tunic, in contact with the testicle—-sometimes adherent to it, in Avhich case the tumor is irre- ducible. Occasionally, a portion of bowel contracts adhesions to the testicle while within the abdomen, and, descend- ing with it at the usual time, constitutes this form of hernia before birth. Strangulation may occur at any time ; it has happened to an infant of but a few days old, and required operation. This is performed as in the ordinary tumor. In the reducible cases, a care- fully adjusted truss is worn constantly; prevent- ing protrusion ; tending to obliterate the peri- toneal opening; and so, speedily and surely, effecting a radical cure. 3. Hernia Infantilis.—This term is applied to a more complicated state of parts, originating also in early life. The communication between the cavity of the tunica vaginalis and that of the abdomen is shut at its upper part; but the former caArity is unusually spacious, and ascends high in the cord, containing more or less serous fluid. Behind this a hernia descends, invested by the ordinary peritoneal sac. In cutting doAvn on such a tumor, we divide first the anterior portion of the tunica vagi- nalis, then the posterior; and, after this, appear the sac and its contents, unless the former, as is not unlikely, be incorporated with the posterior layer of the tunica vaginalis. This form is of rare occurrence. Diagram illustrating the state of parts in Hernia Infantilis' (Liston.) Ventro-inguinal Hernia. This is also called the Direct inguinal hernia. Descent is unconnected with the superior abdominal aperture; and takes place through the ab- dominal parietes, immediately opposite the lower aperture—the common tendon of the internal oblique and transversalis muscles giving way at that point. Sometimes, however, that tendon is pushed before the tumor, and forms one of its investing fasciae—protrusion in that case 1 Luke, Medical Gazette, March 15, 1850. 406 FEMORAL HERNIA. not being through the lower abdominal aperture, but near it. The ordinary coverings are similar to those of the oblique variety; only, this descent being not directly connected with the cord—which is on its outer aspect—there is no cremasteric expansion. The course of the epigastric artery is external to the neck of the tumor (Fig. 174). And hence the general rule, in all cases of inguinal hernia, when strangulated, is to make the deep relieving incision directly upwards, parallel to the linea alba; whether the descent be direct or oblique, the artery is safe. In the direct form, the pressure of the taxis is made directly up- wards. Femoral Hernia. This is most frequent in females; the greater space, in the normal state of the parts, obviously favoring protrusion. Descent takes place through the crural aperture, on the inside of the femoral vessels, and through the saphenic opening of the fascia lata. In the crural aperture the neck of the tumor is contained ; the fundus, resisted in its descent on the thigh, makes a sharp turn upwards, and lies on the lower part of the abdominal parietes ; the neck is beneath Poupart's ligamen^ the fundus may be above it. And this must be attended to in applying the taxis; the tumor being invariably Fie- 177- unbent, as it were, and made straight ere the reductive pressure is applied. The tumor is usually of small size; often not bigger than a pigeon's egg; sometimes it is of even huge dimensions ; but its average bulk is much below that of the inguinal varieties. The coverings are, inte- gument ; the superficial fascia of the thigh; the fascia propria, obtained from the femoral sheath, and con- tinuous with the fascia transversalis and fascia iliaca ; lastly, a covering obtained from the textures which normally occupied and occluded the crural aperture. Very often the two last-named coverings are matted together, into one dense fascia; and thus we may expect occasionally to meet with but two investing layers; one the superficial fascia ; another beneath it, deep, dense, and strong. Not unfrequently the deep layer splits at its lower part; and the fundus of the tumor, emerging through the aperture, may be covered only by the superficial fascia and integu- ment. There are two peculiarities in applying the taxis to this tumor. The position of the patient is as for the inguinal; but with the limb on the affected side bent much upwards, and at the same time carried across Plan of Femoral Hernia, a. The sac. b. The femoral vein. c. The artery, d. The abdominal ring. e. Section of the psoas and iliacus muscles. /. The acetabulum. (From Druitt.) FEMORAL HERNIA. 407 its fellow, so as to relax the crural Fis- 178- arch, on which, and not on Poupart's ligament, constriction depends. The pelvis, too, may be alternately raised and depressed (p. 395). Also, as already stated, the neck of the tumor must be unbent and straight, before reductive pressure is made on the fundus; in other words, the tumor is first pushed doAvn on the thigh, and then upwards into the abdomen. After reduction, a well-made truss is applied; the pad resting on the outside of and beneath the spine of the os pubis. Strangulation is both more com- mon and more severe than in the inguinal forms of hernia; and, con- sequently, operation is more fre- quently required. It is performed thus: The skin having been pinched up, is divided by transfixion, in order that there may be no risk of injury to the important parts be- Femoral Hernia, of unusually large size. [Fig. 179.] [Ordinary site and appearance of Femoral Hernia, with the direction for an oblique incision. (From Fergusson.)—Ed.] neath. The form of this integumental wound may be greatly varied; an inverted T; an inverted Y; aV; a simple oblique cut; or the investing textures are cautiously divided, by the forceps and knife, the latter held horizontally ; and the sac is ex- posed. In may cases, the opening of it cannot be avoided. And, this having been done, the forefinger of the left hand is passed up to the neck of the tumor. Here, as in the oblique inguinal hernia, there may be two strictures, a superficial and a deep. The former is considerably anterior to the ligament of Gimbernat, and inde- 408 FEMORAL HERNIA. Fig. 180. Portion of Bowel, not including its whole caliber, which was caught and strangled at the crural aperture; the symptoms, though modified, proving fatal. During life, no tumor could be discovered at the site of protrusion. (Liston. His Elements, p. 536.) pendent of it; formed by the inner and anterior part of the crescentic portion of the crural arch; felt tight, on the inside of the tumor's neck, while the finger's point is yet at some distance from the actual brim of the pelvis. This resistance is divided by a probe-pointed bistoury, slid flatly along the finger, and afterwards having its edge directed up- wards and inwards. Dilatation is then made by the finger; and, on withdraw- ing this, reduction may be effected readily. If not, then the finger is rein- troduced; and, pushing it upwards, Gim- bernat's ligament is felt tight and re- sisting, on a higher level than the former site of constriction. It is divided in a similar way, the bistoury's point being barely insinuated within the pelvis; the least movement of its blade suffices; a notch in the edge of the ligament is enough; the finger, following, dilates. Were the deep incision to be made di- rectly upwards, Poupart's ligament would be divided—an unnecessary act, that texture being unconnected with the constriction; and, besides, the spermatic cord in the male, and the round ligament in the female, would be endangered. If the obturator artery arise by a common trunk with the epigastric, it is likely to encircle the neck of the sac within the pelvis. And were the bistoury, which divides the higher stricture, to be used rashly, without the guard of the finger, and with any part of its blade thrust over the brim of the pelvis, this vessel would, doubtless, run no slight risk of being wounded. But, with ordinary precaution, the forefinger preceding the knife, and merely the bulbous point of the latter within the pelvic brim, the vessel is safe, whatever be its distri- bution.1 In the extra-peritoneal operation, a smaller wound suffices than in the ordinary method. It is placed on the inside of the tumor, at its upper part; and by means of it, it may be in our power satisfactorily to relieve the stricture, without any interference with the hernial sac. Should this fail, and there be reason to suspect that the stricture is in the sac itself, it is necessary to enlarge the wound, disclosing the parts more thoroughly; and then we may attempt relief by scratching through the faulty external fibres, as in inguinal hernia (p. 400). Failing this, the sac is opened, and the operation completed in the usual way. The after treatment is as for the inguinal operation. It is in femoral hernia that we are most liable to be puzzled, as to the exact nature of the tumor. But the safe general rule, as formerly stated (p. 402), is—when in doubt, operate. 1 For greater safety, it has been proposed to use a knife wholly blunt in the edge. This, pressed upon the resisting tight fibres, may dilate or tear them, while the elastic artery escapes all injury. THE OTHER VARIETIES OF HERNIA. 409 Umbilical Hernia. This is common in infants ; and in women who have borne many chil- dren, it is not unfrequent. In the former it very readily occurs; the exertion of crying forcing the bowel or omentum outAvards, through the yet unconsolidated umbilicus ; forming a soft, impulsive tumor; at first of small size, not larger than a button—commonly called " a starting of the navel." In women, unless congenital, it is seldom a true umbilical hernia; protrusion having taken place near, not through, the navel__ in consequence of a yielding of the abdominal parietes there, probably during parturition. Strangulation is comparatively unfrequent. In the adult, the tumor may attain to an enormous size. In the child, treatment is both simple and effective. The exciting causes—especially crying—are averted, as much as possible. And com- pression is made by means of a conical pad—such as a piece of cork, covered with wadding or soft leather—which is made to occupy the space usually filled by the protrusion, and is retained in its place by strips of adhesive plaster ; the integument is closed over it in a fold; and the whole may be secured by a large circular piece of soap-plaster spread on leather. This simple contrivance is more effectual than any truss or belt, being much less likely to slip ; and it has the equally im- portant advantage of not acting as an excitant of protrusion elsewhere. Or the pad may be secured in its place by means of a belt of elastic material. In the course of a year or two—it may be of months only__ the parts are found consolidated, and farther use of the compress is unnecessary. In the adult, the case is not so easily managed. The tumor is larger and less repressible. A corresponding compress is necessary, secured either by a belt or by the spring of a truss. Its use is merely palliative. When strangulation occurs, relief is obtained in the ordinary way ; by taxis, or by operation. The external wound need not be of large dimen- sions ; most frequently, the hernial contents are found to have no cover- ings but the integument and the sac; the deep incision for relief of constriction, made by a probe-pointed bistoury on the fore-finger, is placed in the mesial line, usually on the lower aspect of the swelling. The taxis is made directly backwards. The other varieties of Hernia. Ventral hernia is a protrusion at any part of the front and sides of the abdominal parietes except the navel and groins ; the result of a giving way at some unusual point, in consequence of bruise, wound abscess, or muscular rupture. There are no peculiarities in the tumor or its treatment; excepting that, as in most cases of the last-mentioned variety of hernia, but few fasciae need be expected to invest the sac. A Perineal hernia is said to exist, when bowel or omentum, with its' sac descends between the bladder and rectum, and presents itself as a swell- ing in the perineum. The term Vaginal is applied, when, in the female the tumor does not reach the perineum, but bulges into the vagina! 410 HERNIA LITRICA. Descent has also taken place through rupture at the fundus of the uterus.' The Diaphragmatic or Phrenic (p. 385), and the Ischiatic forms of hernia—protrusion through the diaphragm and the ischiatic notch—are fortunately rare. They do not admit of accurate diagnosis in life; and are not amenable to surgical treatment, if strangulated— unless the history of the case happen to be so unusually plain, as to warrant incision.2 The Obturatorial Hernia—projecting through the foramen ovale—may be both discovered and relieved. In one case a painful elastic tumor over the foramen ovale was reduced by the simple taxis, Avith complete relief to all the symptoms of strangulated hernia.3 The Hernia Litrica, as noticed by M. Littrd, is said to exist when the protruded viscus is a diverticulum of bowel, not a portion of the normal caliber of an intestine. Fig. 181. The diverticulum may be congeni- tal ; a mere prolongation of bowel, consisting of all the normal coats. Or it may be of recent occurrence, formed by a protrusion of the mu- cous membrane of the intestine through its muscular coat, and consisting of the mucous and peri- toneal coats alone. Both forms, the diverticulum acquisitum as well as the diverticulum congeni- tum, are liable to hernial protru- sion ; the former found only at the crural aperture, and always of slow formation (Fig. 180). This form of diverticulum being made at the expense of the main bowel, the caliber of the latter is narrowed thereby ; and the traction caused by hernial descent also changes the line of direction in the bowel, formino- a sharp angle at the origin of the diverticulum. Above the narrowed and some- what obstructed part, dilatation takes place ; and a train of unpleasant symptoms result, independently of strangulation—costiveness, colicky pains, dyspepsia, flatulency, &c. The congenital form of diverticulum, on the other hand, may protrude without causing any such inconveni- ence. Strangulation, occurring in either case, is marked by the ordi- nary symptoms, follows the ordinary course, and requires the ordinary treatment. But, probably, the symptoms will partake more sparingly of the signs of obstruction, than in ordinary cases, at least in the first instance.4 Diverticulum of the Intestine. Its protrusion con- stitutes the Hernia Litrica. Littre\ Memoires de 1'Academie des Sciences, Paris, 1700. Pott, Chirurgical AVorks, by Earle, vol. ii. Lond. 1808. Scarpa on Hernia, by AVishart, Edin. 1814. Cloquet, Recherches Anatomiques sur les Hernies de TAbdomen, Paris, 1817. Liston, Memoir on the Anatomy of Crural Hernia, Edin. 1819. Cooper, A., The Anatomy and Surgical Treatment of Abdominal Hernia, by C. A. Key, Lond. 1827. Kev. C. A., on the Advan- tages and Practicability of Dividing the Stricture in Strangulated liernia on the Outside 2 Guthrie, Lancet, No. 1483, p. 114. ' Lancet, No. 127G, p. 184. 3 Monthly Journal, March, 1847, p. 695. 4 See on this subject Brit, and Foreign Med. Rev. Oct. 1842, p. 360. HERNIA LITRICA. 411 of the Sac, Lond. 1833. Mayor, sur la Cure Radicale des Hernies, Paris, 1836. Law- rence, Treatise on Ruptures, Lond, 1838. O'Beirne on Defecation; also, on Strangulated Hernia, Dub. Journal of Med. Science, Sept. 1, 1838. Bransby Cooper, Guy's Hospital Reports, Oct. 1840. Reid on Diaphragmatic Hernia, Edin. Med. and Surg. Journal, 1840. Malgaigne, Lecons Cliniques sur les Hernies, &c., Paris, 18(1. Thierry, des Diverges Methodes Operatoires pour la Cure Radicale des Hernies, Paris, 1841. Luke, Med.-Chir. Trans, vol. xxvi. p. 159, Lond. 1843; also ibid. vol. xxxi. Teale on Hernia, Lond. 1846. Gay, on Femoral Rupture, &c. Lond. 1848. Hancock, Observations on the Operation for Strangulated Hernia, Lond. 1850. Hewett, Med.-CJiir. Trans, vol. xxvii. Hilton, Med.-Chir. Trans, vol. xxxi. p. 323. [On the Construction and Efficacy of Trusses in the Radical Treatment of Hernia, see the Reports of a Committee appointed by the Phila- delphia Medical Society, Am. Journal, vols. xvii. and xx.; also, a volume by Dr. Chase of this city. For a very good and condensed account of the various methods employed for the "Radical Cure of Inguinal Hernia," see Roylston Prize Essay for 1847, by Dr. Bryant, Boston, 1852; also Trans. Am. Med. Association, vol. v.—Ed.] CHAPTER XXIX. AFFECTIONS OF THE RECTUM. Abscess Exterior to the Rectum. Abscess in the areolar tissue exterior to the rectum is almost always of an acute character, and most frequently affects adolescents, or young adults of a weakly system. There are tAvo distinct varieties, according to the site. One is quite external in the nates, early pointing outwards, attended with no great constitutional disturbance, not tending to burrow backwards on the bowel, and generally getting well under the simplest treatment. The other originates in a comparatively deep locality, by the side of the bowel, perhaps nearly two inches from the orifice. Pain, in the latter case, is great, and the constitutional disturbance severe; evacuation of the bowels is seriously impeded, and when attempted suf- fering is greatly increased; at first, no fluctuation is to be perceived, but hardness is felt on firm pressure with the finger by the side of the anus, and also when the finger is passed Avithin the bowel; throbbing pain continues, the hardness enlarges, and ultimately a softening may be detected in its centre; matter forms rapidly and in quantity; it may gradually and painfully reach the surface; or, slow in its outward direc- tion, the gut may give way by ulceration, and by this internal aperture the pus may be imperfectly discharged. In treatment, our main object is to procure early and outward escape; attempts to prevent suppuration having previously failed. In the deep variety, the plunge of a bistoury, by the side of the bowel, so soon as softening has begun, is essential to preATent great constitutional disturb- ance and risk of the establishment of anal fistula. After evacuation, great attention to the general health will be required; inasmuch as with- out considerable improA'ement in the tone of system it will be found difficult to heal the wound, and equally difficult to prevent recurrence of the abscess. Not unfrequently a cachexy is met with, which baffles all remedial efforts—connected with phthisis of the lungs. In short, abscess exterior to the rectum is to be looked upon with suspicion, as regards both part and system—and treated accordingly. Redit is. The inflammatory process affects the rectum not unfrequently; of idiopathic origin; or caused by external injury, lodgement of foreign matter, or exposure to cold; or connected Avith an excited state of he- FISTULA IN ANO. 413 morrhoids; or an extension of inflammatory action from a contiguous part. In acute cases, the symptoms are very severe. The part is somewhat swollen, and most exquisitely painful; the sphincter acts spasmodically, and each movement of it aggravates pain to torture; intense burning heat is complained of; a scalding discharge passes away; or, in intense cases, the heat is at first dry as Avell as burning; the constitution suffers severely by fever. The urinary organs sympa- thize; there is painful micturition, and not unfrequently strangury or even actual retention occurs. The progress and results vary. ]Resolu- tion may take place, with copious mucous discharge—perhaps with he- morrhage. Or the discharge is purulent, coming from the mucous coat; and resolution is both slow and incomplete. Or ulceration may take place; superficial and broad, limited to the mucous lining; or circum- scribed and perforating, causing an aperture into the areolar tissue without, Avhere fresh abscess forms, and fistula results. Or, the action proving of a minor but persistent nature, plastic exudation takes place in all the coats, but more especially beneath the mucous; and simple organic stricture is established. Such being the risks of an advanced or obstinate inflammatory pro- cess in the rectum, treatment comes to be regarded as important; early and effectual, to anticipate evil. In the first instance, the cawse is to be ascertained—and, if possible, remoA'ed; foreign bodies, for example, will be taken away, and ascarides expelled. The recumbent posture is enjoined, and blood taken away by leeching. No purgatives are given, but gentle enemata, if necessary. To allay spasm, and to soothe the sympathetic irritation under which the urinary organs generally suffer, opium is useful; in ordinary doses by the mouth; and largely applied to the part, in the form of inunction, enema, or suppository. Fomenta- tion can scarcely be applied too hot or too sedulously. Fistula in Ano. By this is understood a fistula, or sinus (Principles, 3d Am. Ed. pp. 218, 220), by the side of the rectum; sometimes opening externally in the nates, but not communicating with the bowel, and then termed Blind External fistula; more frequently communicating with the bowel, but not yet opening externally, then termed Blind Internal fistula; usually having an Aperture of discharge both externally and into the boAvel, and then said to be Complete fistula. In the complete form—by far the most frequent—there is discharge of purulent matter by the fistulous track; flatus also escapes, and feculent matter. There is heat and much discomfort, often pain, increased by spasms of the sphincter; not unfrequently aggravations take place by recurrence of inflammatory action; and usually the general health is more or less undermined. Healing is prevented by at least three circumstances; the fistulous con- dition of the cavity and aperture—obviously unfavorable to contraction and consolidation; the frequent, almost constant, passage of foreign matters along the track; and frequent motion caused by the action of the levator and sphincter ani. The sinus may be monolocular or multi- locular ; that is, consisting of one simple track, or having more than 414 FISTULA IN ANO. one collateral sinus connected with the main and original one—the minor probably the resulfof intercurrent inflammatory attacks. The cavity may be wide within; more frequently it is narrow—of the nature of true fistula; it may extend high above the sphincter, more frequently its end is within two inches of it. The internal opening—to be found in the great majority of cases—is invariably within easy reach of the finger; usually about an inch and a half from the orifice; of various dimensions, sometimes so small as not to admit the end of a common probe, but seldom if ever so large as to allow the passing of a finger's point; its size, circular form, and general character, denoting its origin to have been by perforating ulceration of the bowel. Such perforating ulceration is the proximate cause of complete fistula; and it may come from without or from within. According to some au- thorities, the origin is always from within; rectitis produces perforation; through the aperture, feculent matter escapes into the areolar tissue Avithout; abscess forms there, which, only partially discharged by the internal and original opening, ultimately gains the surface, on the nates, and is thence mainly eAracuated. That such is the state of matters in many cases, there seems no reason to doubt. But it cannot be denied that not a few may and do follow a different course. Abscess begins in the external areolar tissue, idiopathic, or caused by injury, or following exposure to cold; it slowly advances outwards, at the same time bur- rowing by the side of the bowel. The matter may escape externally, while the bowel's coats are yet intact; constituting blind external fistula. Much more frequently, there is the internal opening too; of secondary formation, however, not primary—caused by pressure from without, and beginning in the peritoneal coat. And that this tunic is capable of taking the initiative in perforating ulcer, although less easily and more rarely than the mucous—even without so poAverful an exciting cause as the pressure of an abscess—cases are not wanting to prove.1 Very frequently, fistula in ano is coexistent Avith pulmonary phthisis; probably caused by it, and constituting but one of the symptoms and signs of that intractable malady. The frequent cough of the invalid, causing straining on the bowel, and the tendency to mucous ulceration in the great gut—so favorable to production of the initiatory perfor- ation—readily explain hoAV the anal and pulmonary affections should not unfrequently be in close connection. The history of fistula is not complete till careful examination has been made, by means of the probe and finger. The latter having been introduced into the bowel, the probe—with a broad and bulky termina- tion to its handle, which renders it more obedient to the hand, and enables it to indicate Avith certainty the direction of the point when curved—is passed gently into the track, or tracks, so as to ascertain their number, position, and extent; but most especially to ascertain the exact position of the internal aperture—that is, on what aspect of the boAvel it has formed, for, as already stated, it is as to height almost ahvays close to the sphincter. In order to facilitate the entrance and movements of the probe, it is sometimes necessary to dilate the external 1 London and Edinburgh Monthly Journal, January 1844, p. 40. FISTULA IN ANO. 415 opening in the first instance. When there is no outward opening, the case being an example of the blind internal variety, there are usually plain enough indications of the site of the abscess—hardness, discolor- ation, pointing, &c. ; and a plunge of a lancet or bistoury will at once change the case into the complete form. Or a probe, bent very much, may be introduced from the rectum into the internal opening ; and by pushing the handle on the opposite nates, its points may be made to project on the affected side, and being felt there may be cut upon. The treatment of fistula is simple—and, if the disease be merely local, usually quite effectual. The main obstacles to healing are the fistulous condition of the track, and the frequent motion by muscular action. By laying open the track, and at the same time dividing the sphincter, both are overcome. The patient is made to stoop over a bed or table, with the limbs unbent and somewhat apart; if anesthesia be employed, he is recumbent Avith the legs raised. An assistant sepa- rates the nates to the full. The surgeon, seated, inserts the probe, taking especial care to lodge its extremity in the bowel through the ulcerated internal opening. The probe may be grooved, so as to admit of a curved, strong, probe-pointed bistoury being passed along it; or, the probe having been withdrawn, its place is occupied by the bistoury— used at first merely as a probe. The point is then met in the boAvel by the fore-finger of the other hand—right or left, according to circum- stances, for here ambidexterity is essential—and with the point pressing firmly on the finger, and with the edge moved in a gently sawing motion, both hands are brought doAvn toAvards the operator, causing division of all that is within the concavity of the instrument. When this is of considerable thickness, or of almost cartilaginous density—as not un- frequently is the case—a particularly stout and *Well-tempered blade must be selected for the service, lest it give way. It is unnecessary, Fig. 182. Plan of the operation of Fistula in Ano, the finger and bistoury met in the rectum previously to division. however, to divide any great extent of parts, for the following reasons: There is almost always an internal opening; this is invariably situate almost immediately within the sphincter ; it is essential to make the line 416 FISTULA IN ANO. of division pass through this aperture; but that having been done, there is in no case any necessity for passing the knife higher, however exten- sive the fistula may be. It is by no means uncommon to find the track passing higher than the internal opening ; yet in these cases the ordi- nary operation is all that is necessary ; the knife entering at the ulcer- ated opening, and no higher. One obvious advantage of this is, the avoidance of danger from loss of blood. A high wound might implicate arterial branches of considerable importance. In the approved opera- tion, only small branches will spring; they are seen at the time of di- vision, and can readily be secured by ligature, if need be—as, however, very seldom is the case. Should any superficial sinus exist, burrowing beneath the integuments, it should be laid freely open. In the external form, in progress of formation by abscess originating in the areolar tissue, it has been proposed to evacuate the abscess, and then at once to complete the operation for fistula; hoping thus to save time and pain. It is better to evacuate, and delay; permitting the abscess to contract, and to degenerate into the condition of fistula; then operating for the cure of fistula. The wound is less painful and less extensive; and the result is at least equally satisfactory. Similar caution is advisable in cases of old standing, in which abscess has repeatedly formed around the anus with burrowing ; it is well to evacu- ate and drain by opening and counter-opening, waiting till the suppu- rated space has contracted, and when much less extenshTe incision will consequently be required. In the blind external form—that is, when we have searched carefully [Fig. 183.] [Fig. 184.] [Fig. 183.—Anal Speculum, made of thick glass, Fig. 18-1.—Another Instrument, made of similar silvered and blackened on the outside; closed at materials; a part of the closed extremity cut off the upper end, with an aperture just below for the obliquely, to allow of inspection and topical appli- examination of the gut, and for local applications. cations being made. (From Fergusson).—Ed.] for the internal opening, and found none—which will seldom be the case—the bistoury, having been passed to the usual site of opening, FISSURE OF THE ANUS. 417 has the edge of its point inclined towards the finger introduced within the bowel; by a gentle rubbing motion perforation is effected ; and then the operation is completed in the usual Avay. The use of the anal speculum may assist in detecting the internal opening. And when this is found, the speculum may be retained as an auxiliary in the operation ; the parts yielding much more readily to the knife when put upon the stretch, than they are by lodgement of the open instrument. Immediately after withdrawing the knife, bleeding is attended to. If an artery spring, it is tied ; if there is oozing, at all formidable, pressure is applied by stuffing the wound moderately with lint. Usually, there is no necessity for any hemostatic ; and it is enough to interpose a small portion of lint, or other dressing, between the lips of the wound, so as to prevent premature closure of the superficial part; our object plainly being, that the whole track shall inflame, granulate, and heal from the bottom. No cramming is necessary; slight dressing is sufficient. Before operation, the bowels have been well cleared out by a purga- tive, aided by an enema if necessary. After the operation, a full opiate is given ; to lull the pain, and at the same time, to prevent movement of the bowels—this not being contemplated for a day or tAvo. At the end of the third or fourth day, a dose of castor-oil, or other simple and bland aperient, is given ; and this, operating, brings away the contents of the rectum, including the dressing of the wound. Afterwards, it is enough to regulate the bowels; to make sure, by examination from time to time, that the wound is not closing prematurely, and that superficial sinuses are not forming; to attend to cleanliness; to apply water-dress- ing, by means of lint and oiled silk—retaining the dressing by a T bandage ; afterwards medicating this dressing by ordinary stimulants, as the state of the granulating surface may require. For obvious rea- sons, a close regard is paid to the system throughout. If fistula in ano coexist, with evident and advanced pulmonary phthisis, a question arises as to the propriety of operation. It may safely be answered in the negative. For, first, the operation will fail in its local effect; the wound, in all probability, will not heal. And secondly, supposing that it did heal, the result Avould probably be most injurious on the system ; the pulmonary disease advancing with fresh virulence on the closing up of an outlet, whence purulent and other products had long been habitually discharged ; in like manner, as the temporarily and locally successful amputation of a strumous joint, may have the effect of greatly shortening the phthisical patient's term of existence (Principles, 3d Am. Ed. p. 496). Fissure and Ulcer of the Anus. Fissures of the anus are extremely troublesome. They are most common in the adult; but no age is exempt; they have been observed in children at the breast. A chap or crack, analogous to what is ob- served on the lip, forms on the verge of the anus, in the mucous coat of the bowel; and is the seat of much pain, often of intense agony, more especially when the bowels are moved ; then, too, spasm of the 27 418 FISSURE OF THE ANUS. sphincter adds greatly to discomfort. Sometimes, indeed, the muscle is found to be in a state of almost perpetual spasm; simulating most of the signs of stricture of the bowel; and the existence of the fissure may be obscured, in consequence of the obstacle which such spasm affords to ocular examination. In looking for fissure, the nates are forcibly separated by an assistant, and downward traction is made upon the anus with the fingers of the surgeon, the patient meanwhile strain- ing steadily as if at stool. Sometimes the assistance of a speculum may even be required. Almost invariably, this affection is found connected with previous disorder of the primae viae—perhaps a long-continued dyspepsia. And, in treatment, this circumstance has an important bearing. For, no local management can be expected to prove fully successful, unless the cause be taken away ; that is, in most cases, the noxious matter lodging in the bowels must be removed, and the functions of the mucous lining must also be amended. In such cases, a cautious dose of calomel will probably be found the most suitable prescription at first ; followed up, according to circumstances, by gentle aperients and alteratives. The part may be touched freely with nitrate of silver, or with the fluid nitrate of mercury ; and relief of pain may be obtained by belladonna ointment, or by chloroform made into the form of ointment, or by hot poultices medicated strongly with opium in solution. Very frequently, however, such local treatment is resisted; and then a simple and slight operation is required. By means of the forefinger and a probe-pointed bistoury an incision is made through the mucous coat, including the fissure. And thus, the irritable sore is at once converted into a simple Avound, which first inflames, and then heals in the usual manner. But, should this fail—as will not often be the case—the knife has again to be used ; pressing it more deeply, the sphincter ani is divided; and the part, thus set at rest, quickly heals. Or, by subcutaneous puncture from without, the muscle may be divided, without interfering with the mucous membrane. To recapitulate ; in all cases, great and primary care of the stomach and bowels is necessary ; with this, some fissures heal under ordinary local treatment suitable to irritable sores ; others require simple incision; and others, more obstinate, demand in addition division of the sphincter. Ulcers of the mucous membrane of the anus are liable to assume the irritable character, and then are productive of the same distressful symptoms as fissure. They require, and are subject to, similar treat- ment. Situated more internally, they are not ordinarily visible, even on the most careful examination. The finger, cautiously introduced, may detect them by the peculiar feel which the ulcerated part conveys to the examiner, and by the great increase to the patient's suffering which is invariably produced by the finger's resting upon that part of the bowel. By means of the speculum their exact circumstances may be accurately surveyed. In those cases which evince no great irri- tability, tannin is often a most serviceable local application, in the form of ointment or suppository. Immediately in front of the coccyx, that is, at the back part of the anus, a broad and deep ulcer, capable of receiving the finger's point, HEMORRHOIDS. 419 is not unfrequently obsenred. For this, exposure by the speculum and the application of nitric acid, or nitrate of mercury, are usually necessary. Hemorrhoids. Hemorrhoids, or Piles, are divided into two kinds; external and internal. They seldom occur before puberty, and arc perhaps more common in females than in males; certainly more troublesome to the higher than to the lower ranks of life. The predisposing causes are whatever tends to determine blood to the rectum, and to retard the return of blood from it ; habitual constipation, pregnancy, abdominal tumors of any kind, torpor of the liver, sedentary avocations Avith luxurious living. And the exciting causes are whatever acts on the bowel itself excitingly, as purging, bilious diarrhoea, exposure to cold and Avet, &c. External piles are of but one structure; a congeries of varicose veins, surrounded by hypertrophied areolar tissue, and covered partly by mucous membrane, partly by loose rugous integument. They may be undergoing the inflammatory process, or they may be indolent and quiet. At one or more points, ulceration may have exposed their inte- rior, and they bleed; or they may be blind, as the phrase is, emitting no blood. The varicose veins may have their normal fluid contents; or these, coagulated, may have caused condensation of the tumor, more or less complete. The tumor may be single; usually, more than one exists. Treatment is either palliative or radical. The latter consists in removing the morbid formation, by scissors or bistoury, leaving the sore which remains to heal in the ordinary way. Palliation varies according to circumstances. If the part be inflaming, rest and the ordinary antiphlogistics are necessary. If it be in the indolent state, stimulants and astringents—iodine, galls, tannin, hellebore—are ap- plied, with the view of puckering up the loose integument, obtaining discussion of the solid abnormal textures, and restoring the normal con- dition of the veins. The bowels are carefully regulated; and, for this purpose, sulphur is the favorite medicine, usually combined, in the form of electuary, with pepper confection ; and sometimes, too, a proportion of copaiba is a good addition, dosed so as to avoid overaction, while it insures a daily and sufficient passage of a semifluid stool. By some, linseed oil, taken internally, is preferred as a soothing and safe laxa- tive.1 If any dyspeptic, or other disorder of the primae vise exist, that must be removed as speedily and thoroughly as possible. Very often the liver is to blame, and requires special treatment. Not unfrequently, a small, recent, tense pile presents itself, acutely inflamed, and exquisitely painful. A simple proceeding not only affords present relief, but also may affect radical cure. With a lancet or bistoury it is to be laid freely open, throughout its entire extent; the coagulated 1 Brit, and For. Rev. Oct. 1850, p. 5G3. 420 HEMORRHOIDS. blood rolls out, a salutary loss of fluid blood takes place, and in subse- quent healing of the Avound consolidation is effected. Internal piles are of different kinds: 1. They maybe of similar structure with the external; varicose veins, surrounded by hypertrophied areolar tissue, and covered by mucous membrane more or less altered; open or blind ; inflaming or indolent. 2. They may be genuine tumors, of the nature of simple sarcoma, more or less pendulous in their form. 3. They more frequently are of the nature of erectile tissue, this abnor- mal development having taken place in the submucous areolar tissue, as well as in the membrane itself. The tumor usually presents a broad base of attachment, and sometimes the surface resembles that of the strawberry. Internal piles are most commonly of the last variety. If large and numerous, they may constantly protrude more or less from the anus, general relaxation of the mucous membrane of the rectum admitting of this. More frequently, they do not show themselves externally, except when the bowels are moved, and then the straining causes them to descend. If not replaced, they may become constricted by the sphincter and inflame. At each stool, it is common for blood to be lost, small arterial jets.taking place from one or more points of the tumor, more especially if constricted. Usually, the patient gets into the habit of replacing the prolapsed tumors, after each evacuation ; and, during the intervals, he may sustain no great inconvenience in the part. If the loss of blood, however, be habitual, even though but a small quantity escape at each time, the system is certain to give way under it, the patient becoming thin, weak, pale or sallow, dyspeptic, annoyed with tinnitus aurium, giddiness, and palpitations (Principles, 3d Am. Ed. p. 357). If the tumors are bulky, and often protruded, they are always in a more or less excited state; there are pain, swelling, heat, and dis- comfort, discharge of mucous and puriform fluid, and these, superadded to the effects of loss of blood, speedily undermine the frame. In extreme cases, the Avhole bowel is relaxed, and prolapsus ani accompanies and untowardly complicates the hemorrhoidal state. At any time, the in- flammatory process may extend from the abnormal structure, and seize the bowel, producing rectitis, probably of an aggravated form. Thence abscess and fistula may result, or, under a minor degree of action, sim- ple organic stricture may form. The urinary organs sympathize greatly during rectal excitement connected with piles, whether these be external or internal. To allow such an affection to follow its own course, is thus seen to be dangerous to both part and system. Treatment is general and local, palliative and radical. The general treatment is to be pursued in all cases; regulating the bowels, looking to the liver, attending to regimen. Hemorrhage may be restrained by the internal exhibition of gallic acid, oil of turpentine, or other suitable astringent. If palliation only be intended, the local treatment will consist of careful reduction, after each evacuation of the bowel, and the occasional injection of some astringent fluid; such as solutions of rhatany, zinc, sulphate of iron, matico, oak- bark, or tannin; or the last-named remedy may be very conveniently and efficiently applied in the form of suppository. If excitement occur, HEMORRHOIDS. 421 then come antiphlogistics, anodynes, and attention to the bladder. The radical treatment consists of removal by ligature. In the case of the solid genuine tumor, the knife may be used with impunity. But such formations constitute a small minority of internal piles. The over- whelming majority are vascular; and the great number of these consist of erectile tissue. To cut them out, were on each occasion to endanger life by hemorrhage; not only because the parts are vascular in them- selves; but also because the interior of the rectum is favorable for continued oozing of blood, and ill adapted for the application of pressure or other direct hemostatics. Consequently, deligation is preferred. The operation by ligature is thus accomplished. The patient having had the bowels freely open, is placed as for the treatment of fistula. By previous straining at stool—renewed at the time of operation, if necessary—the tumors are made to protrude to the full; an assistant separating the nates. If the form be at all pendulous, it is well to seize the fundus by means of a large volsella, and over this to apply a strong ligature, drawn very tightly around the neck of attachment. But if the base be broad, and the form of the swelling irregular, it is necessary to transfix the base by means of a stout needle; and, by ty- ing separately the hahTes of the ligature, so to effect strangulation. Before tightening the second half of the knot, it is advisable to incise the livid fundus, permitting its fluid contents to escape; for then the noose can be tightened more thoroughly ; and the tighter the constric- tion, the more rapid and less painful is the cure (Principles, 3d Am. Ed. p. 262 and 561). Deligation having been completed, the ends of the ligature are cut off close to each noose ; and, by gentle manipulation the strangled parts are replaced within the sphincter. If an external hemorrhoid, or loose fold of skin be found, it is removed by the sweep of a knife or scissors; and if an arterial tAvig of any importance spring, it is at once secured by ligature.1 A full dose of morphia is given, to lull pain and prevent motion of the bowels. The bladder is Avatched; and if strangury or threatened retention occur, warm fomentation is to be sedulously applied to the hypogastrium, along with the internal ad- ministration of henbane and SAveet spirits of nitre, in small and repeated doses. By medicated poulticing, the pain in the anus may be somewhat assuaged. In a day or two, the sphacelated parts separate; and the remaining sore is treated as its circumstances may demand. Fetor is subdued by the chlorides. After cicatrization, nightly use of the tannin suppository is sometimes advisable, to promote and insure complete re- storation of the normal caliber and tone of the bowel. [The late Dr. Horner, of this city, introduced a modification of the ordinary operation for piles, to which he was very partial, and by which he supposed that much of the pain and all the danger from hemorrhage, 1 This removal of loose skin is of great consequence, and should never be omitted ; otherwise the anus remains lax, and predisposes to farther hemorrhoidal formation. Usually, there is a packet of rugous skin connected with each internal hemorrhoid ; and the one is a very useful index of the other. Some surgeons think it sufficient to take away this outer defect, believing that the tight cicatrix will prevent reprotrusion, and that then the hemorrhoidally degenerated part will recover itself. But according to my experience, removal of both piles and skin is essential to a complete and permanent cure. 422 HEMORRHOIDS. which sometimes attends the operation of the ligature, are obviated. It consists in'drawing down the pile and making an incision around that portion of its base Avhich is next the anus, so that the integument at the verge of the latter, just exterior to the mucous membrane, is divided. A wire ligature, looped through a canula, is then applied around the base of the tumor, and drawn sufficiently tight to strangulate it, which it does the more readily and with less pain, in consequence of the pre- liminary incision through the thickened and sensitive integument. (Am. Journal, vol. iv. N. S. 1842.) The Avire and canula are more commonly used in this city than the thread or silk ligature, and it is generally loosened and removed after twenty-four hours.—Ed.] As formerly stated (Principles, 3d Am. Ed. p. 732), anaesthesia may be used, without detriment to the facility or efficiency of the operation. And a subsequent minor use of chloroform is often of much service in assuaging the after pain. In the slighter cases, nitric acid has of late been employed with advantage; when the tumors are small, recent, and composed of altered mucous membrane—investing slightly varicose veins, or perhaps only hypertrophied areolar tissue—the disease being mainly resident in the membrane itself. The parts, having been make to protrude, are rubbed over with strong nitric acid, so as to produce an eschar; and are then replaced within the sphincter, a3 in the case of deligation—carbonate of soda being freely applied so as to prevent unnecessary action of the escharotic. The eschar separates, removing the altered membrane; the sthenic suppurative action, which attends on cicatrization, would seem to act restoratively on the textures around ; and the tightness of the cica- trix, Avhen completed, may by its support prevent recurrence of varix beneath. By the potassa fusa, too, hemorrhoids may be very efficiently destroyed; the neighboring parts being carefully protected by use of vinegar. Patients of greatly deranged livers are subject to general fulness in the lining membrane of the rectum, perhaps with one or more internal hemorrhoids, accompanied by a febrile state of system. In such eases, we are not to operate in any way, until the liver has been restored to a healthy or at least quiet state, and the general excitement has been calmed—otherwise the result might be serious, by aggravation of the internal and constitutional disorder. In elderly, full-living patients, also, affected with disease of the heart, or shoAving a tendency to affection of the head, bleeding piles are not to be rashly interfered with ; else the sudden cessation of discharge, and subsequent plethora, may entail the most calamitous results. The ope- ration, if had recourse to at all, is not performed till after due prepara- tion of the system. And the after treatment is conducted with much care and caution. Similar precaution is requisite in the case of females, from whom blood escapes in large quantity and periodically, because vicarious. Such bleeding, however, is not always connected with piles. It may proceed from the lining membrane of the bowel, little if at all changed. In advanced cases of bleeding piles, it is sometimes difficult to deter- PROLAPSUS ANI. 423 mine whether the bruit, palpitation, and other signs of diseased heart are primary or secondary, dependent on an organic cause, or merely on anaemia. Diagnosis in this respect, requires much caution ; and when in doubt, we may lean to the side of .operation, ready with leeches, seton, or other compensating treatment, should troublesome conse- quences threaten. Polypus of the Rectum. Simple polypi are occasionally, yet seldom, found in the rectum : most commonly in children; and then may be mistaken for prolapsus. In the adult, the fundus may become hard, rough, and ulcerated, and prove troublesome by bleeding. There is frequent desire to go to stool, with discharge, uneasiness, and occasionally pain and SAvelling. At each evacuation, the growth is apt to be protruded, and usually requires replacement. Treatment is removal, by knife or ligature. Obviously, the preferable method is by deligation ; but, after the ligature has been secured on the neck of attachment, the main body may be safely cut away, in order to prevent tension and expedite the cure. Prolapsus Ani. In consequence of relaxation, the rectum may become everted, on straining, and protrude beyond the anus; and the protrusion may be either constant or occasional. Also, it may be either partial or corn- Fig. 185. Prolapsus Ani. plete; that is, the protrusion may consist of the entire bowel—or. as is by some supposed, of rather the sigmoid flexure of the colon; or it may be merely a descent of the mucous coat alone—a frequent con- comitant, as has already been observed, of internal hemorrhoids. This partial prolapsus may occur at any age; and is probably most common in 424 PROLAPSUS ANI. the middle-aged; but the complete form is an affection almost peculiar to the two extremes of life ; old age and childhood. The child is liable to irritation of the bowel, by ascarides, or by a perverted secretion from the general mucous coat; and the habitual straining, which results, tends to the change in question. In the old man, too, there is much strain- ing ; by reason of enlarged prostate, or debility of the muscular coat of the bladder. In the child there is much crying ; in the old man much coughing. Stone and stricture may induce prolapsus at any age. The tumor varies in size, from a mere annular border to the anus— as in the partial prolapsus—to a swelling as large as a child's head. The membrane, if habitually down and exposed, changes more and more to the cuticular character ; much discharge takes place, of a reddish jelly-looking substance; inflammatory aggravations are liable to occur, causing much increase of distress; and, at any time, the existence of descent is accompanied with painful uneasiness in the part, and an op- pressive general languor and debility—at least in the adult. In the child, the affection may generally be removed by riddance of its cause. At the same time, care is taken to replace the protrusion after each descent; the bowels are duly regulated, and evacuation should always be made in the recumbent posture; crying should be avoided as much as possible; astringents may be used both outwardly and within—that is in the form of lotion, ointment, injection, or sup- pository ; and iron or other tonics are usually indicated, on account of laxity of the general system. If protrusion have been neglected, and have attained a large size, some difficulty may be experienced in effect- ing replacement. Pressure is applied, as in the taxis for hernia; the parts having been previously lubricated. And it is well to make the reducing pressure chiefly during the straining or crying efforts of the patient, the verge of the anus then presenting a fixed point on which the reduction may be made. If the protruded part be found constricted, inflaming, and swollen, it is better not at once to attempt reduction; but, in the first instance, to diminish the bulk and inordinate action, by leech- ing, rest, and ordinary antiphlogistic means. In the adult, there is the same necessity for removal of the cause, if possible; but cure seldom follows so simply. The same attention to replacement is to be enforced ; and a pad may be worn, directly compressing the anus, so as to oppose reprotrusion. This pad—slightly conical in form, so as to fit into the anus—may be applied by means of the common T bandage; or, what is better, is adapted to a spring, as in the truss for hernia. Astringents are used, the bowels are regu- lated; and amendment, if not cure, is hoped for. It may be well, perhaps, to procure the daily stool at night; so that afterwards the long recumbency of bedtime may prove favorable in obviating the tend- ency to protrusion, which is greatest after functional excitement of the part. Such is the palliative treatment. For a radical cure, other measures are required. One or more of the redundant folds of the mucous mem- brane may be removed, by knife or ligature; in the hope that the contraction of healing may sustain the replaced parts in their normal relation. But it is better, in most cases, while leaving the bowel STRICTURE OF THE RECTUM. 425 intact, to take away the redundant integument externally; hoping that the subsequently puckered cicatrix may effectually support the parts within, and prevent farther protrusion. This removal of skin may be by knife or scissors, or by actual cautery. The latter agent is perhaps unnecessarily severe; but, whichever is employed, the imme- diate pain may be safely abrogated by the use of chloroform. These means failing, another operation has been proposed ; an abbreviation of the sphincter. By incision, a portion of this muscle is removed; and then the remainder having been brought together, and got to adhere, is expected to constitute a more active and effectual guardian of the mucous outlet. The success of this proceeding, hoAvever, has yet to be proved. And, in any such operation, especial care must be taken lest the task be overdone; and an unnatural tightness of the orifice result. In the adult, accurate diagnosis is always important. Many a patient, during a long course of years, wears a painful truss for what is supposed to be prolapsus, but what is in truth mere looseness of the anal verge, with internal hemorrhoids—remediable, as we have seen, by a very simple operation. Stricture of the Rectum. Contractions here, as in other mucous canals, are of three kinds : spasmodic, organic and simple, malignant. The Spasmodic does not frequently constitute a disease of itself; but is rather an accompaniment of some other affection—as hemorrhoids, fissure, or ulcer of the anus. Its main symptoms are, painful tightness of the part, with difficulty and pain in voiding the feces. The site of constriction is at the orifice of the bowel; and the immediate cause is spasmodic action of the sphincter muscle. If it be but an attendant of another disease, removal of the latter will ordinarily suffice for cure. In the few cases of its single occurrence, treatment consists in rectifying the primae vise, which will invariably be found more-or less deranged; and in the occasional use of a short bougie, of metal or caoutchouc, passed just within the sphincter, and retained for a few minutes on each occasion. An obsti- nate case may render division of the sphincter expedient; and in such circumstances the subcutaneous operation will probably be preferred. Belladonna may be used in the form of ointment. Simple organic stricture is the result of a chronic Rectitis, as already stated. The constriction depends partly on condensation and thicken- ing of the entire coats of the bowel; but mainly on deposit in the sub- mucous areolar tissue. The ordinary site is about two inches from the orifice; and it is seldom indeed that this form of stricture is found beyond reach of the finger. The leading symptom is difficulty in defecation, with slimy discharge; the feces passing in a flattened and attenuated form, like tape, Avhen solid, and when fluid being liable to forcible ejection as if from a syringe. Derangement of the digestive organs, with impairment of the general health, is induced ; the abdomen becomes swollen, perhaps tympanitic; and the urinary organs are sym- pathetically involved. Above the stricture, dilatation takes place ; and 426 STRICTURE OF THE RECTUM. there ulceration is apt to occur in the mucous membrane; greatly aggravating the distressful symptoms, perhaps inducing fistula—and, in the aged, not unlikely to degenerate into malignancy. From the obstructed state of the bowels, enteritic symptoms are not unlikely to arise; but, independently of sudden or casual aggravations, life is ultimately endangered by advancing emaciation and general disorder. Fig. 186. Rectum opened laterally; showing stricture of the bowel at the ordinary site. Treatment consists in maintaining a gently open state of the bowels, mitigating the painful symptoms in the part and neighborhood by suit- able remedies, and gradually obtaining dilatation of the bowel at the contracted part, by a cautious use of bougies; not failing to remember that the cure is not by mechanical dilatation, nor by inflammation, but by gradual absorption of the submucous abnormal deposit. The best form of this instrument is that made of elastic material, pliable, smooth, yet dense enough to resist circular compression. Having been intro- duced gently, it is retained so long as the feelings of the patient per- mit ; and it is well that the lower part of 'the instrument should always be narrow, so as not to distend the sphincter and cause irritation. Or the bougie may be so formed as to lodge wholly Avithin the bowel; an attached ligature or tape protruding, whereby it may be extracted. The portion of the instrument Avhich is intended to pass and lodge in the stricture is gradually increased in size, until a full-sized bougie can be used without difficulty. Then dilatation may be deemed complete; yet, to insure against relapse, an instrument should be passed occasion- ally for some time afterwards. Sometimes a tight callous stricture is found to resist the ordinary treatment. Then the knife's edge may be used with advantage; the surgeon slightly notching the contracted ring at many points, by means of a probe-pointed bistoury introduced on the finger; and afterwards proceeding with dilatation in the ordinary way. Spasm of the anus may simulate organic stricture ; and many of its symptoms also attend on enlargement of the prostate. Consequently, an accurate diagnosis can never be attained without careful examination. IRRITABLE RECTUM. 427 By the frequent and forcible dejection of fluids, diarrhoea may be simu- lated ; and a very erroneous treatment, by astringents, might be en- forced, were examination of the part neglected. In most cases, the stricture is within reach of the finger; and in such there is no difficulty, the finger's exploration removing all doubt. Sometimes, hoAvever, the contraction is higher in the bowel; and then great caution is necessary in employing the exploratory bougie; for a fold of mucous membrane, or the natural promontory of the sacrum, in a healthy bowel, may ob- struct the point of the instrument for a time, more especially if this be rashly and unskilfully introduced. By disreputable empirics, indeed, such obstruction is made use of as a means of deceiving healthy patients into a belief of the existence of stricture. Malignant stricture, or scirrho-contracted rectum is, by no means, uncommon in the aged, and more especially in the female; supervening, usually, on some pre-existing affection of a simple kind, as piles, or simple stricture. The symptoms are such as attend ordinary contrac- tion, with the addition of copious, bloody, fetid, puriform discharge; greater sympathy of the urinary organs; greater difficulty and pain in defecation; and the ordinary constitutional cachexy which attends and characterizes malignant disease. When the verge of the anus only is affected, the diseased parts may be removed by the knife. But if the disease extend some way up the bowel, as it usually does, we must con- tent ourselves with palliation; assisting defecation by enemata and laxatives ; and lulling pain by opiates, applied to both part and system. Death may take place by exhaustion ; but, more frequently, the patient perishes under symptoms of ileus, the malignant deposit having ad- vanced so as to cause complete occlusion of the bowel. Under such circumstances, the only hope of postponing death is by the formation of an artificial opening in the abdomen, for feculent evacuation; a very doubtful proceeding, as will afterAvards be stated. Medullary tumor sometimes forms between the bladder and rectum, causing great distress ; interfering first with the functions of the rectum, and then with those of the bladder also. The treatment can only be palliatiA'e. Irritable Rectum. The lower bowel is liable to become the seat of irritation, unconnected with any structural change; causing pain, heat, itching, frequent desire to go to stool, spasm of the sphincter, and sympathy of the urinary organs. The source of irritation may be within the bowel itself, asca- rides. Or it may be contiguous; stricture in the urethra, or stone in the bladder. Or it may be remote, yet continuous; a depraved state of the mucous membrane of the stomach or upper bowels. Treatment is obviously to be begun by removal of the cause, if possible. After- wards, opium, hydrocyanic acid, or other calmatives, may be applied directly to the part, by means of injection, suppository, or inunction. [Mr. Curling (Treatise on Diseases of the Rectum) recommends highly the local application of chloroform mixed with simple ointment, as a local anaesthetic in all the painful affections of the rectum. The 428 HEMORRHAGE FROM THE RECTUM. ointment which he advises contains 3J-3ij chloroform; %ss oxide of zinc; 5j olive oil, and 3iv lard.—Ed.] Itching of the Anus, an obstinate and distressing complaint—an irritation exterior to the bowel—is often the source of intense suffering to the patient. Generally, it is connected with a depraved state of the mucous membrane of the bowel; and removal of this, by the suitable alteratives—as tar, copaiba, arsenic, &c.—may suffice for cure. Some- times it attends on piles or fissure; and is removed along with these ailments. Sometimes it is connected with a thickened and chapped state of the skin external to the anus; and in these cases, as well as in those where no local cause is apparent, applications to the part are essential. Of these the most successful are hydrocyanic acid, tobacco infusion, and camphor powder. The last may be used alone, or in combination with starch, and preceded by the application of a calomel ointment, 3i~5i to the ounce. [Dr. Physick pointed out, as a cause of the itching, and other symp- toms of irritable anus, the transverse folds of the mucous membrane of the rectum, which act as pouches or sacs to catch and retain portions of fecal or other matters, in their progress along the bowel. These matters produce more or less nervous and vascular disturbance at the part, and even ulceration. These pouches were supposed by Dr. Hor- ner to be normal and constant, giATing trouble, however, only occasion- ally. Their existence may be easily determined by bending a probe, so as to form a hook, oiling it, introducing it into the rectum, and then partially withdrawing it; in this manner the whole circumference of the canal should be examined, and if any of the pouches should be thickened and distended, the end of the probe will catch in them. The operation recommended and frequently performed by Dr. Physick, consists in drawing down the offending pouches with a bent probe, and slitting them with knife or scissors. Subsequently, injections of cold water, or astringent solutions should be employed; and a proper condi- tion of the bowels should be maintained. We must say, that we have seen these pouches slit open by the late Dr. Randolph, at the Pennsylvania Hospital, in cases of obstinate and severe itching of the anus, without the slightest benefit.—Ed.] Hemorrhage from the Rectum. Bleeding from the lower bowel is usually an indication of piles, as has been seen ; of the internal, vascular pile, more especially; and is almost always arterial. In females, however, it not unfrequently is found independent of prominent alteration in the bowel; oozing from the lining membrane, merely congested ; and then usually periodic and vicarious. Or it is frequent and exhausting, proceeding from a small vascular eminence on some part of the membrane, discernible only by the use of the speculum. The treatment is obvious ; according to the cause. Hemorrhoids are to be tied. The uterine function is to be restored, and the general frame amended. The vascular point is to be cauterized; and astringents are at the same time given internally—the FOREIGN MATTER IN THE RECTUM. 429 best, perhaps, gallic acid. The tannin suppository may be used locally. In some way, the drain must be arrested (Principles, 3d Am. Ed. p. 357). Injuries of the Rectum. The anus is liable to wound and bruise, as other parts. The former may be formidable by hemorrhage; the latter by inflammatory action, leading to deep-seated abscess. Treatment is accordingly. A danger- ous form of injury used to occur in hospitals, Avhen the old-fashioned metallic syringe for giA'ing enemata was recklessly used by ill-qualified administrators. The instrument's point pushed rudely upwards, in a straight direction, is likely to lacerate the bowel. It may perforate ; and then the injection, perhaps stimulant and acrid, finds its Avay into the areolar tissue, causing extensive abscess, and sloughing, with violent constitutional disturbance. In such cases, the remedy is to make a free and early incision into the infiltrated parts. But the modern ene- ma-syringe, intrusted only to trustworthy hands, is not likely to lead to any such casualty. Feces and Foreign Bodies in the Rectum. In the elderly of both sexes, but especially in the female, with whom irregularity of the bowels is more habitual, the feces may accumulate within the sphincter, forming a tumor of large size, and occupying not only the whole rectum, but also a portion of the sigmoid flexure. The symptoms are most distressing ; painful fulness in the part, bearing down, frequent desire to go to stool, thin and scanty fluid passed, the bladder irritable, sleep disturbed, the stomach .disordered, and more or less fever induced. Without examination, the affection may be mistaken for diarrhoea or dysentery; with an insufficient examination, the internal swelling may be supposed to be a malignant tumor. In cases of doubt the finger's nail will bring away a sufficiency to test the nature of the concretion. In the milder cases, repeated injections of oil, followed by cathartic enemata, may suffice to clear the bowel. In the more con- firmed examples, it is necessary to introduce the finger or fingers, with a lithotomy scoop, so as to break down the mass ; afterwards clearing all away by injection. And two or more such operations may be neces- sary, at different times; as the higher accumulations may descend only after removal of those which occupied the lower bowel. Afterwards it is obviously of much importance to secure regular movement of the bowels; with a view to avoid reaccumulation. Foreign substances may lodge in the lower bowel; causing inflamma- tion, abscess, and ulceration there, if not removed timeously. They may be pushed upwards from without, by accident, or by malicious de- sign. Or they may be arrested by the sphincter in their progress down- ward, having entered by the mouth ; as fish-bones, bones of poultry or other small animals, kernels of fruit, &c. Or they may have formed within the alimentary canal, intestinal concretions. The smaller sub- stances are readily removed by finger and forceps. Large bodies require 430 IMPERFORATE ANUS. previous dilatation and lubrication of the bowel; and an exploratory use of the speculum may be useful. In extreme cases of impaction, it may be necessary to divide the sphincter. In the case of rough or sharp substances, whose forcible extraction in the ordinary way might seriously injure the bowel, a speculum is first carefully introduced past the for- eign body, so as to sheathe and protect the mucous membrane. Imperforate Anus. Children are occasionally born with the anus closed. There are three kinds of this malformation. 1. The rectum may be fully de- veloped, and have its orifice shut by integumentary membrane only; or the canal may be obstructed by a membranous septum, at some dis- tance from the orifice—which latter may appear in all respects normal. 2. Or the bowel is imperfect; ending in a blind cul-de-sac, at some distance from the integument of the perineum, in Avhich there is a mere depression or vestige marking where the anus ought to be. 3. Or the rectum is almost or altogether deficient; the sigmoid flexure of the colon terminating in a cul-de-sac, at the upper part of the pelvis. The first form is easily managed. An incision is made through the occluding membrane ; and for some days a piece of dressing is inter- posed, to prevent union. But often this precaution will be unnecessary; the passage of meconium and feces sufficing to keep the aperture patent. The second variety is more common, and more troublesome. Some thickness of parts intervenes between the operator and the bowel. And at first the latter may be felt but obscurely, if at all; there being none of the bulging fluctuation Avhich must soon be apparent in the former case. Under such circumstances, we wait until the meconium accumu- lates, and till the bowel in consequence descends and is distended. It may then afford some indication of its presence to the finger from with- out. To assist, let firm pressure be made in the left hypogastric region; and such pressure should also be maintained during the operation for relief. The cries of the child are of sen-ice. He is placed on the knee of a nurse or assistant, in a position as if for lithotomy. By means of a scalpel, an incision is made through the integument; and, by cautious dissection, the bulging cul-de-sac is sought for ; the finger always preceding the point of the knife ; the line of exploration folloAV- ing the natural curve of the bowel, in the hollow of the sacrum, lest the bladder or vagina should be Avounded—not keeping too close upon the bone, lest the bowel be overpassed, and be mistaken for the bladder —and not diverging to either side, lest the pelvic bloodvessels sustain injury. The cul-de-sac having been reached, is opened freely; the meconium escapes; and the wound is to be kept pervious by the careful and patient use of tents—or, Avhat is perhaps better, by the constant wearing, for some time, of a tube such as is used after lithotomy. After even deep dissection, avc may fail to meet the end of the bowel. Then it is quite warrantable to pass a trocar and canula upwards, cau- tiously, in the direction in which the boAvel ought to be ; and, on with- drawing the trocar, we may have the satisfaction of seeing meconium follow. FORMATION OF AN ARTIFICIAL ANUS. 431 Sometimes the deficient rectum opens into the vagina or bladder; constituting a cloaca ; irremediable. Of the existence of the third variety we are made aAvare, when, after waiting for days, not eA'en the slightest indication of bulging or fulness can be detected in the perineum. A perineal Avound and exploration may be made ; but Avith scarcely a hope of success. And, failing in this, we have either to abandon the patient to its fate, or proceed to the establishment of an artificial anus. The Formation of an Artificial Anus. The question of artificially establishing an outlet for the contents of the intestinal canal, elsewhere than in the normal site, comes to be entertained, when the rectum is congenitally deficient, and, also, when it has become in any way insuperably obstructed, by simple stricture, or by carcinomatous and extensive degeneration, or by the impaction of an intestinal concretion, or of some foreign substance from without. In the case of the child, probably the operation will seldom be deemed expedient; for when such a grave malformation exists—as entire defi- ciency of the bowel—others usually accompany it, rendering the via- bility of the patient, under any circumstances, very questionable. It were better to leave such to perish, by the original obstruction of the bowels, than to force on them a more miserable and scarcely less brief period of existence. In the case of malignant disease of the rectum, also, practitioners may well hesitate, before having recourse to a difficult and serious operation, for the purpose of attempting but partial and temporary relief, in an affection which must at no distant period end fatally. In such a case, it would seem to be warrantable only under the following circumstances ; when the general strength is not yet greatly exhausted by malignant cachexy; when the obstruction in the bowel is complete, and plainly insuperable by any direct treatment; when the patient—having had the danger of the operation, and the almost disgusting result of its success, plainly exhibited—himself decides on its performance, and is prepared to abide both the nuisance and the risk. On the other hand, when the rectum is imperviously obstructed by the impaction of foreign matter from within or from with- out, or by disease not malignant nor necessarily and speedily fatal, and when such obstruction is otherwise insuperable—the expediency of the operation may be safely urged upon the patient. The sigmoid flexure of the colon is plainly the part of the intestinal canal to be reached; and it may be sought, either from before or from behind. The former method, first proposed by M. Littre, is of easy performance; being merely a direct incision upon the part through the abdominal parietes and peritoneum, above the left groin. The opera- tion, however, though most simple, is hazardous to life; and, if success- ful, the anus is inconveniently situated, in one respect, the patient being the victim of discomfort to himself as well as the source of annoyance to those around him. The site has its advantages, however, too. The operation is easy, and its steps certain; the anus, after a time, gets to possess something of a sphinctral poAver, from the muscular parietes ; 432 FORMATION OF AN ARTIFICIAL ANUS. and the offensive escape of its contents may be guarded against by wearing a well-fitted truss, the manipulation of which is easily within reach of the patient. The posterior operation, proposed by Callisen, and greatly improved by Amussat, is performed thus: its object being to open the bowel on its posterior part, where it is uncovered by peritoneum, and which bare space may be expected to be considerable Avhen the bowel is much dis- tended by its contents. The patient is laid recumbent, with the trunk bent somewhat to the right side; and with a pillow also placed beneath the abdomen, so as to make the left loin prominent. A transverse in- cision is made, about four inches long in the adult, midway between the last false rib and the crest of the ilium; and, if any considerable obesity exist, the posterior part of the wound is crossed by a second incision, parallel to the range of the spinous processes. The different layers of fat, fascia, and muscle are carefully divided in succession, on the out- side of the border of the sacro-lumbalis and longissimus dorsi; and portions of fat, coming much in the way, may require to be removed altogether. Intestine having been exposed, some doubt may be felt as to its being the colon*or not; the bulging viscus at the bottom of the deep wound may be colon, or small intestine, or kidney. From the last, manipulation and percussion will readily enough distinguish intestine. And the great gut maybe distinguished from the small, by attention to the folloAving circumstances: the colon has its muscular fibres of greater development; the small intestines sustain a motion of alternate ascent and descent, communicated by the diaphragm, and corresponding to expiration and inspiration, while the colon is stationary, being fixed to the loins by areolar tissue; also, if two portions of bowel present them- selves, that may naturally be expected to be the colon which is on the outer or spinal aspect, at the external border of the quadratus lumbo- rum. Having become satisfied that the colon is exposed at the bottom of the wound, it is transfixed by a needle and ligature, at two points, above and below, so that it may not slip from its present relation to the wound, after an opening has been made and the contents haATe begun to escape. The bowel, stretched by the two ligatures drawn outwards, is divided freely between. Air and fluid contents at once pass outwards; but it may be necessary, by means of the finger, scoop, or forceps, to assist in extrusion of the solid matters. The margins of the opening in the boAvel are then secured by ligature to the external wound, so that, by adhesion there, a permanent, safe, and efficient aperture may be constituted for fecal escape. The advantages of this operation, in contrast with that of Littre', are, the peritoneum is uninjured, fecal escape is not so directly in the way of sight, and touch, and smell; there is less risk of prolapsus of the bowel, and control of evacuation is more complete ; indeed, a complete sphincter seems to form in the loins, rendering the occasional exhibition of aperients necessary. The objections are, this neAv sphincter is apt to exceed its office, rendering dilatation or fresh incision requisite to maintain patency of the opening; and the site is not readily Avithin reach of the patient, for managing the pad Avhich requires to be worn carefully adjusted. Great cleanliness must be at all times observed. FORMATION OF AN ARTIFICIAL ANUS. 433 [In an able paper, published in the thirty-fifth volume of the Medico- Chir. Transactions, entitled, " Case of Stricture of the Colon success- fully treated by Operation, with an Analysis of Forty-four Cases of Artificial Anus," Mr. Caesar H. HaAvkins points out many facts of in- terest concerning the formation of an artificial anus, and deduces from his analysis many inferences which could hardly have been suspected a priori. Of the forty-four cases, twenty-one died within the first five Aveeks, so that only twenty-three are considered to haAre recovered from the operation. Of the latter, hoAvever, one is rejected, the operation having been done for the cure of fistulae in ano. Of the twenty-two recoveries, five died within six months; at the end of a year, eight were either alive or left uncertain; nine only survived for about one year or upwards; one lived seventeen years. As to the circumstances affecting the success of the operation, sex seems to have little influence. Of forty-three patients, whose ages are giAren, eight were between twenty and thirty years old, of whom five died ; four between thirty and forty, of whom one died; eleven between forty and fifty, of whom four died; ten between fifty and sixty, of whom seven died; seven between sixty and seventy, of whom two died; two reported as adult, of whom one died; one reported as aged, who died. Exactly half the patients, twenty-one, whose ages are recorded, were, therefore, from forty to sixty years old, of whom eleven died ; while, from twenty to forty, there were twelve cases with six deaths. It seems, then, that, according to these tables, age does not exercise any special influence upon the result of the operation. The nature of the disease for which the operation was practised, is thus stated : fifteen cases of stricture of the rectum and sigmoid flexure of colon, supposed non-cancerous ; three, stricture of ascending or trans- verse colon, supposed non-cancerous ; one, twist of upper part of ascend- ing colon; one, adhesion of rectum to uterus from inflammation; one, strangulation of ileum by a band ; one, fistulae in ano ; one, adhesion of ileum and rectum to cancerous uterus; seventeen cases of scirrhous rectum and sigmoid flexure of colon; one case of cancer of sigmoid flexure of colon, or of omentum; one, stricture of caecum, with scirrhus of its coats from injury; two cases unknown; in all forty-four cases. Thus, of forty- two known cases, nineteen were cancerous ; of these, sixteen had died at the date of this report; ten, hoAvever, recovered from the operation, and one lived rather more than two years after it. Of the twenty-one cases which did not recover from the operation, ten were cancerous. Yet it is not a little surprising that of the nine patients who alone lived for a year, three were cancerous. Mr. Hawkins remarks, in this connection, that " the more rapidly fatal cases of cancer of the intestinal canal are of the softer kind, in which obstruction is less likely to take place; and that the disease of the inner surface, frequently epithelial cancer, so often seen in the rectum, is less injurious to the general system than the softer carcinomatous affection of the intestinal canal." And again : " It appears, therefore, from the table, that an artificial anus, if required for cancer in the rectum or sigmoid flexure, affords nearly, though not 28 434 FORMATION OF AN ARTIFICIAL ANUS. quite, as much chance of immediate success, and of subsequent pro- longation of life, as when performed for all other obstructions not malignant." (P. 109.) Mr. Hawkins doubts the frequency of cancerous stricture above the first five or six inches from the anus; according to his clinical and autopsical experience, " obstructions of the first five or six inches from the anus have been most frequently cancerous, or contracted cicatrices of ulcers; but almost all strictures above this height, which could fairly be said to be in the sigmoid flexure, so as to be scarcely if at all felt by the finger, have been firm, hard thickenings of all the coats of the bowels, generally of an annular shape, without evidence of carcinoma, even when more than one generation has been affected, as I have seen in three instances." The causes of death in the tabulated cases were various. " Of the twenty-one operated on unsuccessfully, there are but two in which peri- tonitis is stated to have followed the operation without having been excited by the previous disease; and there is scarcely one in which the death of the patient is directly assigned to the operation; and I am inclined to believe," says Mr. Hawkins, "that the histories of the cases fairly justify the operators in attributing the fatal result to the previous effects of the disease itself on the constitution of the patients, or to the physical changes in the boAvel. Hence we derive a strong argument for as early a performance of the operation as will be Avarranted by the immediate danger to life, either from the disease or from the operation, and by a fair estimate of the probable condition of the patient after recovery." (P. 111.) Yet the tables show one successful operation after thirty days' obstruction, and three after forty to fifty days' constipation; while others died after operation performed as early as the ninth or tenth day; thus showing that the urgency and frequency of preArious attacks, and the severity of present symptoms, are more important ele- ments in determining upon the operation than the mere duration of the obstruction. Of the operations, tAvelve involved the peritoneum, twenty-six were posterior to this membrane; of the former, seven were unsuccessful; of the latter, only ten.- The right colon and caecum were opened through the peritoneum in four cases, all of which died; and an artificial anus was made in the right colon behind the peritoneum in six cases, of which tAvo died and four recovered; one of the latter living so long as three years. The left colon had been opened through the peritoneum in eight cases, of which three died and five recovered; and of twenty cases of lumbar operation on the left colon, nine died and eleven recovered. From the tables, Mr. HaAvkins concludes that each operator, weighing the advantages and disadvantages of an artificial anus in front of the abdomen, and of one in the lumbar region, is, as yet, fairly justified in selecting whichever situation he thinks best on the left side of the body.—Ed.] Copeland on the Principal Diseases of the Rectum and Anus, Lond. 1814. Howship, Practical Observations, &c. Lond. 1820. Ribes, Recherches sur la Situation de 1'Orifice FORMATION OF AN ARTIFICIAL ANUS. 435 Interne de la Fistule a l'Anus, &c. Revue Medicale, livr. i. p. 174, Paris, 1820. Calvert, Practical Treatise on Hemorrhoids, &c. Lond. 1824. Boyer, de la Fissure de l'Anus, &c. Paris, 1823. Bushe on the Malformations, Injuries, and Diseases of the Rectum and Anus, New York, 1827. Syme on Diseases of the Rectum, Edin. 1828. Salmon on Pro- lapsus of the Rectum, Lond. 1831. Dupuytren, Lecons Orales, Paris, 1831. Amussat, Memoire sur la Possibilite d'Etablir un Anus Artificiel dans la Region Lombaire, &c. Paris, 1832. Brodie on Diseases of the Rectum, Lond. Med. Gazette, vol. xv. p. 845, 1835 ; ibid. vol. xviii. 1836. Houston on the Treatment of Internal Hemorrhoids by Nitric Acid, Dub. Med. Journal, March, 1843. Curling on Diseases of the Rectum, Lond. 1852. Morand, Collection de Plusieurs Observations Singulieres des Corps Etrangers . . . dans le Fondement. Mem. de I'Acad. de Chirurg. vol. iii. p. (506. [Am. Cyclopedia of Medicine and Surgery, by Isaac Hays, M. D. Philad. ; article, " Anus."—El>.'] CHAPTER XXX. CALCULOUS DISEASE. Urinary Calculi. Healthy urine is a straw-colored or amber-colored fluid, retaining all its elements in solution, with the exception of an almost infinitesimal quantity of mucus, which may in most cases be seen to subside after an hour or two from the transparent fluid, forming a very slight cloud at the bottom of the vessel. In various states of disease, on the contrary, the solid matters contained in the urine are apt to be precipitated, either in consequence of simple increase in their quantity relatively to the fluids, or from more complicated changes in the constitution of the secretion. Such solid precipitates, especially if composed of saline or crystalline matters, may give rise to distressing symptoms by causing in the urinary passages the formation of gravel, and of stone or calculus; the first term being applied to the finely granular form of deposit, the last two to solid concretions of more considerable size. A stone, once formed, has always a tendency to increase in size by new accretions of foreign matter upon its surface ; and in consequence calculi, when they have acquired sufficient size to be detained within the bladder or kidney, generally give rise to symptoms of increasing severity, and may, sooner or later, require surgical interference for their removal. Hence the study of urinary deposits is important in a surgical point of view; al- though the constitutional conditions which lead to them fall, for the most part, within the province of the physician, like the other derange- ments of the urinary secretion. These conditions are commonly called diatheses, and may be detected either by the occasional presence of gravelly deposit in the urine, or by such changes in its chemical con- stitution, as are known to give a tendency to precipitation. The ex- istence of any abnormal irritation in the urinary organs, should there- fore in all cases lead to an examination of the urine, and particularly to careful observation of its sediments, if present, with a view to ascer- taining and correcting any calculous tendency. Here, as in all other cases, prevention is better than cure. The means necessary for the examination of urine in relation to surgical disease, are—a good microscope with a magnifying power of at least 200 diameters, a urinometer for testing specific gravity, test- tubes, test-papers, and a few simple chemicals which will be mentioned immediately. By the conjoint employment of the microscope and of chemical analysis, after the manner so fully described of late years by CHARACTERS OF THE URINE. 437 Dr. Golding Bird and others, it is now within the power of every prac- titioner to detect even the earliest traces of calculous tendency; and no one can now be excused for overlooking derangements of the urine, which a few years ago would inevitably haAre been allowed to proceed unchecked, until they ended in calculous formation, or at least in the minor evil of gravel. The normal urinary secretion usually yields, as above mentioned, a slight hazy cloud of mucous sediment, Avhich forms its only precipitate in the state of absolute health. This cloud of mucus presents under the microscope only a very feAv rounded bodies, resembling closely the cells found in pus, and occasionally traces of epithelium-cells from the bladder or some other part of the passages. Often, however, these are absent, or nearly so, and the sediment is altogether impalpable ; occa- sionally, on the other hand, the so-called mucous corpuscles are increased in number, and the mucous cloud which contains them is increased in bulk and opacity. This is the first grade of mucous irritation, and is often found in connection with A'arious kinds of saline deposit. Under a farther progress of this condition the urine may become highly im- pregnated with mucus and epithelium ; or the mucous cloud may be supplanted by a distinct deposit of pus. To the test-paper, healthy urine presents a tolerably distinct acid reaction ; this may be feeble, or the urine may even be occasionally neutral, without the presence of any serious derangement; but any degree of persistent alkalinity must be regarded as distinctly abnormal, and requires correction by treatment, unless in the case of its having been induced by medicine or accidental dietetic conditions, which some- times render the urine temporarily alkaline. According to Dr. Bence Jones, the acidity of the urine undergoes constant changes in amount in healthy persons, according to the condition of digestion ; being inva- riably greatest immediately before meals, and falling to its minimum a few hours after breakfast and dinner; appearing, therefore, to stand in an inverse relation to the acidity of the stomach. The source of the acid reaction of urine is not known with certainty; it is supposed to be owing not to any free acid, but to the presence of some salt, such as the acid phosphate of soda. The specific gravity of the urine, and the proportion of solid matter contained in it, are likewise subject to considerable variation at different periods. After a meal and towards the close of digestion, the density of the urine (which has been called in these circumstances urina chyli) becomes greatest, and may exceed 1030, as tested by the urinometer. After drinking largely, on the other hand (urina potus), it may be re- duced almost to the density of water; Avhile the urine passed in the morning {urina sanguinis), independently of the influence of food or drink, has usually a specific gravity of from 1015 to 102.">. The abso- lute quantity of urine passed in twenty-four hours varies, as might be expected, with the amount of drink ; and has an inverse relation to the specific gravity, which is commonly high in proportion as the urine is scanty. About a quart (forty ounces) of urine may be assumed as an average quantity for an adult. 438 LITHIC OR URIC DEPOSIT. The principal sediments occurring in the urine and tending to the formation of calculi are as follows:— 1. Deposits of free uric acid, or urates of ammonia, lime, magnesia, and soda (Lithi-uria); 2. Deposits of oxalate of liine (Oxal-uria); 3. Earthy phosphatic deposits, consisting of phosphoric acid, with lime, magnesia, and ammonia (Phosphuria); 4. Deposits of a peculiar organic crystalline matter, termed cystin (Cystinuria); 5. Deposits of another organic principle, scarcely crystalline, the uric oxide or xanthic oxide of Marcet (Xanthi-uria). Fibrine, carbonate of lime, and silica have also been mentioned as ingredients of calculi; but the deposition of these substances from the urine is extremely rare, and does not appear to have been the result of any peculiar morbid diathesis or tendency, the know- ledge of which can be of any important use to the practitioner. The Lithic or Uric Deposit.—This consists either of the uric acid, or of the urates, tinged with coloring matter ; and varies accordingly: 1. The most common is amorphous ; consisting chiefly of the urate of am- monia, more or less colored; of a yellow hue, when mixed with the coloring matter of the urine ; reddish, like brick-dust, when combined with the purpurate of ammonia; and when this latter ingredient is in much abundance, the sediment is of a pink color. Such urine is un- usually acid, when tested; is of high density; and has a small relative proportion of aqueous matter. When passed, it is clear ; but, on cooling, the sediment is deposited more or less abundantly. 2. The crystalline; consisting of uric acid, variously tinged by admixture of coloring matter; usually of a reddish hue—the crystals resembling particles of cayenne pepper ; and constituting the most ordinary form of gravel or red sand. Examined under the microscope the amphorous deposit, or brick-dust sediment, appears either in the form of exceedingly minute molecules, sometimes aggregated together, sometimes dis- Fig. 187. persed over the field; or in that of larger globular masses, semi-opaque, brownish in color, and sometimes either grouped together or armed with projecting spiculae like stalac- tites. The last form is unusual, and has been considered by some observers as urate of soda. The crystalline deposit of uric acid assumes generally the form of rhombic prisms, but ap- pears in various modifications of this primary type ; the most usual is that in which the rhom- boids or lozenges are very thick and rounded urate of Ammonia under the mi- at tne angles, so as to resemble, when placed cr.lScope. upon their sides, thick cylinders, for which they may readily be mistaken, especially if grouped together in masses, as frequently occurs. The uric acid crystals are generally colored, and have, under the microscope, a peculiar deep amber tint, which is highly characteristic. All the deposits of either free or combined uric acid are highly solu- ble in caustic potash; in soda, they are less so. The urate of ammonia, which forms the principal part of the amorphous deposit, is tolerably soluble in water at the temperature of the body; and hence is seldom THE LITHIC DEPOSIT. 439 Fig. 188. deposited except on cooling of the urine after excretion. In some cases, however, especially when the urine contains an excess of acid, the urate of ammonia is deposited within the bladder. The uric acid deposit, on the contrary, which is thrown down by the addition of almost any acid to urine holding urate of ammonia in solution, is soluble only to a very slight extent in water, even with the aid of heat; and hence is a comparatively frequent deposit in the urine on emission, although much less common than the amorphous sediment as a result of cooling. Both deposits are decomposed by strong nitric acid with the aid of heat, and leave on evaporation a beautiful lake-colored residue, which be- comes purple in tint by the addition of ammonia (purpurate of ammonia, murex- ide). Urine containing these sediments is usually rather high-colored, of good or excessive specific gravity, highly acid, and often scanty. Not unfrequently the amor- phous deposit is not the result of any de- rangement of the system, but merely arises from deficiency of drink or abundant per- spiration. This is never the case with the uric acid or crystalline sediment. Uric deposits may attend the slightest derangement of health, or the most seri- ous; they denote a sthenic state of system, more frequently than the opposite condi- tion. A trifling disorder of digestion, as by casual error in diet, may cause a toler- ably copious sediment; the progress of hectic, and the decline of inflammatory feArer, are accompanied by plentiful deposit of red poAvder—termed lateritious, from its resemblance to brick-dust. The gouty diathesis is marked by uric deposit. Habitual indulgence in much animal food, with deficiency of exercise, and neglect to maintain a clean and efficient state of the skin, will not fail to establish it. It is obviously connected with climate—at least with locality; the inhabitants of certain places suffering much more than others. It is also connected with age ; prevailing most in childhood, and between the ages of forty and sixty. It is hereditary. It may follow injury of the kidney or its neighborhood; congestion being produced in the secreting organ. It would seem to depend proximately, either on an excess of uric acid being generated in the system—by decay of the effete organism, or by mal-digestion of food; or on the presence of a free acid—the muriatic, acetic, or lactic—Avhich, combining with the base, frees the uric acid and so leads to its precipitation. Or the causes Crystals of Uric Aciil. 440 THE LITHIC DIATHESIS. may be stated in another way, as by Dr. G. Bird: 1. Waste of tissues more rapid than the supply; as in fever, rheumatism, &c. 2. Supply of nitrogen in the food, greater than is required for the reparation of tissues; as by excessive indulgence in animal food, and by too little exercise. 3. Digestion insufficient to assimilate an ordinary and normal supply of food; as in dyspepsia. 4. Obstruction to the cutaneous out- let for nitrogenized excretion; by skin diseases, or other cause. 6. Congestion of the kidneys; following injury of the organs, or disease Avherein they are affected by sympathy. Plainly, the treatment must vary according to the cause. In the fevers already mentioned, the deposit ceases as the constitutional symp- toms subside. In other cases, the treatment may be said to be twofold. By the exhibition of alkalies, with which the uric acid combines, soluble salts are formed, while at the same time—mainly perhaps by the vehicle in which the alkali is given—the aqueous portion of the urine is increased. And by attention to regimen, exercise, and the skin—going more deeply into the matter—we seek to rectify the depraved state of the digestive organs, on which the evil in the great majority of cases primarily depends. Both methods are of service, but the latter is obviously the more important; they are usually combined. Magnesia, soda, and potass may be given. The first may accumulate in the intestines; and on this account is seldom prescribed, at least for any length of time. The phosphate of soda is both safe and useful. The carbonate is grateful, and quite efficient. But potass is usually preferred; its urate being more soluble than that of soda. The bicarbonate is usually given, in half-drachm doses, largely diluted; and it may be pleasantly combined with a few grains of citric acid. The best period for administration, probably, is about two hours after the principal meals—when alkalies are most wanted to neutralize the free acid of indigestion; and Avhen at the same time diges- tion is so far advanced as to render it unlikely that this process shall be interfered with by the alkali. There are also the borate, citrate, and tartrate of potass—all available. Simple though the alkaline remedies seem, let them never be per- severed with carelessly. Their over-sustained use may convert the sthenic state of system into the asthenic, inducing serious constitutional disorder, and causing an ammoniacal and phosphatic state of the urine. The test-paper must be used from time to time, and the state of the system must be carefully attended to. In those cases in which digestion is obviously weak and imperfect, preparations of iron are useful; the citrate, in solution, may be given in moderate doses after each meal. Regimen is carefully attended to; food being regulated as to both quantity and quality. Nothing at all approaching to a surfeit should ever be indulged in ; animal food should be taken sparingly, if at all; vegetables and farinaceous articles may be freely used, provided acidity be not produced ; malt liquors should be abstained from; and wine, if taken at all, must be used with great moderation. The bowels require laxatives or alteratives. In most cases, a mercurial purge is a good beginning of the treatment; and, if the sthenic constitutional symptoms amount to a febrile character, cup-' ping may be also practised on the loins. The skin must be attended to; THE LITHIC DIATHESIS. 441 by ablution, warm clothing, friction, and exercise; and if any eruption exist, means must be taken to remedy that. Occasionally, gentle diu- retics would seem to be of service. Colchicum, it is avcII known, is a powerful eliminator of uric acid; and hence, probably, the main reason of its success in gout and rheumatism. When congestion of the kidnev is suspected, the treatment is by cupping, rest, and antiphlogistic reo-i- men. The term "gravel" is ordinarily applied to the passing of the uric acid deposit. It begins severely, and is liable to aggravations ; and these periods of intensity are termed "fits of the gravel"—characterized by pain in the lumbar region, shooting down towards the groin, with pain and retraction of the testicle; frequent micturition, hot and scalding ; uneasy sensations in the thighs, very frequently; more or less febrile disturbance; and always plain indications of great derangement of the digestive organs. It is in such cases that purging, antiphlogistic regimen, and sometimes local bloodletting, form so excellent a com- mencement to the remedial means. The ordinary treatment may be reduced to the following indications: 1. To diminish the uric formation ; by moderate antiphlogistics ; regu- lation of diet and exercise ; and attention to the skin. 2. To increase the solvent power of the urine ; by diluents, given cold—yet not so as to discourage perspiration; and by gentle diuretics, if necessary. 3. To increase the solubility of the deposit; by preventing or neutralizing the free acid, which, spoliatiA-e of the urate's base, causes precipitation of the uric acid ; and by presenting an alkali as a soluble base to the uric acid. 4. The fourth indication is one of no slight importance—to favor extrusion of the gravel; by diuretics and diluents; by Avarm bathing; and by exercise. And in regard to this, it is well to remem- ber that the particles of uric gravel are especially prone to ao-ore- gation. The Oxalate of Lime Deposit.—The occurrence of oxalate of lime in the urine as a source of calculus has been long known ; but the fre- quency of this deposit was much underrated, until the careful researches of Dr. Golding Bird, who first investigated the form of its microscopic crystallization, and the symptoms connected with its occurrence in the early stages. It constitutes a species of very minute crystalline gravel Avhich readily escapes observation by the naked eye, in consequence of the perfect transparency and absence of color in the crystals. On careful observation, however, they may often be seen as minute glisten- ing points floating in the urine, which usually contains a slight excess of mucus, but is often nearly or absolutely clear. The crystals are probably precipitated within the organism in most instances ; they may, however, be absent from the urine on emission, and be found in great abundance twenty-four hours afterwards. The mode in which they are retained in solution is not known, as the oxalate of lime is exceedingly insoluble in Avater. With the exception of a rather high specific gravity, which is usual, there is nothing very characteristic in the appearance of urine contain- ing oxalate of lime. The amount of urea is generally large; often, also, uric acid and its salts are in excess, and sometimes they form de- 442 THE OXALIC DIATHESIS. Oxalate of Lime under the microscope. posits which coexist or alternate with those of the oxalate. The earthy phosphates are likewise usually in excess in oxaluria, but are held in solution in consequence of the acidity of the secretion. The color of the urine varies from a pale straw-color to an amber tint, the latter being perhaps more common and characteristic. The urine in this dis- ease generally, as already mentioned, deposits an excess of mucus; and along with this there are sometimes found minute quantities of seminal fluid, as indicated by the presence of spermatozoa under the microscope. The most usual form of the oxalate of lime as seen under the micro- scope is that of octohedral crystals, generally not more than yg^^ or jo'ou °f an incn in diameter, and often much less than this ; always perfectly transparent, colorless, and exceedingly sharp and well defined in their angles. Occasionally, the crystals are " made up of a square prism, with a four-sided pyramid at each end, forming a dodecahedron." Another form much more rare, and possibly not composed simply of ox- alate of lime, is that of dumb-bell shaped or oval crystals, often resem- bling "two kidneys with their con- cavities opposed," and possessing a beautiful radiating structure in some cases, while in others they appear homogeneous. _ The crystals are insoluble in alkalies or in vegetable acids ; soluble in muriatic and nitric acid ; and on being subjected to a red heat are decomposed, leaving carbonate of lime, which dissolves Avith effervescence on the addition of acids. In regard to the patholo- gical or physiological origin of oxalate of lime in the economy, many speculations exist; but none of them are sufficiently precise or well founded to claim attention in a practical work. It is very probable that this deposit has some relation to the decomposition of the tissues, and is formed at the expense of urea or uric acid. The attendant constitutional symptoms are occasionally slight; com- monly, however, they are sufficiently characteristic and distressing to require attention and treatment. The patient is languid, weak, and thin; often remarkably depressed in spirits; usually pale, sometimes of a greenish hue in the face—more especially about the eyes and mouth; pustular formations on the skin are common; and so are scaly eruptions; the slightest exertion induces great fatigue; the temper is irritable ; the mind broods over the ailment, and desponds of recovery: dyspepsia is present—troublesome, by flatulence and palpitation, more especially after taking food; aching pain is complained of across the loins ; and the sexual power is usually much impaired. Sometimes the symptoms of phthisis are simulated; sometimes those of heart disease. Not unfrequently, water is made with unusual frequency, and with heat and smarting. The ordinary causes of this affection are, over-exertion of mind or body, excess of venereal indulgence, habitual and gross errors of diet, exposure to cold, injuries done to the lower part of the spine. The THE PHOSPHATIC DEPOSIT. 443 oxalic acid would seem to be the product of faulty assimilation; and it readily meets with its base. According to some, the acid may be introduced from without; it being supposed to be one of those substances which are capable of passing unchanged from the stomach to the kidneys. According to this vieAv, the taking of rhubarb, sorrel, tomata, &c. as articles of food, along with the use of hard Avater as drink, may be deemed very favorable for the establishment of the oxalate of lime deposit. The treatment resembles that for the phosphatic diathesis. The general functions are looked to ; but more especially those of the stomach and skin. Diet is light and nourishing. Malt liquor is forbidden ; and a sparing allowance of brandy and Avater, Avith meals, is found prefer- able to wine. Sugar is abstained from. Warm clothing must be wTorn; and by friction, exercise, and warm bathing, the pores are to be kept free. All sources of exhaustion, and all kinds of depletion are to be avoided. Medicinally, the mineral acids are found of much service ; especially the nitro-muriatic, exhibited in some bitter infusion. And, of the tonics, zinc and iron are to be preferred ; the sulphate of zinc more especially. Colchicum, too, may be found useful. It is well to remember that, in treatment, the oxalic often changes into the uric di- athesis ; indeed, it is probable that these two morbid states readily pass into each other—it costing the urea, as it were, but little effort to change into either the uric or the oxalic acids. When, under treatment, the uric deposit is observed to succeed the oxalic, the use of the acids must be abstained from, at least for a time. The Phosphatic Deposit.—Normal urine contains a considerable pro- portion of phosphoric acid, the greater part of which is in combination with alkaline bases, and forms salts which are highly soluble. The phosphates of lime and magnesia exist also in small but very variable quantity, and are held in solution, probably by the acid of the urine, along with some of its saline constituents. These earthy phosphates are in greatest quantity after a meal, in healthy persons; and in various diseases, especially those attended with emaciation, appear to increase in amount. They are precipitated and form a slight cloudiness in the urine, on the addition of any caustic alkali or alkaline carbonate; and when healthy urine passes into the state of de- composition,, the earthy phosphates are also thrown down, owing to the evolution of carbonate of ammonia from decomposing urea. The precipitate may be either amorphous or crystalline. The former generally consists of phosphate of lime; the other of the triple phosphate of ammonia and magnesia. This last, in a nearly neutral urine, crystallizes in triangular prisms bevelled at one or both ends, exceedingly transparent and color- less, like the prisms of crystals used in optical experiments. These crystals are very friable, and are consequently often observed irregularly Fig. 190. Crystals of the Ammoniaco-magnesian Phosphate. 444 THE PHOSPHATIC DEPOSIT. splintered, or shivered into small fragments; they are always perfectly colorless, and by this character are easily distinguished from uric acid. In a highly alkaline urine (whether spontaneously alkaline or decom- posed after emission), the phosphate of ammonia and magnesia occurs under a variety of crystalline fowns, corresponding to the basic varieties of the salt. "When rapidly formed, this salt generally appears in the form of six-rayed stars, each ray being serrated, or irregularly crenate, often runcinate, like the leaf of the taraxacum." There are, hoAvever, many varieties of star-shaped and foliaceous crystals, consisting of basic triple phosphate ; and generally these are mixed Avith the neutral salt in the ordinary prismatic form aboAre described. All the forms may be readily produced artificially, by adding ammonia or its carbonate in different quantities to the urine. The phosphatic gravel is usually white or pale gray, whether amor- phous or crystalline ; it may be precipitated in the form of plain gravel, or it may be either suspended or precipitated in a cloud resembling that of mucus, or it may form as a pellicle on the surface of the urine. The urine is pale and copious, of low density, occasionally alkalescent, when voided; never more than very faintly acid, often turbid, the last por- tion which is voided presenting a milky appearance, the phosphates being already precipitated; sometimes it emits a heavy, sickening flavor, someAvhat similar to that of weak broth ; not unfrequently it is ammoniacal from the first, dark-colored, and loaded with mucus; in all cases, it very soon putrefies, precipitating the deposit copiously, and exhaling a very offensive odor. Very generally, an iridescent pellicle forms on its surface, consisting of minute shining crystals of the ammoniaco-magnesian phosphate. The symptoms which attend the continuance of phosphatic deposit, are invariably of the asthenic type. The patient is pale, weak, nervous, irritable, incapable of sustained exertion of either body or mind; the bowels are flatulent and irregular, and an oppressive, exhausting pain, or aching, is almost constantly complained of in the loins. The cause may be local or constitutional. Whatever tends to exhaust the general, and more especially the nervous system, tends to induce this deposit—over-exertion, especially of mind, insufficient food, the habitual use of depressing medicines, as mercury, alkalies, saline purga- tives. Also, this deposit is a frequent consequence of injured kidney, and of injury to the spine, and it is an almost invariable attendant on confirmed disease, more especially if organic, in the bladder, kidney, ureter, or prostate. An occasional deposit of phosphates may follow a slight and transient cause, as error in diet, or profuse perspiration under violent exercise. But continuance invariably denotes broken health. The least formidable cases are those in which the ammoniaco-magnesian phosphate alone is found, and the worst are usually those in which the deposit consists of a combination of this salt with the phosphate of lime. Happily, the phosphatic gravel is not prone to agglomerate within the bladder, unless a nucleus be present; then, however, the cohesion of particles, around this, takes place rapidly. In treatment, as in that of the uric deposit, we have to direct attention both to the deposit, and to the causes AA'hich lead to its formation. The THE CYSTINE DEPOSIT. 445 mineral acids, as the muriatic, nitric, or a combination of both, exert a double influence ; they increase the solubility of the phosphates, and at the same time give tone to the primae viae and general system. They are given in doses of a feAv drops, much diluted, and gradually increased. Regimen is carefully attended to. Food should be generous, yet light and moderate, consisting chiefly of solids. Acescent vegetables, fruits, and drinks are injurious, for, hoAvever useful the mineral acids, taken from without, may be, acids engendered within invariably betoken derangement of stomach, and that as invariably reacts most untowardly on the urinary organs. Wine may be taken sparingly. Over-exertion in any way is avoided, free air and laxity of occupation are to be sought, and the skin's function must be well looked to. The boAvels are regu- lated, but mercury and saline purges do harm. Diuretics are not given, neither are alkalies, unless indeed the acids of indigestion plainly are troublesome, and then very small and occasional doses of alkali may be of service. Depletion, in any way, is not to be thought of. Opium is of much service, by subduing the irritability of system. General tonics are plainly indicated. And the decoctions of the diosma crenata, pareira brava, and uva ursi, would seem to exert a beneficial influence specially on the urinary system. The Cystine or Cystic Oxide Deposit.—This deposit is rare, but as it causes one of the most obstinate forms of the calculous diathesis, it is necessary to mention it here. Cystine is always crystalline, though to the naked eye it scarcely appears so, having more resemblance to the paler forms of lithate of ammonia. It forms a yellowish sediment, inso- luble by heat, unaffected by vegetable acids, but dissohred by strong mineral acids and alkalies. Ammonia dissolves it very readily, and on evaporation deposits it unchanged in the crystalline form. Under the microscope, cystine appears in the form of hexagonal plates, often over- lapping each other so as to form rather a confused mass. The ammo- niacal solution, slowly evaporated, gives crystals which can usually be distinguished from all others without difficulty. Urine containing cystine is usually of a more or less deep yellow color, sometimes inclining to green. Dr. Golding Bird has even seen it grass- green. Its odor is either aromatic like that of sweetbrier, or slightly Fig. 191. O Crystal* of Cystine. fetid. The quantity of urea and of uric acid has generally been found below the average; and it is not improbable, from the chemical relations of cystine, that it is formed at the expense of these physiological pro- 446 URINARY CALCULI. ducts. Cystine contains a large proportion of sulphur (26 per cent.), and is therefore probably in some way related to the sulphur-extractive which is found in normal urine. Pathology has not yet succeeded in throwing any useful light upon the circumstances under Avhich the cys- tine diathesis occurs ; the rarity of this deposit proving fortunately, an obstacle to the extension of our knowledge in that direction. ^ Its occur- rence is occasionally hereditary; and appears to be little subject to any therapeutical control. The Uric or Xanthic Oxide Deposit.—This is the rarest of all the urinary deposits ; and was first described by Dr. Marcet, as the consti- tuent of a calculus weighing eight grains. Neither its pathological history, nor its chemical properties and relations, have been so clearly ascertained as to demand notice in a practical work. It has chiefly been discovered in children, in the form of calculus. Dr. Douglas Maclagan lately found in the urine of an hysterical female traces of Avhat appeared to be uric oxide ; and his investigations led him to regard the substance found in this case as identical with one of the normal coloring matters of the urine, precipitated upon a basis of earthy phosphates. It showed under the microscope granular laminae, of irregular form, having the chemical characters described as those of cystine.1 Formation and Varieties of Calculi. The persistent establishment of any of these deposits renders the patient more or less liable to the formation of calculi, and is therefore justly regarded as a calculous diathesis. A nucleus having formed in some part of the urinary passages, the particles of the prevailing deposit are aggregated around it, sometimes in a homogeneous manner, more generally in layers, which may not unfrequently differ Avidely in composition. The nucleus may come from within or from without. A foreign substance introduced into the bladder, by the urethra, by wound, or by ulceration, and remaining in that viscus, soon becomes coated by calculous matter, even though previously no tendency to such deposit existed. Barley-corns, straAvs, beans, portions of bougies, or bullets which have gradually worked their way inwards, may thus prove nuclei; also portions of instruments, lint, or other matters, used in operations on the bladder; or a "portion of necrosed bone may find its way, by ulceration and abscess, into the viscus. By far the most common nucleus, however, is provided by the urinary organs themselves. A few particles of uric acid, or of oxalate of lime—for these, the former more especially, are found to be most prone to formation in the kid- ney—become coherent immediately after secretion ; and by such aggre- gation a nucleus is at once formed, soliciting farther addition. This addition may be made at the original site of aggregation, the kidney; more frequently, however, descent takes place into the bladder; and the small renal concretion then becomes the nucleus of a vesical calcu- lus. Or blood, escaped from the kidney or mucous coat of the bladder, may afford a mass of fibrine, which in like manner may originate the 1 Monthly Journal, Aug. 1851, p. 131. URINARY CALCULI. 447 formation ; all the more readily, of course, if a gravellish tendency pre- viously exist. As the stone enlarges, the original nucleus usually retains its central position; the stone moving loosely in the bladder, and re- ceiving addition equally on all sides. Sometimes, hoAvever, the stone is found to occupy a steady position, even when not encysted; lying undisturbed behind an enlarged prostate, having one side in constant and immediate contact with the mucous membrane, and presenting only a part of its periphery to the source of additional deposit. In such cases, the nucleus will be found occupying a lateral position in the stone's section ; enlargement having taken place almost exclusively on that aspect which looked into the free interior of the viscus. Stones vary in their nature according to the diathesis Avhich prevails during their formation. The following are the varieties : — I. The Uric Calculus; consisting chiefly of uric acid, but often containing a greater or less proportion of urate of ammonia. This is by far the most common class; comprising probably about two-thirds of all calculi. The color is brownish red, sometimes like that of mahogany; the surface is either quite smooth, or finely tuberculated by crystals ; a section shows aggregation of the particles in a concentric arrangement; [Fig. 192.] [Uric Calculus, showing its finely tuberculated surface. (From Gross.)—Ed.] the form is generally oval; and the size may vary from that of a pea to that of an orange. The tests are—solubility in caustic potass ; gradual consumption before the blowpipe; digestion in nitric acid, and gentle evaporation, producing a scarlet residue, Avhich becomes purple on the addition of ammonia. II. Urate of Ammonia Calculus.—This salt, as just stated, enters more or less into the construction of the uric calculi. Sometimes, but rarely, it forms a concretion by itself. The surface is similar to that of the uric ; more frequently tuberculated than smooth ; it is of a clay color; the fracture is fine and earthy ; and the layers are concentric. This comparatively rare calculus is peculiar to children. The tests are as for the preceding; with this addition, that ammonia is evolved during solution in potass. 448 URINARY CALCULI. Fig. 193. Fig; 194. Fig. 195. Fig. 193.—The Triple Phosphate surrounding a mulberry concretion. Fig. 194.—Nucleus surrounded by Oxalate of Lime; and this covered by concentric layers of Urate of Ammonia. From a child. Fig. 195.—Oxalate of Lime, or Mulberry Calculus. III. The Oxalate of Lime, or Mulberry Calculus; not unlike a mulberry in size, form, and color. By no means unfrequent, especially in young people ; always of slow formation. The color is dark brown; density and weight are comparatively great; the surface is almost always rudely tuberculated ; the texture is imperfectly laminated ; the size seldom exceeds that of a walnut; and the stone is always single. The tests are : solution in nitric acid ; the blowpipe, consuming the acid, leaves quicklime in powder, which, if moistened, gives to tur- meric paper a red stain. Small calculi of oxalate of lime, in size, form, and general appear- ance, very like hemp-seeds, sometimes form in the kidney. Descending they may be extruded with the urine ; but if one remain in [Fig. 196.] the bladder, it becomes variously coated, according to the ^H diathesis that prevails. If the oxalic diathesis continue, the yyjl hemp-seed sooner or later passes into the mulberry formation. ^^ IV. Phosphate of Lime Calculus.—Calculi seldom consist see/clioT °f tllis Salt alone* When the7 do' the surface is smooth like iul (From that of Porcelain; the color is a pale brown; the texture is Gross.)- regularly laminated; the form is spheroidal. The stone is ed.] friable, and usually of small size. The tests are; solubility in nitric and muriatic acids, and precipitation by liquor ammoniae ; resistance to the blowpipe, unless at a very intense heat. V. The Ammoniaeo-Magnesian Phosphate Calculus; commonly called the Triple Phosphate Calculus—although that term might with fully as much accuracy be applied to the next variety. This, and the following, seldom occur as composing stones entirely; but rather as coatings or layers of others—the uric and oxalate of lime more espe- cially. The color is nearly white ; the surface is covered with minute shining crystals; the texture is not laminated, or at least is imperfectly laminated ; the stone is soft, easily broken, and pulverized, and may attain to a large size. The tests are: solubility in acetic or muriatic acid; evolution of ammonia, when treated with liquor potassa?; diminution and imperfect fusion under the bloAvpipe, exhaling an ammoniacal odor. URINARY CALCULI. 449 VI. The Fusible Calculus—composed of the ammoniaco-magnesian phosphate, conjoined with phosphate of lime—is white and friable, like Fig. 197. [Fig. 198.] Fig. 197. The Triple Phosphate, surrounding a centre of Uric Acid. [Fig. 198. Calculus of Ammoniaco-Magnesian Phosphate, entire, exhibiting its shining crystal- line surface. (From Gross.)—Ed.] chalk ; and may stain the finger when touched ; the size and form are very various. The test is, its remarkable fusibility before the blowpipe. [Fig. 199.] [Fig. 200.] [Fig. 199. Fusible Calculus. (From Gross.) Fig. 200. Section of the same, showing its in- ternal structure. (From Gross.)—Ed.] VII. The Carbonate of Lime Calculus, is common in the lower ani- mals, but rare in man. It is white, spherical, smooth, and very friable • and dissolves in muriatic acid, with effervescence. VIII. The Cystic Oxide Calculus is also rare;1 of a yellowish-white color ; the surface smooth, but of a crystallized appearance; not lami- nated m texture, but presenting the appearance of a confusedly crystal- lized mass; the fracture exhibits a peculiar shining lustre; small frag- ments are semitransparent. The blowpipe elicits a peculiar odor, like • I had occasion to remove a calculus of this nature, successfully, from a patient from whom Mr. Listen had removed a like stone fifteen years before, —ibmthl,, Journal, 1849 pp. /91 and 886. ' ' 29 450 URINARY CALCULI. that of sulphuret of carbon ; and there is a ready solubility in alkalies and mineral acids. [Fig. 201.] [Fig. 202.] [Fig. 201. Cystic Oxide Calculus. (From Gross.) Fig. 202. Section of the same, showing its in- ternal crystalline appearance. (From Gross.)—Ed.] Fig. 203. IX. The Uric or Xanthic Oxide Calculus is still more rare than either of the preceding. The texture is compact, hard, and laminated; the surface is smooth, the shape ovoid, the color cinnamon-brown. The tests are: consumption before the blowpipe, leaving a white ash, and exhaling a peculiar fetid odor; solubility in acids and alkalies—more readily in the latter; the residue of solution in nitric acid, evaporated to dryness, of a bright lemon-yellow color—whence the name. X. The Lithate of Soda sometimes enters into the composition of calculi; but very rarely constitutes a calculus, of itself. The mass is white, friable, and soft, like what is seen in the tophous concretions of gout, in the neighborhood of joints. The tests are ; solubility in caustic potash, with the aid of heat; in treatment with dilute sulphuric or muriatic acids, the soda is separated, while the uric acid remains, and may be obtained by filtration and washing. XL The Fibrinous Calculus, like the xanthic oxide, occurs with extreme rarity. And, perhaps, the term calculus is scarcely applicable to the al- most solitary case on record; in which small concretions were passed, of the size of peas, yellow, like wax, and com- posed of fibrine—probably the result of a bloody clot, in either the kidney or bladder. Such formations, however, as already stated, may not unfrequently constitute nuclei of the ordinary calculi. XII. The Alternating Calculus, though last in the arrangement, is not the least frequent in occurrence. Few large calculi, indeed, fail to present more or less of the alternating charac- ter ; the nucleus consisting of uric acid or oxalate of lime; variously coated or alternated ; the last covering invariably phosphatic, and most frequently of the Section of an Alternating Calculus; chiefly f f ^ calcuks> Thenml_ composed of uric acid. URINARY CALCULI. 451 berry or uric calculus, having formed, creates much irritation in the urinary organs, and causes changes also in the general system for the worse; the urinary secretion becomes more and more depraved; and at last that derangement is produced which is favorable to the forma- tion of the ammoniaco-magnesian phosphate; this is deposited on the growing stone, and, uniting with phosphate of lime, now furnished by the diseased mucous membrane of the bladder, constitutes the fusible formation. Such are the varieties of Urinary Calculi. Those ordinarily occur- ring are, the uric, mulberry, phosphatic, and alternating. Forming in the kidney, and remaining there, a calculus is said to be Renal; origi- nating in the bladder, or growing there after descent from the kidney, it is said to be Vesical; originating in the urethra, or arrested there in its passage outwards from the bladder, it is said to be Urethral; formed in the prostatic ducts, it is said to be Prostatic. Stone is most common in temperate climates, and in early years ; of adults, the old are more frequently attacked than the young. The sedentary are more liable than the active, the luxurious than the tem- perate, the males than the females. Certain districts are remarkably prolific in stone: Norfolk, for example ; and the east coast of Scotland. The disease is doubtless hereditary, like its kindred affection, gout; and this circumstance may obviously be made somewhat subservient to the explanation of prevalence in certain localities. Frequency of occurrence leads to skilful practitioners and the flocking of patients; the patients recover, and raise a breed of men of like tendencies with themselves. Where the disease is rare, on the other hand, the treat- ment is less skilful; the affected migrate, and the chance of reproduc- tion from those who remain is but slight. Injuries of the spine obviously favor alkaline formations; causing perversion of function in the kidney, and in the lining membrane of the bladder, with want of expulsive or self-cleaning power in the latter viscus. An injury done to the kidney itself also favors stone ; by disor- dering secretion, and at the same time furnishing coagula as nuclei for the formation. Long-continued strictures, and affection of the pros- tate, are obviously predisposing causes; deteriorating the secretion of urine—through disorder of the general health, and prolongation of irritation from the original seat of disease, upwards to the kidney ; at the same time opposing satisfactory expulsion of the bladder's contents. Some children seem born with stone; afflicted with a congenital calcu- lous diathesis. The treatment of calculous disease plainly resolves itself into the following indications: 1. To prevent the formation of stone, by cor- rection of the calculous diathesis. 2. To favor spontaneous expulsion of the stone, when formed. 3. To diminish suffering, and delay pro- gress of the disease. 4. To remove the stone by operation, when cir- cumstances are favorable. 5. Unfortunately, we are not yet warranted in filling up as a fifth indication, removal of the stone by lithontriptics, or other means independent of instruments. 452 RENAL CALCULI. Renal Calculi. Renal calculi at first consist either of uric acid, or of oxalate of lime ; most frequently the former. Particles cohere, either simply to each other, or round a nucleus of fibrine or other animal substance. And a beginning having been made, however slight, addition speedily takes place, provided the calculous diathesis continue—as is not unlikely, seeing that the irritation of the calculus reacts unfavorably on the kid- ney, causing continuance or even increase of depraved secretion. Mere sand may remain in the tubuli; but calculi lodge in the infundibula; and thence may descend to the pelvis of the kidney. And if a calculus continue in any of these cavities for some time, a peculiarity of shape is acquired—diagnostic of such formations—dependent on the form of the cavity ; in fact, the stone—though at first small, oval, and smooth, like uric calculi in general—may often be said to be an accu- rate cast of the pelvis and infundibula. This happens when the calculus continues to be renal; more frequently, however, it descends by the ureter to the bladder; thence to be expelled by the urethra, or to enlarge into a vesical calculus. If it remain in the kidney, serious changes take place in that organ. The cavity or cavities are completely occupied; then, the size increasing, encroachment by pressure is made on the texture of the gland, until this may come to consist of little more than a mere cyst within which the large stone is contained. Sometimes active inflammatory action is kindled; the kidney suppurates; the matter, obeying the general rule of seeking the external surface, may point posteriorly; and, evacuation haA'ing taken place, the stone may be felt by the probe or finger. The symptoms of stone in the kidney are generally as follows: A dull aching, with a sensation of weight, is felt in the loins ; with a sharp pricking feeling in the region of the kidney. Sometimes there is pain in the scrobiculus cordis ; sometimes there are fits of vomiting; generally the stomach is irritable. The urine, from time to time, shows an ad- mixture of blood, more especially after exercise ; and this, when rude and violent, aggravates all the symptoms. Water is made often, and with pain and heat; the testicles are painful and retracted. Numbness, pain, and cramp in the corresponding thigh are Aery common. Febrile aggravations are liable to occur, the kidney becoming the subject of intercurrent seizures of an inflammatory nature. Purulent matter may descend from the pelvis, and be voided with the urine ; and by continu- ance of such discharge, by the hematuria, by the pain, and general disorder, serious exhaustion may ensue. Generally, irritation descends; and the bladder ultimately sympathizes more or less, by functional or organic disorder. Large calculi, occupying the whole gland, may sometimes be felt by external manipulation ; and, in the open suppur- ated condition, a very accurate diagnosis may be arrived at, as already stated. Generally the stone, at no long period after its first formation, de- scends by the ureter ; this movement being induced by its own weight, and by the flow of urine. Sometimes, however, it is arrested in the RENAL CALCULI. 453 passage ; an event towards which the irregular form of the calculus is manifestly favorable. The ureter may be, in consequence, either wholly or partially obstructed. Usually, the form of the calculus is such as to favor the urine's escape by its side; but still, even such partial obstruc- tion, if long continued, may lead to very serious results; dilatation of the ureter aboAre, of the kidney's pelvis, and of the infundibula ; absorp- tion of the proper structure of the kidney ; and consequent interruption to the function of that important organ. Indeed, under such circum- stances, the parts have been found reduced to the condition of a chronic abscess ; the distended pelvis and infundibula being coated Avith a false membrane, and secreting much puriform fluid. And other dangers at- tend on the arrest; inflammatory action, kindled in the obstructed part, may extend to the parts adjoining, and may involve the abdomen in peritonitis ; or ulceration may take place, with perforation ; and through the aperture fatal urinary extravasation may occur. Complete obstruc- tion by the arrest is fraught with the utmost peril; distension of the pelvis and infundibula, rapid and great, is likely to cause suppression of urine— always most hazardous ; there is a greater risk of inflammation and ulcer- ation than in the partial case ; and the over-distended ureter may even give way by bursting. In the case of partial obstruction there is a chance—though a remote one—of ulceration proving chronic and sthenic; preceded and accompanied by plastic exudation, and consequent con- solidation of tissues ; advancing towards the surface ; and ultimately discharging the offending body externally. Or the calculus may remain in the ureter, with partial obstruction ; as it enlarges, it usually assumes the form of an hour-glass, the increase of deposit taking place chiefly at either extremity; and sooner or later death is the result. Not un- frequently, a descending stone is arrested in the termination of the ureter; one part within the ureter, partially obstructing it; the other projecting into the cavity of the bladder, and receiving increase there ; constituting a troublesome variety of vesical calculus. A small, smooth calculus may glide down the ureter imperceptibly. More frequently, descent is marked by symptoms. The patient is sick and vomits; he is alarmed, feeling a change, and afraid of the result; he is attacked by cold chills and shivering ; the pain shifts from the kidney, shoots downwards in the course of the ureter, and often down the corresponding thigh—intense, and sometimes almost insupportable; the testicle is retracted and painful—the seat of neuralgia, or irritation ; sometimes the irritation induces the inflammatory process, and acute orchitis results. The pulse is comparatively little affected, but fever may at any time supervene, in consequence of inflammatory seizure in the ureter, kidney, bladder, or testicle. If arrest and obstruction take place, all the symptoms are much aggravated. The treatment of renal calculus consists in favoring descent, and pal- liating the urgency of the symptoms. The warm bath relaxes ; opium does the same, and assuages pain ; purgatives and diuretics favor de- scent. Smart exercise is also of service. In the first instance, anti- phlogistics are not demanded ; they are held in readiness for the threat- ening of inflammatory action. Not the least important part of the treatment is the adoption and maintenance of such means as are best 454 VESICAL CALCULUS. suited for overcoming the diathesis on which the existence of the stone depends. Should there be reason to apprehend arrest in the ureter, with complete or even great obstruction, diuretics and diluents will of course be refrained from. When, however, descent has been completed, and the bladder is reached, diluents can hardly be plied too actively, so as to favor complete expulsion of the foreign body. When a large stone lodges in the kidney, and its presence can be made out with tolerable certainty, nephrotomy has been proposed ; cut- ting into the gland from behind, and extracting the stone. This is not warrantable, however, except in those cases in which Nature has effected the greater part of the procedure; when suppuration has taken place; when the textures intervening between the stone and the surface are matted together and consolidated; when the stone has become superficial; and when, in short, there is no risk of injury being done to the abdominal cavity. Then the pointing abscess may be opened, or the aperture already existing may be enlarged, and the stone may be seized and removed. Such cases, however, are very rare, as can readily be under- stood. Vesical Calculus. As already stated, Aresical calculus may originate in the bladder, formed on a nucleus there. More frequently, it may be said to be a continuation of the renal concretion. On descent having been com- pleted, the sufferings which accompanied it generally cease ; the patient enjoys a period of comfort; and he is apt to imagine himself rid of the malady. Uneasiness, however, returns; and in no long time the symp- toms of stone in the bladder become marked and characteristic. The water is passed with unusual frequency, and with more or less pain. Desire to evacuate the bladder is not only frequent, but sudden and irresistible ; and the evacuation does not bring relief. On the contrary, the pain, which existed during micturition, is aggravated when the bladder is empty, and when spasmodic contraction of the middle coat brings the morbidly sensitive mucous membrane into direct and rude contact with the calculus. The pain is referred chiefly to the point of the penis, with a sensation as if something lodged there ; and, in conse- quence, the prepuce and end of the glans are liable to be pinched and pulled by the patient involuntarily. This especially takes place in child- ren ; and in them it is common to observe the forefinger and thumb pale and sodden in their points, like those of a washerwoman. We may find elongation and cedema of the prepuce, from the same cause. A slight change of posture may induce the desire for micturition. It is sure to be induced and aggravated, as well as the pain, by exercise; more especially, by being roughly jolted in a cart or other carriage ; and then, too, we may expect the urine which is passed to be more or less bloody. A stooping posture is usually adopted during micturition; sometimes the patient rests on his knees and elbows ; sometimes he leans over and rests on his head; the object being to avert pain, by removing the calculus from the most sensitive part of the bladder—the trigone. The water at first may flow in full stream, and then it may stop sud- VESICAL CALCULUS. 455 denly; the stone having moved to the posterior orifice of the urethra, and temporarily occluded it, causing aggravation of pain. By change of posture, the stone is dislodged, and the flow restored. The stone, acting constantly as a source of irritation to the lining membrane of the bladder, induces congestion there; increase and change in the secretion result ; mucus coming in greater quantity, and more viscid than usual; —a wise provision, the tenacious mucus adhering to the membrane from which it was secreted, and protecting it, to some extent, from injurious contact with the calculus ; what is redundant is discharged with the urine. And hence a common symptom of stone is, the presence of such mucus in the urine; settling down in the bottom of the pot, and often showing itself there in great quantity, on the water being carefully poured off. If a chronic inflammatory process have been lit up in the inner coat, the mucus degenerates still farther, and resembles purulent matter. If true inflammation haA'e occurred, and the membrane have ulcerated, the bladder will contain more or less of true pus. And under such circumstances, the urine will generally be found dark-col- ored, turbid, alkaline, and fetid. The rectum sympathizes, more espe- cially in children ; the bowel becomes irritable; or hemorrhoids form ; or prolapsus ani occurs. Frequently, there is sympathetic uneasiness elsewhere ; the testicles may be tender and retracted, from time to time ; pain often shoots down the thighs ; and unpleasant heat is sometimes complained of in the soles of the feet. The symptoms are not uniformly severe, but are liable to remissions and exacerbations ; the latter, termed " fits of the stone," are attended with great agony—as the self-performed operations of the blacksmith of Amsterdam and the cooper of Konigsberg abundantly testify.1 These aggravations are induced by exercise, error in diet, or constitu- tional disorder; and the greater part of the suffering, it is probable, is directly dependent on spasm of the muscular coat of the bladder. The symptoms also vary according to peculiarity of constitution. One pa- tient may suffer intensely, enjoying scarcely a moment's ease ; while another complains but little, and follows his usual avocations, little dis- turbed; and yet the local circumstances may be very similar in both. And again, a variety in suffering is found to depend very much on the nature of the stone and the diathesis. The mulberry occasions more uneasiness than the smooth uric concretion ; the rough and sharp no- dules of the former coming into frequent and injurious contact Avith the lining membrane of the bladder. And the phosphatic stone will probably occasion more suffering than either ; the general system being more deranged, as well as the mucous membrane ; and both being con- sequently prone to resent the stone's stimulus ; in other words, both the general and the local sensibility are morbidly increased. Also, with a varying diathesis, the intensity of the symptoms will vary. The uric concretion at first gives little trouble ; but it becomes coated with oxalate of lime, and increase of pain may come with the formation of nodules ; again the uric diathesis prevails, the rough eminences are levelled by 1 Goaded on by torture to the desperate effort of ridding themselves from the stone by their own hands. 456 VESICAL CALCULUS. the new deposit, the surface once more is smooth, or at least even, and a remission in the symptoms is experienced. But then the phosphatic diathesis ensues ; both kidneys and bladder are advancing untowardly in disease; a layer is forming of the ammoniaco-magnesian phosphate, or of the fusible calculus; and the symptoms are more severe than they have yet been. For not only is the aggravation of the symptoms local; the constitution also suffers, and that seriously. By supervention of enlargement of the prostate, the symptoms may be either mitigated or increased. If the gland simply increase in bulk, the former result may take place, the swelling coming to occupy the most sensitive part of the bladder, and consequently saving that from contact with the stone. But if the gland be ulcerated towards the blad- der, and the stone rest in contact with the ulcerated surface, suffering will be greatly aggravated. The most ordinary and diagnostic signs of stone are: frequent, sud- den, irresistible, unrelieved desire to make water, pain at the point of the penis, after the bladder is empty, mucous urine, occasionally bloody, occasional stopping of the flow of urine, and restoration of the flow by change of posture. These fully warrant the surgeon in suspecting the existence of vesical calculus, and in adopting the necessary means to detect it; but of themselves, they never prove the existence of stone. The general symptoms of stone—and even these, the most pointed of them—may be very closely simulated by other affections; by organic disease of the kidney, by renal calculus, by irritation or organic disease in the rectum, by disease of the coats of the bladder, by prostatic affection, by stricture of the urethra. Certainty can never be arrived at without the use of the sound. The continued irritation, by the stone's presence, induces serious change in the coats of the bladder. The mucous membrane, as already seen, becomes congested, and sustains perversion of its secretion; the mucus is at first viscid and clear, afterwards discolored and phosphatic. By a chronic inflammatory process the membrane maybe thickened; by true inflammation it may ulcerate, discharging pus copiously. The muscular coat, under frequent stimulus to contract, and frequent obe- dience to that stimulus by violent and spasmodic contraction, becomes hypertrophied; after death, the fasciculi are seen coursing in their interlacements, salient and strong, with depressions between. The cavity of the viscus is contracted, and such diminution in capacity is usually proportioned to the increase of bulk in the muscular fibre. Be- tween the fasciculi, the depressions get deeper and deeper, and fre- quently the mucous coat becomes protruded outwards, so as to form pouches, or sacs, of greater or less size, within which a calculus may become embayed, or a fresh concretion may form. Abscess may occur between the coats, usually discharging itself into the viscus ; sometimes opening outwards, by perforation, into the cavity of the peritoneum, or into the deep areolar tissue of the pelvis—either event most hazardous —or into the rectum. And thus, in three ways, a cavity may be pro- duced for the encystment of calculus ; by internal opening of a parietal abscess, by hernial protrusion of the mucous coat, outwards, through the muscular, by deepening and enlargement of a depression between VESICAL CALCULUS. 457 the hypertrophied fasciculi. The inflammatory process may invade the whole coats, chronic or acute. Gangrene has sometimes occurred, ulceration and abscess are not unfrequent. In the aged, chronic cystitis is almost inevitable; then the phosphatic mucus, which attends this affection, increases the growth of the stone, and phosphatic deposit, becoming entangled in the Adscid mucus which adheres to the lining membrane, may lay the foundation of other concretions, or constitute a broad adherent layer of calculous matter. The prostate sooner or later becomes enlarged, in those advanced in years. The kidneys suffer more and more by derangement of function; ultimately organic disease is not improbably produced. And under such advancement in disease and suffering, it need not surprise us that the issue of the malady is death. At the same time it is not to be forgotten, that many a patient, with large stone, bulky prostate, and diseased bladder, lives for years, and may die of an ailment with which the stone is unconnected. The effects of time on the stone itself are important. The most ob- vious is enlargement; slow, in the case of the mulberry; in the uric, seldom rapid ; in the phosphatic, rapid and untoward. And be it re- membered, that whatever the nature of the original concretion be, its ultimate coatings will be phosphatic, if it remain long; its irritation neArer failing to induce the phosphatic depravity of secretion, in the kidney and in the mucous coat of the bladder. By sacculation of the bladder's walls, an opportunity is afforded for encystment. And if this take place, the symptoms are all mitigated—may, indeed, wholly dis- appear. But the stone slowly receives addition within the pouch ; and probably will come to project through the aperture of communication. Fig. 204. Bladder containing a Calculus in fragments. Spontaneously disrupted. Termination fatal; by inflammatory action. (Liston. Element*, p. 633.) On such projecting portion, deposit takes place with greater rapidity ; and then we may expect the symptoms of stone to be revived more or less intensely. Occasionally, the stone undergoes spontaneous disrup- tion ; sometimes, after unusual violence of exercise, sometimes in con- nection with no assignable cause. In such cases, the stone is usually phosphatic; the particles being more loosely aggregated than in the uric or mulberry concretions. The event is generally to be regarded as 458 TREATMENT OF STONE IN THE BLADDER. untoward, when the stone is of any considerable size.1 Indeed, unless speedy relief be afforded by our art, the issue is almost certainly fatal. The sharp irregular fragments inflict great injury on the urinary organs; some may obstruct the urethra, causing retention of urine, with its various calamitous results ; the rest excite cystitis, acute and intense; the bladder becomes filled with coagulated blood, and from this cause a formidable retention of urine may result; the kidneys sympathize ; and, under a complication of disorders, the system is apt to be overborne. Lately, a case occurred under my observation, in which the immediate perils of retention by coagula in the bladder were got over, as also the first brunt of the cystitis ; but at the end of the third week, the patient perished by abdominal peritonitis, found to result from extravasation of urine through perforating ulcer of the bladder. In a few very rare cases, ulceration of the coats of the bladder has had the happy effect of permitting spontaneous extrusion of the stone; through the abdominal parietes, in the hypogastric region ; into the rectum ; or into the vagina. But such a result, so rare, hazardous, and improbable, manifestly cannot be taken into account in consideration of ordinary treatment. Treatment of Stone in the Bladder. No treatment can be adopted with propriety, until an absolute assur- ance has been obtained of the existence of stone. And this can only be secured, as already stated, by Sounding ; a simple operation, yet one requiring tact and care in its performance. The introduction of an in- strument by the urethra, and its movement in the bladder during per- quisition, must always be attended with more or less suffering—unless anaesthesia by chloroform be employed ; and there must ahvays be a greater or less risk of undue excitement following. It can readily be understood how the careless and rude use of a sound in an irritable bladder and patient—had recourse to after walking, or travelling in any way, and not protected by rest and suitable treatment afterwards— may induce a most serious cystitis, with implication of the kidney; and it is salutary to remember that a cystitis thus caused has once and again proved fatal. A patient—say from the country, and just arrived—pre- senting himself with the ordinary symptoms of stone, is not at once to be sounded, and at once dismissed. We should first ascertain that pulse, kidney, and bladder are sufficiently quiet to admit of this opera- tion being practised with impunity ; and, after its performance, rest should certainly be enjoined for some time, perhaps with sedative, or even antiphlogistic treatment. It is in itself an important operation, and should be regarded as such. In children, and in irritable adults, ™1S W^}A° USe chloroform> as formerly stated (Principles, 3d Am. Ed. p. 740.) r _ The instrument is of steel, of medium size, straight till within two inches of the extremity—where it is sharply curved—and furnished » A small stone spontaneously disintegrated, may be expelled by the urethra, without much suffering, and with no danger. SOUNDING. 459 with a broad and smooth steel handle: of steel, and broad in the handle, so that its impingement on the calculus may be the more dis- tinctly felt; and of a sharp, short curve at its end, so that the straight portion being in the urethra, while the whole of the curve is within the bladder, the end may be moved about in that viscus freely, and in all directions ; of medium size—not so large as to be grasped tightly by the urethra, and so be limited in its movements—and yet large enough to afford a steady grasp to the operator, with surface enough for readily striking the stone. The bladder should be as much distended by re- tained urine as the patient can conveni- ently bear; so as to afford room for the instrument's play. The patient is placed recumbent; and, the sound having been gently introduced, the convexity of its curve is pressed in the direction of the ordinary site of stone—at the most depend- ent part of the bladder, behind the pros- tate. There, a hard substance being felt, the instrument is moved sharply, with a gentle striking movement; and, in addition tO the rub Avhich Was at first Conveyed tO Sounding. The stone in its ordinary the operator's hand, a distinct click will position. be heard, while a more defined and vivid impression of impingement on a foreign body will be felt. And without this combined indication of touch and hearing, the surgeon should never be satisfied of the existence of stone. If nothing be found in the ordi- nary site, the instrument's point must then be moved carefully and in- quiringly in every direction ; groping at first, as a probe ; and, on find- ing resistance, moved with a sharp yet gentle stroke. Of four sources of fallacy we must be constantly on our guard; the rub of the end of the sound on fasciculi of the bladder;' the grating of it on calculous matter entangled in the mucous lining ; the rub of a rough and enlarged prostate ; and the rub and grating of calculous matter in the prostatic or membranous portions of the urethra. If nothing is found in the ordinary site and in the ordinary way, posture is changed, and the search renewed; first in the erect posture, and then with the patient stooping much forward. The space above the pubes, in the latter posi- tion, is particularly explored. The stethoscope may possibly be of service, applied over the region of the bladder ; but it is difficult to repress the thought that, wherever a stone actually is, the signs emitted by the sound's use will be sufficiently distinct, without the aid of mediate auscultation. Change of posture having failed to detect stone, change in the state of the bladder may next be tried. The urine may be al- lowed to dribble away by the side of the sound ; and, as the bladder contracts, the sound is moved gently in various directions, so as to favor 1 In using the catheter for retention of urine in the aged, a fasciculated portion of the thickened bladder sometimes comes suddenly in contact with the end of the instrument, interrupting the urine's flow, and giving the sensation of stroke or rub to the operator's hand. This, to the unwary, may simulate the presence of stone ; and has to be guarded against accordingly.—Vide Adams on Diseases of the Prostate, pp. 76, 77. 460 NATURAL EXPULSION OF STONE. distinctness in the sensation of contact, should the stone descend upon it. Or a catheter, shaped like the sound, may be substituted; and, during rapid contraction of the bladder, contact may be ascertained. After failure by all the ordinary means, success has followed the use of an elastic catheter in this way: With the bladder full, the patient, erect, makes water in a full stream through the instrument; and, as the last drops escape, the stone falls on the point of the catheter and is felt. Whenever difficulty is experienced in detecting a stone, in a case with plain symptoms, it is better to repeat gentle exploration at intervals, than by one continuous and prolonged perquisition to endanger the occurrence of cystitis and sympathy of the kidney—perhaps peritonitis by extension, and death. In children, the prudent surgeon is not sat- isfied with any obscurity ; the click and rub must both be very distinct; the restlessness and crying of the patient being otherwise apt to lead to deception. It is chiefly in such cases that blank lithotomy has been performed. And to guard against this, it is in such cases that the use of chloroform is especially serviceable (Principles, 3d Am. Ed. p. 740). But by the sound's use, we may ascertain some of the characters of the stone, as well as its existence. Moving the point over the stone's surface, we may be able to estimate the smoothness or roughness of it. Passing it over, and on all sides of the stone, we may obtain some idea of its form and bulk ; and by the finger of the other hand in the rec- tum, we may sometimes be greatly assisted in this conclusion, by feeling its weight, as it Avere, while at the same time its diameter, at least in one direction, is made apparent.1 Moving the sound in the bladder, we may have a distinct sensation of one stone being left, while another is encountered by the instrument; or plurality of stones may be indi- cated by another circumstance, the stroke of the instrument eliciting dif- ferent sounds at different parts of the bladder—the sounds differing as to clearness and as to pitch or tone. Also, a large stone is at once de- tected ; a small one may long elude the sound. And again, while the rub and grating imparted by a large stone are most distinct, the click of a small stone is more clear and defined ; and the following practical infer- ence may be almost arrived at—the smaller the stone the sharper and more distinct the click ; the larger the stone the more palpable the feel. Farther, when the symptoms have been of long duration, we may expect a large stone; and vice versa. Also, phosphatic formations are apt to be larger than those of any other kind. Having, by sounding, ascertained the existence of Vesical Calculus, the treatment of it naturally resolves itself into the following indi- cations :— I. Assist Natures effort to expel the offending body.—This, obviously, is applicable only to calculi of small size; those, for example, which have recently descended from the kidney. Their natural progress is outward, with the current of urine. And in females this is usually effected readily; the urethra being short, straight, capacious, with its 1 It is right to remember, however, that, in the adult, stone may not be felt by the finger in the bowel. MEDICINAL DISINTEGRATION OF STONE. 461 current impetuous; and hence one reason why vesical calculus in the female is rare. In males, however, there are many obstacles. The urethra is both long and tortuous, it is comparatively narrow besides, and its current is proportionally defective in expulsive force; spasm, too, is liable to interfere. And yet, judiciously assisting nature, small stones may be thus got rid of, by dilatation of the urethra, diluents, and forcible voidance of the urine. By the occasional introduction of bougies, the urethra is brought to more than the normal dimensions, while its irritability is also diminished;1 and, by the use of diluents, the flow of bland urine is considerably increased. It is well, also, to accus- tom the bladder to considerable distension by its contents. Then, with the bladder full, and the urethra occupied by a full-sized bougie, the patient stands stooping; and, the bougie having been suddenly with- drawn, evacuation is made in as full and forcible a stream as possible. In the case of enlarged prostate, the main obstacle to the escape of a small stone by the urethra is at the lower or posterior part of the out- let ; it is well, therefore, under such circumstances, that the patient expel his urine in a recumbent and prostrate posture. The only objection to this mode of treatment is the risk of arrest in the urethra, inducing retention of urine with its many dangers. II. Attempt disintegration, medicinally.—Attempts at expulsion having failed, or being deemed inadvisable, the following other modes of removal may'be thought of; solution within the bladder, forcible abduction by the urethra, disintegration by mechanical means, excision. The first of these indications may be attempted in two ways; by medi- cines given by the mouth, and by injections into the bladder. Of the former class of remedies, the alkalies are the most prominent; especially the carbonates of soda and potass, given in small doses very copiously diluted, imitations of the natural waters of Vichy, of repute in calculous disorders. The oxalate of lime calculus resists their influence. But the uric formations may be benefited in two ways; alkalies thus given tend to correct the diathesis whereby the calculus has arisen, and at the same time have undoubtedly a sedative and corrective effect on the urinary organs, improving the secretion of the kidneys, and assuaging the irritability and disorder of the mucous coat of the bladder. They arrest growth, and palliate the symptoms of stone; and experience would seem to say that a slow and uncertain diminution of the stone occurs during their sustained use. Farther, the voice of experience certainly conveys the fact that their continued use, provided it be in small doses, greatly diluted, has no injurious consequences either on the renal secretion or on the general health. In the case of phosphatic formations, large doses of alkalies must prove prejudicial; but doses, such as already mentioned, fail to do harm, and at the same time seem to have the effect of favoring gradual disintegration of the stone, by solution of the animal matter, whereby the calculous particles cohere. Farther experience in the use of these simple lithontriptics is much 'It has been proposed to introduce belladonna into the rectum, so that the neck of the bladder may be relaxed and dilated, like the iris. 462 MEDICINAL DISINTEGRATION OF STONE. to be desired. But it is to be feared that the long-continued use which is essential, and the uncertainty of the issue, will prevent any general employment of, or confidence in them. No doubt, however, they are of much value, in a subsidiary place, as means of delaying the increase of uric formations; favoring disintegration of phosphatic calculi, as a pre- lude to Lithotripsy, for example; in all cases of stone, improving the state of the urine and of the lining membrane of the bladder, and so mitigating the distressing train of symptoms.1 Solvent injections into the bladder have been in use since 1792, with various degrees of expectation. As yet, unfortunately, their success is far from great; and we dare only place them in the same subsidiary rank as internal lithontriptics. The agents employed have naturally been alkalies and acids; the one in uric formations, the other in phos- phatic ; introduced by means of a syringe operating on a double canula, whereby a constant stream may be kept in play on the calculus within [Fig. 206.] l:J [Fy7 "'" - [Double Canula, with a Read's Syringe, for injecting the bladder. The middle figure represents the canula, or catheter, divided into two tubes, as marked by the dotted line, and also the star. The nozzle of the syringe is received at o; the fluid is forced along the tube, escapes into the bladder by the aperture marked by one arrow; from the bladder it is withdrawn by the syringe through the aperture marked by the other arrow, and escapes from the tube at d. If the orifices become clogged at any time, they can be reopened by means of the flexible and elastic stylet, cc, which is so large as nearly to fill the tube, and which may be introduced either at a or 6, the latter orifice being represented in the drawing as closed by a plug. (From Fergus- son.)—Ed.] the bladder. The objections are the same as before; delay in treat- ment, and uncertainty in effect. The acid injections, however, may be not without their efficacy, as palliatives of the symptoms attendant on phosphatic calculus; employed weak, as correctives; not strong, as sol- vents. Of late, the carbonate of lithia has been supposed a promising 1 At all times, however, even the most cautiously sustained use of alkalies must be watched, lest serious injury accrue to the system, by its over-saturation with them.—Vide Lancet, No. 1177, p. 318. MEDICINAL DISINTEGRATION OF STONE. 463 solvent for uric concretions ; and the salts of lead have been proposed as suitable for injection in the case of the phosphatic. III. A method of snaring has sometimes proved successful in the case of small calculi. It having been observed that, in removing cathe- ters used on account of retention, small calculi Avere occasionally found entangled in their eyelets, or lodged in the tube, it was thought that in cases of calculus, this, when small, might so be ensnared and withdrawn. M. Bourguenod was the first to adopt the practice, and he met Avith a few imitators. But success depends evidently too much on chance, and that chance is too remote to admit of the procedure being favorably entertained by the practical surgeon. IV. Forcible evulsion may be attempted by the urethra. By the forceps of Cooper, a small stone may be seized and Avithdrawn. But [Fig. 207.J [Sir A. Cooper's Instrument, improved by Mr. Weiss. At thepoint it consists of two blades hollowed within which can be made to open by means of a stylet, connected with a trigger near the handle. When in the bladder, the blades are made to open by pressing upon the trigger, and they close again by their own elas- ticity. Thus, by opening and closing the blades, and moving the instrument, small concretions may be caught. (From Fergusson.)—Ed.] all such proceedings have been justly superseded by Lithotripsy. The perquisition Avas painful and tedious ; in seizing the stone, the lining membrane of the bladder was liable to receive injury; and, after seizure, it was not improbable that the attempt at extraction might prove abort- ive ; the stone perhaps becoming impacted in the urethra, and locked at the same time most inconveniently in the jaws of the instrument. V. The Calculus may be disintegrated by Instruments.—In fulfil- ment of this indication there are two methods ; Lithotrity, and Litho- tripsy ; the latter the more modern and preferable. Lithotrity signifies a boring or rubbing of the calculus, in the hope of its becoming pulverized. This was first put in practice—at all events in modern times1—in 1800, by General Martin ; who operated on him- self, with partial success, by means of a file. In 1813, Gruithuisen proposed the use of a canula, through which, by means of a wire, the calculus was to be noosed, and then attacked by a borer. In 1S19, Elderton invented a more feasible instrument. But neither of these were used in practice. In the same year, Dr. Arnott did good service, in illustrating the capabilities of the urethra and bladder, for the recep- tion and play of suitable apparatus. In 1822, Amussat and Le Roy busied themselves in this department; the latter most ingeniously. And in 1823, M. Civiale, availing himself of the labors of his predecessors, invented a three-branched boring apparatus; well adapted for drilling stones when caught—equally apt, however, to seize the coats of the 1 Albucasis and Sanctorius had notions of bruibing stones, and invented instruments for the purpose. 464 LITHOTRIPSY. bladder, and not very well adapted for disposing of the stone effectually. Its success in practice proved but indifferent. And now, all such im- plements have been superseded by the crushing apparatus—more simple, safe, and effectual—whose use constitutes Lithotripsy. Lithotripsy. To remove calculus by crushing is a more modern idea than that of boring or drilling. Various instruments have been proposed and used; some with screws, some with hammers. At present, the voice of the profession apparently prefers the former; on the principle of the instru- ment originally invented by Mr. Weiss in 1824 ; composed of two blades, abruptly curved at the extremity—the one sliding on the other, and propelled by means of a screw. [The proper selection of instruments being of considerable importance in the performance of Lithotripsy, we shall take the liberty of introduc- ing here, several drawings from Mr. Fergusson's last edition, exhibiting the most approved forms. [Fig. 208.] [Large screw Lithontriptor of Mr. Weiss.] Fig. 208 exhibits a screw instrument of Mr. Weiss, large and strong, for crushing large and dense concretions; the male blade being serrated, and the female fenestrated, for the purpose of breaking the stone, and forcing the fragments from the jaws of the instrument into the bladder [Fig. 209.] [Plan of the Extremity of the Blades.] again, so that when the former is Avithdrawn, the lining membrane of the latter and of the urethra shall not be injured. Fig. 210 represents an instrument of Mr. Fergusson, in which the [Fig. 210.] [Mr. Fergusson's Instrument, the male blade being moved by the key.] LITHOTRIPSY. 465 ordinary screw is modified, so that a key is used to move the male blade. This lithontriptor is introduced into the bladder in the ordinary man- ner; the stone is caught, and, after the surgeon has assured himself [Fig 211.] [The Instrument as held while in the act of crushing the stone.—Ed.] that the mucous membrane is not included in the grasp of the instru- ment, the key is applied and used as shoAvn in Fig. 211, or as in Fig. [Fig. 212.] [The Instrument as held while in the act of crushing the stone.—Ed.] 212. Mr. Fergusson prefers to stand on the patient's left, and holds the instrument as in the last figure. [Fig. 213.] [The French Instrument noticed below. (From Fergusson.)— Ed.] Mr. Fergusson mentions a recent Parisian improvement upon this instrument, which was exposed at the Great Exhibition. (Fi">'!. 506 TUMORS OF THE BLADDER. but may be felt impinging on a soft and movable substance, obviously extraneous to the bladder's coat. It has been proposed to deal with this by means of the lithontriptor; but the prospect of success does not seem very inviting. Malignant tumors may form ; medullary; growing from the coats of the viscus—usually near its neck, in apparent connection with the pros- tate—and occupying the cavity to a greater or less extent. Micturition is frequent and painful; and the pain is greatest immediately after the effort; the urine is bloody and fetid, and often contains flaky sub- stances, or masses of the disorganized tumor; by impaction of these, occasional retention may occur; dull weight is felt in the loins; and the pain of micturition is much more pelvic, and more extensive there, than in the case of stone ; also the sound, on encountering the foreign body, imparts quite a different sensation. There is no remedy for this disease. We can only hope to palliate, by opiates, and the recumbent posture. Sometimes the tumor, expanding, may cause retention which is not capable of being relieved by the catheter; and, in such circum- stances, Ave are called upon to protract existence, by puncturing the bladder above the pubes. Cancerous disease may extend from the rectum to the bladder, involv- [Fig. 223.] [Drawing of a vascular, soft, spongy Tumor of the Fundus of the Bladder. (From Gross.)—Ed.] ing all in one large and loathsome sore. Malignant tumors also form between the two viscera, as formerly stated (p. 427). There is for such cases no cure. DISPLACEMENT OF THE BLADDER. 507 Displacement of the Bladder. It has been already stated that sometimes, though rarely, the blad- der is protruded, so as to constitute the contents of a hernial tumor. And displacements, too, of this organ, by pelvic abscess and tumors, are alluded to elsewhere. Miserable cases are not very unfrequent, in which the anterior half of the bladder is congenitally defective, as well as the corresponding part of the abdominal Avails ; the mucous surface of the viscus becoming consequently protruded to constitute a red moist SAvelling, from which the ureters may be seen throAving out their fluid.1 These admit of mere [Fig. 224.] [Ca°e of congenital Extrophy of the Bladder—the anterior wall of the abdomen, and that also of the bladder being deficient. The patient was 19 years old when the drawing was taken, a, represents the bludder, its mucous membrane everted and protruded through the abnormal opening in the anterior wall of the abdomen, constituting a red, moist, soft, easily-bleeding, painful tumor, bb. Orifices of the ureters, c. Penis without urethra, dd. Symphysis pubis, e. Scrotum and testis. /. Congenital inguinal hernia. (Gross, Diseases and Injuries of tfie Bladder, &c. p. 98.)—Ed.] palliation, by wearing mechanical contrivances adapted for protection and comfort. If the patient live to old age, the mucous coat is apt to become covered with vegetations, which, assuming malignancy, may fungate and bleed, and prove fatal. It has also happened, in the female, that the bladder has been inverted and protruded through the urethra, forming a vascular-looking tumor between the labia.2 Were this removed, under careless diagnosis, by 1 Handyside, Edin. Medic;il and Surgical Journal. 2 Crosse, Trans, of Provincial Med. and Surg. Assoc, vol. ii. IKK;; and Brit, and For. Rev. Oct. 1846, p. 319. 508 DISPLACEMENT OF THE BLADDER. knife or ligature, the most serious consequences must ensue. The true nature of the case may be ascertained by discovering the orifices of the ureters, and finding the whole tumor to be reducible within the pelvis. Sometimes it is irreducible. Laroche, Dissertation sur l'He"maturie, Paris, 1814. Chopart, Traite' des Maladies des Voies Urinaires, Paris, 1821. C. Bell on Diseases of the Urethra, Bladder, &c. Lond. 1822. Howship on Diseases of the Urine and the Urinary Organs, Lond. 1823. Foot on Diseases of the Urethra and Bladder, Lond. 1826. Be'gin and Lallemand, Diet, de Med. Prat. (art. Hematurie) t. ix. Paris, 1833. Coulson on Diseases of the Bladder and Pros- tate Gland, Lond. 1842. Guthrie on the Anatomy and Diseases of the Urinary Organs, Lond. 1843. Brodie, Lectures on Diseases of the Urinary Organs, Lond. 1849. [Civiale, Traite* pratique sur les Maladies des Organes Ge"nito-Urinaires, Paris, 1851; Gross, Diseases • and Injuries of the Bladder, &c. Philada. 1851.—Ed.] • CHAPTER XXXII. AFFECTIONS OF THE PROSTATE. Prostatitis. The prostate is liable to be affected by an acute inflammatory process, during the progress of virulent gonorrhoea. And this may also be ex- cited by direct injury of the part—as by a blow on the perineum, or rash usage of instruments introduced by the urethra; by excessive venereal indulgence ; by imprudent exposure to cold and wet; by sym- pathetic influence from affections of the rectum; by the internal use of cantharides, or other irritants. Heat and pain are complained of in the perineum, near the anus, and there is tenderness on pressure there; water is made frequently, and with pain; and pain is greatest as the accelerator muscles exert themselves to expel the last drops; there is a sensation of weight in the rectum; and that bowel is evacuated with both difficulty and pain; the finger introduced into the rectum ascer- tains the prostate to be large, hot, and tender on pressure; and an attempt to pass a catheter into the bladder is difficult and painful—the difficulty and pain occurring when the instrument's point has reached the prostatic region. Xot improbably, the action extends to the blad- der, and then the ordinary symptoms of cystitis are added to those already described. Treatment is by rigid confinement to the recumbent posture, leeching of the perineum, hip-bath, fomentation, and opiate enemata or suppositories. Sometimes relief is obtained from large, warm, and emollient enemata, which may be supposed to act as a poul- tice applied directly to the part. Direct leeching has been proposed, by means of a tube, or speculum, introduced by the rectum ; but it is probable that the irritation attendant on the application, will more than counterbalance the benefit obtained by such abstraction of blood. Abscess of the Prostate. When the above symptoms sustain sudden aggravation, with rigor, increase of swelling and tenderness in the perineum, greater difficulty of micturition, and greater swelling and tenderness on examination by the rectum, it may be presumed that matter is forming in the gland. Careful examination is made, in order to arrive at correct diagnosis; and as soon as fluctuation can be discovered, hoAvever obscurely, a direct incision is made by the perineum, to procure outward evacuation. If 510 SIMPLE ENLARGEMENT OF THE PROSTATE. an artificial opening be delayed, the abscess may open into the urethra— favoring the formation of urinous abscess ; or into the rectum establish- ing a troublesome recto-vesical fistula; or outwardly by the perineum, after much injury has been done to the intervening tissues. Sponta- neous evacuation into the urethra is indicated by copious purulent dis- charge from the penis. And then it is advisable to use a catheter, gently introduced, as often as may be necessary to empty the bladder— for some days—so as to prevent, if possible, untoward entrance of urine by the ulcerated aperture; or a soft elastic catheter may be passed and retained. Chronic suppuration of the prostate has been observed, causing much distress, with discharge of muco-purulent urine. On examination by the rectum, a soft point has been felt in the gland; and, on pressing it, matter has escaped by the urethra. The plunge of a lancet or trocar into the soft point has given relief, and troublesome fistula has not fol- lowed. Simple Enlargement of the Prostate. Simple enlargement of the prostate is of two kinds; one the result of chronic prostatitis; the other hypertrophy, independent of the in- flammatory process ; the one not uncommon in the adult of middle age, the other peculiar to advanced years. The former variety is dependent on stricture, or gleet, or affection of the rectum, or injury of the peri- neum by habitual horse-exercise; and disappears, usually, on remoAral of its cause. If not, recumbency is to be maintained, a few leeches are applied to the perineum; these are followed by smart counter-irritation, and, at the same time, internal use of the iodide of potassium may be of great service. The bowels are kept gently open, by simple laxatives and enemata. In obstinate cases, an alterative course of mercury is expedient; and, under this, amendment is sometimes both rapid and satisfactory. Hypertrophy of the gland is usually regarded as but one of the many signs of senile degeneracy in the frame. As the eyes grow dim, the trunk bends, the cartilages ossify, and the arteries change in their coats, so the prostate is supposed to grow large and hard. The enlargement may be uniform, the whole gland seeming to expand equally; displacing the urethra as Avell as compressing it, and consequently interfering with its function in regard to the urine. Or the central portion may enlarge with much greater rapidity than the rest of the gland; rising likea mamillary process; projecting backwards into the bladder ; but, ever and anon, liable to move forwards, and so to act as an occluding valve to the outlet of the cavity. In general, the lateral'lobes enlarge un- equally ; and consequently a twist is given to the prostatic portion of the urethra, in the lateral as well as in the vertical direction. The symptoms of this simple hypertrophy are—increasing slowness and difficulty in making water, uneasiness and difficulty in emptying the rectum, with a sensation of weight in that bowel and in the peri- neum ; sometimes the feces are passed flattened, as in stricture of the ENLARGED PROSTATE. 511 rectum. On introducing a catheter, some difficulty is likely to be met with in passing the region of the prostate; and when a finger in the rectum is made to Fl-- --5> press upwards on the catheter, the enlarged prostate is plainly felt betAveen. Without the use of the catheter or bougie, tactile examina- tion is never certain. As the tumor enlarges, calls to empty the bladder are more frequent, and the act is less perfectly accomplished ; as formerly stated, a portion of residuary water remains, cooped up behind the enlargement (p. 499). The bladder sympathizes ; it may become irritable; more frequently, a degree of chronic cystitis is excited. The urine changes in consequence; becoming dark-co- lored, fetid, and full of mucus. The vesical aspect of the projection may ulcerate, giving rise to haematuria, purulent urine, and aggra- vation of all the distress. The difficulty in micturition increases; and, at last, some ca- sualty acting as an exciting cause, retention occurs. Generally, this has not existed long before the " surface-water" comes to dribble away; and, by the establishment of inconti- nence, the retention is partially relieved, as formerly stated (p. 493). It may happen, however, that the obstruction is complete ; and by retention the patient may perish. Or, the whole urinary system having become in- volved in disease, death takes place by gradual exhaustion. Treatment is but palliative. We can scarcely hope to retard, much less to remove the en- largement. Every excess and imprudence is avoided in diet and exercise; and the recum- bent posture is maintained as much as possi- ble. The bowels are regulated by enemata and simple aperients. Opiates are given oc- casionally ; and acids, iron, buchu, &c, are exhibited, as the complication by chronic cys- titis may seem to demand (p. 489). To avert distension of the bladder, the catheter is used as often as may seem necessary. Excision of the gland has been talked of, but scarcely in sober earnest. Wljen retention has occurred, the catheter requires a peculiarity of management. As already stated, the urethra is considerably elongated; and the catheter must be of a proportional length. The prostatic por- tion of the urethra almost invariably has a bend given to it, antero- posteriorly—that is, the convexity is towards the rectum, the concavity towards the pubes; and, to suit this peculiarity of form, the instrument should have a large curve. Very frequently, the central enlargement The ordinary Catheter, of half si/ 512 ENLARGED PROSTATE. Fig. 226. t —or " third lobe," as it is usually called—exists ; and, to surmount it, it is well to have at least one instrument in the prostatic set, whose point makes a sharper curve upon the gene- ral bend. It is introduced carefully; and, to assist the point onwards, the handle is freely depressed after pass- ing the triangular ligament; while, at the same time, the point is elevated by means of the finger in the rectum. If the silver catheter, thus made and managed, refuse to enter, one of elas- tic gum may be tried; bent to the proper shape, and introduced with the stylet. On reaching the prostatic obstruction, the stylet is gently with- drawn, while the catheter is pushed steadily on, and the consequent ele- vation of the point may perhaps lead it over the obstruction. Or, the stylet being held steady, the tube is passed on, and the same effect is pro- duced—the catheter's point curving round that of the stylet, as it were. There is another peculiarity. As the prostate enlarges, not only is the prostatic portion of the urethra un- usually extended and curved ; it is also very considerably enlarged, by dilatation of the prostatic sinuses on each side of the verumontanum.1 In retention, this dilatation is usually full of urine; in fact, may be consi- dered as a small fictitious bladder in front of the real one. On the cathe- ter reaching it, a spoonful or two of urine may be discharged, and the surgeon may in consequence be led to suppose, that he has reached the bladder and emptied it—the remain- ing sAvelling consisting of abscess; the plunge of a trocar may follow; or the patient may be left to his fate, unrelieved. But, by invariably using the long catheter, in such cases, and never resting satisfied unless this The Prostatic Catheter; of half si/.e. instrument be passed teUUS Capulo--- unless, indeed, water flow freely, without such extreme insertion—the surgeon is safe from all such serious error. 1 Deschamps, Traite" de la Taille, torn. i. p. 200. MALIGNANT DISEASE OF THE PROSTATE. 513 Perhaps the prostatic obstruction proves insurmountable. Then the bladder must be relieved at all hazards; and one or other of the follow- ing methods may be adopted : The catheter may be forced through the obstruction; guided in a good direction by the finger in the rectum. Or a trocar and canula may be used instead of the catheter. Or, the bladder may be punctured above the pubes. The operation by the rectum is obA'iously unsuitable. Of these proceedings, perforation of the prostatic obstruction is the most advisable, by means of a suitable trocar and canula; the latter, of the same length and caliber as a full-sized prostatic catheter, but con- siderably less curved. It is passed carefully on to the obstruction, Avith its trocar withdrawn, and Avith its extremity temporarily occupied with a bulbous wire ; and, Avhen satisfied by the finger in the rectum, that the instrument is duly directed towards the bladder, the bulbous Avire is removed, the trocar is inserted and protruded, and the whole is pushed on. The trocar is then wholly withdraAvn; and the canula is retained for some days. When the retention has been of long duration, and there is reason to believe that the kidneys are organically diseased, the urine is to be withdrawn graduallv, for the reasons formerly adduced (p. 499). Malignant Disease of the Prostate. The gland is sometimes, though rarely, the seat of scirrhus. More frequently, it is affected by medullary formation, which enlarges rapidly, ulcerates, bleeds, and follows the usual course of such tumors. The disease is not peculiar to the aged. It may occur in children, as medul- lary tumors in other sites so frequently do. The symptoms are similar to those of mere ordinary enlargement, with the addition of those of tumors in the bladder (p. 505), as Avell as of those which attend and characterize all malignant formations. The disease is incurable. By opiates, the catheter, enemata, and rest, we may hope to palliate and protract. Deschamp, Traite" sur la Taille, torn. i. Paris, 1796. Home, Everard, Practical Ob- servations on the Diseases of the Prostate Cland, Lond. 1811. Lawrence, Lectures in the Lancet, 1829-30, vol. ii. Coulson, on Diseases of the Bladder and Prostate Gland, Lond. 1842. Brodie, on Diseases of the Urinary Organs, Lond. 1849. Adams, on the Anatomy and Diseases of the Prostate Gland, Lond. 1851. [Civiale, Traite des Mala- dies des Orpines Genito-Urinaire, Paris, 1851. Gross, Diseases of the Bladder, Prostate Gland, and Urethra, Philad. 1851.—Ed.] CHAPTER XXXIII. THE VENEREAL DISEASE. The history of the venereal disease is involved in some obscurity. However, it seems extremely probable—if not, indeed, quite certain— that affections of the genital organs, dependent on licentious venereal intercourse, have existed from the earliest ages ; that they have pre- vailed in various degrees of frequency and intensity, at different times and places; that they Avere not directly imported from America to Europe, by Columbus's followers, in the end of the fifteenth century; but that, between the years 1493 and 1495—at the time of the siege of Naples—they experienced an aggravation in Europe, and consequently attracted much more prominently the attention of the profession. They are usually spoken of under the general term of " The Vene- real Disease;" and this again is divided into Gonorrhoea and Syphilis ; both the result of the application of animal virus, engendered by illicit intercourse—or at least communicated thereby; the former an inflam- matory affection of the urethra; the latter a contamination of the whole system, preceded by the formation of pustular ulceration on some part of the penis, or other part of the body. By some, it is still maintained •that the poisons are the same ; that what produces gonorrhoea, is capa- ble of exciting syphilis, and vice versa. The Aveight of authority, hoAv- ever, preponderates largely in favor of an opposite opinion; admitting, perhaps, that gonorrhceal virus is capable of causing the simplest form, only, of venereal ulcer; and even that concession is by many not granted. Gonorrhoea. An acute inflammatory process seizes on the lining membrane of the anterior part of the urethra; caused by the application of gonorrhceal matter, from A second party; and this application usually made during sexual intercourse. There is a period of incubation, of uncertain extent; discharge may show itself Avithin not many hours after connection; or it may not be till after many days have elapsed. About the fifth day may be taken as the .average period of accession. Heat and itching are felt in the glans, Avhich seems fuller and more deeply colored than usual; the urethral orifice is uneasy, red, and swollen; urine is passed in a small stream, sometimes forked, and with increasing heat and smarting; the orifice of the urethra shows an increased secretion; then it becomes dry, more red and swollen, and painful; the stream of urine is more GONORRHOEA. 515 diminished, and the pain which accompanies it is intense ; then discharge returns—no longer limpid, but turbid and puriform—becoming more and more profuse, and ultimately seeming to consist of true pus; and if the action prove intense, there may be a considerable admixture of blood. Sometimes smart fever affects the system ; sometimes there is but little constitutional disturbance. The thighs, loins, and testicles sympathize by a dull aching sensation. Such are the ordinary symptoms at the onset of the disease. But, in the course of its progress, serious additions may be made. 1. Chordee may occur ; that is, abnormal erection may take place; the penis be- coming bent like a bow—forming an arc of which the urethra is the chord—the convexity on the dorsal aspect—probably on account of ex- udation having taken place into the corpus spongiosum, so as to prevent uniform expansion of the erectile apparatus. Such erection is intensely painful, and tends to aggravate the disease; it is also liable to induce profuse hemorrhage, probably by laceration of the mucous membrane. The tendency to chordee is greatest during sleep ; while the patient is Avarm in bed, and perhaps excited by voluptuous dreams. Sometimes, its proximate cause Avould seem to be other than plastic exudation ; normal and abnormal erections alternating with each other. 2. The glans may become excoriated, furnishing a profuse discharge ; establish- ing what is termed Spurious Gonorrhoea. 3. The prepuce may become oedematous; inducing the condition of Phymosis, when the SAVollen pre- puce maintains its ordinary relation to the glans; causing Paraphymosis, when it is reflected behind the glans, and allowed to remain there. The former state aggravates the disease, by retaining discharge, and increas- ing the tendency to affection of the glans; the latter leads to strangulation of the glans, and consequently to intense exacerbation there. 4. The lymphatics may suffer; becoming painful, red, and SAvollen on the dor- sum of the penis; or, Avithout such indication, inflammatory enlargement may take place in the inguinal glands, constituting what is termed Sympathetic Bubo. 5. Abscess may form in the penis; on the dorsum; or beneath, opposite to the lacuna maxima. The latter is the more fre- quent site. A main residence of the inflammatory action—which, in the first instance, does not extend beyond two inches from the orifice —seems to be in this lacuna; Avhich swells and becomes hard; filled Avith accumulated secretion internally, and externally invested by plastic exu- dation. In this exterior true inflammation may occur, causing abscess of greater or less extent. 6. Or abscess forms in the perineum, at a distance from the original site of action—a less frequent complication; threatening retention of urine by compression of the urethra, and urin- ous abscess by opening internally (p. 504). 7. Or prostatitis ensues; sometimes by continuous extension of the inflammatory process along the membrane; more frequently, perhaps, by metastasis. And in severe cases—either originally and innately so, or become urgent in conse- quence of either mal-practice, or imprudence on the part of the patient —abscess may form in the prostate; usually superficial, as regards the urethra ; temporarily causing retention of urine ; early emptying itself internally, and rendering urinous abscess not improbable (p. 510). 8. Or, the inflammatory process extends still farther, and more untowardly 516 ACCIDENTS OF GONORRHOEA. —either by continuity, or by metastasis ; and acute cystitis results; aggravating all the local symptoms, and, by urgent disorder of the sys- tem, bringing even life into peril. From the bladder—with or without abscess of that organ—inflammation has extended to the peritoneum, and proved fatal. 9. Acute rheumatism may supervene; the joints of the limbs becoming painful and swollen, and the system suffering under inflammatory fever. The knee and ankle-joints are those most frequently and prominently involved. The supervention sometimes takes place during the acute stage, sometimes during the decline ; occasionally, the rheumatic symptoms are coeval with those of the gonorrhoea. Or gouty symptoms may be excited, in those of the better ranks, and of advanced years. 10. Very often, in protracted cases, orchitis takes place ; the inflammatory action sometimes seeming to be transferred to the testicle by metastasis, sometimes seeming to creep along from the posterior part of the urethra to the vas deferens, and thence to be extended to the epididymis and testicle—becoming mainly resident in the former. Dur- ing the acute stage of such orchitis, urethral discharge diminishes, and may wholly disappear ; not necessarily proving a metastasis, but explica- ble quite on the principle of relief by counter-irritation. As the orchitis declines, discharge usually reappears. Orchitis may be caused at any period of the case, by a blow on the part, or by imprudence in exercise. If spontaneous in its accession, it usually occurs in the chronic stage ; weeks, perhaps, after the first appearance of discharge. Gonorrhoea is one of those affections which are capable of self-cure. The intensity of the symptoms gradually subsides ; the complications which may have occurred are recovered from; and the discharge becomes less copious, and somewhat restored to the mucous character. This state is termed a Gleet—embers of the previous burning. There is little or no pain, swelling, or redness ; thin discharge is the prominent symptom; with, perhaps, some trouble in micturition. In a patient who has suffered from previous claps, a greater or less degree of contraction in the urethra probably exists; but, in primary attacks, the gleet need not be suspected of such complication. In any case, it is not to be considered that the gonorrhoea has finally ceased—becoming merged in an affection of a different name and kind ; for, from but a slight cause—as unusual exercise, imprudence in diet, or such like—reaccession of the inflamma- tory process may take place ; and the gonorrhoea may be revived in even more than its pristine severity. The Treatment of gonorrhoea varies, according to the stage of advance- ment. At the first onset, what is termed the ectrotic or abortive treat- ment may be attempted; while the inflammatory process is still nascent, and has not reached the suppurative crisis. The nitrate of silver is used, as in similar affections of the surface ; with the view of procuring rapid resolution (Principles, 3d Am. Ed. p. 178). It is applied, in the form of strong solution, to the affected part of the mucous membrane—carefully, by means of a glass syringe, so as to pervade the whole diseased surface. Some prefer the form of ointment.1 A coagulated film is produced, » zi to gi of lard The strength of the injection may vary from fifteen to thirty grains in the ounce of distilled water. TREATMENT OF GONORRHOEA. 517 which, adhering, protects the villous surface beneath during the passing of urine ; besides, the purely antiphlogistic effect of the remedy may be obtained, here, as in erythema ; and, not improbably, a third beneficial indication may be fulfilled—the A'irus may be chemically acted on and neutralized. Such injection or application is made once or tAvice—at an interval of tAvelve or tAventy-four hours ; and strict rest, "with anti- phlogistic regimen, is observed.1 The action may be arrested, resolution may rapidly folloAv, the virus may be destroyed, and the disease may thus be cut short in its outset. Obviously, however, such ^treatment is applicable only to the very earliest stage—which is seldom brought under the cognizance of the surgeon ; in irritable habits it is not likely to succeed; and, under eAren the most favorable circumstances, there is ahvays a risk of failure, with consequent aggravation of the original disease. Failing the ectrotic attempt—or, no opportunity having occurred for its practice—the acute or inflammatory stage is met by ordinary anti- phlogistic means. And it is well to remember, in reference to this, that the first attack of gonorrhoea is generally the most severe. Rest is enjoined ; but, for obvious reasons, this all-important indication is but seldom fulfilled—and hence one cause of this affection often proving tedious and troublesome in its cure. Diet is low ; the part is fomented, and by a handkerchief or bandage it is suspended; antimony is given in nauseating doses ; the bowels are gently moved ; drastic purging does harm, by irritating the rectum, and inArolving the urethra in sympathy ; leeches may be applied to the perineum ; and, if uneasy feelings pervade the hips, loins, and thighs, the hip-bath will be found useful. In ex- treme cases, it may be necessary even to abstract blood from the arm. To mitigate the ardor urinae, bland fluids are drunk abundantly; as linseed tea, a solution of mucilage, &c. To render the urine less acrid, saline draughts are useful; as, a scruple of bicarbonate of soda, with a drachm of Bochelle salt, dissolved in tepid water, and then mixed with soda water; taken three or four times daily. Bland enemata are useful, in regulating the bowels; and, in the case of a sympathizing prostate, they are of service as a fomentation or poultice to that part. The anti- mony is of use, not only as antiphlogistic, but also as antiaphrodisiac ; and this latter indication is to be assisted by suitable moral treatment on the part of the patient. Camphor, too, and lupulin, are useful in the same way. Should painful erections occur, opiates are given, es- pecially at bedtime ; a pill of opium, hyoscyamus, and camphor, is found to be very suitable ; repeated as circumstances may demand. And the patient should lie cool at night, with few bedclothes. Sometimes full doses of colchicum are of service, in relieving chordee—especially in those cases which possess the rheumatic complication. Leeching of the affected part is not advisable ; the leech-bites are likely to cause swell- ing, partly by ecchymosis, partly by oedema ; and such swelling tends to complication by phymosis or paraphymosis ; besides, the wounds are 1 Some employ the nitrate of silver in another way, for ectrosis ; using a weak solution —say two grains to eight ounces of water—and injecting this once every four hours, for ten or twelve times. We would put more faith in the concentrated and less frequent form of application. 518 TREATMENT OF GONORRHOEA. liable to be inoculated by the virus, and troublesome sores may be the consequence. At this stage, ectrotic treatment is not to be thought of. We would not seek for sudden suppression of discharge, were this in our power. If it do occur, it is an untoward event; sure to be followed either by aggravation of the original disorder, or by implication of the prostate, bladder, or testicle, through metastasis. Strong injection, therefore, is not suitable. No doubt, it may temporarily arrest the discharge ; but only because such exacerbation of the inflammatory process has taken place, as checks all secretion ; pain, swelling, and redness are greater than before ; and discharge soon reappears in increased quantity. The inflammatory crisis having passed over, the sternness of the antiphlogistic treatment is gradually departed from. And certain remedies are given,1 Avhich by experience are found to exert a specific influence on the urethra; copaiba and cubebs ; the former the more suitable at first; given in cautious doses, lest a deleterious amount of stimulus be imparted to the membrane. As the case becomes chronic, antiphlogistics are gradually abandoned. And, for the state of congestion which remains in the membrane, the direct application of gentle stimuli is found useful. Pressure may be applied, by a compress OATer the corpus spongiosum ; but this is found irksome, and difficult of management. The method of injection is pre- ferable. A glass" syringe, with blunt point, and long narrow nozzle, is employed ; by means of which—inserted fully into the urethra—appli- cation of the injected fluid may be made accurately to the whole dis- eased surface. BackAvard extension to the bladder need not be appre- hended, the natural collapsed condition of the canal being a sufficient obstacle to this. The fluid injected is at first weak: and its strength is gradually increased, according to circumstances. In nothing is there more room for variety. Some use an infusion of green tea, or other vegetable astringent. Sulphate of zinc is perhaps most commonly em- ployed ; or the acetate of zinc ; or sulphate of copper ; or the salts of iron ; or the nitrate of silver; or alum ; or strychnia. A favorite in- jection is the acetate of zinc, with a proportion of opium. Water is passed before injecting, so that the fluid may reach the membrane directly ; and, on withdrawing the syringe, the point of the penis is held erect for some time, so as to keep the fluid in contact with the affected part. The operation may be repeated three or four times in the day; but should over-excitement ensue, injection must be wholly discontinued for a time ; and when resumed, it must be very cautiously. As already stated, the strength of the injection is gradually increased; and, if it seem to have lost its influence, it is better to change to a different kind, than to increase the first to a strength at all formidable. In fact, the principle of stimulation is conducted as in the use of lotions to a weak sore on the surface of the body (Principles, 3d Am. Ed. p. 234). In 1 These remedies act on the part; as is shown by experiment. If a patient with fistula in perineo have contracted gonorrhoea, and if the whole urine be permitted to pass through the fistula, no benefit will accrue from any dosing with cubebs or copaiba. But when, by shutting up the abnormal aperture temporarily, the urine is made to pass over the whole urethra, amendment is at once observed. TREATMENT OF GONORRHOEA. 519 obstinate cases, benefit may be derived from nitrate of silver rubbed on the perineum, so as to act as a smart counter-irritant. In the truly chronic stage, large doses of cubebs may be given with advantage ; regard always being had to the kidneys, lest over-stimula- tion occur there. And sometimes rapid amendment may be obtained by cubebs combined with copaiba in the form of paste, given in wafer paper—an admirable remedy for the chronic cases, but usually much too stimulant for the early stage. These internal remedies may be employed along with injection. Or they may be alternated. But, in no case, should injection be long and continuously persevered with ; otherwise a discharge of the stimulant's OAvn production may be main- tained, keeping up a state of congestion in the membrane, delaying the cure, and rendering the occurrence of stricture very probable. Sometimes the affection is chronic from the first; passive congestion furnishing the discharge. This is liable to occur in patients of slug- gish temperament, who have had many attacks of the disease. In such cases, antiphlogistics are never suitable; and the stimulant mode of treatment is adopted from the first. The casualties of the disease are met as they occur. Chordee re- quires cool covering of the parts at night, a suitable moral treatment, and sedatives (p. 517). The attack, when spasmodic, may be mode- rated by immersion of the organ in cold water. Hemorrhage often requires no treatment, being regarded as a salutary occurrence, auxil- iary in the treatment; if excessive, it may be restrained by the appli- cation of cold, or by pressure, as already described (p. 493). G^dema is relieved by fomentation and poultices. Bubo requires fomentation and rest; and, its first acuteness over, external application of iodine is likely to obtain resolution. Abscess threatening in the penis, or in the perineum, is opposed by increased and concentrated antiphlogistics ; if matter have formed, an incision cannot be made too early for evacua- tion. Affections of the prostate and bladder require their suitable treatment, already noticed (p. 488, &c). Small cold enemata, contain- ing a moderate quantity of laudanum, are sometimes very useful. And it is well to avoid these attacks, by doing nothing heroically, in the way of injection, after the gonorrhoea is fairly established. With some, no doubt, strong injections are still in vogue, even at an advanced period of the case. But in our opinion, they are warrantable only at the very first, as already stated; and then should consist only of nitrate of silver —which alone seems capable of exerting a purely antiphlogistic influ- ence on the skin and mucous membrane. It is used here, as in inflam- matory affection of the mucous membrane of the throat; it forms a pro- tecting crust, allays irritability, and resolves the inflammatory action. The same strength of sulphate of zinc would prove merely stimulant, and would not fail to cause aggravation. Gout and rheumatism are met by their peculiar treatment. And, obviously, it is important to remove the tendency to uric deposit as speedily as possible ; othenvise, the pass- ing of this cannot fail to maintain, and probably to increase the urethral excitement. Thus, according to the ordinary principles of surgery, would we treat gonorrhoea ; and with a good hope of success; if the indications 520 TREATMENT OF GONORRHOEA. regarding regimen and rest be fully carried out—a difficulty in many cases, as already stated. But there is no disguising the fact, that not unfrequently the disease proves quite intractable ; as if determined to run its own course, regardless of the means employed—unchecked, almost unmitigated and unmodified. In such cases, some peculiarity of constitution will generally be discovered ; scrofula, gout, or extreme irritability of system. And, for such difficulties, no general rules of treatment can be laid down. Each must be met by what seems most suitable under the circumstances; always aAroiding undue activity of practice ; and preferring rather that the disease should run its own course, than that by unfortunate interference more serious affections of the prostate, bladder, testicle, or general system should be induced.1 In general, a tonic treatment is required; specially the preparations of iron and quinia ; with the latter, nux vomica has been successfully combined.2 Bougies are by some recommended; but we would move them alto- gether from gonorrhoea to gleet. Their use in the former affection is extremely apt to over-stimulate, causing reaccession of the disease. In gleet, however, they are very serviceable, by obviating any tendency to contraction in the urethra, and removing the congested state of the lining membrane ; and sometimes by means of a bougie, the citrine or some other stimulant ointment may be beneficially applied to the ante- rior part of the membrane. In obstinate cases, with irritability of the posterior part of the canal, nitrate of silver may be applied—cau- tiously—by means of Lallemand's porte-caustique. In some cases of obstinate gleet, the discharge seems to be kept up by chronic prostatitis, and to come from the follicles of the gland. Under such circumstances, Chian turpentine, in five-grain doses, often arrests the secretion ; seeming to have a special action on these parts.3 After discharge has ceased, and uneasy sensations have almost Avholly disappeared, great care is still necessary on the part of the patient. Cure is not yet complete. A hearty meal, a debauch in wine, venereal indulgence, a long walk or ride, may reinduce the discharge and pain. Avoidance of all such re-exciting causes, therefore, must be scrupulously observed, until at least a week has elapsed. As to the period when contagion ceases, opinions differ. Probably, the discharge is most virulent when first displayed—as yet non-puru- lent in character. Perhaps, as the purulent character is declared, viru- lence may decrease, and soon disappear. Possibly, the creamy thick discharge may not be different in any respect from the ordinary product of simple inflammation. But such matters are, as yet, not fully remoA-ed from uncertainty ; and it is well always to approach error on the safer side ; holding, for practical purposes, that, so long as there is discharge, there is at least a possibility of communicating infection thereby. 1 The length of time during which an obstinate gonorrhoea may persist, is sometimes great; but scarcely so extreme as that mentioned by one eminent modern authority, who gravely tells us of claps contracted at the peace of Amiens in 1800, being still running in 1840 \—Lancet, No. 1203, p. 5)0. & & 2 Brit, and For. Rev. July, 1850, p. 226. 3 Adams ou Diseases of the Prostate, p. 35. GONORRHOEA PRiEPUTIALIS. 521 Sometimes the eyes suffer by gonorrhoea; and one of two affections may occur. Gonorrhoeal ophthalmia includes conjunctivitis and iritis. Gonorrhceal conjunctivitis, as formerly noticed (p. 118), is usually the result of direct contagion; virulent gonorrhoeal matter having been applied from a second party. The inflammatory process is rapid and intense; and the most active measures are necessary, to prevent serious structural change. Gonorrhoeal iritis, on the other hand, is a remote constitutional result of the virus within the patient himself, occurring as a secondary symptom, usually mild in its character, and demanding no severity of treatment. It most frequently occurs in those of a rheu- matic habit, and is not unlikely to be associated with affections of the joints. Often, it is accompanied with corneitis. Secondary symptoms, of any kind, are rare. Sometimes, hoAvever, a febrile disturbance is followed by papular eruption, and gonorrheal lichen is said to be established. This, too, is mild. Under anti-febrile measures, the precursory disorder soon yields, and the eruption will not resist simple and ordinary treatment. Like the primary affection, it is capable of self-cure, and may often be medicinally disregarded. Mer- cury is never necessary. The virus of gonorrhoea is comparatively mild; its seat would seem to be much more in the part than in the system; and, when the latter is inA'olved, it is but slightly. In some constitutions there is intolerance of copaiba; its use being folloAved by the appearance of an eruption, of the nature of urticaria, preceded and accompanied by smart constitutional disturbance. Dis- continuance of the remedy, with antiphlogistic regimen, is enough. Gonorrhoea prseputialis, sometimes termed spurious gonorrhoea, but more correctly balanitis, denotes a condition of the preputial membrane and investment of the glans, similar to that of the urethral lining in gonorrhoea. The disease may be an accession to gonorrhoea; or it may occur independently of this, from the same cause. Or it may be alto- gether simple in its origin; resulting from accumulation of acrid secre- tion, from retention of calculous matter, or from external injury. The part is red, swollen, partially abraded by superficial ulceration, and discharges a profuse puriform secretion. The prepuce is oedematous; and there is more or less trouble in micturition. Treatment is simple. An ectrotic result by nitrate of silver is almost ahvays in our power. The glans, having been exposed, is pencilled lightly over by nitrate of silver in substance; or, what is better, by a strong solution t)f it. Within four-and-tAventy hours, the intensity of inflammatory action and the amount of secretion will be found greatly diminished. And, very probably, another application will complete the cure. Of course, rest and antiphlogistic regimen are not neglected. Warts are a frequent concomitant of the foregoing affection ; or they may form independently of it. They are usually clustered round the corona glandis, and on the frsenum [Principles, 3d Am. Ed. p. 380). The best method of removing them is to take away the projecting por- tions by knife or scissors, and then to touch the stools with an eschar- otic; the nitrate of silver, firmly applied, may prove sufficiently powerful; or some one of the other suitable destructives may be used, as bichloride of mercury, dissolved in alcohol, 3i to Ji; equal parts of savine powder 522 GONORRHOEA IN THE FEMALE. Fig. 227. and burnt alum ; acetic acid, or a strong in- fusion of tormentilla officinalis. A more genuine form of spurious gonorrhoea occurs, when, from some cause, other than the application of gonorrhceal matter, inflamma- tory action is kindled in the anterior part of the urethra, and furnishes discharge. The inflammatory process is common, not specific. The symptoms are comparatively mild ;' and their duration is short. Ordinary antiphlogis- tics suffice for cure. The more common excit- ing causes of such an affection are—the in- AVarts on the Penis. ternal use of cantharides, or other irritants; the application of acrid female secretions in marital intercourse; injury done by instruments, or by the passing of calculous fragments; external injury of any kind; sympathy with the rectum. Gonorrhoea in the Female. The female suffers comparatively little from gonorrhoea. For a few days only the acute symptoms persist, and the chronic stage is attended with but little discomfort. The parts affected are the urethra, as in the male, the vulva and exterior of the vagina, and the os uteri; the last- mentioned part frequently becoming affected by superficial ulceration. Sometimes the inguinal glands enlarge sympathetically. The prominent symptoms are—discharge, painful micturition, pain and swelling in the vulva, oedema of the prseputium clitoridis, uneasiness in sitting and walking; at first, some constitutional disturbance; often an aching in the back and loins. Treatment is simple. At the outset, an ectrotic result may be obtained, the vulva being painted over by nitrate of silver. Failing this, during the short acute stage, recumbency is enjoined, with antiphlogistic regimen ; the parts are diligently fomented; and, if need be, demulcents are given freely. Afterwards injections are to be used, of greater strength than in the male—the pelvis being elevated during, and for some time after injection, so as to prevent premature escape of the fluid; and a piece of lint, soaked in the stimulant solution, may be kept constantly retained in the vulva. Gallic acid may be useful inter- nally; and, ultimately, a tonic system of general treatment may be expedient. Young girls are liable to suffer from a spurious gonorrhoea, caused by some intestinal, rectal, vesical, or general irritation ; and consisting of an excited, and perhaps excoriated state of the vulva and orifice of the vagina, with discharge. It yields readily to removal of the cause, fol- lowed by the simplest local treatment. A knowledge of its nature and origin is obviously of much importance, in a medico-legal point of view. The true gonorrhoea, is apt to be confounded with leucorrhcea; but may generally be distinguished, by attention to the history of the case and its accompaniments ; also remembering that in gonorrhoea there is SYPHILIS. 523 vesical and urethral disorder, with tendency to glandular irritation in the groins, while in leucorrhcea, these affections are comparatively uncommon. Syphilis. This includes, as a general term, all the diseased states, local and constitutional, primary and subsequent, AAThich follow, and are caused by, the inoculation of venereal poison. The action of poisons has already been considered (Principles, 3d Am. Ed. p. 608); as well as the pro- bability that there is here a double process of zymosis. The virus, settling on and in the part, accumulates there, and, at the same time, excites an inflammatory process, soon ending in true inflammation; and this always causes suppuration and ulceration—sometimes sloughing. This constitutes the Primary or Local symptoms. From the specific sore, thus produced, absorption takes place, after the acute crisis of inflammation has passed (Principles, 3d Am. Ed. pp. 115 and 148). And, by absorption, the \*irus enters the system, through the circulation; more or less rapidly, and in greater or less quantity. In the system, a second zymotic process is established; the poison is multiplied; and, acting perniciously on the frame, it declares itself by fever and erup- tion—these constituting the Secondary or Constitutional symptoms. By such an outbreak, the poison may be fully eliminated ; and, if so, then the disease is at an end. If, hoAvever, elimination is incomplete, then other affections—of bone, skin, and mucous membrane—make their appearance at a still more remote date ; and these are termed Tertiary symptoms. The venereal ulcers, or primary sores, are of different kinds ; and these different kinds are liable to be folloAved by corresponding variety in the secondary symptoms. Hence it has been inferred, that there are varieties in the originating virus—that there is a plurality of poisons. At present, the question is involved in much uncertainty. But for practical purposes, it is sufficient for us to know, that all venereal sores are not alike in their characters, progress, and results ; that at least four different varieties exist, and can readily be discriminated; and that each of these requires peculiarity of treatment. But, in the first place, it is important to observe, that all sores of the penis are not venereal; and, farther, that all sores of the penis, caused by impure sexual intercourse, are not necessarily of this nature—the product of a specific virus. The penis is as liable as other parts to ordinary causes of the common inflammatory process ; and common sores may result. Again, it is liable to be excoriated during coition; and a sore may form in consequence, quite unconnected with inoculation of any virus. And, also, the part is liable to herpetic eruptions, of quite a simple nature. Herpes of the penis usually occurs on the integuments of the body of the organ: sometimes it forms on the preputial lining, behind the glans. It may be caused by the contact of acrid female secretions— not virulent; or its accession may be altogether unconnected with sexual intercourse. It is known by the character of the vesicles; their plurality, form, speedy formation, and early disappearance. Rest, 524 SIMPLE VENEREAL ULCERATION. cooling medicine, and some simple soothing application, constitute the necessary treatment. Patients once affected by it are very liable to its recurrence. Simple abrasion is known by its immediate appearance, by absence of the preliminary inflammatory process and pustular formation, by its superficial extent and irregularity of form, by the absence of true ulceration, and by speedy assumption of the healing process. It heals under ordinary simple means. Common sores are known by the history of their production, and by absence of the characteristics of the venereal ulcer. If any doubt exist, it is expedient to treat the sore, locally, as if it were really vene- real. Thus all risk, by mistake, is averted from the patient. And, if it be considered of importance to arrive at certainty on the subject, the test by inoculation may be had recourse to. A portion of discharge from the sore is inserted, by the point of a lancet, in the inside of the thigh ; if the virus be present, a succession of results will occur as in the case of other inoculations; active congestion will form, then pustu- lar formation, and then ulcer. By the third day, the characteristics will be sufficiently plain.1 And then, by freely rooting out the forming pustule by means of an escharotic, propagation of the disease is pre- vented. I.—The Simple Venereal Ulcer. If previous excoriation, or other breach of surface exist, the sore may declare itself at once; the incipient inflammatory process becoming apparent almost immediately after connection. More frequently, the virus has to find its way through entire skin or mucous membrane. And a day or two, consequently, may be occupied by a period of incubation —ranging from one to ten, or more.3 Then the inflammatory process, causing pustular formation and ulcer, advances, as already stated; ulceration being generally established by the sixth day from the time of infection. The progress may be conveniently divided into three stages.— First, that of inflammatory action and pustular formation. Redness forms, with itching and heat: in the centre of the redness vesication takes place ; the contents of the vesicle become purulent, constituting a pustule ; this breaks, with or without scabbing, and discloses an acute ulcer beneath. The second period is that of ulceration; occupying, also, it may be said, from three to ten days. The advancing sore is usually of a circular or oval form, excavacated, of pale surface, sur- rounded by a bright inflammatory areola, and furnishing a thin ichorous discharge. This is the period of infection, inoculation, and arrest by cauterization. The thin ichorous discharge, not yet truly purulent, is certainly most charged with the virus, and consequently most likely to propagate the disease by contagion. It is now that the most favorable 1 For detail of the results of venereal inoculation, see Ricord, Lancet, No. 1278, p. 225. 2 There seems good reason to suppose, that in general the virus begins to act very soon after its application ; within a few hours, in most cases ; and that the examples of appa- rently protracted incubation depend, chiefly, on the circumstance of the poison having been temporarily intercepted, as it were, by a hair follicle, a hardened portion of cuticle" or other obstruction. SIMPLE VENEREAL ULCER. 525 opportunity exists for attempting the test by inoculation—if such be desired. And it is only at the early part of this period, that Ave have it in our power, by converting all into an instant slough, to extirpate the disease while it is yet Avholly local. The third stage is that of repara- tion ; the sore speedily shoAving the characters of the weak class (Prin- ciples, 3d Am. Ed. p. 233). Tall, pale, and flabby granulations sprout up, above the level of the surrounding parts ; and the vascular areola diminishes, in both extent and intensity. In this state, the sore may remain stationary for many days. But, on the healing process being begun, a fourth stage may be said to be in progress—that of cicatriza- tion.1 The negatiA'e signs by which this sore is distinguished, are: the absence of surrounding induration, no elevation of the edges, and no tendency, to phagedaena. Its ordinary site is on the prepuce, and in the sulcus behind the corona glandis; often by the side of the fraenum ; occurring, in short, in the parts most susceptible of, and most exposed to contagion, and where the virus is most likely to nestle, overlooked. All sores near the fraenum are unfavorably situated. The second stage is of long duration, and ulceration is acute; the sore continues to enlarge ; often it burrows beneath the frsenum, causing perforation; and reparation seldom advances, until the fraenum has been wholly destroyed. In all such cases, therefore, it is well to abbreviate the process, by division of the frsenum at once ; care being taken that troublesome hemorrhage do not ensue, from the small but active artery which generally shows itself at the time of incision. In treatment, early application is of the greatest importance. For it is only during the first feAv days that we can be certain of success in the ectrotic attempt. Some authorities extend the favorable oppor- tunity to the sixth day, from the first symptom of infection; and some include the whole period of the second or ulcerative stage. All seem agreed that, Avithin the first three or four days from the application of the exciting cause,2 it is certainly in our power to root out the disease : " punching it out," as it were ; converting the poisoned ulcer into a simple sore ; and preserving the system quite untainted. For this pur- pose, an escharotic is freely applied ; nitrate of silver—or, what is more certain, the potassa fusa—pointed, inserted accurately within the sore and pressed there firmly ; the fluid exudation being wiped up, 'as it threatens to overflow. Water-dressing is applied, until the eschar separates; and then the surface beneath is anxiously scanned. If it present the characters of a simple and healthy sore, Avater-dressing is continued, and healing advances. If, however, the tawny surface and angry appearance of a still virulent ulcer shoAv themselves, the eschar- otic is reapplied. And such repetition is carried out, from time to time, until a satisfactory clearing has been obtained. If profuse and offensive discharge exist, it may be well to medicate the water-dressing, from the first, by one or other of the chlorides. 1 On the glans there is little or no reparative action by organization of new material, whatever kind of sore exist; consequently, there the cicatrix is always depressed, and loss of substance is permanent. 2 Ricord guarantees immunity if ectrotic treatment have been thoroughly applied within the first four days from the application of the virus. 526 SIMPLE VENEREAL ULCER. The healing process having begun, simple water-dressing should not be long continued ; for, sores on the penis, even of a simple nature, tend speedily to the characters of the weak sore. Early medication, by zinc or otherwise, is accordingly required. If, notwithstanding, the granu- lations threaten exuberance, there is no better plan than to touch the elevated surface, every second day, with the nitrate of silver, lightly; applying water-dressing intermediately. During the treatment, rest is of" the greatest importance ; and the organ should also be suspended, by a handkerchief or bandage. If the case be seen too late to admit of ectrotic treatment, the sore being in the third or reparative stage, the application of nitrate of silver is still useful, by subduing the exuberant granulations, and expediting the healing process. We cannot now save the system from contamina- tion, absorption having already been busy. But we may diminish the amount of taint, by shortening the period during which absorption takes place; and, besides, the nitrate may probably act decomposingly on the remaining local virus. Experience tells us, that the more speedily the sore is healed, the less is the likelihood of the occurrence of secondary symptoms. Warts are not an unfrequent complication. They are subject to the same treatment, and are of the same nature, as those which attend on gonorrhoea (p. 521). The secondary symptoms which occur, at a period of from three to six Aveeks after infection, if the ectrotic attempt have failed, or have not been practised, are usually either exanthematous or papular, vene- real roseola, or venereal lichen. The eruption is preceded by fever, and is accompanied by an affection of the throat, similar to Avhat attends other eruptions of the same class. The tonsils, and fauces in general, are red, raw, swollen, and painful; sometimes invested by an aphthous coating, sometimes superficially abraded. The eruption is chiefly situated on the trunk, more especially on the back and belly, but the face and limbs are not exempt. Sometimes there is mere discoloration of the skin, in numerous faint spots. A patient having begun to complain, at the ordinary time of acces- sion, of such symptoms of general disorder as usually usher in the secondary symptoms, it is our object to favor an early and full appear- ance* of the eruption; for, thus the febrile condition will be relieved, and what seems the natural effort towards extrusion of the poison from the system Avill be assisted. To check the skin affection, Avere as unwise as to attempt repression of the eruptions of measles, smallpox, or scar- latina. The bowels are gently acted on, and a Avarm bath is given. Regimen is antiphlogistic, and confinement to the house is enjoined. Antimony is given. Avith more than one object in view; it tends to moderate fever, at the same time determining to the skin, and there is good reason to believe that it is also an auxiliary of no mean poAver in elimination of the virus. The eruption, having attained its acme, gra- dually fades. At the same time, the affection of the throat recedes, but, in general, amendment here may be expedited by use of the nitrate of silver. By warm bathing, restriction of diet, avoidance of exposure, and general attention to the skin—iodide of potassium, sarsaparilla, or ULCER WITH ELEVATED EDGES. 527 other alteratives being given if necessary—purity of the surface is restored, and the cure is complete. It is seldom that the more decided but more dangerous alterative, mercury, requires to be had recourse to. Its sparing exhibition, only as an alterative, is expedient, however, when the eruption either proves obstinate in its first attack, or tends to sundry recurrences, under the ordinary treatment. Tertiary symptoms need not be dreaded. II.— The Ulcer with Elevated Edges. In this, a compound of the irritable and inflamed sores, of the general surface (Principles, 3d Am. Ed. pp. 244 and 246), the reparative stage is late, not occurring until at least two or three weeks have elapsed. The excavated surface is of a brownish hue, and the edges are elevated, not only aboAre this raw surface, but also above the surrounding parts. There is no surrounding induration, and there is no phagedaena, but, sometimes, the ulceration is acute and rapid, destroying the parts, by persistence of acute inflammatory action, almost as formidably as if by phagedaena, more especially if the sore be situated near the frsenum. Treatment is the same as for the former class of sore. But, if the healing process be obstinately deferred, in cases too late for ectrotic treatment, mercury may be cautiously administered; a blue pill, or a pill of iodide of mercury, being given, night and morning, until the characters of the sore shoAv amendment. Even this cautious dose, how- ever, is not expedient, until the more simple and safe means have been fairly tried and found ineffectual. The partially irritable is liable to pass into the thoroughly inflamed sore, here as elsewhere. In such circumstances, all escharotic or other- wise irritant applications must be abstained from, until, by the ordinary means, inordinate inflammatory action has been subdued. In the irri- table condition, the oxide of siher is sometimes of use, in the form of ointment. If the ectrotic attempt have failed, the occurrence of secondary symptoms is extremely probable. Antecedent febrile disturbance is more considerable than in the first class of cases, and the eruption is usually of either the papular or pustular character, more frequently the latter. The pustules are chiefly situated on the chest, back, and face ; occasionally, they degenerate into irritable sores, but the majority fade, and heal by incrustation. Their site is marked by brownish discolora- tion, sometimes of obstinate persistence. Bubo is not unlikely to occur, more especially if the patient fail to observe recumbency ; the lymphatic enlargement not, in general, dependent on a common inflammatory pro- cess, excited by simple irritation on the penis, as in the case of gonorrhoea, or simple abrasion, or herpes, but on a specific inflammatory process, caused by propagation of the virus from the original site, and lodge- ment of it in the ganglia. Iritis, too, may occur, constituting a serious complication. Affection of the throat is tolerably severe, and the ton- sils may display extensive aphthous ulceration. The secondary eruptions require the same general treatment, as those which follow the first class of sore. Bubo is treated by rest, fomenta- 528 HUNTERIAN, OR TRUE CHANCRE. tion, &c.—perhaps by leeching. Iritis demands its own peculiar man- agement, formerly detailed (p. 135). Only in the slightest forms, dare mercury be Avithheld. Its exhibition here is not antisyphilitic, but anti- phlogistic ; and it is managed accordingly. The throat requires soothing by inhalation, in the first instance; afterwards, the nitrate of silver, in substance or in strong solution, applied every second day, will remove irritability in the breach of surface, and expedite cicatrization. If either the throat or the skin affection prove chronic and obstinate; or if, after deceptive disappearance, reaccession occurs—mercury may be given, sparingly ; rather, hoAvever, as a last resource, than as an ordinary part of the treatment. Antimony and the iodide of potassium, with attention to hygiene, prove sufficient in the greater number of cases. A troublesome sore sometimes forms on the orifice of the urethra; and it generally is of this class. Constantly exposed to irritation, by the passing of urine, it is slow to heal; it may, by persistence of ulcera- tion, cause considerable loss of substance; and then cicatrization cannot occur, without producing more or less contraction of the urethra at that part. Hence, it is obviously of great importance to detect its presence early, and to make sure of the ectrotic treatment. During the subse- quent healing, light application of the nitrate of silver is very suitable; this forming an adherent incrustation, protective of the parts beneath. And this protection may be farther aided, by the temporary application of an oiled piece of lint, on each margin of the orifice during micturition. Sores sometimes form more within the urethra ; causing much trouble, by pain, swelling, discharge, and liability to constitutional sequelse; and rendering the occurrence of troublesome stricture all but inevitable.1 They are treated by injections, carefully introduced so as to insure their application to the sore; and of such a kind as would be applied to the ulcer in an ordinary site. After cicatrization, the occasional use of a bougie is expedient, to obAuate the tendency to contraction of the canal. III.—The Hunterian, or True Chancre. This belongs to the indolent class of sores ; but, unlike those on the general surface of the body, is usually indurated from the first. The antecedent inflammatory process is chronic, accom- lg' panied by copious plastic exudation, around and ; beneath the forming sore; giving an almost car- tilaginous hardness to its base and margin, which feel as if a split pea had been inserted into the textures. The sore is circular, and excavated; the surface, of a taAvny or brownish hue, seems as if recently scooped out by an instrument; reparative action is faint, and long delayed; sometimes, the site of granulation is occupied by a thin, ash- a venereal sore on a com- colored, adherent pellicle. There is no surround- mon site. The characters jng vascular areola, after the sore has fairly are chiefly those of the lluu- r„„„,„j rru j- •, , ■, . . terian chancre. (After Ac- ™i med. The ordinary sites are the glans penis, ton.) the preputial reflexion, and the integument of the 1 The presence of such concealed sores in connection with gonorrhoea, probably gave rise to the belief that gonorrhoeal matter had the power of producing syphilis. HUNTERIAN, OR TRUE CHANCRE. 529 body of the organ; the first the most frequent, and showing greatest induration. WThile other kinds of sore may occur in one or two places, this form is in general solitary. Treatment is based on the same principles as that of the preceding varieties. Not only the sore, but also the callous induration around and beneath—in which, it is probable, the virus mainly resides—must be destroyed; and for this purpose no weaker caustic than the potassa fusa is necessary—freely applied, perhaps with repetition. Neither is it enough merely to obtain cicatrization, leaving the hardened base and margin but little altered, if at all. These, constituting essential parts of the disease, must be got rid of. And if, after repeated use of the escharotic, hardness still remain, then removal by discussion is to be sought; by internal means—mercury, or the iodide of potassium ; and also by the local application of these substances. It is better that some farther contamination of the system, by rapid and final absorption, should be risked, than that the part should remain a constant zymotic source of propagation. And discussion may be expedited by the ap- plication of pressure, when the sore is so situate as to admit of this; a piece of folded lint being placed OArer the part, and retained by an elastic band.1 It may happen, that early and free use of the potass thoroughly suc- ceeds in obtaining the ectrotic result; the sore completely changing its character, and healing up, without risk of secondary symptoms. More frequently, however, we fail in this ; probably from being too late in our interference; and the sore refuses to change under local means alone. Then mercury is necessary; given with more freedom than in any of the former cases, though still with caution; never pushing it to excess of ptyalism, and always ceasing from the administration, at least for a time, so soon as amendment seems fairly begun in the sore. It is in- variably our object to accomplish the desired end, at as little cost of the mineral as possible. When the ectrotic attempt fails, as is not unlikely, secondary symp- toms are almost certain to occur. The eruption is scarcely preceded by fever, and is unaccompanied by it. Faint, brownish spots, or maculse. appear—chiefly on the trunk; or, as more frequently happens, an erup- tion of copper-colored blotches occurs, and these subsequently become scaly—evincing the characters either of lepra or of psoriasis. As the primary sore is considered the true Chancre, so the constitutional affec- tion may be termed true Syphilis, or Pox.2 The throat is involved ; but, as in the other symptoms, this shows but a dull amount of inflammatory action. One or both tonsils are found occupied by deep ulceration ; often there is a sore on each, of characters very similar to those of the primary ulcer. For such affections of the system, there is no remedy equal to mercury ; and it seems generally agreed that, when true syphilis has declared itself, the cautious use of that mineral should be immedi- 1 Acton, Lancet, No. 1226, p. 220. 2 By many, the term "chancre" is employed to denote all kinds of venereal sore ; as "cancer" is often made to comprehend all kinds of malignant disease. When a special meaning is intended to be affixed to "chancre," however, it is understood to include only this fourth class of sore. 34 530 THE PHAGEDENIC ULCER. ately begun. No heroic dosings are necessary, however ; an alterative course is still all that is required ; continued till amendment appear; and perhaps revived, at intervals, until final clearance of the poison has been effected. Bubo and iritis, if they occur, are met by their appropriate treatment; in the latter affection, mercurialization may be conducted with especial freedom—for a marked tolerance of the remedy will cer- tainly be found. If the primary and secondary symptoms have not been actively and conclusively dealt with, tertiary symptoms are extremely probable; showing themselves after the lapse of some months. The periosteum of the bones which are most exposed—tibiae, ulnse, clavicles, cranium, sternum—suffers by a chronic inflammatory process; and the bones themselves are similarly involved; creating the condition of Node (Principles, 3d Am. Ed. p. 394), sometimes circumscribed and acute, more frequently chronic and diffuse. The joints, too, are affected with chronic swelling and pain. Fetid, ill-conditioned sores may form be- tween the toes. Condylomata may appear on the nates and perineum. Irritable sores may form on various parts of the general surface. The glands of the neck may be chronically enlarged; especially behind the ears. The testicles may swell; either solid, or with serum in the tunica vaginalis. The throat may again become attacked by ulceration—of a more diffuse and acute character; the palate may be involved, and ex- foliation may ensue. And one or both groins may be occupied by indo- lent bubo. The more ordinary of the tertiary symptoms, however, when mercury has not been abused, are the ostitic and periostitic affec- tions. And for these, as well as for the tertiary symptoms in general, iodide of potassium is found to be the preferable remedy ; begun in full doses, and regulated according to the effects produced. Eight grains, thrice daily, in solution, is a justly favorite form of exhibition; dimi- nished when the physiological effects are threatened to be produced. There is a modification of this class of sore, consisting of induration merely. A callosity forms, after impure intercourse; and it may, or may not ulcerate, at a late period. It is equally prone to contaminate the system as the true chancre ; and requires precisely similar treat- ment. Cure is not complete, so long as any degree of hardness remains. It is not to be forgotten that this form of disease may be simulated, by sores unconnected with venereal virus. From accidental circum- stances, induration may occur here as elsewhere; indolent characters superseding the weak in an ordinary breach of surface. Or, again, a venereal sore, originally of the first or simple class, may become indu- rated, in consequence of frequent and unnecessary use of caustic, or from other sources of irritation. Such simulations, of course, warrant neither the prognosis nor the treatment of true chancre. IN.—The Phagedaenic Ulcer, the Sloughing Ulcer, and the Sloughing Phagedaena. Phagedaena, here, as elsewhere, may be either acute or chronic. The latter is not very formidable; being, as it were, only a degree more THE SLOUGHING AND PHAGEDENIC ULCERS. 531 troublesome than the worst forms of the second class of sore. Its most common site is the root of the glans; but, not unfrequently, it burrows from this, beneath the fascia of the penis, producing much induration and swelling of the organ, Avith copious fetid discharge ; advancing unseen and unchecked, till much mischief is done; probably opening into the urethra, at one or more points; at all events, laying the found- ation of tedious sinus, with perhaps a permanently enfeebled and ab- normal state of the organ. Sometimes, also, this form of sore attacks the posterior part of the dorsum of the penis, and burroAvs beneath the pubes. Acute phagedaena, the sloughing sore, and the sloughing phagedaena, present the same characters here, as elsewhere (Principles, Am. Ed. p. 246, et seq.): attacking the glans and prepuce indiscriminately; and in a short time effecting the most destructhre ravages. The acces- sion and progress of the sore, or sores, are accompanied with marked constitutional disturbance, of the nature of irritative fever, tending mani- festly to prostration. The sinister characters may declare themselves from the first; or, for a day or two, the sore may seem but an unusually foul and active sample of the second class, attended with an unusual amount of constitutional disturbance ; and then, without any apparent exciting cause, rapid aggravation takes place, in both the local and con- stitutional symptoms ; constituting Avhat is ordinarily termed the "black pox." Sometimes such aggravation would seem to be accelerated, if Fig. 229. Fig. 230. Fig. 231. Fig. 229. The Sloughing Sore, as affecting the penis. The prepuce almost gone ; the glans going. (Acton.) Fig. 230. Acute Phagedaena, burrowing beneath the integuments of the penis. (Acton.) Fig. 231. Chronic Phagedaena; with surrounding hardness, almost equal to that of true chancre. (Acton.) not caused, by imprudent administration of mercury. And sometimes mercurialism would seem to have the effect of converting an originally simple sore, of the first or second class, into a tolerably close imitation of this of the fourth. It is important, however, to discriminate between the sore originally of a bad kind, and that which, by casualty, has be- come temporarily occupied by a slough, from overaction ; for the suitable treatment is very different. Active and painful local management is required in the one; rest and simple antiphlogistics are sufficient for the other. As the disease advances, constitutional disturbance increases propor- 532 THE SLOUGHING AND PHAGEDENIC ULCERS. tionally; and this, becoming decidedly typhoid, may prove fatal. Or it may be assisted by hemorrhage. Moderate loss of blood, however, may have an opposite effect, in the less urgent cases; occurring in quantity sufficient to affect the part, resolutively; and not to such an extent as to affect the system, depressingly. In most cases, a fatal result may be avoided; but, in many, serious mutilation is inevitable. The disease, fortunately, is comparatively rare; and is chiefly found in maritime towns, where, by sailors and the lower class of prostitutes, sexual vice is extravagantly perpetrated.1 To change the character of chronic phagedaena, no local application is so powerful as the fluid nitrate of mercury; diluted, so as to have an alterative rather than an escharotic effect. The primse viae are attended to ; regimen is antiphlogistic; warm bathing is useful; and strict rest is enjoined. Acute phagedaena, the sloughing phagedaena, and the sloughing sore, require the active treatment, locally and generally, suitable to this form of disease (Principles, 3d Am. Ed. p. 249); the clearing out of the primae viae, followed by sedatives and anodynes; the stern use of an active escharotic, the characteristic moisture of the sore having first been removed; strict rest, and an antiphlogistic regimen; but, at the same time, a careful watching of the constitutional symptoms, lest typhoid tendency suddenly supervene, and stimulants become indis- pensable. Cover the part in a poultice, treating the case expectantly, as is the manner of some; and serious mutilation will be the probable result. In the outset of an urgent case, one is tempted to imitate nature, and abstract blood. But, generally speaking, the experiment is a rash one; it may irreparably depress the system. While, however, bleeding from the system is unwarrantable, abstraction of blood may sometimes be made from the part, safely and well. A pendulous, half-dead por- tion of prepuce, soon about to slough wholly, may be cut off by the stroke of a bistoury; and bleeding from the wound may be encouraged, to such an extent as may be deemed suitable and safe. Sometimes paraphymosis occurs; as can be readily understood, on account of the swollen state of the parts. This must be instantly reme- died by replacement, if possible; if not, a free, liberating incision should be made on the dorsum of the penis, at the constricted part; otherwise, the progress of destruction cannot fail to be frightfully aggravated. After the acute stage is over, the internal use of iron may sometimes be employed with much benefit. After cicatrization has been completed, it may be in our power par- ' " Most of the young creatures who are brought from that genteel place, Swan-alley, afflicted with phagedaenic ulceration, have had very little wholesome food; they are generally kept by Jews and Jewesses, who give them plenty of gin, though but little proper nourishment; they are half-starved, and, more or less, in a coutiuued state of excitement and intoxication, having connection with lascars, and other dirty foreign seamen, as many times in the day as there are hours. In this manner, their constitutions must soon get into a very disadvantageous state for the favorable progress of any disease whatever; and we cannot wonder that their impaired and imperfectly developed frames, their course of life, and uncleanliness, should promote phagedaenic ulceration, and give it an unusually severe character."—S. Cooper. TREATMENT OF SLOUGHING AND PHAGEDENIC ULCERS. 533 tially to "remedy the damage done, by closing abnormal apertures in the urethra by means of autoplasty. Mercury is never advisable. Persistence of the febrile disturbance is itself a sufficient contraindication. Besides, experience plainly tells us, that its local effect is to accelerate sloughing and phagedaena; seeming to favor the softening and undoing of organized structure, and so fitting it for ulceration, Avhile tendency to this is already ex- cessive. Obviously, in such cases, ectrotic treatment is not always within our power. The local disease may spread too rapidly to permit isolation of the virus, with extirpation of the affected part; at the same time, however, the very acuteness of the inflammation is unfavorable to ab- sorption ; and, consequently, the occurrence of secondary symptoms is not so frequent as might otherwise have been expected. When they do occur, their accession is preceded by serious constitutional disturbance, similar to what attended on the local symptoms, but generally less urgent. The eruption may be pustular; the pustules large rather than numerous, giving way, crusting, and degenerating into foul sores of either the inflamed or irritable characters. Or it may be vesicular ; large flat bullae forming, with contents at first serous, but afterwards purulent; giving way, crusting and forming unhealthy sores beneath. Or it may be tubercular ; broad tubercles forming, which enlarge and suppurate slowly, ultimately degenerating into loathsome and extensive sores. The throat is the seat of asthenic inflammatory action; ulcera- tion quickly forms, and spreads both in width and depth—by sloughing, by phagedaena, or by both. One or other of the large vessels in the neighborhood of the tonsil may be opened into, and fatal hemorrhage may ensue. The larynx may be involved ; ulceration actually extend- ing to it; or oedema, preceding the ulceration, may cause most urgent symptoms. Either event may prove fatal. Bubo is seldom absent, at some period of the case. And when, by suppuration, an opening has taken place, this is apt to assume the same characters as the primary sore ; by this time, perhaps the gland being itself the residence of the same poison—by absorption and zymosis. The treatment of these symptoms is fraught with much anxiety. Still, mercury is withheld. It would but aggravate. Regimen is anti- phlogistic; and antimony is given guardedly—so as not to prostrate; in many cases, it is well to combine it with gentle opiates. Warm bathing is grateful, and may relieve the febrile disturbance. Evacuants are obviously calculated to be of service ; acting on skin, bowels, and kidneys ; yet still, not so as to cause prostration. The sores on the surface are cleaned and calmed, by poultice or water-dressing; after- wards they are dressed with nitrate of silver, chloride of soda, or other lotion. The fauces are diligently fomented by inhalation; the sores are touched with nitrate of silver in substance, or with the fluid nitrate of mercury slightly diluted ;J and, after the acute stage has passed 1 In touching the throat with nitric acid, or fluid nitrate of mercury, of any strength, great care must be taken to avoid redundancy of liquid in the sponge or lint with which the application is made; otherwise, a drop may fall down, and, alighting on or in the glottis, may cause the most alarming dyspnoea. 534 TREATMENT OF THE PHAGEDENIC FORM. benefit will accrue from moderate counter-irritation. Then diet is grad- ually amended; and when all has passed into the chronic stage, much advantage may result from judicious use of the iodide of potassium. Should iritis occur, a serious difficulty is engendered. We wish to give mercury to save the eye; and we at the same time wish to withhold it, to save the constitution. At first we trust, therefore, to smart loss of blood from the neighborhood of the part, and to the substitution of turpentine for mercury as the specific internal remedy (p. 135). Only after this has failed, are we driven to a cautious use of the mineral. The tertiary symptoms which may follow this form of disease, are of a formidable character; more especially, if mercury have been given. Bones are liable to ostitis, and its highest results; abscess, ulcer, caries, necrosis. Tubercles form on the skin, larger, more painful, and degen- erating into worse sores than those of the secondary class; often crust- ing prominently, and assuming the characters of Rupia. Obstinate sarcoceles and hydrosarcoceles form. The throat is liable to be again attacked ; in a more chronic, but very obstinate ulceration ; with the same risk by hemorrhage ; and with the additional risk of ghastly de- formity, by involvement of the bones of the palate and nose. It is in this form, associated with a strumous tendency of system, and maltreated by the false mineral specific, that deformity and death are most likely to occur. But, happily, both of these untoward events are nowadays rare. Modern treatment does not aggravate, if it fail to cure. It consists in ordinary attention to the general functions, with careful regimen—not low but temperate; and in the administration of sarsaparilla, guaiac, or other simple alteratives, so long as febrile excitement or stomachic and intestinal derangement may remain. The primse viae having rallied, and febrile disorder having ceased, the iodide of potassium is brought into play, internally ; and is patiently persevered with—hygiene, meanwhile, being not neglected. In obsti- nate cases, the "liquor hydriodatis arsenici et hydrargyri" may be of service. Condyloma. Condylomata are excrescences of the integument; sometimes white, sometimes of a mucous appearance; sometimes dry, sometimes exhal- ing a thin discharge; forming on the nates, around the anus, in the folds of the thighs, on the perineum, on the scrotum—in the female on the labia. They occupy a doubtful place in the arrangement of pri- mary, secondary, and tertiary symptoms. And there seems little doubt that they are occasionally to be found, pertaining to all the three classes. Discharge trickling from primary sores—more especially from the true chancre—and accumulating filthily in the neighboring folds of integu- ment, doubtless produces such irritation, and probably inoculation, as may lead to condylomatous formation; and this may then be regarded as partly of a secondary and partly of a primary character. Condy- lomata may also show themselves along with ordinary secondary symp- toms ; though this is rare. Again—months after the primary attack, and after a secondary train of symptoms, too, have run their course— CONDYLOMA. 535 condylomata may appear, for the first time, among the tertiary symp- toms; and this is most frequently observed after true chancre. Besides, there is no reason to doubt that, not unfrequently, condyloma forms as Fig. 232. Condylomata. (Acton.) the primary and only form of infection ; whether communicated by a distinct variety of poison, or not, we are not at present in a position to determine. To the primary condyloma a peculiar kind of constitutional affection succeeds. An " exanthematous eruption of a mottled appearance, and of a red or brownish color, occurs ; sometimes preceded by vesication or scaliness, but never by pustules; sometimes elevated," and approaching to the tubercular character. The throat is raw and painful; and, on the mucous surface of the lips, cheeks, palatine arches, and tonsils, " peculiar, white, elevated patches are found ; having the appearance of parts touched with the nitrate of silver, or coated Avith milk ; irregular in form, and presenting occasionally superficial ulcerations on their surface.''1 By some it is supposed that this affection is identical with " sibbens ;" which at one time used to prevail much in this country. The treatment of condyloma consists in repeated applications of sul- phate of copper, nitrate of silver, or more active escharotics, until the excrescences disappear ;2 in rectification of the primae viae ; and in the internal use of iodide of potassium. The affection of the throat and mouth is treated with nitrate of silver, in substance or solution, applied every second day. The internal remedies—it is to be understood—are required only for the constitutional symptoms. Primary condyloma is removable by local treatment—perhaps ectrotic—in the same Avay as any primary sore. 1 Skae, Northern Journal of Medicine, April, 1844. 2 Sometimes dusting with calomel is of service. 536 BUBO. Bubo. Venereal Bubo, like Condyloma, is with difficulty appropriated to a class ; for it, too, may be found of primary, secondary, and tertiary oc- currence. It is a question, whether or not bubo may be truly a primary form of syphilis ; occurring without the formation of sores, of any kind, on any part of the penis ; capable of producing venereal sores, by inoc- ulation of the matter which forms by its earliest suppuration ; and liable to be followed by constitutional pox. The probability is that bubo is never thus " d'embUe ;" and that it is always the result, more or less remote, of venereal ulcer ; the consequence, sometimes, of simple exten- sion of the inflammatory process along the lymphatics ; more frequently arising from angeioleucitis, not only induced but maintained by the virus —which may become resident and accumulated within the affected glands. In gonorrhoea, sympathetic bubo is probably the consequence of simple excitement. Inguinal swelling may, indeed, precede the appearance of discharge; the very first part of the inflammatory process having proved a sufficient stimulus to the lymphatics. True bubo, as it may be termed, is the product of virus proceeding from a venereal sore; and usually occurs after the ulcerative stage of the sore has ceased, when absorption is busily resumed. But at any period bubo may occur, through exercise, debauchery in drink, or other folly on the part of the patient; occasioned then#—if at an early period of the case—by mere extension of the inflammatory process; at a remote period, partly by this, and partly by evil working of the absorbed poison. Bubo of the Penis is said to exist, when the lymphatics on the dorsum are continuously affected by inflammatory action ; and when—usually about the middle of the organ—painful swelling takes place, with much induration; the inflammatory process having thrown out a large amount of plastic deposit, and threatening to advance to central suppuration. Pus generally forms; and may be at once evacuated externally, or may burrow extensively beneath the fascia. Treatment is by rest, leeching, and fomentation, in acute cases. Subacute swelling may be discussed by external application of the iodide of potassium in solution. When suppuration has taken place, early evacuation is practised ; more espe- cially if retention of urine have threatened to occur (p. 497.) Inguinal Bubo affects the upper cluster of glands; and this is a prominent characteristic of venereal affection, in contradistinction to inguinal enlargement in consequence of common sores, or other source of simple irritation, on the thigh, leg, or toes ; in which latter case, the swelling will be found beneath Poupart's ligament. The tumor may be small or great; chronic, subacute, or acute ; indolent, or hastening to suppuration. The acute varieties, prone to suppurate, are those which follow directly on the primary sore ; the chronic and indolent range themselves rather with the secondary and tertiary symptoms; the acute form often affects but one ganglion ; the chronic frequently implicates the whole cluster ; in suppuration of the acute, matter generally is first formed in the areolar tissue exterior to the gland; if the chronic slowly BUBO. 537 come to matter, gradual softening and suppuration take place in the interior, and may originate at more points than one. To such swellings, the ordinary principles of surgery are applied ; not always, hoAvever, with a satisfactory result. Were the acute bubo dependent on simple excitement, or on mere extension of a simple inflammatory process, it would doubtless often yield readily to rest, leeching, and fomentation. But such is not the case ; leeching is found to have but little effect in retarding the onward progress ; and this is to be explained, by the active presence of venereal virus Avithin the part itself—just as antiphlo- gistics would have but little effect in retarding the formation of the primary pustule and sore. Loss of blood, therefore, may in most cases be abstained from; rest, fomentation, poultice, and antimonials are employed; and, when matter forms, this is evacuated. And perhaps it is well that suppuration and evacuation should occur ; there being a tendency thereby tOAvards elimination of Adrus. Should matter form only between the enlarged gland and the skin, it is advisable to insure suppuration of the former, by penetrating its interior by potass intro- duced through the external wound—after the acute stage is over; other- wise, the cure will be tedious and imperfect, and, obviously, little or nothing will be done towards elimination. Under subsequent poultice and water-dressing, the swelling may only partially subside; and in such circumstances discussion of the indolent tumor is to be obtained, by the application of pressure by means of a compress and bandage. Sometimes matter is secreted at different times, and in different sites; and, in consequence, sinuses are apt to form. Then a sufficient opening is afforded to each collection, and pressure is applied ; if this fail, the sinuses are to be laid open by the bistoury. Very frequently, however, pressure, good diet, and the iodide of potassium internally, suffice. If, along with bubo, the primary sores still exist, it is obviously an indis- pensable duty to soothe these, and obtain cicatrization as soon as possi- ble. An open bubo, attacked by sloughing or phagedaena, receives the ordinary treatment applicable to such a state. The subacute bubo may be discussed; by rest, low diet, and external use of the iodide of potassium, followed by gradually increased pressure. Or, if this fail, a blister may be applied, in the hope of thereby either promoting resolution, or accelerating a satisfactory suppuration. The indolent bubo may almost always be discussed ; by pressure or blistering—the former usually preferable—rest, good diet, and internal use of the iodide. If an undoubted connection exist with the third class of sore, a powerful alterative is necessary; mercury, in moderate doses. If matter form, it does so slowly and imperfectly ; and blistering may be useful in hastening the general disorganization of the swelling, which is then desirable. Often, to complete this, free use of potass is neces- sary ; destroying undermined integument, and breaking up obstinate indurations of the glands. Special modes of treatment have been thought advisable in venereal bubo; as, for example, by the local use of corrosive sublimate, and severe pressure. The preponderating weight of authority, however, would seem to be in favor of but little departure from the ordinary rules of simple surgery. 538 A GENERAL VIEW OF THE SUBJECT. In taking a general view of the Venereal Disease, it is obviously resolvable into two great divisions : Local and Constitutional Pox. I. Local or Primary Syphilis.—This consists of some variety of sore ; sometimes of condyloma. It is transmissible to a second party, by contact and by inoculation; chiefly, if not only, during the ulcera- tive stage—in the case of a sore ; and the earlier the secretion, the more impregnated is it, probably, with the virus. In treatment, an ectrotic result is to be obtained by timeous and decided use of an escharotic ; which, converting all the poisoned textures into an instant slough, removes the disease—yet local and circumscribed; at the same time, probably, acting destructively, as a chemical, on the poison. Afterwards, management of the sore is simple; by medicated water- dressing. If, however, the sore be not seen by the surgeon until it has attained an advanced stage, acutely inflamed, red, swollen, and very painful, perhaps with affection of lymphatics in the penis and groin, escharotics must be withheld. The inflammatory action is to be subdued by ordi- nary means; and, meanwhile, perhaps, something may be done towards decomposing and limiting the poison, by applying solutions of the chlorides. When ectrotics fail, mercury is given, alteratively, in addition to the ordinary local treatment, in the third class of sore, and in obstinate samples of the second. During the local treatment of all cases in which ectrosis fails, it is well to stimulate the organs of excretion, by attending to the bowels, promoting the flow of urine by diluents and gentle diuretics, and determining to the skin. Antimony is most useful with this vieAV; the object of such treatment being to favor elimination of the virus, by exaltation of ordinary means, in the hope that it may be excreted from the system as fast as it is conveyed thither by absorption from the primary affection, and that thus systemic zymosis may be prevented. II. Constitutional syphilis consists of secondary and tertiary symp- toms. 1. Those which follow speedily after the primary affection, within a few weeks or months, usually during the second month, con- sisting chiefly of general cutaneous eruption and affection of the throat, ushered in by febrile excitement, and, generally, by more or less change in the complexion, dryness of the hair, rheumatic pains in the ends of the long bones, and violent nervous headache, particularly in the fore- head—aggravated at night, or rather by the recumbent posture.1 2. Those which occur more remotely, after six months or more have elapsed, and after the secondary train has already run its course ; their most prominent and characteristic part being affections of the skeleton, of glands, and of the superficial areolar tissue. It is generally supposed that constitutional syphilis, having once oc- curred, is not so likely to return, or at least in a severe form, in the same patient, after venereal contact or inoculation. And some even imagine that the system once affected obtains complete immunity from return of the disease, as in the case of smallpox. On this latter sup- 1 Ricord, Lancet, No. 1284, p. 384. CONSTITUTIONAL SYPHILIS. 539 position has been grounded an infamous proposal to inoculate as a preventive from syphilis -,1 a proposal only mentioned here for the purpose of characterizing it in Avords of disgust and indignation. 1. The secondary eruptions, which are seldom itchy like those of non- specific origin, are of different kinds. Exanthematous, roseola, follow- ing the simple sore, often at an early period. Not unfrequently it precedes the appearance of other forms of eruption, seeming to be the basis on which they subsequently form. Papular, lichen, the ordinary result of the first class of sore. Pustular, ecthyma, more frequently following the second class of sore than any other. Tubercular, prone to ulcerate untowardly, following the fourth class of sores. Vesicular, rare, large bullae, surrounded by a copper-colored areola, becoming purulent, crusting, and tending to rupia prominens; sometimes following the second, but more frequently found after the fourth class of sore. Scaly, lepra, or psoriasis, usually the result of the third class of sore, true syphilis. Sometimes condylomata form, contemporaneously with the eruption. Such is the general arrangement; but, in practice, occasional con- fusion of the sequences need not excite surprise. Very frequently, the hair loosens and comes away, threatening baldness. The throat is variously affected, by inflammatory process, aphthae, or ulcer. Iritis not unfrequently occurs, and may follow any form of sore ; it is more frequently found associated with the papular eruption, however, than with any other. Sometimes periostitis shows itself, on one or both shins. A question here arises, are sores on the penis ever of a secondary character ? No doubt they are. Eruptions degenerate into sores very frequently on the general surface, and there is no reason why the penis should be exempt from the general liability. Secondary sores there are knoAvn by their history, appearing at a long date after exposure to con- tagion. And they are also distinguished by absence of the ordinary characteristics of primary sores, usually superficial, inflamed, and of a peculiar hue, resembling aphthous ulceration of a mucous surface. Secondary symptoms are shown, by experience, to be transmissible from father to child, from child to mother ;2 the blood being tainted with the virus, which has become multiplied by general zymosis; and the virus being communicated through the medium of tainted secretion. As yet, it is doubtful whether they are communicable by direct contact or inoculation.3 It has still to be shown that the early, ichorous, non- purulent secretion of a secondary sore has not the power of propagating the disease. • Brit, and For. Rev. Jan. 1850, p. 261. 2 The husband procreates an infected child, which may then propagate the secondary poison to the mother. Where there are no children, the mother does not suffer.—Ricord, Lancet, No. 1284, p. 384. A mother affected with secondary syphilis, after primary sores in herself, however, may be expected to communicate the disease to her offspring. A father affected after conception has taken place, does not taint the child then in utero. 3 Some maintain that the husband has the power of communicating syphilis, in the secondary form, to the wife, directly through the semen; and that then the female may produce an infected foetus.—See Whitehead on Hereditary Transmission; and Brit, and For. 31. C. Rev. April, 1852, p. 323. 540 TERTIARY SYMPTOMS. In the papular form of eruption, and in many cases of the pustular, mercury is seldom necessary; in the tubercular, it is often hurtful. Antimony, sarsaparilla, guaiac, and the iodide of potassium are powerful enough alteratives and eliminators; and, along with attention to the general health, suffice for cure. In the scaly form, however, mercury is always given, yet warily, never pushed to extreme ptyalism; and always ceased from, at least for a time, on amendment being begun. In the constitutional symptoms following on the sloughing sore, the phage- daenic sore, or the sloughing phagedaena, mercury is studiously abstained from, experience having amply demonstrated its inefficiency as a means of cure, and the certainty with which it tends to ultimate aggravation. It is never our object to repress the eruption in its first onset; on the contrary, its full appearance is solicited. Obstinate persistence, and repeated recurrence, however, we seek to overcome. And the object of our constitutional treatment is, simply to assist nature in a full, early, and complete elimination of the poison; by acting on the skin, kidneys, bowels, and other organs of excretion. The throat is steamed, fomented, touched Avith nitrate of sihrer, or blistered externally; according as it is the seat of active congestion, in- flammation, ulcer, chronic inflammatory action, or passive congestion. Iritis has its own appropriate treatment, except when the sequel of the fourth class of primary disease ; and then mercury is withheld, if pos- sible—turpentine being substituted (p. 135). Coming baldness is antici- pated, by shaving the head ; and it is well to keep it closely shaved, for months, long after the other signs of constitutional disorder have wholly disappeared. 2. Tertiary symptoms seldom occur, except after the third and fourth classes of sores, and the worst examples of the second; unless when mercury has been profusely and rashly administered. In any case, they are seldom urgent, when the result of venereal poison alone. It is only when this has been associated in the system with the mercurial poison, that severity is declared. In the milder cases, the bones and periosteum are affected by a chronic inflammatory process ; those suffer- ing most which are most exposed. In the more severe cases, suppura- tion takes place; sometimes superficial, between the bone and periosteum; sometimes in the interior of the bone ; sometimes involving the whole girth of the bone ; and resulting in ulceration, caries, or necrosis. Sometimes the skeleton is affected symmetrically ; corresponding bones suffering at corresponding points ; but it may happen that the whole of one side is free, while scarcely a bone of the opposite side of the skele- ton is not more or less affected. The joints are liable to pain, stiffness, and chronic enlargement; similar to chronic rheumatic affections of these parts. The skin is subject to be attacked—more especially after the fourth class of sores—by tubercular formations, Avhich assume the characters of rupia prominens, and degenerate into foul irritable sores; sometimes the initiative is by vesicular formation; sometimes the sore at once is formed by sloughing, followed by acute ulceration. The mucous membrane of the alimentary canal is liable to suffer at either extremity, but especially in the fauces—by congestion, and troublesome ulceration, usually of a chronic yet intractable kind ; the anus may be the seat of TERTIARY SYMPTOMS. 541 aphthous ulceration, fissures, and condylomata. The tongue may become generally swollen; indurated at several points ; at the edges and tip superficially ulcerated—the sores irritable and obstinate, sometimes spreading as if by chronic phagedaena; and the mucous surface of the cheeks and gums, as well as beneath the tongue, may be similarly af- fected. Chronic enlargement of the lymphatic glands on the upper and back part of the neck is common. Deafness is no unfrequent oc- currence ; probably from congestion of the mucous lining of the ear. Iritis and bubo sometimes occur in this class; the latter usually indo- lent ;- and the former tending less to severity than when a secondary symptom. The testicles not unfrequently undergo chronic and simple enlargement, with or without accumulation of serum in the tunica vagi- nalis. Tertiary symptoms are not transmissible in any way.1 Parents affected by them, however, impart scrofula to their children. Whatever their connection, mercury is generally superseded, in treatment, by the iodide of potassium ; and this is assisted by attention to the general health—more especially as regards warm bathing, clothing, and regi- men—and by other alteratives, if need be. In ostitic affections, ob- stinate, and attended with much nocturnal exacerbation, opiates are essential; and it may be that, ordinary means failing, we may be driven to small doses of corrosive sublimate. In obstinate affections of the skin and throat, too, the "liquor hydriodatis arsenici et hydrargyri" may be of service. And besides this constitutional management, the local affection of bones, joints, testicles, glands, are treated according to the general principles of surgery. In tertiary symptoms following the fourth class of sores, the general rule still obtains as to the propriety of avoiding the use of mercury. There are cases, however, of occasional occurrence, which compel its exhibition. When the face or other part of the surface is covered with ulcerating tubercles, when the tonsils are ever and anon the seat of bad ulceration, and when the tongue and cheeks are affected with a constant succession of painful ulcers, surrounded by induration, and extremely slow to heal; when such symptoms have resisted the ordinary non- mercurial treatment, and the patient is obviously declining in health— in such cases, an alterative course of arsenic is sometimes of much service. But, if it fail, mercury is had recourse to ; in combination with small doses of the iodide of potassium; and usually with the very best effect. Iodide of potassium is of great use in the treatment of all venereal affections ; as an eliminator, probably, of the virus, as well as an altera- tive of the system. It is best given in the form of solution ; beginning with a dose of two or three grains, given thrice daily ; and gradually increasing it to half a drachm, or more, according as it is borne. It is not always necessary to induce the physiological effects. Some have a strong prejudice in favor of eight grains thrice daily, in camphor mix- ture ; and adhere to that dose, throughout the whole period of exhibi- tion ; seldom finding any decided intolerance manifested by the system. 1 AV'liitehead and others are of a contrary opinion. See reference in foot-note, p. 539. 542 THE USE OF MERCURY IN SYPHILIS. Again, if a primary sore is slow to change, and to assume the healing process, this medicine is useful; provided there be no inflammatory ex- citement in either part or system—for that provision is always essential to its proper administration. In many of the secondary symptoms, it supersedes the use of mercury in the chronic stage.1 And, in tertiary symptoms of every kind and complication, it is pre-eminent and para- mount. Sarsaparilla and guaiac, in the form of the compound decoc- tion, are also not unimportant auxiliaries. Some affect to believe them quite inert; but we beg humbly to vouch for their possession of an im- portant though minor virtue. In cases of intolerance of the iodide, by reason of idiosyncrasy, they often prove most valuable and efficient substitutes. The Use of Mercury in Syphilis. That mercury is a specific, indispensable as well as infallible, for the venereal disease in all forms, is a maxim which, happily for mankind, is fast falling into desuetude. It is now abundantly established that many forms of the disease, nay, the greater number of cases, are capable of cure without the use of this mineral; that, with simple means, that is, non-mercurial, the cure is shorter, the symptoms prove less grave, and immunity from future calamity—connected with the attack, its progress, or its mode of cure—is much more certain. In other words, the system is cleared quite effectually of the venereal poison, and it is saved from the pernicious effects of the mercurial poison, perhaps not the less formidable of the two. There are certain cases, however, in which it has been shown by experience, that a satisfactory issue cannot be obtained without recourse to mercury. And, in those cases, its judicious employment seldom leaves any deleterious impression on the system, there being then a decided tolerance of its administration (Principles, 3d Am. Ed. p. 169). Its modus operandi is involved in uncertainty. Many, especially of the old school, still believe that it has a specific and destructive influence on the venereal virus; that the two poisons meet in the circulation, and that a destructive influence is exercised there by the mercury on its antagonist. This may in part be true, but it seems reasonable to con- clude that its beneficial operation mainly depends, like that of other constitutional remedies, on its alterative influence on the general sys- tem, and on its power of stimulating secretion and excretion, so favor- ing elimination of what is noxious. Long ago, it seemed the general belief that such elimination was mainly to be achieved through the action of the salivary glands; that the poison, overcome in the blood, Avas to be excreted from it in the form of tainted saliva, and that the more speedily it was thrust out by the mouth, the more rapid and satisfactory would be the cure. Mercury, accordingly, was pushed invariably to i As a general rule, the place of mercury is as an opponent of secondary symptoms, that of the iodide to deal with the tertiary. And practical observation would seem to warrant another broad statement; namely, that obstinate secondary symptoms, for which mercury has been given, are always benefited by iodide of potassium; while obstinate secondary symptoms, for which no mercury has been given, usually require mercury. THE USE OF MERCURY IN SYPHILIS. 543 profuse salivation, either in the belief that such was necessary for satis- factory elimination, or holding that copious ptyalism was the only sure sign of the mineral having been so thoroughly introduced into the sys- tem as to afford a good prospect of the poison's annihilation. In the beginning of the sixteenth, and end of the fifteenth centuries, when the venereal disease experienced such an aggravation as to alarm all Europe, the antidote was plied with a blind, empirical, and desperate profusion, and there is no doubt that, to this circumstance, rather than to any un- usual virulence in the disease itself, its frightful ravages at that period are to be attributed. The primary symptoms were bad, but the second- ary and tertiary symptoms were far worse; under the last, the most frightful deformities and mutilations occurred, by affections of the bones of the face and cranium, and destruction of the soft parts of the nose, mouth, and throat, and death was no unfrequent termination of the hideous misery. Nowadays, we find no such severities, except when mercury has been heedlessly and unnecessarily given, perhaps in a strumous habit. And the undoubted rarity of mutilation, deformity, and death, by any part of the venereal disease, in the present day, is reasonably to be attributed to a greater prudence in the treatment of the affection, more especially in the primary symptoms. Mercury is withheld in many cases, if not in most; when administered, it is given in moderation, and with a reluctant hand, alteratively, not cumula- tively, frequently stopping short of ptyalism, never going beyond mere touching of the gums. Formerly, the ordeal of salivation was such as must have proved to many frames quite intolerable. Even Boerhaave, in the eighteenth century, laid down the following " axioms:" "If there is four pounds of saliva spat every twenty-four hours, it is suffi- cient!" "the salivation is to be continued until the symptoms of the disease vanish, which generally takes up six-and-thirty days ! !" and " a small dose of mercury must be taken for six-and-thirty days more, to keep up a gentle salivation !!!" No wonder that patients died, and no wonder that some were found to prefer death to such a mode of cure.1 And yet, while in Europe suffering humanity was thus outraged by the profession, the natives in the West Indies, by the aid of guaiac alone, were showing an infinitely more favorable result. And among the former, too, there were not Avanting some who became alive to the folly and danger of indiscriminate and extreme mercurialization—some driven to a better mode of reasoning and practice, by the stern rod of personal experience. Ulric de Hutten had himself been salivated eleven times, and thereafter became a zealous apostle of a treatment opposed to that of the majority of his fellow-practitioners. But, while it is contended that mercury and the venereal disease are not inseparable—that a patient affected with the one is not inevitably to be affected by the other—it is yet to be admitted, gratefully, that this mineral is in not a few cases a most important remedial agent; 1 Omnibus certe exulcerebantur fauces, lingua, et palatum; intumebant gingivae, dentes vacillabant, sputum per ora sine intermissione profluebat, unde et labia sic con- tacta ulcus trahebant, et intus buccaj vulnerabantur. Foetebat omnis circa habitatio, atque adeo durum erat hoc curationis genus, ut perire morbo complures quam sic levari mallent.—Ulric de Hutten, 1519. 544 THE USE OF MERCURY IN SYPHILIS. used, however, much more sparingly than in former times ; and, in con- sequence, not only more efficient as a means of cure, but also less likely to peril the future durability and soundness of the frame. By reference to statistics, it has been found that mercury, indiscriminately given in all cases, does not accelerate, but that on the contrary it retards, the ordinary healing of primary sores ; that it does not prevent secondary symptoms, but that these coming after its exhibition are generally se- vere ; and that the tertiary symptoms are both most frequent and most severe, when mercury has been profusely given in the previous stages. On the other hand, an indiscriminate withholding of mercury, in all cases, will present a much less favorable general result, than when mer- cury is judiciously exhibited in those examples of the disease in which it is found by experience to be not only useful, but in a great measure absolutely necessary to full and satisfactory elimination of the poison. If ectrotic treatment of the primary sore have been successfully achieved, of course no mercury will ever be required ; there is no poison in the system, with which it is required to contend. But, failing this, it is given : 1. In the second class of primary sore, when it proves ob- stinate. 2. In the third class of primary sore, always. 3. In the papular and exanthematous secondary eruptions, only when they prove obstinate and recurrent. 4. In the pustular secondary eruption, if it proAre obstinate ; but not if it be consequent upon the fourth class of sore. 5. In the scaly secondary eruption, following the third class of sore, always. 6. In iritis, actively, unless when the affection results from the fourth class of sore. 7. In ostitic affections, of tertiary occur- rence, when other means have failed to procure rest, alleviation of pain, and decadence of the constitutional irritation. 8. In tertiary affections of the skin and throat, of whateArer origin, which have obstinately re- fused to yield otherwise. 9. Experience also shoAvs it to be essential to the removal of that secondary taint of system, whereby a parent conveys syphilitic suffering to the child. It is never given: 1. In any case, during acute inflammation in the primary sore; otherwise, ulcerative action will certainly sustain aggra- vation ; and sloughing, or phagedaena, may be induced. 2. Nor in any case, during persistence of febrile excitement in the system ; otherwise, cure Avill be delayed, and the symptoms aggraA'ated. 3. Nor in anv form of disease connected with the fourth class of sores—excepting the rare cases of a tertiary character already specified (p. 541)—otherwise, such aggravation is to be dreaded as will either end fatally, or fix the deleterious poisons permanently in the frame. 4. It is well to avoid mercury, also, if possible, whenever the active presence of scrofula is plainly and prominently indicated. The mode of exhibition varies according to circumstances : 1. It may be given in the form of calomel and opium ; in the ordinary way. 2. Or blue pill maybe given, in such doses as the cure demands; combined with opium or hyoscyamus, if pain or purging be occasioned; if mere griping occur, it may be enough to let each dose follow closely on a meal. 3. Either of these forms disagreeing, hydrargyrum cum creta will probably be found suitable; and this is the preferable form for children. 4. The corrosive sublimate, in very small doses, in pill or ERETHISM US. 545 solution, is generally preferred in obstinate ostitic affections. And in such cases, also, it is sometimes of use to combine the mercurial with a tonic, or with small doses of the iodide of potassium. 5. In habits suspected of struma, the iodide of mercury is a suitable form ; or a com- bination with iron may be given, in the " ferruginated" blue pill. G. Inunction is useful, as an adjuvant to the internal exhibition, when speedy affection of the system is desirable ; in iritis, for example, mer- curial ointment is rubbed on the forehead and temple, while calomel and opium are given internally (p. 133). It is also used alone, in cases which exhibit intolerance of the remedy given internally, in any form; then it is rubbed in, night and morning, in the axillae, or on the inside of the thighs. 7. Fumigation, also, is sometimes employed, when other forms seem to disagree. The fumes are obtained from the red sulphuret put on a heated iron; and they are applied to the system by inhalation; to a part, by means of an oiled-silk tube or bag. Fumigation, however, is seldom used, except in cases of obstinate chronic affection of the throat, and tertiary enlargements of the testicle. In the primary affections, amendment often shows itself before the mineral has given any other eA'idence of haA'ing affected the system. In secondary affections, the yielding is seldom so rapid ; such continuance is usually necessary as touches the gums ; and then the remedy is no longer pushed ; but a minor dosing is maintained ; the object being not to increase, but simply to maintain, the approach to ptyalism, until de- cadence begin to appear satisfactorily. Then the remedy is altogether withdrawn ; although, it may be, that persistence or recurrence of the symptoms may aftenvards require its resumption. In tertiary symp- toms, also, it is generally necessary to attain to the eA'idence of systemic seizure ; maintaining this, if need be, with the same niggard caution and economy. Certain idiosyncrasies require consideration, in regard to the exhi- bition of this medicine. 1. Some patients are slow to shoAV ptyalism, even under great and sustained doses. In them, it is not necessary to push the medicine until ptyalism is produced. 2. Others have their mouths touched—perhaps severely—with but a few grains. And, in their case, the dosing must be both minute and guarded. 3. Some suffer by pain and purging, in whatever form the mercury is given internally. In these, careful inunction is to be made trial of. 4. Some are actually poisoned by the mineral; the condition termed Erethismus being induced.1 To such patients mercury can never be given, in any form; for the symptoms induced are such as imminently to endanger life. The patient is anxious, under an apprehension of great and impending evil; his muscular system is prostrate ; he trembles, Avalks with difficulty and uncertainty, and his heart's action is weak and flut- tering ; breathing is difficult; an unpleasant sensation of weight or tightness is felt at the praecordia; both mind and body are incapacitated for all exertion; and during some ordinary effort he may expire by syncope. Such symptoms require instant discontinuance of the mer- 1 For Pearson's own description of Erethismus, see his work on Lues Venerea, 2d edit. p. 154. 35 546 EFFECTS OF MERCURY. cury, removal to a better and freer air, cautious use of stimuli, friction of the chest, generous diet, and avoidance of all exertion and excite- ment. 5. The system may not suffer, but the surface may; a very troublesome eruption occurring; vesicular, the Eczema mercuriale. This may be the result of either external or internal exhibition; when the former, it usually occurs in and around the part on which the ointment or plaster has been applied; when the latter, the first appearance is usually in the axillae, or on the inside of the thighs, and thence the eruption may extend over the trunk. The vesicles soon break; and, instead of healing, are apt to degenerate into painful excoriations. Sometimes there is smart attendant constitutional disturbance. Treat- ment is by instant removal of the cause, and by exhibition of the sooth- ing remedies which are suitable to such eruptions in general; the pain may be assuaged by opiate applications, the itching by an aqueous dilu- tion of hydrocyanic "acid. Liability to such an eruption does not forbid the use of mercury; but requires that it should be administered, Avhen essential, in small doses, and with unusual caution. Its external use is certainly contraindicated. 6. Some systems evince their intolerance of the remedy, by gradual loss of flesh, strength, and spirits—an asthenic state, partly anemic and partly hectic, becoming established. In such circumstances, mercury is to be discontinued; generous diet, with iron or other tonics, is given; and cure of the venereal affection must be sought by other than mercurial means. Violent salivation may be caused by imprudent and excessive dosing, and by sudden exposure to cold during use of the medicine; or it may de- pend on an idiosyncrasy of system. The mercury must be discontinued; diet should be Ioav ; cool and pure air is to be breathed; and the mouth is rinsed, and the throat gargled with weak brandy and water, or with solutions of the chlorides. If this prove insufficient, leeches may be applied over the angle of the jaw, followed by fomentation; so that a directly sedative effect on the salivary glands may be obtained. Chlo- rate of potass, given internally, has been found useful. After the fe- brile excitement has abated, diet is improved; and superficial ulcerations, in the mucous membrane of the mouth and throat, are touched occasion- ally with the nitrate of silver. Of the remote evil consequences of mercury on the system, much might be said. Of itself, sakelessly given, it may cause the most obsti- nate and serious affections of the skeleton. Associated untowardly with the venereal poison, its evil results show themselves as tertiary symptoms —even at a very remote period—and may be most formidable: nodes, ulcer, caries, necrosis of bones; intractable ulcerations of throat, tongue, cheeks, and gums; exfoliation of the hard palate, and of the nasal bones; lupous ulceration of the nostrils, lip, or face; hideous deformity by loss of the nose and palate ; caries of the skull, perhaps implicating the interior by perforation ; ulcers and tubercular formations in the skin and areolar tissue; pain, misery, deformity, and death. Such calami- ties, happily, are now rare; but our museums can speak to their fre- quent occurrence in times not long bygone. The worst evils occur, when the mercurio-syphilitic cachexy is aggravated by association with the strumous. In treatment, Ave have not"much in our power; and we SYPHILIS IN THE CHILD AND FEMALE. 547 may well plume ourselves more on prevention than on cure. The iodide of potassium and sarsaparilla are perhaps the only remedies which de- serve a special mention, as antagonists of this depraved state of system ; the rest is done by general treatment and hygiene. Syphilis in the Child. A father, laboring under secondary syphilis, may transmit the taint to his child (p. 539). Or a mother, herself affected with secondary syphilis, may communicate the disease to the foetus. Or a mother, laboring under genital sores, may give direct contagion to the child during parturition. Or the child may be infected, at a more remote period, by sucking a female possessed of secondary syphilis; the milk coming from tainted blood, and charged with the virus accordingly. Thus, in one or other, or in all of these ways, disease may be com- municated at the earliest age. Sometimes the child is born laboring under the symptoms; more frequently, they show themselves after birth. The more prominent are—hoarseness of cry ; a shrivelled, lean state of body; an anxious expression of face, often senile ; chaps at the flexures of the limbs, and on the nates; a copper-colored eruption, sometimes studded with pustules, more frequently scaly; discharge from the nostrils; excoriation of the mouth and throat. When the mother is syphilitic at an early period of pregnancy, the child often does not arrive at maturity, but comes away dead and putrid, as an abortion; and this may happen repeatedly, until complete 'elimination of the poison from the parent's system has been obtained. For this purpose, a mercurial course is generally necessary—as can be readily under- stood, seeing that it is generally the true syphilis, or scaly eruption proceeding from the true chancre, which is communicated in this way. For a like reason, mercury is generally necessary in the child. It may be given indirectly through the nurse; or directly—as is to be pre- ferred in most cases—by inunction, or by guarded doses of the hydrar- gyrum c. creta internally. Or mercurial ointment may be spread on flannel, and bound round the trunk, once a day, until the symptoms yield. In nursing, precaution is necessary; as it is thought that a healthy nurse may have constitutional syphilis communicated in this way; the excoriated or ulcerated lips of the child producing a similar condition of the mammilla, and the ordinary class of secondary symptoms fol- lowing. In such cases tubercles are apt to form about the anus and vulva of the nurse; and these may be the means of infecting her hus- band. It is possible, that in some cases the sores on the child's mouth may be primary, caused by lodgement of virus there during parturition— the unfortunate mother laboring under primary disease at the time. Syphilis in the Female. In the female, syphilis is peculiar only as regards the primary affec- tions; and their peculiarity is chiefly as to their site; their general character, progress, and results, being very similar to the occurrences 548 PSEUDO-SYPHILIS. in the male. Females are more subject to condylomata; and, if clean- liness be neglected, warts are very liable to form, sometimes attaining to large size, and involving the labia in hypertrophy. _ Sores are usually situated on the inner surface of the nymphae, and in the orifice of the vagina; but they are also found in all parts of the vagina, on the os uteri, and sometimes in the urethral orifice; sometimes they affect the anus. Treatment is as in the male. Warty formations occasionally are of such size, as to require a regular dissection for removal of the hypertrophied mass (Principles, 3d Am. Ed. p. 386). Pseudo-syphilis. Certain diseases, not supposed to be of venereal origin, resemble some of the forms of constitutional syphilis more or less closely; the Radesyge in Norway; the Button-scurvy in Ireland; the Yaws in America; the Sibbens in Scotland—this, hoAvever, is lately supposed to be identical with the constitutional disorder consequent on condy- loma (p. 534). These affections belong to the province of the phy- sician. Astruc, de Morbis Venereis, Venet. 1760. Hunter, John, A Treatise on the Venereal Disease, Lond. 1786. Bell, Benjamin, a Treatise on Gonorrhoea and Lues Venerea, Edin. 1793. Pearson, Observations on Various Articles in the Cure of Lues Venerea, Lond. 1807. Carniichael on the Symptoms and Distinctions of Venereal Diseases, Lond. 1818; Ibid, on Venereal Diseases, and the Uses and Abuses of Mercury in their Treat- ment, Lond. 1825. Devergie, Clinique de la Maladie Syphilitique, avec un Atlas colorie, Paris, 1826. Bacot, Treatise on Syphilis, &c. Lond. 1829. Travers, Observations on the Pathology of Venereal Affections, Lond. 1830. Lawrence on the Venereal Diseases of the Eye, Lond. 1830. Titley, Practical Treatise on Diseases of the Genitals of the Male, &c. Lond. 1831. Wallace, a Treatise on the Venereal Disease and its Varieties, Lond. 1833. Judd, a Practical Treatise on Urethritis and Syphilis, Lond. 1836. Colles, Practical Observations on the Venereal Diseases, and on the Use of Mercury, Lond. 1837. Ricord, Traite" Pratique des Maladies V^ne'riennes, &c. Paris, 1838. Mayo on Syphilis, Lond. 1840. Acton, Treatise on Venereal Diseases, Lond. 1841. Guthrie on the Treatment of Syphilis without Mercury, Med.-Chir. Trans, vol. viii. Lane, Lectures in the Lancet, 1841 and 1842. Skey on Venereal Diseases, Lond. 1841. Cazenave and Schedel, on Diseases of the Skin, by Burgess, Lond. 1842. Parker, A Safe and Successful Method of Treating Secondary, Constitutional, and Confirmed Syphilis, &c. Lond. 1850. AVhite- head on the Transmission, from Parent to Offspring, of some Forms of Disease, &e. Lond. 1851. Wilson, Erasmus, on Syphilis, Constitutional and Hereditary, Lond, 1852. [Ricord, Edition of J. Hunter on Syphilis, with Notes and Additions, Paris, 1852; Clinique Iconographique de l'Hopital des Viuiericns, Paris, 1851, Philad. 1852 : Let- tres sur la Syphilis, Paris, 1852, Philad. 1853. H. J. Johnson, Clinical Observations on the Diseases of the Genito-Urinary Organs—Part I. Gonorrhoea and its Consequences, Lond. 1851. J. C. Egan, Treatise on Syphilis, Dublin, 1853.—Ed.] CHAPTER XXXIV. AFFECTIONS OF THE URETHHA. Stricture. Contraction of the urethra may depend on one of three different causes. 1. There may be Spasm of the muscles connected Avith the membranous portion of the urethra, causing temporary diminution of caliber at that part, as well as resistance to instruments attempted to be introduced; and there is good reason to believe that a similar result is sometimes occasioned, in the anterior portion of the urethra, by spas- modic action of the muscular fibres which have lately been shown to form part of the normal structure of the urethra, and to extend through- x out its whole length—continuous posteriorly with the muscular coat of the bladder.1 These conditions are liable to be suddenly induced, by ordinary exciting causes ; and they generally disappear readily—often rapidly—under ordinary treatment; hip-bath, fomentation, opiate enema or suppository, perhaps a sedative by the mouth, rest, quietude, and antiphlogistic regimen. 2. Inflammatory action, by its attendant swelling, may cause contraction. It may affect the lining membrane itself; either at one point, as in consequence of injury ; or over a con- siderable space, as in seArere gonorrhoea—one of the symptoms of which, as Ave have seen, is an obvious diminution of the stream of urine, de- pendent on the contracted state of the canal. Or the inflammatory process may be exterior to the urethra; in the substance of the prostate, in the areolar tissue of the perineum, or by the side of the rectum ; and the bulging of the phlegmon, or abscess, may not only diminish the caliber of the urethra, at the affected part, but may even shut it up altogether, causing retention of urine. The treatment of such a case has already been considered (p. 407;; it is by antiphlogistics ; withhold- ing the catheter as long as possible, and using the bistoury for evacua- tion of matter at the earliest practicable period. 3. The canal may be narrowed by chronic structural change, occurring in the urethra itself; and this constitutes true Stricture ; a condition which is ever liable to aggravation by the two preceding causes of contraction—spasm and in- flammatory action. And it is well to limit the use of terms thus : understanding "spasmodic stricture" and "inflamed stricture" to be aggravations of true organic stricture in one or other of these ways; understanding the terms "spasm of the urethra" and "urethritis," to 1 Hancock, Lancet, No. 1486, p. 187. 550 STRICTURE of the urethra. include the condition of temporary narrowing of the canal by spasm and the inflammatory process; and understanding by " stricture" an organic change in the urethra, causing a narrowing of the canal, which may be altogether independent both of spasm and of existing inflammatory action. But stricture results from the inflammatory process, in and near the urethra; and this, as we have seen, may be excited in various ways. 1. It may follow the application of specific virus, as in gonorrhoea; and this is perhaps the most frequent cause of stricture. Clap is of common occurrence; the inflammatory process is often of long duration, as Avell as of such a kind as to favor plastic exudation ; and treatment by injection is not unlikely to be so misconducted, as to cause main- tenance or aggravation of such action. 2. Stricture may follow a chronic inflammatory process, always of a minor grade—never reaching beyond active congestion—occasioned by constant excitement of the canal; as by excess in venereal indulgence, or by an acrid state of the urine. The latter is no uncommon cause; the urine may be simply acid, in excess; or it may hold more or less deposit; the bladder is emptied frequently; and, on each occasion, the urethra smarts under the passage of the urine. At length, a continued state of congestion is induced; and that brings not only discharge from the free surface of the mucous membrane, but also a certain amount of plastic exudation which remains. 3. External injury may be the exciting cause ; lighting up an actiATe inflammatory process in and around the injured part, and tending much to solid deposit—not always easily removed by absorption. Hence, Woavs and kicks on the perineum are found to produce the worst forms of the affection. A less amount of violence, often repeated, may induce gradual formation of stricture; as by contusion of the perineum on the saddle, in dragoons, or others much employed on horseback. Also, there is good ground for fearing, that the disease not unfrequently originates in the unskilful and unnecessary use of bougies, lithontriptors, and other instruments. 4. Ulceration of the urethra cannot well heal, Avithout causing more or less contraction of the canal; and this ulcera- tion may be the product either of a common or of a specific inflammatory process. There is no more troublesome stricture than contraction of the orifice, in consequence of venereal ulceration there. The proximate cause of stricture is plastic deposit, and consequent structural change, both in the substance of the lining membrane of the urethra, and also in the submucous areolar tissue; and it is important to remember, that it is in the latter situation chiefly that the deposit takes place. The ordinary sites of stricture are—at the orifice; at the neck of the glans, about an inch from the orifice; at the natural bend of the penis, from the suspensory ligament, between three and four inches from the orifice; and in front of the membranous portion of the urethra, between six and seven inches from the orifice.1 The most fre- quent are the two last named. But it is seldom that a tight stricture is found at the posterior part of the urethra, without more or less con- 1 The researches of Sir C. Bell, and others, have demonstrated that seldom, if ever, does contraction of the urethra occur posterior to the last-named site. SYMPTOMS OF STRICTURE. 551 traction also at the ordinary sites in front; in other words, in cases of bad stricture, a plurality of contractions may generally be expected. When the affection results from external injury, the site obviously de- pends on the application of this. The extent and degree of contraction vary. Sometimes a shred of plastic deposit passes across the canal; and this rare form is termed the bridle-stricture. Sometimes the stricture is tight, but very limited, seeming as if a thread had been tied tightly on the part. More fre- quently, the contraction is of greater extent, from a quarter of an inch to an inch; sometimes involving several inches of the canal. And the degree of contraction varies, according to the duration and treatment of the disease, from the slightest narrowing of the canal to its complete occlusion. Behind the constricted point, dilatation takes place. Anteriorly to the actual stricture, there are collapse and contraction. The dilatation may be to such an extent as to hold more than one ounce of urine, and the mucous lining of the dilated part becomes prone to ulceration. Cal- culous matter may be retained there, and a stone may form, occupying the whole space. The mucous lining of the entire canal sympathizes more or less. From the strictured part, and also from the general sur- face of the membrane, an abnormal discharge proceeds, usually clear, sometimes puriform, and liable to be increased by casual excitement— this inducing aggravation of the congestion. Chronic prostatitis is apt to be induced, increasing the discharge. The lining membrane of the bladder becomes affected; the muscular coat, too, is changed, becoming hypertrophied-; and, in consequence, both fasciculation and sacculation of the viscus may take place. The enlarged muscular fibres, arranged in fasciculi, act strongly on the urine; and the urine, not getting freely away through the strictured urethra, reacts on the mucous membrane, causing protrusion of this through the interspaces of the fasciculi. Cysts, thus formed, receive gradual additions to their parietes, and may attain to a large size, riA-alling the bladder itself in magnitude. Chronic cystitis may folloAv. And morbid sympathy does not end with the bladder; the kidneys are in many cases involved; first in irritation, causing functional derangement only; aftenvards in organic disease. The pelvis of the kidney and the ureters are often enormously dilated, their lining membrane furnishing much puriform discharge. The form- ation of stone, too, is favored, as Avas formerly remarked ; derangement of the kidney's secretion leads to calculous deposit, and this is obstructed in its outward passage by the urethral change. The symptoms of stricture are of gradual invasion, and may for some time escape the patient's notice. The urine is passed in an attenuated stream, sometimes twisted, sometimes scattered ; the act is both frequent and tedious, and sometimes it is accompanied by pain and uneasiness in the bladder and penis, which abate on the bladder being emptied. After the patient supposes evacuation complete, a few drops, in some cases a considerable quantity, pass away involuntarily, coming from the dilata- tion behind the stricture. In consequence, the clothes are usually soiled and stained. The increased frequency of micturition is most observed at night. Discharge comes from the urethra, as already stated; and 552 TREATMENT OF STRICTURE. excess in diet or exercise may induce aggravation, resembling an attack of gonorrhoea, and very probably implicating the bladder. Pain is complained of in the loins and thighs, and in the perineum; often erection is painful. In tight strictures, the urine may pass only gutta- tim ; and then, too, there may be no escape of semen in emission—this fluid passing backwards into the bladder, to be afterwards discharged in an altered state along with the urine. The testicles are liable to enlargement; and the rectum frequently sympathizes, becoming pro- lapsed, or inflamed, or fissured, or ulcerated, or affected with hemor- rhoids ; sometimes strictures of the urethra and of the bowel are found to coexist. The straining, in bad cases, is such as to empty the rectum as readily as the bladder; and, in consequence, the water-closet has to be used, instead of the chamber-pot. Often hernia is induced. The prostate is liable to become not only excited but enlarged; and if this enlargement be chronic and simple, relief from the symptoms of stricture may be experienced; the prostatic tumor acting as a breakwater in favor of the part originally affected. But if ulceration or abscess affect the gland, then aggravation must necessarily ensue. As the kidneys suffer, their secretion becomes more and more changed; and the acrid urine, passing frequently along the urethra, reacts unfavorably on the urethral disease. The complications of ague and gout are by no means unfrequent in those advanced in years and who have lived freely. Re- tention of urine is at any time liable to occur ; the degree of constriction being suddenly increased by spasm, or by inflammatory action, or by both. From this cause, extravasation of urine may follow; urinous abscess, however, ending probably in the formation of fistula in perineo, is more common, generally producing mitigation of the symptoms, at least for a time, as will afterwards be explained. In severe and pro- tracted cases, the general health suffers materially, independently of all accident; the flesh and strength fail, the digestive organs are impaired, the face is sallow, and the features Avear an expression of anxiety almost pathognomonic of the disease. Constitutional irritation sets in; the symptoms denoting organic disease of the kidneys become more and more marked; purulent, mucous, ammoniacal urine passes often, in small quantities, and with much distress; febrile exacerbations recur A\-ith greater force and frequency; emaciation advances ; the appetite and digestion fail more and more completely; at length coma may supervene, and the patient perishes. Treatment is conducted on simple principles ; but a satisfactory cure is often of very difficult attainment. Our object plainly is, to get rid of the redundant deposit which causes the contraction ; and this may be effected in one of two ways : 1. By simply procuring absorption, under the stimulus of pressure. 2. By so managing the application of pres- sure, as to establish a temporary and active congestion in the part, Avhich, on its resolution, may induce rapid diminution of the deposit— someAvhat in the same Avay as the injection of a hydrocele removes a redundancy of serum (Principles, 3d Am. Ed. p. 190). Advance of such action to a high grade is obviously to be avoided ; true inflamma- tion will cause farther deposit around ; and ulceration—at the time per- haps Avidening the canal—is likely ultimately to lead to renewed and USE OF THE BOUGIE. 553 probably aggravated contraction, by puckering of the cicatrix. Besides, ulceration, to prove effectual on the submucous deposit—the true cause of the stricture—must first penetrate and destroy the mucous mem- brane ; an event never desirable. 3. In bad cases, the knife may be necessary to free the contracted part; not, however, as a sole means of cure ; but to assist the bougie in aftenvards establishing the normal condition of the part. To obtain the curative result, in ordinary cases, cautious management of the metallic bougie is now universally acknowledged to be the most suitable means. But, in the first instance, exploration is necessary ; to ascertain whether a stricture exists or not, as also its nature and extent. A metallic instrument may be used for this purpose ; but one of wax is sometimes preferred, as less formidable to the patient, and capable of conveying very explicit information as to the state of the urethra. A large one is not suitable obviously; neither is one of small size—for it is liable to catch a lacuna, and so to indicate stricture when there is none; or, passing through a stricture of no great tightness, it may lead to the belief that the canal is clear, while contraction really does exist. One of a medium size is selected; and, having been warmed gently, and made pliable, by the hand, is introduced cautiously. If obstructed, it is gently withdrawn a little, and then pushed on again ; a fold of the urethra may have been in the way. If, however, still opposed, the ex- istence of stricture may be fairly presumed; and its site is noted, by observing the extent to which the instrument has passed. To elicit farther information, the bougie is pushed steadily onwards, so as to fix its point in the stricture ; and, on withdrawing it, a tolerably accurate idea may sometimes be obtained of the extent and character of the con- traction, by observing the marking of the instrument's point. The wax bougie is then laid aside; its office is exploration;1 and now, for the cure, one of metal is taken up, of such a size as is likely to pass with- out much difficulty. The most convenient kind of bougie is that manu- factured of Berlin silver; holloAv, and consequently light, yet firm enough ; and always possessing a smooth surface. The curve should be gradual and slight—a segment of a large circle; and the set of instru- ments are arranged in a gradually ascending scale, from the smallest wire-like form, to what is likely to fill the average canal in its normal state. The selected instrument, oiled, or smeared with cold cream— sad mischief has happened from croton oil having been mistaken for the bland fluid—is passed down to the seat of stricture, and steadily pressed onAvard, with intent to pass through it. Having succeeded in this, the instrument is permitted to remain, from a minute to half an hour, ac- cording as the patient's feelings may indicate. If sickness occur; or if much pain be felt, and on the increase ; or if the patient express a de- cided wish for removal of the instrument, stating his belief that it is "hurting" him—it should be withdrawn; remembering that our object is, to excite not inflammation, but absorption only. Rest and temper- 1 Many surgeons never use the wax bougie, even for exploration. No doubt, the metallic instrument is quite capable of fulfilling all ordinary indications in this way. But if a wax repetition is made in four or five days, after irritation has passed away. It is probable that what are termed "elastic" strictures—strictures which dilate under the ordinary treatment, but speedily relapse, and become tight as before—often depend on an unusual irritability of the canal; and that they will be more appropriately treated by the occa- sional application of nitrate of silver—in conjunction with the ordinary use of the bougie, and suitable general treatment—than by the employ- ment of cutting instruments. Lately another mode of external incision has been adopted;2 namely, passing a small grooved staff through the stricture, and cutting into the groove at the contracted part, by perineal wound. To avoid hemor- rhage, the incision is placed carefully in the perineal raphd ; and on withdrawing the staff, a catheter is introduced and retained as after the old operation. Until this is done, it is well to have the patient deep in anaesthesia, with a view to avoid urinary infiltration by voluntary action of the bladder. By subsequent use of the bougie, in the ordinary way, permanent as well as rapid dilatation of the canal may in many cases be obtained. The advantages of this procedure are, accuracy of division, and rapid approach to cure. The disadvantages are, the ordinary risks of such operative procedure, and the uncertainty of being able in all cases to insinuate (not force) a small instrument through the contracted part. Some few strictures, we believe, are really " impenetrable;" and are consequently to be treated ordinarily by the "tunnelling method" (p. 555)—in the crisis of retention by perineal incision according to the old way (p. 500). The great majority of " penetrable" strictures, on the other hand, are capable of safe and satisfactory cure, without the use of cutting instruments. But to some few of those which refuse to yield to ordinary treatment, and in whom great irritability of system prevails, this mode of operation seems very suitable—an operation Avhose proper character will probably be fixed hereafter, as neither so safe , nor so generally applicable as its promoter at first imagined, nor yet so dangerous or disappointing as some of its opponents have declared.3 Another mode of treating obstinate stricture—recently devised—is by tubular dilatation ; introducing a small bougie or director through the stricture, and, on that passing down, tubes of increasing size; the object of the apparatus being to secure accurate introduction and rapid dilatation.4 Time is yet wanting to warrant a decided opinion of the 1 AVade on Stricture, Lond. 1849. 2 Syme on Treatment of Stricture by Perineal Incision, Edin. 1849. 3 Lancet, March 22, 1851. * Wakley, Lancet, No. 1438, March, 1851; ibid. No. 1484, p. 144. 36 562 URINOUS ABSCESS. merits of this proposal; but facts, as far as they go, speak in its favor, as being both suitable and safe. Urinous Abscess. This consists in the condition of abscess, complicated with a com- munication with the bladder or urethra, and consequently having a greater or less admixture of urine in its contents. The formation may occur in one of two ways ; from without or from Avithin. 1. An abscess may form exteriorly to the urinary passages—excited by injury, or by the irritation of stricture or stone ; and, in its progress by en- largement, it may open into the urethra, or bladder—according to its site. Then, through the ulcerated aperture, urine enters. Its stimu- lus, within the purulent cyst, necessarily kindles a fresh amount of in- flammatory action. If this advance rapidly to ulceration of the tissues composing the limits of the original abscess, urinous infiltration takes place, with sloughing of the affected parts. But if the pyogenic mem- brane remain entire—perhaps strengthened by a renewed and plastic exudation—then the escaped urine remains limited within the suppu- rated space, and the state of urinous abscess is established. The col- lection may assume quite a chronic character; but, in general, it extends more rapidly than an ordinary acute abscess, hastening to the surface, and discharging thin, dark-colored, and fetid contents. 2. Or, as more frequently happens, the affection originates in ulcera- tion of the lining membrane of the urethra or bladder. Acute ulcera- tion, and also direct laceration, of the mucous membrane is liable to occur, as we have seen in the case of retention of urine (p. 496) ; then rapid escape of that fluid takes place, under powerful action of the hypertrophied muscle of the bladder ; and the most formidable extrava- sation results. But, unconnected with any such crisis, a more gradual giving way may take place ; the urine, escaping first in a few drops, may excite an inflammatory process of a sthenic type; the abscess formed has all the ordinary characters—the important limiting barrier of plastic exudation not excepted: and, as it enlarges, these are not destroyed. Before the actual ulceration, too, it is probable that an in- flammatory process has been slowly advancing in the tissue exterior; Avhich has thus become in some measure consolidated, before any urine has had an opportunity of entrance. Or, as has already been stated, the commencement may not be by ulceration, but by wound or tear—inflicted by an unskilful use of cathe- ters, bougies, or other instruments (p. 556). But the term " Urinous, or Urinary Abscess," is generally under- stood to refer to the urethra. Its origin is commonly from within ; and the usual exciting cause is stricture. The urethral ulceration may be either immediately behind the stricture, or at some distance posteriorly. The ordinary site is in the perineum. There a hard swelling is dis- covered, on pressure ; the ordinary symptoms of stricture undergo ag- gravation ; simmering and febrile disturbance occur; and, perhaps, by the pressure of the abscess, retention of urine may be occasioned. Treat- ment consists in making a free external incision, for the evacuation of FISTULA IN PERINE0. 563 matter and urine ; afterwards removing the cause, the stricture, in the ordinary Avay. Urinary Fistula. This may follow wound in the perineum, implicating the urethra. More frequently, it is the result of urinous abscess. The collection has opened spontaneously in the perineum, temporarily relieving the symp- toms, both of abscess and of stricture; but, by persistence of the latter, closure and cicatrization of the abscess are prevented; the irritation of the stricture maintains a morbid degree of excitement, and the obstruc- tion which it occasions forces the urine into the abnormal channel. The abscess consequently does not close ; but partially contracting, Fig. 236. Example of Fistula in perineo. degenerates into the condition of fistula. There may be but one fistula, or several; in the perineum, or traversing the scrotum, or anterior to the scrotum, or on the nates. Sometimes abscess burrows beneath the fascia of the penis, and opens near the glans ; sometimes the opening is on the dorsum of the penis. Also, one abscess, having more than one external outlet, may lead to the establishment of more than one fistula; or, each fistula may be connected with a separate abscess. The dis- charge is thin and gleety ; often copious. Sometimes a constant drib- bling of urine exists; in other cases, urine escapes only during an ex- pulsive effort. The surrounding parts are tender and excoriated ; the patient is in a constant state of discomfort; and very frequently his general health suffers seriously. Treatment is simple; directed to the stricture, not to the fistula—at least in the first instance. The stricture having been thoroughly dilated, the urine comes again by the normal channel; the fistula contracts and dries ; and, in many cases, it wholly closes, without any direct treat- ment having been received. Should contraction prove tedious and in- complete, the hot wire may be used; applied not to the mere orifice, but deep in the track—lest premature closure of the external part might take place; not repeated frequently, but at long intervals—it being our 564 LACERATION OF THE URETHRA. object to obtain the benefit of the healing process which follows remotely on the burn, not the destructive and inflammatory effects which are its primary result (p. 189). If sinuses communicate with fistulae, it will probably be necessary to lay them open with the bistoury. In cases long neglected, in which the whole urine has for years been passing by the perineum, the urethra anterior to the opening contracts greatly, and may be almost completely obliterated. Dilatation is then effected with great difficulty; and recourse to the method by incision will pro- bably be expedient. Sometimes the abscess opens, not in the perineum, but into the rectum; and fistula forms in the bowel. Urine passes per anum, and air, or even feces, may escape by the urethra. Treatment is the same as for the more common varieties; the speculum ani being used to protect the bowel, when it is necessary to employ the cautery. Laceration of the Urethra. This has been already spoken of (p. 498). The first object is to pre- vent infiltration of urine; and that can be accomplished only by early introduction of the catheter, Avhich should be retained until a sufficient time for consolidation of the injured parts has transpired. If a catheter cannot be passed, incision must be had recourse to, as already explained. But extravasation of urine is not the only risk that demands our regard. That over, the risk by inflammatory action remains; a minor amount is likely to cause stricture ; true inflammation will cause abscess; and this, communicating with the urethra, will degenerate into perineal fistula. Leeching, fomentation, rest, and antiphlogistic regimen, are therefore very essential after the injury. Neglect a severe kick or blow of the perineum, and stricture, abscess, and fistula are almost sure to follow. Everard Home, Practical Observations on the Treatment of Strictures in the Urethra, &c. Lond. 1805. Arnott, Treatise on Strictures of the Urethra, &c. Lond. 1819. Charles Bell, Treatise on Diseases of the Urethra, &c. by Shaw, Lond. 1822. Ducamp, Trait^s des Retentions d'Urine Caus6es par le Retr^cissement de l'Uretre, &c. Paris, 1822. Lis franc, des R6tr£cissements de l'Uretre, Paris, 1824. Macilwain, on Stricture of the Urethra, Lond. 1830. Amussat, Lecons sur les Retentions d'Urine Causees par le Retre"cissement du Canal de l'Uretre, &c. Paris, 1832. Stafford, on Strictures of the Urethra, Lond. 1836. Brodie, Lectures on Diseases of the Urinary Organs, Lond. 1842. AVade, on Stricture of the Urethra, &c. Lond. 1853. Syme, on Treatment of Stricture by Perineal Incision, Edin. 1849. Lizars, on Strictures of the Urethra, &c. Edin. 1851. AVakley, Lancet, 1851. [Civiale, Traite" des Maladies des Organes G^nito-Urinaires, Paris, 1851. Gross/ Diseases of the Bladder, &c. Philad. 1851.—Ed.] CHAPTER XXXV. AFFECTIONS OF THE TESTICLE. Fig. 237. Orchitis. The inflammatory process affecting the testicle may be acute or chronic ; original, as following external injury ; or secondary, the con- sequence or attendant of gonorrhoea. Sometimes it is an accompani- ment of Mumps—inflammatory enlargement of the glands in the upper part of the neck; not improbably depending then on metastasis. Secondary gonorrhceal orchitis is usually acute, and is the most fre- quent form of the affection. It is also known as Hernia humoralis. There being an increased susceptibility in all the genital system, during the existence of gonorrhoea, orchitis may be lighted up at any time, by the application of a slight exciting cause ; a squeeze, excess in walking or diet, exposure to cold and wet, or premature use of strong injection. But, without any apparent exciting cause, the attack is liable to occur ; and then seldom, until some time has elapsed—usually in the third week of the gonorrhoea. It may be the result of metastasis; more frequently, the action extends by continuity of tissue, descending along the vas deferens; seizing on the epididymis, and chiefly residing there. In fact, the affection may in strict language be designated as an Epididymitis ; although the whole testicle seems to swell, yet the epididy- mis is the true seat of disorder, and the general swelling depends chiefly on acute effusion of serum into the tunica vaginalis. Pain, and a sense of weight are felt in the cord and testicle, the skin reddens, and uneasiness is felt in the groin and loins. The swelling and pain increase, often becoming excru- ciating ; and then sensation in the loins is as if the back were sawn across. Discharge from the urethra diminishes, and ceases—an exam- ple, generally, not of metastasis, but of the effect of counter-irritation. The scrotal swelling becomes tense, red, glistening, and intolerant of the slightest pressure ; the cord, too, is swollen, red, and painful. Fe- Acute Orchitis; attendant on gonorrhoea. 566 ACUTE ORCHITIS. brile disturbance is considerable; and vomiting is both a common and distressing symptom. Sometimes such pain is complained of, in the lower part of the abdomen, as to lead to a simulation of enteritis—and for this the complaint has actually been mistaken. Treatment requires to be decidedly antiphlogistic ; leeching, rest, fomentation, low diet, antimony. Recumbency is essential; and the weight of the tumor must be taken off the cord, by suspension, or by the arrangement of a pillow between the thighs. Opiates, too, are of much service; in full doses, and of frequent repetition. When the body of the testicle is undoubtedly involved in acute action, the antiphlogistic use of mercury is both Avarrantable and expedient; to save, if possible, the delicate structure of the gland. If tension be great, it is well to open a vein in the scrotum; at the same time perforating the tunica vaginalis with the lancet, so as to evacuate the accumulated serum. French surgeons have advised that the puncture should implicate the testis; but this does not seem necessary, the testis seldom being so affected as to require wound for the relief of tension; and it is inexpe- dient also, on account of the risk of exciting or aggravating intense in- flammatory action there, from which the patient might otherwise have been exempt. As the action subsides, resolution may be hastened by stimulants to absorption; a solution of the iodide of potassium, with iodine, may be painted on the surface, and pushed to vesication; at a more advanced period, a gum and mercurial plaster may be applied; or pressure may be made by means of adhesive plaster, cut in strips, and applied as if to a limb—the testicle being separated from its fellow, and made to protrude, so as to admit of such application. By some, it is proposed to apply this pressure from the first; but, surely, its proper place is only after the chronic stage has been fairly established. In the acute stage, pressure, however carefully applied, must prove in- tolerable, or at least must cause aggravation, if the action be resident in the testicle itself. In the case of epididymitis, there may be a greater tolerance of the application; but still its usefulness as an antiphlogistic is more than doubtful. As the complaint yields, discharge may be expected to reappear at the orifice of the urethra. Very frequently, resolution is incomplete; hardness and swelling remaining in the epididymis. These require active perseverance in the employment of local discutients ; and the iodide of potassium may be useful internally. In some cases, resolu- tive absorption is not only rapid but excessive. The gland, after regaining the normal size, continues to diminish, and may ultimately dwindle down to a mere shred, wholly destitute of the peculiar function. Sometimes Abscess forms; but seldom, in gonorrhceal orchitis, unless some casualtyor mismanagement have occurred, so as to involve the testis in true inflammation. In simple orchitis, however, the result of direct injury, the occurrence is not so rare. It is attended with much suffering; and the tubular structure of the organ is endangered. An incision must be made as soon as matter has formed; and, in the after treatment, care must be taken to obviate the tendency to fungous pro- trusion which the substance of the testicle usually manifests. CHRONIC ORCHITIS. 567 Chronic Orchitis, and Fungus of the Testicle. Chronic orchitis may be the result of an acute attack, imperfectly resolved; or—as more frequently happens—the action may be chronic from the first; it also may be either primary or secondary—that is, occurring as an independent affection, or as a consequence of gonorrhoea. Very frequently, it depends on stricture of the urethra; not unfre- quently it is of syphilitic origin. The body of the testicle is completely involved, as well as the epididymis—though the latter is usually first affected. The swelling, at first irregular, extends from the lower part of the epididymis, and imTolves the whole organ in a firm, inelastic, uniform tumor, usually of an oval form, and seldom exceeding twice or three times the bulk of the healthy gland. The attendant uneasiness is slight; and, after some time, the characteristic sensibility of the organ under pressure is in a great measure lost. The enlargement is found to depend in part on the deposit of a yellow, cheesy, fibrinous exudation, condensed, non-vascular—intra-tubular, as well as in the interposed areolar tissue. On making a section of the tumor, after remoA'al, this deposit and its peculiar characters are very apparent. Slow softening of this deposit may take place ; matter is formed; the swelling increases, with subacute exacerbation ; the integument thins, and gives way by ulceration; and through the opening the tubular structure protrudes, in the form of a hard, firm, light-colored, compara- tively painless, and slowly increasing fungus. The softening, in such a case, is but partial, and the amount of suppuration slight. Not unfre- quently, opening and protrusion take place apparently without the intervention of any such action ; the tunica albuginea gives way, under gradual increase of deposit; the tunica vaginalis becomes adherent, and ulcerates at this point; and then the integument soon yields also. If the opening be small, the protrusion may be proportionally trifling. But, sometimes, almost the whole of the organ projects; its surface studded with granulations, from which a copious thin secretion is dis- charged. Chronic orchitis requires the ordinary discussive means for its arrest and removal, and abstraction of the cause, when practicable, is not to be omitted. Simple enlargements of the testicle always lead to a suspicion of stricture in the urethra, and that canal is examined accordingly. If stricture be found, it must be removed, before any amendment can be expected from treatment directed towards the testicle. When syphilis is the originating cause, indicated by the history of the case, large size, and slow progress of the tumor, the concurrence of other syphilitic signs, and nocturnal exacerbations of pain in the testicle, that taint must be combated by the appropriate means, and cautious mercurialism may be required.1 1 Authors speak of two forms of syphilitic orchitis, simple and tubercular; the former seldom suppurating, and usually requiring mercury for its cure: the latter often becoming disorganized, and better treated by a combination of iodide of potassium, with gentle mer- curials. Mr. Hamilton thus describes these affections: "In the simple syphilitic sarco- 568 FUNGUS OF THE TESTICLE. In the open condition, when fungus has formed, a slight operation is necessary, the object being to reclaim the fungus, producing absorption of the abnormal deposit, reducing the swelling, and clearing the tubuli. The thickened integument around, constituting the closely adherent margin of the ulcerated opening, is loosened by dissection ; and, having been brought completely over the protrusion, is secured by suture. Consolidation takes place, partly by the first, but mainly by the second intention (Principles, 3d Am. Ed. p. 598), tendency to protrusion is repressed, and, by the contraction incidental to cicatrization, such pres- sure is exerted by the integument on the parts beneath, as leads to gradual removal, at least in part, of the abnormal structure. After cicatrization, such pressure may be supposed to continue, in some degree, for a time, and is then to be aided by the discussive means applicable to occult chronic enlargements. This is infinitely preferable to the old method of shaving off the fungus from time to time, and treating the remaining wound as an ordinary ulcer. The cure was tedious, and, besides, frequent use of the knife in this way was tantamount to castration. By the new method, for which the profession is chiefly indebted to Mr. Syme,1 cure is accelerated, and the function of the testicle is preserved. A question, however, still remains to be settled; whether the whole of the protruded part is capable of being reclaimed, whether the intra- tubular deposit will wholly disappear, and the tubes everywhere recover their normal state and function. The probability is that, in the out- ward part of the fungus, disorganization has often advanced too far to admit of this, and that, therefore, this portion, seldom more than a thin slice, may be removed by the knife, before the rest is covered in by raised integument, without sacrificing any recoverable virile power, and cele the testicle will be found enlarged to the size of a lemon or turkey-egg, of an ovoid or pyriform shape, sometimes flattened at the sides, either uniform on the surface, or with the epididymis distinguishable as an irregular ridge along the back; hard, particularly in the situation of the epididymis; heavy, with the integuments of the scrotum of a dusky red; generally, neither tender nor painful, except that the hanging weight causes a feel- ing of uneasiness in the loins and inside of the thighs. In this respect it differs remark- ably from gonorrhoeal orchitis, where the tenderness is so exquisite and the pain usually so great." " The tubercular syphilitic sarcocele is much more common, and differs ma- terially, both in local and constitutional symptoms, from the simple form. The testicle is enlarged from two to four times its natural size, but the increase of size is generally not remarkable; of very irregular shape, so that the ordinary form of the testicle is often entirely lost, presenting, instead, an uneven hard, knotty mass, in which it is impossible to distinguish the body from the epididymis. At other times, the irregularity is seen to arise from the enlarged and indurated epididymis, which gets of a great size compared to the body of the testicle; that remains but little altered, and readily distinguishable from it. In the gonorrheal orchitis, we well know that the inferior globus of the epididymis is usually the part most enlarged and hard, and often keeps so long after the testicle has recovered; whereas, in the tubercular syphilitic sarcocele, I have more frequently met with enlargement of the upper globus of the epididymis, sometimes excessive and dispro- portioned to the other parts of the testicle. The reason of this may be, that in gonorrhoeal orchitis the inflammation extends from the vas deferens at the inferior part of the epidi- dymis to the cellular tissue external to it, with effusion of lymph, causing swelling and induration; whereas, in the tubercular syphilitic sarcocele, the swelling of the superior globus of the epididymis depends on the presence of a tubercle imbedded among the vasa efferentia of which it is constituted."—Hamilton, Essays on Suphilis, Dublin 1849- see also Lancet, No. 1188, p. 620. 1 Contributions to Surgery, p. 204, Edin. 1848. SCROFULOUS TESTICLE. 569 with the effect of still farther expediting the cure. Often, the opera- tion cannot be performed immediately on the patient's presenting him- self; some days of preparatory treatment are usually necessary, that the part may be brought to a clean, granulating, and quiet condition, favorable to adhesive results. Central suppuration may occur in chronic orchitis. The matter may slowly reach the surface, and be discharged. Sometimes, it remains long stationary, in the condition of chronic abscess. Then the fluid portion of the matter may be absorbed, Avhile the solid part remains in a concrete mass, resembling tubercular deposit, but distinguished from it by being confined Avithin a distinct cyst—what Avas the pyogenic membrane. Scrofulous Testicle. Tubercular deposit is not uncommon in the testicle, occurring either in aggregated masses, or diffused in the tubular structure, Avhich becomes atrophied under the pressure of accumulation. Such affection is termed Scrofulous Testicle. The swelling is gradual and very indolent, little pain or uneasiness is felt, the tumor seldom attains to a large size, and the tubercular diathesis is usually indicated by strumous affections in other parts of the body. After a time, one of the prominences enlarges, reddens, and becomes painful; softening and suppuration have occurred there, the integument gives way, and pus and tubercular matter are dis- charged. The sore presents the ordinary appearances consequent on tubercular softening (Principles, 3d Am. Ed. p. 235). Other parts may soften, point, and break, and sinuses communicate one with another. After a time, the greater part of the tubercular matter may be dis- charged ; then the swelling diminishes, and the sores assume a healing tendency. Should any considerable part of the tubular structure have remained entire, it may protrude and form a fungus, as in the case of simple chronic orchitis. This fungus may be repressed in the ordinary way, and solid and permanent cicatrization may occur. But, some- times, a fistulous opening remains, discharging thin pus, Avith occasion- ally also the secretion of the tubuli, and then the condition of Spermatic Fistula is said to be established. Treatment varies according to the stage of advancement. In the indolent state, discussives are employed, along with antistrumous con- stitutional treatment; and gradual subsidence of the swelling may result. In the softened state, incision is suitable—for evacuation. If then the amount of deposit and suppuration seems slight, cicatrization is to be attempted. If, however, as is more frequently the case, sup- puration and deposit are extensive, it is Avell to favor speedy disintegra- tion and discharge of the abnormal mass, by free use of the caustic potass. Afterwards, pressure, by strapping, is of much use in favoring closure and cure. Sometimes, the tubercular matter protrudes slightly; but this fungus is readily distinguished from that which is composed of the substance of the gland, by being of less size, soft, crumbling, vary- ing, and temporary. For the one, preservation is suitable; the other requires destructive use of an escharotic. Sometimes the extent of 570 IRRITABLE TESTICLE. suppuration and disorganization in the part, and the degree of disturb- ance in the constitution, are such as to call for more summary pro- cedure ; and, to save the system, the part has to be sacrificed, by castration. In the indolent stage of scrofulous testicle, and during the progress of simple enlargement dependent on chronic orchitis, it is not uncom- mon for serum to accumulate in greater or less quantity; masking the character of the tumor, and increasing its apparent bulk. It is detected by softness, translucency, and fluctuation. If the accumulation prove considerable, occasional removal by tapping is of use ; permitting the discussive applications to act more efficiently on the solid enlargement. Tumors of the Testicle. These were wont to be included under the general term Sarcocele. The most common is the simple enlargement dependent on chronic orchitis. The scrofulous tumor is not uncommon. Occasionally, the fibrous tumor is found. Cystic sarcoma is as frequently formed here as in any other situation. Carcinoma and cancer are not of frequent occurrence. Cephaloma has no more frequent site ; sometimes, though rarely, it is combined with melanosis; and sometimes the open medullary tumor degenerates into the condition of Fungus Haematodes. These tumors present the ordinary characters, and require the ordi- nary treatment (Principles, 3d Am. Ed. p. 288, et seq.) The simple enlargements are capable of discussion. The strumous tumors may be either discussed or disintegrated. The rest can be removed only by castration. Prognosis, in the case of malignant formations, may be more favorable here, than at any other site. Irritable Testicle. This term is usually made to include mere increase of the sensibility of the organ, as well as decided neuralgia. The former is almost always dependent on some affection of the urethra, bladder, or kidney, or on disorder of the general system ; and is to be remedied accordingly. But it may—like the tumid and sensitive breast of the female—be the tem- porary consequence of change at puberty ; and it may also follow mere excess in venereal excitement. The latter is a formidable disease; inasmuch as it is attended with great suffering, and is but little amenable to any treatment. Uneasi- ness is almost constant, the part is tender to the touch, and violent pain comes in paroxysms. There is little or no enlargement, or other mor- bid indication, in the organ; in general, it is intolerant of pressure and manipulation; and, during the paroxysm, it is retracted close upon the groin. The patients most liable to suffer from such affections are the weak, nervous, and dyspeptic; more especially if they have indulged in venereal excess. Occasionally, the affection is combined with cirsocele; and seems to depend on that morbid condition of the veins. But, in general, the origin of the affection is equally obscure as in most other cases of neuralgia. The treatment is such as is generally applicable to HYDROCELE. 571 this disease (Principles, 3d Am. Ed. p. 587). Among the more suc- cessful local applications, aconite, belladonna, and nitrate of silver may be mentioned; among those used internally, iron, and the liquor arsenicalis. Frequently, but little improvement follows the most skilful management; and the patient may be driven by his sufferings to demand castration. This request is seldom if eArer to be complied with, how- ever ; inasmuch as the neuralgia is likely to return, in the cord ; being not dependent on any local cause capable of being removed by the operation. Atrophy of the Testicle. Gradual wasting of the testicle may follow acute orchitis, as already noticed ; and a blow or squeeze may result in this, with the intervention of a slight inflammatory process.1 It is not uncommon for atrophy of the testicle to supervene on cirsocele. The pressure of hydrocele, too, would appear, in some few cases, to cause diminution of the gland; and the same result has followed the pressure of fatty or other tumors. Continence, and the prolonged use of iodine internally, are supposed to tend to atrophy; but the truth of the supposition seems more than doubtful. Suppuration of the testicle may cause disorganization of part of the tubular structure, with obstruction and consequent absorption of the remainder. Atrophy of one or both organs, it has been supposed, has followed injuries of the head. Occasionally, examples of the affec- tion occur while no exciting cause can be assigned. Obviously, but little is in our power in the way of treatment; except by removal of the cause, when that is practicable. In the case of cirsocele, for example, if we succeed in curing this, wasting of the testicle may be expected to cease. Restoration of the normal bulk, however, is scarcely probable. Hydrocele. The term denotes chronic accumulation of serum, in connection with the genital organs; and this may occur in more than one site; in the tunica vaginalis, in the cord, or in the sac of a hernia. I. Hydrocele of the Tunica Vaginalis Testis.—There is no more com- mon disease. It may follow on injury, and a minor amount of orchitis; sometimes it is attributed by the patient to a strain ; very frequently there is no assignable cause. Swelling takes place slowly, and with little or no uneasiness ; ascending from the lower part of the scrotum upwards. The tumor may ultimately attain to a large size, encroach- ing closely on the groin. It is of pyriform shape, except when much distended ; and then the narrowness of the upper part is undone by ex- pansion there. It is translucent, unless the coverings be preternaturally thickened. Fluctuation can be felt, unless distension is great. The testicle usually occupies the back of the cavity, near the middle—nearer 1 Squeezing of the testicles is a mode of castration in oriental courts ; complete atrophy being found to result. And the same method is applied to the lower animals ; bucks, for example. 572 HYDROCELE. the lower than the upper part; and seldom can be felt distinctly. On grasping the tumor firmly at that part, however, a hard substance may be felt; and the patient experiences the peculiar sensation which com- pression of the testicle is calculated to produce. However translucent the rest of the swelling, at that part it is opaque. Sometimes the tes- ticle is situate in front; and then can be felt distinctly. It is never found at the lower part of the scrotum, and separate from the general swelling, as in hernia. The finger and thumb can always be carried above the tumor, at its neck; and the spermatic cord can be felt free. The tumor has no impulse afforded to it, on coughing, or during any other exertion of the abdominal muscles; unless there be a commu- nication between the cavity of the tunica vaginalis and that of the abdominal peritoneum—as in the case of congenital hernia. The ac- cumulation generally consists of a straw-colored serum; and sometimes loose solid bodies are found, as in serous cysts elsewhere. The tunica vaginalis is, in general, merely distended; sometimes it is thickened ; sometimes it is intersected, so as to constitute minor cysts. In simple hydrocele, the testicle and epididymis are structurally sound. Not un- frequently, however, they are the subject of chronic enlargement; and then the disease is technically termed Hydro-sarcocele (p. 570). The treatment of hydrocele is either palliative or radical. The for- mer consists in simply withdrawing the fluid, by tapping; the swelling and uneasiness are removed for a time; but they return, and sometimes rapidly. The latter treatment consists in withdrawing the serum, and injecting a stimulant fluid instead, whereby an acute congestion may be established, whose resolution, when complete, shall have the effect of restoring the normal balance between exhalation and absorption (Principles, 3d Am. Ed. p. 190). Simple tapping may be performed by the thrust of a lancet; the flat end of a probe being afterwards used to keep the wound open, during the flow of serum, if necessary. Or a flat trocar and canula may be employed. When injection is contemplated, a round trocar and canula are to be preferred. The patient is placed erect. The surgeon, graspino- the tumor firmly behind, with his left hand, renders it tense and prominent in front; then the instrument is entered, perpendicularly ; afterwards it is passed obliquely upwards, so as to avoid wound of the testicle, and yet taking care that the obliquity is not such as endangers separation of the coverings of the sac, and non-entrance into the sac itself. The serum having been withdrawn, a caoutchouc bottle, Avith stopcock and nozzle, is adapted to the canula—or a syringe is employed; and the cavity is partially filled Avith some stimulant fluid. Port wine, undiluted, or a solution of the sulphate of zinc, used to be much employed. Now, the favorite injection is iodine, in solution; one part of the tincture to three of water. Or, a small quantity of pure tincture of iodine having been thrown in, may be permitted to remain permanently in the sac— disappearing ultimately by absorption. If the dilute injection be used, three or four ounces are injected; and are temporarily retained, by withdrawing the bottle or syringe, and turning the stopcock of its nozzle—which is left pendent from the canula. After waitinc a few minutes, the patient will begin to feel pain in the testicle, shooting up HYDROCELE. 573 the cord into the loins; and a sensation of faintness will probably come upon him. Then the stopcock is opened, and the fluid drains away. The patient is put to bed, with the scrotum supported. If subsequent Fig. 238. Fig. 239. Fig. 23S. Operation of tapping Hydrocele; the trocar entering. Fig. 239. Diagram showing the direction of the Trocar ; a, the direction of perforating, to avoid splitting of the parietes; the direction afterwards changed to 6, to avoid wound of the testicle. action threaten to be excessive, fomentation is applied, and antimony may be given internally. The tumor reforms quickly, with heat and pain; sometimes the acute accumulation seeming greater than the first. By and by, recession in the action gradually occurs ; the tumor subsides; the pain ceases; and, in eight or ten days, we may expect to find the parts restored, permanently, to their normal state. It has been pro- posed to retap, for evacuation of the acutely effused serum, and thus to abridge the period of cure; but this seems to be, in most cases, unneces- sary. It is very seldom that the operation fails. Should it do so, it is to be repeated, with a stronger stimulant. The method by pure tincture of iodine, alloAved to remain, is then specially suitable. Before injecting any stimulant, it is most necessary that the surgeon satisfy himself that the point of the canula is fully within the cavity of the tunica vaginalis ; otherwise, injection of the areolar tissue of the scrotum may take place, followed by sloughing, and severe constitutional disturbance. A case of hydrocele presenting itself, injection cannot at once be determined on. It is first necessary to ascertain whether the testicle i3 sound or not; and this cannot be done until the serum has been discharged. If the organ be then found in its normal state, injection may at once be proceeded with. Otherwise, it must be delayed; we are first to turn our attention to cure of the chronic enlargement; and, 574 CONGENITAL HYDROCELE. after that has been accomplished, the radical operation may then be undertaken. When the testicle is diseased, the accumulation of serum is but a symptom of this affection, and it is to be treated accordingly. The palpable cause of the redundant secretion must be removed; other- wise, reproduction can scarcely fail to occur. For the radical cure, by injection, is not effected by gluing the serous surfaces together, and obliterating the cavity of the tunica vaginalis, as was at one time sup- posed. The excited action seldom advances to plastic exudation; and the cure is simply by restoring normal function in the membrane. A hydrocele of large size is not at once to be injected, though the testicle be sound. It is simply tapped ; and when, by reaccumulation, an average bulk has been attained, then the radical cure is to be pro- ceeded with. The painful operations by seton, caustic, and incision are now fallen into complete desuetude. Of late, it has been proposed to operate by acupuncture; making small openings with a needle, through Avhich the serum may gradually escape, partly externally, but chiefly into the areolar tissue—thence to be absorbed. The mode is tedious and un- certain ; but being safe, and little painful, it may be had recourse to, when the patient decidedly objects to the ordinary treatment by injection. Children are liable to hydrocele. And in them, treatment is very simple. We may succeed in dispelling the fluid, by discutient lotions —such as a solution of the muriate of ammonia; or by the external application of iodine, used cautiously. Failing in this, the serum is to be evacuated by the simple puncture of a lancet. And this, in the great majority of cases, is sufficient to effect a radical cure. The part swells, reddens, and is painful, as after injection in the adult; and, on resolution being completed, the parts are found in a normal state. By the term Congenital Hydrocele, is usually understood a condition of parts such as leads to congenital hernia (p. 405); the vaginal process of peritoneum not having become obliterated. The fluid consequently communicates with the cavity of the peritoneum, usually by a small aperture; and may be made to disappear gradually from the scrotum, by pressure upwards. In treatment, the first object is to shut up the vaginal process; and this may in general be effected, by the constant pressure of a truss. In the child, this may suffice for the whole cure; absorption of the fluid being afterwards hastened by discutient applica- tions. In the adult, the ordinary treatment may be necessary; but never is injection to be had recourse to, until we are satisfied that all communication with the peritoneum has been completely obliterated. To obtain this result, use of the truss is also important in another point of view. The testicle is liable to injury ; by slight injuries the inflam- matory process may, at any time, be lighted up in the tunica vaginalis; and, from thence, extension to the abdominal peritoneum will be easy and direct, unless the communication have been closed. By Encysted Hydrocele is understood an accumulation of serous fluid within a cyst, or cysts, independent of the cavity of the tunica vaginalis. Such adventitious formations are usually found connected with that portion of the tunica vaginalis Avhich covers the epididymis ; HYDROCELE OF THE CORD. 575 but they may arise in connection Avith any part, either of that mem- brane or of the tunica albuginea. The growth is more irregular than in common hydrocele, and the tumor seldom attains to a large size; the testicle is situated sometimes in front, sometimes on the lateral aspect; sometimes at the bottom ; seldom on the back part, as in the common form ; and the fluid is generally paler and less albuminous, than that Avhich is found in the tunica vaginalis. When the bulk is such as to occasion inconvenience, tapping is had recourse to ; and, if nothing contraindicate, injection may be practised. Should this fail—as is not unlikely, in the case of a plurality of cysts—a seton may be introduced, and retained until consolidation has occurred. The tunica vaginalis has been found the site of much calcareous deposit, and filled with turbid fluid containing cholesterine. In such a case, cure can result from nothing short of free incision ; and, after all, castration may not improbably be required. Spermatozoa are sometimes observed in fluid withdrawn from hydro- cele ; and such fluid is usually of a milky appearance. It seems uncer- tain whether these have escaped from an accidental wound or giving Avay of the tubular structure, either of the testicle or of the epididy- mis; or whether the cyst, from which they are derived, has been formed by dilatation of a part of the tubular structure—as takes place in lac- teal tumor of the breast, and in ranula. WhateA'er their origin, their presence is not found to contraindicate the ordinary cure by injection. Hydrocele and hernia may coexist; and, as the former enlarges, the cord and abdominal aperture may come to be so occupied and com- pressed as to prevent hernial descent. A hydrocele, thus enacting the part of a truss, need not be interfered with, unless productive of much inconvenience by its weight and bulk. II. Hydrocele of the Cord.—This may be either diffuse or encysted. The Diffuse form is comparatively rare. A serous fluid accumulates in the areolar tissue of the cord, and is inclosed in a distinct sheath; this again is covered by the cremasteric expansion. The swelling is seldom of large size ; uniform, and somewhat pyramidal; of slow formation ; and not attended with any considerable uneasiness. The base rests on the point where the spermatic A^essels join the testicle, and is separated from the tunica vaginalis by a dense septum ; hence the testicle is felt, distinct, in its ordinary site. If the abdominal aperture be not en- croached upon, there can be no difficulty in diagnosis ; but, when the swelling extends Avithin this, it is apt to be mistaken for omental hernia. The chief points of difference are, the completeness in reduction of the hernia, the clearness of the cord after reduction, and the impulse given upon coughing; in the hydrocele, also, fluctuation is in general tolerably distinct. The fluid has been found reducible within the abdomen, but not into the abdominal cavity ; passing up along the spermatic cord— probably in its areolar tissue—and, when past the abdominal ring, forming a distinct tumor in the abdominal parietes. Unless the swelling prove large and inconvenient, it need not be in- terfered with. The best mode of cure, probably, is acupuncture, aided by local discutients. The punctures are made at the lower part of the tumor, and need not be numerous; for the fluid readily escapes from 576 HEMATOCELE. space to space; and, not unfrequently, these are broken down into larger compartments. Encysted hydrocele of the cord is the more common variety. The serous fluid is contained within a distinct cyst; sometimes of adventi- tious formation ; sometimes formed of an unobliterated portion of the vaginal process of peritoneum. Growth is slow and painless. The tumor is circumscribed, oval, tense, and fluctuating; often plainly trans- lucent ; always movable on the cord. The testis is felt distinctly sepa- rate. And no difficulty in diagnosis exists, unless, as sometimes hap- pens, the swelling extend within the abdominal parietes. In general, howeArer, the tumor can be pulled down from the abdominal aperture, permitting the cord to be felt free above ; and, besides, the tumor can never be wholly reduced within the abdomen—a certain degree of tense fulness always remaining in the upper part of the canal. In the child, this affection will disappear under discutients. In the adult, it seldom demands interference. If it should, it may be got rid of by tapping and injection ; or a seton may be temporarily applied. III. Hernial Hydrocele.—When a scrotal hernia has been reduced, and the neck happily becomes obliterated, the sac, remaining, may be filled by serous accumulation. A pyramidal, fluctuating, and translu- cent tumor will result; of easy diagnosis ; and amenable to the same treatment as an ordinary hydrocele. The affection is of rare "occurrence. IV. Hydrocele in the Female.—The term Hydrocele is applied to an oedematous state of the round ligament; analogous to diffuse hydrocele of the cord in the male. Also, a prolongation of peritoneum, along the round ligament of the uterus, may remain in communication with the abdominal cavity, by means of a narrow aperture at its neck ; and this pouch may become the seat of serous accumulation, constituting a tumor analogous to congenital hydrocele of the male. Besides, the round ligament is liable to be the seat of cystic formation; analogous to encysted hydrocele of the cord in the male. The affections are rare, and seldom require active treatment. Hsematocele. Fis- 2l°- This may be the consequence of external injury ; or it may be of spontaneous occur- rence. By the term is understood an accu- mulation of blood, in one of three localities : the areolar tissue of the scrotum, the areolar tissue of the cord, and the tunica vaginalis. 1. Hsematocele of the Scrotum is the result of bruise or oblique wound; and is analogous to an ordinary bruise, both in nature and in treatment. The scrotum SAvells, and is dis- colored ; the hue is blackish, like that of urin- ous infiltration ; but the diagnosis is easy, by attention to the history of the case—also not- ing that there are none of the signs of gan- n*matoceie of the Scrotum. grene present, and that the system is com- CIRSOCELE. 577 paratively unaffected. The treatment consists in arresting inflammatory action, and afterwards favoring absorption of the extravasated blood by local sorbefacients. Incision is withheld, unless suppuration have un- fortunately occurred. 2. Hsematocele of the Cord.—A spermatic vein may give way, under external injury, or great bodily exertion; and extravasation into the areolar tissue will result, forming a tense, discolored tumor there. The treatment is as for the preceding variety. 3. Hsematocele of the Tunica Vaginalis is the most common form ; and to it, in strict accuracy, the term may be limited. The blood is extravasated into the cavity of the tunic ; and may be associated, or not, with hydrocele. By wound of the testicle, in tapping—or by a blow or other external injury, or by the spontaneous giving Avay of a bloodvessel—a hydrocele may at any time be converted into haema- tocele. The tumor suddenly increases in size, and is the seat of pain ; and, when handled, is found heavier, and less fluctuating than before. The blood, if in small quantity, becomes diffused in the serous fluid ; when copious, a portion coagulates, and assumes the fibrinous arrange- ment. This, acting as a foreign substance, may excite inflammatory action ; and suppuration may take place, with much increase of swelling and pain. Very frequently, the affection is associated with chronic en- largement of the testicle—Haemato-sarcocele. When haematocele is unconnected with hydrocele, the treatment is as for other simple extravasation—antiphlogistic and sorbefacient; the formation of matter being the only indication which requires use of the knife. When the extravasation supervenes on hydrocele, simple tap- ping is in the first instance to be had recourse to. To inject then, how- ever, would be productive of no good result; and, very probably, would cause overaction and suppuration. The fluid is allowed to collect again; and tapping is repeated. After several withdrawals, the fluid may be found once more of the same character as in simple hydrocele ; and then injection may be proceeded with, not only in safety, but with a good prospect of success—provided the testicle is sound. In the con- firmed cases—and more especially when suppuration is already threat- ened—the only mode of obtaining a radical cure is by free incision ; laying the cavity fully open, turning out the coagula, and obtaining closure of the gap by granulation; care being taken to avoid wound of the testicle. If the tunica vaginalis be found thickened, and otherwise much altered, the greater portion may be cut away ; as thus the amount of suppuration, and the period of cure, will be materially abridged. Cirsocele. A varicose condition of the veins of the spermatic cord is termed Cirsocele, or Varicocele. The pendent nature of the part predisposes to this affection. And the ordinary causes are such as favor varix in general (Principles, 3d Am. Ed. p. 572); especially constipation, and laborious exertion in the erect posture; as also tumors, trusses, and whatever causes obstruction to upward flow in the cord. The left side is much more frequently affected than the right; the left testicle usually 578 CIRSOCELE. hanging lower than the right; and the left spermatic vein being not only longer in its course, but also more exposed to-compression by fecal accumulation in the sigmoid flexure of the colon. The swelling is usually pyriform ; with its base on the testicle, its apex upwards ; and on manipulation, the veins can be distinctly felt rolling under the fin- gers, like cords or earth-worms. There is a sensation of weight and uneasiness in the part; the testicle may be the seat of neuralgia, some- times it becomes atrophied. An aching sensation in the groin and loins is not unfrequent. Sometimes the swelling proAres very inconvenient, from its mere pendulousness and bulk; as in saddlers and others, who require close approximation of the thighs in their vocational labor— and in those who are much on horseback. Occasionally a mental de- spondency is observed, greater than the bodily ailment would seem to warrant. Treatment is palliative or radical. The former consists in avoiding or removing the more obvious causes of the affection, keeping the. testicle well supported by a bandage, and bathing the parts frequently in cold water. When the integuments of the scrotum are Very re- dundant, the testicle may be retained in close contact with the groin, by invagination of the loose integument through a padded metallic ring. Or such trussing may be more effectually maintained, by removing the redundant skin by incision; support of the testicle being then intrusted to the cicatrix. When the testicle is suffering either by neuralgia or by atrophy, or when much uneasiness and discomfort are experienced, eradication of the disease is naturally sought for. With this view, the varix may be treated here as elsewhere—by obliteration of the veins. 1. The actual cautery may be used; a heated wire being applied to the \Teins, isolated and fixed between the finger and thumb. The practice is safe and effectual, but the formidable nature of the application is a serious ob- jection.. 2. The veins may be compressed by suture, applied on needles passed beneath them by transfixion ; as in ordinary varix (Principles, 3d Am. Ed. p. 575); care being taken to exclude the vas deferens and the Spermatic artery. Obstruc- tion of the duct is tantamount to castration, and obliteration of the artery can hardly fail to be followed by atrophy of the testicle. 3. The operation of M. Vidal may be per- formed. The varicose veins, having been separated from the rest of the cord, are placed betAveen tAvo silver wires, passed by the transfixion of needles, and emerging at the same openings. By tAvisting together the ends of the wires, the interposed veins are compressed; and, by a continuance of the twisting, they are rolled up round the wires, while at the same time the testicle is some- what elevated. The ends are then secured, on a roll of bandage placed on the integument. By farther twistino- o-. [Fig, 241.] [Veins compressed hy needles and ligatures. (From Fergusson.) —Kd.I TUMORS OF THE CORD — CASTRATION. 579 the united ends, by means of a turnstick, the compression and twisting of the veins are gradually increased; and this is continued, until the wire's free themselves by ulceration—thus declaring section and oblitera- tion of the veins to be complete. 4. Obliterative pressure may be maintained on the veins at the groin, by means of a spring truss. But this, for obvious reasons, is not advisable. Moderate pressure there, however, is found very serviceable, not merely palliating, but sometimes obtaining cure ; probably by affording support to the veins, while they are at the same time relieved from the superincumbent weight of blood. Such moderate pressure is best applied by a light and accurately fitted truss.1 One great advantage of such treatment is its simplicity, and freedom from risk by phlebitis. A variety of varicocele occasionally occurs, affecting the veins within the inguinal canal, and at the groin; while those of the scrotum are comparatively free. It is very liable to be mistaken for hernia, as formerly noticed (p. 388). The best test is the peculiar sensation im- parted to the finger and thumb when the part is pinched and rubbed. Palliative treatment usually suffices. But should a radical cure be sought, the preferable means is the application of pressure by a truss. Tumors of the Cord. Occasionally, adipose tumors form in the areolar tissue of the sper- matic cord. Their bulk is inconvenient, and their pressure may cause atrophy of the testicle. They are to be remoA'ed by incision. Fibrous tumors and osseous formations have also been found here ; but are rare. The testicle, arrested at the groin, in its descent, may become affected by tumor ; and in that situation may require removal by operation.2 Castration. This severe and painful mutilation is seldom required, except for tumors of the testicle ; malignant, or such as, though simple, are not amenable to either discussion or disintegration. In neuralgia of the testis, and in cirsocele, it is sometimes demanded by the patient; but in neither case is the surgeon warranted in acceding to the wish. All hair having been removed from the scrotum and groin, the patient is placed recumbent. By grasping the tumor behind, the skin is made tense. The bistoury is entered at the neck of the swelling, and carried to its fundus; diverging over the body of the tumor, so as to include a sufficiency of skin within an elliptical incision. This form of wound is especially necessary, when a fungus, ulcer, or other involvement of the skin requires to be taken away. A simple rectilinear wound would suffice for removal of the tumor; but a redundancy of skin would be left, constituting a pouch for untoward accumulation of .blood or pus. On the other hand, it is very necessary to avoid excessive removal of • ' Curling, on the Testicle; and Thomson, Monthly Journal, Nov. 1848, p. 295. " Evans's moc-main lever truss" is very suitable. . 2 Lancet, No. 1214, p. 617. 580 IMPOTENCE. the skin, lest, on contraction, a bare sufficiency be found for effectually covering the remaining organ. And, in connection with this, it is im- portant to remember that the covering of a large sarcocele is borrowed from the adjoining parts; and that, consequently, after incision, a great degree of resilience in the integument is certain to occur. The dissec- tion is advanced, first at the upper part of the wound, so as to expose the cord; this, having been isolated, is entrusted to the firm grasp of an assistant, to prevent retraction within the abdominal aperture ; and then it is cut across. The apex of the tumor being now everted, dis- section is rapidly proceeded with—a dissection rendered comparatively painless and bloodless, by early section of the cord. Care is taken not to wound the septum, and thus to expose the sound testicle. The arteries of the cord are then tied. And, should they have slipped from the fingers of the assistant, an upward enlargement of the superficial wound may be required. The scrotal vessels are secured with especial care; experience warning us that, otherwise, troublesome bleeding after reaction is almost certain to occur. The wound is brought together, and treated in the ordinary way. The loAver part seldom heals but by granulation; and, therefore, need not be closely approximated. The cord requires to be carefully watched ; diffuse suppuration being apt to occur there ; and should this threaten, early incision must be had recourse to. But, by suitable antiphlogistic precautions, all necessity for resumed use of the knife may generally be avoided. It is important to remember that, like hydrocele, sarcocele may co- exist with hernia; and that the latter may be temporarily restrained by the bulk of the tumor of the testicle. On removal of this, however, the hernia, descending during the cries or straining of the patient may ap- pear at the wound. Impotence. This may depend on imperfect development of the testis; but not on imperfect descent. The organs are as efficient, functionally, in the abdomen as in the scrotum. Ablation and atrophy of both organs cause impotence ; but either testicle may be lost with comparative impunity. The oxalic diathesis, and diabetes, diminish the sexual ap- petite and power ; and so does the phosphatic diathesis, to a less degree. The pressure of hydrocele may cause impotence, even without atrophy of the testicle. Affections of the brain are sometimes followed by it. In the newly married, a temporary loss of power is sometimes caused by mere predominance of mental emotion. Excessive A'enery, inducing an irritable state of the whole genital system, is perhaps the most fre- quent cause. Effete roues thus " read their sin in their punishment." Cure can be expected, only in those cases which are unconnected with structural change in the testicles. The cause having been remoA'ed, certain medicines are supposed to have a tendency to restore this animal function, and are hence termed Aphrodisiacs. Of these, the most im- portant are, Indian hemp, conium, and phosphorus; the two former most suitable in cases of irritability ; the latter given, in very guarded doses, for the more chronic examples. Musk, cantharides, steel, and , SPERMATORRHEA. 581 other tonics, may also be of service ; and diet should be generous. The mental cases may be left to work their own cure. Spermatorrhoea. An irritable state of the testicles, seminal vesicles, bladder, and ure- thra, with a turgid and especially irritable condition of the prostatic portion of the urethra, leads to involuntary and frequent emission of the seminal fluid. By much the most frequent cause of this morbid state is masturbation ; and, next in order, comes excess in venereal in- dulgence. Stricture, prostatic diseases, and irritation communicated from diseased rectum, are common causes of minor forms of the affection. In consequence of the irritability, an impression much inferior to the normal stimulus suffices for production of seminal discharge. Slight venereal excitement, by day or night, causes emission ; and semen is also discharged during straining at stool, and by the effort of evacuating the last drops of urine in micturition. The testicles are soft, and hang Ioav in the scrotum, which is loose and flabby. Impotence results ; by in- capacity of erection, as well as by reason of preternatural haste in emission, and by the vitiated character of the secretion itself. The di- gestive organs become deranged; the general health fails; many anoma- lous sensations are felt, and many serious diseases are simulated ; a de- jected expression of countenance is acquired; and the air and bearing are those of a poltroon. The principles of treatment are obvious. Chastity in thought, word, and deed; cold bathing, and a tonic system of treatment; regulation of bowels, but avoidance of purgatives, or other sources of local irritation and general exhaustion; early rising, cheerful society, and healthful occupation of body and mind. If the irritability continue, nitrate of silver may be applied to the posterior part of the urethra, by means of the porte-caus- tique of Lallemand.1 This instrument having arrived at the tender part —which is at once indicated by the feelings of the patient—has the stylet projected, so as to expose the caustic ; and, by gently turning the in- strument, an efficiency of application is insured. • Afterwards, strict rest, with antiphlogistic regimen, should be maintained for a day or two; and, if need be, sedatives are given, either by the mouth or by the rec- tum. Repetition may be required, after a considerable interval. In mild cases, the occasional introduction of a common metallic bougie may succeed in removing the irritability; rendering recourse to the more painful and hazardous cauterization unnecessary. Cold enemata, and counter-irritation in the perineum, may be of service. Compres- 1 This instrument " consists of a straight or curved platina canula, or tube, rather smaller than a middle-sized catheter, through which plays a caustic holder; in the farther extremity of which there is a narrow groove, eleven lines in length, for the purpose of holding the caustic. After filling the groove with the nitrate of silver, by fusing it over a spirit-lamp, it becomes so securely fixed, that there is no longer any danger of it escap- ing. At the other end, there is a sliding screw, or stop, by which the action of the remedy may be limited to any extent less than the groove which contains it. Another sliding stop affixed to the canula serves, after the distance of the orifice from the part to be cau- terized has been ascertained, to prevent the instrument passing farther into the canal. [See Fig. 235.—Eu.] 582 SPERMATORRHEA. sion of the urethra, by a pad applied to the perineum, has also been found useful.1 This obscure and distasteful class of cases are still much in the hands of unprincipled practitioners and quacks. This is no reason, however, for leaving the unfortunate victims in such a predicament, or for deny- ing the existence of such affections. Acknowledging the disease, it seems plainly the duty of our science and art to afford what assistance may be in our power, at the same time remembering, that without strict purity of conduct on the part of the patient, all treatment will prove of little avail. On Diseases of the Testicle, see Warner, An Account of the Testicles, their Coverings and Diseases, Lond. 1774. Pott, A Treatise on the Hydrocele, &c. in his Chirurgical Works, vol. ii. Lond. 1783. Benjamin Bell, A Treatise on Hydrocele, &c. Edin. 1794. Earle, A Treatise on Hydrocele, Lond. 1796. Ramsden, Practical Observations on the Sclerocele, &c. Lond. 1811. Astley Cooper on the Structure and Diseases of the Testis, Lond. 1830. Russell, Observations on the Testicles, Edin. 1833. Curling, A Practical Treatise on Diseases of the Testis, &c. Lond. 1843. 1 Ranking's Retrospect, vol. ii. p. 118. See also, on this subject, Lallemand, des pertes seminales involontaires, Paris, 1842. Brit, and Foreign Review, April, 1843, p. 346. Phillips, Med. Gazette, Jan. 1843. Civiale, M6moire sur l'Emploi des Caustiques dans quelques Maladies de l'Uretre, Paris, 1842. CHAPTER XXXVI. AFFECTIONS OF THE SCROTUM AND PENIS. Erysipelas of the Scrotum. Erysipelas not unfrequently attacks the scrotum, in a distinct and marked form, peculiarly asthenic in its type, partaking much of the characters of diffuse areolar infiltration. It occurs in adults of weak and broken-down system, given to drink and other dissipation, and usually follows a kick, blow, or other injury. Swelling is great and rapid, with marked symptoms of constitutional irritation from the com- mencement. Thin, unwholesome matter speedily forms, and is diffused into the areolar tissue. The skin—at first red, tense, and glistening— blackens, or assumes a taAvny hue, shrivels, and becomes cold and fetid. Sloughing is begun and advancing. Very frequently the groins are involved, and the mischief extends upwards in the abdominal parietes. The constitutional symptoms soon pass from the irritative into the typhoid type, and fatal sinking follows. Local and general safety can be obtained only by early and active interference, free incision, and constitutional support (Principles, 3d Am. Ed. p. 223). Erythema may occur at any time in the scrotum, under the ordinary exciting causes. It folloAvs the ordinary course, and requires the ordi- nary treatment. The areolar tissue of the scrotum is very liable to oedema, occurring sometimes as a distinct affection, much more frequently as a concomitant of general anasarca. When excessive, relief and diminution may be obtained from a few dependent punctures, made cautiously, however, lest asthenic and diffuse inflammatory action ensue. Elephantiasis of the Scrotum. The scrotum is liable to chronic enlargement by hypertrophy, form- ing a large, simple tumor, within which the genital organs come to be altogether concealed, the prepuce alone remaining visible, at the lower part of the swelling, thickened, and warty; and from this point the urine is discharged in a scattered stream. The affection is much more frequent in hot climates than in this country. There is no cure, but by use of the knife. When the tumor is of no vast size, the incisions may be planned so as to save the penis and testicles, and dissection is conducted cautiously with this view.1 In the case of a large tumor, 1 Farther details of this affection, and of the operative treatment required, with dia- grams, will be found given by Dr. Brett, Lancet, No. 1174, p. 241. 584 ELEPHANTIASIS OF THE SCROTUM. Fig. 242. Hypertrophy, or Elephantiasis of the Scrotum, in a Hindoo. Fig;. 243. An aggravated example of Chimney-sweepers' Can. cer; much superficial texture destroyed. however, such an attempt may be hazardous, the patient being apt to undergo fatal exhaustion, under the tedious and painful operation, and the copious loss of blood. It is then better, probably, to sacrifice everything, and to effect remoA7al, at once, by a few rapid strokes of a long bistoury. Before proceeding to any operation, however, and more especially to summary ablation, it is most necessary to ascertain whe- ther or not scrotal hernia exist. If such be found, the incisions must be planned and conducted with peculiar care. Chimney - Sw eeper s Cancer. The integuments of the scrotum are liable to malignant ulceration ; more frequently found in chimney- sweepers than in others—probably on account of the irritation of soot, and habits of uncleanliness; but not limited to that peculiar vocation. The ulcer begins in the form of a wart; and frequently is surrounded by warty formations. It may spread rapidly. Cure is by excision, or by thorough destruction by means of chloride of zinc paste; and certainty of success is to be hoped for only at an early stage—when the disease is as yet limited to the integument, and Avhen no great amount of even this tissue is involved. At a more ad- vanced period, when the testicle is exposed, and probably contaminated, a chance may yet be afforded by castration; provided the groins are free from secondary enlargement, and the constitution is not much broken down. Priapism. Permanent erection of the penis occurs in three forms. 1. From injury of the spine. This has been already noticed, as a distressing symptom of spinal fracture (p. 335). 2. From vascular and nervous excitement, induced by excessive venereal stimulus. The turgescence may be such PHYMOSIS. 585 as temporarily to occlude the urethra, causing retention of urine ; and this is to be treated by antiphlogistics and antispasmodics, as formerly noticed (p. 497). 3. A more formidable variety may occur, from the same cause as the preceding; dependent on extravasation of blood into the corpora cavernosa—a vessel of some size having given way. In a case of urgency, it may be necessary to evacuate the extravasated blood by incision ; but, in general, it is better to treat the case according to the general principles applicable to bruise; averting inflammatory action, and favoring absorption. If incision be made, there is great risk of troublesome suppuration following ; incapacitating the organ afterAvards for normal erection. Sometimes chronic deposit, of a plastic kind, and probably of inflam- matory origin, takes place in the corpus cavernosum ; producing thick- ening, perhaps with enlargement of the part, and more or less oblitera- tion of the erectile tissue. Erection, consequently, is imperfect and painful. Treatment will mainly consist of counter-irritation and sorbe- facients to the part, with alteratives internally. Should stricture co- exist, that must be removed in the ordinary way.1 Phymosis. Phymosis and Paraphymosis both depend on preternatural contrac- tion of the preputial orifice ; the difference being, that in the one case the contracted portion occupies its normal position in front of the glans ; in the other it is reflected behind the glans, and acts as a con- striction there on the body of the penis. Phymosis may be congenital; an original malformation. In this case, if the contraction be great, the child is apt to suffer much. The urine escapes imperfectly ; and, in conse- quence, chronic balanitis may ensue,, or a Fig- 244- calculous concretion may form. In after life, the preputial contraction may have the same effect as a tight stricture of the urethra ; causing first irritability of the genito-urinary system, afterwards organic change—stricture of the urethm, altera- tion in the coats of the bladder, dilatation of the ureters, and finally renal disease. Should these dangers pass by, and an advanced age be reached by the patient, ulceration is apt to take place at the con- tracted part; and, very frequently, the Phymosis. ulcer assumes ultimately a malignant ac- tion, and extends so as to involve the glans and body of the penis. It is important, therefore, on many accounts, to remove this source of evil as early as possible. Acquired phymosis may be acute or chronic. The former is the result of an acute inflammatory process; following external injury ; or 1 H. J. Johnson, Lancet, No. 1473, p. 481. 586 PHYMOSIS. sympathetic with gonorrhoea, balanitis, or venereal sores. The areolar tissue becomes infiltrated with serum; the swelling, thus caused, pre- vents the glans from being uncovered in the usual way; and discharge accumulating, aggravates the disorder. The main treatment is by rest, fomentation, poultice, and general antiphlogistics. And, under this management, swelling may more or less rapidly disappear, and the normal state be regained. Failing this, and if there be urgency for exposure of sores—which may be extending rapidly, and may require activity in direct applications—incision is necessary. It may be that the urgency is such as to demand incision very early in the case, while the sores are yet fully impregnated with virus; and then there is risk of the disease being much extended, by contamination of the recently made wound. Such risk may be in a great measure obviated, however ; by applying an active escharotic immediately to the sore, so as to anni- hilate both the local poison and the poisoned part; and by touching the wound slightly with the nitrate of silver, so as to make a protecting crust on the raw surface. In general, the operation is to be delayed, until the sores are of such a date as to render impregnation of the wouud at least improbable—the reparative stage having been reached, when dis- charge probably ceases to be virulent (p. 525). The chronic form of acquired phymosis may result from gradual in- crease of original malformation, or from cicatrization of ulcer or wound. Like the congenital form, it is to be relieved only by operation. And this may be performed in various ways. 1. A simple and very suitable mode consists of inserting a director into the preputial cavity, retaining it by the side of the fraenum, intro- ducing on it a sharp-pointed curved bistoury, and by this transfixing and dividing the prepuce at its lower aspect. The director's point must in the first instance be moved about freely, to make sure that it is in the preputial cavity, and not in the urethra. The site of the incision is chosen, for obvious reasons. If placed on the dorsum, two unseemly flaps are formed, and the glans is left permanently uncovered. By the side of the fraenum, a less amount of wound suffices ; the glans is equally well exposed; and, after cicatrization, no unseemliness results, nor is there any departure from the normal relative position of the parts. To prevent resilience of the integument from the mucous membrane, and thereby to prevent an unnecessary extent of raw surface, a fine suture on each side is required; and this is retained, until spontaneously freed by ulceration, or until consolidation has taken place by plastic exuda- tion—whereby the natural resilience is obviated. 2. When the pre- puce is redundant in front of the glans, the following operation is suita- ble. The prepuce having been stretched, so as to clear the glans, the mere orifice is taken away, by the stroke of scissors or a knife. Circum- cision, in fact, is performed, to a limited extent. The skin is found free enough, but the mucous membrane is still tight; and this is slit up, by scissors, at two or more points. The end of each flap of mucous mem- brane is then secured, by a fine suture, to a corresponding portion of the integument. This mode of procedure is well suited to those cases, which are connected with a cluster of venereal sores on the very verge of the prepuce ; both diseases being got rid of at once. It is also ad- PARAPHYMOSIS. 587 visable when, in any case, the end of a long prepuce is much indurated or otherwise permanently altered in structure. • [Mr. Fergusson is in the habit of attaching together the mucous membrane and integument at several points, instead of only at the point of the flaps of the mucous membrane. The advantage of introduc- ing several fine sutures is, that union by primary adhesion will probably occur; and thus the liability of cicatrization and contraction, consequent on the granulating process will be obviated or diminished, with pro- portionate diminution in the probability of reproduction of the stricture. (Fergusson, op. cit.) For the same reason, the use of a few sutures in the operation last described by Professor Miller would probably be an improvement upon it. Another very neat operation is that of Cullerier. It is applicable to those cases of Phymosis, in which the integuments do not appear to be much condensed or indurated; but in which the stricture is due chiefly to the more unyielding mucous membrane. The operation consists in passing the blunt-pointed blade of a pair of very delicate scissors be- tween the glans and the prepuce, while the sharp-pointed blade is thrust into the substance of the prepuce, being separated from the other blade by the mucous membrane; the latter is now divided to a sufficient length to allow the prepuce to be drawn back. This operation has been fre- quently performed by Dr. Peace, of this city, and with success.—Ed.] Paraphymosis. A tight preputial orifice, reflected behind the glans, and permitted to remain there, constricts the body of the organ, and gives rise to very unpleasant consequences. The superficial areolar tissue swells greatly, on each aspect of the stricture; the glans swells too; and an acute inflammatory process is kindled, under unfavorable circumstances—the strangulated parts being obviously ill provided with the power of resist- ance or control. There is the same necessity for relief, as in the case of strangulated hernia, so far as the preservation of structure is con- cerned ; and relief is sought in the same way. Reduction generally is practicable, in recent cases. The patient's trunk having been steadied, and the parts well oiled, the surgeon grasps the glans with the fingers of the right hand, and makes steady pressure thereon, also pushing it steadily from him ; at the same time, with the fingers of the left hand, he draws forward the constricting orifice; the object being to push the glans, diminished by pressure, through the narrow preputial orifice. Failing in this, and there being no marked urgency, another mode of reduction may be attempted. The penis is placed erect, and on the glans a stream of cold water is maintained for some time. This may have the effect of so diminishing the bulk of the formerly turgid part, as to admit of its being replaced without much difficulty within its pre- putial covering. But should these attempts at simple reduction fail, or should the case be already so far advanced as not to warrant their being practised, in- cision is required. And little more than a scratch suffices, if rightly 588 HYPOSPADIAS. Fig. 245. placed. The general bulge behind the glans is not to be widely laid open; but it is separated, by means of the fingers, into its two component parts. In the depth between these, the constriction is found, as a narrow band or thread; and that alone requires division. After reduction, the wound seems a mere notch in the preputial verge. If neglected, the glans may slough or ulcerate very destructively ; or, the glans remaining merely congested, the stricture may cause ulceration of the body of the penis, opening the urethra, and pa^hymosis; the dark producing urinary fistula. Operating lately on a portion is the lining of the case of this kind, in a boy, after the paraphymosis prepuce, reflected; the pre- ha(j existed unreduced for three months, I divided strictLe'lsbehJnd,between a piece of thread which encircled the penis—deeply the two sweiimgs. imbedded in it—and which had been secretly ap- plied as a jugum, to prevent punishment on account of enuresis (p. 494). When paraphymosis and venereal ulcer of the glans coexist, there is an especial necessity for immediate relief; otherwise, acute phagedaena, or sloughing, cannot fail to supervene. It may happen that the con- striction has been slight, and of old standing; and that, in consequence, even after extensive incision on the dorsum of the penis, reduction is found impracticable; the parts being firmly glued to their abnormal site by plastic exudation. Under these circumstances, we must be contented Avith simple relief of the stricture, by suitable incision ; leaving resto- ration of normal relative position to be effected, when resolution of the inflammatory action has become complete. Hypospadias. This term denotes an imperfect condition of the urethra, at or near its orifice; the result sometimes of accident or disease, but usually a con- genital malformation. /There may be a vestige of the normal opening at the apex of the glans, the urethra terminating somewhere behind this; or, as more frequently happens, the anterior portion of the canal—to the extent of an inch or more—appears as if slit up, the margins of the wound having become rounded off; in other words, the lower part of the wall of the canal is deficient. In extreme cases, the whole antepubal part of the urethra may be thus imperfect. The inconveniences of the affection are, a scattered and ill-projected stream of urine, perhaps ineffi- cient emission of the seminal fluid, and a raw, congested state of the exposed mucous membrane. When there is rather a slitting up, than a deficiency of parts, the edges may be pared and brought together over a catheter. When the parts are actually deficient, autoplasty must be had recourse to ; a portion of integument being borrowed from the neighboring perineum or scrotum, and engrafted into the hiatus. In the minor cases, however, which constitute a decided majority, no inter- ference is necessary; the inconveniences, if any, being slight. MALIGNANT DISEASE OF THE PENIS. 589 Hyperspadias or Epispadias. . This is an analogous, but opposite state ; the splitting up—or rather the non-development—having taken place on the dorsal aspect. The chasm may extend from the glans to the symphysis pubis. In general, there is a sufficiency of parts to admit of paring the edges, and approxi- mating them by suture over a catheter. Immediate union is not likely to occur at every part; but permanent closure may ultimately be ob- tained, either by repetition of the operation at the unclosed points, or by occasional application of the heated wire. Imperforate Urethra. A congenital malformation, in this respect, is obviously to be reme- died in but one way ; by the plunge of a round trocar and canula, in the proper direction ; and by keeping the artificially constructed canal pervious, by the lodgement of a catheter—changed occasionally to pre- vent calculous deposit. Malignant Disease of the Penis. This is found only in the aged; and frequently, as already stated, it may be traced to the irritation of congenital phymosis; beginning in the preputial orifice, by ulceration, and extending thence to the body of the organ—or, it may be, beginning in the glans itself. The glans is enlarged and indurated ; angry ulcers penetrate it in various places; the body of the penis suffers likewise; the lymphatics on the dorsum swell and harden; the glands of the groin are involved; retention of urine may ensue, by pressure of the secondary tumors on the neck of the bladder; the cachexy advances; and the patient perishes—his end perhaps hastened by hemorrhage from the open and deep cancer. Nothing but the knife can afford a chance of cure. When the pre- puce alone is affected, its removal is sufficient. Sometimes a malignant ulcer attacks the integument of the body of the penis, originating there; it may be long and successfully resisted in its advance, by the dense fibrous fascia which invests the organ subintegumentally; and, in such a case, removal of the affected surface by dissection may suffice. When the glans and body are involved, nothing short of amputation of the entire thickness affords a prospect of cure—cutting in sound parts, be- tween the disease and the symphysis pubis; and the attempt is warrant- able, only when as yet the lymphatics show no sign of implication. When the glands are already enlarged, there is nothing left in our poAver but palliation; and, as formerly stated, puncture of the bladder above the pubes may be required, towards the close of the case, on account of retention of urine (p. 499). I lately met with an affection which strongly simulated malignancy. In a gentleman of middle age, one half of the lining membrane of the prepuce was occupied by a flat growth; partly warty and hard, partly smooth and villous, in every part highly vascular. This Avas the seat of 590 AMPUTATION OF THE PENIS. intense irritation; the least touch was agony; frequently, pain shot violently down the thigh; sleep was denied at night; the general health was wasted; and the patient professed himself, as he seemed, most miserable. The corresponding part of the glans was red and excoriated. The disease was removed freely by the knife ; and perfect cure resulted. Amputation of the Penis. This is had recourse to on account of malignant disease, affecting the body of the organ ; but only when there is a sufficient space of sound texture between the disease and the pubes, and when the glands yet show no sign of contamination. The ordinary mode of perform- ance is exceedingly simple. The organ, stretched by the left hand pulling it outwards, is lopped off by one sweep of an ordinary ampu- tating knife—laid upon the part, and moved rapidly across from point to heel, or conversely. The integument is encouraged to contract towards the pubes ; so that, during the puckering of cicatrization, it may not overlap and interfere with the orifice of the urethra. And this is kept of the normal caliber, by a suitable use of bougies. Ricord's method of operating is preferable, however, being well cal- culated to obviate the principal difficulty—namely, tendency to contrac- tion in the orifice of the urethra. Rapid healing of the wound is also promoted; and, at the same time, a sufficient covering is provided for the corpora cavernosa. The procedure is conducted thus: After ampu- tation in the ordinary way—enough skin being left to cover the corpora cavernosa, and no more—the surgeon seizes with forceps the mucous membrane of the urethra, and with a pair of scissors makes four slight incisions, so as to form four equal flaps; then, using a fine needle, which carries a silk ligature, he unites each flap of membrane to the skin by a suture. The wound heals by the first intention; adhesions form be- tween the skin and mucous membrane: and these textures become con- tinuous—a condition analogous to what is observed at the other natural outlets of the body. The cicatrix then contracting—instead of operat- ing prejudicially, as in the old method—tends to open the urethra, In- pulling its lining membrane outwards. When, in the case of a short stump, incom'enience results from in- ability to direct the stream of urine in a sufficiently outward jet, the deficiency of the organ may be temporarily compensated, when' the patient makes water, by a mechanical adaptation—a funnel-shaped canula, of sufficient length, its base resting on the pubes. Travers on Phymosis and Paraphymosis, Lond. 1818. Earle and Travers on Chimney- Sweeper'. Cancer, M«.-Chir. Trans, vol xii. Larrey, Men,, de la Chir. Militaire, torn. n. p. 110. Titley, Med.-Chir. Irans. vol. vi. p. 71. Liston, Edin. Med and Surer Jour- nal, vol. xix. p. 566, 1823. Key, Case of Hoo Loo, Med. Gazette, vol. >iSp 93 im Bergson, Die Beschneidung vom Historicheu, &c. Berlin, 1844. CHAPTER XXXVII. AFFECTIONS OF THE FEMALE GENITAL ORGANS. The affections included in this chapter are considered very briefly, the great majority belonging to the exclusive province of the- obstetric practitioner. Inflammation of the Vulva Occurs at all ages. In the adult, it presents no marked peculiarity in its history or treatment. In the child, it forms the disease generally called infantile gonorrhoea, or infantile leucorrhoea. This affection, which was long mistaken for the result of attempted impure connection, may occur at any period of adolescence. It is most frequently seen in delicate, unhealthy children ; and more among the children of the lower than of the higher classes. Not unfrequently it comes on during convalescence from the eruptive fevers, or during teething (p. 522). Sometimes no cause can be assigned; or it may be induced by worms or other rectal irritation, by want of cleanliness, or by exposure of the parts to damp and cold. The symptoms are, constant irritation and pain, so that the child is frequently moving its hand towards the part; pain and scalding in making water, to which the calls are sometimes inordinately frequent; and, in addition, the ordinary signs of slight febrile excitement. On inspecting the pudenda, they are found bathed in pus; the whole surface of the vulva is SAvollen, red, and tender; and there is frequently, on and around the vulva, an eruption of a feAv red and inflamed spots, which may either disappear, or go on to form small pustules. Treatment is simple. In mild cases, nothing but cleanliness may be required. In the more severe, it is necessary to exhibit laxative and alterative medicine, to keep the patient in bed, to allay feverish irrita- tion by hot bathing, to apply locally hot fomentations at the outset, and subsequently to use various washes—as a Aveak solution of nitrate of silver, or of sulphate of zinc. The decoction of poppies is often useful to remove irritation. If the skin is broken, care must be taken, during the healing, to prevent cohesion of the labia. Sometimes the disease affects children along with a low form of fever; and the inflammation may go on to sloughing. The vulva is also sometimes the seat of extensive and unhealthy ulceration, and of noma, with accompanying fever of a low typhoid character. 592 THROMBUS OF THE VULVA. Abscess of the Vulva May be the result of mechanical violence, or the secondary consequence of sanguineous extravasation into the subcutaneous or submucous areolar tissue. It may follow erysipelas, or acute phlegmonous inflammation of the glandules of the areolar tissue of the part, arising without assigna- ble cause. Occasionally, there is a succession of such abscesses in the vulva; apparently induced by inflammation or irritation of the vagina, or of the deeper-seated organs. It is a common affection of prosti- tutes; and in them frequently ends by forming fistulae. When the dis- ease is a consequence of sanguineous extravasation, it also sometimes ends in fistula; the purulent deposit extending, like the sanguineous, from the vulva upwards along the walls of the vagina—or in other di- rections, as toward the anus. The origin and progress of abscess in this situation does not materi- ally differ in any respect from its history as originating elsewhere. Generally, the accompanying pain is severe; but if the abscess has fol- lowed extravasation of blood, the pain and constitutional symptoms may be comparatively slight. The affection is distinguished from thrombus by the presence of more or less fever, by the acuteness of the pain and tenderness, by gradual progress of the swelling, and by the color of the integument over it ; from varicose veins of the vulva, by its sensibility on pressure ; by its tension, and by not disappearing when the patient lies down ; from hernia, by the absence of impulse on coughing, its history, progress, &c. There is no special point to be attended to in the treatment. The abscess should be opened early; and, in preference, from the skin, not from the mucous membrane. Every attention must be paid to the en- couragement of speedy healing, in order to avert the danger of the formation of fistula. If, in spite of all care, a fistula vaginae does form, and proves tedious, it must be dealt with in the same way as fistula in ano (p. 416). Thrombus of the Vulva May be in either labium, or in both. It is most frequently caused by the efforts of parturition; but may also follow external violence, efforts at stool, &c. Persons affected with varicocele of the labia are predisposed to the affection. The thrombus may attain to very large size, so as, in the case of parturition, to prove an obstruction. In such circumstances, the treatment consists in making a free incision, evacuating the blood and coagula, and restraining hemorrhage by pressure ; with or without stuffing of the wound. In the case of accidental wound risk by hemor- rhage is great. If the tumor is small, it may cause no uneasiness; and requires no treatment, except the use of cooling and discutient lotions, with rest. PRURITUS OF THE VULVA. 593 Warty Excrescences of the Vulva May be situated on the labia, nymphae, or vestibulum; or all these parts may at the same time be affected. The growths may be of con- siderable size; and when numerous they distend the vulva. They may be of syphilitic origin or may arise from other causes. They are the source of much pain, irritation, and annoyance; and may pro- duce a quantity of muco-purulent discharge, especially if seated on the mucous membrane. If small and recent, the application of nitrate of silver may disperse them; or they may be poAvdered with calomel and chalk. The larger may be removed by strong caustics, as potass, or the acids; but in most cases it is better to cut them off by scissors—subse- quent hemorrhage being checked by cold and styptics. The bulky growths, as already stated, may require a regular dissection for their removal (p. 5IS). Oozing Tumor of the Labium Is a rare disease. One or both labia may be affected. The part— hard, sulcated, and discharging a watery acrid fluid—is the seat of much pain and itching; and the neighboring parts are irritated. Local treatment by caustics, iodine, astringent lotions, &c, combined with the use of laxative and alterative medicine, may be effectual in curing the complaint; if not, the affected textures must be removed by the knife. But after all this, the disease is apt to recur. Pruritus of the Vulva Is a frequent accompaniment of pregnancy, and of disease in the rec- tum or vagina—especially leucorrhcea. It is more common in advanced life than in youth; and is a cause of very great suffering. To some women it renders life absolutely miserable. The skin of the parts is generally dry, and often has a rough and cracked appearance ; some- times it is indurated, and more than usually callous in ordinary sensa- tion. Not unfrequently there is a rush of small, inflamed, and exces- sively irritable papulae over the affected parts; or there may be spots of chronic eczema, especially on the labia, or aphthous incrustation of the nymphae and vestibule. If there is any marked exciting cause, its removal will do much to- wards effecting a cure; and permanence of the relief may be established. But under other circumstances, the disease generally proves very in- tractable, especially in those of advanced years. If the patient labors under irritable bowels from any cause, that must be remedied; if worms are present, they must be expelled; if there are piles, they must be cut or tied; if leucorrhcea exist, its cause is to be inquired into and removed; if there are pediculi, they must be destroyed and cleanliness enjoined. In general, some laxative and alterative medicine is beneficial. Numerous local applications are of service. Among these are— 38 594 EXCRESCENCE IN THE ORIFICE OF THE URETHRA. camphor and chalk powder in equal parts; or calomel—to dust on the part. Simple iced water ; or very warm water ; or infusion of tobacco, with borax or carbonate of soda added; or Goulard's lotion; or decoc- tion of poppies, with sugar of lead; or a weak solution of nitrate of silver ; or camphor mixture, with carbonate of soda ; or diluted hydro- cyanic acid, or solution of borax with sulphate of morphia—as lotions. Among ointments, the diluted citrine, the mercurial, the hydrocyanic, the sugar of lead, are recommended; as also borax and honey. Malignant Ulcer of External Parts Occasionally shows itself. It is recognized by the ordinary characters of malignant ulceration, and demands the ordinary treatment. Early and wide removal is the only remedy. Sometimes the labia are found enlarged, and more or less extensively and deeply ulcerated; forming a disease which, from its intractability, may well be called malignant; although it has no other character of a cancerous sore. Strong caustics may succeed in producing healing action ; but if not, the knife must be resorted to. Tumors of the Labia. In the Labium, fatty tumors are the most common; easily remov- able by the knife. Simple enlargement sometimes takes place in one labium, or in both; constituting a tumor analogous to the Elephanti- asis Scroti of the male (p. 584). Encysted tumors occasionally form ; when of small size, removable by incision, and evulsion of the cyst; when large, to be dealt with by regular dissection. Hernial tumors, be it remembered, are also met with in the labium ; recognizable by the ordinary signs, and amenable to the ordinary treatment. Varicocele is also common in this situation (p. 94). Hypertrophy of the Clitoris and Nymphse. These parts are liable to simple enlargement. Ordinary cases require no remedial interference. But it may happen, that the swellings are not only inconvenient by their bulk, but also of a suspicious character as regards malignancy; and, in such circumstances, removal by the knife may become necessary. A Red Fleshy Excrescence in the Orifice of the Urethra Is productive of intense suffering, on account of the part's extreme sensibility to the urine, and to all external influences. It is easily made to bleed, and is generally about the size of a pea; sometimes as large as a small hazel-nut; usually at the verge of the canal, partially pro- jecting, but sometimes also prolonged upwards into the urethra; and sometimes it forms a complete circle surrounding it. The only remedy is by excision : or by simple ablation, folloAved by the use of an escharo- VAGINAL FISTULA. 595 tic to repress growth. During healing of the wound, the nitrate of silver is of much use in restraining inordinate sensibility; applied lightly, every alternate day. But the growth is apt to reappear; again demanding treatment. Laceration of the Perineum. This is a casualty of parturition ; the parts tearing doAvn towards the anus—perhaps with implication of the boAvel. The Avound is kept clean, and approximation is effected and maintained by adduction of the thighs. By and by, the healing process is stimulated by medicated water-dress- ing. If necessary, the unclosed portion, having had its edges made raw by the bistoury, is brought together by means of the quilled suture— the form of suture found most suitable, in almost all cases of solution of continuity in these parts. Suture in the recent state of the injury is quite improper; and should in fact be long delayed, as nature gene- rally makes sufficient reparation. [After the closing of the wound by the quilled suture, it will often be found that the edges are subjected to considerable tension, and the sutures dangerously strained. Under such circumstances the expedient of Dieffenbach will be found an important addition to the ordinary ope- ration. It consists in making an incision on each side of, and parallel with the wound, at the distance of half an inch, more or less, from its margins, and deep enough to relax the strain upon the sutures. These incisions will close by granulations, and the original Avound having been pared, will be more likely to unite by primary adhesion.—Ed.] Vaginal Fistula. Of this there are three varieties: Vesico-vaginal, Urethro-vaginal, and Recto-vaginal; all the result, usually, of accident in parturition. By an unskilful use of instruments, the parts are torn; or, they are subjected to prolonged and severe pressure by the child's head, and sloughing consequently ensues. Vesico-vaginal Fistula denotes an abnormal communication between the vagina and bladder. During parturition, the parts suffer irrecover- able injury. Shortly afterwards a slough may separate ; if the urin>e have not been previously discharged, a gush follows; and aftenvards, a draining away of that fluid remains ; or there may be a discharge of urine, per vaginam, from the first. The patient is in constant discom- fort and suffering. In spite of every attention, congestion and excoria- tion of the external parts ensue; and if constant diligence is not applied to maintain cleanliness both of person and dress, the patient's proximity may be noisome to others. As the chasm closes, the discharge dimi- nishes. In some rare cases, spontaneous closure may be complete. In the great majority, an aperture remains; sometimes such as will barely admit a common director ; sometimes a loathsome chasm, admitting several fingers. The aperture usually is in the mesial aspect behind the origin of the urethra. It can be felt by the finger; and may be disclosed by the bivalve speculum; or flat copper spatulse may be used to hold 596 TREATME-NT OF VAGINAL FISTULA. aside the walls of the A7agina. In consequence of this canal having suffered other injuries, it may become distorted and irregular ; and the discovery of the fistula, if small, may in consequence be very difficult. Detection is effected by placing a metallic catheter in the bladder, and examining the septum upon the catheter by a finger introduced per vagi- nam ; or a probe may be passed from the vagina through any sinus, till it come in contact with the catheter. The existence of this abnormal state does not necessarily prevent reimpregnation. Treatment, palliative or radical, should be commenced as soon as possible after the discovery of the disease. The former consists in taking measures calculated to prevent the constant and involuntary discharge of urine; the latter implies an attempt to close the abnormal aperture of communication. It is quite possible to dilate the vagina; to expose the injured parts; to pare the edges of the opening by a bistoury in situ, or after bringing them externally by traction with the volsella; to effect approximation by suture, by means of such instruments as are employed in staphyloraphe; and to leave a catheter in the urethra, so as to conduct off the urine before it distends the bladder. Some- times, however, the catheter cannot be tolerated; and then the prospect is less hopeful. All this can be done, with difficulty to the operator, and pain to the patient; but a successful issue is extremely improbable. The ligatures may remain in situ even for two or three weeks, and all the urine be naturally discharged for that time, without adhesion of the edges of the wound having been effected. And so discouraging has been the result of such attempts hitherto, that many surgeons are agreed in the propriety of treating most cases of severe Vesico-vaginal Fistula by palliative means alone. The minor cases are remediable by simpler procedure; the occasional use of heated iron. The part is exposed by means of curved wooden spatuloe, or by an ivory speculum with an aperture in its side. If a metallic speculum is used, the cautery must be handled with care, so as not to touch the instrument. The iron, at a white heat, is accurately applied to the aperture; and, at long intervals, the application is repeated. The judicious operator, who wisely seeks only the remote, cicatrizing, and puckering effect of the burn, will seldom, if ever, make the interval shorter than three weeks; and often a much longer period may be found advisable. At the same time, all avoidable exertion is abstained from, the recumbent posture is main- tained as much as possible, the vagina is temporarily occupied by a sponge or other plug, cleanliness is much attended to, and the marital use of the parts must, of course, be utterly abstained from. Mere fistulae are quite curable in this way. And in the case of any opening, not of larger size that what is barely sufficient to admit the end of the little finger, cure may be thus attempted. In small fistulae, the appli- cation of lunar caustic every three or four days is occasionally effectual. Palliative treatment consists in the use of the adjuvant means just mentioned ; occupying the vagina by a restraining plug ; attending to cleanliness ; preventing filth, fetor, and excoriation. Probably the best means of occupying the vagina is by a piece of sponge, repeatedly changed; or by a pyriform caoutchouc bottle of moderate size ; enve- loped in a piece of oiled silk ; introduced in a state of collapse, and TREATMENT OF VAGINAL FISTULA. 597 then inflated by means of a nozzle and stopcock—or by means of such a valve as is used in air-tight cushions. Thus accurate compression is made on the aperture, so as to prevent escape of urine ; and both com- fort and cleanliness are obtained. The bottle is withdrawn daily, the air being previously permitted to escape ; at the same time, the vagina may be cleared of accumulated secretion by means of a syringe, and fetor may be removed by a solution of the chlorides. The bottle, having been cleaned, is replaced. Immediately after the occurrence of the accident, something may be done to favor spontaneous contraction of the aperture, and perhaps spontaneous cure. The patient is directed to lie as much as possible on her face; a catheter is constantly retained—being removed only for the purpose of being cleaned ; a sponge, or some dressing, which must be changed with great gentleness, is placed in the vagina, of sufficient size to exert a moderate closing pressure on the injured part—so as to pre- vent cohesion of the wound to the walls of the vagina, with consequent complication of the case. Unfortunately, however, the catheter cannot, in all cases, be tolerated, and consequently the benefit of this plan of treatment is lost. The bowels are kept gently open, so as to preclude the necessity of straining. [Much attention has been devoted, in this country, to the treatment of vesico-vaginal fistula, and it is believed that unusual success has been gained, particularly by Dr. Hayward, of Boston, Dr. Mettaiier, of Vir- ginia, and Dr. Sims, of Alabama. Dr. Hayward is stated, by Dr. Sims, to have performed the first successful operation in the United States, for this affection. Dr. Hayward's operation consists in introducing a large bougie of highly polished Avhalebone, through the urethra into the bladder, by means of which the posterior wall of the bladder is depressed by an assistant, and thus the fistula brought into vieAV. The margin of the orifice is pared by scissors or knife, and the mucous membrane of the vagina dissected up from its connections to the extent of about three lines. This latter step was taken in order to gain a larger surface for union to take place, and partly to obviate the necessity or the liability of passing the sutures through the bladder. Finally, a needle, holding a thread, was inserted through the mucous membrane of the vagina and the subjacent cellular tissue, at about a third of an inch from the edge of the fistula, carried across the latter, and brought out upon the oppo- site side through the mucous membrane of the vagina and the cellular tissue, at about the same distance from the margin of the orifice at which it was first introduced. Three such sutures were passed, and then tied, or more if necessary. For the operation the patient is placed as for lithotomy, and etherized ; afterwards, she is allowed to lie upon the side, and a catheter is retained in the bladder for a few days, being removed sufficiently often for cleansing; but later, it is only introduced every three hours to remove what urine has collected. Dr. Hayward has thus operated twenty times on nine patients; on one patient six times, on another five times, on two twice, and on five 598 TREATMENT OF VAGINAL FISTULA. once each. Of these, three were entirely cured ; five were relieved, and one was not benefited.1 The operation of Dr. Mettaiier does not differ materially from the preceding, excepting that the mucous membrane of the vagina is not raised around the fistula, and the sutures are made of fine leaden wire instead of thread. These wires are left hanging from the vagina, and on the third, and again on the seventh day, the sutures are tightened (Am. Journal, July, 1847). Dr. Sims has contributed to the American Journal for January, 1852, a very interesting paper on this subject, in Avhich all the different steps of his operation, and the instruments he employs, are fully described, and illustrated with numerous drawings. There are several peculiarities in Dr. Sims's procedure which are worthy of notice, although the details are too numerous to be introduced here. Instead of placing the patient upon her back, as is recommended by most operators, Dr. Sims places her upon her knees, the nates being elevated, and the head and shoulders depressed ; the vagina is then opened, and the recto-vaginal septum elevated by means of a peculiar " lever speculum" held by an assistant. Sometimes, where a particularly strong light is required, the sunlight is made to fall upon a small mirror, so placed as to trvrow a bright reflection upon the part to be ex- amined. The margin of the fistula is pared, as in other operations, the instru- ments used being, however, somewhat peculiar. The most distinctive feature in this proceeding, is the kind of suture employed. The thread is of annealed silver wire as fine as horsehair. It is introduced at about half an inch from the edge of the opening, pushed deeply into the vesico-vaginal septum, without entering the blad- der, however, and brought out just at the edge of the mucous lining of the latter, at the margin of the fistula ; it is then carried across the chasm, and thrust through the Aresico-vaginal septum, in the same man- ner as before, reappearing at the same distance from the edge of the fistula. This is accomplished by the use of several instruments, very simple, yet very advantageous. After as many wires are passed as are considered requisite, at proper distances from each other, they are tightened by clamps, so that Dr. Sims terms this suture the " clamp suture." A' solid leaden rod, a little longer than the fistula, and a line in diameter, or an equally small silver tube, perfectly smoothed and polished, is perforated at the proper distances by holes through which the silver suture wires are passed, and secured either by twisting around the bar, or by being passed through small perforated shot, and bent firmly over; thus the distal ends of the Avires are secured. The proxi- mal end of each wire is then, in the same manner, passed through its appropriate hole in another similar bar, Avhich is introduced into the vagina, and placed parallel Avith the proximal margin of the fistula ; the bars are approximated as closely as is deemed advisable—not too closely, lest strangulation be induced—and the ends of the wire are se- cured as in the first case, and cut off. 1 American Journal Med. tfci. vol. xxiv. 1839 ; Boston Med. and Surg. Journal Aoril 1851. ' F ' TREATMENT OF VAGINAL FISTULA. 599 On the third or fourth day after the operation, an examination is made to ascertain the condition of the parts, and again on the sixth or seventh day ; if the sutures are not producing any unpleasant effects they are allowed to remain until the ninth or tenth day. In order to prevent any injurious action of the urine upon the wound, Dr. Sims retains in the bladder a silver catheter of a peculiar form, so shaped, indeed, that it maintains itself in the bladder, without any retentive means being necessary. The recumbent posture is to be strictly maintained, and the catheter is to be worn, for at least fifteen days, when Dr. Sims usually finds that the orifice has become pretty firmly closed. The bowels are not per- mitted to be moved, and, to secure their quiescence, opium is used as freely as may be necessary. A variety of vaginal fistula, not enumerated in the text, is the vesico- uterine, in which the urine passes into the uterus, through a fistulous orifice in the bladder, and thence into the vagina. . This affection seems to have been first pointed out by Madame La- chapelle, and subsequently more clearly by Stoltz, of Strasbourg; more recently still, M. Jobert (de Lamballe) has gtven it a prominent place in his Traite des Fistules, Paris, 1S52. The seat of vesico-uterine fistula is in the posterior wall of the bladder and the corresponding part of the neck of the uterus, above the attach- ment of the vagina. Generally, it is below the point of peritoneal re- flexion, involving the latter membrane only when higher up and more extensive than usual. Ordinarily, too, only the anterior wall of the cervix uteri is implicated ; but it has happened that the cause which has produced the anterior orifice has also acted upon the posterior wall of the uterine canal, inducing sloughing there, and thus permitting the urine to pass from the bladder directly through and across the cervical canal of the womb, into the peritoneal cavity behind the latter, forming a double fistula, a vesico-uterine and utero-abdominal; this was the con- dition in the case published by Stoltz. (See Jobert, Traite, p. 14.) The fistulous orifice is sometimes round, sometimes irregular; and occasionally it is lined by a firm membrane. The os uteri may be healthy, but is more commonly partially destroyed; the canal of the cervix is red and vascular, sometimes studded with indurations. The cause of this accidental communication is unusual and long con- tinued pressure of the child's head, in parturition, due either to the large size of the head, or to deformity of the pelvis ; or, again, to the unskilful use of instruments, or to pressure of fragments of bone after craniotomy. The sign by which the accident may be recognized is, the constant escape of urine by the vagina, Avhen the patient is recumbent, and its partial flow when she is standing. But the detection of the site of the fistula is not easy; the speculum alone is not sufficient to betray it, for though the urine may pass into the speculum seemingly from the uterus, it can only be proved to come from the uterine cavity by alternately opening and closing the os uteri, by injecting fluid into the bladder, and observing its free exit from the cervix, by, if possible, passing a 600 TREATMENT OF VAGINAL FISTULA. sound into the bladder, and meeting it with one introduced through the os uteri. The treatment is a matter of great difficulty. Caustics cannot be relied upon, partly on account of the situation and functions of the parts implicated, partly because of the great loss of substance which has occurred. The employment of the knife and suture, therefore, can alone be trusted for the radical cure. In the use of these means, M. Jobert has certainly displayed much originality in device, and boldness in executing. One difficulty, indeed the first, to be overcome, was the concealed situation of the fistula, and the consequent obstacle imposed upon any inspection. In order to sur- mount this, M. Jobert diligently examined the connections of the parts in the subject, and satisfied himself that the neck of the uterus might be pretty freely divided laterally, in the direction of the commissures, without danger of wounding the peritoneum. This division may safely be extended as high up as the attachment of the vagina, but it ought not to be continued much above this point. The uterine artery was not divided in M. Jobert's experiments when the incision was limited as recommended. The operation, then, which he advises, consists in making a section on each side of the neck of the uterus, in the line of the lateral com- missures ; the division being carried high enough up to enable the operator to gain a good vieAV and command of the vesical fistula, which is to be sought for at the point where the bladder rests upon the ante- rior face of the neck of the uterus. The best instrument for dividing the neck of the womb, is a pair of strong, blunt-pointed scissors, the os uteri having been previously seized with two pairs of claw-pointed forceps, and drawn down towards the vaginal orifice, where it is held by an assistant. The neck of the uterus having been divided, two flaps are thus made, an anterior and a posterior. The former is thrown for- ward and upwards, and the fistulous opening is consequently exposed to view; its edges are now paired by means of a scalpel, and then are brought into accurate apposition, and retained in contact by sutures. If this simpler operation proves effectual, and the fistula remains closed, well. If not, or if from any cause the edges cannot be properly approximated, then M. Jobert has another resource to fall back upon. He makes raw the surface of the canal of the cervix uteri from the lower margin of the fistula doAvnwards, then brings together the two flaps of the neck previously made in the performance of the first opera- tion, and retains them in apposition by three sutures, one on each side, and one in the middle. Thus, the communication between the uterine cavity and the vagina is completely cut off, and the menstrual blood will pass into the bladder at each monthly period. During the treat- ment after either operation, a catheter is retained in the bladder, until the urine manifests a disposition to pass naturally; or, if the blad- der be too irritable for this, the water is frequently removed by the instrument. M. Jobert reports a case in full, in which the first operation was successfully performed. The text is illustrated by wood-cuts, so that the steps of the operations are easily folloAved. TREATMENT OF VAGINAL FISTULA. 601 Another variety of the affection is the vesico-utero-vaginal, produced by the same cause which induced the preceding, but differing from the other in that the destructive process has attacked the vagina, at the point of its connection with the uterus, as Avell as the neck of the uterus. The loss of substance may be so great that nothing but a vestige of the neck of the womb remains, Avhile the whole anterior wall of the vagina is wanting. Abnormal adhesions not unfrequently exist, the result of inflammation, so that the uterus cannot be draAvn towards the ostium vaginae, and the use of instruments is very much interfered with. The principle of the operation which M. Jobert recommends for this deformity, is the same as that already detailed. lie pares the edges of the fistulous communication, and also that portion of the neck of the uterus which remains, and unites them together by sutures, at the same time making various incisions into the vagina and adventitious mem- branes, of such forms, and to such extent, and in such situations, as to allow the parts to yield, so that no tension or strain comes upon the sutures. The latter are passed pretty deeply through the substance of the tissues, and are withdrawn on the fifth or sixth day. Thus, the neck of the uterus, or that portion of it which has escaped destruction, which is generally but the posterior wall, is made to assist in closing the gap like a flap, and consequently the communication between the uterine cavity and the vagina is cut off, the catamenial exudation escaping from the former into the bladder. M. Jobert reports, in full, four remarkable cases, illustrative of the different steps in this complicated procedure; of these, three were entirely cured, and one died of peritonitis, on the fifth day after the operation. An important element of success in all the operations practised by M. Jobert, consists in the liberating incisions which he makes in the parts near the points of sutures, so as to preArent any strain or traction upon the latter.—Ed.] Urethro-voginal Fistula denotes a preternatural communication be- tween the vagina and the urethra ; caused, probably, by the imprudent use of instruments. In general, the same disagreeable results occur as in the former case. Sometimes there is power of retention ; but, in evacuating the urine, it trickles through the vagina, and over the limbs. The treatment is the same, but more frequently successful. Recto-vaginal Fistula.—Laceration of the septum between the vagina and the bowel takes place, by the rash use of instruments, or by tearing in the natural efforts of parturition, or as a consequence of sloughing from pressure. In the latter case, the perineum usually suffers lacera- tion also. The parts are to be kept clean and quiet; and spontaneous diminution of the chasm is favored by every possible means. When the fistulous condition has been arrived at—that is, when the margins of the tear have healed, and contraction has ceased—the parts are exposed, by means of a speculum, if necessary ; the edges are made raw by paring, and approximation is effected by means of the quilled suture (Principles, 3d Am. Ed. p. 602). The parts, in this case, being comparatively super- ficial, the operation is performed not only with comparative ease, but 602 TREATMENT OF VAGINAL FISTULA. also with a good prospect of success. If the aperture is small, it may be treated by caustic or cautery, like the vesico-vaginal fistula. [In a case of Recto-vaginal Fistula, which had been but partially closed by suture, Velpeau performed a plastic operation. The flap was cut from the left labium majus, and drawn, by a thread attached to its upper extremity, through the vagina into the fistula in the rectum, Avhere it was fixed. It mortified, however, in two-thirds of its extent, so that the fistula was diminished only by one-third of its size. M. Velpeau remarks upon the operation, " that in patients more tracta- ble, and by taking every possible precaution not to weaken the vitality of the flap, elytroplasty by the tegumentary plug will offer some pros- pect of success in this kind of fistula." (Mott's Ed. of Velpeau, vol. i. p. 673.) Dr. Barton, of this city, succeeded in curing a case of Recto-vaginal fistula by seton, as follows: The thread was passed into the vaginal orifice of the fistula, along the track of this false passage into the rectum, and out at the anus; then the vaginal and anal ends of the seton were tied; after a few days, the vaginal thread was carried, by means of an eyed probe, suitably bent, into the fistulous orifice, and down between the vagina and rectum to the perineum, where an incision Avas made, through which the probe and the ligature Avere withdrawn. Thus, the anterior wall of the rectum Avas included within the loop of the seton, which was tightened from day to day, until the ligature cut its way out, as in an ordinary case of fistula in ano treated by ligature. So soon as the new fistulous passage became larger than the old, the feces and gas, which before had escaped by the latter, now took the former route, and the abnormal opening into the vagina was readily closed. (Am. Journ. vol. i. 1840.) Dr. Mott, of New York, has performed a similar operation for this affection. In these cases the fistula was small, and the rectal orifice considerably higher than the vaginal. M. Jobert, having, without satisfactory success, tried the method by cauterization, by seton, by flaps brought from neighboring surfaces, as in M. Velpeau's case, has in his last work, already cited, exposed a much more simple and successful plan, Avhich is suited to all cases, es- pecially to those in which the fistula is large from loss of substance of the parts; these being, he thinks, beyond relief by the other means proposed hitherto. The patient, after having undergone a proper preparative treatment, is placed on her back, as for lithotomy, the knees being supported by assistants; the vulva is fully opened, and the Vesico-vaginal Septum well raised up by means of a uni-valve speculum. Then, the fistula being clearly exposed to view, its edges are pared and brought closely together by a sufficient number of tolerably large, waxed-thread sutures, to prevent any escape of air or feces from the rectum. The last, and a very essential step, consists in making such incisions through the mucous membrane of the vagina, as shall prevent all straining upon the sutures; constituting, in fact, a species of autoplastic operation, Avhich M. Jobert terms, " autoplastic par glissement, on par locomotion." The number of these incisions must depend upon the mobility or fixed- IMPERFORATE VAGINA. 603 ness of ther« tissues; the precise sites to be selected for them must be determined by experiment in each case; they may be longitudinal, transverse, semicircular, or in all of these directions, as seems best • adapted to produce the desired effect. The sutures should be allowed to remain eight or ten days, unless they should produce bad effects sooner. The bowels should be kept confined, and the recumbent position strictly maintained.—Ed.] In the advanced stages of cancer of the female organs, these fistulae frequently are produced by malignant ulceration of the septa. Of course, in such cases, no surgical treatment is admissible. Stricture of the Vagina. This may be the result of preA'ious inflammation, indurating the mu- cous and submucous tissues of a part of the vagina; or it may follow on the healing of a wound received during artificial delivery, or otherwise; or it may be consequent on ulceration produced by a badly arranged pessary. Finally, it may be the result of cancerous deposit. Under ordinary circumstances, it is amenable to the same treatment by gradual dilatation, as contractions of other mucous canals. But the surgeon's aid is seldom called for, except during the crisis of parturition ; the progress of the child having become obstructed, by an unyielding con- traction of the Aragina—usually situated at the upper part of the canal, and usually the result of a previous unfortunate labor. The duty of the surgeon is, by a probe-pointed bistoury, introduced on the finger, to notch the contracted part at various points ; and then, by progress of the child's head, or by the finger of the operator, dilatation is effected. Obliteration of the Vagina, To a greater or less extent, is occasionally met with ; arising from the same causes as stricture. Then much constitutional disorder must result, from arrest of the uterine discharges; and it is desirable to restore the canal, at least to such an extent as to admit of a due performance of the excretory functions of the organ. The knife, or the trocar, is used, guided in a normal direction by the finger in the rectum ; and the pas- sage made is kept dilated, by means of tents or bougies. If the patient has ceased to menstruate, no operation may be required. Imperforate Vagina or Hymen. The vagina may seem well formed externally; but, on examination, may be found terminating in a blind cul-de-sac, at no great distance from the orifice. In such a case, no exploratory incision is warrantable, in search of the uterus, in the adult; unless, on careful examination, by the rectum and otherwise, there is a tolerable certainty of that organ being present. A more frequent imperfection occurs at the orifice; the other part of the canal being Avell developed, and in a normal state. The membrane of the hymen may be excessiAre, and imperforate; or the vagina itself 604 PROLAPSUS OF THE VAGINA. may be shut up, by a more solid and fleshy structure. Interference is not necessary, and, indeed, the malformation may not be discovered, until about the time of puberty; and then, on account of non-appear- ance of the menstrual discharge, and the persistence of uneasy sen- sations in the pelvis and parts affected, attention is directed to the state of the genital organs. The obstructed fluid may be found bulging through a thin membranous septum; or there may be but a vestige of the normal opening, and solid flesh beneath, devoid of bulge or fluctu- ation. In the one case, simple division of the membrane suffices to establish the normal state. In the other, careful incision is required, as in the case of imperforate anus ; and the same necessity exists, for afterwards maintaining the proper caliber of the part by suitable means. Immediately after incision, it is well to insure thorough evacuation of the pent-up fluid; washing out the vagina Avith tepid water, by means of a syringe. In cases of this kind, the accumulated menstrual fluid may fill and dilate not only the vagina but also the uterus, expanding the latter as in pregnancy, and causing even some of the equivocal symptoms of that state. The operation of evacuation is not without danger, especially if performed in hospitals ; the dangers being by purulent fever and phle- bitis. The fluid evacuated is generally dark red, or mahogany colored, very viscid and grumous; but these characters vary. Sometimes, adhesion of the nymphae takes place in children; the opposed surfaces having become raw, on account of neglect of cleanli- ness, or in consequence of these parts suffering in sympathy with dis- order elsewhere, and a purulent discharge having become established (p. 591). In general, the cohesion is slight, and easily broken up by means of the flat end of a probe. For some days, interposition of dressing is necessary, to prevent reunion. Foreign Bodies in the Vagina. These may be introduced by the patient herself, under some morbid excitement; or, violently and criminally, by a second party. And they may be of such bulk, or so impacted, as to resist the ordinary means of extraction. By dilatation and lubrication of the passage, and by the judicious use of forceps or lever, dislodgement may be effected, without injury of the parts. In difficult cases, division of the impacted sub- stance, or, if that is impracticable, of the sphincter, may be necessary, as in the analogous case of the rectum (p. 429). Prolapsus of the Vagina May exist in various degrees; the dislocated part still remaining in the vaginal cavity, or protruding from it at the vulva. It may be partial or complete. Partial prolapsus consists in the falling down of a part of the vagina; generally, either of the anterior (vaginal cystocele), or of the posterior wall (vaginal rectocele). Complete prolapsus resembles prolapse of the bowel per anum; the Avhole circumference of the vagi- nal tube descending. It is distinguished from prolapsus of the uterus, THE PASSING OF THE FEMALE CATHETER. 605 by the anatomical characters of the mucous membrane of the vagina, and by reaching the os uteri with the finger passed through and above the swelling. It is generally accompanied by a feeling of much weight and uneasi- ness ; and often there is considerable irritation with discharge. The functions of the bladder and rectum are more or less impeded or de- ranged; and if the dislocation has been suddenly produced, there may be obstinate constipation and strangury. It is a complaint extremely obnoxious to the female; not only causing uneasiness or pain in sitting or walking, but often exciting unjustifiable alarm. The affection is most common in women who have borne many child- ren, or suffered frequent abortions, or Avho labor under menorrhagia or aggravated leucorrhcea. In short, anything which tends to relax the parts involved, favors its occurrence; not forgetting the influence of de- ranged general health, and feeble constitution. It may be caused sud- denly and kept up by any violent effort, as in coughing, sneezing, laughing, lifting a heaAry weight, or straining at stool. Sometimes removal of the exciting cause—with or without the use of cold and astringent lotions and general tonics—is sufficient to effect a cure. The wearing of an understrap is often beneficial. Sometimes a pessary, in shape adapted to the parts, is enough. But if the case prove incurable and cause much annoyance, it may be dealt with by the knife, as in prolapsus ani—special care being previously taken to ascertain the relations of the bladder and rectum to the parts to be excised. If either of these organs come in the way of the incisions required, of course no cutting is at all admissible. The passing of the Female Catheter. In this operation, much delio»cy is required. When, from prolapsus uteri, or other causes, there is much relaxation or change of relative position, ocular inspection may be necessary. But, in ordinary cases, all is done by touch alone, under the dress or bedclothes. The patient should be in the recumbent position, with the nearer thigh flexed. If the surgeon is at the left side of his patient, the fore-finger of the left hand, if on the right side the fore-finger of the right hand, is passed to the upper part of the orifice of the vagina, which is distinguished from the vestibulum by its rugosity ; the catheter is placed about an inch over this—and, by moving the point downwards, in the mesial line, it slips into the orifice of the urethra. Or, the finger is moved in search of the urethral orifice ; which is recognized by feeling a depres- sion, with an elevation on its vaginal aspect; and, along the finger, the catheter is then directly introduced. When there is displacement of the parts, a common elastic catheter may be found more suitable than the silver instrument; as then there may be both twisting and elonga- tion of the canal. The ordinary silver catheter should be flat, very slightly curved, about six inches in length, and having some projection or knob on its outer orifice, to prevent its slipping into the canal alto- gether. 606 L E U C 0 R R II ffi A . [The editor has found the following directions to be more easily fol- lowed: Introduce the tip of the fore-finger into the upper part of the orifice of the vagina, so that its palmar surface is gently pressed against the pubic arch ; if now the point of the finger be thrust slightly forward, it will feel directly the orifice of the urethra. The catheter should be introduced upon the point of this finger, either by the left hand, or, after a little practice, with the disengaged fingers of the right hand. Sometimes the orifice of the urethra is dragged somewhat downwards, as in prolapsus uteri; or drawn upwards and behind the pubic arch, as in pregnancy, and intra-pelvic tumors connected with the uterus. In such cases, a little more difficulty will be experienced in discovering and entering the canal.—Ed.] Plugging of the Vagina Is a most useful and important operation, as a hemostatic, when flooding (not post partum) has to be arrested. In every form of hemorrhage from the vagina, it may be of the greatest service ; and often is in fact the means of saving life. The simplest and most convenient method of plugging is to use pieces of sponge, or lint, or linen; placing them in the vagina one after the other, every piece being lodged as high as pos- sible. When the bleeding is passive, not many pieces may be required; but if vessels haA'e been opened by operation, the plugging must be done very efficiently; the vagina being well crammed, and a T bandage applied to support the pledgets, which may be previously saturated with vinegar, or solution of matico, or other astringent and styptic lotion. Great care must be paid to watch against return or persistence of the discharge ; and the plug should be carefully removed at the end of about twelve hours; to be replaced, if necessary, with new materials. Another plan, not so easy of execution, is to pass the centre of a napkin into the vagina ; thus making a blind pouch there open from without, and into which the necessary amount of stuffing may be passed. Or, a bladder may be passed and inflated with air, or with refrigerant solutions. Or the same may be done with bags of vulcanized caout- chouc ; and some ingenious instruments have been constructed for the purpose. Leucorrlnva Is a nosological term, used to indicate a state of disease having dis- charge of a mucous or muco-purulent character from the vagina as its most prominent phenomenon. Apart from its occurrence as a symptom of almost all the more serious uterine affections, it is the most common of female diseases; and occurs in a great variety of forms. The discharge commonly called " Whites," may exist Avithout any defined disease in the vagina or uterus, and may be the result of general debility and relaxation of system, especially if in a scrofulous consti- tution ; or it may occur during amenorrhoea. Occasionally, it supervenes after the manner of a common catarrh. Often, also, it is a persistent excess of secretion post partum. INFLAMMATORY AFFECTIONS OF THE CERVIX UTERI. 607 In such a case, if examination be made by the speculum, no organic lesion may be discovered. Sometimes, however, the mucous membrane of the cervix is found red and injected, or slightly abraded—especially if the case has been neglected, and allowed to run a protracted course. In this, as well as in all other forms of leucorrhcea, the symptoms com- plained of by the patient may be either feAv or numerous. They are a class of symptoms common to all uterine affections; viz., disorders of the menstrual function; pain in the back and loins, in the hypochondria, across the hypogastrium, and down the limbs; feelings of bearing down and unnatural Aveight in the perineum ; besides the ordinary accompa- niments of disordered stomach and boAvels. In most such cases, no local treatment is required. On the contrary, by causing excitement and irritation, it would probably aggravate the complaint. Cold spong- ing, or the cold hip-bath, with attention to the general health will suffice. The tincture of cantharides, and the various preparations of iron taken internally, often seem to have a good effect in diminishing the dis- charge. If the case be one of vaginitis, simple or specific, there will, in addi- tion to the other symptoms already mentioned, be those of febrile acces- sion, along with much local pain, irritation of bladder, ardor urinae, pain in defecation and in walking. The discharge will not be white and mucous, but muco-purulent. In such circumstances, vaginal examina- tion will reveal a preternaturally red color of the mucous membrane, with much tenderness; and, in addition, there may be more or less ex- coriation, or superficial ulceration of the cervix. Treatment consists in maintaining the horizontal position, fomenting or poulticing the parts externally, and internally using a bland or sedative injection; besides employing purgatives and all the ordinary treatment of gonorrhoea (see p. 522). After an attack of vaginitis, a disagreeable muco-purulent discharge may continue ; or, by neglect, a simple white discharge may be aggra- vated to this character. But the most frequent cause of these leucor- rhceal complaints, when they come to demand local treatment, is an inflamed and ulcerated, or otherivise morbid state of the cervix uteri. The disease may occur in an acute form, but is more frequently met with as a chronic complaint. The symptoms are severer than in the case of "whites," and the general health suffers severely. The dis- charge may vary much in quantity ; it may .also be of various consist- ence ; it may be muco-purulent, or almost pure pus; and it may, or may not be tinged with blood. If of long continuance and profuse, it often causes much irritation of the labia externally. Sometimes it is compli- cated with displacement of the womb, or Avith chronic inflammation, or engorgement and hypertrophy of the whole organ ; and these circum- stances much retard the progress of cure. All women are liable to such complaints; but the married and childbearing suffer both most fre- quently and most severely. In this brief sketch it is expedient to treat of the numerous morbid, non-malignant states of the cervix together; more especially when avc consider that they cannot in any way be distinguished from each other, 608 ULCERATION OF THE CERVIX UTERI. without a tactile and visual examination of the implicated parts; and farther, that the treatment, in its general features, is similar in all. Passing over, Avith simple mention, the aphthous, herpetic, and other forms of integumental disease rarely observed, we notice the simply in- flamed and ulcerated cervix. All the signs of inflammation are present; but the pain and tenderness may not be very severe. The part may be more or less indurated, and the degree of swelling varies. Sometimes the cervix acquires considerable bulk, is hard, and somewhat nodulated, and may cause some difficulty in diagnosis from cancer; the more espe- cially as the weak, pallid, and cachectic appearance of the patient often appears to favor the notion of malignancy. It happens very rarely, however, that carcinoma of the uterine neck is actually mistaken for hypertrophy ; for it is generally found, even on a first examination, to be in an advanced state. At the same time, it is to be remembered, that hypertrophy is not unfrequently mistaken for carcinoma ; and sometimes even the most experienced find a difficulty in diagnosis, till the result of treatment has been ascertained. The following points are distinctive in most cases. In carcinoma, there is the peculiar cachexy of system; and the morbid deposit may extend from the cervix more or less over the roof of the vagina, rendering the uterus fixed in the pelvis. There is generally great induration; and if there be ulceration, the indurated points projecting into it are friable under the finger; the ulceration is deep and irregular in form ; and the discharge is frequently fetid, and sometimes mixed with blood. In inflammation of the cervix, the accompanying ulceration most fre- quently attacks the posterior lip. The ulceration may be of various kinds; simple or healthy, indolent, irritable, or weak (Principles, 3d Am. Ed. p. 233). The cervix uteri is also liable to a granular form of inflammation. The part is tender, red, and having the mucous membrane abraded or superficially ulcerated, and bears numerous red points on its surface. Generally, it is also somewhat enlarged; and frequently, in this case, the vagina is irritated, or more or less inflamed around the cervix. Sometimes, also, the cervix is found with small nodulations over its surface, apparently the result of inflammation in the glands of the part. When the ulceration is healthy, and there exists no complication, it is easy to effect a cure, by enjoining rest of the parts, and using any simple detergent or mild astringent lotion. If it is protracted in dura- tion, or unhealthy in its character, the lunar caustic may be used through the speculum, every third or fourth day; care being taken to secure its proper application, by cleansing the parts with a small sponge, or dossil of lint, previously. In all forms of inflammation of the cervix Avith ulceration, this is one of our most useful resources ; and, in most cases, along with proper regulations as to rest of the parts, and atten- tion to the general health, it is successful. If the ulceration prove ob- stinate, however, other means may be tried, as the sulphate of copper, nitric acid, the acid nitrate of mercury, or even the cautery. After the ulceration has been healed, it is generally necessary to continue the adjuvant treatment for a considerable time ; and to check the leucor- ULCERATION OF THE CERVIX UTERI. 609 4 rhoea which may persist, a variety of astringent lotions may be used, as circumstances demand. Among these may be mentioned the simple douche of cold water, injected into the vagina for a feAv minutes, once or twice a day; the use of strong infusion of green tea, Avith some borax added, eight or ten ounces being injected morning and evening: the use of decoction of oak-bark in the same Avay, or of Aveak solutions of sulphate of zinc, alum, acetate of lead, chloride of zinc, or nitrate of silver in small quantity. Sometimes the application of leeches internally, by means of a tube. is useful to dispel inflammation, and to remove local congestion. And the application of iodine in tincture through the speculum, or its use in the form of iodide of lead ointment introduced into the vagina, is often advantageous in dispelling engorgement. The most intractable cases are those where the disease is chronic, and where there is more or less enlargement of the cerA'ix. In these. there is frequently a degree of hypertrophy of the whole uterus, also often displacement of the organ ; and although reduction of the size of the cervix, and arrest of the leucorrhcea, frequently remove the entire affection, there constantly recur cases where this does not happen and the symptoms of uterine disease persist. In such circumstances, the progress to cure is often tedious, and treatment must be directed to the engorgement and hypertrophy of the womb, and to the general health, simultaneously. In reducing the enlarged cervix, it is sometimes neces- sary, in addition to the means already described for the cure of ulcera- tion, to resort to more heroic means. After destroying a part of the diseased tissues by means of strong caustics, absorption and disappearance of the remaining portion are induced. For this, various plans have been recommended ; such as the careful application, through an ivory speculum, of a cautery at white heat. Thus a slough is produced, and a healthy ulceration may follow ; the application afterwards being re- peated or not, according to circumstances. The application of potassa cum calce has also been advised ; but a more efficient and satisfactory plan is to apply freely to the most indurated part the potassa fusa, through a glass speculum; guarding the neighboring parts by irrigating them immediately and abundantly with dilute acetic acid strongly in- jected. • [Dr. W. Tyler Smith has recently made the subject of Leucorrhcea a matter of careful study, in connection with the microscopical anatomy of the os and cervix uteri. And his researches have thrown much light upon the diagnosis of the seat of this affection, and also upon its treat- ment. (See Med.-Chir. Trans, vol. xxxv. 1852.) He has shown more clearly than any other observer, that there arc important differences in structure between the vaginal portion of the cervix uteri and the canal of the cervix—differences which are associated with functional peculiarities. Without attempting to repeat at all, in full, the anatomical descriptions given by Dr. Smith, which would be out of place here, we will state the most important facts only. The epithelium of the os and cervix uteri is of the tessellated or squa- mous variety, and forms a membrane of considerable thickness. It closely resembles the epithelial covering of the vagina with which it is continu- 39 610 ULCERATION OF THE CERVIX UTERI. ous. Just beneath this layer, the basement membrane is seen, cover- ing numerous villi or papillae which stud the whole surface. These villi vary in size ; sometimes two or three are united together upon a common pedicle, generally they are single. Each one contains a bloodvessel which curves upon itself at the end of the villus, and returning to the base inosculates with the bloodvessel of the contiguous villus. No fol- licular structure can be distinctly made out. ' Just within the os uteri a small tract of smooth surface exists, inter- vening between the mucous membrane of the exterior face and the pecu- liar penniform, rugose lining of the canal of the cervix uteri. The structure of this portion resembles that before described, excepting that the epithelium is of the cylindrical instead of the scaly variety, and the villi are larger; the arrangement of the bloodvessels of the villi is the same; and between the bloodvessels and the basement membrane num- bers of large oil-globules are found, as well as small granular cells. The cervical canal presents a very different appearance. Its internal surface is arranged in four rugae or folds of mucous membrane, having an oblique, curved or transverse direction. Smaller folds are observable between these principal ones, with fossae between them. This arrange- ment allows of great expansion of the mucous membrane in pregnancy and parturition; and it also affords a vast surface for glandular develop- ment. For over the whole area crypts and follicles are abundant; and besides, villi are scattered over the surface similar to those of the lower part of the cervix. The epithelium covering this follicular surface is cylindrical, and ciliated low down in the cervix. The normal mucus secreted by the canal of the cervix is extremely viscid and almost transparent; it consists chiefly of mucus-corpuscles, caudate corpuscles, minute oil-globules, and occasionally cylindrical epithelium, all entangled in a thick tenacious plasma. It is alkaline in its reaction. The normal mucus of the vagina and the vaginal surface of the neck of the uterus, is pearly and semitransparent, containing numerous curdy particles which, when in considerable quantity, give it a creamy appear- ance. It contains large amounts of scaly epithelium and epithelial debris. It is acid in its reaction. From this view of the comparative complexity of structure of the vaginal and cervical mucous membrane, Dr. Smith contends that by far the larger proportion of the leucorrhceal discharge must come from the lining membrane of the cervical canal, from Avhich the secretion becomes, from certain causes, incessant, instead of being pretty much limited to about the catamenial period. At first, the discharge is merely increased in quantity; but soon contains, besides, or instead of, epithe- lium and a few mucus-corpuscles and oil-globules, numerous blood- globules, pus-cells, and exudation-corpuscles, and in amount so great as to constitute a grievous drain upon the system. This constitutes what Dr. Smith terms the Mucous or Corpuscular Leucorrhcea of the Cer- vical Canal. When the vagina and the external surface of the neck of the womb are the seat of the disease, the secretion is less abundant, and consists, so long as the surface remains unbroken, or is merely denuded of its ULCERATION OF THE CERVIX UTERI. 611 epithelium, of a plasma holding suspended multitudes of scales of epi- thelium, in every stage of formation from mere nuclei to the detritus of old epithelium. This variety Dr. Smith calls Epithelial Leucorrhcea of the Vagina. When the tissue beneath the epithelial layer becomes implicated, the discharge assumes characters which closely resemble those of the cervical leucorrhceal discharge. The pathological condition of the mucous membrane in chronic leu- corrhcea may be briefly stated as follows : the epithelium of the external portion of the os and cervix uteri may be partially or entirely removed, or removed in patches. The surface is then red, the vascular villi being exposed; the latter also are frequently enlarged, and they stand out more prominently, giving to the surface a velvety look and feel. In that condition of the os uteri, which would be called after death super- ficial ulceration, not only is the epithelium removed, but the villi also are partially or wholly destroyed in patches; the extent of these patches is of course variable. Thus, two grades or stages of alteration are found ; the first may be termed epithelial abrasion, the epithelium being alone deficient; the second, villous abrasion, erosion, or ulcera- tion, the villi, and even the base from which they spring, being affected by a superficial ulcerative process. Sometimes not only are the villi more or less destroyed, but portions of the rugae of the cervical canal are eaten away. In certain cases, what are called the Ovules of Naboth occur; these have been generally considered to be obstructed mucous follicles. Dr. Smith regards them as a form of vesicular disease, seated at first in the deeper structures of the mucous membrane. They are found where no mucous follicles exist, often. These vesicles are generally accompanied by a profuse discharge from the cervix, with a patulous condition and engorgement of the os uteri. They are found as high up in the cervical canal as the summit of the rugose columns. They ordinarily mature and rupture, leaving ulcers behind them. Sometimes they continue to enlarge without bursting; and Dr. Smith surmises that the vesicular polypi of the os and cervix originate in this manner; and that the solid polypi arise from enlarged villi. After long-continued leucorrhcea, partial inversion of the lower part of the cervical canal takes place, giving rise to much pain, and exposing sometimes the rugose arrangement of the lining membrane. This con- dition has been considered a form of ulceration, called the "cock''s-comb" granulation ; the penniform rugae are denuded of epithelium, and their villi are florid and enlarged ; presenting, on the whole, some considera- ble resemblance to a cock's comb. The causes of leucorrhcea may be, a3 stated by Professor Miller, vaginitis, local injuries, eruptive disorders affecting the parts. But, according to Dr. Smith's observation, the most common cause of vaginal leucorrhcea is the irritation produced by the morbid secretion from the canal of the cervix. And this effect he attributes to the fact that the discharge from the latter is alkaline, while the vagina is accustomed to the presence of an acid secretion. This he illustrates by reference to the effect of alkalies, long contained, upon the stomach; of alkaline urine upon the bladder; of the alkaline spermatic fluid upon the urethra. 612 INVERSION OF THE UTERUS. Besides these local causes, some derangement of general health must also be supposed to exist. The treatment of leucorrhcea must embrace both local and general remedies. But it is obvious, from the preceding considerations, that the local applications must be made to the internal surface of the cervix, as well as to the vagina and the vaginal portion of the neck. Injections are serviceable when the disease is confined to the latter situations; but when the cervical canal is affected, the remedies must be applied di- rectly by a camel-hair pencil, unless the mouth of the uterus is widely open. We have made these copious extracts from Dr. Smith's paper, in consequence of the novelty of the facts and the soundness of the deduc- tions. The Memoir is accompanied by numerous beautiful drawings, and may be read with great advantage.—Ed.] Inversion of the Uterus Is the turning of the organ inside out; and it may happen in various degrees. It has been observed to occur idiopathically even in the virgin; and in a minor degree is probably a not unfrequent concomitant of polypus springing from the body or fundus of the womb. But the great majority of cases occur soon after delivery, in consequence of im- proper treatment after the birth of the child; and occasionally it happens spontaneously at this time. Into these details this is not the place to enter. It is sufficient to state that if the organ be not reduced very soon after the displacement has occurred, it will speedily become irre- ducible. If death do not quickly follow, the case becomes one of chronic inversion, which, inducing as it does large losses of blood, ex- hausting discharge, with rectal and vesical irritation, is the cause of constitutional disorder so serious as to suggest the propriety of com- pletely removing the inverted organ. The statistics of the operation are not sufficient to found a decided opinion upon ; but they are en- couraging, when we consider the gravity of the complaint. The sur- geon has to decide Avhether his patient's best chance lies in tolerating the disease and combating its effects, or in submitting to the risk of operation. On the one side, there is a grave disorder which frequently proves fatal, by exhausting the patient—if not more directly ; and on the other, we have the favorable experience of numerous surgeons who have practised extirpation of the organ. It is sometimes difficult to diagnose this affection from polypus ; but in general it can be made out with great certainty. In inversion, we observe the absence of the body of the uterus from its natural position; a state of matters as easy to determine in the thin and relaxed female, as it is difficult under the reverse condition. There is a tumor in the vagina, sensible or even tender, and the handling of which is liable to induce sickness ; it is rough on the surface, dark in color, easily made to bleed, regularly rounded in form, and with the base larger than any other part; or only moderately constricted, by the cervix; having little mobility ; and occasionally, if prolapsed, showing the openings *of the Fallopian tubes, into which a stylet may be introduced. If the finger is INVERSION OF THE UTERUS. 613 passed above the inverted parts, it first reaches the cervix, more or less completely encircling the base of the tumor ; and the finger or bougie, introduced between the cervix and the tumor, quickly reaches a cul-de- sac all round the latter. Farther, the history of the case is peculiar. The reverse of almost all these points is predicable of a polypus ; and some of them, if certainly made out, are quite distinctive. When inversion is partial and the result of polypus, it will probably disappear spontaneously on removal of the cause. In an ordinary case of chronic post-partum inversion, an attempt should be made to reduce it by direct pressure; premising the use of warm baths, local bleedings, pur- gatives, &c. If this fail, and extirpation of the organ is recommended, it is sufficiently easy of execution. The womb is drawn doAvn between the labia by forceps, and a very tight ligature is applied around it beloAV the cervix, care being taken that no intestine has descended into the inverted organ. Or the mass may be transfixed by a double ligature, and tied in two parts. Or a metallic ligature may be thrown around the mass ; and by the aid of Gooch's double canula or other similar in- strument, this may be gradually tightened till it cuts its way through and separates the mass. It occasionally happens that the already ex- isting constriction at the neck of the womb is such as to cause sloughing without surgical assistance. [In the thirty-fifth vol. of the Medieo-Chir. Trans., is a paper by Mr. J. G. Forbes, on Inversion of the Uterus after Parturition, with a, tabular statement of the result of operations practised in thirty-six cases of the accident. The table is drawn up with much care, and pre- sents many interesting facts. The operations practised were by ligature, by excision, and by exci- sion after the use of the ligature. The duration of the complaint pre- vious to the operation, varied from one month to many years. The comparative proportion of the uterus removed, also varied in different cases. 1. Of those treated by ligature only, twenty-one were successful, fiAre were unsuccessful. Of the latter, three died and two recovered without extirpation of the tumor, the severity of the symptoms induced by the ligature having necessitated the removal of the latter. Of the three fatal cases, one died on the fifth day, the patient sink- ing after the operation ; one from peritonitis on the twelfth day ; one from peritonitis on the fourth day. In the twenty-three patients who recovered, the operation produced Ariolent pain, threatenings of peritonitis, or peritonitis itself, and more or less severe constitutional disturbance. The ligature, Avhich was made sometimes of silk waxed, sometimes of cat-gut, annealed Avire, &c. &c, separated with the tumor in from ten days to three weeks, generally in from fourteen to seventeen days. In some instances the catamenia reappeared after the operation. 2. Of the two cases treated by excision, one Avas successful, and one was unsuccessful. In the first, the patient was well in less than a month, after having been extremely ill during the first three days folloAving the operation. In the second, the patient died in two days, of peritonitis. 3. Of the eight cases treated by excision and ligature, five were sue- 614 PROLAPSUS OF THE UTERUS. cessful and three unsuccessful. In the former, the symptoms following the operation were, of course, similar to those witnessed in the first series of cases. The patients were well in from four to six weeks. In one, a protrusion of intestine occurred after three weeks, through the broken up cicatrix; yet the patient recovered. Of the three fatal cases, one died from hemorrhage and peritonitis, on the third day; one on the seventh day, with phlebitis or peritonitis, but with inflammation of the lining membrane of the ventricles of the brain, softening of their surfaces and of the central portions of both hemispheres, and slight extravasation of blood at these parts; in one, death followed in twenty-four hours from the shock of the operation. In nine of these thirty-six cases, the tumor was mistaken for a poly- pus. In a case of inversion narrated in full by Mr. Forbes, great advantage in arresting the periodical hemorrhage from the im-erted womb, was derived from the close application around the tumor of strips of lint soaked in a strong solution of alum, conjoined with absolute rest'in the recumbent position. During the intervals of the catamenial periods, good diet, gentle carriage exercise, chalybeates, &c, were advised. Under this treatment the patient's life was evidently prolonged ; she died, however, at the end of eighteen months, exhausted by the large and repeated hemorrhages.—Ed.] Prolapsus of the Uterus May be partial or complete, the former term indicating an abnormal approximation of the uterus to the os externum vaginae ; the latter denoting that the organ lies in part, or in whole, without the os ex- ternum, forming a tumor between the patient's thighs. The affection may occur at any age, but increases in frequency with the adATance of life, as well as according to the number of labors. Small tumors in the uterus, or the pressure of large tumors upon it, monorrhagia and leu- corrhcea, are local predisposing causes, as also relaxation of the A'agina, from whatever cause, and largeness of pelvis. It is met with in every rank of life, but when in a very aggravated state is most frequent in the lower classes, especially in those unfortunate women whose avoca- tions require much straining and effort, which not only predispose to the disease, but also aggravate it when it exists. It may occur at any stage of pregnancy, or through it all, and even during delivery at the full time, but this rarely. This condition is easily distinguished by finding the os and cervix, and ascertaining that the former leads into the cavity of the organ. Partial prolapsus is extremely frequent in its occurrence, is' easily replaced in most cases, and seldom causes any serious disturbance. In complete prolapsus, also, the tumor is often easy of replacement; some- times, indeed, it resumes its natural position spontaneously, Avhen the patient lies down. But in aggravated cases, replacement may be a matter of difficulty from various causes. Of these, congestion and inflammation, with their consequences, are the most important. In some cases this latter has been so intense as to end in gangrene and TREATMENT OF PROLAPSUS OF THE UTERUS. 615 separation of the parts, resulting in either death or cure of the patient. When the prolapsus is large and of long standing, it may be quite impossible to replace it. The uterus, carrying with it the bladder and rectum, becomes swollen and condensed, and forms a large pouch, con- taining other viscera prolapsed into it, in this state resembling an old and large hernia, the contents of which can with difficulty, if at all, find room for return to the abdominal cavity. In such cases, the pro- truded parts generally present large and unhealthy patches of ulcera- tion, and the corresponding portions of the thighs are more or less irritated and excoriated. Prolapsus of the uterus is generally the cause of much undefined suffering in the region of the pelvis. Patients complain of distressing feelings of bearing down, weight in the perineum, dragging in the loins. and there may be much disturbance, or even temporary arrest of the functions of the bladder and rectum. Often, there is difficulty in walk- ing. In cases of complete descent, great uneasiness is of course pro- duced by friction of the thighs upon the tumor, and the irritation caused by urine passing over the exposed mucous surface is extreme, often ending in unhealthy ulcerations. There is also generally much derangement of the functions of the stomach. The complaint is sometimes complicated by hypertrophy or tumors of the uterus, or of the ovaries, by ascites, by polypus of the uterus, by leucorrhcea, by menorrhagia, or by calculus in the bladder. The objects of treatment are threefold. 1. To replace the organ ; 2. To retain it in its proper situation; and 3. To protect and support it Avhen it is irreducible. The replacement, as already remarked, is frequently effected without aid, on the patient assuming the recumbent posture ; or, it may be done with more or less force directed against the tumor, always in the direc- tion of that axis of the pelvis through which it is at the time passing. If any difficulty is apprehended, care must be taken to secure complete evacuation of the bladder and rectum before the attempt is made. Some- times, from the causes already enumerated, it is for the time at least irreducible. But continued maintenance of the horizontal position, and the use of local antiphlogistics, if necessary, will generally restore reducibility. In some rare cases of long standing, the reduction, although easily enough effected, cannot be tolerated by the patient, and in others reduction remains altogether impossible. When the case is recent, and produced by violence, simple reduction, with maintenance of the horizontal position for a few days, will be sufficient. In some examples, it is necessary, in addition to this, to use means to restore the tonicity and contraction of the relaxed and extensile vagina. For this purpose, frequent irrigation of the canal, with cold water, or continued use of astringent ointments and lotions, are very serviceable. Attention must be at the same time paid to heal up ulceration, and to remove leucorrhcea. In most cases, however, the use of a pessary is required. It may be either worn constantly, except when removed for the sake of cleanliness for a few minutes, or it may be laid aside during the night. It should always be as small as is con- sistent with efficiency, the size ranging according to the conditions ol 616 DISPLACEMENTS OF THE UTERUS. the case. If the perineum is much injured, a bandage may be neces- sary to retain the pessary. And this must be kept clean, by removing and replacing it, with a frequency varied according to the material of which the pessary is made. A great deal has been written concerning the material of the pessary, and its shape. Different practitioners are in the habit of using different forms, and it not unfrequently happens that after trying several, the patient herself is the best judge of what is most suitable. The ball pessary of boxwood is one of the most useful; the ring pessary is often recommended to married women, but requires particular watching, lest the cervix uteri pass through the ring and become strangulated there. Pessaries more or less cup-shaped, and having a stem attached, are particularly applicable to those cases Avhere the destruction of the perineum renders a bandage necessary. }n some cases the wearing of the instrument eventually effects a cure; but in others, dependent on relaxation, it may prevent that re- sult ; and in these it should not be used till other remedies have been tried in vain. In all cases, the utero-abdominal supporter of Hull, or some of its numerous modifications is very useful, if no special cause exist to pre- vent the patient wearing it. By supporting partly the weight of the bowels, it lightens the pressure upon the womb; the padded understrap counteracts the prolapse from below; and the machine gives general support and a feeling of security to the patient. Operative interference has been resorted to in aggravated cases, and not without some success; it is most applicable to those not exposed to the risk of childbearing. The labia have been made raw, and adhesion between them effected, so as to occlude the vagina, excepting a small passage for the vaginal excretions. Episoraphy has also been success- ful ; it consists in carefully paring off longitudinal slips of the mucous membrane of the vagina, and uniting the edges of the wounds by the necessary number of interrupted sutures. Cauterization by the hot iron, or the mineral acids, has also been resorted to for the same pur- pose. When the knife is used, great care must be taken to arrest bleeding timeously. Finally, if reduction is impossible, a protecting and supporting truss must be adapted to the case, after the manner of a suspensory bandage. Displacements of the Uterus. This organ is frequently found lying in an abnormal position. It may be dislocated en masse, or its body may be displaced in regard to the cervix; and the most common malpositions are either backwards or fonvards, forming, in the one case, an anteversion or a retroversion, and in the other an anteflexion or a retroflexion. The flexions, especially the retroflexion, are sometimes congenital. These changes may be simple or complicated. Frequently they coexist with tumors, chronic metritis, hypertrophy of the womb, leucorrhcea, or ovarian irritation. When uncomplicated, they may cause no painful symptom whatever ; but sometimes they produce great difficulty in standing or walking for even a short time, disturbance of the functions of the bladder or of the STRICTURE OF THE CERVIX UTERI. 617 rectum, a feeling of weight and bearing down, a sense of pressure at the anus, pain on going to stool, as well as many of those numerous neu- ralgic and other symptoms which accompany all the chronic uterine affections. On passing the finger to the roof of the vagina, the cervix uteri is found more or less displaced from its natural position; and a hard, often tender, rounded tumor is felt through the vagina. This is found to move with the cervix, and may sometimes be traced to be continuous with it. In thin and relaxed women, it is possible during examination, by placing the free hand over the hypogastrium, and using the neces- sary palpation and pressure, to feel the position and relations of the entire organ. The affection is diagnosed by introducing a bougie or probe into the cavity of the organ, and ascertaining its entrance into the tumor felt through the roof of the vagina. Generally, by means of the probe, it can be depressed or removed from the finger by replacement. Treatment consists in remoATing all local congestion and inflamma- tion, combating uterine hypertrophy and engorgement, arresting leucor- rhcea ; in short, removing, as far as possible, everything which can be regarded as a cause of the production or continuance of displacement. Maintenance of the horizontal posture, for a length of time, is often of great service as an adjuvant. In some cases, the vaginal, and in others the intra-uterine pessaries of Dr. Simpson may be tried with caution. Stricture of the Cervix Uteri May be congenital, or may result from inflammatory engorgement and induration. The stricture, if congenital, is generally at the os exter- num, or at the os internum. If acquired, it may be found at any part of the cervix, or may partially close up some extent of it. It is not of frequent occurrence ; ,but when present is often the cause of dysmenor- rhoea, and sometimes it preA-ents conception. It is discovered by the symptoms of dysmenorrhcea ; or, physically, by the difficulty of passing even a small probe through. Every case, however, where a probe cannot be easily passed, is not therefore to be considered a case of stricture. There may be obstacles to passing a probe into the cavity of the uterus from many other causes, as flexion or version of the uterus, the presence of tumors, and difficulty of adjusting the probe to the direction of the long axis of the neck and cavity of the organ. Treatment consists in dilating the cervical canal. This may be effected by a succession of bougies, or of small pessaries with an intra- uterine stem, as is done in stricture of the urethra or rectum. The instrument, however, may be safely left much longer in situ than in the cognate affections. In fact, it may often be left for days with safety. If the disease is inflammatory in its origin, however, the pessaries Avould merely irritate, without producing benefit. In such cases, espe- cially if there is any engorgement, it is often better to use the bistouri- cache, or the uterotome of Dr. Simpson, a similar instrument, adapted to this particular case. By means of this, the stricture is divided from Avithin outwards; the blade being made to project only to a small 618 UTERINE POLYPUS. extent. If the neck is small, the incision must be proportionally dimi- nished, as there is danger from dividing the vascular trunks which lie on the peritoneal aspect of the proper tissue of the cervix. Uterine Polypus. Uterine Polypi may be of various structure (Principles, 3d Am. Ed. p. 390). Before their removal, we can in some cases determine their pathological nature by their consistence, by their seat of insertion, by their size, by their history, and by the concomitant symptoms. The size of the polypus may A'ary from that of a millet-seed to that of a child's head. In fact, their growth is limited only by the capacity of the pelvis. The largest tumors are generally fibrous in their struc- ture. The mucous vary much in size ; the smallest being generally vesicular or cellular in structure. Sometimes, the mucous polypus is so small and sessile as to be with difficulty discovered. The insertion of these tumors may be at any point on the internal surface or os of the uterus. Very rarely, they are found implanted in the vaginal walls; either having originally sprung from that part, or, as still more seldom happens, having formed a second insertion by ad- hesion. Polypi have sometimes been observed growing by two roots from the uterine walls ; the roots having an identity of structure; and sometimes the second root is merely the accidental result of adhesion. A polypus may be inserted by a pedicle or stalk ; or it may be sessile. The pedicle may be of any thickness; it may be several inches long; or its length may be inappreciable. Sometimes polypi are found projecting from the vagina, suspended from the uterus by a long slender pedicle. These have been designated by French authors polypes a pendicle; and are generally observed in women considerably advanced in life, in whom the polypus has grown without occasioning much if any annoyance. , The vesicular, mucous, and cellular polypi may spring from any part of the internal surface of the uterus. Not unfrequently several may be met with at the same time in the cervix, or adhering to the os. The fibrous polypus generally grows from some part of the body of the uterus. The most urgent symptom of the affection is loss of blood. This is the chief source of the mischief the tumors produce; and the considera- tion of its arrest is generally what leads to their discovery. It rarely happens that a woman dies directly of loss of blood from this cause; but there frequently results an extreme state of anemia, leading ulti- mately to a fatal termination. Violent, and sometimes fatal post-partum hemorrhages are occasionally connected with this as a cause. Bleeding may take place at the monthly periods, or at irregular in- tervals. It is frequently brought on by long continuance in the erect posture, by exertion in walking, or by jumping from a height; or it may occur without any assignable cause. It may in its flow resemble the ordinary menstrual discharge ; or the blood may issue in a continuous stream from the vagina. The quantity lost has no constant relation to the size of the tumor. The fibrous polypus is generally believed to be TREATMENT OF UTERINE POLYPUS. 619 the most frequent cause of serious hemorrhages; but these may occur Avith polypi of any kind, even the smallest. Farther, in some cases, there may be no bleeding at all; there may even be amenorrhoea. • In the intervals of hemorrhage, there may be no discharge from the vagina. Generally, however, there is a mucous or muco-purulent se- cretion ; and in cases of large polypi, this is often abundant. Some- times it is mixed with blood; occasionally it is very fetid, especially if the polypus is ulcerated or breaking up. When the growth is intra- uterine, the blood may sometimes be observed distilling from between of; the lips of the cervix. The other symptoms accompanying polypus need no particular de- scription. They are those common to all affections of the uterus. Occasionally, one of these symptoms is very prominently complained of; as pain in the hips, verging to sciatica; also pains in the mamma. Examination with the finger generally discovers the growth. If, however, it be very small, care may be required. Sometimes a smooth, soft, and easily movable polypus, with small pedicle, remains undis- covered, although of considerable size; the finger ahvays pushing the growth before it, instead of passing round it, as in general is easily done. If the tumors are small, and lodged in the cervix, they may be better exposed after dilatation of this, by means of a sponge tent. By the same means, an intra-uterine polypus may be detected. The spe- culum also may be used to expose a polypus for examination by the eye. But, it may be added, that these growths not unfrequently cause no in- convenience Avhatever; and are discovered only by accident. Polypus is distinguished from cauliflower excrescence, by the latter having a broad attachment to the cervix, by its free bleeding when touched, by its profuse watery discharge, by its rough granular surface, by its accompanying cancerous cachexia, and lastly, by the results of treatment. Polypus is also liable to be mistaken for inversion of the womb (p. 612). The treatment of uterine polypus consists simply in effecting its re- moval. Bleeding has the same treatment as other forms of uterine hemorrhage unconnected with labor. If violent, and proving danger- ous,-it may be commanded by the plug. If slighter, it may be arrested by placing the patient in the horizontal posture, keeping her cool, ap- plying cold locally over the vulva and hypogastrium, administering cold enemata, or, in some cases, cold and astringent vaginal injections, cautiously, and using internally the common astringent and refrigerant medicines. As in many other hemorrhages, opium is of service (Prin- ciples, 3d Am. Ed. p. 351). Removal may be effected in various ways. The quickest, and in most cases the best plan, is the direct use of the knife or scissors, through the speculum—or without it, using the finger, or fingers, as a guard. When the polypus is large, and can be well seized by a volsella, it may be dragged down to the vulva, and its stalk divided there by knife or scissors. If the growth be very bulky, it may be necessary to enlarge the vaginal opening by incisions. When the stalk or base is large and broad, it is safer to cut near the tumor, rather than near its insertion ; on account of the danger of incisions implicating the uterine 620 EXTIRPATION OF THE CERVIX UTERI. walls. If difficulty is felt as to the proper site of the incisions, it is preferable to use some of the slower, but in this instance safer methods of removal. And in all cases it is to be remembered that it is not necessary to take away the whole pedicle; for the part left after separa- tion of the polypus quickly disappears. After removal there is rarely any alarming hemorrhage ; but it must be carefully watched for, and early arrested. A ligature of whipcord, or silver wire, may be thrown around the pedicle, by means of Gooch's well-known double canula (p. 613), or by any of the numerous modifications of it, which best suits the operator's fancy. The ligature is to be daily tightened, till it cuts its way through the stalk; when both polypus and instrument are to be removed. But the direct use of the. knife is perhaps, upon the whole, the safest method; as the other modes are tedious, and on account of con- tinuance of fetid discharges from the half separated and decaying polypus, as well as from the irritation of the ligature, there is risk of untoward inflammation being excited—especially phlebitis. It may happen that a polypus of moderate or small size may be difficult to deal with, either by ligature or cutting instrument; and under such circumstances,' it is sometimes possible to destroy it by compression, or by bruising with strong forceps; as a stone is crushed by a lithontriptor. It may then be either left to slough away; or, if soft and easily lacerable, it may be twisted off and brought out with the instrument. Small, sessile, mucous polypi may often be conveniently destroyed by nitrate of silver; or a stronger caustic may be used, if necessary. Extirpation of the Cervix Uteri Is performed chiefly in cases of malignant disease still confined to this part, and when the peculiarities of its site, and its prominence into the vagina, render complete removal feasible. The operation is sufficiently simple; the only point requiring particular care being to keep the inci- sions in the cervix below the peritoneal reflections—at the same time removing as much as can safely be done. The patient is laid on her back, in the position for lithotomy; or flat on her face, with the hips raised, and the legs dependent. The cervix is seized by strong hooked forceps, and gently but determinedly dragged downwards, till it appear at the os vaginae, through which it is at length drawn. If the patient has never borne children, or if the os vaginae be small and contracted, it may be dilated by one, two, or three small incisions, made either posteriorly or laterallv. After the cervix has been drawn down, the insertion of the Angina is made out, in order to judge of the position of the peritoneal reflections, and to avoid in- cluding the bladder in the incisions. The necessary amount is then taken away, either by large and powerful scissors, or by the scalpel. Our chief confidence for the arrest of hemorrhage is to be placed in careful and thorough plugging of the vagina by lint (p. 606). The amount of bleeding may be inconsiderable; or a large quantity may be lost. And it may happen that a case, otherwise adapted for MALIGNANT DISEASE OF THE UTERUS. 621 the operation, may be unable to bear, without the greatest risk, even a small loss of blood. Under such circumstances, a modification of the operation may be resorted to. After dragging down and exposing the cervix, it may be encircled in a strong ligature; or it may be transfixed, as often as may seem fit, by a needle armed Avith a double ligature; the different parts being separately tied. And the part beloAv the ligature may then be excised Avith safety. Malignant Disease of the Uterus May assume one of three principal forms ; the corroding ulcer, malig- nant ulceration without much interstitial cancerous deposit; the cau- liflower excrescence, springing from the cervix; and the common cancer of the uterus, which may be scirrhous or encephaloid, very rarely colloid. The Corroding Ulcer is not a common affection. It is distinguished from simple ulceration by its granulated surface, by the fetor and profuseness of the discharge, by the occurrence of hemorrhages, by the nature of the pain, which is generally severe and lancinating, by the unhealthy malignant local characters, and by the presence of the malignant cachexia of system. From ordinary cancer of the womb it is easily known, by the want of extensive induration, by the mobility of the womb ; and often, though not always, want of tenderness to touch is also distinctive. As it advances, it consumes or corrodes the tissues; spreading into the uterine cavity; attacking and destroying the recto-vaginal and vesico-vaginal septa. The disease is irremediable. But attempts have been made to arrest its progress while the cervix alone was implicated, by excising the part in the usual way. Frequently, the use of caustics seems to retard advance, to improve the nature of the discharges, and to diminish the tendency to repeated hemorrhage. For this purpose, the pencil of lunar caustic, and the actual cautery are of most service. The extreme fetor of discharge is to be corrected by copious use of the chlorides upon the recipients of the discharge, and as a lotion; used very gently internally, if there is little tendency to bleeding. A weak solution of the chloride of soda is suitable for this purpose. In addition, all the general rules for the palliation of cancerous disease are here applicable (Principles, 3d Am. Ed. p. 315). • Cauliflower excrescence is also an unfrequent complaint. It consists in the projection of a malignant mass, Avhich may be of various shapes, into the vagina. It springs from the cervix, and generally has a large base. It is covered by a number of small pedunculated bodies or gran- ulations, which are often in bunches, and give the general appearance of a head of cauliflower. It is of a bright red color, and easily made to bleed. The general symptoms are those of ordinary cancer of the uterus ; but the watery and bloody discharge is usually excessive in amount. On examination, a tumor is discovered, with the characters above stated; it is felt to be movable and polypoid ; and if the disease is in an early stage, the uterus also is not fixed. It is to be distin- guished from the polypoid masses of encephaloid, Avhich sometimes grow 622 MALIGNANT DISEASE OF THE UTERUS. from the interior of the cervix, but along with which there is much diffused cancerous infiltration. If the excrescence be the sole discov- erable malignant affection, and if there be every reason to think that it might be completely and favorably extirpated, the operation of excising the cervix should be performed. And during healing of the wound, care should be taken, by the use of caustics, to procure healthy cica- trization, and prevent, as long as may be, any tendency to repullulation of the growth. In numerous cases, the operation has been successful in procuring complete relief, and apparent cure—at least for a very con- siderable time. During the course of the disease, cold and astringent lotions are sometimes of service in checking the amount of discharge. Cancer of the Uterus occurs at all ages; but increases in frequency from the period of puberty till the end of menstrual life. It presents itself most frequently in the form of scirrhous infiltration, and more rarely encephaloid. The scirrhous deposit generally commences in the neck, and spreads from thence ; the encephaloid more frequently attacks other parts of the organ first, and sometimes forms projecting and polypoid masses in the vagina, or on the cervix and body of the uterus ; it is softer to the touch, and probably givts rise to bleedings at an earlier period. With encephaloid, too, there is more enlargement and hypertrophy of the non-cancerous parts of the organ, than with scirrhus. It sometimes but rarely happens that the vesico-vaginal or recto-vaginal septa are first affected with malignant deposit—the disease spreading from thence to the cervix uteri. At the outset, there is frequently much ill-defined derangement of the general health, which proves but little amenable to treatment, and often distracts the attention of patient and practitioner from the real seat of disease. And even when the malady has made some progress, but is still in an early stage, the distance of the severest pains from the womb, their lancinating and neuralgic character, and the small quantitv, or even unusual absence, of discharge, may deceive. But as soon as ulceration is established, the nature of the discharges and their mixture with blood at once give the alarm. Patients frequently suffer from pain in the mamma, also in either the right or left hypogastric region, of a wearing kind, with frequent recur- rences of stabbing and lancinating shoots; also from fixed pain, often of a burning kind, in the region of the Avomb ; from pain in the back ; * from pain and restlessness in the legs; from pruritis of the vulva, and irritation of the bladder ; also from constipation, and feeling of bearing down or pressure upon the anus. These sufferings may continue during all the course of the disease, or may be at different times substituted the one for the other. Before active ulceration commences, there may be no discharge ; or there may be a secretion of thin, serous, acrid fluid. Sometimes, even when there is superficial and slowly progressive ulceration, there may be little or no discharge ; as is sometimes seen in cases of open scirrhus of the mamma. But, in general, as soon as ulceration commences there appears a large quantity of muco-purulent secretion, which soon be- MALIGNANT DISEASE OF THE UTERUS. 623 comes fetid and mixed with debris from the seat of disease. Hemor- rhage also occurs; either merely at times tinging the discharge more or less, or, if a considerable vessel has been ulcerated through, flowing in a continuous stream. On examination in an early stage of the disease, the cervix uteri is found enlarged, hard, irregularly nodulated, more or less tender to the touch ; the os much increased in size, and more or less dilated. On inspection, the cervix is seen to be generally of an unhealthy red color, and there may be excoriations in the sulci betAveen the nodules; the excoriations being of a deep red color, and the nodules projecting and often showing very little redness. Cancer of the uterus is generally of easy diagnosis ; patients generally presenting themselves after ulceration with its accompanying discharges has commenced, and infiltration into the cervix and surrounding tissues is considerably advanced. It is liable to be confounded with hypertro- phy of the cervix, with fibrous tumor of the uterus, and with polypus ; and the grounds of distinction have already been given in treating of these subjects. The disease is incurable ; and treatment is confined to palliation. Sometimes the excessive watery discharge may be moderated by the use of astringent lotions, or the application of astringent ointments ; espe- cially those having tannin in their composition. If there is much tend- ency to hemorrhage, no local application can be used with safety. Bleeding, when it oecurs, must be arrested in the usual way—horizontal position, cold, styptics, astringents and opiates internally, and plugging if necessary. Fetor in the discharges is corrected by use of the chlo- rides. The pains in the hypogastrium and loins may be relieved for a time by blistering, or by cupping ; no blood, or a small quantity, being taken—according as there is little or much sharpness and frequency of pulse, or the reverse. The local application of ice, or of refrigerating mixtures, through the speculum, has sometimes been of service. But for the pains of this, as of all other forms of cancer, the great remedy is opium. When the disease is seen in an early stage, the cervix still mobile, and presenting only some prominent indurations—and if other circum- stances, as the general health and age of the patient, are propitious— an attempt may be justifiable to remove the part by excision, or by strong caustics used as already described, in speaking of the inflamma- tory hypertrophy of the cervix, and of corroding ulcer. If this cannot be done, it is prudent to interfere with the parts as little as possible. If there is much cancerous deposit and induration, any violence, such as even introduction of the speculum, is liable to do much harm, by tearing or bursting the lacerable structures and inducing hemorrhage. Books on Midwifery, passim.—Leake, Astruc, Clarke, Dewees, Gooch, Boivin and Duges, Blundell, Meigs, Hamilton, Lee, Lever, Ashwell, Churchill, on Diseases of Women, or of the Uterus. Dupuytren, Lecons Orales. Nauche, Maladies propres aux Femmes. Lisfranc, Maladies de l'Uterus. Duparcque, Alte"rat. Organiques de 1'Uterus. Siebold's Frauen- zimmerkrankheiten. Meissner, Ueber die Polypen, &c. Bennett on Inflammation of Cervix Uteri. Locock, Art. Leucorrhcea, in Cycl. of Pract. Med. &c. Mackintosh's Practice of Physic. Whitehead on Abortion and Sterility. Waller, Art. Uterus, in Cycl. of Pract. Med. Safford Lee on Tumors of Uterus, &c. Ingleby, Facts and Cases in Obst. 624 MALIGNANT DISEASE OF THE UTERUS. Med. Simpson, Dublin Journal, Nov. 1846, also May, 1848 ; also various articles in Edinburgh Monthly Journal. Newnham on Inversion of the Uterus. D6neux, Tumeurs sang, de la Vulve. Jobert, Traite" de Chir. Plastique. Walshe on Cancer, &c. &c. &c. [On Vesico-uterine Fistula, see Madame Lachapelle, Pratique de l'Art des accouche- ments, Paris, 1821, 1825. Stoltz, Me"moire sur les Perforations du col de l'Ut6rus et les Fistules Ve'sico-Uterines et Vesico-Abdominales a la Suite de l'Accouchement, par M. le Docteur Stoltz, de Strasbourg. Jobert (de Lamballe), Traite" des Fistules Ve"sico-Uterines, V6sico-Utero-Vaginales, Entero-Vaginales et Recto-Vaginales, Paris 1852. Cases of Vesico-Vaginal Fistula successfully treated, by Geo. Hayward, M. D., Boston, 1851. On the treatment of Vesico-Vaginal Fistula, by J. M. Sims, M. D., Am. Journal, Jan. 1852.—Ed.] CHAPTER XXXV II I. OPERATIONS ON THE BLOODVESSELS OF THE LOWER EXTREMITY. The Aorta. Compression of the Aorta may often be of service in cases of pelvic hemorrhage ; assisting both Nature and the surgeon in their hemostatic means. And it can be readily effected by direct compression of the vessel against the vertebral column—a little above, and to the left side of the umbilicus—Avhen obesity, abdominal tumor, or intestinal disten- sion, do not interfere. Deligation of the Aorta is very seldom required of the surgeon. Spontaneous obstruction of the vessel, doubtless, has occurred, in a few cases, without serious consequences ensuing. But this eA'ent is wholly different from the abrupt mechanical obstruction by ligature; and, be- sides, the ligature cannot be applied without the infliction of a most hazardous wound. From the operation, a permanently successful result cannot be ex- pected; it must, we fear, be regarded as ineA'itably fatal. But circum- stances may, notwithstanding, occur, such as warrant its performance with the object of protracting existence for a few hours; saving the patient, perhaps, from death by the direct effect of hemorrhage, and affording an opportunity for the arrangement of temporal affairs; yet inspiring no rational hope of ultimate recovery. The vessel may be reached in one of two ways; directly, by incision through the abdomen; or indirectly, on the outside of the peritoneum, by extension of such a wound as is suitable for deligation of the common iliac. Were there a chance of successful issue, the latter method, though the more difficult, would certainly be preferred. But, as it is, the direct mode is likely to be adopted, by any one who may unfortunately find himself compelled, by a sense of duty, to undertake so unpromising and serious a proce- dure. The bowels having been opened by a warm purgative, so as to void both their gaseous and their solid contents, a suitable incision is made in the mesial line, commencing above the umbilicus, and terminat- ing a little beloAV it. The intestines are carefully pushed aside, the peritoneum is again cut through, the vessel is exposed, and a ligature applied. Aneurism of the Abdominal Aorta itself, is obviously remediable only by general treatment (Principles, 3d Am. Ed. p. 555). In the nerATous, hysterical, dyspeptic, and anemic, the affection is simulated by 40 626 DELIGATION OF THE EXTERNAL ILIAC. great abnormal pulsation in the course of the vessel. It is known by distinct perception of a tumor, which is not movable ; by observing that the tumor pulsates equally in all directions; by pulsation and bruit being limited to this one part of the vessel, not diffused equally along its course; by the bruit being equally distinct in the supine and in the erect postures; and by the pulsation being constant, not occasional and intermittent. At the same time, it is right to state that the diagnosis of abdominal aneurism, especially in its incipient state, is often very obscure ; solid tumors, in the neighborhood of the artery, partaking of the aneurismal characters very closely. The Iliacs. On account of inguinal aneurism, and aneurism affecting the common femoral artery—also on account of hemorrhage not otherwise repressi- ve—the External Iliac may require deligation. Due systemic prepa- ration having been made, the patient is placed recumbent, with the abdominal parietes relaxed by position ; and the surgeon proceeds to operate, with the intention of securing the vessel without injury of the Fig. 246. Ligature of the External Iliac. The wound supposed to be held open. a. Artery, b. Vein. c. Peritoneum. d. Spermatic Cord.—(Skey, p. 270.) peritoneum. Many forms of incision have been proposed and followed. That of M. Lisfranc is exact and suitable ; exposing the vessel readily DELIGATION OF THE INTERNAL ILIAC. 627 enough; not calculated unnecessarily to weaken the abdominal parietes; and, at the same time, causing little risk to the spermatic cord and artery, or to the circumflex artery and vein. The knife is entered, two lines above, and an inch within, the anterior superior spinous process of the ilium ; and, being carried downwards, the incision is terminated at an inch above the level of the spine of the pubes, and about an inch and one-third on its external aspect. By cautious dissection, the ab- dominal layers are divided ; the fibres of the transversalis muscle— pinched up with forceps—being cut with extreme caution. The trans- versalis fascia is then scratched through with the point of the knife— near the upper abdominal aperture, where the cord enters the inguinal canal, and where this fascia may be expected to be especially distinct, as well as loosely connected ; and, the finger having been introduced through the aperture, on this the rest of the fascia is divided in safety. The peritoneum, separated from the fascia, is pushed aside; and is held out of the way, either by the fingers of an assistant, or by means of a flat copper spatula. The inner border of the psoas muscle is traced with the finger; and, by its pulsation there, the artery will be detected. The vein is found on the inner side, and is cautiously separated by the fin- ger-nail, or by the point of the knife ; the artery is then more fully isolated, by the same means; and the aneurism-needle is passed on the inner side—being inserted between the artery and vein. The wound is managed in the ordinary way ; and, by position of the trunk and limbs, abdominal relaxation is maintained. This operation is, in general, easily performed ; unless, when great obesity is encountered ; and is, perhaps, the most successful of its class. In aneurism, the point for securing the vessel must necessarily vary, according to the bulk and site of the tumor. The Internal Iliac may require deligation ; on account of aneurism of, or hemorrhage from, its branches. Bleeding from deep perineal wounds, for example, may not otherwise be restrained. And in false aneurism of the gluteal or ischiatic arteries, this operation is usually considered preferable to direct incision of 'the tumor. The securing of the vessel, however, is attended with a considerable amount of both difficulty and hazard ; and, fortunately, is but seldom required. The patient having been placed as before, an incision is begun over the upper abdominal aperture, and carried upwards, as in the line of the former incision, to the extent of three, four, or five inches ; the extent varying according to the contemplated depth of the vessel, and ahvays leaning rather to the side of unnecessary amplitude. The comparative length of the external wound, intrinsically, will have but little effect on the success of the operation; and yet it has a most important bearing thereon, according as it facilitates, or impedes, the accomplishment of exposure and deligation. The abdominal muscular layers having been cautiously cut through, the transversalis fascia having been divided, and the peri- toneum having been pushed aside, the sacro-iliac articulation is felt; and there the vessel will be found pulsating, in close connection with its vein, and perhaps with the ureter also—both of which parts are to be avoided carefully. The origin of the vessel is nearly opposite the cen- tre of a line, drawn from the anterior superior spinous process of the ilium to the umbilicus. Frequently, the external iliac—first found—will 628 THE FEMORALS. prove the best guide to the internal. Isolation is effected by the finger- nail, or by the end of the needle. It is not safe to use the knife's point at such a depth. The vein, situated posteriorly, is especially cared for. The wound being then fully opened by assistants, the needle is passed, Fig. 217. AVound of the Abdominal Parietes; supposed to be held aside showing the Iliacs. a. A ligature round the Internal Iliac, b. A ligature on the Common Iliac.' c. Ligature of the External Uiac. from within outwards ; taking care to avoid the ureter and peritoneum internally, and the external iliac vessels externally ; and selecting the point of deligation at a suitable distance from the iliac bifurcation. The Common Riac may require deligation, on account of either aneu- rism or hemorrhage implicating the external and internal iliac arteries; or on account of secondary hemorrhage after high amputation in the thigh. It is reached by an incision similar to that just described ; and is, perhaps, as easy and promising an operation as the preceding. The vein is found on the inner and posterior aspect of the artery, on the left side; behind and external to the artery, on the right. A similar incision, extended upwards, may serve, as already stated, for deligation of the aorta (p. 625). The Femorals. Aneurism of the common femoral, as formerly observed, requires deligation of the external iliac. False aneurism may form in the super- ficial femoral; and, for this, the ordinary operation for such an accident is requisite; namely, incision of the sac, and deligation of the artery above and below the wounded part. Aneurismal varix, too, is occa- PRESSURE, IN POPLITEAL ANEURISM. 629 siotially met Avith here, of traumatic origin ; a penetrating wound having been inflicted by the grasping of a knife, or other sharp-pointed instru- ment, between the thighs. It may prove but little troublesome, and demand no other treatment than support of the part by bandaging. The Popliteal is probably the most common of all external aneurisms; and, hitherto, the Hunterian application of ligature to the superficial femoral, has been the only approved mode of treatment. Latterly, however, as elsewhere explained (Principles, 3d Am. Ed. p. 545), the application of pressure, instead of the ligature, has been employed. And experience is, almost daily, giving direct and undoubted testimony to the efficacy of the practice. There are some patients, doubtless, who may prove intolerant of pressure; and there may be others who prefer the apparent certainty of the knife and ligature, to the apparent uncer- tainty and delay of the compressor. But the greater number of cases are assuredly capable of cure by pressure properly applied ; without risk, with but little pain or inconvenience, and without any wearisome amount of privation or confinement. The skin, which is to bear the pressure of the instrument, is protected by a layer of thick soap-plaster; and that, again, may be covered by leather. More than one compres- sor is used; or, at least, pressure is made at different parts, at different times; so that the burden of it may not all be thrown on one point, but, by being subdivided, may be rendered more tolerable.1 Using several 1 The mechanical means for compression are undergoing change, and are, doubtless, destined to become more simple and more perfect. Dr. Carte's instruments for making accurate and elastic pressure on the vessel at the groin, and in the upper part of the thigh, are efficient and ingenious, but complicated and expensive. Some have used [Fig. 248.] [Carte's Instrument for compressing the artery in Femoral or Popliteal Aneurism. (From Fergusson.)—Ed.J common leaden weights placed over the vessel, and have found them suitable and satis- factory. For a detailed description of the different instruments, see Tufnell on the Treatment of Aneurism by Compression, Dublin, 1851. 630 POPLITEAL ANEURISM. instruments, along the course of the vessel in the thigh, they may be slackened and tightened alternately; or the same instrument may be shifted in its site, with a like effect. It is never to be forgotten that all severity of pressure is unnecessary, and that it is not essential to arrest the arterial flow at the compressed point. And it is also import- ant to remember that, should this mode of treatment fail, it by no means interferes with subsequent performance of the ordinary opera- tion ; but, on the contrary, the constitutional treatment suitable for pressure, renders the success of subsequent deligation all the more pro- bable. Those surgeons who obstinately adhere to the old operation may adduce, as their apology, a series of successful cases so treated. But this is very plainly a contracted view of the subject; and as well might such practitioners prefer successful amputation of the hand to amputation of a finger, for a simple affection of the latter only. A sur- geon of the olden time, who had succeeded in curing seAreral successive cases of popliteal aneurism by amputation of the thigh, might very na- turally entertain a distrust and dislike of the proposal to treat the same disease by ligature of the femoral; but the naturalness of such an aver- sion to the minor and modern practice, would not render it one whit the more reasonable or praiseworthy. And an impartial observer will not consider any one justified in subjecting his patient to serious risk of life, by hemorrhage, suppuration, and gangrene, while he has it in his power to effect cure by a minor means, comparatively devoid of risk, and the failure of which will not militate against subsequent recourse to the major procedure, if necessary. Why should a mode of treatment, which causes little or no risk, always be passed by; or why should an operation always be had recourse to, which may, and not unfrequently does, result in direct loss of life ? And the question comes in much force, if it be admitted—and statistics will scarcely warrant even feeble contradiction of this any longer—that the tAvo methods are at least equally successful for the cure of aneurism. Recorded facts seem to proAre the following conclusions: 1. That, in popliteal aneurism, skilful compression of the femoral is capable of curing the disease, and that with comparative, and almost absolute safety to life and limb. 2. That the time expended in cure is, on an average, not greater than in the treatment by ligature. 3. That failure by compression does not compromise subsequent recourse to deligation. 4. And that consequently, compression, Avhen skilfully employed, being equally certain, far more safe, and not more tedious than the ligature, should, in the great majority of cases, be preferred. The only dis- advantage of compression is the care and trouble necessary on the part of the attendant, with irksomeness and sometimes suffering on the part of the patient. The obvious and only advantage of deligation, on the other hand, is the facility and dispatch of its execution, with probable exemption from suffering afterwards by the patient, in the successful cases. The formidable disadvantage is, its proved risk to life and limb.1 But should a case occur, suitable for deligation, on account of in- 1 Vide Tufnell, op. cit., and Brit, and For. Med.-Chir. Rev. Oct. 1851, p. 470. DELIGATION OF THE POPLITEAL. 631 tolerance or failure of pressure, or on account of expressed wish and preference by the patient, the operation is performed as follows : The patient is placed recumbent, with the upper part of the thigh suitably exposed. He is directed slightly to adduct and raise the thigh, so as to make the inner edge of the sartorius salient, and, along this, the superficial femoral is traced. An incision of two or three inches in length is then made, in the course of the vessel; so placed, that its centre may correspond to the part of the artery where it is intended to place the ligature. By cautious dissection, the common sheath is exposed, and, very carefully, this is opened, and the arterial coats isolated, to the requisite extent. In the external Avound, the saphena vein is avoided ; in the deep dissection, avoidance of the femoral vein cannot too prominently occupy our regard. The needle is passed very cautiously, so as to avoid all injury to the vein, Avhich is situated poste- riorly, and may be partly seen bulging out on the inner aspect of the artery. The point usually chosen for deligation is where the vessel is crossed or concealed by the sartorius, sufficiently removed from the profunda, as a cross branch, and not too distant from the aneurismal tumor. In performing this operation, the surgeon should always make sure that the tightening of his ligature has a satisfactory effect on the tumor, for there is the same risk of a high division here, as in the case of the humeral artery (p. 292), and, consequently, tAvo parallel vessels may require ligature. After deligation, a relaxed position of the limb is maintained, for obvious reasons. For aneurism affecting the lower part of the femoral artery, a similar operation may be required. For aneurism of the superficial femoral, in its upper part, the Common Femoral may be tied. But this vessel is obviously not favorably circumstanced for successful deligation, and, in consequence, the equally simple and greatly more certain operation, on the external iliac, is to be preferred. In recent wound of the common femoral, however, with or without the formation of false aneurism, the ordinary rules of surgery are to be upheld; the part is cut directly into, and each orifice of the wounded vessel is secured. The femoral vein, here on the pubic side of the artery, is carefully avoided. The Popliteal. For aneurism, or for bleeding, in connection with the posterior tibial. the Popliteal artery may be tied; but ligature of the superficial femoral, below where it is crossed by the sartorius, is a preferable operation. For wound of the popliteal itself, however, ligature of that vessel is necessary, according to the general principles of surgery. The patient having been secured in a prone posture, a free incision is made, tra- versing the popliteal space, and penetrating through the skin, areolar tissue and fascia. The deep dissection is continued cautiously, along the borders of the semitendinosus and semimembranosus muscles. On the edge of the latter muscle, the artery may be felt beating; per- 632 DELIGATION OF THE POPLITEAL. haps overlapped by it. The vein is superficial, and somewhat external to the artery. The nerve is both on a more superficial plane, and on Fig. 249. Ligature of the popliteal at its upper and lower parts, a. The popliteal vein. b. The popliteal artery. c. The posterior saphena vein. The sciatic nerve, on the outside of the artery, has been accidentally omitted in the diagram. the exterior of the mesial line. The vessel is most readily exposed and secured in the upper part of its course. The Tibials. These vessels may require ligature, on account of recent wound, or on account of false aneurism formed at some part of their course. For secondary hemorrhage, ligature of the femoral is to be preferred; when recourse to an operation of this kind is deemed expedient. Ligature of the Posterior Tibial, at the upper part of the leg, is an operation of considerable difficulty. Two methods are recommended. One consisting of a direct incision on the vessel, through the centre of the gastrocnemius and solseus; the other reaching the vessel from the lateral aspect. The latter is usually preferred. The limb having been placed on its outer side, a free incision is made between the edge of the tibia and the border of the gastrocnemius ; the tibial origin of the solaeus is then divided; and, the deep fascia having been cut through, the artery will be found about an inch from the tibia, between the con- comitant veins, and with the nerve on its fibular side. Separation of the veins is made very carefully, while the edges of this deep wound are as much retracted as possible by means of copper spatulae; the knee being bent, and the foot extended, so as to relax the muscles of the calf. The needle is passed from without inwards. At the lower part of the leg, the vessel is reached much more readily; by making an incision on the inner side of, and parallel to, the tendo Achillis, through the two layers of fascia; opening the sheath, DELIGATION OF THE TIBIAL ARTERIES. 633 separating the artery from its concomitant veins, and applying the liga- ture in the ordinary way. Fig. 250. Fig. 251. Fig. 250. Ligature of the posterior tibial, at various parts. The wounds are supposed to be held asunder. The ligature is under the vessel. Fig. 251. Ligature of the anterior tibial, at various parts. The wounds are supposed to be held asunder. The ligature is under the vessel. At the ankle, the operation is also simple. A semilunar incision is made on the inner side of the malleolus, about a finger's-breadth distant from it; indeed, the finger, applied behind the malleolus, may be a suf- ficient guide to the knife. The fascia of the leg having been divided, a strong aponeurosis is exposed; this having been cautiously cut through, the common sheath is found; and, the vessel having been separated from its concomitant veins, the needle is passed from the heel towards the ankle, to avoid the nerve which is situated between the artery and the tendo Achillis. The Anterior Tibial may be tied, either at the upper or at the lower part of the leg. The superior operation is difficult. A free incision 634 DELIGATION OF THE TIBIAL ARTERIES. is made between the extensor communis digitorum and tibialis anticus; and it is well to make a slight transverse division of the investing fascia, at each extremity of the wound. The foot is flexed. The re- laxed muscles are separated down to the interosseous ligament; and, on this, the artery will be found. In the middle of the leg, the artery is placed between the tibialis anticus and the extensor proprius pollicis. At the lowest part of the leg, a less incision is necessary; the vessel being much more superficial. The wound is made on the fibular side of the extensor proprius pollicis. The venae comites, and the anterior tibial nerve, are carefully excluded from the ligature. Should it seem necessary to secure the vessel on the instep, by regular dissection, it is found by an incision on the fibular side of the tendon of the extensor proprius pollicis. * The Peroneal artery may be exposed, by a free incision on the pos- terior and tibial aspect of the fibula. It is found concealed under the inner edge of the flexor longus pollicis. Deligation of the arteries of the leg, however, being seldom if ever required except on account of recent wound, all rules for regular dissec- tion may be in a great measure dispensed with; the extent and form of incision depending very much on those of the wound already existing, and the bleeding point being the best guide to the injured vessel. Manec on Ligature of Arteries, Paris, 1832. Harrison, Surgical Anatomy of the Arteries, Dublin, 1833. Knox, the Arteries, from Tiedemann, 1835. R. Quain, Anatomy of the Arteries, with large plates, London, 1840. Dermott, Illustrations of the Arteries connected with Aneurism, 1841. Tufnell on the Treatment of Aneurism by Compression, Dublin, 1851. CHAPTER XXXIX. AFFECTIONS OF THE JOINTS OF THE LOWER EXTREMITY. Morbus Coxarius. The hip-joint is liable to the common diseases of articulations; but, from its position, the exciting causes of synovitis affect it but little, comparatively. It is a common seat of porcellanous deposit, inter- stitial absorption, adventitious deposit, and other chronic structural changes (Principles, 3d Am. Ed. p. 492, et seq.). It is sometimes affected by neuralgia, also; and then is constituted the true Coxalgia— a term, which, like its analogue Omalgia, has been improperly applied to structural change. But the most important as well as the most com- mon affection to which this joint is liable, is chronic disorganization of the head of the bone; to which the term Morbus Coxarius is applied. There is reason to believe that the morbid changes usually observe the following sequence. Interstitial absorption takes place in the can- cellated tissue of the neck of the bone; perhaps with deposit of tuber- cular matter in the opening texture. After a time, a chronic inflam- matory process is kindled; and softening and disintegration ensue, affecting chiefly that part which is immediately beneath the articulating cartilage. The cartilage is then involved; partly by ulcerative erosion, partly by necrosis of patches. Matter is effused into the synovial capsule; and acute disintegration is established. The cartilage perishes more and more; the head of the bone crumbles down; the acetabulum is secondarily involved in similar decay; the joint fills, and is reduced to the condition of abscess; the matter makes its way, more or less rapidly, and at one or more points, through the restraining textures; corresponding pointing takes place, followed by evacuation ; and then, either the work of disintegration may advance with a fresh and fatal energy, or a lull may be experienced, and anchylosis may ensue. Such we believe to be the ordinary course. But the diseased action may oc- casionally commence, or at least be contemporaneous in the acetabulum. A more rapid and acute destruction of the joint may follow inflam- matory action primarily affecting the synovial apparatus. But the term morbus coxarius is, in strict accuracy, limited to the chronic and gradu- ally nascent affection, which commences in the hard textures. The disease is conveniently divided into two stages. The first, the period which is occupied in the incipient change of structure ; without such loss of substance as to cause change of form, and with the synovial capsule yet entire ; denoted by apparent elongation of the limb. The 636 MORBUS COXARIUS. second, corresponding to loss of substance, change of form, and destruc- tion of the joint; indicated by the limb's shortening and distortion. Fig. 252. Fig. 253. Fig. 252. Articular Caries, affecting the hip-joint. Fig. 253. Wasting of muscles shown, with elongation of limb, in disease of the hip-joint. The muscular deficiency is but imperfecUy re- presented ; the change of the natal fold, result- ing from it, is, however, sufficienUy apparent. The affection is most common in the young, more especially in those of strumous habit; and it may, or may not, be connected with some external injury as its exciting cause. The primary symptoms are deceptive. They are such as may attend on dentition in childhood, or on general disorder of health in adoles- cence ; they may simulate rheumatism also; and they are eArery day mistaken for primary affection of the knee. Obscure pains are felt in the knee and thigh, and occasionally in the hip. The limb is weak, and its weakness is complained of—increasing with exercise; it is felt to be long as well as weak ; it is dragged, rather than moved, in walking ; in standing, it is somewhat advanced, while but little weight is borne on it; and all these symptoms are most observable during fatigue conse- quent on exercise. An inspection, with the body naked from the waist, is essential. The knee, in which for some time great and almost con- stant pain has been complained of, may be quite of a normal appear- ance, and also tolerant of manipulation. The affected limb is decidedly MORBUS COXARIUS. 637 thinner, softer, and more shrunk in appearance than the sound one, and somewhat advanced in position; resting on the toes and ball of the foot, with the heel raised from the ground. To bring the two heels together requires an effort, with a suitable inclination of the pelvis; and the effort usually causes aggravation of uneasiness. As in the analogous affection of the humerus, the shoulder is flattened by wasting of the deltoid (p. 304) ; so here is found a flattening of the hip, by wasting of the glutei. The fold between the nates and thigh—deep and almost transverse in the normal state—is sloping, superficial, and sometimes almost effaced. Place the patient recumbent; straighten the spine, and equalize the position of the pelvis as much as possible—and elongation of the limb will be observed ; the knees and heels by no means corre- sponding to each other. Part of this elongation, no doubt, is apparent only—from twisting of the spine and pelvis, which it is impossible alto- gether to undo ; but part of it is real—dependent on relaxation of the ligamentous apparatus, and on increasing accumulation of fluid within the capsule, while as yet no change of form has occurred in the bone ; and a^so in part dependent on the comparative, or even actual disuse of that limb, in bearing the weight of the body during the erect posture. The foregoing symptoms, however, may almost all be found in the delicate adolescent, without disease of the hip. ' And a farther exami- nation is necessary for diagnosis; by jarring the joint suspected. Forci- ble abduction of the thigh causes pain in the hip ; so does rotation of the limb ; and a still more distinct sensation follows concussion, applied either directly or indirectly—by striking the knee, or the sole of the foot, or the trochanter-major, smartly. There is also tenderness of the groin, and behind the trochanter. Thus far—the first stage—the disease is capable of complete cure ; the limb being left of its normal length, and restored to its normal form and capabilities. But, too frequently, the morbid process advances. Pain and tenderness increase; swelling of the hip becomes more and more apparent; and the thigh is increasingly flexed on the pelvis. A bulging is observable behind the trochanter; and this bone seems dis- placed somewhat backwards. Enlargement also may form over the groin; and the SAvellings maybe felt to fluctuate. Opening and evacua- tion ultimately take place; with one of the two results already stated. In this, the second stage, shortening of the limb is observed; the toes resting on the ground, without any advancement of the limb. As the shortening advances, the toes may not reach the ground at all; but, turning inwards, may dangle over the opposite member, as in dislocation. Or the toes may be everted, as in fracture of the neck of the thigh bone. And it is supposed that comparative destruction of the acetabulum tends to inversion, while comparative destruction of the head of the bone favors eversion of the foot. This shortening is plainly symptomatic of organic change in the joint; destruction of hard tissues as well as soft, deepening of the acetabulum, and abridgment of the head of the femur. And towards such shortening, no doubt, a spastic action of the muscles of the hip contributes somewhat. The hip appears more and more broad and prominent; though really flat and wasted; apparent enlarge- ment depending on atrophy of the rest of the limb, with twisting of the 638 MORBUS COXARIUS. pelvis. As disorganization advances within, the joint becomes more and more loose; and dislocation may occur, by muscular action alone— Fig. 254. Fig. 255. Fig. 254. Shortening, swelling, deformity, lame- Fig. 255. Luxation of Hip, in consequence of ness; the advanced stage of Morbus Coxarius. Morbus Coxarius. without the intervention of a fall or other injury. The dislocation is usually upwards, on the dorsum of the ilium ; and this event is of course Fig. 256. Cure (?) of Morbus Coxarius by Anchylosis. followed by increase of shortening in the limb, and by a still greater and more marked deformity of the hip. Matter, in general, continues TREATMENT OF MORBUS COXARIUS. 639 to form ; and is evacuated at various points ; at the groin behind the trochanter, in the thigh. Not unfrequently, perforation of the aceta- bulum takes place; and then the matter may accumulate within the pelvis, fatally; or it may again take its way outwards, through the sciatic notch, and discharge itself at some part of the hip or thigh; or evacua- tion may take place by the rectum. Structural change may advance from bad to worse; the patient perishing of hectic. Or anchylosis may take place; the patient recovering with a stiff joint, and a shrunk and deformed limb. In the case of dislocation—by no means of frequent occurrence—it sometimes happens that morbid action ceases, and the head of the bone acquires a new recipient cavity on the dorsum of the ilium. More frequently, however, the head of the bone seems to act as a foreign body in its new site, and causes much inflammatory excite- ment. Acute affection of the synovial apparatus in the hip—by some termed the Acute form of Morbus Coxarius—shows the ordinary characters of synovial disease. There is rapid and uniform swelling of the hip, with acute pain in the hip, thigh, and knee, much increased by movement and pressure of the hip; the thigh is bent upAvard, by spastic action of the muscles; and, very often, an apparent shortening of the limb is to be observed, dependent on twisting of the pelvis; acute fever attends; walking and even the erect posture are impracticable; often the slightest movement, even during recumbency, is attended with great agony. If the action be not speedily arrested, suppuration takes place ; the matter is discharged, by one or more openings; and extreme articular dis- organization too frequently results, with corresponding disorder of the system. Such a case is met by the ordinary treatment adapted to acute synovitis (Principles, 3d Am. Ed. p. 465, et seq.). Not unfrequently, the affection is of rheumatic origin. The chronic disease, or true morbus coxarius, is also amenable to the general rules of practice. But, as already stated, it is only in the first stage that complete cure and restoration to health can be hoped for. The disease cannot be opposed too soon; consequently, tact and experi- ence are of much value, in enabling the practitioner to detect with certainty the obscure and insidious commencement. The paramount indication is rest; one, however, which it is often very difficult to main- tain effectively. The patient must be wholly confined to the recumbent and sitting postures; the weight of the body must not, for an instant, be felt by the affected limb. And the best way of accomplishing this, is to put the patient to bed, and keep him there ; the parents and attendants having been previously enlisted in the cause, by having the importance of the privation fully explained to them. Should the patient prove refractory, a light splint may be applied, as for fracture of the neck of the bone. And by some, indeed, the wearing of this splint is recommended throughout the whole period of cure, in order to oppose the decided tendency to flexion of the thigh which invariably exists—increasing along with the disease. [The best splint for these cases, is one made partly to inclose the limb, commencing, indeed, several inches above the crest of the ilium, and extending nearly to the outer ankle. It may be made of Gutta-percha, moulded to correspond 640 TREATMENT OF MORBUS COXARIUS. accurately with the shape of the limb, by being first warmed; of papier mache ; of stout binders'-board; of sole-leather, or of wire ; in any case fitted to the limb; or it may be carved out of wood.—Ed.] But, pro- bably, relief is obtained by this spontaneous assumption of posture, as in analogous affections of the knee-joint; and, to thwart Nature in this, were to denude ourselves of an important item of the means of cure. Encourage flexion, rather, until the disease has begun to subside; and then undo it gradually, ere rigidity has occurred. A few leeches are applied over the hip—perhaps with repetition, should heat or pain seem to require this; and then moderate counter- irritation is maintained, by inunction of croton-oil, or tartar-emetic. If the tubercular cachexy be suspected, the suitable opposing constitu- tional management is put in force—especially cod-liver oil. And by steady perseverance in such treatment, for some weeks, all symptoms of disease may subside ; the patient may rise, without any feeling of local ailment; and, cautiously renewing the use of the limb, he may find, in due time, all its functions fully restored. But if the disease threaten to advance, recourse to a higher degree of counter-irritation is expe- dient ; the actual cautery may be applied behind the trochanter; or a seton may be placed either there or in the groin. Rest and moderate counter-irritation were enough, for the period of absorption; but when structural change, by chronic inflammatory results, has fairly begun, the highest grade of counter-irritation is demanded. In the advanced period of the second stage, all severity of treatment is inexpedient, there being then no longer any hope of saving structure. When matter has formed, and is plainly discernible, seeking the surface, an early opening is advisable—here as elsewhere; an opening must form sooner or later, and early evacuation may not only give relief but may also limit disorganization. Then we may hope only for a minor result of treatment—enchjdosis; or for gradual cessation of morbid action, leaving the joint crank weak, yet movable, and a limb impaired in both its symmetry and function. To conduce towards such ends, we mainly trust to general treatment; keeping the parts steady by means of splints. Now there can be no harm in undoing flexion completely, and keep- ing the limb straight. Tension of the joint is not likely to occur; so much disorganization having taken place. And by maintaining the straight posture—by means of the long Avooden splint, if necessary- dislocation is rendered less likely, and the position is made more faA'or- able for usefulness after anchylosis. In open disorganization of the joint, the straight splint may not be tolerated; then relief is obtained from the gum or leather splints, as elsewhere noticed (Principles, 3d Am. Ed. p. 486). When from synovitis, imperfectly resolved, stiffness of the hip re- mains, orthopaedic treatment may be applied with advantage; friction, passive motion, and perhaps subcutaneous section of resisting muscles. But in the case of anchylosis following structural change in the joint, the result of morbus coxarius, all such attempts will be wisely desisted from ; we ought rather to content ourselves Avith possession of a partial cure, than incur the risk of return of the disease in an aggravated form. DIAGNOSIS OF MORBUS COXARIUS. 641 There are cases, however, in which the propriety of resection may be not unreasonably entertained; when, in an open state of the joint, after spontaneous dislocation, the head of the bone seems to cause much excitement in its new site; when there is good reason to suppose that the disease has all along been chiefly limited to the head of the bone, leaving the acetabulum comparatively uninjured; and when it seems probable that, after removal of the head of the femur, quiet might be restored to the joint, and a certain degree of useful motion might be regained. Successful cases are already on the records of surgery.1 The diagnosis of morbus coxarius from other diseases is important. It is simulated by sciatica, by enlargement of bursas, by lumbar dis- ease, by rheumatism, by interstitial absorption of the neck of the thigh- bone in the aged, and by wasting of the limb consequent on general irritation in the young. 1. Sciatica is known by the pain following the course of the sciatic nerves ; the whole thigh is lame; position of the trochanter, and the length of the limb, are unchanged. 2. Beneath the conjoint tendon of the psoas magnus and iliacus internus muscles, a bursa is interposed where the tendon plays on the capsule of the hip- joint. And this bursa is liable to chronic enlargement; causing pain in the hip and knee, flexion of the thigh, disuse and wasting of the member. The enlargement may be felt, and is painful on pressure ; succussion of the joint itself causes no pain ; abduction and rotation of the limb are not attended with inconvenience; but forcible extension of the thigh and inversion of the foot cause pain, by stretching the affected part; and pain is also felt when the patient himself flexes the thigh, or everts the foot—the tendon then acting directly on the bursal swelling. 3. Disease of the lumbar vertebrae, inducing neuralgic pains in the hip and limb, and impeding progression, is suspected when there is absence of the positive signs of hip-joint disease, as well as those of bursal affection ; and its existence may be ascertained by minute inquiry into the history of the case, with careful manipulation of the lumbar and sacral regions. 4. Young girls, about the time of puberty, or earlier, are apt to fall into a state of general disorder of system. Among other signs of this, lameness of one limb may occur, perhaps with occasional pain of the knee ; and, on examination, the limb may be found smaller than its fellow, the muscles soft and flabby, and the hip, consequently, somewhat flattened. Abduction, rotation, and succussion, however, are all well borne; and on the affected limb the patient may hop round the room, with impunity. It were cruel, as well as futile, to confine that patient to constant recumbency, to leech the hip, or to bring out crops of pustules over it. It is sufficient to enjoin moderate exercise, sea- bathing, friction, and general tonic treatment. 5. The other affections mentioned, as liable to simulate hip-joint disease, are detected by ordi- nary care in diagnosis ; they require no special remarks. 1 Vide Lancet No. 1285, p. 414. In the same Journal, the question of resection, as applicable to this joint, will be found well stated, No. ]2b'S, p. 302. 41 642 CHANGE OF FORM IN THE HIP-JOINT. Resection of the Hip-Joint. Till lately, this operation has not had a place in surgery. And it is still begirt with difficulty and danger. As just stated, in a few cases of advanced morbus coxarius it may be deemed Fis- 257- warrantable ; when the head of the femur is dislocated, and is causing continuance or ag- gravation of excitement; when the joint is open; when the muscles are Avasted, and the head of the bone, consequently, is covered with little else than skin and areolar tissue; and when there is reason to believe that the acetabulum is comparatively free from dis- ease. In connection with this last point, it is well to remember that, after dislocation, the acetabulum may take on a healing action, and, instead of remaining ulcerated, become occupied by a fibrous tissue. Also, in gun- shot wounds and other similar injuries, in- volving the head and neck of the femur only, removal of these parts is preferable to ampu- tation of the whole limb ; and may be had recourse to unhesitatingly, with a good pros- pect of success. No decided rules can be laid down to guide the manipulations. The form and extent of the wound will depend, very much, on the nature of the openings which already exist. A sufficiency of the diseased or injured bone having been re- moved, and the wound having been adjusted, the limb is placed straight, and retained in that position by means of the long splint suitable for fracture. In the case of an anchylosed hip, the neck of the bone may be divided; with the view of forming a false articulation at the sawn part, and so restoring motion (Principles, 3d Am. Ed. p. 504). Success has already attended the experiment; its reputation for safety and expe- diency, hoAvever, is as yet by no means determined. Cure of Morbus Coxarius by anchy- losis, bisected; at a, section might be made, with a view to the formation of a false joint. Change of Form in the Hip-Joint. The chronic changes of form which frequently occur in the hip-joint, have been formerly treated of (Principles, 3d Am. Ed. p. 493). Bv osseous deposit, and porcellanous change—but especially by interstitial absorption of the head and neck of the femur—most serious lameness occurs ; slowly, but steadily advancing, often under the cover of symp- toms characteristic of chronic rheumatism in the part. Rest, gentle counter-irritation, and constitutional alteratives—especially the iodide of potassium—constitute the treatment; but too often are of little avail. AFFECTIONS OF THE KNEE AND HAM. 643 Fig. 258. Fig. 259. Fig. 25S.—Head of Femur and Acetabulum much altered by chronic deposit; causing shortening of the limb, and stiffness of the joint. Fig. 259.—Femur bisected; Head atrophied and altered; Neck gone; the result of interstitial ab- sorption. Sliortciiinz and lameness inevitably great. Affections of the Knee and Ham. Affections of the knee are not so peculiar as to require separate con- sideration. This joint, it will be remembered, is especially subject to synovitis, chronic and acute ; to disease of the bone, and of the car- tilages ; and to the formation of loose bodies within the synovial cavity. It is not suitable for the operation of Resection. Housemaid's Kne>-—that is, enlargement of the bursa over the patella—is extremely common in housemaids, shopkeepers, and others who habitually exert much pressure on this part. The affection is usually chronic; sometimes, however, the case is acute, and apt then to be associated with erysipelas. The ordinary treatment is required (Principles, 3d Am. Ed. p. 511). Abscess of the Ham is by no means unfre- quent ; and may be connected with exfoliation from the posterior part of the femur. When the portion of dead bone is large, considerable difficulty may be experienced in effecting its removal; and free incision may be necessary. In such circumstances, caution is obviously i • • i 1 „ ±« ±V,„ „„<-~..,t Enlarged Bursa over the Patella, required, lest injury be done to the artery, the rJ;lt of prcssure ,„_.. Vein, Or nerve. maid's Knee. 644 TUMORS OF THE HAM. Tumors may form in the ham. As already stated, it is perhaps the most frequent site of external aneurism. Ganglionic and bursal enlargements form, producing more or less inconvenience; and these may be treated by repeated puncture by means of a trocar and canula, or by puncture followed by injection, as in hydrocele. Erectile, fatty, encysted, and fibrous tumors are also met Avith. The ordinary treatment is required. Removal should be early, before deep and inconvenient attachments have been formed. In addition to the ordinary authorities on Diseases of the Joints, see Coulson, on Dis- eases of the Hip-Joint, London, 1841. Hugman, on Morbus Coxarius, &c. London, 1850. CHAPTER XL. INJURIES OF THE LOWER EXTREMITIES Fractures. Fractures of the Pelvis. The bones of the pelvis give way only under great and crushing force; a heavy weight, for example, passing over or falling on the part. There is but little displacement; muscles not tending thereto. The great risk is from injury done to the important parts within. The bladder may be torn, or it may be punctured by a spiculum, as formerly noticed (p. 504); a portion of bowel may be ruptured ; or great extra- vasation of blood may occur. From such lesions of structure, imme- diate danger to life results. A risk somewhat more remote follows mere bruise of the interior; inflammatory action being lighted up within, and advancing both rapidly and untowardly. Or, instead of union, abscess may form at the site of fracture. In treatment, little is to be done in the way of replacement; the chief care must be directed towards avoidance of motion, and the avert- ing of inordinate action. The application of a broad, firm bandage suffices for the former indication ; the latter is fulfilled in the ordinary way. 1. A wagon wheel, rolling over the pelvis, may detach the Crest of the Ilium from the body of the bone. The upper fragment is displaced inwards ; and replacement may be effected by the fingers, ere swelling has occurred. 2. From a heavy and high fall, fracture of the Sacrum may result. The fracture is usually longitudinal; and there is no dis- placement. 3. xV kick or fall may cause fracture of the Coccyx ; and there may be considerable displacement inwards. By means of the finger in the rectum, accurate readjustment may be effected ; and it is very obvious that, in the after-treatment, both purgation and constipa- tion are to be avoided. 4. The Os Pubis may give way in its hori- zontal body, or in its descending ramus. This fracture is especially hazardous, from the risk which displacement of the sharp fragments, inwards, entails upon the bladder. The necessary treatment was for- merly considered (p. 505). 5. The ascending ramus of the Ischium is as frequently broken as any other part of the pelvis. Crepitus is readily felt by the finger in the rectum or vagina ; and, by the same means, readjustment of the fractured portions is to be effected. 6. The 646 FRACTURES OF THE FEMUR. Acetabulum may be split; and injury of the neck of the femur may be simulated. There is no shortening of the limb ; and crepitus is felt by the finger in the rectum or vagina—when the pelvis is moved, not during mere rotation of the thigh. Fractures of the Femur. I. Fracture of the Neck, within the Capsule.—This accident is almost peculiar to advanced years ; and occurs more frequently in women than in men. The external dense portion of the bone is atrophied, a mere thin shell inclosing the cancellous texture; the neck tends to become rectangular, instead of being oblique, in relation to the shaft of the bone; and there is, besides, the brittleness of the osseous texture pecu- liar to old age. The accident may be produced by direct violence, as by falls on the hip; more frequently it is the result of indirect violence, as by a slip or stumble, of comparatively trivial amount. The upper fragment remains in situ ; the lower fragment is drawn upwards by the muscles of the hip, and rests above and on the brim of the acetabulum —farther elevation being resisted by the capsular ligament. Such dis- placement may not occur immediately, however; not until spastic action of the muscles takes place—it may be, some hours after receipt of the injury ; and if the periosteal investment be not wholly torn through, the displacement after all may be but slight. When shortening, to a marked extent, occurs suddenly after some hours, there is reason to infer that the periosteal investment, at first but partially torn, has then given away entirely. By muscular action, also, the lower fragment is everted; the muscles inserted into the trochanteric fossa, inter-tro- chanteric line, and trochanter minor, especially conducing to this change. On examination—best conducted Avith the patient laid straight on his back—the following signs of the injury are observable: There is shortening of the limb, from half an inch to nearly tAvo inches; but perhaps not immediate, as just explained. The toes are everted, and the eversion can be undone by the surgeon, though not Avithout the infliction of much pain. Like the shortening, the eversion may at first be but slight. In some few cases, inversion is found; but that position is accidental; resulting from the nature and direction of the inflicting force, and from absence of the muscular action which ordinarily deter- mines the displacement, and which might have undone the position in which force had first placed the limb. The trochanter is higher and flatter than its fellow. Voluntary motion and power are greatly abridged; forced motion is preternaturally extensive. On rotation of the limb, the hand or ear, placed over the trochanter or on the groin, perceives distinct crepitus; but only when extension has previously been made, so as to bring the fragments into apposition. By gentle exten- sion, the shortening may be undone, and the two heels may be brought together; but on ceasing to extend, muscular action soon restores the shortening as before. On rotating both thighs, the trochanters will be found " moving in the arcs of different circles ; that on the injured side rolling on its own axis, while the healthy trochanter describes an arc of FRACTURES OF THE FEMUR. 647 which the neck forms the radius." There is no great amount of swelling; as can readily be understood, Avhen the nature of the injured parts is considered. It is possible that impaction may take place—the upper fragment being driven into the lower; in which case the shortening and eversion will be slight, and crepitus will be absent unless impaction be undone by extension. Union of this fracture is quite possible, but yet improbable—espe- cially when the bones are unimpacted. The following are the more important obstacles to such ah occurrence : 1. There is an obvious dif- ficulty in maintaining accurate apposition; restraining splints cannot be applied to the part itself, and it is difficult to maintain uniform Fig. 201. Fig. 262. Fig. 261 Fracture of the N'eck of the Femur, within Fig. 262. The same. A section showing the lino the capsule; thoroughly and accurately reunited. of union. (From the collection of Sir A. Cooper.) ascendency over the retracting muscles. If the periosteal investment remain partially entire, hoAvever, there may be little displacement, and proportionally slight shortening; and, in such circumstances, a better issue may be looked for—as Avell as in the case of impaction. 2. There must be a want of provisional callus; there being no structure from which it may be produced, and in which it may be formed and sustained; the synovial capsule is obviously barren in this respect. The fractured ends may be said to be steeped in an increased secretion of synovia. 3. Also the definitive callus, which, if uninterrupted, might alone achieve consolidation—as happens in other fractures, when from any cause the provisional formation proves defective—is ever liable to acci- dent, by even slight movement of the parts. 4. The upper fragment, or head of the bone, nourished only through the round ligament, must be of weak power, and ill able to execute the exalted nutritive action necessary for reparation. 5. The age of the patient, and the atrophied condition of the bone itself, are obviously unfavorable to reunion. 648 FRACTURES OF THE FEMUR. With such adverse complications, it is no wonder that examples of union in this fracture are most rare. And yet circumstances may occur, in which that result may be attempted and expected, with every reason- able prospect of success. When, for example, the patient is compara- tively young; when the shortening is slight, indicating but partial division of the periosteal investment; or when, besides this, there is absence of crepitus, indicating impaction; when the patient joins heartily with the surgeon in the use of means calculated to maintain apposition, and to prevent all movement of the fragments; and when neither becomes weary of the prolonged period of vigilance required— for, be it remembered, provisional callus is wanting, and the definitive must do all (Principles, 3d Am. Ed. p. 658). The ordinary result, however, is the formation of a false joint; the parts becoming accom- modated to each other by absorption, connected by new fibrous texture, and farther restrained by a thickened state of the capsular ligament; the limb remaining deformed, and comparatively powerless, yet admit- ting of tolerable comfort and usefulness, with the aid of a stick or crutch. In the extremely old, fatal sinking is probable; under the shock of the injury, and the irritation of pain and confinement. In the last-named class of patients, the use of splints and bandaging for retention of the fragments is not expedient. Success cannot result; the annoyance will but aggravate the general disorder ; and, not im- probably, sloughs will form at the points where the splint exerts its pressure. It is sufficient to arrange the limb comfortably on pillows, and by very gentle swathing or deligation to restrain motion. In the more hopeful cases, the long splint is to be applied as in treatment of the following injury. II. Fracture external to the Capsule, and above the Trochanter.—This is usually an impacted fracture ; the upper fragment being driven into the cancellated texture between the trochanters, and more or less firmly wedged there. In such circumstances, there is but little displacement; crepitus, even, may be obscure; and power of the limb, both as to motion and the sustaining of weight, may be wonderfully preserved—continuity in the bone having been restored by the impaction, immedi- ately after it had been dissolved by the fracture. Not unfrequently, however, impaction is not so complete as this; and sometimes it neither does nor can occur, on account of comminution attending on the fracture; and then the amount of displacement and shortening may be very considerable. This form of injury usually results from direct and severe violence, as by falls or heavy blows on the hip. It differs from the preceding; in the mode of oc- currence, as just stated ; in its liability to occur at any age; in a greater amount of swelling and pain following—the fleshy textures being more or impacted Fracture, through less extensively implicated ; in a greater amount the Trochanters The upper Qf constitutional sympathy being manifested—the fragment is wedged into the . . . J l J & wuwv. ""^ lower. inJury being altogether more severe ; in there Fig. 263. FRACTURES OF THE FEMUR. 649 being usually a less amount of shortening and eversion, with a greater amount of power and motion; and in crepitus being very palpable only when full extension, and consequent disentanglement, have been effected —obscure, or altogether wanting, until then. When impaction has not occurred, often the slightest motion causes very distinct crepitus ; there being comparatively little retraction of the lower fragment. The degree of shortening may be said to vary from half an inch to an inch and a half. A more important difference exists, in this fracture being capable of satisfactory union. The best mode of treatment is by application of the straight, light, wooden splint. It should extend from a little below the axilla, to a little beyond the ankle, when the patient is straight and Fig. 204. Splint, ready for application. recumbent; and, having been well padded, more especially at the points where pressure is likely to be greatest—at the trochanter, external con- dyle, and malleolus—it is made one with the limb, as it were, either by bandaging, or by the swathing of a broad linen sheet. Then a soft Fig. 265. The Splint applied. shawl, or other suitable band, is passed beneath the perineum, on the affected side ; and has both its ends tied on the upper end of the splint— there being two holes placed there for this purpose. A broad bandage or belt is also applied firmly round the pelvis, so as to bind the splint more securely on the limb, and keep the broken surfaces in apposition. By tightening the perineal band, from time to time, the splint is forced downwards; the splint, having been made of a piece with the limb, brings the latter with it; and thus such extension is made, as is likely to prevent retraction by the muscles, and to maintain the limb of its proper length. Indeed, in practice, it is well to have the extension such as to make a seeming elongation on the affected side. On resump- tion of the erect posture, and use of the limb, such lengthening soon disappears. 650 FRACTURES OF THE FEMUR. Fig. 266. [A modification of the splint originally recommended by Desault, and one which is certainly much superior to it, as well as to that advised in the text, is in common use in this country. It was introduced many years ago by Dr. Physick, of this city. It consists of two pieces of light, but firm wood, one for the outer, the other for the inner side of the limb. The external splint is made long enough to extend from the axilla to four or five inches beyond the foot; the upper extremity may be excavated, like the head of a crutch, and should be broader than the lower, the splint gradually tapering. To the inside of the splint, at the distance of two or three inches from the lower end, is fixed a block, which should be deep enough to project to the line of the middle of the foot, when the splint is applied to the limb. The advantage of this block is that it enables the extension to be made in the normal axis of the leg. The inner splint is made of the same material as the other; it should extend from the pelvis nearly to the internal ankle; and, like the first, it should be rather broader than the thick- ness of the limb from before backwards, of course tapering from above downwards. Before applying these splints, they should be wrapped in a piece of strong muslin, about two yards long, and as wide as the inner splint; one splint being folded at one end of the muslin, and the other at the opposite, leaving a space between the two boards sufficient to receiATe, with considerable tight- ness, the leg and a junk-bag on each side of it. The intention of these bags is to serve as cushions for the protection of the limb, and also as compresses to assist in maintaining the proper extension, in order that the whole burden of the latter may not fall upon the extending and counter-extending bands. The junk-bags may be made of muslin, pretty firmly stuffed with bran ; they should be almost or quite as wide, when com- pressed, as the splints, and should correspond in length with that of the thigh and limb. The counter-extending band may be made of a strong silk handkerchief, folded like a cravat; or of a long narrow muslin bag, stuffed with bran or cotton, and having a strong tape firmly secured to each extremity. The extending force may be exerted through a cravat ap- plied upon the foot, as shoAvn in Fig. 267; or through tapes attached to a gaiter made of linen lined Avith buckskin, cut to the shape of the foot, and secured upon it by lacing, as in Fig. 268. The apparatus having been thus prepared, the broken limb is carefully placed upon the splint-cloth, between the two splints, or this is gently slid under the member, and the junk-bags are laid one on each side of the latter, as before remarked; the counter-extending band is passed under the upper part of the thigh and over the groin, and its two ends are drawn through holes made in the upper extremity of the long splint, and firmly secured upon the latter ; then, while an assistant steadies the The long Splint of Physick's Apparatus. FRACTURES OF THE FEMUR. 651 upper fragment and the splint, the surgeon takes hold of the limb by the ankle and the lower fragment, and firmly but gently and steadily Fig. 2G7. Fig. 268. draws the latter towards him, his knee, the while, pressed against the end of the long splint; after sufficient elongation and coaptation have been gained, an assistant passes the gaiter-straps over the block and through holes at the end of the external splint, and there ties them tightly; strips of muslin are also tied around the splints, at suitable distances along the limb, in order to compress the soft parts and to aid the action of the extending and counter-extending bands. The use of the long splint in the treatment of fracture of the thigh is apt to be attended with excoriation or sloughing of the integuments of the foot and also of the perineum, in consequence of the pressure produced at these points by the extending and counter-extending bands. But this is by no means a necessary evil, for it may, in the vast majority of cases, be prevented by attention to proper precautions.' Thus, before applying the gaiter or the cravat to the foot, and the counter-extending band to the perineum, the skin covering these parts should be well rubbed Avith some moderately stimulating liquid, as the spirits of camphor, soap-lini- ment or whiskey, for the purpose of rendering the skin thicker and more capable of resisting pressure. During the first week of the treat- ment, these parts should be examined twice daily, and even more fre- quently if the patient complain of pain or undue itching ; and the skin should be rubbed with the liniment, and the extending and counter- extending bands be reapplied in, if possible, a somewhat different posi- tion, so that no one point of the integuments shall have to bear pressure for too long a time continuously. Again, in making extension and counter-extension, the requisite traction should be accomplished not through the extending and counter-extending bands, because if these be so drawn upon a dangerous pressure will be exerted upon the skin of the parts involved; but the surgeon should lay hold of the ankle and the lower fragment near the knee, and make the extension while an assistant draws in the opposite direction upon the superior fragment, and when the desired length has been gained the whole limb should be compressed by the forcible lateral approximation of the splints, and then the gaiter and perineal straps should be tied; these are to be used not to make the extension and counter-extension with, but simply as aids in retaining what has been gained by other means. The patient should be laid upon a hard, level mattress ; a bedpan should be used to receive the evacuations from the bowels, or preferably, 652 FRACTURES OF THE FEMUR. Fig. 269. a fracture-bed may be employed, having an aperture in the mattress, and in the bedstead, corresponding in situation with the patient's fund- ament, and closed at pleasure by a firm cushion upon which the pelvis of the individual reposes; when the bowels are to be moved, this cush- ion is taken away, and a vessel of the proper kind is placed opposite the hole. Thus all undue motion of the body is rendered unnecessary. Generally, the limbs are allowed to rest parallel with each other upon the bed, or the uninjured member may be moved at the patient's pleasure. But when the fracture is above the upper third of the femur, the broken limb should be drawn out from the middle line, so that the axis of the loAver fragment may be made to correspond with that of the upper, which has been acted upon by the abductor muscles; unless this precaution be attended to, an angular deformity will be liable to occur. If proper care be bestowed upon the patient during the treatment of the fracture, a most excel- lent cure may be obtained by the employment of Physick's splint; and without great care no splint will succeed in curing the injury, except with con- siderable shortening, and, probably, angular de- formity. The editor would not, however, advise its use as an exclusive means. Indeed, he thinks that when the fracture is so situated as that there is decided projection of the point of the upper frag- ment, in consequence of the powerful contraction of the iliacus internus and psoas magnus muscles, it will be better to treat the patient upon a double inclined plane, as advised by Professor Miller.1— Ed.] A method of treating fractured thigh has been recently explained to me, by Dr. Kimball, of Lowell, Massachusetts. Two long pieces of strong adhesive strap are applied, one on each side of the limb, ex- tending from above the knee to the ankle, and these are secured by a roller. The end of each strap is uncovered with adhesive matter, and hangs loose from the foot. The splint, as represented in the accompanying diagram, having been applied, the ends of each strap are secured to the cross-bar at the splint's extremity, and the limb is made one Avith the splint in the ordinarv wav. Bv turning The American Splint. .1 ,1 i_ • -i "^ *i a. The movable crutch. the screw> the ?™ss-bar is moved up or down, at b. The screw which Axes will, and extension consequently is regulated with the crutch, c. The cross, botli accuracy and power. The perineal band is ^ rap^"^ employed besides, but should its pressure prove at d. The moving screw. any time galling, it may be temporarily discontinued 1 [For farther details concerning the employment of the straight splint, see the Editor's Treatise on Minor Surgery.—Ed.] FRACTURES OF THE FEMUR. 653 with safety, the crutch of the splint being moved up into the axilla to sup- ply its place. This splint is the joint invention of Dr. Kimball, and his nephew, Dr. G. K. Sanborn. It seems a most efficient apparatus; and the use of adhesive strap for extension, a method applicable to other fractures, is at once simple and successful.1 [It would certainly be unwise to trust to the axilla as a point d'appui for counter-extending pressure, for this is not a fixed point, being mov- able at the will of the patient, and yielding to upward pressure made against it. It would surely be better, in cases where the perineal band cannot be employed, to treat the patient by the double inclined plane; or the apparatus of Hagedorn, as modified and improved by Dr. Gib- son, of this city, may be tried. This apparatus consists of two long splints extending from the axillae to below the feet, one on each side; at their loAver ends they are con- nected by a footboard, which traverses up and down upon the splints, so as to alter the length of the latter; the footboard is long enough to re- ceive both feet betAveen the splints, and corresponds in depth to the length of the feet. When applied, this apparatus admits the body and both lower limbs of the patient between the splints, while the feet are securely confined upon the footboard by gaiters or cravats; to retain the limbs more completely, bands are passed around the whole, at suit- able distances from each other; and junk-bags, similar to those described at p. 650, should be interposed between the limbs, and also between these and the splints, partly for the sake of the patient's comfort, and partly to assist in maintaining the requisite extension. By this apparatus, counter-extension is made upon the acetabulum of the sound leg, and extension upon the ankle of the injured limb; and it is obvious that, so long as the sound limb is kept perfectly straight (and in order to secure this position the editor has been in the habit of confining it upon a straight splint), and the lateral splints are closely compressed against the body, and the feet properly fastened to the foot- board, there cannot be much shortening of the broken leg. The editor has employed this apparatus in several cases of fracture of the thigh, and has been much pleased with the results of the treat- ment. For farther details, and an illustration of the splint applied, See Sargent's Minor Surgery.—Ed.] On discontinuing the splint, at the usual time, from four to six weeks, a considerable amount of oedematous swelling generally pervades the whole limb, removable by friction and bandaging. Weight should be placed very gradually on the foot, especially in the aged, and in those of infirm health; for in these, even slinging of the foot, in attempts to walk with crutches, has caused serious displacement of the fracture. [The editor ventures to suggest, in opposition to the text, that/owr or 1 This method of dressing fractures has been more particularly brought into notice by Dr. Josiah Crosby, of New Hampshire, U. S. [The employment of adhesive plaster for this purpose was first proposed, there is reason to believe, by Dr. Gross, in his Treatise on Diseases of the Bones. The editor has had frequent opportunities of testing its value, and can commend it most highly, as being perfectly reliable for the purpose of extension, and as being free from the objection which applies to the gaiter and the cravat, viz., the lia- bility to excoriation and sloughing which attend their use.—Eu.] 654 FRACTURES OF THE FEMUR. six weeks is too short a time for sufficient consolidation to have occurred to render it proper to dispense with the use of the splints. It is much safer and more judicious to retain them for ten or twelve weeks.—Ed.] Cases of complete impaction would require little or no treatment, were we content with a permanently shortened limb. But, in order to obtain a perfect cure, it is evident that the impaction must be undone by extension, and the normal length of the limb thus restored. III. Fracture through the Trochanters.—This is also the result of direct and severe violence. There is usually much displacement, and, in consequence, crepitus may at first be obscure. On extension and rotation, the hand, placed over the trochanter, ascertains that the upper fragment is fixed, while the lower alone moves with the thigh. Treat- ment is by the long splint. IV. Fracture of the Trochanter Major.—This process may be broken off from the shaft of the bone. It is displaced upwards, by the action of the lesser glutsei muscles, and a hiatus can be felt between the two portions. The signs of solution of continuity in the shaft are absent. Accurate approximation and retention are effected with difficulty, and, in consequence, union is generally by ligament. Splints are unneces- sary ; it is sufficient to maintain recumbency, in such a posture as is likely to conduce to relaxation of the displacing muscles. V. Fracture below the Trochanter Minor.—The indications of this accident are sufficiently plain. The end of the upper fragment is tilted much forwards, by the action of the psoas and iliacus muscles, while, by the muscles of the thigh, the lower fragment is drawn upwards, and usually inwards, the action of the adductors preponderating. The con- sequent deformity and shortening are great. Extension and rotation cause distinct crepitus, and the preternatural mobility of the part, with loss of continuity in the shaft, are very apparent. Adjustment having been made, by extension and coaptation, the limb may be secured to the long straight splint; and sometimes it is expedient, in addition, to place pasteboard splints directly on the fractured part—one on the inside extending from near the perineum, one on the outside extending from the trochanter major, and both reaching the knee. They are secured by bandaging, before the long splint is applied. But, in some cases, the double inclined plane is preferable—Maclntyre's splint, sim- plified and improved by Liston (p. 658), the spontaneous rising of the [Fig. 270.] [Maclntyre's Splint, simplified and improved by Mr. Liston. (From Ferguson.)—F.P.] upper fragment being thus humored, while the lower part of the limb is brought up to it. The trunk should also be somewhat elevated, to relax FRACTURES OF THE FEMUR. 655 the muscles of the minor trochanter. In children, it is well to varnish the bandaging, and so to prevent the necessity for frequent renewal of dressings, on the score of cleanliness. VI. Fracture of the Shaft near its middle.—Here the signs of the injury are self-evident, and need not be detailed. Displacement is usually great, and unless this be undone, and permanently opposed, most serious deformity must ensue. The retentiA^e apparatus will con- sist either of the straight splint, or of the double inclined plane, the latter bent to a tolerably acute angle. In ill-adjusted cases, not only is deformity great by shortening and bulging at the part; but the knee is apt to become weak and loose, the ligament of the patella proving altogether inert. VII. Fracture above the Condyles.—The lower frag- ment is usually displaced backAvards, by the action of the popliteus and gastrocnemius. The upper fragment, pushed forwards, may penetrate muscles and skin, and so render the case compound. The signs of the injury are obvious and plain. Treatment is by the double inclined plane, with the knee considerably bent. VIII. Diastasis, or separation of the shaft of the bone from its epiphysis, may take place in the adoles- cent; simply, by direct violence; or with more or less rotation of the detached part, the limb having been twisted by a wheel, or in machinery. Retention is best effected in the straight position; with the use of com- mon splints, of Avood or pasteboard; or laying the limb in Maclntyre's splint, fully extended. IX. Fracture of the Condyles may take place, ex- tending into the knee-joint. There is much swelling of the joint, and crepitus is felt on the slightest motion. This is also best treated in the straight position. But watchfulness and activity are especially requisite, to avert inflammatory action, which is apt to seize upon the synovial capsule, and to prove severe. After the first fortnight, to prevent stiffness, gentle passive motion of the joint is expedient; provided the parts are quiet enough to admit of this. In all fractures of the thigh, the limb's use must be resumed very gradually, crutches being used to bear weight at first, lest bending and shortening occur after apparent consolidation. And this precaution, indeed, is necessary in all fractures of the lower extremity—especially in those enfeebled by age or disease, as already stated. X. Compound Fractures of the thigh, especially at the upper part, are prone to an unfavorable issue; by suppuration and constitutional disturbance. No peculiarities of treatment need be specified; farther than that the patient's fate usually hinges on the prophylactic and anti- phlogistic constitutional treatment of the first ten days (Principles, 3d Am. Ed. p. 664, &c). Diastasis of Femur. Reunited. 656 FRACTURES OF THE PATELLA. Fracture of the Patella. Longitudinal fracture of this bone is the result of direct violence, and may be attended with comminution. Inflammatory action is liable to occur, implicating the joint, and active prophylaxis, in this respect, is in consequence essential. Bony union readily takes place, unless action prove excessive. No complicated apparatus is necessary; it is sufficient to prevent motion, by a short splint under the ham, lightly retained by bandaging. Transverse fracture is common; the result more frequently of muscu- lar action than of direct injury—as when a person, in full exercise, endeavors suddenly to save himself from falling. In other words, when the knee is bent, and the extensor mass of muscles acts violently, the patella is apt to be broken across, over the condyloid surface of the femur. The lower fragment remains in situ. The upper portion is retracted upwards on the thigh, by the extensor muscles, when the severance of fibrous as well as osseous texture is complete, and a wide hiatus is left between, in which the condyloid surface of the femur may be plainly felt, and even seen. The limb is powerless, more especially when descent in progression is attempted, the extensor muscles proving impotent. Treatment is usually simple, position often being alone sufficient to effect reduction and retention. The limb is straightened and elevated, so as to relax the extensors on the thigh; a bandage is applied, from the toes upwards, to prevent engorgement of the limb, and, if coapta- tion be not quite complete, the bandaging may be arranged in the form of the figure 8, at the knee, so as to force the fragments gently into apposition. The trunk is also elevated, in a half-sitting posture. Ac- curate apposition and osseous reunion may be obtained, but this result is not desirable, the knee being apt to prove crank and limited in its movements, and recurrence of the fracture being by no means impro- bable, under the application of a comparatively slight cause. Short ligamentous union is preferable, affording sufficient firmness and resist- ance for action of the muscles, leaving the play of the joint unfettered, and proving less liable to recurrence of a solution of continuity. As the consolidation advances, passive motion is gently begun, otherwise the muscles may prove slow in recovering their function. Should peculiarities of the case render such simple treatment insuffi- cient, and a ligamentous union of redundant length be threatened, more coercive measures are necessary. A broad leather belt is passed round the limb above the patella, another below it; by cross-belts, tightened as circumstances require, the circular girths are brought together, and their approximation includes that of the fragments of the patella. Or Lonsdale's apparatus may be worn, which has the advantage of avoid- ing constriction of the limb. In cases of non-union, the constant wear- ing of such an apparatus restores the limb to a great degree of useful- ness. Lately a case occurred to me, in which it was found quite impos- sible to maintain satisfactory apposition of the fragments, on account of a large bulging in the thigh, caused by exuberant callus, the result of previous fracture, ill-adjusted. FRACTURES OF THE LE*1.. 657 [Fig. 272.] [Lonsdale's Apparatus. A B. Two vertical iron bars, each supporting a horizontal one; these horizontal arms slide upon the vertical bars, but can be secured at any point by the screws C D. To the horizontal beams are attached other vertical rods, which are movable, and yet flxable by screws, as at E. Finally, to each of these last upright pieces is fixed an iron plate, F F, by means of a hinge point, which keeps the patella in place. The foot-piece is movable up and down upon the main body of the apparatus, and can be made fast at any point, so as to adapt the splint to limbs of different length.—Ed.] Compound Fractures of the patella have generally an unfortunate issue; the joint inflaming acutely, and becoming disorganized. Not unfrequently, amputation is required, to save life. Instead of the patella giving way, under intense muscular action, the combined tendon of the extensors of the thigh may be torn asunder; causing a hiatus at the injured part, with pain, swelling, and lameness— the power of flexion being alone retained. Treatment is conducted on the same principles as in the case of transverse fracture of the patella. Fractures of the Leg. Fracture of the Head of the Tibia is the result of great and direct violence : the fracture extending into the knee-joint. Treatment is as for the analogous fracture of the femur, at its condyles. The limb is placed straight, so that the condyles may act as retaining splints on the fragments; and the limb is also elevated, so as to relax the extensor muscles, which, through the ligament of the patella, act on the lower fragment. Passive motion is expedient, so soon as consolidation has advanced so far as to admit of it. Fracture of the Tibia immediately below its Tubercle.—The peculiarity of this form of injury is, the tendency to rising in the upper fragment, through agency of the muscles acting by the ligamentum patellae. The risincr is aggravated by flexion of the knee. The limb is therefore placed and retained in the straight posture, and elevated. Fracture of the Tibia, at any lower point, is best treated on the double inclined plane. When this bone suffers alone, there is usually but little displacement; the fibula acting as a restraining splint. Fracture of the Fibula.—This bone most frequently gives way near its lower extremity, at a short distance above the external malleolus. When force is suddenly applied, so as to cause eversion%f the foot— as in twisting the foot, on the side of a stone, or in a' gutter—this eversion is resisted by the external malleolus ; but if the force be suffi- cient to overcome the resistance, the bone snaps at its weakest point— from two to three inches above the ankle-joint—and eA^ersion of the foot is effected. There is immediate lameness, and the patient may be sensi- 658 FRACTURES OF THE LEG. ble of something having snapped in the leg; the foot is found turned out; and, if progression is attempted, the patient leans on the inside of the foot, so as to support himself on the tibia. A marked depression is obsen'ed on the outside of the limb, at the site of fracture; and, on replacing the foot, and making rotatory movement of it, crepitus may Fig. 273. Fracture of the Fibula; with the Splint applied. The foot should be more inverted. be distinctly perceived. The deltoid ligament is ruptured; and the end of the tibia is necessarily displaced, more or less, from the correspond- ing surface of the astragalus ; not unfrequently it is moved forwards on the dorsum of the foot. Treatment is by Dupuytren's splint; a light piece of wood, in breadth proportioned to the limb, and of length suffi- cient to extend from the knee to a few inches beyond the ankle. It is applied on the inside of the limb; provided with a pad—considerably thicker at the ankle than at the upper part. To a hole at the upper part of the splint a linen roller is attached; and application of this is begun at the ankle—the bandage being occasionally turned over notches made for this purpose in the distal extremity of the splint, so as to maintain complete inversion of the foot, and consequent apposition of the fragments. The more thoroughly the foot is turned in over the malleolar pad as a fulcrum, the more sure are we of accurate read- justment. In effecting reduction, the knee is flexed, so as to relax the Liston's modification of Maclntyre's splint, a. The screw which increases or diminishes the angle of flexion ; at b, there should be a knob on the footboard, whereby the foot may be slung. The limb is arranged so as to show the facility afforded for dressing the wound, in the case of compound fracture. muscles of the leg; and care is taken that replacement of the tibia is effected not only in the lateral but also in the antero-posterior direction. Fracture of both Bones of the Leg may be the result either of direct FRACTURES OF THE LEG. 659 or of indirect A'iolence: a heavy weight falling on, or passing over the part; or the patient falling, and alighting on his foot. In the former case, the fracture is usually transverse, and the bones give way at cor- responding points. In the latter case, the fracture is usually oblique, and the bones give way each at its weakest point; the tibia a little above the ankle, the fibula about two or three inches below its head. This latter form of injury is especially apt to occur, in falls or leaps from a vehicle in motion; and one or other of the sharp fragments may protrude through the integument, rendering the case compound. Treat- ment is best effected by the double inclined plane. Should pressure on the heel be much complained of, the limb may be laid on its outer side, incased in two pasteboard splints, extending from the knee to beyond the ankle. To prevent such undue pressure, [Fig. 27-5.] [An Apparatus for Slinging a Broken Leg, devised by Mr. Salter, of London. The case in which the leg rests may be made of metal. As represented in the drawing, a swinging motion laterally is permitted; and also a sliding up and down, by the rolling of the pulley-wheels upon the horizontal bar. The frame is made of iron for greater strength. (From Fergusson.) An apparatus for accomplishing the same purpose, and applicable either to the thigh or to the leg, has been used by Dr. Smith, of Baltimore, for many years. It is described by him in the 2d vol. p. 220, of the Trans. of the Am. Med. Association.—Ed.] during the use of the double inclined plane, it is well always, when practicable, to suspend the heel and foot by means of a sock—the end of which is hung, by a piece of tape, on a nob placed for this purpose on the upper and outer part of the footboard. It is also well, in all cases, to have the limb, in its splint or splints, considerably elevated; either by slinging or otherwise. Compound Fractures of the leg require no special notice. They are, in general, best treated on the double inclined plane; for the wound, being usually either in front or on a lateral aspect, may be completely exposed and frequently inspected and dressed, without the limb being at all disturbed or the retaining apparatus undone. [One of the simplest as Avell as one of the best means of treating compound or other fractures of the leg, is to place it in a fracture-box, 660 FRACTURES AT THE ANKLE. Fig. 27G. Compound and Comminuted Fracture of the Leg. the sides of which are connected to the bottom-piece by hinges, so that they can be made to exercise, Avhen closed, considerable lateral compres- sion upon the leg. Rectification of the [Fig. 277.] shape of the leg can be secured by the proper position of compresses above and below the fracture. In simple injuries, the limb should be placed upon a pillow; in compound fractures, the box may be filled with bran, in Avhich the leg maybe buried; thus all the discharge will be absorbed as fast as it is poured out. (See Sargent's Minor Surgery.—Ed.] Fractures at the Ankle. The Internal Malleolus may be broken off, by tAvisting of the foot inwards. The fracture is oblique; the displacement is marked and considerable. The foot is dislocated inwards, presenting its outer edo-e to the ground. Sometimes, instead of only the malleolus being sepa- rated, the fracture includes the whole thickness of the lower end of the tibia, passing obliquely upwards. Replacement having been effected. by manipulation, while the limb is flexed, Dupuytren's splint is applied on the fibular aspect of the limb. The External Malleolus may be detached in a similar manner bv forcible eversion of the foot; but, as already stated, the fibula is more likely to give way at a point somewhat higher—its weakest part. The same splint is employed as in the more ordinary fracture (p. 657). The Tarsal Bones are occasionally fractured; usually, by intense and direct Adolence. In general, disorganization is such as to leave no hope of recovery; and primary amputation, consequently, is often required. The Astragalus, however, may be split and fissured, by a heavy fall received on the calcaneum ; there may be little or no displacement; and a satisfactory issue may ensue. The part is kept steady by lateral splints, or by means of the double inclined plane. Sometimes the tube- rosity of the Calcaneum is snapped, by the action of the sural muscles. The symptoms and treatment are the same as in the case of ruptured tendo Achillis. DISLOCATION OF THE PELVIS. 661 Fractures of the Foot. Fractures of the metatarsal bones and phalanges are seldom effected but by a crushing force. Their issue is rarely prosperous, especially when compound. The metatarsal bones, after readjustment, require no splints. It is sufficient to keep the foot at rest and elevated. The phalanges, if not demanding immediate amputation, are arranged and retained by small splints, as in the case of the analogous injuries of the superior extremity. Dislocations. Dislocation of the Pelvis. From heavy and high falls, it has occasionally happened that the Os Innominatum has been displaced upwards; separated from the sacrum at the sacro-iliac junction, and from its fellow at the symphysis pubis. The following are the diagnostic marks of the injury: The limb of the affected side is shortened and powerless; yet the signs, both of disloca- tion and of fracture of the thigh-bone, are absent; and the limbs, when each is measured from the anterior superior spinous process of the ilium, are quite of the same length. The spine and horizontal ramus of the os pubis are unusually elevated; forming a hard ridge in the or- dinary site of the iliac fossa. The anterior superior spinous process, and the crest of the ilium are on a higher level than those of the oppo- site side. By examination from the rectum, the tuberosity of the ischium will be found raised, and nearer the mesial line; and the de- scending ramus of the os pubis will probably be on a plane considerably posterior to that of the sound side. The fold of the nates is higher than on the other side; and, on the injured side of the sacrum, a de- pression will be felt at the junction of that bone with the ilium. More or less difficulty may be experienced in evacuating the bladder. Should the nature of the case be distinguished in time, moderate efforts may be made for readjustment; by extension of the limb, and forcing the ilium downwards with the hand. The bladder is relieved by the catheter, as often as circumstances may require; and a flexible catheter is likely to pass more readily than the metallic instrument. The same attention to the state of the internal organs is required, as in the case of fracture of the pelvis. Indeed, fracture of the os pubis is not unlikely to be associated with such an accident. Prognosis is unfavorable. Separation of the Symphysis Pubis is said occasionally to occur, in difficult labor. It may also result from direct injury. Displacement is not great. By a broad belt the parts are kept unmoved, as well as in apposition. Dislocations of the Hip. The head of the femur may be displaced, in various directions. The displacing force is usually indirect; but the accident occasionally results from direct blows or falls upon the hip. It may take place at any time 662 DISLOCATION ON THE DORSUM ILII. of life; but most frequently affects the young or middle aged adult. In youth it is rare—except in the congenital form (Principles, 3d Am. Ed. p. 674); in old age, fracture of the neck of the femur is much more likely to occur. I. Dislocation upzvards on the Dorsum of the Ilium.—This is by far the most frequent form of the injury; usually resulting from a fall Fig. 278. Dislocation on the Dorsum Ilii. under a heavy weight. Examination is best made in the erect posture. The limb is shortened, from an inch and a half to two inches : and is turned imvards, the toes resting on the opposite instep, with the knee advanced somewhat in front of its fellow. Motion is much abridged, especially in an outward direction. The trochanter is less prominent than it should' be, and is also preternaturally near to the anterior superior spinous process of the ilium. If there be not much swelling, the head of the bone may be felt rolling in its new site, during rotation of the knee inwards. There is also diminution of roundness in the injured hip. Fracture of the neck of the femur is the injury most likely to be mistaken for this dislocation. Diagnosis rests on the folloAving points : In dislocation, the motions of the limb, both voluntary and forced, are abridged; there is invariably inversion of the foot, and this inversion cannot be undone, until reduction has been effected; the toes may be moved round forcibly, but the Avhole body turns with them ; on exten- sion being made, the normal length of the limb cannot be restored, until reduction has occurred; and then there will be no recurrence of DISLOCATION OF THE HIP ON THE DORSUM ILII. 663 the shortening, unless fracture of the brim of the acetabulum exist. True crepitus is felt only in the case of fracture. The occurrence of dislocation is much more rare than that of fracture; and, while dislo- cation may occur at any age, fracture within the capsule seldom if ever is found under the age of fifty. Fracture external to the capsule is at once known by the distinctness of the crepitus—when extension and rotation are made, and when the trochanter is pressed inwards. Reduction is effected, with or without the aid of pulleys, and their auxiliaries ; according to the date of the injury, the robustness of the patient, and the other circumstances of the case (Principles, 3d Am. Ed. p. 679). The patient is placed recumbent on his back; and exten- sion is made obliquely across the opposite limb; the thigh crossing its fellow a little above the knee. The laque, to which the pulleys are attached, is applied either above the knee or at the ankle, as the sur- geon may prefer (Principles, 3d Am. Ed. p. 680). Counter-extension is made, by means of a strong belt—well padded—passed beneath the perineum, and secured to a fixed point behind the patient. When ex- tension has been made for some time, the limb is rotated outAvards. It is seldom that we shall find it expedient to forego the use of chlo- roform ; and when this is employed, no other mode of reduction need Mode of reducing Dislocation shown. The counter-exten.-ion effected by a band passed around the upper part of the thigh: the extension, by the pulleys attached to a laque, secured above the knee. be tried than the simplest—that just stated. But, if anaesthesia from peculiar circumstances be not available, another method may be tried, if the first fail. The patient being placed erect—resting his weight on the sound limb, stooping over a firm table, and having his pelvis fixed securely thereon—the surgeon takes hold of the foot of the affected limb with one hand, and, flexing the leg on the thigh, presses steadily with the other hand on the popliteal space, dowmvards. After extension has thus been applied for some time, sudden rotation is made on the hip; and the bone may, thus simply, move at once into the acetabulum. After reduction, the patient is placed gently in bed; and no reten- tive means are necessary—unless the patient be careless, or violent, by delirium or otherwise. Then it is well to secure the two limbs together, by bandaging, at the knees and ankles ; pads being interposed at these points. If, as rarely happens, the upper edge of the acetabulum have been broken, retention is effected with difficulty; and it is necessary to 664 DISLOCATION OF THE HIP BACKWARDS. maintain permanent extension of the limb, by means of a long splint with perineal band, as used in the case of fracture (p. 649). II. Dislocation backivards, into the Ischiatic Notch.—In point of frequency, this form may be placed next in order. " The head of the Fig. 280. Dislocation into the Ischiatic Notch. thigh-bone is placed on the pyriformis muscle; between the edge of the bone which forms the upper part of the ischiatic notch, and the sacro- sciatic ligaments; behind the acetabulum, and a little above the level of the middle of that cavity."1 The accident results from the application of force, while the body is bent forward on the thigh, and the knee is pressed inwards. The signs bear a general resemblance to those of the preceding injury; but occur in a minor degree. The shortening is from half an inch to an inch. The foot is inverted, and the great toe rests on the ball of the great toe of the opposite foot. The trochanter is behind its usual place, and is slightly inclined towards the acetabulum. The head of the bone can seldom be felt distinctly. The joint is pre- ternaturally fixed ; flexion and rotation, in any considerable degree, being quite impracticable. The whole body cannot be straightened in the recumbent posture ; if the trunk be smoothed down, the thigh rises up ; and if the limb be forcibly and painfully straightened, the loins are found immediately and insuperably arched—and this characteristic will not cease, until reduction has been effected. Reduction is made with the patient recumbent, on his sound side; Astley Cooper on Dislocations. DISLOCATION OF THE HIP DOAVNWARDS. 665 and the affected limb is extended obliquely, so as to bring it across the middle of the sound thigh. After extension has been maintained for some time, the head of the bone is lifted over the margin of the aceta- bulum, by means of a towel placed under the upper part of the thigh; extension in that direction being made, by passing the loop of the towel over an assistant's neck, Avhile counter-extension is exerted by his hands resting firmly on the patient's pelvis. But it is not to be supposed that such movements are to interfere with the main extending force; the two are carried on consentaneously. III. Dislocation downwards, into the Foramen Ovale.—This—as well Fig. 281. Dislocation into the Foramen Ovale. as the following variety—is comparatively rare. It is usually caused by a heavy weight falling on the pelvis, while the trunk is bent forwards, and tjie thighs are separated from each other. The limb is elongated, to the extent of nearly two inches; and is advanced in front of its fellow, the toes usually showing neither inversion nor eversion. The thigh is much abducted, and cannot be brought near its fellow. The trunk is bent forwards, during maintenance of the erect posture ; and the tense ridge, formed on the inside of the thigh by the stretched psoas and iliacus muscles, can generally be both seen and felt. The trochanter is flattened and depressed. The head of the bone can be felt—only in thin patients, and in the absence of swelling—by pressure on the inner and upper part of the thigh towards the perineum. The position of the limb somewhat resembles that which attends on the first stage of morbus coxarius; a mistake in diagnosis would be fraught with the most direful consequences; but, with ordinary care, such a misfortune is not likely 666 DISLOCATION OF THE HIP FORWARDS. to occur. Elongation of the space between the anterior superior spinous process of the ilium and the trochanter major, is of itself a sufficient test of the dislocation. The patient is placed flatly recumbent; and counter-extension is made across the pelvis, by means of a strong belt passed round it. Extension is applied in the opposite direction, at right angles to the pelvis; the pulleys being attached by means of a loop passed under the upper part of the thigh, and with one portion of the loop passed over the belt, Fig. 282. Reduction of Dislocation into the Foramen Ovale. whereby counter-extension is made. Extension is exerted gradually, until the head of the bone is felt moving from its abnormal site. The surgeon then, passing his hand behind the ankle of the sound limb, grasps the ankle of the dislocated member, and draAvs it inwards, towards the mesial line of the body. The foot should not be raised, lest the head of the bone slip into the ischiatic notch—a casualty, hoAvever, which is far from being irreparable. Or, the patient having been placed recumbent, on the sound side, and the apparatus arranged as before, extension is made directly upwards, while the knee and foot are pressed down. IV. Dislocation forwards on the Pubes.—This accident happens when a person, while Avalking, puts his foot into some unexpected hollow; his body being at the moment bent backwards. The head of the bone is then forced upwards and forwards, on the horizontal ramus of the os pubis. The limb is shortened to the extent of an inch. The knee and foot are turned outwards, and cannot be rotated inwards. The head of the bone may be distinctly felt and seen, forming a globular tumor ; resting above the level of Poupart's ligament, on the outside of the femoral vessels; and obedient to the motions of the thigh. The patient is placed flatly recumbent on a table, with the affected limb projecting over the edge. Counter-extension is made in the ordinary way, by the perineal band—secured behind, and a little above the level of the patient. Extension is made in a line behind the axis of the body, DISLOCATIONS OF THE HIP. 667 carrying the thigh downwards and backwards. After some time, the head of the bone is lifted over the margin of the acetabulum, by means Fig. 283. Dislocation on the Pubes. of a towel placed under the upper part of the thigh. And rotation inwards is also likely to be of service. Fig. 284. Reduction of Dislocation on the Pubes. Anomalous dislocations of the Hip.—Besides the ordinary varieties of dislocation, the following have been observed : 1. The head of the femur has been displaced, so as to rest on the anterior superior spinous process of the ilium—or rather on the space between the tAvo spinous processes of that bone, the trochanter major lying on the dorsum; such displacement having been determined by the direct effect of the force, 668 DISLOCATIONS OF THE KNEE. and muscular action having, from some cause, failed to modify displace- ment in the usual way. 2. Or, in like manner, the head of the bone may rest on the anterior inferior spinous process of the ilium, the tro- chanter major lodging in the acetabulum. 3. The head of the bone has been found resting on the tuberosity of the ischium, and also upon the spinous process of that bone. Dislocations of the Knee. Dislocations of the knee-joint are caused only by great violence, and are rare. The displacement cannot occur without much disruption of the retaining parts ; and, in consequence, replacement is generally effected Avithout difficulty. The Tibia may be luxated from the femur, in four different directions: 1. Backwards, behind the condyles of the femur; causing shortening of the limb, prominence of the condyles in front, depression of the ligament of the patella, and bending of the leg forwards. 2. Forwards. —The condyles are thrown back, and compress the popliteal vessels ; the tibia and patella are elevated in front; the limb is shortened and slightly flexed. These dislocations are complete ; the other two are only partial. 3. Inwards.—The internal condyle of the femur rests upon the external semilunar cartilage; and the tibia projects plainly on the inner side of the joint. 4. Outwards.—The external condyle rests on the inner semilunar cartilage; and the projection is on the outside of the joint. Reduction is in general readily effected, by extension and coaptation. Antiphlogistics are required subsequently, to ward off or modify the intense inflammatory action, which is apt otherwise to ensue after so serious an injury. The compound luxations usually require immediate amputation. Gradual displacement of the knee, by muscular action, in the case of advanced structural change, has been already considered (Principles, U Am. Ed. p. 483). The Semilunar Cartilages are sometimes displaced, by twisting the joint; as when a person in Avalking, with the foot everted, strikes the toes against an obstacle; or when the foot, in walking, becomes sud- denly caught in a crevice or hole. Perhaps there is a predisposing cause in operation; namely, unusual relaxation of the retaining liga- ments of these cartilages. The cartilages are pushed from their normal site, by the condyles of the femur, which then come in direct contact with the head of the tibia. The limb is immediately rendered stiff, and incapable of bearing weight; and a sickening pain is felt. Extreme flexion of the joint, by disengaging the parts, usually suffices for restor- ation of the normal state; the cartilages, by their elasticity, seeking their own place, when free. The production of such flexion may re- quire force, and is painful. After the joint has remained a little in that position, the limb is brought doAvn again with a sudden moA-ement. The knee remains weak and swollen for some considerable time—perhaps the seat of rheumatic pains; and the use of a knee-cap is expedient. If chronic structural change threaten to ensue, that must be opposed by the ordinary means. DISLOCATIONS OF THE PATELLA. 669 Dislocation of the head of the Fibula is a rare accident. It may take place, by violence, either backwards or forAvards. Reduction is effected by direct coaptation; and bandaging sufficiently effects retention. Should displacement depend on relaxation of the retaining ligament, the pressure of a knee-cap or bandage is necessary ; Avith stimulation of the part, to restore the normal state if possible. Dislocations of the Patella. The Patella is liable to be displaced, in various directions; by external A'iolence, applied directly or indirectly. But such accidents are rare. 1. Outivards.—This is the most common; and is apt to occur in per- sons who are knock-kneed. The bone is throAvn outwards on the ex- ternal condyle, and forms a manifest projection there; the knee is incapable of flexion. 2. Inwards.—This is the result of direct injury; the bone being struck on its outer side, while the foot is turned inwards. The mal-position is the reverse of the preceding. Reduction in either case is effected by raising the leg, so as to relax the extensor muscles on the thigh, fully; at the same time, Avith the hand, forcing the bone back to its place. 3. The patella may be displaced by Semirotation ; one edge resting on the middle of the articular surface between the condyles of the femur, while the other projects beneath the tense integument. Reduc- tion in this case is to be effected by flexing the knee to the utmost; so as to free the bone, and admit of its being drawn into its normal position by the action of the extensor muscles. Should this means fail, it may be expedient to divide the ligamentum patellae, by subcutaneous incision. 4. The bone can be displaced Upwards, only on division of the liga- mentum patellre, by wound or tear. The treatment is as for transverse fracture of the patella (p. 655). 5. Slight displacement, Downwards. may follow rupture of the tendon of the rectus muscle. Dislocations of the Ankle. I. Dislocation of the Tibia inwards.—This, as already stated, usually coexists with fracture of the lower end of the fibula (p. 657). The foot is everted; and the internal malleolus projects greatly. Reduction is effected by extension of the foot; while the limb is bent at a right angle, so as to relax the gastrocnemii muscles. And this flexed posi- tion of the leg, be it remembered, is essential in the treatment of all luxations at the ankle. Replacement having been accomplished, Dupuytren's splint is applied on the inner side of the limb; and should it seem necessary, for complete retention, a minor splint may be placed on the outer side also. II. Dislocation of the Tibia forwards.—This, too, attends on fracture of the fibula. It may also occur independently of fracture ; but then the fibula is usually displaced along with it; and the case is one of luxation of both bones.1 The tibia rests on the upper surfaces of the 1 I have seen the tibia displaced forwards and inwards—the dislocation all but com- pound, while the fibula remained not only in its place, but entire. 670 DISLOCATIONS OF THE ANKLE. navicular and internal cuneiform bones, and on a small part of the anterior surface of the astragalus. The foot is fixed, and appears much shortened ; the heel is proportionately elongated ; the toes are pointed downwards ; there is a marked depression in front of the tendo Achillis; and the end of the tibia is felt to be resting on the middle of the tar- sus. Treatment is as in the former case ; a splint being applied on each aspect of the limb. A minor form of the injury may occur ; the end of the tibia resting partly on the navicular bone, and partly on the astragalus.- III. Dislocation of the Tibia outwards.—In this case, the fibula is associated in the displacement; and both bones form a manifest pro- jection on the outer aspect of the joint. The foot is turned inwards, its outer edge resting on the ground; and the toes are pointed down- Avards. The internal malleolus is obliquely fractured and detached. Treatment is as in the other cases. But especial watchfulness is neces- sary, as to the consequences ; this form of injury being always the result of much violence, and untoward action being consequently apt to ensue. IV. Dislocation of the Tibia backwards is extremely rare. The end of the bone rests on the os calcis, in front of the insertion of the tendo Achillis; the heel is shortened, and the foot is proportionately elongated. The foot has also been found forced upwards between the tibia and fibula; these having separated. But this may be regarded as merely an aggravation of dislocation of the tibia inwards. The treatment is still by extension of the foot, during flexion of the leg; and by the application of lateral splints. V. Compound Dislocation of the Ankle.—This is the most common of the compound dislocations of joints ; and usually takes place inwards. The patient having fallen forcibly, with the foot everted, the end of the tibia is driven through the integuments on the inner aspect of the joint; and protrudes to a greater or less extent. Even in extreme eases, the posterior tibial artery generally escapes untorn. This accident may occur to any one ; but is especially frequent in adults of advanced years and intemperate habits; and, in these, but a slight amount of violence Avould seem to suffice for its infliction. The complication of delirium tremens is not unfrequent. Reduction is effected as in the simple form ; and subsequent treat- ment is conducted according to the general principles elsewhere stated (Principles, 3d Am. Ed. p. 683). Should anchylosis occur, motion and usefulness are considerably regained, by compensating increase of moATe- ment in the tarsus. According to the high authority of Sir Astley Cooper, immediate amputation will probably be expedient; " when the ends of the tibia and fibula are very much shattered; when, in addition to the compound dislocation of these bones, some of the tarsal bones are displaced and injured ; when one or other of the tibial arteries is divided, and cannot be secured without extensive enlargement of the wound, and disturbance of the soft parts; when the common integu- ments, with the neighboring tendons and muscles, are considerably torn ; when the protruded tibia cannot by any means be reduced; and when the constitution of the patient is enfeebled at the time of the acci- dent, and not likely to endure pain, discharge, or long confinement." The amputation suitable is that of the ankle-joint. DISLOCATIONS OF THE ASTRAGALUS. 671 Secondary hemorrhage may ensue from the posterior tibial, in a case otherwise affording a chance of cure. In such circumstances, ligature of the superficial femoral may be performed, if all the other points of the case are favorable. But if there be profusion of unhealthy dis- charge, manifest indication of ulceration in the joint, or signs of in- cipient gangrene in the Avound and on the foot—then amputation is to be performed, with as little delay as possible. Dislocations of the Tarsus. I. Of the Tarsal range of bones, the Astragalus is the most frequently displaced by violence. Its dislocation may be either complete or partial; and it may take place in A'arious directions. 1. Forwards. This is by far the most frequent form. When the ankle is fully extended, a large amount of the upper articular surface of the bone is exposed ; and if, by a fall, a powerful shock should then be applied to the calcaneum, the astragalus is very apt to be loosened and displaced—forwards and inwards—coming to rest on the naAricular bone. Sometimes the dis- placement is forwards and outwards; the bone resting on the os cuboides. The nature of the accident is at once declared, by the manifest appear- ance of the astragalus in its abnormal site. Reduction is to be attempted by perseAering extension of the foot, with the leg flexed; while the bone is,pushed backwards to its place. And, with the aid of chloroform, we shall not despair of success in all recent cases (Principles, 3d Am. Ed. p. 735). If the luxation have been complete, and remain unreduced, tension of the integument will be such as to render sloughing inevitable at the tense part; and the case so becomes compound. Then, three modes of procedure are open to the surgeon ; to retain the parts as they are, and endeavor to bring them through the risks of open suppuration ; to perform amputation at the ankle; or to excise the displaced bone, and hope to save both the limb and the joint. The last is usually to be preferred. Primary amputation is unnecessarily severe ; and the first mode is declared by experience to be hopeless of a successful issue. When, therefore, the case is from the first compound, when it ulti- mately becomes so by sloughing or ulceration of the strained and bruised integument, and also when the circumstances are such as to render it plain that sloughing or ulceration must soon occur—the luxated bone is to be removed by incision, the limb is to be carefully adjusted, retention is to be maintained by the adaptation of suitable splints, and the case is then to be treated as a compound dislocation of the ankle-joint. In partial displacement, no such severity is ever necessary ; in complete luxation, it may not be required ; but in a luxation which is both compound and complete, and in complete luxa- tion which is certain to become compound, such treatment is certainly preferable to the greater severity of immediate amputation—as well as to the perils of profuse suppuration, constitutional suffering, and the almost certain prospect of secondary amputation, which must follow an attempt to retain the bone. 672 DISLOCATIONS OF THE FOOT. Fig. 285. 2. The astragalus may be dislocated backwards ; becoming firmly wedged be- tween the tendo Achillis and the posterior surface of the tibia. The bone is readily felt in its unnatural site ; it is seen pro- tuberant there; and the end of the tibia is felt projecting in front. Reduction, for obvious reasons, must be difficult. In only one case, probably, has the attempt ever proved successful without choloform; one which occurred to Mr. Liston.1 3. The astragalus has been displaced upwards ; wedged between the tibia and fibula. But this accident is extremely rare. 4. Dislocation has taken place out- wards; and it has also taken place in- wards. Such injuries are usually not only compound, but also complicated with fracture of one or other malleolus. They may be so severe as to demand immediate amputation at the ankle; or they may admit of replacement of the limb, in the hope of saving it, after the dislocated bone has been removed. II. The Os Calcis and Astragalus may be separated from the other bones of the tarsus; the foot becoming displaced inwards, as in talipes Amarus. Reduction and retention are easy; the former by extension and coaptation ; the latter by placing the limb on the double inclined plane, and securing the foot firmly on the footboard. III. The Cuneiform bones may sustain displacement. Of these, the internal is most likely to suffer. The bone projects inAvards, and is also drawn upwards by the action of the tibialis anticus. Reduction will be difficult. But, after a time, the limb may become little less useful than before, even though the displacement remain unreduced. Compound Dislocation of the Astragalus (Sir A. Cooper.) Dislocation of the Metatarsus. One or more of the metatarsal bones may be displaced upwards on the front of the tarsus, the foot having undergone a severe wrench, as by a fall from horseback Avhile the foot is retained in the stirrup. Under chloroform, the parts are easily reduced, and no retentive means are necessary. Leeching, with other antiphlogistics, will probably be re- quired, hoAvever; such displacement not being likely to occur without the infliction of much violence. Dislocation of the Toes. Luxation of the phalanges of the toes is rare. Reduction is readily effected, by extension and coaptation. Compound luxations usually require amputation. 1 Lancet, July 6, 1839. RUPTURE OF THE TENDO ACHILLIS. 673 Subluxations and Sprains of the Lower Extremity. The hip is seldom sprained. The knee suffers not unfrequently. The twist is usually such as to strain the inner aspect of the joint; and there the ligamentous apparatus may partially give way. Pain is great and sickening; much swelling ensues, perhaps involving the synovial cap- sule ; and the part is apt to remain Aveak, and prone to recurrence of the injury. In addition to the ordinary treatment suitable for sprain (Principles, 3d Am. Ed. p. 686), the wearing of a knee-cap is essential for some time, until the part, by consolidation, regain its power of resisting the more ordinary applications of force. Sprains of the ankle are extremely common ; by twisting the foot, by a fall, or by a " false step." The most ordinary sprain is caused by twisting the foot inwards; and the consequent pain and swelling are on the outside of the foot—often great over the belly of the short extensor of the toes. Treatment is by rest, fomentation, leeching, &c. And an elastic bandage on the ankle is necessary for some time after walking has been resumed. 286. Injuries of the Tendo Achillis, and Gastrocnemius Muscle. Rupture of the Tendo Achillis.—By sudden and violent exertion of the sural muscles, as in leaping, dancing, or running—more especially if the patient be muscular, advanced in years, and un- accustomed to such exercise—the tendo Achillis is apt to give way, close to or at its insertion into the calcaneum. There is immediate lameness ; the patient falls, and is quite unable to resume the ordinary erect posture; much pain is complained of in the part; and, on manipulation, a very palpable gap is found at the site of injury. Usually there 'is, at the time of rupture, a sensation of something having given way ; sometimes there is an audible snap; not unfrequently the patient com- plains of having been struck at the injured part, although no blow has been sustained there. Treatment is simple. Position alone suffices for replacement. The leg is bent, and the foot is extended, so as to relax the sural muscles completely, and favor approximation. This position is maintained by simple means. A slipper is placed on the foot; to the heel of the slipper a stout cord or tape is attached; and this is fastened to the thigh, by means of a circular belt applied there—or to the 43 Outline of Limb, showing the slipper and ligature useful for maintaining flex- ion in ruptured tendo Achillis. 674 ununited tendo achillis. loins, in a like manner—as tightly as is necessary for securing the re- quisite degree of flexion. Bending may be voluntarily increased by the patient; and this does no harm. But extension is absolutely prevented. Reparation is slow (Principles, 3d Am. Ed. p. 688); and the period of confinement requires to be extended a week or two beyond that required in the case of fracture. After consolidation, extension is made gradu- ally, lest the uniting medium be over-extended, and disruption of it ensue. The patient, when first allowed to move about, with a crutch or stick, is provided with a high-heeled shoe; and, every day or two, a thin slice is cut from this heel, so as to permit a gradual approach of the sole to full planting on the ground. Wound of the Tendon is managed in a similar way. Accidental wounds—as by a scythe, knife, or reaping-hook—are usually compound. And in them the cure may be facilitated by approximating the two portions of tendon by means of suture. Ununited Tendon.—Cases sometimes present themselves in which rupture of this tendon has not been repaired. The retracted portion has become rounded off; the calcaneous portion is similarly changed; and the space between is occupied by dense deposit, quite inefficient for restoring function to the muscles. The hiatus being considerable—per- haps to the extent of two inches or more—the limb is quite useless in progression. To remedy this state, an incision may be made, the rounded ends of the tendon may be cut off, and approximation may be effected by suture. But this is severe practice. I have lately applied, quite successfully, the principle of subcutaneous section (Principles, 3d Am. Ed. pp. 671 and 688); by a stout needle making raw the extremities of the tendon, and breaking up the intenrening space completely; so re- storing the parts to a resemblance of their condition immediately after the original injury; applying the same simple, retentive, and approxi- mating apparatus, as after recent rupture ; and, after consolidation, employing the same caution in permitting resumed use of the limb. Laceration of the Muscle.—Instead of tendon giving way, the mus- cular fibres of the gastrocnemius may yield. The laceration seldom implicates more than a few of the fibres; and the site of injury is usually where the muscular fibre ceases and tendon begins. The causes are the same as those of the former injury; the symptoms are very similar, and the treatment is identical (Principles, 3d Am. Ed. p. 687). Sometimes it is the plantaris which yields in either its muscle or tendon. For Bibliographical reference, see p. 332. CHAPTER XL I. AFFECTIONS OF THE FOOT. Talipes. By this term is understood the deformity of Clubfoot; generally con- genital, yet not unfrequently acquired. The original development of the bones is not faulty; but displacement of these is gradually effected, by a predominance of action in certain muscles; such predominance being dependent, either on spasm of those which so act, or on want of action in those which ought to be their antagonists. There is no actual dislo- cation of the tarsal bones; there is merely gradual change in their relative positions. A case is related by Delpech which well illustrates the mode of production. A soldier had " the external popliteal nerve injured by a shot;" the peronei, the tibialis anticus, and the extensor Fig. 287. Fig. 288. Fig. 287.—Talipes Equinus. Fig. 288.—Talipes Kquinus after division of the tendo Achillis. muscles became paralytic in consequence; and, from the unopposed action of the opponents of these muscles, clubfoot resulted.1 There are varieties of this deformity. 1 Little. Introduction, p. 35. 676 TALIPES. I. Talipes Equinus.—The muscles of the calf are contracted; the tendo Achillis is rigid; the patient steps on the toes without bringing the heel to the ground; the foot is, in other respects, well-formed; but the extensor tendons being on the stretch, there is a turning up of the toes, independently of that which is caused by pressure in progression. Fig. 289. Fig. 290. Fig. 289.—Talipes Varus. Fig. 290.—The same dissected; showing the altered relative position of the bones. IL Talipes Varus.—This is the most common variety; consisting of extension, adduction, and rotation of the foot—the rotation being anal- ogous to supination of the hand. The muscles of the calf and the ad- ductors of the foot are contracted; the heel is drawn up; the toes turn inwards; the outer edge of the foot rests on the ground; and, in pro- gression, weight is borne on the outside of the foot and on the outer ankle, where adventitious bursse usually form of some size. The toes are extended, as in the former case. III. Talipes Valgus is the reverse of the preceding. There are ab- duction, rotation, and partial flexion of the foot ; the rotation being analogous to pronation of the hand. The front of the foot is raised from the ground ; and the patient rests on the inside of the instep, and on the inner ankle. The tendons of the peronei muscles are chiefly to blame. IV. Talipes Calcaneus.—The muscles in front of the leg are con- tracted ; the foot is extremely flexed; and, in progression, the heel alone touches the ground. One foot, or both, may be affected by Talipes. In the former case, the affected limb is found thinner and more flabby than the other; and, sometimes, by arrest of development, it is shortened as well as weak. The mode of progression is painful and imperfect. And, not unfre- quently, contraction takes place at the knee, to a greater or less extent. Spurious Talipes is said to occur, when displacement of the foot TREATMENT OF TALIPES. 677 takes place by muscular change or integumental contraction, following on burns, extensive suppurations, ulcers, &c. Treatment of Talipes. In the minor cases, which occur in children, mechanical means—early employed, skilfully adapted, and duly persevered with—are alone suffi- cient to effect a normal relation of parts. Many such cases occur; and it is quite unnecessary to subject the little patients to the pain of tenotomy. When the deformity obviously depends on a paralytic condition of certain muscles—as is more likely to be the case in the acquired than in the congenital examples—attempts may be made to obviate this con- dition, by remedies directed both to the syst^a and to the part. At- tending to the nervous centres, to the chylopoietic viscera, and to the general functions—:we may find the symptoms yield, as in the analogous' affection of strabismus. And the local means most likely to be of service are, blistering, the endermic use of strychnia, galvanism, exercise, friction, and passive motion. Tenotomy is had recourse to, when structural shortening of muscle, of tendon, or of both has occurred; and Avhen the obstacles to replace- ment cannot otherwise be overcome. A large number of cases are so circumstanced. The operations, however, are but part of the remedial means ; and will certainly fail, unless suitable apparatus be afterwards employed, well and sedulously. Instead of waiting for reunion of the tendons, and then extending their new bond of union, painfully and slowly, it is better to effect the required change of relative position immediately after section; leaving the interspace to be filled up by new matter. In the congenital form, the operation may be had recourse to about the twelfth or fourteenth month, when the patient is just begin- ning to walk ; the mechanical and general remedial means having been in use previously. Extreme cases in the elderly adult should be re- garded as irremediable. Tenotomy will fail to effect a cure; and may do harm, for a time at least, by impairing very seriously the acquired usefulness of the limbs. In Talipes Equinus, division of the tendo Achillis is usually sufficient. In Talipes Varus, division of this tendon may suffice, along with the use of mechanical aid. But, very frequently, it is necessary also to divide the tibialis posticus and flexor longus pollicis. In confirmed cases, the tibialis anticus, and extensor proprius pollicis must be added to the list. In Talipes Valgus, the peronei are divided along with the tendo Achillis. In Talipes Calcaneus, the tibialis anticus is cut, along with the extensors of the toes. The tendo Achillis is divided a little above its insertion into the cal- caneum. The patient having been placed in a' prone position, the limb having been steadied, and the foot having been bent, a tenotomy knife or needle is introduced obliquely ; and, by bringing its edge or point on the rigid tendon, the fibres are cut from without inwards; an assist- ant flexing the foot forcibly, so as to assist in the disruption. This having been completed, the instrument is withdrawn, and a compress is 678 FLAT-FOOT. applied to the aperture. Or division may be reversed; from within outwards ; but there is thus a risk of accidentally wounding the integu- ment. The tibialis posticus may be divided, either above the ankle, or near its insertion in the navicular bone. The tibialis anticus is divided in front of the ankle; from below outwards, so as to save the joint. The flexor longus pollicis is divided, where felt tense, in the sole of the foot. Sometimes it is expedient to divide the plantar fascia also ; from below outwards, to save the important textures beneath. The peroneus longus and peroneus brevis may be divided above the external malleolus, or near their points of insertion ; the rest, at such points as circum- stances may render apparently the most suitable. As a general rule, in such operations, the knife is moved away from, not towards, arteries and nerves. It is not improbable thgfc, occasionally, reunion of the divided tendon does not take place; but that a new attachment is formed. Obviously, section of tendon should be avoided within thecae; as, in such a locality, there is but little capability of the expected plastic exudation. The mechanical apparatus need not be described. Many varieties are in use; the simplest usually the best. For the Talipes equinus, and the Talipes varus—the two most common varieties—the indications are simple, and may be simply executed; flexion of the foot, by acting on the ankle ; and restoration of the normal position of the foot, as regards rotation and abduction, by acting on the foot itself. Flat-foot. Young adolescents, of delicate health, and exposed to considerable exertion on the feet, are liable to serious lameness from sinking of the arch of the tarsus ; apparently in consequence of relaxation of the connecting ligaments. The arch of the foot is lost, the tibia projects inwards, the foot turns out, the ankle is apt to SAvell, and progression is slow, awkward, difficult, and painful. The deformity affects both sexes, and all classes; excited, in Fig. 291. the poor, by overwork ; in the rich, by absurd eversion of the feet, and overtasking of the limbs, in at- tempts to impart polite accomplish- ments to these organs. In most cases, a state of system very similar to the strumous will be found. By discontinuance of the exciting causes, by friction, by bandaging and the wearing of a roborant Fiat-foot. plaster on the part, and by general tonic treatment, relief is obtained. It is well also to have the sole of the shoe, or boot, considerably thicker on the inner than on the outer side. And, if matters do not advance favorably, an apparatus may be worn, which will both support the ankle and invert the foot. Sometimes, the young patient, in the process of farther development, recovers both symmetry and usefulness. PODELKOMA. 679 In confirmed cases, both deformity and lameness are great. " The peronei and anterior muscles of the foot obtain a preponderance, and eversion of the foot becomes ultimately as considerable as in true talipes valgus. The preponderating muscles undergo structural shortening; the outer margin of the foot, and even sometimes the front of the foot o-enerally, is raised from the ground; and locomotion is effected to a considerable extent on the heel. The gastrocnemii then waste, and the gait becomes very unsightly." Such cases are to be treated as ex- amples of Talipes. Tenotomy is required, with the subsequent use of rectifying apparatus. And the tendons which require division are, the tibialis anticus, all the peronei, the extensor proprius pollicis, and the extensor longus digitorum. Podelkoma. This has been elsewhere described, as a form of multiple ulceration peculiar to the foot (Principles, 3d Am. Ed. p. 254). By others it has Fig. 292. Podelkoma, or morbus tuberculosa pedis, a. The toes, much altered. 6. The outer side of the foot, in pome parts showing cicatrices, c. The line of amputation at the ankle, d. The astragalus. The swelling is often much greater than here represented. been noticed as morbus tuberculosus pedis.1 The milder forms may be remedied by pressure and constitutional alteratives; the advanced cases generally result in amputation. Corns and Bunions. These painful affections are the result of pressure, exerted by ill-con- structed shoes and boots. They are more easily prevented than cured. 1. The shoe or boot should be large enough to contain the foot easily; and an allowance should be made for the occasional swelling to which the part is liable by exercise, heat, and a dependent position. 2. The sole should be at least as broad as that of the foot. The outline of the foot__represented on a piece of paper, on which the patient leans in the erect posture—should be the measure of the sole of the boot or shoe. 3. The boot or shoe should be square, or, rather, rounded in front; not sharp, with the point nearly in a central position. The point corre- sponding to the end of the great toe should be nearly in a line with the inside of the instep. And abundance of room should be given for ' Godfrey, Lancet, No. 1187, p. 593. 680 CORNS AND BUNIONS. each toe to occupy its own place, without any crowding, or overlaying of its fellows. Corns consist of two parts. A thickening of the cuticle, and a hypertrophied and irritable condition of the corresponding papillae of the true skin. The inflammatory process may supervene. And then a small abscess may form; very painful, because the matter is confined by the dense cuticle; and frequently leading to smart erythema or erysipelas of the foot. Corns are also said to be Soft and Hard. The former situate on the outer points; the latter placed between the toes, where there is naturally considerable moisture. Another division of corns is into the Laminated and Fibrous. In the former, hypertrophied cuticle is arranged in a laminated form ; and there is uniform enlarge- ment of the papillae beneath. In the fibrous, the central papillae are much enlarged and project; each is surrounded by a sheath of epi- dermis ; and, consequently, while the circumference of the corn is laminated, the central portion presents a fibrous appearance. And, in ordinary language, these projecting papillae are termed the " roots of the corn." The indications of cure are simple. 1. To remove the cause, by wearing suitable boots and shoes, or by leaving the part altogether un- fettered for a time. 2. By careful dissection, to remove the hardened and hypertrophied cuticle; and, by repetition, to prevent reproduction. 3. To remove the irritability, and to restore a normal state of the cutis vera, by occasional application of the nitrate of silver. 4. If inflam- mation have occurred, poulticing, fomentation, and rest are suitable. And the subsequently open state of the parts is taken advantage of, so that a free and effectual use of the nitrate may be made. 5. Inveterate cases are palliated, by wearing roomy and soft shoes and boots; also protecting the corns, by means of thick plasters, which are excaArated opposite the tender points. And into the excavations, it may be well to insert, occasionally, extract of belladonna, or some other anodyne substance. Bunions are formed thus: 1. Inordinate pressure has been habitu- ally made, by boot or shoe, on the ball of the great toe. The skin, consequently, becomes congested and tender; and the part is red and swollen. This is one form of the affection; remediable by abstraction of the cause, by rest and fomentation, and by a subsequent light use of the nitrate of silver, or of a solution of iodine. 2. Or an adventitious bursa forms over the joint, and enlarges gradually. Occasionally, it may show an unusual size, by reason of bursitis. The remedies for this form are— abstraction of the cause, discutient applications in the chronic stage, an- tiphlogistics in the acute. A thin caoutchouc envelop is sometimes of service, by equalizing the pressure of the shoe. 3. Or, in consequence of repeated attacks of bursitis, the cyst suppurates, and opens externally; the aperture becomes fistulous; the cyst contracts, but continues to dis- charge fluid, more or less; and acute accessions are ever liable to occur. In this case it is necessary to destroy the cyst, by inserting a piece of potass into the cavity. Afterwards, the granulating sore is brought to heal under the ordinary means—rest, and simple applications. 4. There is an aggravated class of cases in which there is enlargement of AFFECTIONS OF THE TOES. 681 the osseous texture. Blistering and rest may make some favorable im- pression. By suitable adjustment of the shoe, palliation is obtained. 5. The joint may be partially displaced, in the rheumatic and gouty adult; the toe riding over its fellows, and pointing to the outer side of the foot. This, too, can be but palliated. Onyxis and Onychia, Exostosis, and Contraction of the Toes. Onyxis and Onychia require the same treatment as when affecting the fingers. The great toe is the especial site of Onyxis (p. 300). Exostosis of the Distal Phalanx of the Great Toe is a troublesome affection, not unfrequent in occurrence. Sometimes the growth takes Fig. 293. Fig. 294. Exostosis of Distal Pha- lanx of Great Toe. Onyxis, affecting the Great Toe. place from the plantar aspect of the phalanx; but much more frequently from the dorsal; elevating the nail, causing pain, and seriously interfering with progression. Excision is performed, by means of a strong knife, or by cutting- pliers ; and, should any reproduction threaten, during cure of the remaining wound, the chloride of zinc is applied. Should excision fail, amputation of the phalanx is had recourse to (Principles, 3d Am. Ed. p. 451). Contraction of the Toes.—The toes, more espe- cially the one next the great toe, are liable to extreme contraction. whereby considerable deformity is produced, the wearing of boots and shoes is rendered painful, and the functions of the foot are interfered with. Subcutaneous section of the extensor tendon usually permits sufficient restoration of the normal position. But it is not uncommon to find amputation of the offending toe expedient; other means having proved unavailing, and the patient being himself anxious for a summary procedure. Little on the Nature and Cure of Clubfoot, &c. London, 1839. Tamplin, Nature and Treatment of Deformities, London, 1846. Bishop, Lectures in the Lancet, 1840. AVeis. de Tenotomia Talipedibus applicata, Havniae, 1844. Durlacher on Corns, Bunions, &c. London, 1845. CHAPTER XLII. AMPUTATION. Mutilation by removal of a limb, or part of a limb, is the last resource of our art; and ought never to be had recourse to, until it is evident that other means either have proved or must prove unavailing. The profession have reason to rejoice that necessities for the perform- ance of amputation are much less frequent than in former times ; yet the circumstances are not few—and in all human probability never will be few—in which nothing but the sacrifice of a part of the body will suffice for the retaining of existence. We are constrained to amputate; in spreading gangrene, as speedily as possible, if there be a sound space in which to make our incisions ; in chronic gangrene, when the line of separation has been formed, and is advanced; in tumors which are of a malignant kind, and involve a bone or joint; in diseases of the joints, which have baffled our skill, and have caused urgent hectic; in cases of recent injury, when it is evident that the parts are lo far mutilated as to render recovery impossible; and in cases of attempted preservation of limbs, after injury, when it is plain that farther continuance of the attempt must be attended with unwarrantable peril of life. Not unfre- quently, also, a partially recovered limb proves so stiff, useless, and in- convenient, as to urge the possessor to seek its removal; and such operations of complaisance are not always to be declined. In the case of injury, amputation is either primary or secondary; the former, when done immediately, after the system has emerged from the state of shock, and before it has become involved in febrile excite- ment ; the latter, when performed after febrile accession has occurred, and when—it may be after some weeks—life is threatened by excessive suppuration, disease of bone, disease of joints, or sloughing of the soft parts. The comparative merit of primary and secondary amputation is still, with some, a disputed point. The question has already been considered (Principles, 3d Am. Ed. p. 631). For its decision, a mere comparison of statistical details is obviously insufficient; for, in one class are necessarily included all the most severe cases, while the other contains many of a very minor character. The two chief objections to the primary operations, are: 1. Two shocks may overpower a patient, who might have rallied successfully from one. To this it is answered, that the operator must choose his time skilfully; not bringing the two shocks into immediate contact; but waiting until the former has wholly passed away; and not operating at all, unless a sufficient rally shall have taken place. It is seldom that a patient perishes of mere sinking, after amputation. And besides, AMPUTATION. 683 by the use of chloroform—an agent which is seldom dispensed with in amputations nowadays—it is to be remembered that the shock is very much modified, and a positive tolerance of the operation seems to be imparted to the system (Principles, 3d Am. Ed. pp. 715). 2. It is alleged that a robust state of body—in which the patient may be, at the time of the accident—is less favorable to recovery than the com- paratively reduced state which obtains after subsidence of the inflam- matory fever. This objection obviously can be removed, by judicious antiphlogistic treatment of the case. Not unfrequently, inflammatory fever, and its results, afford no opportunity to judge of the expected favorable condition for secondary operation; the patient dying during the inflammatory period. But we would rather refrain from the discussion in this place ; and would simply repeat the practical rule, on which the great majority of surgeons are agreed—That, when an injury has been sustained by a limb, of such a character as to render it impossible, in the opinion of the surgeon, that the part can be retained; when, in other words, it is obvious that amputation must be performed at some period of the cure— it is better to amputate at once, so soon as the system has rallied from the primary shock; preferring to encounter the minor risk by rapid succession of a second shock, rather than to meet the more perilous in- vasion of intense inflammatory action, with its serious consequences to both part and system. Another question, scarcely yet arranged, is as to the comparative merits of the old circular method of operation, and of the modern operation by flaps. In this part of the country, the latter is tacitly preferred; recourse to the circular method being quite the exception to Fig. 295. Fig. 296. Fie 295.—The Tourniquet, unapplied ; but with its two plat- Fig. 206.—Signoroni's Compressor, a. forms as much separated, as if in actual use. The point of counter-pressure, b. The pad which acts directly on the vessel. 684 FLAP-AMPUTATION. [Fig. 297.] the general rule of operating. And the obvious advantages are ; more rapid performance ; a cleaner cut; a better covering to the end of the bone; and a power of selection, as to what parts shall constitute the covering. The vessels are cut obliquely, no doubt; but, if the liga- tures be applied carefully—as they always ought to be—there is no risk of secondary bleeding on this account (Principles, 3d Am. Ed. p. 349). In temporarily restraining hemorrhage, during the incisions, the hands of an assistant are usually preferable to any tourniquet; as has already been explained (Principles, 3d Am. Ed. p. 342). And pressure is not applied until the knife has begun to penetrate; in order that no unnecessary loss of blood may be occasioned, by venous congestion beneath the site of compression. [Mr. Skey has contrived a tourniquet, which seems to be a very good one, having the merit of being susceptible of firm attachment around the limb, without interfering with the venous circulation. It is represented in the accompanying drawing. It is composed of two semicircles, one of which moves upon the other in a grooAre, and may be fixed at any point by a spring-catch, so that the circle may be enlarged or diminished to suit limbs of different sizes. The pressure is made upon two points only, the rest of the cir- cumference of the member being untouched (Skey's Op. Surgery, Am. Ed. p. 313).—Ed.] In the Flap Operation, the following are the more important points of detail. The patient is arranged comfortably recumbent, on a firm table, of convenient height for the operator; who places himself on the left of the patient, so that his right hand may be used, freely, for the in- cisions. The sound limb is held steady, and out of the way, by an assistant; or is secured by a towel—in the case of the lower limbs—to a leg of the table. Ordinary assistants are ready to control the motions of the patient, to reassure him, if need be, and to minister to his wants. An experienced administrator undertakes the whole charge of the chlo- roform, from the beginning to the end of the operation; never allowing himself to be distracted by the details of this from a close and uninter- rupted watching of the patient. A trustworthy assistant is ready to command the hemorrhage, by the pressure of his own fingers, or by that of a tourniquet. Another is prepared to retract the flaps, and to tie the arteries. A third is stationed to hand what things may be re- Mr. Skey's Tourniquet. FLAP-AMPUTATION. 685 quired; and these are suitably arranged on an adjoining table—tourni- quet, bandage, lint, ligatures, sutures, knives, saw, cutting-pliers, artery- forceps, sponges^chloroform. If necessary, an assistant, seated in front of the patient, steadies and supports the limb to be removed. Fig. 298. Fig. 299. Fig. 298.—The Flap Operation, illustrated in the Thigh. The sloping wounds, whence the Flaps have been taken, shown in the amputated part. Fig. 299.—The Corresponding Stump; intended to exhibit the comparatively small extent of wound that remains; in contradistinction to Fig. 301. Suppose that the thigh is to be amputated by double flaps. The surgeon grasps the flesh in front of the limb with his left hand, so as to raise it from the bone; thereby facilitating the making of a full flap anteriorly. As the knife's point is about to enter, pressure is applied to the femoral. Transfixion is made, by pushing the knife down to the centre of the bone, horizontally; gently passing the point round the bone to the front; then pushing across, so as to make the point of exit as nearly as possible opposite to that of entrance. Moving the knife downwards and outwards, with a gentle sawing motion, a sufficient flap is formed anteriorly, and this is retracted by the assistant; or, rather, is simply elevated. The knife's point is then re-entered, about an inch beneath the site of former transfixion; in order to avoid cross-cutting of the integument, which is otherwise apt to occur. And, the second transfixion having been effected, a second flap is formed posteriorly. This is quickly laid hold of by the assistant's other hand; and he now retracts both flaps ; pulling steadily, and keeping his own fingers out of the way. The surgeon, by circular sweeps of his knife, divides the soft parts completely, as high as the fleshy commissure of the flaps will permit • effecting this leisurely and coolly, in order that it may be done thoroughly Not even a shred of periosteum should be left at the point which is to be sawn; and this should be as close to the adherent cushion of muscle above, as the instrument can be made to go. The form of the wound—the flaps unretracted—is conical; and the sawn end of the bone must occupy the very apex of the cone. The assistant continuing to keep the flaps out of harm s way, the 686 CIRCULAR AMPUTATION. saw is applied to the isolated portion of bone—the side of the instru- ment lying close upon the fleshy wall above. The saw is held perpen- dicularly, and is " grooved" by drawing it lightly from heel to point. By steady sweeps, section is effected ; the surgeon, meanwhile, con- trolling the lower limb with his left hand ; making sure that it is not held too high, so as to lock the saw by shutting it up in its own groove; and taking equal care to prevent its being too much depressed, so as to favor splintering of the bone when the section is nearly completed. During, and after the use of the saw, the assistant takes care to apply no traction to the flaps, lest the periosteum be unnecessarily stripped upwards. Should this happen to any considerable extent, necrosis and exfoliation may scarcely fail to ensue. Should any roughness remain on the end of the bone, either by splintering or from natural construc- tion, this is to be removed by means of the cutting-pliers. Attention is now immediately directed to the arteries; the largest being at first secured. Each is laid hold of with the artery-forceps, and, by being pulled outwards, is separated from all surrounding tex- tures ; partly to insure deligation of the arterial coats only; partly to secure application of the ligature beyond the oblique section of the vessel. By neglect of this, nerve and vein may be unnecessarily in- jured ; and the ligature's noose, traversing the oblique section, not going beyond it, may leave a part of the arterial mouth still open, and ready to afford a troublesome hemorrhage. So soon as the larger arte- ries have been secured, the assistant relaxes his pressure above, or alto- gether removes it. The smaller vessels can be quite commanded by the finger-points ; and, were the high pressure continued, venous loss of blood must necessarily ensue. Removal of the pressure, above, is usually sufficient to arrest the venous flow. But, should this continue, direct pressure is made, either by the finger applied to the venous ori- fices, or by shutting the flaps and pressing them firmly together, for a short time. Deligation of a vein is unwarrantable (Principles, 3d Am. Ed. p. 354). Bleeding having been satisfactorily arrested, the flaps are partially approximated by a few stitches ; and, a wet cloth having been applied to the line of wound, the patient is removed to bed. The subsequent treatment is conducted according to the principles formerly described (Principles, 3d Am. Ed. p. 593, et seq.); our object generally being to obtain adhesion ; yet, not unfrequently, preferring a moderate suppura- tion—as when the system has been long previously subjected to copious discharge, the sudden arrest of which might seriously endanger the internal organs (Principles, 3d Am. Ed. p. 490). The Circular amputation is performed thus; again supposing the thigh to be the part concerned. An assistant, grasping the limb with both his hands, draws up the skin as far as possible. The surgeon, holding the knife lightly, and with his arm at first placed under the thigh, divides the skin and areolar tissue in one continuous sweep. The assistant now retracts the skin, more decidedly than before ; and he is assisted in this, by the surgeon touching the subcutaneous tissues at various points with the knife. Close to the retracted integument, the knife is again laid on ; and, by a second sweep, the superficial muscles CIRCULAR AMPUTATION. 687 are divided. These are pulled upwards by a retractor—a portion of linen or leather, slit at one end; and, by a third sweep of the knife, laid on close to the retractor, the bone is made bare. Retraction is then applied to all the fleshy textures ; touches of the knife assisting Fig. 300. Fig. 301. Fig. 300.—Circular Amputation, illustrated in the Fig. 301.—The Corresponding Stump; intended Thigh. The terraced arrangement of the wound, to exhibit the comparatively large extent of wound shown in the amputated part. that remains; in contradistinction to Fig. 299. to expose the bone at a higher point; and, this having been reached, complete isolation of the bone is effected there. The saw is applied, while by the retractor the muscles are protected from injury. Bleed- ing having been arrested, the soft parts are let down, and are arranged so as to make the line of wound rectilinear. Amputation of the Fingers. Amputation at the Distal and Middle Joints is performed thus. An assistant controls bleeding, by grasping the wrist tightly. Another separates the fingers from that which is doomed; at the same time steadying the hand in a pronated position. The surgeon lays hold of the finger, slightly bending the joint at which removal is to take place; and the articulation is then laid open, by a sweep of a narrow straight bistoury. Division of the lateral ligaments is completed, if need be, by the point of the instrument; and the joint is more flexed, to favor disarticulation. This having been effected, the knife's blade is placed behind the head of the bone; and, by cutting downwards and outwards, a sufficient flap is formed on the palmar aspect. Previously to disarti- culation, the surgeon lays hold of the part on its dorsal and palmar aspects; in making the flap, his hold is lateral. Or the procedure may be reversed. The hand being placed in a state of supination, transfixion is made in front of the joint; by cutting downwards and outwards, the flap is made in the first instance; and then, by a sweep of the knife, 688 AMPUTATION OF THE FINGERS. disarticulation is effected, and the integuments on the dorsal aspect are divided. Usually, no hemostatics are required. The flap is turned over Fig. 302. Amputation of the Finger, at the Distal Articulation. the joint; and is retained in its place, by a single point of suture, or by bandage or strap alone. The Proximal phalanx, if not wholly involved in injury or disease, need not be entirely sacrificed. Amputation may be performed near the middle of the bone; in obedience to the general rule, of saving as much as possible of the organ of prehension. A stump of the fore- finger is especially useful. By transfixion, on the palmar aspect, a long flap is formed there; and a small semilunar flap of integument is made on the dorsal aspect, by a subsequent sweep of the knife. Or corre- sponding flaps may be made on the sides of the finger; in cases of ex- ternal injury, when the palmar aspect is much mutilated. The bone, having been made bare at the upper part of the wound, is severed by cutting-pliers. And in using this instrument care is taken to place its smooth side always where the stump is to be; otherwise, splintering and irregularity are apt to occur. Hemorrhage having been arrested, the flaps are united and retained in the ordinary way. Amputation at the Metacarpal Joint may be performed in one of two ways. The hand is held pronated. 1. The finger, well separated from its fellows, is laid hold of by the surgeon, and pushed to one side. On the exposed and tense web, the bistoury is passed upwards, from point to heel, so as to expose that side of the articulation ; at the same time, leaving on its outer side a flap of suitable dimensions. With the knife's point, disarticulation is effected; the finger being pushed much across to facilitate the process. Were the blade to be used for this purpose, ragged wounding of the integument could not well be avoided. The head of the bone having been detached, the blade of the knife is placed behind it; and, by cutting obliquely outwards, a second flap is formed, to suit the former—Avhile at the same time, detachment of the finger is completed. 2. Or the knife's point is entered on the centre of the knuckle; and, by one continuous movement, is carried round the finger, so as to make two equal, lateral, semilunar flaps, at the same time exposing the joint. Disarticulation is then completed, and the part removed. The digital arteries usually require ligature. Approxima- AMPUTATION OF THE METACARPAL BONES. 689 tion is effected by bringing the two adjoining fingers together, and retaining them so by means of a slip of bandage. Cold pledgets of lint are applied; and, otherwise, the Avound is managed in the ordinary Avay [Principles, 3d Am. Ed. p. 593, et seq.). When operating on the fore and little fingers, it is well to extend the incisions a little upAvards, to expose the head of the metacarpal bone, and to remove its articulating surface by means of the cutting-pliers. The stump is more rounded, and has a more seemly appearance after cicatrization, than when the end of the metacarpal bone is left project- ing. But, in doing this, care must be taken not to injure the transverse ligament. Amputation of the Metacarpal Bones of the fingers is sometimes required; in consequence of disease affecting one or more of them. The incisions vary, necessarily, according to the extent of the disease, and the site of the openings already existing. Disarticulation from the carpus requires both skill and caution. The fingers are taken with the metacarpal bones ; for, the former become useless appendages, when deprived of their support. If in amputating a finger and its metacarpal bone, the corresponding carpal surface be found in a carious state, by the use of a gouge the diseased parts may be removed; and the progress of cure may prove most satisfactory. Disease or injury of three metacarpal bones, does not warrant removal of the whole hand. The stump which results from amputation of the Fig. 303. Stump of the Hand, in whirh the thumb and little finger, with their metacarpal bones, were left alone, after amputation on account of injury by a printing machine. The thumb and finger acquired great mobility and power, and the stump proved most serviceable. affected parts only, is infinitely more serviceable than that which fol- lows complete mutilation. When the lower part, only, of a metacarpal bone is affected, disar- ticulation at the carpus is not attempted, but section of the bone is made in its shaft, by means of the cutting-pliers. _ The knife is entered on the dorsal aspect, at the point where section is to be made, and is carried down in the mesial line, till the knuckle is reached; there a divergence is made, on either side, as in amputation of the finger only, but without passing the knife so deeply as to open the# articulation. Then, by dissection, the diseased portion of the bone is isolated, care being taken to leave the palm entire. Also when a single metacarpal bone is removed entire, it is well to 44 690 AMPUTATION OF THE THUMB. spare the palm, the hand being afterwards both more useful and more seemly than it otherwise would be. Amputation of the Metacarpal Bone of the Little Fingeris accomplished thus : The finger is laid hold of, and separated from the others ; and the bistoury, laid on the stretched web, is carried up at once, along the inside of the metacarpal bone, to its articulation with the unciform bone of the carpus. The doomed part being much pushed ontwards, disar- ticulation is effected with the point of the knife. And then, the blade having been placed behind the base of the bone, a suitable flap is formed on the outer side, by bringing the knife doAvnwards and outwards, causing it to emerge a little below the metacarpal articulation. Hemorrhage having been arrested, the flap is accurately adjusted to the raw meta- carpal surface, and retained in the usual way. Or the flap may be made in the first instance, by transfixing at the carpal articulation, and carrying the knife downwards and outwards, as before; or, by marking out the flap with the knife's point, and dissect- ing it up, cutting from without imvards. One obvious advantage of this v mode of operating is, that, should the base of the metacarpal bone be found not diseased, it may be saved; instead of disarticulation, the bone is cut across by the pliers. Amputation of the Thumb. The phalanges of the thumb are removed in the same way as the phalanges of the fingers. Amputation of tlie Phalanges, with the Metacarpal Bone, may be effected in the same way as remoAral of the little finger and its meta- Fig. 304. Amputation of the Thumb and its Metacarpal Bone. carpal bone, by placing the bistoury on the web between the thumb and forefinger, passing it up to the articulation with the trapezium, dis- articulating there, and forming a suitable flap by bringing the knife down on the opposite side of the bone. Or, by transfixing at the arti- culation with the trapezium, and making the flap in the first instance; afterwards effecting disarticulation, isolating the bone, and removing the member. Or the flap may be made by dissection upwards. Or AMPUTATION OF THE AVRIST. 691 the bistoury may be entered over the trapezium, and carried down on the dorsum of the metacarpal bone, having reached the distal extremity of this bone, it may be SAverved to the inside; thence it may be made to transfix the ball of the thumb, emerging where it first entered ; and, by cutting outwards and downwards, the flap may be constructed. .imputation of the Wrist. Hitherto, pressure on the wrist has sufficed temporarily to restrain hemorrhage. Now, compression of the humeral is expedient; and is best effected by the firm and steady grasp of an assistant—on the lower F'g- 30)- part of the arm—the nerves being excluded from pressure as much as possible. Hitherto, also, a narrow, straight, sharp-pointed bistoury has been the preferable instrument, for making the incisions. Now, a regular ampu- tating knife is required. An ex- aggeration of the former instrument, in a fixed wooden handle; straight, sharp-pointed, and of fine edge and temper ; light yet firm. The ampu- tating case contains various sizes; proportioned to the dimensions of the parts which may require their use. For the wrist, the shortest size will suffice; the blade not much larger than that of a full-sized bistoury. The arm is steadied, with the hand in a state of pronation. The knife is laid on below the styloid process farthest from the operator—who stands on the patient's left— and is carried across the limb so as to form a semilunar wound on the dorsal aspect, whose centre extends as far as the second carpal range, and whose termination is below the styloid process on the side next the surgeon. An assistant retracts the flap thus formed. The wrist is bent, and disarticulation effected. The blade of the knife is then laid behind the carpus; and, by cutting outwards and downwards, a suitable flap is formed on the palmar aspect. In the last part of the proceeding, the pisiform bone is to be avoided; and, in endeavoring to escape from it, care must be taken not to notch the corresponding portion of integu- ment. The radial, ulnar, and interosseous arteries, require ligature. Amputation of the AArrist. Amputation of the Forearm. Pressure being made on the humeral, the limb is steadied, with the hand in a state of pronation. Two flaps are formed; one on the dorsal, the other on the palmar aspect. Below the middle of the forearm, it 692 AMPUTATION OF THE FOREARM. Fig. 306. is not easy to obtain a sufficiency of fleshy covering. Yet when circum- stances will at all permit—the general rule is not to be rashly deviated from ; of removing as little as possible from the organs of prehension. And besides, another practical axiom comes into play ; namely, that the farther removed an amputation is from the trunk of the body, the less is the risk to life thereby. The flaps may be made either by transfixion, or by cutting from without inwards. The former mode is usually preferred. In the case of the left fore- arm, the surgeon Avith his left hand pinches up the cushion of flesh on the dorsal aspect, and enters his knife hori- zontally OArer the ulna, bringing it out at a corresponding point over the radius. The knife is again introduced, beneath the ulna, and pushed through on the palmar aspect of the bones ; not at the same point as the former transfixion, but about half an inch lower down—a precaution which is to be attended to in all double-flap amputations, as already stated (p. 687). An assistant retracts the flaps ; with a few circular sweeps of the knife the surgeon clears the bone of soft parts, at the very upper The ordinary tourniquet shown in applica- tion to the brachial artery; a bandage enact- ing the part of compress over the vessel—not very accurately placed. Fig. 307. Amputation of the Forearm. part of the wound ; the interosseous space is freed, by the knife beino- passed between the bones ; and the saw is then applied. At least, the AMPUTATION OF THE ELBOW-JOINT AND ARM. 693 three principal vessels require ligature. The wound is then adjusted in the ordinary way. In transfixion, it is obvious that care must be taken to avoid passing the knife between the bones. On this account, the position of the limb here recommended is preferable to the middle state between pronation and supination ; and during the incisions, care must be taken that the position is maintained unaltered. .imputation of the Elbow-Joint. If space enough be left on the forearm, in extensive disease or injury of that part, the humerus need not be interfered with. An excellent operation may be done at the elbow; making a single flap in front. The limb is steadied, with the hand in a state of supination. Transfixion is made, by passing the knife OA'er the condyles, in front of the joint; and, by cutting downwards and outwards, a large and suitable flap is constructed. With a circular sweep, the integuments behind are divided; and disarticulation is then effected. The olecranon may be sawn across; or, extending the forearm, this process may be wholly removed, the attachment of the triceps having been severed. The flap is then suitably adjusted over the trochlea of the humerus. Amputation of the Arm. Pressure is made on the upper part of the humeral, or in the axilla. The surgeon with his left hand steadies the limb, below the point of incision; an assistant, seated in front of the patient, supports the hand Fig. 308. Amputation of the Arm. and forearm. The knife is entered, horizontally, over the bone near its centre, on the side of the limb nearest the surgeon ; the point, having touched the bone, is passed lightly round to its anterior surface, by depression of the handle ; then the handle is raised again to its former 694 AMPUTATION OF THE SHO ULDER-JOINT. level, and transfixion is completed. By cutting downwards and out- wards, an anterior flap is formed. The knife is re-entered on the op- posite aspect of the bone, a little lower down ; and, after transfixion, is brought out so as to construct a corresponding flap posteriorly. The flaps having been retracted, the bone is bared, and the saw applied. Amputation of the Shoulder-Joint. Hemorrhage is restrained by pressure applied to the subclavian, above the clavicle ; by the fingers alone, or by means of the handle of a key, well padded; or by means of any other suitable compressing agent. The pressure is not made downwards merely; but downwards and backwards, so as to jam the vessel between the compressing agent and the first rib. The patient may be either seated or recumbent. The former position is the more convenient for the operator, as well as for the compressor; but, if it be adopted, it is necessary to secure the patient against changing his position, through fainting or restlessness, by lashing him to the back of the chair by means of a sheet or towel, as well as by a suitable arrangement of supporting assistants. And now that chloroform is almost invariably employed, this posture is generally superseded by that of recumbency. In cases of injury, the selection of flaps, as to position and form, may not be left to the surgeon's choice; but may have been already indicated by the nature of the accident. When space and opportunity for selection are afforded, however, the operation may be accomplished in a variety of ways. The method by transfixion, and by the formation of an outer and inner flap, is so generally preferred and practised, that to it alone need Fig. 309. Amputation of the Shoulder. attention be directed. The steps of the operation vary according to the limb operated on. In the right shoulder it is effected thus: A long knife is entered on the top of the shoulder, about an inch below the acromion; and, passing round the joint, on its exterior, is brought out immediately Avithin the posterior border of the axilla. By cutting out- AMPUTATION OF THE TOES. 695 wards and doAvmvards, a large outer flap is formed. The arm is then carried across the chest; and the head of the bone, thus made promi- nent, is cut down upon by a SAveep of the knife. The capsule is opened, and disarticulation effected; and the blade of the knife, laid on the inside of the head of the bone, is carried rapidly inAvards and down- wards, so as to form an internal flap, considerably smaller than the other. The main artery is immediately secured by ligature ; and then pressure on the subclavian is removed, lest, by its continuance, venous hemorrhage should be favored. On the left side, the knife, having been entered Avithin the margin of the posterior border of the axilla, is made to emerge on the top of the shoulder, a little beneath the acromion; and the outer flap is formed as before. The arm is then carried over the chest, disarticulation is effected, and an inner flap is formed. Or the outer flap may be marked out by a bistoury, and dissected up. After cicatrization, the stump requires artificial protection; other- wise, the prominent acromion is apt to sustain injury. Amputation of the Scapula. Disease and injury sometimes, though rarely, render it necessary to take away the scapula along with the superior extremity. No fixed plan can be laid down for the incisions; they must vary according to the circumstances of the case. When such extensive mutilation is required on account of injury, the greater part of the incisions will probably be found already made. Amputations of the Loaver Extremity. Amputation of the Toes. The Phalanges of the toes are removed in the same way as those of the fingers. The metatarsal articulation, however, lies considerably deeper than the corresponding joint of the superior extremity; and the incisions require to be made accordingly. There is no necessity for removing the head of the metatarsal bone; the more ample the base of support, the more efficient is its function. The Metatarsal Bone of the Great Toe is not unfrequently diseased in the greater part of its extent. It may be disarticulated; but it is better to divide it a little below its base, if possible, in order to leave the tendinous insertion there undisturbed. By a bistoury, such a flap is indicated as will efficiently cover the wound. The instrument is en- tered over the tarsal articulation, on the dorsum of the bone, and is carried down, along the dorsum, until the metatarsal joint is reached ; a sweep is then made on the inner side of this, or rather a little below the joint; and the incision is continued upwards, leaving an interspace of about an inch and a half between the returning line of wound and that which descended. The flap, thus indicated, is dissected up; the bone along with the corresponding toe, is isolated from its connections, 696 AMPUTATION OF THE FOOT. by a suitable use of the knife's point; and is either disarticulated, or cut across by the pliers, according to circumstances. After removal of the diseased part, and arrest of hemorrhage, the flap is brought down and adjusted to the raw surface. The other Metatarsal Bones are liable to the same operations as the analogous bones of the superior extremity. A very useful foot may be left, after removal of even three of the toes with their metatarsal bones. In estimating the extent of incisions required, it is important to remember the oblique direction of the metatarsal range. Amputations of the Foot. All the Toes may require removal at their metatarsal articulations, on account of frost-bite. A transArerse incision is made on the dorsal aspect; sloping imvards, so as to make a short anterior flap. Disarti- culation is then effected, at each joint; and, the blade of the knife having been laid behind the heads of the phalanges, a suitable flap is made from the plantar aspect. In the case of more extensive disease or injury, similar flaps may be formed—the plantar being made by transfixion; and then the metatar- sal bones are divided by the bone-pliers. Hey's Amputation.—The whole metatarsal range may be taken away, leaving the foot very useful. Hemorrhage is restrained by the pressure of an assistant at the ankle—mainly exerted on the posterior tibial. The patient is laid recumbent on a table, with the foot projecting over the edge. The surgeon, with his left hand, steadies and commands the toes. On the right foot, the prominence of the base of the metatarsal bone of the little toe is felt for; the knife's edge, laid on immediately above this, is carried across the dorsum of the foot in a semilunar di- rection, terminating at the articulation of the base of the metatarsal bone of the great toe with the internal cuneiform bone. The short anterior flap, thus indicated, is dissected up; and disarticulation is effected at each joint; the surgeon pressing heaA'ily downwards on the toes and metatarsal range, so as to favor this, by rendering the joints more open. The peculiarity of the relative position of the base of the second metatarsal bone has to be borne in mind; and the point of the knife, only, should be used for its detachment. Should anchylosis have taken place there, the pliers or saw are to be employed ; diAriding the bone on a line with the general range of articulation. Disarticulation having been effected, the blade of the knife is laid on behind, and a sufficient flap is made from the sole of the foot—longer on the inner than on the outer aspect. Or the flap may be fashioned, and dissected up, probably more accurately by cutting from without imvards. The bleeding vessels having been secured, the flaps are adjusted by suture and strap. In operating on the left foot, the dorsal incision is begun over the articulation of the metatarsal bone of the great toe Avith the internal cuneiform bone, and terminates behind the prominent head of the metatarsal bone of the little toe; in other respects the operation is the same. RESECTION OF THE ANKLE. 697 Chopart's Operation.—Amputation may be performed still higher, leaving a useful stump. Disarticulation is effected between the astra- galus and the navicular bone ; all the bones of the foot and tarsus being removed, except the astragalus and calcaneum. The operation is con- ducted on the same principles as the preceding; a short flap being made in front; and the main flap being obtained from the sole of the foot. The marks for laying on the knife in its dorsal sweep are, the articula- tion of the navicular bone with the astragalus—behind the prominence of the navicular bone, in front of the inner ankle; and the articulation Fig. 310. Amputation of the Foot. (Chopart's.) of the cuboid with the os calcis—about midway between the outer ankle and the prominent base of the metatarsal bone of the little toe. Often, however, these marks cannot be discerned, on account of swelling. After cicatrization, the remnant of the foot is not displaced back- wards, so as to bring the cicatrix in contact with the ground in walking, as might have been expected, from preponderating action of the muscles of the calf. The muscles on the front of the leg, forming new attach- ments, seem to counteract this effectually. A third amputation of the foot—intermediate between the two pre- ceding—may be performed, by disarticulating the cuneiform bones from the navicular, and sawing the cuboid bone across at a corresponding point. The general plan of the incisions is the same as in the two pre- ceding cases. Resection of the Ankle. When disease is limited to the ankle-joint and upper part of the tarsus, it is a question whether or not excision of the diseased parts may not be performed, leaving the foot. On this principle, Mr. Wakley has removed the calcaneum and astragalus, at the same time sawing off the malleolar surfaces of the tibia and fibula.1 Farther experience of this operation, howeA'er, will probably be required, ere it be receiAred as a substitute for that next described. Lancet, No. 1296, p. 5. 698 AMPUTATION OF THE ANKLE. Amputation of the Ankle. When no part of the foot and tarsus can be saved, amputation is required either in the leg or at the ankle. The latter site is preferable on more than one account; risk to life is less, the mutilation is less, and the stump is not only more useful in progression, but also less liable to neuralgia and exfoliation. Disease of the ankle-joint does not contraindicate the operation, unless it extend beyond the ends of the bones. And, in most cases of diseased ankle, indeed, it were now unwarrantable to perform any other operation. For the revival and more general introduction of this procedure, the profession is indebted to Mr. Syme. The patient having been suitably arranged on a table, a tourniquet is applied, so as to compress the popliteal artery, or the fingers of an assistant may be employed, as in amputation of the foot (p. 696). A Fig. 311. Amputation of the Ankle. semilunar incision, directed forwards, is made over the instep, with a strong bistoury or short amputating knife, and a corresponding wound is made across the sole of the foot. " The foot being placed at a right angle to the leg, a line drawn from the centre of one malleolus to that of the other, directly across the sole of the foot, Avill show the proper extent of the posterior flap. The knife should be entered close up to the fibular malleolus, and carried to a point on the same level of the opposite side, which will be a little below the tibial malleolus. The anterior incision should join the two points just mentioned at an angle of 45°, to the sole of the foot, and* long axis of the leg. In dissecting the posterior flap, the operator should place the fingers of his left hand upon the heel, while the thumb rests upon the edge of the integuments, and then cut between the nail of the thumb and tuberosity of the os calcis, so as to avoid lacerating the soft parts which he, at the same time, gently but steadily presses back until he exposes and divides the tendo Achillis. The foot should be disarticulated before the malleolar AMPUTATION OF THE LEG. 699 projections are removed, which it is always proper to do, and which may be most easily effected by passing a knife round the exposed extremities of the bones, and then sawing off a thin slice of the tibia connecting the tAvo processes."1 In most cases, the operation will be most readily conducted by completely opening the joint from the front, before dissecting off the soft parts from the calcaneum. Bleeding hav- ing been arrested, the flaps are brought together by suture, and care must be taken, during the cure, to prevent accumulation of pus in the pouch which may be formed by the posterior flap. After cicatrization, a most efficient, round, callous stump is produced, the patient resting on the integuments of the heel, well accustomed to pressure, and retaining a full use of the knee and leg. It has been said that division of the posterior tibial artery, before it divides into its plantar branches, should be avoided; otherwise, partial sloughing of the flaps is apt to ensue. Usually, however, incision will not be found to interfere with the arterial trunk in question. And it is probable that in those cases in which sloughing has occurred, the acci- dent was not wholly attributable to deficiency of arterial supply. Should circumstances not be suitable to the plan of incision as above described, lateral flaps may be made, leaving the integument of the heel as much entire as possible. The operation may be readily effected in this way, but there is risk of a less convenient cicatrix resulting, and consequently of the stump proA'ing less useful in progression. Amputation of the Leg. This is not altogether superseded by the operation at the ankle. There are still not a few cases occurring, in which the latter procedure would prove quite insufficient. And in regard to some of these it is to be feared that the natural preference for a new operation may lead to its performance in circumstances quite unsuitable. The affected parts of the leg-bones having not been sufficiently removed, sinuses and fistulae may form, communicating with caries, long retarding complete cure, rendering the stump but little serviceable, perhaps, even when healed, and, probably, at length, demanding a second amputation. Near the ankle, a fleshy stump is not to be obtained in thin persons ; and in these, consequently, we may be compelled to cut somewhat higher than otherwise might have been necessary. On the other hand, there are stout limbs, their rotundity mainly caused by a solid oedema, in which it is desirable to amputate low down, in order to avoid redundancy of soft parts. Hemorrhage is restrained by pressure on the popliteal, either by a tourniquet, or by the fingers of an assistant, or by the assistant's pres- sure on the femoral artery, as it passes over the brim of the pelvis. The patient is laid on a firm table, of convenient height, with the limbs projecting over its edge; the sound ankle is secured to the leg of the table by means of a towel, the work of an additional assistant being thus spared and the doomed limb is supported by an assistant seated i Syme, Contributions to Surgery, p. 146, and Monthly Journal, Feb. 1850, p. 173. 700 AMPUTATION OF THE LEG. in front. The surgeon, feeling the exact outline of the bones, trans- fixes, passing his knife as closely as possible to their posterior surface; Fig. 312. Malan's Flat Tourniquet, applied to the Popliteal. and, by carrying it downwards and outwards, a long posterior flap is formed. The knife is then laid on at the upper margin of the wound; Fig. 313. Amputation of the Leg. by a sweep in front, in a semilunar direction, the integument is divided; this having been retracted, the interosseous space is cleared by the knife passed between the bones, and the saw is then applied as close to the soft parts as possible. If the ridge of the tibia project, much and sharply, it may be rounded off by means of the bone-pliers. Bleeding having been arrested, the flap is brought up and secured. To facilitate transfixion, and guard against locking of the knife between the bones, it may be well to make a little alteration in the procedure. Supposing that the right leg is operated on, the knife is entered on the outside of the fibula, about an inch, or more, beneath the point where transfixion is contemplated; with a sawing motion the instrument is carried upwards along the outside of the bone, until the site of transfixion is reached; the blade is then applied in front, to form the anterior wound; and, the point having arrived at the inside of the AMPUTATION OF lHE KNEE-JOINT. 701 Fig. 314. The forceps shown at work. The artery fairly isolated, and made to project. Seldom it protrudes so far; but when it does, the ligature is applied close to the base, and scissors or knife amputates the redundant part. tibia, transfixion is effected—the instrument emerging at the upper part of the wound formerly made on the outside of the fibula. In operating immediately below the knee, the fibula is sawn across. along with the tibia. Disarticulation of the head of the former bone may improA'e the appearance of the stump, at the time of its formation: but experience has shown that the procedure is not warrantable, on account of the risk of subsequent inflammatory seizure in the knee-joint. A short stump having been made, the patient usually rests on the knee, with the stump bent at right angles; and to the knee the artificial limb is adapted. When the stump is long, however, the motions of the knee-joint are retained, and the false limb is adapted to the leg imme- diately above the cicatrix. When stout muscular men sustain such injury of the leg as requires amputation below the knee, a redundancy of flesh cannot fail to be obtained in the flap, by the ordinary mode of operation. And, accord- ingly, Mr. Liston has advised, in such cases, a modification of the cir- cular amputation. " Supposing the left leg to be injured: with a com- mon amputating knife an anterior semilunar incision is made through the skin, commencing from the inner side of the tibia, about four fingers' breadth below its superior extremity, and passing over its anterior aspect. A similar semilunar incision is made at the posterior part of the leg, its extremities joining the horns of the previous incision. The integument is then reflected upwards to a sufficient extent to cover the bones, and the operation is finished after the manner of the circular amputation." Amputation of the Knee-Joint. Latterly, this operation has also been revived ; when injury or dis- ease extend no higher than the condyles of the femur, and involve these only to a superficial extent. A semilunar incision is made on the front of the limb, passing beneath the patella ; the integuments are 702 AMPUTATION OF THE THIGH. dissected up, and transfixion is made behind ; by cutting downwards, a very long flap is made from the back part of the leg ; and, the soft parts having been all detached, section of the bone is made through the condyles. Bleeding having been arrested, the flaps are approximated. The operation is easily enough accomplished, but experience seems to have unequivocally decided on this revival unfavorably. Amputation of the Thigh. The patient is arranged as for amputation below the knee, but with the pelvis resting on the edge of the table. The femoral is compressed Fig. 315. Amputation of the Thigh. by an assistant, as it passes over the horizontal ramus of the pubes. The operation is by double flaps. Low down in the thigh, a suitable amount and character of soft parts can be obtained only from the lateral aspects of the limb. Transfixion accordingly, is made perpendicularly. On the upper part of the thigh, the flaps are anterior and posterior (p. 687); transfixion is horizontal; and the operation is performed in the same way as the analogous procedure in the arm. The posterior flap should be considerably longer than that in front; to compensate for the greater displacement upwards, by contraction, to which the muscles on the posterior part of the thigh are liable—and for the greater amount of permanent atrophy by absorption, which the posterior flap invariably undergoes. Immediately after section by the saw, the mus- cles inserted into the trochanter-minor project the end of the bone for- wards ; and, in consequence of this, protrusion at the upper angle of the wound Avould be apt to take place, were the flaps made laterally ; while, as it is, the more the bone is bent forwards, the more completely is its extremity covered by the anterior flap. AMPUTATION OF THE HIP-JOINT. 703 Amputation of the Hip-Joint. Amputation at the hip-joint is seldom required. The operation is one of great severity, and eminently perilous to life; yet, when circum- stances are urgent and decided, Ave need not shrink from its perform- ance. There are already nearly thirty successful cases in the records of surgery.1 For malignant disease of the femur, the operation is un- advisable; experience having shown that, even although the operation itself may be temporarily successful, return of disease in the interior will surely carry off the patient—probably at an earlier period, and more painfully, than if the tumor had been left undisturbed in its original site. The patient is placed on the table, with his pelvis projecting from the edge. A steady assistant compresses the femoral; and is ready to follow the knife with his fingers, during formation of the anterior flap, so that he may grasp the end of the vessel almost as soon as it is divided. The knife is entered about midway between the trochanter-major and the anterior superior spinous process of the ilium, and is- made to emerge on the inside of the thigh, after having passed in a somewhat curved direction over the articulation; the assistant, who supports the limb, gently rotating the thigh inwards. By cutting downwards, a suitable anterior flap is formed. The assistant, then abducting the thigh, presses it backwards; and, by a determined sweep of the knife over the head of the bone thus made prominent, the joint is cut into. With the point Fig. 316. Amputation of the nip-Joint. of the instrument, the round ligament is divided, and disarticulation effected. The blade of the knife is then placed behind the bone, and carried downwards and backwards, so as to form the posterior flap; the assistant managing the limb so as to prevent locking of the instrument by the trochanter-major. Or the posterior flap may be formed by cut- i Brit, and For. Rev. No. 43, p. 112. 704 AFFECTIONS OF STUMPS. ting from without inwards. However made, it is instantly covered by a sponge; and the vessels there are rapidly secured. Afterwards, the assistant is relieved from his charge of the femoral. By some, the formation of lateral flaps is preferred. Not unfre- quently, in cases of injury, there may be no room for selection; the extent of the accidental wound precluding all attempts at regular ope- ration, and compelling the surgeon to shape his flaps according to what may be, perhaps, quite an original mode of procedure. Affections of Stumps. Neuralgia of the stump is no unfrequent result of amputation, how- ever skilfully conducted (Principles, 3d Am. Ed. pp. 398 and 585). It is most commonly observed after amputation below the knee. If no change of structure in the nerve can be detected, the treatment must be such as is suitable for neuralgia in general; and, of the remedies usually found most useful, iron internally, and the light application of nitrate of silver to the part, may be specially mentioned. If neuromata plainly exist, entangled with the dense cicatrix, they ought to be re- moved ; and, for this purpose, a repetition of the amputation on a minor scale is usually necessary; care being taken in the fashioning of the Fig. 317. Neuromata of Stump, after amputation of the arm. A large neuromatous mass at a; opposite 6 the tumors are more defined. stump, and in the after-treatment of it, that the nerves be not again similarly circumstanced. Not unfrequently, however, notwithstanding every care, neuralgia returns—obviously dependent on a general more than on a local cause (Principles, 3d Am. Ed. p. 590). The neuralgic part should not be pressed upon in the adaptation of any artificial limb. Exfoliation from the stump seldom follows a well-conducted flap-ope- ration. It is most likely to occur Avhen section has been made in the dense part of a bone, as in the middle of the femur. The sequestrum may consist of a mere scale from the saAvn surface; or it may be of some length—involving the whole thickness of the bone at its lower AFFECTIONS OF STUMPS. 705 part, and tapering, upwards, of a cancellous texture. Healing of the wound is necessarily delayed until detachment and extrusion of the sequestrum have taken place. Sometimes, in an ill-formed stump, or when the soft parts have perished by sloughing, the end of the bone projects, uncovered, par- tially necrosed, and in part, perhaps, carious. In such a case, renewal of the amputation is necessary; or the making of such incisions as may admit of the bone being sawn, at a point sufficiently high for subsequent fleshy covering. The accidents of exfoliation, and protrusion of the end of the bone, ought to be prevented, by fashioning the flap or flaps so as to afford a full covering for the end of the bone—allowance being always made for subsequent contraction and atrophy, by sawing the bone, carefully. close to its connection with the soft parts—not leaving any portion bare and projecting, stripped of both flesh and periosteum, at the time of the operation ; by so conducting the cure as to prevent untoward accessions of inflammatory action, whereby ulceration, sloughing, or Fig. 318. Fig. 319. Fig. 318.—Necrosis of the Femur, after amputation. At a, the sequestrum in process of separation. At 6, the parent bone enlarged, and undergoing inflam- matory change, necessary for detachment and repair. Fig. 319.—The sequestrum detached; at its lower part, a, including the whole thickness of the bone, but gradually shelving upwards, as such sequestra usually do. long gaping of the wound might occur ; by opposing excessive retraction of the muscles if need be, by bandaging—in those cases in which the process of granulation is interrupted or tedious. The face of a well- formed stump is " fenced with firm skin, and no more liable to accident than a man's finger-ends." ,•,„,, ,. -, A Bursa usually forms over the end of the bone; tending towards 45 706 AFFECTIONS OF STUMPS. tolerance of pressure. A blow, or other injury, may induce painful enlargement of this ; and the fluctuation, and other characters of the swelling, may simulate the condition of acute abscess very closely. Accuracy of diagnosis is obviously of importance; as, in the one case, early incision is advisable; while, in the other, rest and fomentation, with perhaps leeching, prove sufficient. Hemorrhage.—Bleeding, taking place within a few hours after the operation—when the patient grows warm in bed, and recovers fully from the state of shock—usually requires an undoing of the partial approxi- mation of the wound, and the application of ligatures to the open vessels. But if at the time of operation, due care have been taken to apply deli- gation accurately to each likely orifice, the occurrence of such a casualty need seldom be apprehended. Hemorrhage which occurs at a more remote period, in consequence of ulceration having attacked the stump, may, if slight, be restrained by pressure. But, in general, deligation of the arterial trunk is neces- sary ; for example, deligation of the femoral, after amputation below the knee; deligation of the humeral, after amputation of the forearm (Principles, 3d Am. Ed. p. 353). Roux, Relation d'un Voyage fait a, Londres, Paris, 1814. Hammick on Amputations, Fractures, &c, Lond. 1830. Alcock, Lectures on Amputation, Lancet, 1840-41. Cox, Memoir on Amputation at the Hip-Joint, Lond. 184-3. Maingault's Operative Surgery, by Cox, Lond. 1845. Liston's Practical Surgery, Lond. 1846. Malgaigne, Operative Surgery, by Brittan, Lond. 1846. Bourgery, Operative Surgery, Paris, 1846. Skey, Operative Surgery, Lond. 1850. Fergusson, Practical Surgery, Lond. 1852. Larrey, M6moire sur les Amputations, Me"m. de Chir. Milit. vol. ii. I AT I) E X . Abdomen, affections of, 367 Abdomen, bruise of, 36 8 Abdomen, wounds of, 369 Abdominal aorta, aneurism of, 625 Abdominal parietes, abscess of, 367 Abdominal tumors, 36S Abscess of the abdominal parietes, -367 Abscess of the antrum, 180 Abscess of the brain, 51 Abscess of the cornea, 123 Abscess of the dura mater, 51 Abscess of the ear, 237 Abscess of the ham. 643 Abscess, lumbar, 343 Abscess of the mastoid cells, 238 Abscess of the neck, 245 Abscess of the pharynx, 225 Abscess, psoas, 343 Abscess exterior to the rectum, 412 Abscess of the septum narium, 171 Abscess of the tonsil, 221 Abscess of the vulva, 5'2 Abscess, pelvic, 373 Abscess of prostate, 509 Abscess and ulcer of cranium, 82 Abscess, urinous, 562 Acetabulum,.fracture of, 646 Achillis, tendo, injuries of, 673 Acids, swallowing of, 263 Accidents of venesection, 296 Accidental swallowing of irritant fluids, 263 Acromion, fracture of, 312 Albugo, 126 Amaurosis, 141 Amputation, 682 Amputation of the ankle, 698 Amputation of the arm, 693 Amputation, circular, 686 Amputation of the elbow-joint, 693 Amputation of the forearm, 691 Amputation of the fingers, 687 Amputation of the foot, 696 Amputation of the hip-joint, 703 Amputation of the knee-joint, 701 Amputation of the leg, 700 Amputations of the lower extremity, 69., Amputation of the metacarpal bones, 688 Amputation of the metacarpal bone of little finger, 690 j Amputation of the metatarsal bone of great toe, 695 Amputation of the metatarsal bones, 696 Amputation of the penis, 590 ! Amputation of the shoulder-joint, 694 i Amputation of the scapula, 695 i Amputation of the thumb, 690 Amputation of the toes, 695 Amputation of the thigh, 702 ! Amputation of the wrist, 691 Amussat's operation for artificial anus, 432 Ammoniaco-magnesian phosphate calculus, 448 Anal fistula. 413 Anal prolapsus, 423 | Ankyloblepharon, 95 Aneurism, false, of temporal artery, 31 Aneurism, popliteal, 631 Aneurism of abdominal aorta, 625 Aneurism of common femoral, 628 Ankle, amputation of, 698 Ankle, compound dislocation of, 670 Ankle, dislocation of, 669 : Ankle, fracture of, 660 Ankle, resection of, 697 Anonyma, arteria, ligature of, 288 Anus, artificial, 371 Anus, fissure of, 417 Anus, imperforate, 430 Anus, itching of, 428 Anus, ulcer of, 417 Anus, formation of artificial, 431 j Anus, prolapsus of, 423 Antrum, abscess of, 180 Antrum, collection of fluid in, 180 Antrum, polypus of the, 180 , Anchylosis of the jaw, 212 Aorta, abdominal, aneurism of, 625 | Aorta, compression of, 625 Aorta, deligation of, 625 I Aquo-capsulitis, 123 Arcus-senilisj 127 Arm, amputation of, 693 Arm, bend of the, affections of, 295 Arteria, anonyma, deligation of, 288 Arteries of the neck and superior extremity, affections of the, 287 Arteries of the forearm, deligation of, 293 Arteriotomy, 30 708 IND EX. Artery, anterior tibial, deligation of, 633 Artery, aorta, deligation of, 625 Artery, axillary, deligation of, 291 Artery, common carotid, deligation of, 287 Artery, common iliac, deligation of, 628 Artery, common femoral, deligation of, 628 Artery, external carotid, deligation of, 288 Artery, external iliac, deligation of, 626 Artery, humeral, deligation of, 292 Artery, internal iliac, deligation of, 627 Artery, popliteal, deligation of, 631 Artery, posterior tibial, deligation of, 632 Artery, peroneal, deligation of, 634 Artery, radial, deligation of, 293 Artery, superficial femoral, deligation of, 631 Artery, subclavian, deligation of, 288 Artery, temporal, false aneurism of, 31 Artery, temporal, wounds of, 30 Artery, ulnar, deligation of, 293 Artificial anus, 371 Artificial pupil, 137 Artificial pupil, operations for, 138 Artificial anus, formation of, 431 Arteriotomy, ulceration after, 30 Astragalus, dislocation of, 671 Astragalus, fracture of, 660 Asphyxia, 262 Atrophy of the testicle, 571 Auricle, affections of, 243 Auricle, hypertrophy of the, 243 Axillary artery, deligation of, 291 Auxiliaries to the taxis, 396 Balanitis, 521 Beer's knife, 149 Bend of the arm, affections of, 295 Biceps, displacement of tendon of, 327 Bladder, affections of, 488 Bladder, displacement of, 507 Bladder, hematuria from the, 491 Bladder, inflamed, 488 Bladder, injuries of, 504 Bladder, irritable, 490 Bladder, puncture of, 500 Bladder, puncture of, by perineum, 500 Bladder, puncture of, by rectum, 501 Bladder, puncture of, above pubes, 501 Bladder, stone in the, 454 Bladder, treatment of stone in the, 458 Bladder, tumors of, 505 Blepharitis, 92 Blepharoplastics, 104 Blood, extravasation of, affecting the brain, 47 Boiling water, swallowing of, 253 Bougie, caustic, 560 Bougie, protesting, 554 Bougies, use of, in stricture of urethra, 553 Bowel, protrusion of the, 369 Bowels, wounds of, 369 Brain, abscess of, 51 Brain, concussion of, treatment of, 38 Brain, concussion of, consequences of, 41 Brain, compression of, by extravasation of blood, 47 Brain, compression of, 43 Brain, concussion of, 32 Brain, foreign bodies in, 70 Brain, protrusion of, 71 Brain, puncture of, 76 Brain, wounds of, 69 Breast, female, affections of, 361 Breast, carcinoma of the, 364 Breast, pendulous, 363 Bronchocele, 281 Bronchotomy, 258 Bronchotomy, in what cases advisable, 258, 274 Bridle-stricture of urethra, 551 Bruise of the abdomen, 308 Bruise of the larynx, 262 Bruise of the scalp, 22 Bubo, 536 Bubo, inguinal, 536 Bubo, venereal, 536 Bunions, 679 Bursa over olecranon, affections of, 2'"7 Bursa over patella, affections of, 643 Bursa, thyro-hyoid, enlargement of, 285 Bursae over stumps, 705 Calcaneum, fracture of, 660 Calculi, prostatic, 485 Calculi, urethral, 483 Calculous disease, 436 Calculous disease, treatment of, 452 Calculi, urinary, formation and varieties of, 446 Calculi, urinary, 436 Calculi, renal, 452 Calculus, alternating, 450 Calculus, ammoniaco-magnesian phosphate, 448 Calculus, carbonate of lime, 449 Calculus, cystic oxide, 449 Calculus, oxalate of lime, 448 Calculus, fibrinous, 450 Calculus, fusible, 449 Calculus in the female, 485 Calculus, lithate of soda, 450 Calculus, mulberry, 448 Calculus, palliation of vesicle, 483 Calculus, phosphate of lime, 448 Calculus, preputial, 485 Calculus, urate of ammonia, 447 Calculus, uric, 447 Calculus, uric or xanthic oxide, 450 Calculus, vesical, 454 Calvarium, tumors of the, 85 Cancer, chimney-sweeper's, 584 Cancer of the eyelids, 95 Cancer of the uterus, 620 Cancrum oris, 195 Capitis paracentesis, 76 Capsular cataract, 146 Cauliflower excrescence of uterus, 621 Carotid artery, common, deligation of, 287 Carotid artery, external, deligation of, 288 Caries of vertebrse, 341 Caries of the teeth, 200 INDEX. 709 Carbonate of lime calculus, 449 Carpus, dislocation of, 330 Carpus, fracture of, 323 Caries of the skull, 82 Caruncula lacrymalis, affections of, 110 Castration, 579 Cataract, 143 Cataract, breaking up of, 151 Cataract, capsular, 146 Cataract, capsulo-lenticular, 146 Cataract, couching of, 150 Cataract, distinguished from glaucoma and amaurosis, 144 Cataract, depression of, 150 Cataract, dissolution of, 151 Cataract, drilling for, 151 Cataract, extraction of, 147 Cataract, false. 144 Cataract, hard, 144 Cataract, lenticular, 144 Cataract, Morgagnian, 145 Cataract, operations on, 146 Cataract, radiated, 145 Cataract, symptoms of, 143 Cataract, spurious, 144 Cataract, soft, 145 Catarrhus vesicae, 488 Catheter, female, passing of, 605 Catoptrical test, 144 Caustic bougie, 560 Cerebri, hernia. 71 Cerumen in the ear, 240 Cervix uteri, extirpation of, 620 Cervix uteri, inflammatory affections of, 607 Cervix uteri, stricture of, 617 Cervix uteri, ulceration of, 608 Ceruminous secretion, deficiency of, in the ear, 240 Cervical vertebrae, disease of, 285 Chancre, Hunterian, or true, 528 Cheiloplastics, 195 Cheek, sinus of the, 188 Cheek, tumors of the, 187 Chemosis, 115 Chest, affections of, 346 Chest, wounds of, 348 Child, syphilis in, 547 Chimney-sweeper's cancer, 584 Chopart's amputation of the foot, 697 Choroid coat, affections of, 131 Choroiditis, 131 Circular amputation, 686 Cirsocele, 577 Cirsocele, diagnosis of, 578 Clavicle, dislocation of, 324 Clavicle, fracture of, 309 Clitoris, hypertrophy of, 594 Cloaca, 431 Club-hand, 301 Club-foot, 675 Coat, choroid, affections of, 131 Coat, sclerotic, affections of, 130 Coccyx, fracture of, 645 Columna nasi, formation of, 175 Compression of the brain by depressed bone, 66 Compression of the brain by abscess, 51; treatment of, 54 Compression of the brain by extravasation, 47 Compression of the brain, 43 Compression of the spinal cord, 334 Compressor, Signoroni's, 683 Compression of aorta, 625 Compound fractures of thigh, 655 Concussion of the brain, 32 Concussion and compression combined, 46 Concussion of the spinal cord, 333 Concussion of the brain, treatment of, 38 Concussion of the brain, consequences of, 41 Concussion and compression, distinction be- tween, 46 Concretions, salivary, 219 Condyloma, 534 Congenital hydrocele, 574 Congenital hernia, 405 Congenital occlusion of the meatus audito- rius, 243 Conjunctiva, granular, 115, 119 Conjunctivitis, purulent, 115 Conjunctivitis, simple, 112 Conjunctivitis, strumous, 119 Conjunctiva, affections of the, 112 Contraction of toes, 681 Contre-coup, 48 Coracoid process, fracture of, 312 Coretomia, 138 Corectomia, 134 Coredialysis, 140 Cord, spermatic, hsematocele of, 576 Cord, spermatic, hydrocele of, 575 Cord, spermatic, tumors of, 579 Cord, spermatic, varix of, 577 Cornea, affections of the, 121 Cornea, abscess of, 123 Cornea, conical, 129 Cornea, hernia of, 125 Cornea, opacities of, 126 Cornea, over-distension of, 129 Cornea, staphyloma of, 127 Cornea, ulcer of, 124 Corneitis, 121 Corneitis, strumous, 123 Corns, 679 Coronoid process of ulna, fracture of, 318 Corroding ulcer of uterus, 621 Couching, 150 Coup, 48 Coxalgia, 635 Cramp, writers', 301 Cranium, abscess and ulcer of the, 82 Cranium, affections of, 82 Cranium, depression of, 66 Cranium, exostosis of the, 84 Cranium, fissure of, 56 Cranium, fractures of, 56 Cranium, fractures of, at base, 57 Cranium, fissure at base of, 57 710 IND Cranium, fracture of, without displacement, 60 Cranium, fracture of, with displacement, 60 Cranium, fracture of external table of, alone, 65 Cranium, fracture of inner table of, alone, 66 Cranium, injuries of, 32 Cranium, ordinary fractures of, 56 Cranium, penetrating cuts of, 65 Cranium, punctured fractures of, 63 Croup, 267 Cut-throat, 254 Curvatures of spine, 337 Curvature, lateral, of spine, causes of, 337 Cynanche tonsillaris, 221 Cystitis, 488 Cystitis, acute, 488 Cystitis, chronic, 488 Cystocele, vaginal, 604 Crystalline lens and capsule, affections of, 143 Cysticercus tela? cellulosae, 156 Cystic oxide calculus, 449 Cuneiform bones, dislocation of, 672 Cynanche membranacea, 269 Cystine deposit, 445 Dacryolithes, 110 Dacryadenitis, 110 Deafness, 239 Deformities of hand, 303 Deformities of foot, 673 Deligation of carotid artery, 287 Deligation of anonyma, 288 Deligation of subclavian, 288 Deligation of axillary, 291 Deligation of humeral, 292 Deligation of radial and ulnar, 293 Deligation of aorta, 625 Deligation of external iliac, (526 Deligation of internal iliac, 627 Deligation of common iliac, 628 Deligation of common femoral, 631 Deligation of superficial femoral, 631 Deligation of popliteal, 631 Deligation of posterior tibial, 632 Deligation of anterior tibial, 633 Deligation of peroneal, 634 Delirium after injuries of the head, 41 Deposit, lithic, 438 Deposit, oxalate of lime, 441 Deposit, phosphatic, 443 Deposit, cystine, 445 Deposit, uric, 446 Deposit, xanthic oxide, 446 Depressed fracture of the cranium, 66 Depression of cataract, 150 Diaphragm, affections of the, 385 Diaphragm, paralysis of the, 385 Diaphragm, rupture of the, 385 Diaphragmatic hernia, 409 Diastasis of the femur, 655 Diatheses, 436 Diathesis, lithic, 438 EX. Diathesis, oxalic, 441 Diathesis, phosphatic, 443 Diphtheritis, 269 Diplopia, 142 Diseases of scalp and cranium, 78 Dislocations of superior extremity, 324 Dislocation of the carpus, 330 Dislocation of the lower jaw, 211 Dislocation of the clavicle, 324 Dislocation of the scapula, 324 Dislocation of the shoulder, 325 Dislocation of the elbow, 328 Dislocation of the ulna, 328 Dislocation of the radius, 329 Dislocation of the wrist, 330 Dislocation of the fingers, 331 Dislocation of the thumb, 331 Dislocation of the spine, 336 Dislocation of the ribs, 347 Dislocation of the pelvis, 681 Dislocation of the hip, 661 Dislocation of the knee, 668 Dislocation of the patella, 669 Dislocation of the ankle, 669 Dislocation of the tarsus, 671 Dislocation of the toes, 672 Dislocation of tibia at the knee, 668 Dislocation of tibia at the ankle, 669 Dislocation, compound, of the ankle, 670 Dislocation of the head of fibula, 669 Dislocation of the astragalus, 672 Dislocation of the os calcis and astragalus, 672 Dislocation of the cuneiform bones, 672 Dislocation of the metatarsus, 672 Dislocation of the crystalline lens, 152 Displacement of the bladder, 507 Displacements of the uterus, 616 Distichiasis, 97 Distoma oculi, 155 Diverticulum of intestine, 410 Dropsy of the eye, 154 Dropsy, ovarian, 374 Duct, nasal, obstruction of, 109 Duct, nasal, obliteration of, 110 Duct, nasal, absence of, 110 Dura mater, abscess of, 51 Ear, affections of, 235 Ear, polypus of, 235 Ear, hemorrhage from, 242 Earache, 239 Ecchymosis of eye, 91 Ectropion, 102 Eczema mercuriale, 546 Elbow, amputation of, 693 Elbow, dislocation of, 328 Elbow-joint, resection of, 307 Elephantiasis of scrotum, 583 Emphysema, 346 Empyema, 352 Encanthis, 111 Encysted hydrocele, 575 Encysted tumors of scalp, 79 Encysted tumors of eyelids, 94 INDEX. 711 Enlargement of prostate, 510 Entozoa in the eyeball, 155 Entropion, 98 Entropion, Crampton's operation for, 100 Enuresis, 493 Enuresis in children, 493 Epididymitis, 565 Epiphora, 105 Epispadias, 589 Episoraphy, 616 Epistaxis, 167 Epulis, 205 Erectile tumors of orbit. 90 Erectile tumors of scalp. 79 Erectile tumor of tongue, 215 Erectile tumor of nose, 167 Erethismus, 546 Erysipelas of face, 186 Erysipelas of scalp, 78 Erysipelas of scrotum, 583 Eustachian tube, affections of, 241 Exfoliation of skull, 83 Exfoliation from stumps, 704 Exomphalos, 409 Exostosis of cranium, 84 Exostosis of great toe, 68 Extirpation of cervix uteri. 620 Extraction of cataract, 147 Extraction of teeth, 202 Extravasation of blood within cranium, 46 Extravasation of blood between bone and dura mater, 27 ; treatment of, 48 Extravasation of blood on or in brain, 48; treatment of, 49 Extravasation of urine, 502 Extravasation, vesical, of urine, 502 Extravasation, urethral, of urine, 503 Extremity, superior, affections of arteries of, 287 Extremity, superior, diseases of articulations of, 304 Extremity, superior, injuries of, 309 Eye, dropsy of, 154 Eyeball, affections of, 112 Eyeball, congenital deficiency of, 157 Eyeball, entozoa in, 155 Eyeball, extirpation of, 156 Eyeball, tumors of, 156 Eyeball, wounds of, 155 Eyelid, hypertrophy of, 95 Eyelids, injuries of, 91 Eyelids, cancer of, 95 Eyelids, closure of, 95 Eyelids, foreign bodies in, 91 Eyelids, swellings of, 93 Eyelids, tumors of, 94 Eyelids, warts on, 94 Eyelids, wounds of, 91 Face, affections of, 186 Face, erysipelas of, 180 Face, neuralgia of, 187 Face, spasm of, 186 Face, warts of, 184 Face, wounds of, 186 False aneurism, 31 False passages in urethi'a, 555 False cataract, 144 Fascia, palmar, contraction of, 301 Female, calculus in the, 485 Female, gonorrhoea in the, 522 Female, retention of urine in the, 500 Female, syphilis in the, 547 Femoral artery, compression of, 628 Femoral artery, deligation of, 628 Femoral artery, common, aneurism of, 628 Femoral hernia, 400 Femur, fractures of, 646 Femur, fracture of neck of, within capsule, 646 Femur, fracture of, external to capsule, and above trochanter, 648 Femur, fracture of, through trochanters, 664 Femur, fracture of trochanter-major of, 654 Femur, fracture of, below trochanter-minor, 1 654 Femur, fracture of shaft of, 655 Femur, fracture of, above condyles, 655 ! Femur, fracture of condyles of, 655 ! Fibula, dislocation of head of, 661 Fibula, fracture of, 657 Filaria oculi humani, 155 Fingers, amputation of, 687 Fingers, dislocation of, 331 Fingers, hypertrophy of, 303 Fingers, supernumerary, 303 Fingers, webbed, 303 Fissure at the base of cranium, 57 Fissure of the anus, 417 Fissure of the cranium, 56 Fissure, spinal, 336 Fistula after lithotomy, 479 Fistula, fecal, 372 Fistula in ano, 413 Fistula in perineo, 563 Fistula lachrymalis, 107 Fistula, recto-vaginal, 601 Fistula, salivary, 188 Fistula, spermatic, 500 Fistula, tracheal, 272 Fistula, urinary. 563 Fistula, urethro-vaginal, 601 Fistula, vaginal, 595 Fistula, vesico-vaginal, 595 Flap-amputation, 683 Flat-foot, 678 Foot, affections of, 675 Foot, amputation of, 696 Forearm, amputation of, 691 Forearm, deligation of arteries of, 293 Foreign bodies in the brain, 70 Foreign bodies in the ear, 235 Foreign bodies in the eye, 91 Foreign bodies in the nostrils, 170 Foreign bodies in the oesophagus, 231 Foreign bodies in the pharynx, 227 Foreign bodies in the rectum, 429 Foreign bodies in the vagina, 604 I Foreign bodies in the windpipe, 258 Fracture of acromion, 312 712 INDEX. Fracture of astragalus, 660 Fracture of fibula, 657 Fracture of body of scapula, 312 Fracture of both tibia and fibula, 658 Fracture of both radius and ulna, 322 Fracture of calcaneum, 660 Fracture of cranium, without displacement, 60 Fracture of cranium, with displacement, 60 Fracture of external table of cranium alone, 65 Fracture of inner table of cranium alone, 66 Fracture, depressed, of cranium, 66 Fracture of carpal bones, 323 Fracture of clavicle, 309 Fracture of coracoid process, 312 Fracture of cranium, 56 Fracture of femur, 646 Fracture of humerus at its condyles, 316 Fracture of humerus at its neck, 314 Fracture of humerus at its shaft, 315 Fracture of leg, 657 Fracture of lower jaw, 210 Fracture of malar bone, 189 Fracture of malleoli, 660 Fracture of metacarpal bones, 323 Fracture of nasal bones, 162 Fracture of patella, 656 Fracture of pelvis, 645 Fracture of phalanges of fingers, 323 Fracture, punctured, of cranium, 63 Fracture of radius, 318 Fracture of ribs, 346 Fracture of scapula at its neck, 313 Fracture of spine, 334 Fracture of sternum, 347 Fracture of tarsal bones, 660 Fracture of ulna, 317 Fractures at ankle, 660 Fractures, compound, of leg, 659 Fractures, compound, of thigh, 655 Fractures of foot, 661 Fractures of tibia, 657 Fraenum linguae, division of, 216 Frontal sinus, polypus of, 85 Fungus of testicle, 567 Fusible calculus, 449 Ganglia in forearm and wrist, 298 Galactirrhcea, 362 Gastrocnemius muscle, rupture of, 673 Gastrocnemius muscle, laceration of, 674 Gastrostomy, 382 Gastrotomy, 382 Genital organs, affections of female, 591 Gland, lachrymal, affections of, 110 Gland, lachrymal, atrophy of, 111 Gland, lachrymal, tumors of. 111 Gland, parotid, tumors of, 187 Gland, thyroid, affections of, 281 Gland, thyroid, tumors over the, 285 Glaucoma, 154 Glaucoma and amaurosis distinguished from cataract, 114 Glandular enlargement of neck, 245 i Glenoid cavity, fracture of, 313 Glossitis, 213 Glottis, spasm of, 264 Goitre, 281 Gonorrhoea, 514 Gonorrhoea in the female, 522 Gonorrhoea praeputialis, 521 Gonorrhoea spuria, 515 Gonorrhoea, accidents of, 515 Gonorrhoea, treatment of, 516 Gonorrhoeal ophthalmia, 118, 521 Gonorrhoeal lichen, 521 Gonorrhoeal orchitis, 565 Gorget, 481 Grando, 94 Granular conjunctiva, 119 Gravel, 441 Great toe, exostosis of, 681 Great toe, amputation of, 695 Gums, recession of, 203 Gums, tumors of, 205 Gumboil, 205 Hsematocele of neck, 245 Hasmatocele of scrotum, 576 Haematocele of spermatic cord, 577 Haematocele of tunica vaginalis, 577 Haemato-thorax, 350 Haematuria, 491 Haematuria from kidney, 491 Haematuria from bladder, 492 Haematuria from urethra, 493 Ham, affections of, 643 Ham, abscess of, 643 Ham, tumors of, 644 Hand, deformities of, 303 Hand, affections of, 298 Hare-eye, 96 Harelip, 190 Harelip, single, 190 Harelip, double, 191 Harelip, complicated, 192 Heart, wounds of, 359 Hemorrhage after extraction of teeth, 203 Hemorrhage after lithotomy, 476 Hemorrhage from ear, 242 Hemorrhage from rectum, 428 Hemorrhage from stumps, 706 Hemorrhoids, 419 Hemiopia, 142 Hernia, 386 Hernia bronchalis, 285 Hernia, causes of, 386 Hernia cerebri, 71; prevention of, 71 ; cure of, 71 Hernia, component parts of, 386 Hernia, congenital, 405 Hernia, coverings of, 386 Hernia, diagnosis of, 387 Hernia, diaphragmatic, 410 Hernia, direct inguinal, 405 | Hernia, enterocele, 387 Hernia, epiplocele, 387 Hernia, entero-epiplocele, 387 Hernia, femoi-al, 406 INDEX. 713 Hernia humoralis, 565 Hernia, incarcerated, 392 Hernia infantilis, 405 Hernia, intermuscular inguinal, 404 Hernia, irreducible, 391 Hernia, ischiatic, 410 Hernia littrica, 387, 410 Hernia of the lungs, 347 Hernia, oblique inguinal, 403 Hernia, obturatorial, 410 Hernia of the cornea, 125 Hernia, perineal, 410 Hernia, phrenic, 410 Hernia, radical cure of, 390 Hernia, reducible, 389 Hernia, scrotal, 403 Hernia, strangulated, 392 Hernia, strangulated, operation for, 399 Hernia, umbilical, 409 Hernia, vaginal, 409 Hernia, ventral, 409 Hernia, ventro-inguinal, 405 Hernial hydrocele, 576 Hernial contents, 387 Hernial sac, 387 Herpes of penis, 523 Hey's amputations of foot, 696 Hip, dislocation of, 661 Hip, dislocation of, upwards, 662 Hip, dislocation of, backwards, 664 Hip, dislocation of, downwards, 665 Hip, dislocation of, forwards, 666 Hip, anomalous dislocations of, 667 Hip-joint, amputation of, 703 Hip-joint, change of form in, 638 Hip-joint, disease of, 635 Hip-joint, resection of, 642 Hordeolum, 93 Housemaid's knee, 643 Humeral artery, ligature of, 292 Humerus, condyles, fracture of, 316 Humerus, dislocation of the, at the shoulder, 325 Humerus, fracture of, 314 Humerus, fracture of neck of, 314 Humerus, fracture of shaft of, 315 Humors of eye, affections of, 154 Hunterian, or true chancre, 528 Hunter's forceps, 483 Hydrocele, 571 Hydrocele, congenital, 574 Hydrocele, diagnosis of, 571 Hydrocele, encysted, 574 Hydrocele, hernial, 576 Hydrocele in the female, 576 Hydrocele of the cord, 575 Hydrocele of the neck, 245 Hydrocele of tunica vaginalis, 571 Hydrophthalmia, 154 Hydrorachitis, 344 Hydrothorax, 352 Hydro-sarcocele, 572 Hymen, imperforate, 603 Hyo-thyroid bursa, enlargement of, 28j Hyperspadias, 589 Hypertrophy of the auricle, 243 Hypertrophy of clitoris and nymphae, 594 Hypertrophy of the eyelid, 95 Hypertrophy of the fingers, 303 Hypertrophy of the mamma, 363 Hypertrophy, partial, of the mamma, 363 Hypertrophy of the tongue, 214 Hypertrophy of the tonsils, 222 Hypoaema, 135 Hypopion, 135 Hypospadias, 588 Iliacs, deligation of, 626 Iliac, common, deligation of, 628 Iliac, external, deligation of, 026 Iliac, internal, deligation of, 627 Ilium, fracture of, 645 Imperforate anus, 430 Imperforate urethra, 589 Incarcerated hernia, 392 Incisions, mode of making, 18 Incontinence of urine, 493 Induration of the tongue, 214 Infantile hernia, 405 Inflammation, orbital, 88 Inguinal bubo, 536 Inguinal hernia, 404 Inguinal hernia, intermuscular, 405 Inguinal hernia, direct, 405 Injuries of the cranium, 32 Imperforate vagina or hymen, 603 Impotence, 580 Instruments, use of, 18 Intercostal artery, wound of, 348 Intestines, injuries of, 369 Inversion of uterus, 612 Iris, affections of, 132 Iris, adhesions of the, 135 Iris, tremulous, 137 Iritis, 132 Iritis, rheumatic and arthritic, 136 Iritis, strumous, 136 Iritis, syphilitic, 136 Irritable bladder, 490 Irritable mamma, 361 Irritable testicle, 570 Ischiatic hernia, 410 Ischium, fracture of, 645 Itching of the anus, 428 Jaws, affections of, 205 Jaw, anchylosis of the, 212 Jaw, lower, caries and necrosis of, 210 Jaw, lower, dislocation of, 211 Jaw, lower, extirpation of, 207 Jaw, lower, fracture of, 210 Jaw, lower, tumors of, 206 Jaw, upper, extirpation of, 182 Jaw, upper, tumors of, 181 Jaw, upper, large osteosarcoma of, 181 Joints of lower extremity, affections of, 635 Jugular vein, external opening of the, 252 Knee, affections of, 643 Knee-joint, amputation of, 701 714 INDEX. Knee, dislocations of, 668 Knee, housemaid's, 643 Kidney, haematuria from the, 491 Knee, injuries of, 643 Labium, oozing tumor of, 593 Lachrymal apparatus, affections of, 105 Lachrymal fistula, 107 Lachrymal gland, affections of, 110 Lachrymal gland, atrophy of the, 111 Lachrymal gland, tumors of the, 111 Lachrymal sac, affections of, 106 Lachrymal sac, chronic affections of, 106 Lacteal enlargement in breast, 362 Lallemand, M., his porte-caustique, 560 Lagophthalmos, 96 Laryngeal ulceration, 271 Laryngismus stridulus, 264 Laryngotomy, 276 Laryngitis, acute, 265 Laryngitis, chronic, 269 Laryngitis, chronic, thickening of mucous membrane from, 269 Laryngitis fibrinosa, 267 Laryngitis purulenta, 269 Laryngitis cedematosa, 265 Laryngitis simplex, 265 Larynx, apoplexy of the, 263 Larynx, follicular disease of the, 270 Larynx, formation of matter near the, 274 Larynx, diseased cartilage of, 272 Larynx, injury of, 262 Larynx, stricture of, 273 Larynx, ulceration of the, 271 Larynx, warts of, 273 Leg, amputation of, 700 Leg, fractures of, 657 Leg, compound fractures of, 659 Lens and capsule, affections of the crystal- line, 143 Leucoma, 126 Leucorrhoea, diagnosis of, 607 Lipoma of the nose, 162 Lippitudo, 93 Lips, affections of, 190 Lips, ulcers of, 192 Lithate of soda calculus, 450 Lithectasy, 482 Lithic diathesis, 438 Lithic deposit, 438 Lithontriptics, 451 Lithotripsy, 404 Lithotrity, 464 Lithotomy, 400 Lithotomy, aggravation of renal disease by, 478 Lithotomy, bilateral, 480 Lithotomy, constitutional irritation after, 479 Lithotomy, cystitis to be obviated in, 478 Lithotomy, erysipelas after, 479 Lithotomy, hemorrhage after, 476 Lithotomy in children, 480 Lithotomy, lateral, 470 Lithotomy, a deux temps, 481 Lithotomy, peritonitis after, 478 Lithotomy, recto-vesical, 481 Lithotomy, rectal fistula after, 479 Lithotomy, risks of, 476 Lithotomy, supra-pubal, 481 Lithotomy, urinary infiltration after, 477 Lithotomy, urinary infiltration and perito- nitis after, 478 Lithotomy, varieties in, 480 Little finger, amputation of metacarpal bone of, 690 Lower extremity, subluxations and spraiuo of, 673 Lower extremities, injuries of the, 645 Lumbar abscess, 343 Lungs, wounds of, 349 Lungs, hernia of the, 347 Lupus, 172 Malar bone, fracture of, 189 Malleoli, fracture of, 660 Mamma, affections of, 361 [ Mamma, chronic abscess of, 362 Mamma, fungus haematodes of, 364 Mamma, extirpation of, 365 ! Mamma, hypertrophy of, 363 | Mamma, irritable, 361 Mamma, lacteal tumor of, 363 Mamma, malignant tumors of, 364 Mamma, partial hypertrophy of, 363 | Mamma, tumors of, 364 Mamma, tumors external to the, 366 Mammilla, affections of, 366 Mammitis, 361 Mammitis, acute, 361 Mammitis, chronic, 361 Mastoid cells, abscess of, 238 Maxilla, superior, affections of, 179 Maxilla, extirpation of superior, 182 Maxilla, tumors of the, 181 Meatus auditorius, congenital occlusion of the, 243 Medullary nasal polypi, 167 Membrana tympani, perforation of, 242 Meningeal artery, injury of, 47 Mercury, effects of, 545 Mereurio-syphilitic ulcers of nose, 171 Mercury, use of, in syphilis, 542 Metacarpal bones, affections of, 301 Metacarpal bones, amputation of, 688 Metacarpal bones, fractures of, 323 Metacarpal bone of little finger, amputation of, 690 Metacarpal bones, tumors of, 302 Metatarsal bone of great toe, amputation of, 695 Metatarsal bones, amputation of, 696 Metatarsus, dislocation of, 672 Milium, 94 Monostoma lentis, 156 j Mons veneris, malignant disease of, 594 Morbus coxarius, 635 Morbus coxarius, diagnosis of, 641 I Mulberry calculus, 448 Muscae volitantes, 132 INDEX. 715 Mydriasis, 136 Myocephalon, 125 Myosis, 137 Nail, diseased matrix of, 300 Nasal bones, fracture of, 162 Nasal duct, absence of the, 110 Nasal duct, obliteration of, 110 Nasal duct, obstruction of, 109 Nasal polypus, 163 Nasal tubes, passing of, 170 Nebula, 126 Neck, abscess of, 245 Neck, affections of, 245 Neck, affections of the arteries of, 287 Neck, glandular enlargement of, 245 Neck, hydrocele of the, 245 Neck, suspension by the, 262 Neck, tumors of, 251 Neck, wounds of, 254 Necrosis of skull, 83 Neuralgia of the face, 187 Neuralgia of the ear, 239 Neuralgia of stumps, 704 Nipple, affections of, 366 Noli me tangere, 172 Noma, 591 Nose, affections of, 162 Nose, dense fibrous polypus of, 166 Nose, erectile tumor of, 167 Nose, lipoma of, 162 Nose, partial restoration of, 176 Nose, polypus of the, 163 Nostrils, foreign bodies in, 170 Nostrils, plugging of, 168 Nostrils, ulcers of, 171 Nymphae, hypertrophy of, 594 Orbit, tumors of, 89 Orbit, wounds of, 88 Orbital inflammation, 88 Orchitis, 565 Orchitis, acute, 565 Orchitis, chronic, 567 Os calcis, dislocation of, 672 Oscheocele, 403 Osteocephaloma, 181 Osteocystoma, 206 Osteoma, 206 Osteosarcoma, large, of upper jaw, 181 Otalgia, 239 Otitis, 236 Otitis, external and internal, 236 Otoplasties, 243 Otorrhcea, 237 Ovarian dropsy, 374 Ovarian tumors, 374 Ovariotomy, 379 Oxalata of lime calculus, 448 Oxalic diathesis, 441 Ozaena, 172 Palate, affections of, 196 Palate, congenital deficiency of, 196 Palate, ulcer and exfoliation of, 199 Palmar arch, wounds of, 294 Palmar fascia, contraction of, 301 Palsy of the -oesophagus, 234 Pannus, 121 Paracentesis abdominis, 377 Paracentesis capitis, 76 Paracentesis pericardii, 359 Paracentesis thoracis, 352 Paraphymosis, 587 Paralysis of the pharynx, 227 Paronychia, 299 Parotid, tumors of, 187 Parulis, 205 Patella, compound fractures of, 657 Patella, dislocations of, 669 Patella, fractures of, 656 Patella, longitudinal fracture of, 656 Patella, transverse fracture of, 656 Pelvic abscess, 373 Pelvis, dislocation of, 661 Pelvis, fracture of, 645 Pendulous breast, 363 Penis, affections of, 583 Penis, amputation of, 590 Penis, bubo of, 536 Penis, herpes of the, 523 Penis, malignant disease of, 589 Penis, warts on the, 521 Perforation of membrana tympani, 242 Pericranitis, 81 Perineal fistula, 563 Perineal hernia, 409 Perineum, laceration of, 595 Peritonitis, after lithotomy, 477 Perityphlitis, 373 Peroneal artery, deligation of, 634 Phagedaena, sloughing, 530 Pliiigedaenic syphilis, 530 Oblique inguinal hernia, 403 Obliteration of vagina, 603 Occlusion of the pupil, 137 ; three modes of operation, 138 (Edema glottidis, 265 (Edema glottidis, chronic, 270 (Edema of the uvula, 220 Oesophagitis, 230 (Esophagotomy, 233 (Esophagus, affections of the, 230 (Esophagus, foreign bodies in, 231 (Esophagus, palsy of the, 234 (Esophagus, stricture of, 230 Olecranon, fracture ofv 317 Olecranon, affections of bursa over, 297 Omalgia, 304 Onychia, 300 Onyx, 123 Onyxis, 300 Operations, 17 Ophthalmia, 112 Ophthalmia, gonorrhoeal, 118 Ophthalmia, neonatorum, 118 Ophthalmia, purulent, two varieties of, 11') Ophthalmia tarsi, 93 Ophthalmitis, 155 Orbit, affections of, 88 716 INDEX. Phagedaenic ulcer, 530 Phalanges of fingers, affections of, 298 Phalanges of fingers, dislocations of, 331 Phalanges of fingers, fractures of, 323 Phalanges of fingers, tumors of, 301 Pharyngeal abscess, 225 Pharyngitis, 225 Pharynx, affections of the, 225 Pharynx, foreign bodies in, 227 Pharynx, paralysis of, 227 Pharynx, passing of instruments in, 228 Pharynx, sacculated, 227 Pharynx, spasm of, 226 Pharynx, stricture of, 225 Pharynx, tumors of, 227 Phosphatic diathesis, 443 Phosphate of lime calculus, 448 Phthisis laryngea, 272 Phymosis, 585 Piles, 381 Piles, blind, 419 Piles, external, 419 Piles, internal, 420 Pleura, wounds of, 348 Plugging of the nostrils, 168 Plugging of the vagina, 606 Pneumothorax, 351 Pneumocele, 347 Podelkoma, 679 Polypus of the antrum, 180 Polypus of the frontal sinus, 85 Polypus, dense fibrous, of nose, 166 Polypus of the ear, 235 Polypus of the nose, 163 Polypus of the rectum, 423 Polypus of the uterus and vagina, 618 Popliteal aneurism, 629 Popliteal artery, deligation of, 631 Preputial calculus, 485 Pressure in treatment of aneurism, 629 Priapism, 584 Probang, use of, 226, 231 Prolapsus ani, 423 Prolapsus uteri, 614 Prolapsus vaginae, 604 Prostate, affections of, 509 Prostate, abscess of, 509 Prostate, enlargement of, 510 Prostate, malignant tumors of, 513 Prostatic calculus, 485 Prostatitis, 609 Protesting bougie, 554 Pruritus of the vulva, 593 Pseudo-syphilis, 548 Psoas abscess, 343 Pterygium, 121 Ptosis, 97 Pubes, fracture of, 645 Puffy tumor of the scalp, 53 Puncture of the bladder, 600 Puncture of bladder by perineum, 500 Puncture of bladder by rectum, 501 Puncture of bladder above pubes, 501 Punctured fracture of the cranium, 63 Pupil, artificial, 137 Pupil, artificial, operations for, 138 Pupil, contraction of the, 137 Pupil and iris, changes in the, 136 Pupil, occlusion of, 137 Pupil, unusual dilatation of the, 136 Purulent conjunctivitis, 115 Radius, dislocation of, 329 Radius, dislocation of, at the elbow, 329 Radius, dislocation of, at the wrist, 331 Radius and ulna, dislocation of, at the wrist, 330 Radius and ulna, dislocation of, at the elbow, 327 Radius and ulna, fracture of both, 322 Radius, fracture of, 318 Radial artery, ligature of, 293 Ramollissement of spinal cord, 333 Ranula, 216 Reclination of cataract, 150 Rectal fistula after lithotomy, 479 Rectitis, 412 Rectocele, vaginal, 604 Recto-vaginal fistula, 601 Rectum, abscess exterior to, 412 Rectum, affections of, 412 Rectum, foreign bodies in the, 429 Rectum, hemorrhage from, 428 Rectum, injuries of, 429 Rectum, irritable, 427 Rectum, itching of, 428 Rectum, malignant stricture of, 427 Rectum, medullary tumor of, 427 Rectum, polypus of, 423 Rectum, scirrho-contracted, 427 Rectum, stricture of, 425 Rectum, simple organic stricture of, 425 Rectum, spasmodic stricture of, 425 Renal calculi, 452 Resection of ankle, 697 Resection of elbow-joint, 307 Resection of hip-joint, 642 Resection of shoulder-joint, 305 Resection of the wrist, 308 Retention of urine, 495 Retention of urine, from abscess in the peri- neum, 497 Retention of urine from pelvic abscess, 497 Retention of urine from blood in the bladder, 499 Retention of urine from calculus, 497 Retention of urine from diseased prostate, 499 Retention of urine from imperforate urethra, 500 Retention of urine from injury of perineum, 497 Retention of urine from malignant disease of penis, 500 Retention of urine from paralysis, 498 Retention of urine from priapism, 497 Retention of urine from spasm, 496 Retention of urine from stricture, 496 Retention of urine from urethritis, 496 Retention of urine in the female, 500 INDEX. 717 Retina, affections of, 141 Retinitis, 141 Retro-uterine sanguineous tumors, 374 Rheumatic iritis, 136 Rhinolithes, 167 Rhinoplasties, 173 Ribs, caries and necrosis of, 347 Ribs, dislocation of, 347 Ribs, fracture of, 346 Ruspinis styptic, 168 Sacrum, fracture of, 645 Salivary concretions, 219 Salivary fistula, 188 Sarcocele, 570 Sanguineous, retro-uterine, tumors, 374 Scalp, bruise of, 22 Scalp, erectile tumors of, 80 Scalp, erysipelas of, 78 Scalp, contused and lacerated wounds of, 28 Scalp and cranium, diseases of, 78 Scalp, malignant tumors of, 81 Scalp, malignant ulcer of, 81 Scalp, punctured wounds of, 29 Scalp, simple incised wounds of, 27 Scalp, solid tumors of, 80 Scalp, tumors of,. 79 Scalp, wounds of, 27 Scarpa's needle, 150 Scapula, amputation of, 695 Scapula, displacement of angle of, 324 Scapula, fracture of body of, 312 Scapula, fracture of neck of, 313 Schneiderian membrane, simple ulceration of, 171 Schneiderian membrane, congestion of, 170 Scirrho-contracted rectum, 427 Sclerotic, staphyloma of, 130 Sclerotitis, 130 Sclerotic coat, affections of, 130 Scrofulous testicle, 509 Scrotal hernia, 403 Scrotum, affections of, 583 Scrotum, cancer of, 584 Scrotum, elephantiasis of, 583 Scrotum, erysipelas of, 583 Scrotum, haematocele of, 576 Secondary symptoms of syphilis, 523, 538 Semilunar cartilages, displacement of, 668 Septum narium, abscess of, 171 Searcher, 474 Shoulder, amputation of, 694 Shoulder, dislocation of, 325 Shoulder, subluxation of, 327 Shoulder-joint, disease of, 304 Shoulder-joint, resection of, 305 Signoroni's compressor, 683 Sinus, frontal, polypus of the, 85 Sinus of the cheek, 1 88 Skull, caries of the, 82 Skull, exfoliation of, 83 Skull, necrosis of the, 83 Sloughing phagedaena, 530 Sloughing ulcer, 530 Sounding, 458 Spasm of the face, 186 Spasm of the glottis, 264 Spasm of the pharynx, 226 Spermatic cord, haematocele of, 577 Spermatic cord, tumors of, 579 Spermatic fistula, 569 Spermatorrhea, 581 Spina ventosa, 206 Spine, affections of, 333 Spine, causes of lateral curvature of, 337 Spine, caries of, 341 Spine, curvature of, 337 Spine, dislocation of, 336 Spine, fracture of, 335 Spine, malignant disease of, 345 Spina bifida, 344 Spinal cord, compression of, 334 Spinal cord, concussion of, 333 Spinal cord, ramollissement of, 333 Spinal cord, softening of, 333 Spinal fissure, 336 Split palate, 196 Sprains of lower extremity, 673 Squinting, 157 Squinting, varieties of, 157; convergent, di- vergent, 157 Stammering, 216 Staphyloma of the cornea, 127 Staphyloma of the sclerotic, 130 Staphyloraphe, 196 Sterno-cleido-mastoid, division of, 253 Sternum, caries and necrosis of, 347 Sternum, fracture of, 347 Stillicidium lacrymarum, 105 Stomach-pump, use of, 234 Stone in the bladder, 454 Stone in the bladder, treatment of, 458 Stone, boring of, 463 Stone, crushing of, 464, 480 Stone, disintegration of, medicinally, 401 Stone, evulsion of, 463 Stone, excision of, 469 Stone, natural expulsion of, 460 Stone, snaring of, 463 Strabismus, 157 Strabismus, congenital, 159 j Strangulation of hernia, 392 Strangulated hernia, operation for, 399 Stricture of cervix uteri, 617 Stricture of the oesophagus, 230 Stricture of the pharynx, 225 Stricture of the rectum, 425 Stricture of the urethra, symptoms of, 554 Stricture of the urethra, treatment of, 552 Stricture of the urethra, use of bougie in, 553 Stricture of the urethra, 549 Stricture of the vagina, 603 Stricture of the windpipe, 273 Strumous conjunctivitis, 119 Strumous iritis, 136 Stumps, affections of, 704 Stumps, bursae over, 705 Stumps, exfoliation from, 704 Stumps, hemorrhage from, 706 Stumps, neuralgia of, 704 718 INDEX. Stye, 93 Styles in fistula lacrymalis, 108 Styloid, process of ulna, fracture of, 318 Subclavian artery, deligation of, 288 Subluxations of lower extremity, 673 Suicidal wounds of neck, 254 Suspension by the neck, 262 Swellings of eyelids, 93 Symblepharon, 96 Symphysis pubis, separation of, 661 Synechiae, 135 Synchysis oculi, 154 Syphilis, 523 Syphilis, constitutional, 523, 538 Syphilis, common sores in, 524 Syphilis in the child, 547 Syphilis in the female, 547 Syphilis, primary, 523, 538 Syphilis, secondary symptoms of, 538 Syphilis, simple abrasion in, 524 Syphilis, tertiary symptoms of, 540 Syphilis, use of mercury in, 542 Syphilitic iritis, 136 Syphilitic testicle, 567 Talipes, 675 Talipes calcaneus, 676 Talipes equinus, 675 Talipes, spurious, 676 Talipes, treatment of, 677 Talipes valgus, 676 Talipes varus, 676 Tarsus, dislocation of, 671 Tarsus, fracture of, 660 Tartar on Teeth, 203 Taxis, 395 Taxis, auxiliaries to the, 396 Teeth, affections of, 200 Teeth, caries of, 200 Teeth, crowded, 200 Teeth, extraction of, 202 Teeth, hemorrhage after extraction of, 203 Teeth, injuries of the, 204 Teeth, tartar on the, 203 Temporal artery, aneurism of, 31 Temporal artery, ulcer of, 31 Temporal artery, wounds of, 30 Tendo Achillis, rupture of, 673 Tendo Achillis, ununited, 674 Tendo Achillis, wounds of, 674 Teudo Achillis, injuries of the, 673 Tertiary symptoms of syphilis, 540 Testicle, affections of, 505 Testicle, atrophy of, 571 Testicle, descent of, 388 Testicle, fungus of, 567 Testicle, irritable, 570 Testicle, removal of, 579 Testicle, scrofulous, 569 Testicle, syphilitic, 567 Testicle, tumors of, 570 Thigh, compound fractures of, 655 Thecal collections on wrist, 298 Thigh, amputation of, 702 Throat, wounds of, 254 Thrombus of the vulva, 592 Thumb, amputation of, 690 Thumb, dislocation of, 331 Thumb, spastic flexion of, 301 Thyroid cartilage, ossified, fracture of, 263 Thyroid gland, affections of, 281 Thyroid gland, tumors over the, 285 Thyro-hyoid bursa, enlargement of, 285 Tibia, dislocation of, 668 Tibia, dislocation of, at the ankle, 669 Tibia, fractures of, 657 Tibial artery, posterior, deligation of, 632 Tibial artery, anterior, deligation of, 633 Tic douloureux, 187 Toes, amputation of, 696 Toes, contraction of, 681 Toes, dislocation of, 672 Toes, exostosis of, 681 Tongue, affections of, 213 Tongue, erectile tumor of, 215 j Tongue, encysted tumors beneath, 218 | Tongue, fatty tumors beneath, 218 Tongue, hypertrophy of, 214 Tongue, induration of, 214 Tongue, removal of portions of, 215 1 Tongue-tie, 216 I Tongue, tumors beneath, 218 I Tongue, ulcers of, 213 Tongue, wounds of, 213 Tonsillitis, 22] Tonsils, abscess of, 221 Tonsils, hypertrophy of, 222 Tonsils, malignant disease of, 224 Tonsils, ulcers of, 222 Toothache, 201 Torticollis. 252 Trachea, rupture of the, 263 Tracheal fistula, 272 Tracheotomy, 277 Tremulous iris, 137 Trephining, 66 Trichiasis, 97 Trochanters, fracture of, 654 Truss, 390 Tumor, chronic mammary, of Cooper, 366 Tumor, lacteal, 363 Tumor, medullary, of rectum, 427 Tumor, oozing, of labium pudendum, 593 Tumors of the antrum, 180 Tumors of the bladder, 505 Tumors of the cheek, 181 Tumors of the eyeball, 156 Tumors of the ham, 644 Tumors of the labia, 594 Tumors of the lachrymal gland, 111 Tumors of the lower jaw, 206 Tumors' of the mamma, 363 Tumors of the metacarpal bones and pha- langes, 301 Tumors of the neck, 251 Tumors of the orbit, 89 Tumors of the pharynx, 227 Tumors of the scalp, 79 Tumors of the testicle, 570 Tumors of the tongue, 215 INDEX. 719 Tumors, solid, of the scalp, 80 Tumors, malignant, of the scalp, 81 Tumors, erectile, of the scalp, 80 Tumors of the calvarium, 85 Tumors, soft, of orbit, 89 Tumors, encysted, of the eyelids, 94 Tumors, erectile, of nose, 167 Tumors of superior maxilla, 181 Tumors of parotid gland, 187 Tumors over parotid gland, 188 Tumors, malignant, of mamma, 364 Tumors external to the mamma, 366 Tumors over thyroid gland, 285 Tumors of the abdominal parietes, 368 Tumors of the uterus, 374, 381 Tumors, fibrous, of the uterus, 381 Tumors of spermatic cord, 579 Tumors, hard, of orbital parietes, 89 Tunica vaginalis testis, hydrocele of, 571 Tunica vaginalis, haematocele of, 577 Tympanum, perforation of, 242 Ulcer of the anus, 417 Ulcer and exfoliation of the palate, 199 Ulcer, cancerous, of the nose, 173 Ulcer after arteriotomy, 31 Ulcer of the cornea, 124 Ulcer, malignant, of the scalp, SI Ulcer, phagedaenic, 530 Ulcer, sloughing, 530 Ulcer, simple venereal, 524 Ulcer, venereal, with elevated edges. 527 Ulcers of the lips, 192 Ulcers of the lips, malignant. 193 Ulcers, mercurio-syphilitic, 174 Ulcers of nostrils, 171 Ulcers of the tonsils, 222 Ulcers of the tongue, 213 Ulceration of cervix uteri, 608 Ulceration of the larynx, 271 Ulceration, simple, of Schneiderian mem- brane, 171 Ulceration, tubercular, of windpipe, 272 Ulna, dislocation of, 328 Ulna, dislocation of, at the elbow, 328 Ulna, dislocation of, at the wrist, 331 Ulna, fracture of, 317 Ulnar artery, deligation of, 293 Umbilical hernia, 409 Ununited tendo Achillis, 674 Urethra, affections of, 549 Urethra, false passage in, 555 Urethra, haematuria from the, 493 Urethra, imperforate, 589 Urethra, laceration of, 564 Urethra, stricture of, 549 Urethra, vascular excrescence in, 594 Urethral calculus, 483 Urethral extravasation of urine, 503 Urethro-vaginal fistula, 601 Uric calculus, 447 Uric deposit, 438 Uric or xanthic oxide calculus, 450 Uric diathesis, 440 Urinary calculi, 436 Urinary calculi, formation and varieties of, 446 Urinary deposits, tests of, 436 Urinary fistula, 563 Urinary infiltration after lithotomy, 478 Urine, characters of the, 436 Urine, extravasation of, 502 Urine, incontinence of, 493 Urine, mucous, 437 Urine, pathology of, 43(5 Urine, retention of, 495 Urine, retention of, in the female, 500 Urine, vesical extravasation of, 502 Urine, urethral extravasation of, 503 Urinous abscess, 562 Uterus, cancer of, 622 Uterus, cauliflower excrescence of, 021 Uterus, corroding ulcer of, 621 I Uterus, displacements of, 616 I terns, fibrous tumors of, 381 Uterus, inversion of, 612 Uterus, malignant disease of, 621 Uterus, removal of neck of, 620 Uterus, polypi of, 618 Uterus, prolapsus of, 614 | Uvula, oedema of the, 221 I Uvula, elongation of, 221 Uvula and tonsils, affections of the, 221 Vaginitis, 607 Vagina, foreign bodies in, 604 Vagina, imperforate, 603 Vagina, obliteration of, 603 Vagina, plugging of, 606 Vagina, polypi of, 618 Vagina, prolapsus of, 604 Vagina, stricture of, 603 Vaginal hernia, 409 [ Vaginal rectocele, 604 Vaginal cystocele, 604 | Vaginal fistula, 595 Variocele, 577 Vein, jugular, opening of, 252 Velosynthesis, 196 Venereal disease, 514 Venereal disease, general view of, 538 Venereal ulcer with elevated edges, 527 yenereal ulcer, simple, 524 Venesection at the bend of the arm, 295 . Venesection, accidents of, 296 Venesection in the neck, 252 Ventral hernia, 409 Ventro-inguinal hernia, 405 Vertebrae, caries of the, 341 Vertebrae, cervical, disease of, 285 Vertebrae, continuous absorption and simple ulceration in bodies of, 341 Vertebrae, diseases of, 341 Vertebrae, interstitial absorption of bodies of, 341 Vesical extravasation of urine, 502 Vesical calculus, 434 Vesical calculus, palliation of, 483 Vesical calculus, treatment of, 558 Vesico-vaginal fistula, 595 720 Vulva, abscess of, 592 Vulva, inflammation of, 591 Vulva, pruritus of, 593 Vulva, thrombus of, 592 Vulva, warty excrescences of, 593 Warts of the face, 186 Warts of the larynx, 273 Warts of the penis, 521 Warts on the eyelids, 94 Water, boiling, swallowing of, 263 Webbed fingers, 303 Wens, 79 Whartonian ducts, concretions in, 219 Whites, 606 Whitlow, 298 Windpipe, diseases of, 265 Windpipe, foreign bodies in, 258 Windpipe, passing of tubes into the, 276 Windpipe, stricture of the, 273 Windpipe, tubercular ulceration of, 272 Wounds of the bowels, 369 Wounds of the brain, 69 Wounds of the chest, 348 Wounds of the eyeball, 155 DEX. Wounds of the eyelids, 91 Wounds of the face, 186 Wounds of the lips, 195 Wounds of the lung, 349 Wounds of the neck, 254 Wounds of the orbit, 88 Wounds of the palmar arch, 294 Wounds of the pleura costalis, 348 Wounds of both pleurae and of lung, 349 Wounds of the heart, 359 Wounds of the abdomen, 369 Wounds of the scalp, 27 Wounds of the temporal artery, 30 Wounds of the tendo Achillis, 674 Wounds of the throat, 254 Wounds of the tongue, 213 Wrist, amputation of, 691 Wrist and hand, affections of, 298 Wrist, dislocation of, 330 Wrist, resection of, 308 Writers' cramp, 301 Wry-neck, 252 Xanthic oxide deposit, 446 Xeroma, 105 THE END. CATALOGUE OF BLANCHARD & LEA'S MEDICAL AND SURGICAL PUBLICATIONS. PHILADELPHIA, SEPTEMBER, 1853. TO THE MEDICAL PROFESSION. In submitting the following catalogue of our publications in medicine and the collateral sciences, we beg to remark, that no exertions are spared to render the issues of our press worthy a continuance of the confidence which they have thus far enjoyed, both as regards the high character of the works themselves, and in respect to every point of typographical accuracy and mechanical execution. Gentlemen desirous of adding to their libraries from our list, can in almost all cases procure the works they wish from the nearest bookseller, who can readily order any which he may not have on hand. From the great variation in the expenses of transportation through territories so extensive as those of the United States, prices cannot be the same in all sections of the country, and therefore we are unable to affix retail prices to our publications. Information on this point may be had of booksellers generally, or from ourselves, and all inquiries respecting any of our books will meet with prompt attention by addressing BLANC HARD & LEA, Philadelphia. September. 1S-53. TWO MEDICAL PEBIODICALS, FKEE OF POSTAGE, FOR FIVE DOLLARS PER ANNUM. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to _ postage, when not paid for in advance,.......$5 00 THE MEDICAL NEWS AND LIBRARY, invariably in advance, - - 1 00 or, both periodicals furnished, free of postage, for Five Dollars remitted in advance. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D., is published Quarterly, on the first of January, April, July, and October. Each number contains at least two hundred and eighty large octavo pages, appropriately illustrated, wherever necessary, by engravings on copper, stone', or wood. It has now been issued regularly for a period of thirty- five vears, during a quarter of a century of which it has been under the control of the present editor. Throuo-hout this long space of time, it has maintained its position in the highest rank of medical periodicals both at home and abroad, and has received the cordial support of the entire pro- fes-ion in this country. Its list of Collaborators will be found to contain a large number of the most distinguished names of the profession in every section of the United States, rendering the de- partment devoted to ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to all practitioners. As the aim of the Journal, however, is to combine the advantages presented by all the different varieties of periodicals, in its REVIEW DEPARTMENT will be found extended and impartial reviews of all important new works, presenting subjects ol novelty and interest, together with very numerous BIBLIOGRAPHICAL NOTICES, mr-lndine nearly all the medical publications of the day, both in this country and Great Britain, with a choice selection of the more important continental works. This is followed by the BLANCHARD & LEA'S MEDICAL QUARTERLY SUMMARY, being a very full and complete abstract, methodically arranged, of the IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. This department of the Journal, so important to the practising physician, is the object of especial care on the part of the editor. It is classified and arranged under different heads, thus facilitating the researches of the reader in pursuit of particular subjects, and will be found to present a very full and accurate digest of all observations, discoveries, and inventions recorded in every branch of medical science. The very extensive arrangements of the publishers are such as to afford to the editor complete materials for this purpose, as he not only regularly receives ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, but also twenty or thirty of the more important Journals issued in Great Britain and on the Conti- nent, thus presenting in a convenient compass a thorough and complete abstract of everything interesting or important to the physician occurring in any part of the civilized world An evidence of the success which has attended these efforts may be found in the constant and >teady increase in the sub^riplion li.-t, which renders it advisable for gentlemen desiring the Journal, to make known their wishes at an early day, in order to secure a year's set with certainty, the publishers having frequently been unable to supply copies when ordered late in the year. To their old subscribers, many of whom have been on their list for twenty or thirty years, the publish- ers feel that no promises are necessary; but those who may desire for the first time to subscribe, can rest assured that no exertion will be spared to maintain the Journal in the high position which it has occupied for so long a period. By reference to the terms it will be seen that, in addition to this large amount of valuable and practical information on every branch of medical science, the subscriber, by paying in advance, becomes entitled, without further charge, to THE MEDICAL NEWS AND LIBRARY, a monthly periodical of thirty-two large octavo pages. Its "News Department" presents the current information of the day, while the " Library Department" is devoted to presenting stand- ard works on various branches of medicine. Within a few years, subscribers have thus received, without expense, the following works which have passed through its columns :— WATSON'S LECTURES ON THE PRACTICE OF PHYSIC. BRODIE'S CLINICAL LECTURES ON SURGERY. TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. Parts I., II., and III., with numerous wood-cuts. WEST'S LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. MALGAIGNE'S OPERATIVE SURGERY, with wood-cuts, and SIMON'S LECTURES OX GENERAL PATHOLOGY. While the year 1853, presents THE CONTINUATION OF TODD & BO WOMAN'S PHYSIOLOGY, BEAUTIFULLY ILLUSTRATED ON WOOD. t^ Subscribers for 1853, who do not possess the commencement of Todd and Bowman can obtain it, in a handsome octavo volume, of 552 pages, with over 150 illustrations, by mail, free of postage, on a remittance of $2 50 to the publishers. It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber will obtain a Quarterly and a Monthly periodical, EMBRACING ABOUT FIFTEEN HUNDRED LARGE OCTAVO PAGES mailed to any part of the United States, free of postage. These very favorable terms are now presented by the publishers with the view of removing all difficulties and objections to a full and extended circulation of the Medical Journal to the office of every member of the profession throughout the United Slates. The rapid extension of mail facili- ties, will now place the numbers before subscribers with a certainty and dispatch not hertotbre attainable; while by the system now proposed, every subscriber throughout the Union is placed upon an equal footing, at the very reasonable price of Five Dollars for two periodicals, without further expense. Those subscribers who do not pay in advance will bear in mind that their subscription of Five Dollars will entitle them to the Journal only, without the News, and that lhey will be at ihe expen>e of their own postage on the receipt of each number. The advantage of a remittance when order- ing the Journal will thus be apparent. As the Medical News and Library is in no case sent without advance payment, its subscribers will always receive it free of postage. It should also be borne in mind that the publishers will now take the risk of remittances by mail, only requiring, in cases of loss, a certificate from the subscriber's Postmaster, that the money was duly mailed and forwarded I3P Funds at par at the subscriber's place of residence received in payment of subscriptions. Address, BLANCHARD & LEA, Philadelphia. AND SCIENTIFIC PUBLICATIONS. 3 ASHWELL (SAMUEL), M.D. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. With Additions by Paul Beck Goddard, M. D. Second American edition. Iu one octavo volume, of 520 pages. One of the very best works ever issued from the press on the diseases of females.—Western Lancet. This is an invaluable work.—Missouri Medical and Surgical Journal. We strongly recommend Dr. Ashwell's Treatise to our readers as a valuable book of reference, on an extensive, complicated, and highly important class of diseases.—Edinburgh Monthly Journal of Med. Sciences. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, of 484 pages, with about two hundred illustrations. ABERCROMBIE (JOHN), M. D. PATHOLOGICAL AND PRACTICAL RESEARCHES ON DISEASES OF THE STOMACH, INTESTINAL CANAL, &c. Fourth edition, in one small octavo volume, of 2C0 pages. BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS AND ITS APPENDAGES, and on Ulceration and Induration of the Neck of the Uterus. Third edition. In one neat octavo volume, of 350 pages, with wood-cuts. We shall not call it a second edition, because, as Dr. Bennett truly observes, it is really a new work. It will be found to contain not onlya faithful histo- ry of the various pathological changes produced by inflammation in the uterus and its annexed organs, in the different phases of female life, but also an ac- curate analysis of the influence exercised by inflam- mation in the production of the various morbid con- ditions of the uterine system, hitherto described and treated as functional.—British,and Foreign Medico- CMrurgical Review. Few works issue from the medical press which are at once original and sound in doctrine ; but such, we feel assured, is the admirable treatise now before us. The important practical precepts which the author inculcates are all rigidly deduced from facts. . . . Every page of the boolt is good, and eminently practical. ... So far as we know and believe, it is the best work on the subject of which it treats.— Monthly Journal of Medical Science. We refer our readers with satisfaction to this work for information on a hitherto most obscure and diffi- cult class of diseases.—London Medical Gazette. One of the beat practical monographs amongst modern English medical books.—Transylvania Med. Journal. BEALE (LIONEL JOHN), M.R.C.S., &c. THE LAWS OF HEALTH IN RELATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one handsome volume, royal 12mo., extra cloth. BILLING (ARCHIBALD), M. D. THE PRINCIPLES OF MEDICINE. Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth, 250 pages. BLAKISTON (PEYTON), M.D., F PRACTICAL OBSERVATIONS ON CERTAIN CHEST, and on the Principles of Auscultation R. S., &.C. DISEASES In one volume, 8vo., pp. 384. OF THE BENEDICT (N. D.), M. D. COMPENDIUM OF LECTURES ON THE THEORY AND PRACTICE OF MEDICINE, delivered by Professor Chapman in the University of Pennsylvania. In one octavo volume, of 258 pages. BURROWS (GEORGE), M. D. ON DISORDERS OF THE CEREBRAL CIRCULATION, and on the Con- nection between the Affections of the Brain and Diseases of the Heart. In one 8vo. vol., with colored plates, pp. 216. 4 BLANCHARD & LEA'S MEDICAL BUDD (GEORGE), M. D., F. R. S., Professor of Medicine, in King's College, London. ON DISEASES OF THE LIVER. Second American, from the second and enlarged London edition. In one very handsome octavo volume, with four beautifully colored plates, and numerous wood-cuts. pp. 468. New edition. (Now Ready.) The reputation which this work has obtained as a full and practical treatise on an important class of diseases will not be diminished by this improved and enlarged edition. It has been carefully and thoroughly revised by the author; the number of plates has been increased, and the style of its me- chanical execution will be found materially improved. The full digest we have given of the new matter introduced into the present volume, is evidence of the value we place on it. The fact that the profes- sion has required a second edition of a monograph such as thiit before us, bears honorable testimony to its usefulness. For many years, Dr. Budd's work must be the authority of the great mass of British practitioners on the hepatic diseases ; and it is satisfactory that the subject has been taken up by so able and experienced a physician.—British and Foreign Medico-Chirurgical Review. We cannot too strongly recommend the diligent study of this volume. The work cannot fail to rank the name of its author among the most enlightened pathologists and soundest practitioners of the day. — Medico-Chirurgical Review. We feel bound to say that Dr. Budd's treatise is greatly in advance of its predecessors. It is the 6rst work in which the results of microscopical anatomy and the discoveries of modern chemistry have been brought fully to bear upon the pathology and treat- ment of diseases of the liver; and it is the only work in which a method of studying diseases of this organ, founded upon strictly inductive principles, is de- veloped.— Dublin Medical Press. Having thus attempted to give a brief summary of the more important contents of this work, we would, in conclusion, recommend it to every practitioner and student as well worthy of a careful and patient perusal.— The New Orleans Medical and Surgical Journal. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp. 460. BRIGHAM (AMARIAH), M.D. ON MENTAL CULTIVATION AND EXCITEMENT. 18mo., extra cloth. In one neat volume, BRODIE (SIR BENJAMIN C), M. D., &c. CLINICAL LECTURES ON SURGERY. 1 vol. 8vo., cloth. '350 pp. BY THE SAME AUTHOR. PATHOLOGICAL AND SURGICAL OBSERVATIONS ON THE DIS- EASES OF THE JOINTS. 1 vol. 8vo., cloth, pp. 216. BY THE SAME AUTHOR. LECTURES ON THE DISEASES OF THE URINARY ORGANS. 1 vol. Svo., cloth, pp.214. *#* These three works may be had neatly bound together, forming a large volume of" Brodie's Surgical Works." pp. 780. BIRD (GOLDING), A. M., M. D., &c URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. A new American, from the third and improved Londou edition. With over sixty illustrations. In one royal 12mo. volume, extra cloth, pp. 338. The new edition of Dr. Bird's work, though not increased in size, has been greatly modified, and much of it rewritten. It now presents, in a com- pendious form, the gist of ull that is known and re- liable in this department. From Its terse style and convenient size, it is particularly applicable to the stmlunt, to whom we cordially commend it.— The M"lical Examiner. ' It can scarcely be necessary for us to say anything of the merits of this well-known Treatise, which so admirably brings into practical application the re- sults of those microscopical and chemical researches regarding the physiology and pathology of the uri- nary secretion, which have contributed so much to the increase of our diagnostic powers, and to the extension and satisfactory employment of our thera- peutic resources. In the preparation of this new edition of his work, it is obvious that Dr. Golding Bird has spared no pains to render it a faithful repre- sentation of the present state of scientific knowledge on the subject it embraces. Although, of course, there are many topics which are open to differences of opinion, we cannot point to any well-substantiated result of inquiry which the author has overlooked.— The British and'Foreign Medico-Chirurgical Review. BY THE SAME AUTHOR. ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro- duction to the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From the third London edition. In one neat volume, royal 12mo. pp. 402. AND SCIENTIFIC PUBLICATIONS. 5 BARTLETT (ELISHA), M. D., Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and Surgeons, New York. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. Third edition, revised and improved. In one octavo volume, of six hundred pages, beautifully printed, and strongly bound. In preparing a new edition of this standard work, the author has availed himself of such obser- vations and investigations as have appeared since the publication of his last reviVion, and he has endeavored in everyway to render it worthy of a continuance of the very marked favor with which it has been hitherto received. Of the value and importance of such a work, it is needless here to speak; the profession of the United States owe much to the author for the very able volume which he has presented to them, and for the careful and judicious manner in which he has exe- cuted his task. No one volume with which we are acquainted contains so complete a history of our fevers as this. To Dr. Bnrtlett we owe our best thanks for the very able volume he has given us, as embodying certainly the most complete, methodical, and satisfactory account of our fevers nnywhere to be met with.— The Charleston Med. Journal and Review. The masterly and elegant treatise, by Dr. Bartlett is invaluable to the American student and practi- tioner.—Dr. Holmes's Report to the Nat. Med. Asso- ciation. We regard it, from the examination we have made of it, the best work on fevers extant in our language, and as such cordially recommend it to the medical public.—St. Louis Medical and Surgical Journal. Take it altogether, it is the most complete history of our fevers which has yet been published, and every practitioner should avail himself of its con- tents.— The Western Lancet. BY THE SAME AUTHOR. AN INQUIRY INTO THE DEGREE OF CERTAINTY IN MEDICINE, and into the Nature and Extent of its Power over Disease. In one volume, royal 12mo. pp. 84. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. volume, royal 12mo., with numerous illustrations, pp. 288. In one neat, BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. With numerous illustrations. In one neat volume, royal 12mo. pp.350. COLOMBAT DE L'ISERE. A TREATISE ON THE DISEASES OF FEMALES, and on the Special Hygiene of their Sex. Translated, with many Notes and Additions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, octavo, with numerous wood-cuts. pp. 720. The treatise of M. Colombat is a learned and la- M. Colombat De L'fsere has not consecrated ten borious commentary on these diseases, indicating years of studious toil and research to the frailer sex very considerable research, great accuracy of judg- in vain; and although we regret to hear it is at the ment, and no inconsiderable personal experience, expense of health, he has imposed a debit of gratitude With the copious notes and additions of its experi- as well upon the profession, as upon the mothers and eoced and very erudite translator and editor, Dr. | daughters of beautiful France, whieh that gallant Meigs, it presents, probably, one of the most com- nation knows best how to acknowledge.— Ntw Or- plete and comprehensive works on the subject we leans Medical Journal. possess.—American Med. Journal. COPLAND (JAMES), M. D., F. R. S., een-Gtirgeon to Guy's Hospital; and the volume before .us may be said to consist of an account of the resuSts of his surgical experience during that long penicd We cordially recommend Mr. Bransby •Cooper'* Lectures as a most valuable addition to our eurgacal literature, and one which cannot fail to be of service both to students and to those who are acbh'ety.engaged in the practice of their profes- sion.—The Lancet. A good boot by a good man is always welcome; jffld JMr. Braiisby Cooper's book does no discredit to COOPER (SIR ASTLEY P.), F. R. S., &c. A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. Edited by Bransby B. Cooper, F. R. S , Sec. With additional Observations by Prof. J. C. Warren. A new American edition. In one handsome octavo volume, with numerous illustra- tions on wood. BY THE SAME AUTHOR. ON THE ANATOMY AND TREATMENT OF ABDOMINAL HERNIA. One large volume, imperial Svo., with over 130 lithographic figures. BY THE SAME AUTHOR. ON THE STRUCTURE AND DISEASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial Svo., with 177 figures, on2 j . even by those advanced in the study, who may be de- H„?£?hP;t"\^ sirous of refreshing their memory I«- f< rgottcn K^Snnrinn" ^f?£° ^'^ itPr°f*"j! t0 j ting details r*.?«,"£2f « ' /"r k a"d FOre'S" iU4U°' technical difficulties, instead of explaining them, Lhirurgicat Keview. j *■ . u- . c \ ■ i ■ . r • . " I and of treating subjects of high scientific interest A work well adapted to the wants of the student, in an unscientific way .—Edinburgh Monthly Jour- It is an excellent exposition of the chief doctrines | nal of Meiical Science. GRAHAM (THOMAS), F. R.S., Professor of Chemistry in University College, London, 4c. THE ELEMENTS OF CHEMISTRY. Including the application of the Science to the Arts. With numerous illustrations. With Notes and Additions, by Robert Bridges, M. D., &c. i5cc. Second American, from the second and enlarged London edition PART I. (Lately Issued) large Svo., 430 pa^es, 185 illustrations. PART II. (Preparing) to match. The great changes which the science of chemistry has undergone within the last few years, ren- der a new edition of a treatise like the present, almost a new work. The author has devoted several years to the revision of his treatise, and has endeavored to embody in it every fact and inference of importance which has been observed and recorded by the great body of chemical investigators who are so rapidly changing the face of the science. In this manner the work has been greatly increased incize, and the number of illustrations doubled ; while the labors of the editor have been directed towards the introduction of such matters as have escaped the attention of the author, or as have arisen since the publication of the first portion of this edition in London, in 1850. Printed in handsome style, and at a very low price, it is therefore confidently presented to Ihe pro- fession and the student as a very complete and thorough text-book of this important subject. GROSS (SAMUEL D.), M. D., Professor of Surgerv in the Louisville .Medical Institute, &c A PRACTICAL TREATISE ON THE DISEASES AND INJURIES OF THE URINARY ORGANS. In one large and beautifully printed octavo volume, of over seven hundred pages. With numerous illustrations. A volume replete with truths and principles of the utmost value in the investigation of these diseases.— American Medical Journal. Dr. Gross has brought all his learning, experi- ence, tact, and judgment to the task, and has pro- duced a work worthy of his high reputation. We feel perfectly safe in recommending it to our read- ers as a monograph unequalled in interest and practical value by any other on the subject in our language; and we cannot help saying, that we es- teem it a matter of just pride, that another work bo creditable to our country has been contributed to our medical literature by a Western physician. —The Western Journal of Medicine and Surgery. We regret that our limits preclude such a notice as this valuable contribution to our American Medical Literature merits. We have only room to say that the author deserves the thanks of the profession for this elaborate production; which cannot fail to augment the exalted reputation ac- quired by his former works, for which he has been honored at home and abroad.—X. Y. Med Gazette. Whoever will peruse the vast amount of valuable practical information it contains, and which we have been unable even to notice, will, we think, agree with us, that there is no work in the English language which can make any just pretensions to be its equal. Secure in the esteem and confidence I commendation by their own perusal of it of the profession in this country, at least, its distin- I and Foreign Medico-Chirurgical Review. guished author will doubtless rereive their warmest congratulations that he has succeeded in producing a treatise so creditable to himself, nnd, as we hum- bly believe, to American surgical literature.__N. Y. Journal of Medicine. It has remained for an American writer to wipe away this reproach ; and so completely has the tnsk been fulfilled, that we venture to predict for Dr. Gross's treatise a permanent place in the literature of surgery, worthy to rank with the best works of the present age. Not merely is the matter good, but the getting up of the volume is must creditable to transatlantic enterprise; the paper and print would do credit to a first-rate London establishment; and the numerous wood-cuts which illustrate it, de- monstrate that America is making rapid advances in this department of art. We have, indeed, unfeigned pleasure in congratulating all concerned in this pub- lication, on the result of their labours; and expe- rience a feeling something like whatanimates a long- expectant husbandman, who, oftentimes disappointed by the produce of a favorite field, is at last agree- ably surprised by a stately crop which may bear comparison with any of its former rivals. The f rounds of our high appreciation of the work will e obvious as we proceed; and we doubt not that the present facilities for obtaining American books will induce many of our readers to verify our re- British GRIFFITH (JOHN WILLIAM), M. D., &c. A PRACTICAL MANUAL ON THE BLOOD AND" SECRETIONS OF THE HUMAN BODY. Royal 12mo., with plates. (See " Manuals on Blood and Urine.") 16 BLANCHARD & LEA'S MEDICAL GLUGE (GOTTLIEB), M. D., Professor of Physiology and Pathological Anatomy in the University of Brussels, &c. AN ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva- nia. In one volume, very large imperial quarto, with three hundred and twenty figures, plain and colored, on twelve copperplates. nite service to those who desire to investigate the subject systematically, and who have felt the diffi- culty of arranging in their mind the unconnected observations of a great number of authors. The development of the morbid tissues, and the formation of abnormal products, may now be followed and studied with the same ease and satisfaction as the best arranged system of physiology. — American Med. Journal. We are glad to see this excellent work of Gluge translated into English by so competent a hand, and put within the reach of the profession in this coun- try. The history of the development and changes of the elements of pathological tissues, has become now a necessary introduction to the study of morbid anatomy. It can no longer be looked upon as merely accessory. Bearing the same relation to it as does normal histology to normal anatomy, it appears to us to be of still higher importance, since it has a closer and more direct bearing upon practical medi- cine. Whatever makes our knowledge of diseased structure clearer, must throw light also upon the plan of cure, and show us, too, in many instances, where a cure is impossible. This being, as far as we know, the only work in which pathological his- tology is separately treated of in a comprehensive manner, it will, we think, for this reason, be of infi- Professor Gluge's work will be found a very valu- able addition to the necrologist's collection. It contains, in the compass of one volume, a concise description and well-executed illustrations of the elements to be observed under the microscope in the principal pathological lesions.—Dublin Quarterly Journal of Medical Science. GRIFFITH (ROBERT E.), M. D., &.C. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- tists. In one large octavo volume, of 5G8 pages, double columns. Dr. Griffith's Formulary is worthy of recommen- dation, not only on account of the care which has been bestowed on it by its estimable author, but for its general accuracy, and the richness of its details. —Medical Examiner. Most cordially we recommend this Universal Formulary, not forgetting its adaptation to drug- gists and apothecaries, who would find themselves vastly improved by a familiar acquaintance with this every-day book of medicine.—The Boston Med. and Surg. Journal. A very useful work, and a most complete compen- dium on the subject of materia medica. We know of no work in our lang-uage, or any other, so com- prehensive in all its details.—London Lancet. Pre-eminent among the best and most useful com- pilations of the present day will be found the work before us, which can have been produced only at a very great cost of thought and labor. A short de- scription will suffice to show that we do not put too high an estimate on this work. We are not cog- nizant of the existence of a parallel work. Its value will be apparent to our readers from the sketch of its contents above given. We strongly recommend it to all who are engaged either in practical medi- cine, or more exclusively with its literature.—Lond. Med. Gazette. A valuable acquisition to the medical practitioner, and a useful book of reference to the apothecary on numerous occasions.—Amer. Journal of Pharmacy. BY THE SAME AUTHOR. MEDICAL BOTANY; or, a Description of all the more important Plants used in Medicine, and of their Properties, Uses, and Modes of Administration. In one large octavo volume, of 704 pages, handsomely printed, with nearly 350 illustrations on wood. One of the few books which supply a positive de- ficiency in our medical literature.—Western Lancet. We hope the day is not distant when this work will not only be a text-book in every medical school and college in the Union, but find a place in the li- brury of every private practitioner.—X. Y. Journal of Medicine. One of the greatest acquisitions to American medi- cal literature. It should by all means be introduced, at the very earliest period, into our medical schools, and occupy a place in the library of every physician in the land.—South-western Medical Advocate. Admirably calculated for the physician nnd stu- dent — we have seen no work which promises greater advantages to the profession.—.Y. O. Med. and Surg. Journal. GREGORY (WILLIAM), F. R. S. E., Professor of Chemistry in the University of Edinburgh, &c. LETTERS TO A CANDID INQUIRER ON ANIMAL MAGNETISM. Description and Analysis of the Phenomena. Details of Facts and Cases. In one neat volume, royal 12mo., extra cloth. GARDNER (D. PEREIRA), M. D. MEDICAL CHEMISTRY, for the use of Students and the Profession: being a Manual of the Science, with its Applications to Toxicology, Physiology, Therapeutics, Hygiene In one handsome royal 12mo. volume, with illustrations. &c. AND SCIENTIFIC PUBLICATIONS. 17 HASSE (C. E.), M. D. AN ANATOMICAL DESCRIPTION OF THE DISEASES OF RESPIRA- TION AND CIRCULATION. Translated and Edited by Swaine. In one volume, octavo. HARRISON (JOHN), M.D. AN ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume, 292 pages. HUNTER (JOHN). TREATISE ON THE VENEREAL DISEASE. With Notes and numerous Additions, by Dr. Ph. Ricord, Surgeon to the Venereal Hospital of Paris. Translated from the French, with additional Notes, by F. J. Bumstead, M. D. In one octavo volume, with plates. (Nearly Ready.) Ricord's Annotations to Hunter's Treatise are very extensive, amounting: to nearly half as much as the original work, and bringing it thoroughly up to the present state of the subject. HORNER (WILLIAM E.), M. D., Professor of Anatomy in the University of Pennsylvania. SPECIAL ANATOMY AND HISTOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, of more than one thousand pages, hand- somely printed, with over three hundred illustrations. This work has enjoyed a thorough and laborious revision on the part of the author, with the view of bringing it fully upto the existing state of knowledge on the subject of general and special anatomy. To adapt it more perfectly to the wants of the student, he has introduced a large number of additional wood-engravings, illustrative of the objects described, while the publi>hers have en- deavored to render the mechanical execution of the work worthy of the extended reputation which it has acquired. The demand which has carried it to an EIGHTH EDITION is a sufficient evi- dence of the value of the work, and of its adaptation to the wants of the student and professional reader. HORNER (W. E.) in connection with H. H. SMITH. ANATOMICAL ATLAS. One volume, imperial 8vo. (See Smth.) HOBLYN (RICHARD D.), A. M. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revised, with numerous Additions, from the second London edition, by Isaac Hays, M. D., &c. In one large royal 12mo. volume, of four hundred and two pages, double columns. We cannot too strongly recommend this small and cheap volume to the library of every student and practitioner.—Medico-Chirurgical Review. HOPE (J.), M. D., F. R. S., &c. A TREATISE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Edited by Pennock. In one volume, octavo, with plates, 572 pages. HERSCHEL (SIR JOHN F. W.), F. R. S., &c. OUTLINES OF ASTRONOMY. New American, from the third London edition. In one neat volume, crown octavo, with six plates and numerous wood-cuts. (Just Issued.) JOHNSTON (ALEXANDER KEITH), F. R. S.f &c. THE PHYSICAL ATLAS OF NATURAL PHENOMENA. For the use of Colleges, Academies, and Families. In one large volume, imperial quarto, handsomely and strongly bound, with twenty-six Plates, engraved and colored in the best style. Together with 112 pages of descriptive letter-press, and a very copious Index. 18 BLANCHARD & LEA'S MEDICAL JONES (T. WHARTON), F. R. S., &.c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. Edited by Isaac Hays, M. D., &c. In one very neat volume, large royal 12mo., of 529 pages, with four plates, plain or colored, and ninety-eight wood-cuts. We are confident that the reader will find, on perusal, that the execution of the work amply fulfils the promise of the preface, and sustains, in every point the already high reputation of the author as an ophthalmic surgeon as well as a physiologist and pathologist. The book is evidently the result of much labor and research, and has been written with the greatest care and attention; it possesses that best quality which a general work, like a sys- tem or manual can show, viz.: the quality of having all the materials whencesoever derived, so thorough- ly wrought up, and digested in the author's mind, as to come forth with the freshness and impressive- ness of an original production. We regret that we have received the book at so late a period as pre- cludes our giving more than a mere notice of it, as, although essentially and necessarily a compilation, it contains many things which we should be glad to reproduce in our pages whether in the shape of new pathological views, of old errors corrected, or of sound principles of practice in doubtful cases clearly laid down. But we dare say most of our readers will shortly have an opportunity of seeing these in their original locality, as we entertain little, doubt that this book will become what its author hoped it might become, a manual for daily reference and consultation by the student and the general practi- tioner. The work is marked by that correctness, clearness, and precision of style which distinguish all the productions of the learned author.—British and Foreign Medical Review. KIRKES (WILLIAM SENHOUSE\ M. D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, ic; and JAMES PAGET, F. R. S., Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital. A MANUAL OF PHYSIOLOGY. Second American, from the second and improved London edition. With one hundred and sixty-five illustrations. In one large and handsome royal 12mo. volume, pp. 550. (Just Issued.) In the present edition, the Manual of Physiology has been brought up to the actual condition of the science, and fully sustains the reputation which it has already so deservedly attained. We consider the work of MM. Kirkes and Paget to constitute one of the very best handbooks of Physiology we possess —presenting just such an outline of the science, com- prising an account of its leading facts and generally admitted principles, as the student requires during his attendance upon a course of lectures, or for re- ference whilst preparing for examination. The text is fully and ably illustrated by a series of very supe- rior wood-engravings, by which a comprehension of some of the more intricate of the subjects treated of is greatly facilitated.—Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it contains all the recent improvements in this department of medical science. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know, without special details, which are read with interest only by those who would make a specialty, or desire to possess a criti- cal knowledge of the subject.—Charleston Medical Journal. One of the best treatises that can be put into the hands of the student.—London Medical Gazette. The general favor with which the first edition of this work was received, and its adoption as a favor- ite text-book by many of our colleges, will insure a large circulation to this improved edition. It will fully meet the wants of the student. — Southern Med. and Surg. Journal. It possesses the especial merit of being clear and concise, and at the same time affording a good out- line of Physiology.—Western Lancet. Numerous new and superior illustrations have been introduced for the purpose of making the sub- ject of more easy comprehension by the student. This edition has evidently been prepared with great care, and is handsomely printed on good paper, and will prove a very valuable book for the student in acquainting himself with all the leading well-es- tablished facts in physiology, and I" >r the practitioner as a work of reference.—Xew York Medical Times. Particularly adapted to those who desiTe to pos- sess a concise digest of the facts of Human Physi- ology.—British and Foreign Med.-Chirurg. Review. We conscientiously recommend it as an admira- ble " Handbook of Physiology."—London Journal of Medicine. KNAPP (F.), PH. D., &.c. TECHNOLOGY; or, Chemistry applied to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by Prof. Walter R. Johnson. In two hand- some octavo volumes, printed and illustrated in the highest style of art, with about rive hundred wood-engravings. LEHMANN. PHYSIOLOGICAL CHEMISTRY. Translated by George E. Day M. D. In one very large octavo volume. (Preparing.) ' LEE (ROBERT), M. D., F. R. S., &.c. CLINICAL MIDWIFERY; comprising the Histories of Five Hundred and Forty-five Cases of Difficult, Preternatural, and Complicated Labor, with Commentaries. From In one royal 12mo. volume, extra cloth, of 238 pages. the second London edition. AND SCIENTIFIC PUBLICATIONS. 19 LAWRENCE (W.), F. R. S., &.C. A TREATISE ON DISEASES OF THE EYE. Third American edition, much improved and enlarged. With over two hundred illustrations. By Isaac Hays, M. D., Surgeon to Wills Hospital, Philadelphia, &:c. In one very large and handsome octavo volume, of over eight hundred pages. This new edition to be ready by July. This work, by far the largest and most comprehensive on the subject within reach of the profes- sion in this country, will receive an entire revision on the part of the editor. Brought up in this manner to the most advanced state of science, and presenting an equal improvement over its prede- cessors as regards mechanical execution, it is confidently presented as worthy of the extended repu- tation which it has hitherto enjoyed. BY THE SAME AUTHOR. A TREATISE ON RUPTURES; from the fifth London edition. In one octavo volume, sheep, 480 pages. LEIDY (JOSEPH), M. D. Professor of Anatomy in the University of Pennsylvania, &c. ATLAS OF PATHOLOGICAL HISTOLOGY. By Gottlieb Gluge, M. D. Translated from the German, with Additions, by Joseph Leidy, M. D , Professor of Anatomy in the University of Pennsylvania. In one vol., large imperial quarto, with 320 figures, plain and colored, on twelve plates. BY THE SAME AUTHOR. HUMAN ANATOMY. By Jones Quaix, M D. From the fifth London edition. Edited by Richard Qi-ain, F. R. S., and William Sharpey, M.D., F. R. S., Professors of Anatomy and Physiology, in University College, London. Revised, with Notes and Additions, by Joseph Leidy, M. D . Prot'e~' volume in any language.— .V. Y. Journal of Without doubt the ablest exposition of the prin- 1 Medicine. etples of that branch of the healing art in any Ian- i by the same author. (Now Ready.) THE PRACTICE OF SURGERY. Third American from the second Edin- burgh edition. Edited, with Additions, by F. W. Sargent, M. D , one of the Surgeons'to Will's Hospital, dec. Illustrated by three hundred and nineteen engravings on wood. In one larse octavo volume, of over seven hundred pages. This new edition will be found greatly improved and enlarged, as well by the addition of much new matter as by the introduction of a large and complete series of handsome illustrations. An equal improvement exists in the mechanical execution of the work, rendering it in everv respect a companion volume to the " Principles." We had occasion in a former number of this Jour- nal, to speak in deservedly high terms of Professor Miller's work on the " Principles of Surgery," and we are happy to be able to pronounce an equally favorable judgment on the manner in which the pre- sent volume is executed. * * # We feel no hesitation in recommending Professor Miller's two volumes as affording to the student what the author intended, namely, a complete text-book of Surgery. —British and Foreign Medical Review. Although, as we are modestly informed in the preface, it is not put forth in rivalry of the excel- lent works on Practical Surgery which already exist, we think we may take upon ourselves to say that it will form a very successful and formide.ble rival to most of them.—Northern Journ. of Medicine. Taken together thev form a very condensed and complete system of Surgery, not surpassed, as a text-book, by any work with which we are ac- quainted.— 111. and Ind. Med. and Surg. Journal. Mr. Miller has said more in a few words than any writer since the days of Celsus.—N. O. Med. and Surg. Journal. MALGAJGNE (J. F.). OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French, by Frederick Brittan, A. B., M. D. With numerous illustrations on wood. In one handsome octavo volume, of nearly six hundred pages. We have long been accustomed to refer to it as one To express in a few words our opinion of Mal- nf the most valuable text-books in our library.— gaigne's work, we unhesitatingly pronounce it the Buffalo Med. and Surg. Journal. very best guide in surgical operations that has come Certainly one of the best books published on ope- before the profession in any language.— Charleston rative surgery.—Edinburgh Medical Journal. Med- and SurS- Journal. MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, of 570 pages, with over 500 engravings on wood. It is a book, however, which will be in the hands of almost everyone who is much interested in phar- maceutical operations, as we know of no Other pub- lication so well calculated to fill a void long felt.— Medical Examiner. The book is strictly practical, and describes only manipulations or methods of performing the nume- rous processes the pharmaceutist has to go through, in the preparation and manufacture of medicines, together with all the apparatus and fixtures neces- sary thereto. On these matters, this work is very full and complete, and details, in a style uncom- monly clear and lucid, not only the more compli- cated and difficult processes, but those not less im- portant ones, the most simple and common.—Buffalo Medical Journal. The country practitioner who is obliged to dis- pense his own medicines, will find it a most valuable assistant.—Monthly Journal and Retrospect. 22 BLANCHARD & LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. forming one volume, very large imperial quarto. With Sixty-eight Jarge and splendid Plates, drawn in the best style, and beautifully colored. Containing one hundred and ninety Figures, many of them the size of life. TOGETHER WITH COPIOUS AND EXPLANATORY LETTER-PRESS. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. Copies can be sent by mail, in five parts, done up in stout covers. This great work being now concluded, the publishers confidently present it to the attention of the profession as worthy in every respect of their approbation and patronage. No complete work of the kind has yet been published in the English language, and it therefore will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy to which the student and practitioner can at all times refer, to ascertain the exact relative position of ihe various portions of ihe human frame towards each other and to the surface, as well as their abnormal de- viations. The importance of such a work to the student in the absence of anatomical material, and to the practitioner when about attempting an operation, is evident, while the price of the book, not- withstanding the large size, beauty, and finish of the very numerous illustrations, is so low as to place it within the reach of every member of the profession. ' The publishers therefore confidently anticipate a very extended circulation for this magnificent work. vailed, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand. T" the publishers, the professioa in America is deeply indebted for placing such a valuable, such a useful work, at its disposal, and at such a moderate price. It is one of the most finished and complete pictures of Surgical Anato- my ever offered to the profession of America.— With these plates before them, the student and prac- titioner can never be at a loss, under the most despe- rate circumstances. We do not intend these for commonplace compliments. We are sincere; be- cause we know the work will be found invaluable to the young, no less than the old, surgeon. We have not space to point out its beauties, and its merits; but we speak of it en masse, as a whole, and strongly urge—especially those who, from their position, may be debarred the privilegeand opportu- nity of inspecting the fresh subject, to furnish them- selves with the entire work.—The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. AVe know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. A careful study of these plates, and of the commentaries on them, would almost make an ana- tomist of a diligent student. And to one who has studied anatomy by dissection, this work is invalu- able as a perpetual remembrancer, in matters of knowledge that may slip from the memory. The practitioner can scarcely consider himself equipped for the duties of his profession without such a work as this, and this has no rival, in his library. In those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory. We appeal to our readers, whether any one can justifiably undertake the practice of medi- cine who is not prepared to give all needful assist- ance, in all matters demanding immediate relief. We repeat that no medical lihrary, however large, can be complete without Maclise's Surgical Ana- tomy. The American edition is well entitled to the confidence of the profession, and should command, among them, an extensive sale. The investment of the amount of the cost of this work will prove to be a very profitable one, and if practitioners would qualify themselves thoroughly with such important knowledge as is contained in works of this kind, there would be fewer of them sighing for employ- ment. The medical profession should spring towards such an opportunity as is presented in this republica- tion, to encourage frequent repetitions of American enterprise of this kind.— The Western Journal of Medicine and Surgery. One of the greatest artistic triumphs of the age in Surgical Anatomy.—British American Medical Journal. Too much cannot be said in its praise; indeed, we have not language to do it justice.—Ohio Medi- cal and Surgical Journal. The most admirable surgical atlas we have seen. To the practitioner deprived of demonstrative dis- sections upon the human subject, it is an invaluable companion.—N. J. Medical Reporter. The most accurately engraved and heautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.—Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a "work, is offered at so moderate a price.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medi- cal Examiner. Every practitioner, we think, should have a work of this kind within reach.—Southern Medical and Surgical Journal. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given.—Boston Medical and Surgical Journal. As a surgical anatomist, Mr. Muclise has- proba- bly no superior.—British and Foreign Medico-Chi- rurgical Review. Of great value to the student engaged in dissect- ing, and to the surgeon at a distance from the means of keeping up his anatomical knowledge.—Medical Times. The mechanical execution cannot be excelled.— Transylvania Medical Journal. A work which has no parallel in point of accu- racy and cheapness in the English language.—X. Y. Journal of Medicine. To all engaged in the study or practice of their profession, such a work is almost indispensable.— Dublin Quarterly Medical Journal. No practitioner whose means will admit should fail to possess it.—Ranking's Abstract. Country practitioners will find these plates of im- mense value.—N. Y. Medical Gazette. We are extremely gratified to announce to the profession the completion of this truly magnificent work, which, as a whole, certainly stands unri- 11®*' The very low price at which this work is furnished, and the beauty of its execution require an extended sale to compensate the publishers for the heavy expenses incurred. ' AND SCIENTIFIC PUBLICATIONS. 23 MULLER (PROFESSOR J.), M. D. PRINCIPLES OP PHYSICS AND METEOROLOGY. Edited, with Addi- tions, by R. Eglesfeld Griffith, M. D. In one large and handsome octavo volume, extra cloth, with 550 wood-cuts, and two colored plates. The Physics of MQller is a work superb, complete, I tion to the scientific records of this country mav be unique: the greatest want known to English Science j duly estimated by the fact that the cost of the oriei- could not have been better supplied. The work is I nal drawihsrs and engravings alone has exceeded the of surpassing interest. The value of this contribu- sum of £2,1)00 —Lancet MAYNE (JOHN), M. D., M. R. C. S., &c. A DISPENSATORY AND THERAPEUTICAL REMEMBRANCER Com- prising the entire lists ol Materia Medica, with every Practical Formula contained m the three British Pharmacopoeias. U ,th relative Tables subjoined, illustrating, by upwards of six hundred andsixty examp es, the Extemporaneous Forms and Combinations suitable for the different Medicines. Edited, with the addition of the Formulae of the United States Pharmacopoeia, by R. Eglesfeld Griffith, M. D. In one 12mo. volume, extra cloth, of over 300 large pages. MATTEUCCI (CARLO). LECTURES ON THE PHYSICAL PHENOMENA OF LIVING BEINGS Edited by Pereira. In one neat royal 12mo. volume, extra cloth, with cuts, 388 pages. MARKWICK (ALFRED). A GUIDE TO THE EXAMINATION OE THE URINE IN HEALTH AND DISEASE. Royal 12mo. (See Manuals on Blood and Urine.) MEDLOCK (HENRY), AND F. SCHOEDLER. BOOK OF NATURE; or Elements of the Science of Physics, Astronomy Chem- istry, Mineralogy, Geology, Botany, Zoology, and Physiology. (See Schoedler.) In one vol. large 12mo. An admirable work for families and District Schools. NEILL (JOHN), M. D., Demonstrator of Anatomy in the University of Pennsylvania; Surgeon to the Pennsylvania Hospital, &c; and FRANCIS GURNEY SMITH, M.D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. Second edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of" over one thousand pages, with three hundred and fifty illustrations on wood. Strongly bound in leather, with raised bands. (Extensively used by students.) PREFACE TO THE NEW EDITION. The speedy sale of a large impression of this work has afforded to the authors gratifying evidence of the correctness of the views which actuated them ui its preparation. In meeting the demand for a second edition, they have therefore been desirous to render it more worthy of the favor with which it has been received. To accomplish this, they have spared neither time nor labor in embo- dying in it such discoveries and improvements as have been made since its first appearance, and such alterations as have been suggested by its practical use in the class and examination-room. Considerable modifications have thus been introduced throughout all the departments treated of in the volume, but more especially in the portion devoted to the " Practice of Medicine," which has been entirely rearranged and rewritten. The authors therefore again submit their work to the profession, with the hope that their efforts may tend, however humbly, to advance the great cause of medical education. Notwithstanding the increased size and improved execution of this work, the price has not been increased, and it is confidently presented as one of the cheapest volumes now before the profession. In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recommend it to all last course students, but there is a class to whom we very sincerely commend this cheap book as worth its weight in silver — that class is the graduates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left it off.—The Stethoscope Having made free use of this volume in our ex- aminations of pupils, we can speak from experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them ; and this is unquestionably the best of its class. Let every practitioner who has pupils provide himself with it, and he will find the labor of refreshing his knowledge so much facilitated that he will be able to do justice to his pupils at very little cost of time or trouble to himself.—Transyl- vania Med. Journal. 24 BLANCHARD & LEA'S MEDICAL NELIGAN (J. MOORE), M. D., M. R. I. A., &c. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. In one neat royal 12mo. volume, of 334 pages. (Just Issued.) We know of no other treatise on this interesting I The greatest value of Dr. Neligan's treatise con- and important class of diseases that so happily meets | sists in the plain and thoroughly practical exposition the urgent wants of the great mass of physicians.— I he has given of this class of maladies.—Brit, and N. Y. Journal of Medicine. \ For. Med.-Chirurg. Review. PHILLIPS (BENJAMIN), F. R. S., &c. SCROFULA; its Nature, its Prevalence, its Causes, and the Principles of its Treatment. In one volume, octavo, with a plate. PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of most of the Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia Medica. Edited by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the Universily of Pennsylvania. In two very large octavo volumes, on small type, with about four hundred illustrations. Volume I.—Lately issued, containing the Inorganic Materia Medica, over 800 pages, with 145 illustrations. Volume II.—Embracing the Organic Materia Medica, was left by the late author in nearly a com- plete state, is now revising with his MSS., by Alfred S. Taylor and G. Owen Rees, and may be expected in October 1853, with plates and several hundred wood-cuts. The present edition of this favorite and standard work, will be found far superior to its predeces- sors. Besides very large additions and alterations which were made in the last London edition, the work has undergone a thorough revision on the part of the author expressly for this country ; and has farther received numerous additions from the editor. It is thus greatly increased in size, and most completely brought up to the present state of oifr knowledge on this important subject. A similar improvement will be found in its mechanical execution, being printed with new type on fine white paper, with a greatly extended series of illustrations, engraved in the highest style of art. The work, in its present shape, and so far as can be judged from the portion before the public, forms the most comprehensive and complete treatise on materia medica extant in the English language.— Dr. Pereira has been at great pains to introduce into his work, not only all the information on the natural, chemical, and commercial history of medi- cines, which might be serviceable to the physician and surgeon, but whatever might enable his read- ers to understand thoroughly the mode of prepar- ing and manufacturing various articles employed either for preparing medicines, or for certain pur- poses in the arts connected with materia medica and the practice of medicine. The accounts of the physiological and therapeutic effects of remedies are given with great clearness and accuracy, and in a manner calculated to interest as well as instruct the reader.—The Edinburgh Medical and Surgical Journal. PAGET (JAMES), F. R. S., AND W. S. KIRKES. MANUAL OF PHYSIOLOGY. Second American edition. One vol., large 12mo. (See Kirkes.) PIRRIE (WfLLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Demonstrator of Anatomy in the University of Pennsylvania, Surgeon to the Pennsylvania Hospital, &c. In one very handsome octavo volume, of 780 pages, with 316 illus- trations. (Just Issued.) However well it may be adapted for a text-book (and in this respect it may compete with the best of them) of this much our rending has convinced us, that as a systematic treatise, it is carefully and ably written, nnd can hardly fail to command a prominent position in the library of practitioners; though not complete in the fullest sense of the word, it never- theless furnishes the student and practitioner with as chaste and concise a work as exists in our lan- guage. The additions to the volume by Dr. Neill, are judicious; and while they render it more, com- plete, greatly enhance its practical value, as a work for practitioners and students.—N. Y. Journal of Medicine. We know of no other surgical work of a reason- able size, wherein there is so much theory and prac- tice, or where subjects are more soundly or clearly taught.—The Stethoscope. There is scarcely a disease of the bone or soft parts, fracture, or dislocation, that is not illustrated by accurate wood-engravings. Then, again, every instrument employed by the surgeon is thus repre- sented. These engravings are not only correct, but really beautiful, showing the astonishing degree of perfection to which the art of wood-ensfraving has arrived. Prof. Pirrie, in the work before us, has elaborately discussed the principles of surgery, and a safe and effectual practice predicated upon them. Perhaps no work upon this subject heretofore issued is so full upon the science of the art of surgery.— Nashville Journal of Medicine and Surgery. We have made ourselves more intimately acquaint- ed with its details, and can now pronounce it to be one of the best treatises on surgery in the English language. In conclusion, we very strongly recom- mend this excellent work, both to the practitioner and student.—Canada Med. Journal. Our impression is, that as a manual for students, Pirrie's is the best work extant.—Western Med. and Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 25 RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY", in reference to the Process of Parturition. Sixth American, from the last London edition. Illustrated with one hundred and forty-eight Figures, on fifty-five Lithographic 1 lates. In one large and handsomely printed volume, imperial octavo, with 520 pages. In this edition, the plates have all been redrawn, and the text carefully read and corrected. It is therefore presented as in every way worthy the favor with which it has so long been received. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and ns being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our country. We recommend the student who desires to mas- I When the whole profession is thus unanimous ter this difficult subject with the least possible in placing such a work in the very first rank us trouble, to possess himself at once of a copy of this regards the extent nnd correctness ol nil the details work.—American Journal of the Med. Sciences. \ of the theory and practice of so important njjrnnch It stands at the head of the long 1 dbstetric works published in the last Great Britain, Ireland, and the Conti rooe. We consider this book indispensable to the | "■■■»»" ««» "■• . — ■ "'.,'r"..".' T*.'.r»n.V library of every physician engaged in the practice "P™ "'e profession.-JX. O. Med. Journal. of midwifery .—Southern Med. and Surg. Journal. RIGBY (EDWARD), M. D. Physician to the General Lying-in Hospital, tec. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, 422 pages. The repeated demands for this work, which has now for some time been out of print, have in- duced the publishers to prepare another edition. The reputation which it has acquired for the clearness of its views, especially as regards the physiological portion of obstetrical science, will secure for it the confidence of the profession. A copy of the first edition was placed in the hands uf the late Professor Dewees, a few weeks before his death, and obtained from him the expression of his most favorable opinion. RICORD (PH.), M. D. HUNTER ON VENEREAL, with extensive Additions by Ricord. (Nearly Ready.) See Hinter. ROYLE J. FORBES), M.D. MATERIA MEDICA AND THERAPEUTICS; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. With ninety-eight illustrations. In one large octavo volume, of about seven hundred pages. This work is, indeed, a most valuable one, and I ductions on the other extreme, which are neces- will fill up an important vacancy that existed be- sarily imperfect from tlieir small extent.—British tween Dr. Pereira's most learned and complete and Foreign Medical Review. system of Materia .Medica, and the class of pro- | REESE (G. OWEN), M. D. ON THE ANALYSIS OF THE BLOOD AND URINE IN HEALTH ANI) DISEASE, and on the Treatment of Urinary Diseases. Royal 12mo., with plates. (Sec Blood and Urine, Manuals of.) RICORD (P.), M. D. A PRACTICAL TREATISE ON VENEREAL DISEASES. With a Thera- peutical Summary and Special Formulary. Translated by Sidney Doane, M. D. Fourth edition. One volume, octavo, 340 pages. SKEY (FREDERICK C), F. R. S., &.c. OPERATIVE SUUGERY. In one very handsome octavo volume of over G50 pages, with about one hundred wood-cuts. Its literary execution is superior to most surgical We cannot withhold from this work our high corn- treatises. It abounds in excellent moral hints, and mendation. Studentsand practitioners will find it an is replete with original surgical expedients and sug- invaluable teacher and guide upon every topic con- gestions.— Buffalo Med. and Surg. Journal. nected with this department.—JV. Y. Medical Ga- .. , , ztlte. With high talents, extensive practice, and a long experience, Mr. Skey is perhaps competent to the A work of the very highest importance—a work task of writing a complete work on operative sur- by itself.— London Med. Gazette. gery.—Charleston Med. Journal. 26 BLANCHARD & LEA'S MEDICAL SHARPEY (WILLIAM), M.D., QUAIN (JONES), M.D., AND QUAIN (RICHARD), F. R. S., &.C. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M.D. Complete in two large octavo volumes, of about thirteen hundred pages. Beautifulry illustrated with over five hundred engravings on wood. It is indeed a work calculated to make an era in anatomical study, by placing before the student every department of his science, with a view to the relative importance of each ; and so skilfully have the different parts been interwoven, that no one who makes this work the basis of his studies, will hereafter have any excuse for neglecting or undervaluing any important particulars connected with the structure of the human frame; and whether the bias of his mind lead him in a more especial manner to surgery, physic, or physiology, he will find here a work at once so comprehensive and practical as to defend him from exclusiveness on the one hand, and pedantry on the other.— Monthly Journal and Retrospect of the Medical Sciences. We have no hesitation in recommending this trea- tise on anatomy as the most complete on that sub- ject in the English language; and the only one, perhaps, in any language, which brings the. state of knowledge forward to the most recent disco- veries.—The Edinburgh Med. and Surg. Journal. Admirably calculated to fulfil the object for which it is intended.—Provincial Medical Journal. The most complete Treatise on Anatomy in the English language.—Edinburgh Medical Journal. There is no work in the English language to be preferred to Dr. Quain's Elements of Anatomy.— London Journal of Medicine. SMITH (HENRY H.), M. D., AND HORNER (WILLIAM E.), M. D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, with about six hundred and fifty beautiful figures. With the view of extending the sale of this beautifully executed and complete "Anatomical Atlas," the publishers have prepared a new edition, printed on both sides of the page, thus mate- rially reducing its cost, and enabling them to present it at a price about forty per cent, lower than former editions, while, at the same time, the execution of each plate is in no respect deteriorated, and not a single figure is omitted. These figures are well selected, and present a complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- late the student upon the completion of this Atlas, as it is the most convenient work of the kind that has yet appeared ; and we must add. the very beau- tiful manner in which it is " got up" is so creditahle to the country as to be flattering to our national pride.—American Medical Journal. SARGENT (F. W.), M. D. ON BANDAGING AND OTHER POINTS OF MINOR SURGERY. In one handsome royal 12mo. volume of nearly 400 pages, with 128 wood-cuts. The very best manual of Minor Surgery we have seen ; an American volume, with nearly four hundred octavo pages of good practical lessons, illustrated by about one hundred and thirty wood-cuts. In these days of "trial," when a doctor's reputation hangs upon a close hitch, or the roll of a bandage, it would be well, perhaps, to carry such a journal as Mr. Sargent's always in our coat-pocket, or, at all events, to listen attentively to his instructions at home.—Buffalo Med. Journal. We have carefully examined this work, and find it well executed and admirably adapted to the use of the student. Besides the subjects usually embraced in works on Minor Surgery, there is a short chapter on bathing, another on anaesthetic agents, and an appendix of formulae. The author has given an ex- celleutwork on this subject,and his publishers have illustrated and printed it in most beautiful style.— The Charleston Medical Journal. I STANLEY (EDWARD). A TREATISE ON DISEASES OF THE BONES. extra cloth, 280 pages. In one volume, octavo, SMITH (ROBERT WILLIAM). A TREATISE ON FRACTURES IN THE VICINITY OF JOINTS AND ON DISLOCATIONS. One volume octavo, with 200 beautiful wood-cuts. SIMON (JOHN), F. R. S. GENERAL PATHOLOGY, as conducive to the Establishment of Rational Principles for the Prevention and Cure of Disease. A Course of Lectures delivered at St. Thomas's Hospital during the summer Session of 1850. In one neat octavo volume. (Lately discoveries in Pathology, but that which is even more valuable, a systematic outline for the prosecu- tion of their future studies and investigations. Alto- gether, we look upon it as one of the most satisfactory and rational treatises upon that branch now extant. —Medical Examiner. Issued.) His views are plainly and concisely stated, and in such an attractive manner, as to enchain the atten- tion of the reader, and should they be adopted by the profession at large, are calculated to produce im- portant changes in medicine. Physicians and stu- dents will obtain from its perusal, not only the latest SMITH (TYLER W.), M. D.f Lecturer on Obstetrics in the Hunterian School of Medicine. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one large duodecimo vo ume, of 400 pages. AND SCIENTIFIC PUBLICATIONS. 27 SOLLY (SAMUEL), F. R. S. THE HUMAN BRAIN; its Structure, Physiology, and Diseases. With a Description of the Typical Forms of the Brain in the Animal Kingdom. From the Second and much enlarged London edition. In one octavo volume, with 120 wood-cuts. SCHOEDLER (FRIEDRICH), PH.D., Professor of the Natural Sciences at AVorms, &c. THE BOOK OF NATURE; and Elementary Introduction to the Sciences of Physics, Astronomy. Chemistry, Mineralogy Geology, Botany, Zoology, and Physiology. Trans- lated from the sixth German edition, wiih Additions, by Henry Mi-dlock, F. C. S.,\Vc. And Additions and Alterations by the American Editor. In one thick volume, small oclavo, with over 600 illustrations on wood. (Suitable for the higher Schools.) SMITH ANALYTICAL (F. GURNEY), M. D., AND JOHN NEILL, M. D. COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE. One vol., large 12mo. (See Neill.) TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Third American, from the fourth and improved English Edition. "With Notes and References to American Decisions, by Edward Hartshorne M. D. In one large octavo volume, of about seven hundred pages. (Just Ready.) In the preparation of the English edition, from which this has been printed, the author has found it necessary to revise the whole of the chapters, as well as to make numerous alterations and addi- tions, together with references to many recent cases of importance. A Glossary has also been added for the convenience of those whose studies have not been directed specially to this subject. The notes of the American editor embrace the additions formerly made by Dr. Griffith, who revised the work on its first appearance in this country, together with such new matter as his experience and the progress of the science have shown to be advisable. The work may therefore be regarded as fully on a level wilh the most receut discoveries, and worthy of the reputation which it has ac- quired u» a complete and compendious guide for the physician and lawyer. So well is this work known to the members bo*h i to desist before completing it. In the last London iif the medical and legal professions, and so highly is it appreciated by thern,that it cannot be necessary for us to say a word in i ts commendation ; its having already reached a fourth edition being the best pos- sible testimony in its favor. The author has ob- viously subjected the entire work to a very careful revision. We find scattered through it numerous additions nnd alterations, some of them of consider- able importance; and reference is made to a large number of cases which have occurred since the date of the last publication.—British and Foreign Med.- Chirurg. Review. The fourth edition of Dr. Taylor's Manual of Medical Jurisprudence needs merely a simple an- nouncement at our hands; the merits of the work have been freely canvassed by us on a former occa- sion, and we have now but to say that the author has spared no pains in keeping it on a par in all re- spects with the advance of both medical and legal science.—Dublin Med. Journal. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest extant on the subject of medical jurisprudence. It is certainly one of the most attractive bodks that we have met with ; sup- plying so much both to interest and instruct, that we do not hesitate to affirm that after havincr once commenced its perusal, few could be prevailed upon edition, all the newly observed and accurately re- corded facts have been inserted, including much that is recent of Chemical, Microscopical, and Patholo- gical research, besides papers on numerous subjects never before published; in the supervision of this, the third American, one of the last labors of the la- mented Dr. Griffith, we find a goodly number of notes and additions. The publishers deserve the support of the profession for the publication of a work of such sterling merit.—Charleston Medical Journal and Review. It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In saying this, we do not wish to be understood as detracting from the merits of the excellent works of Beck, Ryan, Traill, Guy, and others; but in interest and value we think it must be conceded that Taylor is superior to anything that has preceded it. The author is already well known to the profession by his valuable treatise on Poisons ; and the present volume will add materially to his high reputation for accurate and extensive know- ledge and discriminating judgment. Dr Griffith has, in his notes, added many matters of interest witn reference to American Statute Law, Sec, so that, the work is brought completely up to the wants of the physician and lawyer at the present day.—N. W. Medical and Surgical Journal. BY THE SAME AUTHOR. OX POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo volume, of 0*sS pages. The most elaborate work on the subject that our literature possesses.—British and Foreign Medico- Chirurgical Review. It contains a vast body of facts, which embrace all that is important in toxicology, all that is necessary to the guidance of the medical jurist, and all that can lie desired by the lawyer. — Medico- Chirurgical Review. One of the most practical nnd trustworthy works on Poisons in our language.—Western Journal of Medicine. It is, so far as our knowledge extends, incompa- rably the best upon the subject; in the highest de- gree creditable to the author, entirely trustworthy, and indispensable to the student and practitioner.— N. Y. Annalist. THOMSON (A. T.), M. D., F. R. S., &c. DOMESTIC MANAGEMENT OF THE SICK ROOM, necessary in aid of Medical Treatment for the Cure of Diseases. Edited by R. E. Griffith, M. D. royal 12mo. volume, with wood-cuts, 360 pages. In one larg 28 BLANCHARD & LEA'S MEDICAL TODD (R. B.), M. D., AND BOWMAN (WILLIAM), F. R. S. PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With numerous handsome wood-cuts. Parts I, II, and III, in one octavo volume, 552 pages. Part IV will complete the work. The distinguishing peculiarity of this work is, that the authors investigate for themselves every fact asserted; and it is the immense labor consequent upon the vast number of observations re- quisite to carry out this plan, which has so long delayed the appearance of its completion. Part IV, with numerous original illustrations, is now appearing in the Medical News and Library for 1853. Those who have subscribed since the appearance of the preceding portion of the work can have the three parts by mail, on remittance of $2 50 to the publishers. TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. VOLUME V, for 1852, large 8vo., of 940 pages, with numerous maps. Also to be had, a few sets of the Transactions from 1848 to 1851, in four large octavo volumes. These volumes are published by and sold on account of the Association. WATSON (THOMAS), M. D., &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Third American, from the last London edition. Revised, with Additions, by D. Francis Condib, M. D , author of a " Treatise on the Diseases of Children," &c. In one octavo volume, of nearly eleven hundred large pages, strongly bound with raised bands. To say that it is the very best work on the sub- ject now extant, is but to echo the sentiment of the medical press throughout the country. — JV. O. Medical Journal. Of the text-books recently republished Watson is very justly the principal favorite.—Holmes's Rep. to Nat. Med. Assoc. By universal consent the work ranks among the very best text-books in our language.—Illinois and Indiana Med. Journal. Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medicine extant.—St. Louis Med. Journal. We consider this as the ablest work in the En- glish language, on the subject of which it treats; the author being the first stethoscopist of the day. —Charleston Medical Journal. The examination we have given the above work, convinces us that it is a complete system or treatise upon the great speciality of Physical Diagnosis. To give the reader a more perfect idea of What it con- AT THE BEDSIDE AND AFTEF Published under the authority of the London handsome volume, royal 12mo., extra cloth. (- Did not the perusal of the work justify the high opinion we have of it, the names of Dr. Walshe, the originator, and of Dr. Ballard, as the editor of the volume, would almost of itself have satisfied us that it abounds in minute clinical accuracy. We need not say that the execution of the whole reflects the highest credit not only upon the gentlemen men- tioned, but upon all those engaged upon its produc- tion. In conclusion, we are convinced that the possession of the work will be almost necessary to every member of the profession—that it will be found indispensable, to the practical physician, the pathologist, the medical jurist, and ubove all to the medical student.—London Medical Times. We hail the appearance of this book as the grand desideratum.—Charleston Medical Journal. This little work, if carefully read by even old practitioners, cannot fail to be productive of much good; as a guide to the younger members of the pro- fession in directing their attention specially to the best mode of investigating cases so as to arrive at Confessedly one of the very best works on the principles and practice of physic in the English or any other language.—Med. Examiner. Asa text-book it has no equal; as a.compendium of pathology and practice no superior.—New York Annalist. We know of no work better calculated for being placed in the hands of the student, and for a text- book ; on every important point the author seems to have posted up his knowledge to the day.— Amer. Med. Journal. One of the most practically useful books that ever was presented to the student. — N. Y. Med. Journal. tains, we should be glad to copy the whole table of contents and make some extracts from its pages, but our limits forbid. We have no hesitation in recom- mending the work as one of the most complete on this subject in the English language; and yet it is not so voluminous as to be objectionable on this ao- count, to any practitioner, however pressing his engagements.—Ohio Medical and Surgical Journal. ; DEATH, IN MEDICAL CASES. Society for Medical Observation. In one very rust Issued.) correct diagnosis, it will prove exceedingly valua- ble. The great difficulty with beginners, who have not been under the immediate training of an expe- rienced physician, is continually found to be in the appreciation of the true condition of the organs and tissues. Let such provide themselves with this work and study it thoroughly, and they will find much of the difficulty removed.—Southern Medical and Surgical Journal. This is truly a very capital book. The whole medical world will reap advantages from its publi- cation. The medical journals will soon show its influence on the character of the il Reports of Cases" which they publish. Drs. Ballard and Walshe have given to the world, through a small but useful medical organization, a cheap but invaluable book. We do advise every reader of this notice to buy it and use it. Unless he is so vain as to imagine him- self superior to the ordinary human capacity, he will in six months see its inestimable advantages.__ Stethoscope. WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London. DISEASES OF THE HEART, LUNGS, AND APPENDAGES; their Symptoms and Treatment. In one handsome volume, large royal 12mo., 512 pages. WHAT TO OBSERVE AND SCIENTIFIC PUBLICATIONS. 29 WILSON (ERASMUS), M.D., F. R. S., Lecturer on Anatomy, London. A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- can, from the last English edition. Edited by Paul B. GoddaRd, A. M., M D. With two hun- dred and fifty illustrations. Beautifully printed, in one large octavo volume, of nearly six hun- dred pages. ' In many, if not all the Colleges of the Union, it has become a standard text-book. This, of itself, is sufficiently expressive of its value. A work very desirable to the student; one, the possession of which will greatly facilitate his progress in the Btudy of Practical Anatomy.—New York Journal of Medicine. Its author ranks with the highest on Anatomy.— Southern Medical and Surgical Journal. It ofTers to the student all the assistance that can be expected from such a work.—Medical Examiner. The most complete and convenient manual for the student we possess.—American Journal of Medical Science. In every respect, this work as an anatomical guide for the student and practitioner, merits our warmest and most decided praise.—London Medical Gazette. BY THE SAME AUTHOR. THE DISSECTOR; or, Practical and Surgical Anatomy. Modified and Re- arranged, by Paul Beck Goddard, M. D. A new edition, with Revisions and Additions. In one large and handsome volume, royal 12mo., with one hundred and fifteen illustrations. In passing this work again through the press, the editor has made such additions and improve- ments as the advance of anatomical knowledge has rendered necessary to maintain the work in the high reputation which it has acquired in the schools of the United Slates, as a complete and faithful guide to the student of practical anatomy. A number of new illustrations have been added, espe- cially in the portion relating to the complicated anatomy of Hernia. In mechanical execution the work will be found superior to former editions. BY THE SAME AUTHOR. ON DISEASES OF THE SKIN. Third American, from the third London edition. In one neat octavo volume, of about five hundred pages, extra cloth. (Just Issued.) Also, to be had done up with fifteen beautiful steel plates, of which eight are exquisitely colored ; representing the Normal and Pathological Anatomy of the Skin, together with accurately colored delineations of more than sixty varieties of disease, most of them the size of nature. The Plates are also for sale separate, done up in boards. The increased size of this edition is sufficient evidence that the author has not been content with a mere republication, but has endeavored to maintain the high character of his work as the standard text-book on this interesting and difficult class of diseases. He has thus introduced such new matter as the experience of the last three or four years has suggested, and has made such alterations as the progress of scientific investigation has rendered expedient. The illustrations have also been materially augmented, the number of plates being increased from eight to sixteen. The "Diseases of the Skin," by Mr. Erasmus Wilson, may now be regarded as the standard work in that department of medical literature. The plates by which this edition is accompanied leave nothing to be desired, so far as excellence of delinea- tion and perfect accuracy of illustration are con- cerned.—Medico-Chirurgical Review. As a practical guide to the classification, diag- nosis, and treatment of the diseases of the skin, the book is complete. We know nothing, considered in this aspect, better in Our language; it is a safe authority on all the ordinary matters which, in this range of diseases, engage the practitioner's attention, and possesses the high quality—unknown, we believe, to every older manual—of being on a level with science's high-water mark; a sound book of practice.—London Med. Times. Of these plates it is impossible to speak too highly. The representations of the various forms of cuta- neous disease are singularly accurate, and the color- ing exceeds almost anything we have met wilh in point of delicacy and finish.—British and Foreign Medical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, beautifully printed, with four exqui- site colored plates, presenting more than thirty varieties of syphilitic eruptions. This, in many respects, is a remarkable work, pre- senting views of theory and principles of practice which, if true, must change completely the existing state of professional opinion.—New York Journal of Medicine. Dr. Wilson's views on the general subject of Syphilis appear to us in the main sound and judi- cious, and we commend the book as an excellent monograph on the subject. Dr. Wilson has pre- sented us a very faithful and lucid description of Syphilis and has cleared up many obscure points in connection with its Iransmissibilit.y, pathology and sequelae. Hisfactsand references will, weare satis- fied, be received us decisive, in regard to many questiones vexatre. They appear to us entitled to notice at some, length. \Ve have perhaps been some- what prodigal of space in our abstract of this book. But it is certainly a very good resume of received opinions on Syphilis, and presents, to many, original and striking views on the subject.—Med. Examine. WHITEHEAD (JAMES), F. R. C. S., &c. THE CAUSES AND TREATMENT OF ABORTION AND STERILITY; being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus. In one volume, octavo, 368 pages. 30 BLANCHARD & LEA'S MEDICAL • WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, with illustrations. (Just Ready.) So liltle is generally known in this country concerning the causes, symptoms, and treatment of aural affections, that a practical and scientific work on that subject, from a practitioner of Mr. Wilde's great experience, cannot fail to be productive of much benefit, by attracting attention to this obscure class of diseases, which too frequently escape attention until past relief. The im- mense number of cases which have come under Mr. Wilde's observation for many years, have afforded him opportunities rarely enjoyed for investigating this branch of medical science, and his work may therefore be regarded as of the highest authority. WEST (CHARLES), M. D., Senior Physician to the Royal Infirmary for Children, Sec. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. In one volume, octavo, of four hundred and fifty pages. The Lectures of Dr. West, originally published in the London Medical Gazette, form a most valuable addition to this branch of practical medicine. For many years physician to the Children's Infirmary, his opportunities for observing their diseases have been most extensive, no less than 14,000 children having been brought under his notice during the past nine years. These have evidently been studied with great care, and the result has been the production of the very best work in our language, so far as it goes, on the diseases of this class of our patients. The symptomatology and pathology of their diseases are especially exhibited most clearly; and we are con- vinced that no one can read with care these lectures without deriving from them instruction of the most important kind.—Charleston Med. Journal. Every portion of these lectures is marked by a ge- neral accuracy of description, and by the soundness of the views set forth in relation to the pathology and therapeutics of the several maladies treated of. The lectures on the diseases of the respiratory ap- paratus, about one-third of the whole number, are particularly excellent, forming one of the fullest and most able accounts of these affections, as they present themselves during infancy and childhood, in the English language. The history of the seve- ral forms of phthisis during these periods of exist- ence, with their management, will be read by all with deep interest.—The American Journal of the Medical Sciences. WILLIAMS (C. J. B.), M. D., F. R. S., Professor of Clinical Medicine in University College, London, &c. PRINCIPLES OF MEDICINE; comprising General Pathology and Therapeu- tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and Hygienics. Edited, with Additions, by Meredith Clymer, M.D. Fourth American, from the last and enlarged London edition. In one octavo volume, of nearly five hundred pages. JYomt Ready. This new edition has been materially enlarged and brought up by the editor. It possesses the strongest claims to the attention of the medical student and practitioner, from the admirable manner in which the various inquiries in the different branches of pathology are investigated, combined, and generalized by an experienced practical physician, aud directly applied to the investigation and treatment of disease.—Editor's Preface. The best exposition in our language, or, we be- I Few books have proved more useful, or met with lieve, in any language, of rational medicine, in its | a more ready sale than this, and no practitioner present improved and rapidly improving state.— I should regard his library as complete without it. British and Foreign Medico-Chirurg. Review. | —Ohio Med. and Surg. Journal. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE RESPIRATORY ORGANS; including Diseases of the Larynx, Trachea, Lungs, and Pleurae. With numerous Additions and Notes, by M. Clymer, M. D. With wood-cuts. In one oclavo volume, pp. 508. YOUATT (WILLIAM), V. S. THE HORSE. A new edition, with numerous illustrations; together with a general history of the Horse; a Dissertation on the American Trotting Horse ; how Trained and Jockeyed ; an Account of his Remarkable Performances ; and an Essay on the Ass and the Mule. By J." S. Skinnkr, formerly Assistant Postmaster-General, and Editor of the Turf Register. One large octavo volume. BY THE SAME AUTHOR. THE DOG. Edited by E. J. Lewis, M. D. With numerous and beautiful illustrations. In one very handsome volume, crown 8vo., crimson cloth, gilt. ILLUSTRATED MEDICAL CATALOGUE. BLANCHARD & LEA have now ready a Catalogue of their Medical and Surgical Publi- cations, containing descriptions of the works, with Notices of the Press, and specimens of the Illustrations, making a pamphlet of forty-eight large octavo pages. It has been prepared with great care, and without regard to expense, forming one of the most beautiful specimens of typographical execution as yet issued in this country. Copies will be sent by mail, and the postage paid, on application to the Publishers, by enclosing a three cent postage stamp. AND SCIENTIFIC PUBLICATIONS. 31 R. & L. subjoin a condensed list of their publications in general and educational literature, of which more detailed catalogues will be furnished on application. HISTORY AND BROWNINGS HISTORY OF THE HUGUE- NOTS, 1 vol. Svo. CAMPBELL S (LORD) LIVES OF THE LORD CHANCELLORS OF ENGLAND, from the earl- iest rimes to the Reign of George IV. In seven handsome crown octavo volumes, extra cloth or half mor,occo. CAMPBELLS (LORD) LIVES OF THE CHIEF JUSTICES OF ENGLAND, from the Norman Conquest. In two handsome crown octavo vols., to match the " Chancellors." DIXON'S LIFE OF WILLIAM PENN. A new work. 1 vol. royal 12mo , exira cloih. GRAHAME'S COLONIAL HISTORY OF THE UNITED STATES. 2 vols. Svo. A new edition. HERVEYS MEMOIRS OF GEORGE II. 2 vols royal 12mo, extra cloth. INGERSOLL'S HISTORY OF THE LATE WAR. 2 vols. Svo. 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