UNITED STATES OF AMERICA *• a . V FOUNDED 1836 WASHINGTON, D. C. OPO 18—87244-1 THE LECTURES O F SIR ASTLEY COOPER, BART. F.R.S. ... SURGEON TO THE KING, &c, ON THE PRINCIPLES AND PRACTICE O F SURGERY; ADDITIONAL NOTES AND CASES. **, BY FREDERICK TYRRELL, ESQ., Burgeon to St Thomas's Hospital, and to the London Opthalmic Infirmary. THIRD AMERICAN FROM THE LAST LONDON EDITION. VOL. III. ^* ° BOSTON —LILLY AND WAIT. G. &. C. & H. CARVILL, AND E. BLISS, NEW-YORK ; CAREY & HART, PHI- LADELPHIA ; W. & J. MEAL, BALTIMORE J LITTLE & CUMMINGS, AL- BANY ; M. CARROLL, N. ORLEANS J AND S. COLMAN, PORTLAND. 1831. wo C1UL 1831 V-3 Wl»> no ,/WSi/ CONTENTS. XXXI. On Hernia, 1 XXXII. On Irreducible Hernia?, 13 XXXIII. Account of the Operation continued, 36 XXXIV. On Femoral Hernia, 62 XXXV. On Umbilical Hernia, 79 XXXVI. On Wounds, 109 XXXVII. On Contused Wounds, 119 XXXVIII. On Wounds of Arteries, 132 XXXIX. On Wounds of Veins, 150 XL. On Wounds of Joints, 181 XLI. On Dislocations, 195 XLII. On Dislocations of the Elbow, 235 XLIII. On Dislocations of the Hip, 262 XLIV. On Dislocations of the Knee, 310 XLV. On Dislocations of the Ankle, 339 WLtttUV€8t LECTURE XXXI. ON HERNIA. Importance of the subject.—This, of all the dis- eases to which the human body is liable, demands, upon the part of the surgeon, a large share of ana- tomical knowledge, great promptitude and decision, and the utmost skill and dexterity in the performance of an operation, when it is rendered necessary, by a defeat of the means employed for its reduction. In other important cases, consultations may be held, or the patient be sent to a distance to obtain the advan- tage of the best opinions; but in hernia the fate of the patient is decided almost upon the instant, and an hour's delay may turn the scale of success against the surgeon, and.destroy the prospect of safety on the part of the patient. Definition.—A hernia is a protrusion of any viscus from its proper cavity; but the term is principally applied to tne protrusions of the abdominal viscera, to which it is at present my intention to confine my description. Abdomen particularly liable to such protrusions.— The abdomen is particularly liable to such protru- sions, on account of the moveable state of its viscera, of the natural openings from it to give passage to 1 2 blood vessels, and unnatural apertures from defi- ciency of structure, and from the great changes in bulk to which the omentum and mesentery are sub- ject ; so that instead of being surprised at the fre- quency cf its occurrence, it might be expected, from a knowledge of anatomy, that it would occur in many more instances than it does. Kinds of hernia.—There are several genera of abdominal herniae; four of which, however, are more frequent than the others; viz. the inguinal, the fe- moral, the umbilical, and the ventral; but beside these, there is a hernia through the ischiatic notch, one through the foramen ovale, a pudendal, a perin- eal, a vaginal, occasionally a protrusion takes place through the diaphragm, the kidneys have been found in a swelling in the loins, and the small intestines have been seen between the laminae of the mesent- ery and mesocolon; but, to the two latter, the term hernia is scarcely strictly applicable. Of Inguinal Hernia. Of this hernia, there are four different species:— Species—1. The oblique taking the course of the spermatic cord. 2. The direct descending from the abdomen im- mediately through the external abdominal ring. 3. The congenital, or a protrusion into the tunica vaginalis. 4. The encysted hernia, composed of a bag and protrusion suspended in the tunica vaginalis. Contained in a sac.—Before any hernia is formed, unless in wounds, laceration, or deficiency of struc- ture, a bag of peritoneum precedes the protruded viscera, and forms a sac in which they are contained, and which is usually called the hernial sac. This protrusion is somewhat thicker than the natural pe- 3 ritoneal lining of the abdomen, the pressure of the viscera leading to an interstitial deposition into the membrane; it is not placed loosely in the parts into which it is protruded, but it adheres by cellular tis- sue to all the surrounding structures. Of the Oblique Inguinal Hernia. Synonymes.—This is also called bubonocele when seated in the inguinal canal; and, when it further descends, is named scrotal; as it takes the course of the spermatic cord, it might well be denominated spermatocele. Before I describe the course and dissection of this hernia, it is necessary that I should say something on the structure of the inguinal canal, and of the course of the spermatic cord. Structure of the inguinal canal.—The spermatic cord first quits the abdomen midway between the anterior and superior spinous process of the ilium and the symphisis pubis; it here passes between two layers of the fascia transversalis, the anterior layer of which is fixed in Poupart's ligament, whilst the pos- terior layer descends behind Poupart's ligament, and assists in covering the femoral artery and vein, and in forming the crural sheath ; above the passage of the spermatic cord, the two planes of this fascia unite, and form a lining to the transversalis muscle, extend- ing as far as the diaphragm. As the cord penetrates between these two planes, which form the internal ring, a thin layer of fascia unites it to the edge of each. No part of importance is situated between the an- terior superior spinous process of the ilium, and the point at which the spermatic cord passes through the fascia transversalis ; but between the latter place and the pubes, the epigastric artery takes its course. This artery is situated from one-fourth to one-half 4 an inch upon the inner side of the internal abdomi- nal ring, or passage of the spermatic cord, from the abdomen, and it passes to the inner part of the rectus muscle. The external iliac artery and vein are di- rectly behind this internal abdominal aperture, and this opening is the beginning of the inguinal canal, in which the spermatic cord is next continued. Boundaries of the inguinal canal.—The inguinal canal is bounded anteriorly by a superficial fascia from the abdominal muscles, and by the tendon of the external oblique; posteriorly, by the fascia trans- versalis, and by the tendon of the transversalis mus- cle ; above, by the edges of the internal oblique and transversalis muscles, and below by Poupart's liga- ment ; the canal is about two inches in length, and terminates at the external abdominal ring. External ring.—The external abdominal ring is formed by two columns of the tendon of the external oblique muscle united by fibres from Poupart's liga- ment; the upper column is inserted into the symphisis pubis, the lower column into the tuberosity of the pubes, the pubes bounds the opening below; between these columns the spermatic cord passes ; and from the edge of the ring, as well as from the surface of the tendon of the external oblique muscle, a thin fascia descends, uniting the cord to the edges of the opening, and passing down upon it to the tunica vagi- nalis ; this fascia is then situated between the skin and the cremaster muscle; which muscle arises within the inguinal canal from the internal oblique muscle; it descends with the spermatic cord, and passes through the external abdominal ring; spread- ing over the fore and lateral parts of the cord as far as the tunica vaginalis into which it is inserted. Spermatic cord.—Behind the fascia and cremaster muscle the spermatic cord is found passing to the testis; it is covered by the tunica vaginalis, and is composed of the spermatic artery and vein, absorb- 5 ents, and nerves, with the vas deferens and an ar- tery accompanying it. Origin and course of the hernia.—The oblique in- guinal hernia first enters the upper opening of the inguinal canal, or internal abdominal ring, so that at its commencement it is placed just mid-way between the anterior superior spinous process of the ilium and the symphisis pubis, and close above Poupart's liga- ment ; it has the spermatic cord behind it, and the epigastric artery to its inner side: when in the in- guinal canal it is about two inches in length, and is covered anteriorly by the superficial fascia of the external oblique muscle and by the tendon of that muscle, the inferior edges of the internal oblique and transversalis muscles form an arch over it; the cremaster muscle covers it partially; it has a thin slender covering from the edge of the internal ring; the fascia transversalis, strengthened by the tendon of the transversalis, is situated behind it, and to its inner side; and Poupart's ligament is placed below it. Appears at the external ring.—Having descended through the inguinal canal, it next emerges at the external abdominal ring, and it is then usually deno- minated scrotal hernia. Increases more rapidly.—Its increase being then much less restrained than before, it descends on the fore part of the spermatic cord to the testicle, at the upper part of which it usually terminates. Dissection of the hernia.—rUpon dissecting this her- nia below the external ring, there is found covering it;—first, the fascia of the spermatic cord, derived from the external oblique tendon and the edge of the abdominal ring; this substance is dense, and forms a strong covering, which has often been mis- taken for the hernial sac; when this has been divid- ed, the cremaster muscle becomes exposed, covering the fore and lateral parts of the hernial sac. The 6 cremaster muscle is thicker than the fascia of the cord, and its muscular texture is easily distinguished in the living body. On cutting through this muscle, and a dense cellular tissue, the hernial sac is laid bare, united on the fore part to the cremaster mus- cle, and on the posterior part to the spermatic cord, resting below upon the tunica vaginalis of the tes- ticle. Usual contents of the sac.—The usual contents of the hernia are either intestine or omentum ; if the former, it is called enterocele; if the latter, it is de- nominated omental, or epiplocele. In the young, omental hernia is rarely met with, it being generally intestinal, for this obvious reason, that the omentum in the young subject covers only the superior abdo- minal viscera. Varieties of Oblique Inguinal Hernia. Varies in size.—From the description which I have given of this hernia, it is clear that it may vary in length, from the upper ring to the testicle, and consequently that it is sometimes seen occupying only the inguinal canal. Sometimes very large.—In some cases the hernia is so large as nearly to reach the knee, but in general it does not exceed Iavo fingers' breadth, and barely reaches to the upper part of the testicle ; its bulk depends considerably upon the time which it has existed, upon the degree of relaxation of the patient, and upon his inattention to the disease. Unusual protrusions.—I have seen the pylorus de- scend to the mouth of the hernial sac. The urinary bladder is also occasionally situated within it ;* and * When the caecum or urinary bladder are protruded, there is not a complete peritoneal sac; but it is deficient at that part of either viscus not naturally covered by it. 7 we have an excellent specimen in the collection at Guy's Hospital, of an inguinal hernia in the female, where the ovarium and fallopian tube are protruded into the hernial sac* Usual situation of the spermatic cord.<—The spe'r- matic cord is usually situated behind the hernial sac; but in one of the preparations in the Museum at St. Thomas's Hospital, the cord is divided, the vas de- ferens passing upon one side, and the spermatic ar- tery and vein upon the opposite side. I have seen also the spermatic artery and vein passing over the fore part of the sac, while the vas deferens passed behind it. Symptoms of Inguinal Hernia. Distinction from other diseases.—It is discriminat- ed from other diseases by the following marks:—it gradually descends from the abdomen in the course of the spermatic cord : it usually protrudes in the erect, and retires when the patient is in the recum- bent posture: it dilates upon coughing, and upon all exertions of the abdominal muscles : flatus may be often felt in it when it is intestinal, and it retires with a gurgling noise: when omental it has a doughy feel, is much less elastic than the intestinal hernia, and re- tires into the abdomen more slowly; the intestinal is accompanied with costiveness, and with pain across the abdomen; the omental rarely produces any dis- turbance of the abdominal functions, when in the re- ducible state; the hernia of the bladder is distin- guished by the diminution of the swelling during the evacuation of the urine. The following are the principal marks of distinc- tion from the diseases with which it is most likely to be confounded. * See hernia in the female. 8 From hydrocele.—From hydrocele, by that dis- ease beginning below, and gradually ascending, by its transparency, by its fluctuation, its pyriform shape, its involving the testicle, and by the want of dilata- tion from coughing; however, there is an exception to this, if the hydrocele enters the upper part of the scrotum, when it sometimes dilates upon coughing, and the only means of distinction are in its history, its transparency, and its fluctuation. From hydrocele of the cord—From hydrocele of the spermatic cord, it is with great difficulty distin- guished, unless the hydrocele emerges from the ex- ternal ring, when its transparency indicates its true nature. Hernia and hydrocele sometimes combined.—Hydro- cele and hernia are sometimes combined in the same individual, of which there is a beautiful specimen in the collection at St. Thomas's Hospital; a case of this kind occurred to Mr. Thomas Blizard, on which he operated, and a similar one to Mr. Henry Cline; in each case the water was in the first instance dis- charged, and then the hernial sac became exposed behind the tunica vaginalis. Hydrocele is also connected with hernia, when there is water in the abdomen; and I have tapped a hernial sac in ascites for the discharge of the accu- mulated water, and it is the best mode of operating in such a case, when it is quite certain that neither the omentum or intestine are descended, and that you can decide by the transparency. From hematocele.—Hernia is known from haemato- cele, by the latter being usually the result of a blow, and by the ecchymosis which at first accompanies it, by its not extending to the inguinal canal, by its not dilating upon coughing, by the bowels being undis- turbed, and by its not returning into the abdomen. From diseased testicle.—Hernia is little liable to 9 be confounded with disease of the testicle, the his- tory of the swelling, its form, the distinctness of the spermatic cord, the want.of intestinal obstruction, the absence of dilatation on coughing,- and its not re- turning into the abdomen, are sufficient marks of the latter disease. Hernial sac connected to the spermatic cord.—I have seen, however, diseased testicle complicated with hernia, and have twice been under the necessity of dissecting the hernial sac from the spermatic cord, during the extirpation of the diseased testicles. In one case I opened the sac unintentionally in the ope- ration, but it did not prevent the patient from doing well. Acute inflammation of the testicle, mistaken for her' nia.—The acute inflammation of the testicle is the only state which I have known confounded with hernia; the tenderness of the part, the swelling ex- tending up the cord, and the vomiting accompanying the disease, led to a doubt which could only be re- moved by a knowledge of the history and progress of the complaint. From varicocele.—The disease with which hernia is most frequently confounded is varicocele, or en- largement of the spermatic veins; this is a very common complaint, it occurs most frequently upon the left side, and is supposed to be founded in the termination of the left spermatic vein, at right an- gles with the emulgent. It sometimes dilates upon coughing; it appears in the erect, and retires in the recumbent position. It is distinguished from hernia by its feel, (which resembles that of a bag of large worms,) by its being unattended with intestinal ob- structions, by placing the patient in the recumbent posture, and emptying the swelling into the abdo- men ; then pressing the finger upon the external ring to prevent any visceral descent, by which the 2 10 free return of blood by the spermatic vein is ob- structed, and the swelling re-appears when no hernia could escape. Truss applied for varicocele.—I have more than once known a truss applied for this disease, and in one instance to the son of a medical man, by his father. This hernia most frequent on the right side.—Ingui- nal hernia occurs more frequently upon the right side than the left, probably because the greatest exer- tions are made of the right side, from the preference we give to the use of the right arm, two-thirds of inguinal hernia are upon the right side. Causes of Hernia. Loose connexion of viscera.—The loose connexions of the jejunum, ilium, colon, and omentum, give a proneness to the disease. The other viscera are rarely found in hernia. JYatural apertures.—The natural apertures for the passage of the blood vessels also lead to the ready production of hernia. Malformations.—Malformations also give rise to hernia, as when the abdominal ring is unnaturally large. Some species of hernia are originating en- tirely from malformation, as the phrenic and ventral. Increase of omentum or mesentery.—Great increase of the omentum or mesentery in obesity leads to hernia. Pregnancy produces it. Violent exercise frequently occasions it, by forcing the viscera through the apertures. Great exertions of the abdominal muscles in lifting weights, more especially in the stooping posture, is a common cause of this disease, as also coughing or straining violently. Flatulent food, and food difficult of digestion, tends to produce hernia. Great wasting of the body, by leaving the abdominal apertures relaxed, is also a cause. 11 Thus, then, the parietes give rise to hernia, by their formation, malformation, and contraction; and the viscera by their pressure, and from the changes they undergo, especially in old age. Climate.—The lax state of fibre, induced by a long residence in warm climates, may also be men- tioned as pre-disposing to the formation of hernia. Of the Reducible Hernia. A hernia is said to be reducible when it can be returned into the cavity of the abdomen. Treatment.—In order to put the patient into a state of safety, and to prevent a future descent, a truss is to be applied. A truss is requited for the smallest hernia, as the danger from this disease, is in an inverse ratio to the size of the tumour. Salmon and Ody's truss.—Salmon and Ody's truss is most easily worn, and most appropriate for recent and small hernia; but the objection to it is, that it cannot be worn during the night, and therefore the patient requires one of a different kind in bed. They are, however excellent trusses. Egg's truss.—Egg's truss, and those of the com- mon kind, are worn day and night, and make a stea- dy pressure on the part. Pindin's truss.—Hernia, very difficult to support, are best prevented protruding by Pindin's truss, which has no springs; I have seen it succeed when no other answered the purpose. To obtain a truss, it is only necessary to send the measure of the pelvis to the instrument maker. The principle upon which the pad of the truss is to press, is the whole length of the inguinal canal; that is, to reach from the upper to the lower ring. Effect of a truss.—Will this cure me? the patient inquires: Yes, if he be young, assuredly; if old, I 12 have known it do so in a few instances. How long must 1 wear it ? to which the answer is, A year af- ter the hernia does not appear when the truss is re- moved for a few hours, the patient at the time tak- ing his usual exercise. Am 1 to wear it at night as well as by day ? Yes, or you have little chance of being cured; and there is otherwise danger of stran- gulation. In consequence of wearing a truss, the sac falls in- to folds, and gradually contracts; but more particu- larly at its orifice. If hernia be complicated with hydrocele from the abdomen, both diseases are cur- ed by wearing a truss. Danger of leaving off the truss.—Giving up the use of a truss before the cure is complete, is very dangerous; as from the contraction and thickening of the mouth of the sac, there is more liability to stran- gulation. The shut sac of a hernia will sometimes produce hydrocele by the secretion from its inner surface. 13 LECTURE XXXII. IRREDUCIBLE HERNIA It is so called when it is uninflamed, but does not return into the cavity of the abdomen; and it ac- quires this state from the following causes:— Causes.— 1st. Growth of the protruded omentum or mesentery, rendering it too large to return through the orifice of the hernial sac. 2nd. Adhesion of the omentum, mesentery, or in- testine, to the inner surface of the sac. 3rd. Membranous bands formed across the sac by adhesion. 4th. Omentum entangling the intestine. 5th. A protruded ccecum, in which the intestine adheres by cellular membrane behind, and the sac exists only on the fore part. 6th. A portion of omentum suddenly protruded, of too large a size to be immediately returned. Danger of Irreducible Hernia. Rupture of intestine.—If intestine be protruded, it is sometimes ruptured from a blow upon the tumour. Liability of strangulation.—There is a constant lia- bility of strangulation from any slight additional pro- trusion. Formation of abscess.—I have known an abscess form in the protruded omentum, and prove de- structive. 14 Treatment of Irreducible Hernia. To give support.—Nothing can be done in some of these cases, but to give support to the pah by the application of a laced bag truss. When it arises from obesity, attention to diet, and to the means of reduc- ing the patient, may sometimes succeed, for I saw a gentleman who became reduced from dropsy in his chest, and had a hernia return, which had been for a long period irreducible. Use of Ice.—Apparently in irreducible omental hernia of recent formation, I have known the appli- cation of ice succeed when there was not any in- flammation proceeding, as far as could be ascertain- ed by the pain. Case.—A physician who had an omental hernia irreducible for a fortnight, had ice applied to it through the medium of a bladder, for four days, dur- ing which period it gradually returned. In another case the same treatment was successful; and it ap- peared to me that the ice was serviceable, by occa- sioning a constant contraction of the skin, and sup- porting moderate pressure on the part. Of the Strangulated Oblique Inguinal Hernia. Definition.—When the parts protruded into the hernial sac cannot be returned into the abdomen, and the pressure is so great as to prevent the free circulation of blood through the vessels of the pro- truded viscera, the hernia is said to be strangulated, and the following symptoms are usually present. Symptoms.—The patient directly feels violent pain in the region of the stomach, as if a cord were bound tightly round his body ; and this is followed by frequent eructations which continue until the strangulation be removed;—there is a great desire 15 for a fcecal discharge ; but the person only passes a small quantity of fceces from the large intestines. The tumour feels hard, and if it be intestine which has descended, it is often extremely tender to the touch. Vomiting soon occurs; first the patient throws up the contents of the stomach, afterwards bile, which is regurgitated from the duodenum; and if it be a portion of the large intestine which is stran- gulated, fcecal matter is sometimes discharged from the stomach," as the symptoms become more urgent. The pulse is at first hard, and rather quicker than natural. More urgent symptoms.—On the next visit to the patient, the vomiting is more urgent, the costiveness remains, the abdomen is tense from flatulence, the tumour is harder and more tender, the pulse is more frequent, smaller, but still hard. Peritoneal inflammation.—Strangulation still con- tinuing, the abdomen becomes extremely tender to the touch, on account of the peritoneum becoming inflamed, at the same time the pulse is very small, thready, and frequent: in addition to the other symp- toms, hiccough occurs, the vomiting and costiveness continue, the tumour becomes more tense, often is inflamed upon its surface, and now and then the marks of the fingers, when pressed upon it, remain. Last stage.—In the last stage, the pulse frequent- ly intermits, the patient is covered with a cold per- spiration, but his mind appears less depressed, and as his pain is less, he has more expectation of re- covery. Explanation of symptoms.—With respect to these symptoms, the pain in the abdomen, and the vomit- ing, are at first sympathetic; and the discharge of bile and fceculent matter afterwards is kept up by the anti-peristatic motion, which takes place above that portion of intestine contained in the hernia; per- 16 haps the valve of the colon may in some instances be imperfect, by which the vomiting of fceculent matter may be accounted for; the obstruction to the passage of the foeces by the usual course, is prevented by the strangulation of the intestine ; the tension of the ab- domen arises at first from accumulation of flatus, and subsequently from peritoneal inflammation, which also occasions the tenderness of the abdomen; the hiccough has been considered as an indication of gangrene; but I have known operations performed in many cases, after its appearance, and the patients have done well, the contents of the hernial sac not being found in a gangrenous state; the tension of tjie tumour is caused at first by accumulation of blood from obstructed circulation in the part; afterwards it increases from effusion into the hernial sac, in part of serum, and part of fibrin. Evacuations just before death.—It sometimes hap- pens just previous to the patient's death, that he has evacuation from his bowels, and this probably takes place from the tension of the affected parts being lessened by the approach of dissolution.* * I have introduced the following case as presenting some unusual peculiarity respecting the evacuation from the bowels, during the continuance of the symptoms of strangulation. Thomas Davis, a porter, aged fifty-nine, (who had for two years been subject to hernia,) on Saturday, the 12th of March, 1825, after making some unusual exertions, found that the swelling formed by the hernia had much increased in size, and resisted his repeated attempts to reduce it. On Sunday morn- ing, the 13th, he experienced pain in the tumour, and in the abdomen, which was soon followed by vomiting. In the even- in<", as he did not get better, he applied to a surgeon in his neighbourhood, who for some time tried the taxis, but ineffec- tually; in consequence of which he was taken to St. Thomas's Hospital. On examination, a femoral hernia was discovered on the right side, about the size of an egg, hard, and tender to touch. He was bled, and placed in the warm bath, and when he appeared faint, the taxis was again employed, under which the hernia became apparently lessened, but not completely (lis- 17 Variation in the symptoms.—The symptoms of strangulation do not always continue equally severe; but for short intervals the patient is often nearly free from suffering, and then again the symptoms be- come violent. persed. As he was not perfectly certain of its being quite re- ducible before the existing symptoms, I was induced to order an enema; and directed, in case of a free discharge from the bowels after its use, that some purgative medicine should be given by the mouth. He had a copious motion from the enema, and in consequence some pills of cathartic extract and calomel, were given, after which, during the night, he had three more abundant motions. On the following morning, (the 14th,) how- ever, 1 found that the tumour had regained its former magni- tude and tension ; that it was very tender, as also was the abdo- men, and that he had hiccough, with occasional vomiting. Under these circumstances, after a further short trial of the taxis, and which made no impression upon the swelling, I performed the operation. The hernial sac was surrounded with enlarged glands; it contained a little fluid, and a portion of intestine, which was highly inflamed and perfectly incarcerated. This was liberated and replaced in the cavity of the abdomen without much difficulty, and the wound was dressed as usual. In consequence of much tenderness of the abdomen, on pres- sure, in the evening, I ordered, Hirud. xxiv. abdom. Fot. Pa- paveris, et Tinct. Opii gutt. xxv. 15th. Less pain and tenderness of the abdomen. He had slept comfortably, (pulse 80, and feeble,) but he was troubled with occasional sickness; the hiccough had subsided: ordered, Mist: Efferv : pro re nata. c Tinct: Opii gutt. v. Sin. dos, if the sick- ness continued. At two o'clock he was seized with dyspnoea and more frequent vomiting, but had no increase of tenderness. Ordered enema commun. c Oleo Ricini, and to continue the mixture. The enema was repeated in the afternoon, but did not produce any evacuation, and late in the evening he died. On examining the body after death, I found the peritoneum much inflamed, and exhibiting marks of previous disease, there being old and firm adhesions. The portion of intestine which had been strangulated consisted of a complete fold of the ilium, including the whole diameter of the gut; it had still the mark from the stricture upon it, and was much more discoloured than any other part.—T. 3 18 Dissection of the Hernia. Before the commencement of gangrene.—If gan- grene has not taken place, a small quantity of serum is found under the skin, and in the hernial sac a coffee coloured effusion of the same nature; this is usually more abundant when intestine has descend- ed, than when omentum alone is protruded. The intestine is of a dark chocolate brown, and has its surface covered by a coat of adhesive matter, by which it is in part glued to the hernial sac, but not very firmly. Directly under the seat of stricture, the intestine has suffered particularly, and often gives way to very slight pressure of the fingers. If omen- tum has protruded, it is found red, and somewhat harder than natural. When gangrene has occurred.—When gangrene has taken place, the skin over the tumour is emphysem- atous, and retains any marks made by the pressure of the fingers. When the sac is opened, a highly offensive smell is emitted, and if intestine be pro- truded, it is of a deep port wine colour, and has on its surface numerous greenish spots, and its texture is so altered, that its surface loses its brilliancy, and it gives way to very slight pressure. Omentum, when gangrenous, is of a dark colour, easily breaks, and feels somewhat like a portion of lung, crackling under the pressure of the fingers. Appearances in the abdomen—On opening the ca- vity of the abdomen, the peritoneum is found in- flamed, red lines can be traced on the intestines, where they are lying in contact, and here adhesions are formed from effusion of fibrin. The intestines are immensely distended with flatus. Symptoms less severe from omental hernia.—If omentum alone has descended, the symptoms are usually much less severe, and the patients live longer than when the hernia is intestinal. 19 Seat of Stricture. External ring.—In old and large hernia, the seat of stricture is at the external abdominal ring, but in by far the greater number of cases, the stricture is seated at the orifice of the hernia from the abdomen, at the internal ring, and here it is occasioned by the semi-circular edge of the tendon of the transversalis becoming thickened, as well as that portion of the hernial sac pressed on by this tendon. In the inguinal canal.—I have also seen the stric- ture midway between the two rings, and it appeared in these cases to be occasioned by a thickening of the sac, which, by the exertions of the patient, had been frequently forced down to the external ring, and had again retired into the inguinal canal. Stricture from membranous band.—There is also a beautiful specimen in the collection at St. Thomas's Hospital, showing a stricture formed by a strong membranous band within a hernial sac; the patient, from whom it was taken, had been operated on by one of the surgeons of that Hospital; and although the inguinal canal had been freely opened, yet the surgeon could not return the intestine without doub- ling it back, which he did, and brought the integu- ment together over it by sutures. On the day fol- lowing the operation, the intestine peeped out be- tween the sutures, and was in a gangrenous state, and the case terminated fatally. Omentum entangling intestine.—Another occasion of stricture is from omentum entangling the intes- tines, an excellent example of which I operated upon in the case of a patient of Mr. Richard Pugh, of Grace-church Street. Cause of strangulation.—The cause of strangulation is generally a sudden protrusion of an additional por- tion of intestine or omentum. The eating of vegeta- 20 ble food so as to produce flatulence, or very indiges- tible animal matter, is a frequent cause. Dano-er in small hernia.—A small hernia is much more easily strangulated than a larger one. Of the Treatment of Strangulated, Oblique, Inguinal Hernia. Danger of strangulation.—As the danger is entirely consequent on the pressure of the stricture upon the protruded viscus, the great object of the surgeon is to return the protruded part into the abdomen, as quickly as he can with safety. Taxis, and mode of employing it.—The operation for effecting this reduction is called the taxis, and it is performed in the following manner:—The patient is placed in a recumbent posture, with his head and shoulders a little elevated, and his thighs at right angles with his body. His bladder should be pre- viously emptied. The surgeon, standing on the right side of the patient, passes his right hand down be- tween the thighs, to grasp the swelling, and with his left thumb and fingers he kneads the hernia at the upper part of the inguinal canal. Slight pressure and elevation of the scrotum, with a kneading of the upper part of the hernia, are used for the purpose of returning a small portion of the protruded parts, when the whole usually follows without difficulty. The pressure should be continued a quarter of an hour, at least, for I have known it succeed after a trial of twenty minutes. The object is to use a con- tinued steady pressure, and not violent means; which, in several instances which have come under my ob- servation, have caused a rupture of the intestine, so that, in the operation, as soon as the sac has been opened, fceculent matter has escaped. If the stran- gulation has been long continued, the employment of force becomes doubly dangerous. 21 Intestinal hernia most easily reduced.—The intesti- nal hernia is more easily reduced than the omental, it returns more suddenly, and with a gurgling noise, but sometimes the tenderness of the part is such as to forbid the immediate employment of the taxis. Case.—I attended a young man, with Mr. Croft, in the city, who, from tenderness, could not bear the swelling to be touched. I ordered ice to be applied, and in seven hours the hernia returned without the aid of the taxis.* Bleeding, advantage of—If the taxis does not suc- ceed, bleeding from the arm should directly be had recourse to. In all cases it is best to employ it, on two accounts. First.—By the faintness which it produces, it frequently becomes the means of assist- ing t he return of the hernia. Second.—If the hernia be not reduced, it saves the patient from the danger of peritoneal inflammation, which an operation is likely to produce. 1 never saw it do harm; and have in many cases witnessed its extreme efficacy. In strong athletic persons it should be carried to a very great extent; in the old and infirm, little need be taken away. Consequence of not bleeding.—From neglect in bleeding, the patient very often dies, four or five days after the operation, from peritoneal inflamma- tion. The object is to produce a fainting state, otherwise the bleeding does very little good. Pulse deceptive.—Persons are very often deceived * In the month of May last, I was requested to see a publican in the Borough, who was suffering from the strangulation of a ventral hernia, about the size of an orange, seated in the linea alba, between the ensiform cartilage and umbilicus. The tu- mour was so extremely tender, that he could»not bear me to make the slightest pressure upon it. I directed ice to be ap- plied, which was kept on for three hours; after this period I succeeded easily in reducing the hernia, which had been stran- gulated nearly two days.—T. 22 in peritoneal inflammation, on account of the small thready pulse with which it is accompanied; but this, instead of being a bar to the abstraction of blood, only indicates a greater necessity for it. I shall have occasion to mention the great benefit derived from it, in a case in which hiccough was extremely violent. Warm bath.—The next object which the surgeon has in view, when bleeding and the taxis fail, is to put the patient in the warm bath, which is of no use unless it occasion faintness; and since I wrote my work on hernia, 1 have had several opportuni- ties of witnessing its efficacy in assisting the reduc- tion. If there is not immediate convenience for its use, no time should be lost in procuring it, as there are other and more powerful remedies. Tobacco glyster.—The most powerful agent in the treatment of strangulated hernia, is the tobacco glys- ter; for if when the patient is under the influence of this remedy, the hernia cannot be returned by the taxis, there is but little chance of any mode short of an operation succeeding. The manner of making it is to infuse one drachm of tobacco in one pint of wa- ter, and of this one half should be first thrown up, and according to the effect produced in twenty mi- nutes, or half an hour, the other half may be inject- ed, or not. This is the safest plan of administering the tobacco; it produces extreme langour and relaxa- tion of all the fibrous structures, and is certainly the most potent remedy which is employed, but at the same time requires the utmost caution in its use. Fatal effects of tobacco.—Case.—I have seen a pa- tient with strangulated hernia expire under the ef- fects of tobacco, which had been used in the quanti- ty of two drachms, without reduction of the hernia; he was placed upon the operating table, but as his pulse could scarcely be felt, his countenance showed extreme depression, and as he was covered with a 23 cold sweat, the operation was not performed, and the patient died, as the assistants were removing him. Case.—A girl, who was sent to Guy's Hospital, by Mr. Turnbull, surgeon, had^a single drachm of the tobacco in infusion injected, to assist the reduction of a strangulated hernia. She, soon after its being ad- ministered, complained of violent pain in the abdo- men, and vomited. The hernia was reduced, but she died in thirty-five minutes after the use of the tobacco, and evidently from its effects. Mr. Wheeler, senior, of St. Bartholomew's Hos- pital, told me he had known it destroy life, but pru- dently employed it in the way that I have recom- mended ; it is the most efficacious of the remedies proposed for the reduction of hernia. Beneficial effects of tobacco.—The effect to be wish- ed for from the use of tobacco, is a universal relaxa- tion, so that the patient has not power to exert any of the voluntary muscles; when this is produced, a hernia may be sometimes reduced with very little force, after having previously resisted a firm and continued pressure. Under the influence of tobacco, hernia, which has before its employment felt tense, will become soft, and this is not occasioned by any partial reduction of the hernia, but only by the force of ciruclation being for a time greatly diminished. Cold.—I have several times known the applica- tion of cold succeed in reducing a hernia, and it has this great advantage ;—that it arrests the progress of the symptoms, even when it does not ultimately succeed; therefore, when an operation cannot be immediately performed, it should always be employ- ed. Ice broken into small pieces and put into a bladder; or water cooled by adding equal parts of muriate of ammonia, and nitrate of potash to it, are the most convenient modes of producing the desired 24 effect. I have known the cold produced by the eva- poration of spirits of wine and water, succeed in re- ducing a hernia. Caution in applying ice.—It is very improper to apply ice in such a manner that the patient or his bed clothes become wet as the ice melts; it is also wrono- to continue it upon the part for a long time together, as it may occasion sloughing, as occurs from the effects of frost bite. A case in which sloughing was produced in this way, was attended by Mr. Sharp, and Mr. Cline, who had directed the ap- plication of ice over a strangulated hernia, and con- tinued it for thirty-six hours. The part, to the ex- tent of four inches, froze, became hard and white ; the hernia was reduced, but soon after the removal of the ice, the part thawed, becoming red and in- flamed; in about ten days it assumed a livid hue, and sloughed to the extent that it had been frozen. Purgatives.—Purgatives used formerly to be very much given, but are now little employed. Calomel given by the mouth, and a strong enema of the com- pound extract of colocynth, sometimes are useful. Fomentations.—If the parts be exquisitely tender, fomentations may be employed, which if long contin- ued, may by their relaxing effects answer the same purpose as the cold. Of Direct Inguinal Hernia. Sometimes a hernia protrudes nearer to the pubes than that I have just described, descending from the abdomen immediately behind the external abdominal ring, and having the epigastric artery situated on its outer side. First observed by Mr. Cline.—Mr. Cline first ob- served this species of hernia, in opening the body of a Chelsea pensioner, with Mr. Adair Hawkins, on 25 the 6th of May, 1777. The hernia was on the right side, and the mouth of the hernial sac was situated an inch and a half on the inner side of the epigastric artery. I have myself witnessed several cases of this description. Course of—I have carefully dissected this hernia, and found that it passed on the inner side of the epi- gastric artery, and protruded through the external abdominal ring, under the fascia of the cord, pushing the spermatic cord to the outer and upper part of .the tumour. I traced a covering upon it, formed in part by the tendon of the transversalis muscle, and in part by the fascia transversalis; beneath which is situated the hernial sac. The coverings of this her- nia are, therefore, the integument, the fascia of the cord, a part of the cremaster crossing obliquely the outer part of the swelling, then the fascia and ten- don of the transversalis. Differs from the oblique hernia.—-It differs from the oblique inguinal hernia in not taking the course of the inguinal canal, but in protruding directly through the external ring, and having the epigastric artery to its outer side, and in having but an imperfect cover- ing from the cremaster, and a perfect one from the fascia transversalis and tendon of the transversalis united. Distinguishing marks.—The distinguishing marks between the direct and oblique inguinal hernia, are the situation of the spermatic cord, and the direction of the tumour; in the first, the spermatic cord is on the outer and upper part of the swelling, and the swelling may be traced in a direction towards the umbilicus:—in the latter, the spermatic cord is si- tuated behind the hernia, and the inclination of the tumour is towards the spine of the ilium. Causes.—The direct inguinal hernia may be pro- duced suddenly from a laceration of the tendon of 4 26 the transversalis, in which case the covering from this tendon will be found wanting. Case.—A gentleman applied to me, having a di- rect inguinal hernia, which had appeared immediate- ly after he had been thrown from his horse, and had fallen with the lower part of the abdomen upon a post, by which accident I imagine the tendon of the transversalis might have been ruptured. Seldom becomes large.—I have never seen this her- nia acquire the size of the common inguinal hernia, and in most of the cases I have witnessed, the pa- tients have had some disease of the urethra. Case in which six hernia existed.—In a patient of Mr. Weston's, of Shoreditch, who had for a long time laboured under difficulty in passing his urine, I found six hernia of this description, of which I have given a plate. I also found several strictures in his urethra, and a stone lodged behind one of them. Treatment of Direct Inguinal Hernia. Truss.—When reducible, the truss employed should be longer than that applied for common in- guinal hernia, as the part at which the hernia quits the abdomen, is an inch and a half nearer to the pubes. The pad of the truss should not rest on the pubes, but press principally a little above the abdo- minal ring, otherwise the general form of the truss may be the same. When irreducible.—If the hernia be irreducible, the means recommended for the oblique irreducible hernia will be proper. When strangulated, taxis.—When strangulated, the reduction must be attempted in a different direction to that required for the oblique. The tumour is to be grasped as in the oblique hernia, with one hand, while the fingers and thumb of the other hand are to be placed over the abdominal ring, to knead the 27 neck of the swelling, and the pressure must be di- rected upwards and inwards, instead of upwards and outwards. Case.—In this manner I quickly succeeded in re- ducing a direct hernia which had become strangulat- ed, in a patient who was admitted into Guy's Hospi- tal, for some other complaints. The hernia was small, it had the cord to its outer side, and could not be traced higher than the abdominal ring. Hernia apparently reduced.—This hernia may ap- parently be reduced by the employment of the taxis, and strangulation still exist; a case of this kind oc- curred a short time ago at Guy's Hospital. A man applied at the surgery, having a direct hernia stran- gulated, and the taxis was had recourse to, by which the gentleman in attendance thought he had succeed- ed in reducing the hernia, as he had pushed it through the abdominal ring. The symptoms of strangulation, however, still continued, and in two or three days the man died. On examination of his body, the hernia was found placed immediately be- hind the external ring, with a stricture still existing at the mouth of the sac. Operation for Strangulated Inguinal Hernia. When necessary.—When the means I have recom- mended have been tried, without enabling the sur- geon to reduce the hernia, or relieve the strangula- tion, it becomes necessary that an operation should be performed, to liberate the strangulated viscus. But little danger.—There is but little danger attend- ing this operation, if the person upon whom it is to be performed be free from other disease. The cause of persons who have undergone this operation, so frequently dying, is not to be attributed to the operation, but to the degree of mischief which has taken place previously to its being performed. 28 Gangrene.—When strangulation has existed for a long time, the contents of the hernia either become gangrenous, or in a state so nearly approaching to it, that they do not recover their proper functions, otherwise inflammation extends from the strictured portion to the viscera, within the cavity of the abdo- men, and thus the surgeon has to combat with a se- vere disease after the removal of the strangulation. The danger is therefore in the delay, and not in the operation. Danger of delay.—Very frequently much time is unnecessarily lost; before an operation is proposed ; and too much cannot be said in condemnation of such practice. A patient is submitted again and again to the taxis, and the swelling is rendered extremely tender, by being so often compressed, in the hope of avoiding an operation, until at length the rapid in- crease and urgency of the symptoms point out the impropriety of such delay; and an operation is per- formed when but little prospect of success remains. It is extremely important that the operation should, if possible, be performed before the abdo- men becomes tender under pressure. Distension of the intestines from flatus, often produces tension of the abdomen, soon after strangulation has occurred; but still the patient can bear pressure without expe- riencing pain; but when he does complain of pain under pressure, it indicates the extension of inflam- mation to the cavity of the abdomen, which is likely to be*much increased by the operation. Progress of inflammation varies.—The progress of inflammation, and extent of mischief, are not always in proportion to the time that strangulation has ex- isted, for the period between the commencement of the symptoms, and the fatal termination, varies ex- ceedingly. 29 Small hernias more frequently require operation.—A large hernia when completely strangulated, is more quickly fatal than a smaller one ; but the latter more frequently requires the performance of an op- eration, on account of the greater firmness of the stricture. Intestinal hernia most dangerous.—A hernia con- taining a portion of strangulated intestine alone, is more rapidly fatal than one containing omentum only; and that containing both intestine and omentum, takes a middle course between the two above men- tioned. Old hernias, most likely to be reduced.—When a her- nia has existed for a long time, and become strangu- lated, the attempts at reduction will be more likely to succeed than if it were of recent formation; in the first instance, the parts are more easily relaxed, having been accustomed to repeated dilatation; while in the latter case, the powers of resistance are much greater. Also in very old or young persons.—Also in very young, or very old persons, strangulated hernia? are more frequently reduced, than when they occur at the middle period of .life, during which the fibrous structure i9 firmer, and the muscular strength greater than at any other period. In very old persons, also, the strangulation/is not so rapidly fatal; as long a period as twenty days have been known to elapse between the commencement of the symptoms, and the death of the patient. Of the Operation for Inguinal Hernia. Bladder to be emptied, and parts cleansed.—Previ- ous to the operation, the patient should be directed to empty his bladder, and the integument upon the tumour and surrounding parts, must be cleansed from the hair usually covering it. 30 Position of the patient.—The patient is then to be placed upon a table, about three feet six inches in height, on his back, the shoulders should be raised, and the thighs a little flexed towards the body, so as to relax the abdominal muscles; the hams are to be brought to the edge of the table, so that the legs may be allowed to hang over it. Operation.—The surgeon should now place himself between the patient's thighs, and grasp the tumour with his left hand, so as to put the integument cov- ering it upon the stretch, and then having a scalpel in his right hand, he should commence the operation by making an incision through the skin, on the ante- rior part of the swelling, which incision should be begun opposite the upper part of the external ab- dominal ring, and carried down to the inferior part of the tumour, unless the swelling be of a large size. Besides the skin and cellular substance, the external pudendal artery may be divided by this in- cision, as it always crosses the sac near the abdo- minal ring. The haemorrhage from this vessel may usually be stopped by pressure; but if very trouble- some, it will be necessary to put a ligature upon it. Fascia of the cord exposed.—rBy this incision the fascia of the cord becomes exposed, which generally forms the thickest covering of the hernia. This must be carefully cut through in the centre, so as to admit the entry of a d.rector which is to be passed under the fascia, upwards to the ring, and downwards to the extent of the external incision, that the fascia may be safely divided upon it. Cremaster exposed.—Thus the cremaster muscle is brought into view, forming the next covering, which must be opened and divided in the same manner as the fascia, and with equal care, and the cellular tis- sue beneath must be cautiously cut through. Hernial sac exposed.—When this has been com- 31 pleted, the hernial sac itself is laid bare, and the surgeon must proceed with the utmost caution to open it in the following manner. He first nips up a small portion of the membrane on the anterior and inferior part of the tumour, between his fore-finger and thumb of the left hand, and slightly rolling the membrane between them, he easily distinguishes if any intestine or omentum be included; and if so, he raises a fresh portion. Being satisfied that he has only a part of the sac raised, he is to place the edge of the knife horizontally against it, and make an opening of sufficient size to admit the end of a di- rector, which is then to be introduced, that the sac may be opened upon it. Caution in dividing the coverings.—In dividing the different coverings, a very cautious operator will make more layers than I have described, being fear- ful of doing mischief which might be irreparable. Appearance of the sac.—When the hernial sac is exposed, it has usually a bluish tint, and is semi-trans- parent. If the contents be not adherent to the sac, it generally contains a quantity of fluid, and a sense of fluctuation may be usually perceived at the infe- rior and anterior part of it, for which reason this part should be first opened, as the intestine is there in the least danger. Escape of fluid.—Immediately the sac is opened, this fluid escapes. If the strangulation have not existed long, it is occasionally of a serous colour, but more frequently of a darker, or coffee colour, and sometimes it has an offensive smell. Quantity of fluid.—This fluid is most abundant in intestinal hernia, and is in quantity in proportion to the bulk of intestine strangulated. If, however, the hernia be omental, or if the intestine adhere to the interior of the sac, little or no fluid is found, so that it must not always be looked for as an indication of the sac being opened. 32 Sac opened.—The sac being opened, the surgeon is enabled to see its contents, which he must atten- tively examine. If both intestine and omentum have been strangulated, the latter is found above and anterior to the former; in some instances cov- ering the gut partially, in others completely. Appearance of omentum or intestine.—If the hernia has not been long strangulated, the omentum has much of its usual character, being only a little darker than natural, and having its veins distended ; but the intestine is found covered with a thin coat of adhe- sive matter, and is of a red colour. When the stran- gulation has existed for a long time previous to the operation, or when the stricture has been unusually tight, the intestine presents a dark brown chocolate colour. Seat of stricture ascertained.—The surgeon should now pass his finger into the hernial sac, and examine accurately the seat of the stricture, which he will find in one of the three following situations:— First.—At the internal abdominal ring, in the mouth of the sac. Second.—In the inguinal canal, an inch, or an inch and a half within the external ring. Third.—At the external ring. At the internal ring.—The most frequent seat of stricture is at the internal abdominal ring, from an inch and a half to two inches above, and outwards from the external ring, and it is occasioned by the pressure of the internal oblique and transversalis muscles upon the mouth of the hernial sac, which becomes thickened, more especially on its pubic side. How exposed.—Should the stricture be situated at this part, it has been thought necessary to divide the external ring, and to slit up in part the inguinal canal, by dividing a portion of the tendon of the external 33 oblique muscle, in order to give the operator a dis- tinct view of the protruded parts, and to enable him to divide the stricture without danger to his pa- tient. This may be done by passing the finger into the sac, through the external ring, as far as the seat of stricture, and then introducing a curved bistoury with a probed extremity between the upper part of the finger and the sac, and cutting through the ten- don, superficial fascia, and integument, forming the anterior boundary of the inguinal canal. Having thus exposed the contents of the hernial sac as far as the seat of stricture, the operator should insinuate the point of his finger, or a director, under the stricture, between the sac and its contents at the upper part, carefully keeping the latter from turning over the finger or director. He should then pass the knife for dividing the stricture upon the finger or director, under the stricture, and by a gentle mo- tion divide the stricture in a direction parallel with that of the linea alba, and to an extent sufficient to allow the finger to be easily passed into the cavity of the abdomen. The knife should then be with- drawn in a careful manner. In this case I have adopted with advantage the following plan :—The sac being opened to the external ring, I have put my finger into it, and hooked down the sac; I have then directed an assistant to draw up the tendon of the external oblique at the ring, and have thus been able to bring the stricture into view without cutting the tendon of the external oblique to the upper ring. Knife for dividing the stricture.—The knife best adapted for dividing the stricture is blunt at its ex- tremity for about a quarter of an inch, sharp for half an inch, and then again blunt, only cutting so far as is necessary to divide the stricture, without endan- gering the neighbouring parts. Stricture in the inguinal canal.—The second seat of 34 stricture is in the inguinal canal, and is formed by the sac itself in the following way:—a person becomes the subject of oblique inguinal hernia, and the pres- sure on the neck of the hernial sac at the internal ring, creates a thickening of the sac at this part. From any sudden exertion or straining, which occa- sions a further protrusion, this part of the sac is forced into the inguinal canal, and when the patient is in the recumbent position, part or the whole of the contents of the sac being returned into the cavity of the abdomen, the portion of the sac which had been previously situated at the internal ring, and had been thickened, again takes its former position. This oc- curs again and again; but at length the sac becoming elongated, the thickened portion which had been originally placed at the internal ring, no longer re- turns to this situation when the contents of the sac are reduced; but it remains in the inguinal canal, and may here at any future time be the cause of strangulation. How exposed and divided.—When the stricture is thus formed, the surgeon should freely expose the contents of the hernial sac as far as the stricture, and then divide it in the same manner, and in the same direction as before described. Stricture of the external ring.—Sometimes, but rarely, the seat of stricture is at the external ab- dominal ring, in Avhich casfethe same plan of dividing the stricture should be adopted; but it is not neces- sary to make so large an opening. If the hernia be direct, it is to be remembered that the spermatic cord is placed on its outer side. It is covered by the fascia of the cord, by the cre- master partially, and is contained in a sac formed by the tendon of the transversalis muscle, assisted by the fascia transversalis, beside a peritoneal sac, as in other hernia. 35 Best direction for dividing the stricture.—The di- vision of the stricture directly upwards is then appli- cable to every common case of strangulated inguinal hernia whether oblique or direct; it is equally safe with any other division that has been proposed, and the operation is by it more simplified than by adopt- ing a different mode of dividing the stricture for each variety. 36 LECTURE XXXIII. Examination of viscera.—After having sufficiently divided the stricture, the surgeon should carefully examine the protruded intestine, particularly that part which has been immediately under the stricture, and ascertain whether the circulation becomes re- stored, which he may do by employing pressure to empty the vessels, and then observe if they be again immediately filled. Should the circulation be free, he should then gradually and very carefully return the intestine by small portions at a time, until the whole is reduced. At this time the patient should be placed much in the same position as when the taxis is employed. Adhesions.—When adhesions have taken place between the intestine and sac, great care is required in opening the latter, as little or no fluid e.xists in it, to separate it from the intestine, which may be in consequence easily wounded. The sac being opened, if the adhesions be found long, and not very numer- ous, they may be divided to allow of the return of the protruded part. Sometimes these adhesions are only found at the mouth of the sac, or are otherwise partial; in either case they should be carefully sepa- rated, that the hernia may be completely reduced; but the division of such adhesions, particularly at the mouth of the sac, is attended with considerable dan- ger. Sometimes the sides of the fold of intestine which has been strangulated are found glued to- gether: in this case it is best to separate such adhe- sion, if it can be easily done, a? the free passage of the faeces is afterwards interrupted, if the intestine 37 be returned doubled back into the abdomen with such adhesion remaining. Intestine gangrenous.—Should the intestine be in a state of gangrene, it will have a foetid smell, the peritoneal surface will have lost its brilliancy, and be of a dark port wine colour, with greenish spots on it; it will not possess any sensibility, and will easily give way under slight pressure. Treatment of gangrenous intestine.—Under these circumstances, the stricture should be divided in the manner I have described, after which a free incision should be made into the gangrenous intestine, to al- low of the escape of its contents, and then it should be returned to the upper part of the sac, the wound should be left open, and a poultice applied ; but if the portion of intestine which has descended be not large, it should not be disturbed from its adhesions to the sac. Case.—I was requested, during the absence of Mr. Chandler, to operate upon a woman who had been admitted into St. Thomas's Hospital, under his care, with strangulated hernia. From the examination of the part, and from the history of the case previous to my seeing the patient, I imagined that gangrene had commenced, and I soon found this opinion to be correct; for before 1 had opened the hernial sac, there was a highly offensive and putrid smell. On opening the sac, I found the intestine in the state I have before described ; I therefore divided the stricture, and then made an incision of about an inch and a half in extent, on the anterior part of the gan- grenous intestine, through which the faeces readily escaped. I afterwards directed that a poultice should be applied. Faeculent matter continued to be discharged through the wound; but nine days sub- sequent to the operation she had a stool, per anum, after which the patient passed her stools by the 38 natural passage, occasionally at first, then more fre- quently, as the artificial anus and wound closed, and she completely recovered. This patient was con- fined five months alter the operation, and delivered of a full grown but dead child, by Mr. Brown, a re- spectable surgeon at Rotherhithe. It is extraordi- nary, that being considerably advanced in her preg- nancy at the time of the operation, she did not mis- carry. Termination without an operation.—When a patient with strangulated hernia will not submit to-the oper- ation necessary for his relief, or if the proper assist- ance cannot be procured, and gangrene takes place, the hernia sometimes suddenly returns into the cavity of the abdomen, and the patient survives only a few hours. Sometimes the skin and other coverings inflame and slough, when the faeces are discharged through the opening thus produced, and the symptoms of stran- gulation subside, after which an artificial anus is formed, rendering the remainder of the patient's life miserable. Artificial anus.—Occasionally, however, it happens that the external wound and artificial anus are grad- ually closed, and the patient entirely recovers. Case.—A case of this kind occurred under the care of my friend, Mr. John Cooper, surgeon, of Wotton Underedge, Gloucestershire. He was requested to attend a poor woman, aged sixty, who was the sub- ject of strangulated crural hernia. When he first saw her, she had been labouring under symptoms of strangulation for a fortnight, and the hernia was evi- dently in a state of mortification. Thinking, there- fore, that there would not be any chance of saving her life by an operation, he only directed that her strength should be supported, and the part poulticed. In a few days the mortified parts began to separate, and the faeces were discharged through the wound. 39 This continued for three months, during which period several inches of one of the small intestines sloughed. After this, a small quantity of faeces began to pass by the natural channel, and in six months the woman had perfectly recovered. . > Danger of.—The formation of an artificial anus is dangerous, according to its situation in the intestinal canal. If the opening be near to the stomach in the jejunum, the patient will die in consequence of the small surface for the absorption of chyle being inade- quate to produce sufficient nourishment. If the opening be in the lower part of the ilium, or in the colon, then the patient may recover, as there is but little interruption to nutrition. Case.—A man about fifty years of age was admit- ted into Guy's Hospital, with a strangulated umbili- cal hernia, which sloughed, and occasioned an arti- ficial anus. As he was recovering from the effects of the strangulation and sloughing, and was allowed to take food in any considerable quantity, it was ob- served that part of what solids he ate passed out at the artificial anus, within half an hour after he had swallowed them, and that fluids passed out in ten minutes after they had been taken into the stomach. ^ Although he took sufficient food to support a healthy person, he wasted rapidly, and died in three weeks. On examining his body after death, and tracing the jejunum, the lower part of that intestine was found entering the hernial sac, and in it the opening was situated. The other viscera were healthy. From inversion of the intestine.—When an artificial anus has been formed, care must be taken to guard against any inversion of the intestine at the artificial opening, as such an occurrence will mos* likely pre- vent the perfect recovery of the patient, by render- ing the false opening permanent. Case.—A patient of Mr. Cowell's, in St. Thomas's 40 Hospital, underwent the operation for a strangulated hernia; the intestine was found to be gangrenous, and the consequence was the formation of an arti- ficial anus. For three weeks after the operation, the faeces passed in part by the artificial opening, and in part by the natural aperture, but most by the lat- ter; at this period the intestine became inverted, and protruded at the artificial opening; after which the faeces were entirely discharged by the false pass- age. The man lived eleven years after this, but always discharged his stools by the artificial anus. Appendices epiploicce removed.—If a portion of the colon has been strangulated, and the patient be fat, the appendices epiploicae are sometimes found much more diseased than the intestine, so much so that it becomes necessary to remove them, which I have hjad occasion to do. Examination of omentum.—Having returned the intestine, the surgeon should carefully examine the omentum, and if it be not in a large quantity, or of an unhealthy appearance, it should be returned into the abdomen, with as gentle a pressure as possible. If a very large portion of omentum be protruded, a part should be removed, which may be done with- out any danger to the patient by means of the knife; and, if any arteries sufficiently large to afford a trou- blesome haemorrhage, are divided, they must be se- cured by fine ligatures; the divided surface should then be returned to the mouth of the sac, so as to form a plug, and the ligatures should remain hang- ing from the external wound. Use of the ligature abandoned.—The old mode of applying a ligature around the protruded portion of the omentum to occasion it to slough off", is now, I believe, entirely abandoned; and it appears extraor- dinary, that it should ever have been adopted, as it is the object of the operation to remove the strict- 41 ure, which would be thus immediately restored with increased severity. Omentum mortified.—If the omentum be in a state of mortification, which may generally be known by its crispy feel, and the distension of its veins by coa- gulated blood; or even if any suspicion arise of its being in an unsound state, it should be removed by excision at the sound part. In doing this, the stran- gulated portion should be drawn down a little, so as to expose some of the sound part, which should be held by an assistant to prevent its sudden retraction into the abdomen, while the surgeon cuts off the dis- eased part; and when this has been completed, any bleeding vessels should be secured as before direct- ed. Should the omentum, in an unsound state, ap- proaching to gangrene, be returned into the cavity of the abdomen, the danger of the patient will be much increased. Sloughing of omentum.—Case.—I have, however, known a patient recover, in whom sloughing of the omentum took place after it had been returned into the cavity of the abdomen. This occurred in a man who had undergone the operation for a strangulated hernia in Guy's Hospital. The sac contained both intestine and omentum; and the latter, although much changed in appearance, was returned into the abdomen. Some days after the operation, the man appeared to be dying; the ligatures, holding the edges of the wound together, were removed, and poultices and fomentations employed, when, on the following day, a portion of gangrenous omentum was found protruding from the wound, and for several days more continued to present itself, until the whole of the portion which had been previously strangulat- ed was exposed, and gradually sloughed off*; after which the patient recovered. Omentum adherent.—When the omentum alone ad- 6 42 heres to the sac, it may be freely separated and re- turned, any vessels likely to afford a troublesome haemorrhage being previously secured. Omentum hard like scirrhus.—Should the protrud- ed omentum be much hardened, or have a scirrhus feel, it should also be removed in the same manner as I have already described. • Treatment after the Operation. Employment of sutures.—When the contents of the hernial sac have been returned into the cavity of the abdomen, the wound should be well cleansed, and its edges should be afterwards brought into contact by means of sutures, in order to promote adhesion, two or three sutures being necessary, according to the extent of the wound. Care should be taken in passing these sutures only to include the integument, otherwise, by penetrating the sac, much subsequent mischief may arise. Of plaister.—The approximation of these parts should be assisted by the application of slips of soap plaister, and a compress should be placed over the wound, and retained there by means of a T bandage, to close the orifice of the sac, and prevent anv fur- ther protrusion into it, and at the same time the scrotum should be well supported. Position in bed.—The patient should then be car- ried to bed in a horizontal position, and placed with his shoulders a little elevated, and the thigh, on the same side as the wound, moderately flexed towards the abdomen. JYecessity of the recumbent position.—As it is per- fectly necessary that the patient should keep the recumbent position during the cure, a folded sheet must be placed under him, into which he should dis- charge his stools, otherwise should he rise to use the 43 night-chair, much mischief may arise from the effort. Mr. Cline had operated upon a patient for strangu- lated hernia; and some hours after the operation the patient got out of bed to use the night-chair, and from the exertions he made in getting up and in passing his motion, the intestine, which had been reduced, again descended into the sac: Mr. Cline again reduced the intestine, and gave strict orders for the man to keep the recumbent position, and the patient ultimately did well. Usually, if the patient be left to himself, he will have some natural stools in a few hours after the operation; but, if several hours elapse without arc evacuation, either castor oil or sulphate of magnesia should be given, or a purgative enema, containing colocynth, or castor oil, should be thrown up, and the abdomen should be fomented with spirituous fomenta- tion, which will assist the action of the bowels, and afford much comfort to the patient. Medicines.—As the safety of the patient depends -much upon procuring evacuations from the bowels, the exhibition of opium soon after the operation should, if possible, be avoided; but if the irritability of the stomach Continue, or if the patient have a troublesome cough, it should be administered in con- junction with calomel. Purgatives.—It is not only necessary to procure evacuations from the bowels soon after the opera- tion, but it is extremely desirable to keep up a free action upon them for several days following; as I have frequently known patients die in a few days after the operation with constipation and peritoneal inflammation, although they had passed several stools within twenty-four hours after the strangulation had been relieved. Sutures removed.—Should the patient go on well, the wound should be dressed on the third day, and 44 afterwards daily. The sutures may be removed on the fourth and fifth day; but the patient must be kept in bed until the wound is entirely closed. Operation successful.—When the operation has been performed at any early period after the stran- gulation has taken place, the patient generally does well; but when much time has elapsed from the strangulation of the hernia before the performance of the operation, dangerous symptoms frequently arise. Sometimes not.—Sometimes the intestine does not recover its function, when the vomiting and constipa- v tion continue, and the patient dies. Peritoneal inflammation.—Sometimes peritoneal in- flammation continues, in which case the abdomen is extremely tender and tense, although the bowels are open, and the life of the patient is soon destroyed. The best means of relieving this inflammation are by local and general bleeding, fomentations, purga- tives, and extremely low diet. Diarrhaa.—Occasionally the patient is attacked with a violent diarrhoea, which continues for many days, producing so great a state of debility as to pre- vent recovery. In such cases, the treatment I have found most efficacious, consists in exhibiting small doses of opium frequently, and the employment of injections of starch and opium, with a light but nu- tritious diet, as gruel, or milk, with isinglass, &c. Hiccough.—-In a few instances I have known a troublesome hiccough continue for several days after the operation, but entirely unconnected with gan- grene, being the result of peritoneal inflammation. Case.—The most remarkable^example of this kind I ever met with, was in a gentleman at Maidstone, for whom I performed an operation upon a large strangulated intestinal hernia. The symptoms had been unusually severe, and inflammation had taken 45 place in the peritoneum. The abdomen continued tender to pressure for several days after the opera- tion, and the hiccough continued until the sixth day. The patient was bled and purged freely, and he eventually recovered. As this symptom depends upon inflammation of the peritoneum when gangrene has not taken place, the proper means of relieving it are the same as directed for the inflammation of this membrane, as local and general bleeding, purga- tives, &c. The operation does not prevent a future protrusion. —The performance of the operation for strangulat- ed hernia does not prevent the future descent of the intestine or omentum, but perhaps renders the pa- tient more liable to its recurrence, as the mouth of the sac is by the operation considerably enlarged. It is, therefore, perfectly necessary before the patient be allowed to get up, or use any exertion, that he should be fitted with a truss, which will effectually prevent any protrusion, by keeping the mouth of the sac closed, otherwise he may in a short time again become the subject of strangulated hernia. Truss to be again applied.—When the truss is first applied, a dosil of lint should be placed under the pad, to protect the recently healed wound. Removal of the sac recommended.—In consequence of a radical cure not being produced by the opera- tion I have described, some persons have recom- mended the removal of the hernial sac by excision or ligature, or that it should be returned into the abdomen. Case.—In a patient of Mr. Holt's, at Tottenham, I had an excellent opportunity of seeing the effects of removing the sac by excision. A woman, who, for several years, had been subject to a femoral her- nia, applied to Mr. Holt, on account of the swelling having become so painful and tender as to prevent 46 her from following her ordinary occupations, although the bowels appeared to act very regularly. Mr. Holt requested me to visit the patient with him, and I made many ineffectual attempts to reduce the her- nia, and in a few days afterwards I recommended Mr. Holt to operate, as the symptoms had not in the least subsided. On opening "the hernial sac, a small portion of intestine was found at the mouth of the sac, inflamed, and adherent to it. Mr. Holt care- fully separated the adhesions, and returned the in- testine into the abdomen. The sac itself being but little attached to the surrounding parts, I requested Mr. Holt to allow me to remove it, which I did, close to the mouth of the sac. I then closed the orifice by sutures, and the external wound was treated in the usual way. On the sixth day, the li- gatures came away, and the wound was closed on the tenth. I saw this woman a month after the op- eration, when she had a hernia nearly as large as the one for which the operation had been perform- ed, and at the same spot; she was subsequently obliged to wear a truss constantly, to prevent the protrusion of this hernia. Removal of the sac not successful.—From this it appears that the removal of the sac will not prevent the re-formation of a hernia, nor do I think, upon reflection, that it scarcely could be expected to do so, as the aperture from the abdomen remains equally large, and the peritoneum alone offers resistance to the formation of another hernia, and this had been insufficient to prevent the protrusion of the first. Objection to removal of the sac by a ligature.—The removal of the sac by ligature is equally objectiona- able, even if it could be done without risk, which it hardly could, more especially in oblique inguinal her- nia, as the ligature ought, in such cases, to be applied close to the internal ring, which could not be done 47 without a very tedious and hazardous dissection; be- sides, the spermatic cord is sometimes divided by the sac, which would increase the difficulty and danger of such an operation. Danger of.—The great danger of this operation is in the inflammation, which is likely to be induced by the action of the ligature upon the peritoneum, and in this inflammation extending to the cavity of the abdomen. Of Large Hernial. Different operation required.—In very large inguinal herniae a very different mode of operating is required, to that which I have already described, for the fol- lowing reasons :— Difficulty of reducing.—When a large hernia has existed for some time, the cavity of the abdomen becomes diminished, from the habitual loss of a large portion of its natural contents, and such a resistance is offered when any attempt is made to return the contents of the hernial sac, that the intestine some- times gives way, or is lacerated from the violence employed in attempting to reduce it, and even if it can be returned, the slightest exertion will occasion a further protrusion. Danger from the taxis.—Also, in large hernia, a considerable extent of protruded intestine being sub- mitted to much violence in the attempt to reduce it, often gives rise to inflammation, which may produce fatal consequences. Extensive adhesions.—Sometimes extensive adhe- sions have been formed between the sac and protrud- ed intestine, or the portion of peritoneum which has descended, and is forming part of the sac, may have brought with it a portion of the intestine, to which it is naturally closely connected, as the ccecum, 48 and which thus becomes irreducible : in either case the reduction of the hernia is of course prevented. Mode of operating.—Instead of performing the same operation, as in other cases, I should, under these circumstances, merely expose the upper part of the hernial sac, and divide the stricture without opening the peritoneum, unless the stricture hap pened to be seated in the mouth of the sac itself. Case.—The first time that I had an opportunity of performing the operation in this manner, was upon a patient of Mr. Birch's, in St. Thomas's Hospital. The man was between fifty and sixty years of age, and had been subject to a hernia from his infancy, which, becoming strangulated, and not yielding to the usual measures, rendered an operation necessary. From the size of the hernia, which reached half way to the knees, and its duration, I conceived that such adhesions might have occurred as would render its reduction impossible, and that the ordinary mode of operating would be extremely hazardous, on account of exposing so large a surface of intestine; I there- fore determined upon trying what could be effected by a division of the stricture, without opening the hernial sac. Operation.—I commenced by making an incision, beginning about one inch and a half above the ex- ternal abdominal ring, and terminating about the same distance below it; this exposed the tendon of the external oblique, and the fascia of the cord. I then carefully made an opening into the latter, large enough to admit a director, which I introduced, and upon it divided the fascia so as to expose the cremaster mus- cle as far as the external ring; after this I passed the director between the cremaster and edge of the external ring, and introducing a probed bistoury, I cut through a part of the tendon of the external oblique, so as to enlarge the external ring. On 49 passing my finger into the inguinal canal, to the edge of the transversalis muscle ; I felt some further re- sistance, and again introducing the director, I care- fully separated some fibres of this muscle. The contents of the hernial sac were then reduced, and the edges of the wound being approximated, the patient was put to bed. The wound healed kindly in about three weeks, although the hernia was protruded upon the slight- est exertion, which would have occasioned much ir- ritation, had the sac been opened. The patient was subsequently obliged to wear a laced bag truss. Division of the stricture.—Should the stricture be seated in the neck of the hernial sac itself, of course the division of the parts exterior to it, Avill not re- lieve the strangulation; in this case the sac must be opened carefully at the upper part only, so as to al- low of a division of the stricture. Care in returning the viscera.—Having divided the stricture, the surgeon must avoid violence in attempt- ing to return the protruded parts, for the reasons I have before mentioned. 1 have knoAvn the intestine ruptured in forcibly endeavouring to effect the re- duction after the liberation of the stricture. The case occurred in St. Thomas's Hospital, and terminat- ed fatally. The ruptured intestine is preserved in the collection at that Hospital. Some surgeons object to the division of the strict- ure without opening the hernial sac, urging that the intestine or omentum may be in a gangrenous state, and that this cannot be ascertained unless the sac be opened; but I should imagine that a very limited experience would enable the surgeon to form an ac- curate opinion in this respect. 7 50 Of Hernias, in the Inguinal Canal. Appearance.—The oblique hernia is sometimes confined entirely to the inguinal canal, and does not emerge through the external ring. It is often diffi- cult to detect in the living subject, as there is no distinct tumour perceptible, but merely a fulness above Poupart's ligament. When strangulated, the usual symptoms are present, and the part is very tender on pressure, or during coughing. Coverings.—This hernia is covered by the super- ficial fascia, the tendon of the external oblique mus- cle, by a thin fascia from the edge of the internal ring, and in part by the cremaster muscle, the sper- matic cord and the epigastric artery lie posterior to it. Mistaken.—These herniae, when strangulated, are often mistaken for cases of peritoneal inflammation, as the patient is not conscious of having a swelling; and thus he may fall a victim to the disease, without a suspicion of its true nature. Case.—A patient was admitted into St. Thomas's Hospital with a hernia of this description, strangulat- ed, which was treated as peritoneal inflammation, for five days before the true nature of the com- plaint was discovered. There was a fulness above Poupart's ligament, which was painful on pressure or during coughing; and on pressing the part, a small tumour appeared at the external ring, which disap- peared when the part above was not pressed. The operation was performed, and a portion of the circumference of one of the small intestines was found strangulated, but not gangrenous. Although the strangulation had existed for so long a perjod, and the patient had suffered from hiccough, and ex- treme tenderness of his abdomen, yet he ultimately recovered. 51 Mode of operating.—The mode of operating in these cases is as follows :-—The hair having been re- moved from the part, and the patient being placed in a convenient position, an oblique incision is to be made, commencing at the upper part of the swelling, about midway between the anterior superior spi- nous process of the ilium and symphisis pubis, and terminating a little above the external abdominal ring. This incision should divide the integument and superficial fascia, and expose the tendon of the external oblique muscle, which is to be carefully cut through in the same direction, when the hernial sac will be seen covered by a very thin fascia, which is given off from the upper aperture. Part of the cremaster muscle is also found covering the lower part of the sac. The sac is to be opened with the usual precautions, and the stricture, which will be found at the upper orifice, is to be carefully divided upwards, by first passing a small director under it, and then introducing the hernia knife upon the di- rector. Hernial sac returned.—The return of the hernial sac into the cavity of the abdomen has been recom- mended in this form of hernia; but it does not ap- pear that any advantage is gained by it, independent, in many cases, of the difficulty of effecting it. Cases.—Mr. Weld, junior, surgeon, at Romford, having occasion to perform an operation upon a wo- man, on account of the strangulation of a hernia of this kind, after liberating the stricture, returned the sac into the abdomen. The woman recovered, but some time after became the subject of hernia at the same spot, as she would not wear a truss after the operation. I am indebted to my friend Mr. Thomas Blizard, for the following curious and interesting case of her- nia, descending behind the spermatic cord, which had 52 been accompanied with hydrocele, in the tunica va- ginalis of the same side. The patient had been the subject of hernia on the right side, for six years, for which he had worn a truss ; and from his own account a hydrocele had formed on each side, two years previous to his com- ing under the care of Mr. Blizard; but that on the right side had gradually disappeared, leaving the tes- tis wasted and drawn up to the groin. The hernia becoming strangulated, and not yield- ing to the usual means employed for reducing it, Mr. Blizard performed the operation about twenty-four hours after the commencement of the symptoms. Having laid bare what he thought was the hernial sac, he punctured it, and then freely opened it upon the director. It extended through the external ring, into the inguinal canal, which Mr. Blizard in part cut open, in order to make the necessary examina- tion of what he conceived to be the hernial sac; this, however, proved to be the tunica vaginalis, which had formerly been distended by the hydrocele, hav- ing the hernia seated behind it. The posterior part of this tunic was then cut through, exposing the her- nial sac, which was found to contain a portion of in- testine nearly of a black colour, from strangulation. The stricture which was seated at.the mouth of the sac was divided in the usual manner, and the intes- tine returned. The patient did well. Mr. Henry Cline had occasion to operate upon a similar case. Of Inguinal Hernia in the Female. Structure of parts.—The structure of the inguinal canal in the female is very much the same as that which I have described in the male, only that the round ligament in the former takes the place of the spermatic cord existing in the latter. 53 Round ligament.—The round ligament, which com- mences at the fundus uteri, passes from the abdomen midway between the anterior superior spinous pro- cess of the ilium to the outer side of the epigastric artery, above Poupart's ligament, and below the transversalis and internal oblique muscles, as the spermatic cord in the male; it takes a course ob- liquely downwards, and inwards to the external ab- dominal ring through which it passes, and is lost up- on the pubes. This round ligament, however, being much smaller than the spermatic cord of the male, passes through openings corresponding to its size, which are conse- quently much less than those for the spermatic cord, and on this account the formation of inguinal hernia in the female is of comparatively rare occurrence. Course of the hernia.—When this hernia does oc- cur in the female, it takes the course of the round ligament, is at first confined to the inguinal canal, where it is covered by the tendon of the external oblique, and subsequently it protrudes through the external ring, and forms a swelling at the upper part of the labium, which seldom acquires a large size ; here it is covered by a superficial fascia given off from the tendon of the external oblique. Causes.—It is produced by the same causes in the female as in the male, and presents the same symp- toms. The sac usually contains either intestine or omentum, or both, but sometimes the appendages of the uterus are found in it. Less liable to mistake than in the male.—As the round ligament in the female is not liable to the same affections as the spermatic cord of the male, the her- nia in the former case is not likely to be confounded as it frequently is in the latter case with such dis- eases. I have, however, known this form of hernia in the female mistaken for a femoral hernia, which 54 may readily be imagined when we recollect the prox- imity of the parts concerned. . How distinguished from femoral.—A careful exa- mination will readily enable the surgeon to distinguish between the two, as in the inguinal, the neck of the tumour is above Poupart's ligament and in the fe- moral below ; in the former, also, the spinous pro- cess of the pubes can be readily felt outside the swelling, which it cannot be in the latter.* Reducible.—When this hernia can be reduced, a truss, similar to that necessary for a male, is to be employed. Irreducible.—When irreducible, the same treat- ment as recommended for the male will be proper. If intestinal and small, a truss with a hollow pad ; if omental, a common pad ; and when the hernia is very • large, a T bandage, to give support, and prevent in- crease. Strangulated.—Should this hernia become stran- gulated, the taxis should be first employed in the same way as in the other sex ; and should this not succeed, bleeding, the warm bath, ice, the tobacco enema, or other means to assist reduction, should be had recourse to. The usual means having failed to relieve the stran- gulation, an operation becomes necessary, which should be performed in the following manner. Operation.—The hair having been removed from the surface of the tumour, and the patient being placed in the same position that I directed the male should be under similar circumstances, the surgeon should make an incision through the integument, com- mencing a little above the external abdominal ring, * Another good diagnostic mark is in the direction of the im- petus given to the swelling, when the patient coughs or sneezes; in inguinal hernia being downwards, and in femoral, upwards from the thigh.—T. 55 and terminating at the lower part of the swelling. This exposes the fascia covering the hernial sac, which should next be carefully divided to the extent of the first incision. The sac, being thus laid bare, should first be cautiously punctured as before mentioned, and then should be further opened upon the director. The portion of the hernial sac below the external abdominal ring may perhaps contain only a quantity of the dark serum usually found ; in which case the operator must introduce his finger into that part of the sac which is in the inguinal canal, and there he will feel the portion of intestine or omentum which is strangulated. He should then slit up the canal and sac towards the anterior superior spinous pro- cess of the ilium, so as to expose the strangulated parts; and, ascertaining the seat of stricture, he should pass a small director under it, and carrying the hernia knife upon the director, the stricture should be divided upwards, or upwards and out- wards, after which the protruded parts are to be returned, if they be not in a state of gangrene. The last case of inguinal hernia in the female, in which I had an opportunity of witnessing the opera- tion was under the care of Mr. Forster, in Guy's Hospital. Case.—Upon opening the sac below the external ring, a quantity of fluid escaped, but there was not any appearance of intestine or omentum. However, upon passing the finger into the sac, through the ex- ternal ring, a portion of intestine could be distinctly felt, which Mr. Forster subsequently exposed, by slit- ting up the inguinal canal. The stricture, which was seated at the internal ring, was divided upon a di- rector in the usual manner, and the patient did ex- tremely well. After treatment.—The after treatment does not differ from that I have directed for the other sex. 56 In the inguinal canal.—When the inguinal hernia in the female has not descended through the exter- nal ring, it may become strangulated, and occasion fatal consequences, as in the male, without its exist- ence having been recognised during the life of the patient. Case.—A patient was admitted into St. Thomas's Hospital, under the care of Sir Gilbert Blane, with symptoms of strangulated hernia; but, upon being closely questioned by Sir Gilbert, she denied the ex- istence of any tumour at the groin, navel, or else- where, and the case was consequently treated as one of inflammation. The woman died; and Sir Gilbert, supposing that some concealed hernia might have been the cause of her death, inspected the body, and found a small strangulated inguinal hernia on the right side, which did not protrude an inch from the internal ring. Operation.—When necessary, the operation in this case is similar to that required for the same disease in the male. I have never seen direct inguinal hernia in the female. Of Congenital Hernia. Aro proper sac.—In this hernia the protruded parts have not any proper peritoneal sac, as the common inguinal hernia, but are contained in the tunica vagi- nalis of the testicle. All herniae seated in this cavity are not, however, congenital, as such protrusion may occur at the adult period for the first time. Origin.—This hernia is originating from the des- cent of the testicle in the foetus. Usually about the seventh month, the testicles, which are up to that period seated upon the loins, begin to descend into the scrotum. At this time, a strong ligament is found 57 connected with the inferior part of the testis and epididimis, and passing to the.scrotum in the same direction as the spermatic cord is afterwards placed; it is called the gubernaculum, and appears to guide the testicle into the situation provided for it. The testicle and its vessels are covered by peri- toneum, except just where the latter enter at the posterior part of the former. Descent of the testicle.—In its descent, the testicle takes with it a portion of peritoneum, which after- wards becomes the tunica vaginalis; and it is usually found in the scrotum at the ninth month; but there is considerable variety as to the period when the descent is complete, sometimes being earlier or later than the ninth month, sometimes one testicle comes down first, and the other does not descend until some time afterwards. In some cases, the testicles never quit the abdomen, and in others they only descend to the groin. When the testicle has reached the scrotum, the opening through which it quitted the abdomen gen- erally closes, but at what period is not precisely as- certained. If, however, it should remain open at the time of birth, the efforts of the child in breathing or crying cause the protrusion of a small portion of in- testine into the cavity, and thus the congenital hernia is formed. Called the windy rupture.—From its appearance and feel, more particularly when the child cries, the nurses call it the windy rupture, in opposition to the term watery rupture, which they apply to an hydro- cele, when it occurs in the infant, and this is not very unfrequent. Sometimes occurs at the adult period.—1 have found the tunica vaginalis sufficiently open at the adult period to admit the introduction of a female cathe- ter ; and I have known hernia, similar to the true 8 58 congenital form, occur in persons between twenty and thirty years of age. In these cases I imagine the opening at first to have been so smnll as not to admit the descent of a hernia under ordinary circum- stances, but that when the patients have been under the necessity of doing very laborious work, or dur- ing a state of great relaxation, the protrusion has taken place. Course.—The congenital hernia must necessarily take the course of the spermatic cord, passing in the same direction as an oblique inguinal hernia, from which it is to be distinguished by the following marks. In common oblique inguinal hernia, the testicle is perfectly distinct from the hernial sac; whereas, in the congenital disease, the testicle is confounded with the sac. In the latter case, also, the appearance of the part very much resembles that of a hydrocele; more especially if, as sometimes happens, a quantity of fluid descends into the sac with the intestine or omentum which, upon a close inspection, gives a transparent appearance to the swelling. To distin- guish these joint diseases, the contents of the hernia should be returned into the cavity of the abdomen whilst the patient is in a recumbent posture; after this, a moderate pressure is to be made against the abdominal ring, with the finger, so as to prevent the descent of the intestine or omentum; if the patient then assume the erect position, the water will escape into the tunica vaginalis, but the intestine or omen- tum will be felt pressing against the finger above. Sometimes the testicle does not descend to the bottom of the scrotum, and then, if a congenital her- nia form, the tunica vaginalis becomes elono-ated, and reaches considerably below the situation of the testicle. Division of the cord.—In the congenital form of hernia, also, the cord is occasionally divided, the ar- 59 tery and vein being on one side, and the vas deferens taking its course on the other side. Reducible.—When the congenital hernia is reduci- ble, it requires the use of a truss, as the common in- guinal hernia, provided that the testicle has com- pletely descended into the scrotum, or does not rest at the groin. For the first three months, perhaps a pad and bandage may be sufficient to prevent the descent of the hernia; but after this period a truss with a spring may be employed with safety, or even at a younger period if necessary. Testicle in the groin.—If the testicle be seated in the groin, a truss cannot be worn without risk of in- juring the gland, and it is better to allow of such a protrusion as will assist the complete descent of the testicle, before any truss or other means of suppress- ing the hernia be resorted to. Case.—A young man who now holds a situation of importance, and who is the father of several chil- dren, was brought to me formerly by his father, on account of his having a congenital hernia ; but be- cause the descent of the testicle on the same side was incomplete, I directed that the protrusion should not be retarded. The testicle afterwards descended into the scrotum, a truss was then applied for the hernia, and the disease was ultimately subdued. Closure of the tunic.—After the truss has been worn for some time, the tunica vaginalis becomes closed at the upper part, and near the testicle, but sometimes remains open between, allowing a space for the deposit of fluid which occasionally takes place, forming hydrocele of the cord, and for the cure of which I have had to perform an operation on several occasions. Irreducible.—With regard to the treatment of this hernia in the irreducible state, the same as directed for common inguinal hernia, is here applicable ; and 60 when strangulated, the same means as recommended in the latter case, should be employed for the relief of the patient. Operation.—When an operation is required, it should differ from that described as necessary for common oblique inguinal hernia, in the following particular. Having laid bare the tunica vaginalis, it should not be opened low down on account of ex- posing the testicle, but a sufficient quantity of the tunic should be left whole to cover this gland. Large quantity of fluid.—On opening the tunica vaginalis, a much larger quantity of fluid generally escapes than is found in the sac of a common ingui- nal hernia. Seat of stricture.—The seat of stricture will be generally found under the edge of the transversalis muscle, or at the internal ring, when it should be divided in the same manner as in other cases of hernia ; after which, the protruded parts, if not ad- herent, should be returned. If extensively adhe- rent, the stricture should be divided in the same way, but the surgeon should not attempt to separate the adhesions, unless very few and slight, in qrder to allow of the return of the parts ; but they should be left; and after the wound has healed, a bag truss will be required, as for other irreducible scrotal -herniae. In operating for this form of hernia, the testicle is sometimes found in the inguinal canal in contact with the intestine; in which case the intestine only should be returned into the abdomen, the testicle being left in the canal. The stricture in this case is at the orifice of the tunica vaginalis. 61 Of Encysted Hernia of the Tunica Vaginalis. How formed.—This is a particular species of her- nia, which occurs in the following manner. The tunica vaginalis becomes closed, by adhesion, oppo- site the abdominal ring, but remains open above and below it; and when a protrusion of intestine occurs, this adherent portion of the tunic becomes elongat- ed, forming a distinct hernial sac within the proper tunica* vaginalis. Case.—I had an opportunity of witnessing the fol- lowing case, under the care of Mr. Forster, in Guy's Hospital. A man was admitted into the house with symptoms of strangulated hernia, which the usual means failed to relieve, and the operation was pro- posed and urged ; but the patient would not submit, choosing rather to die. On examining his body after death, a sac was found within the tunica vaginalis, descending from the abdominal ring towards the testicle. This sac contained a portion of one of the small intestines which had become gangrenous. The stricture was at the mouth of the sac. Operation.—In operating upon a case of this kind, the tunica vaginalis should be opened freely, to ex- pose the sac, otherwise some difficulty may arise. Mr. Hey, in his surgical observations, has related a case similar to that of Mr. Forster. 62 LKCTURE XXXIV. On Femoral Hernia. Anatomy of the parts.—Before I proceed to de- scribe the symptoms of femoral hernia, I shall give an account of the anatomy of the parts directly or indirectly concerned. Superficial fascia.—The superficial fascia, which covers the external oblique muscle, is continued down over Poupart's ligament upon the thigh, where it is found of considerable density, and serves to keep the superficial veins and absorbent vessels in their proper situations. Crural arch.—Under Poupart's ligament, which stretches from the anterior superior spinous process of the ilium, to the spinous process of the pubes, is a space called the crural arch, which gives passage to the femoral artery and vein, the anterior crural nerve, and psoas and iliacus internus muscles, with absorbents, &c. GimbernaCs ligament.—From that portion of Pou- part's ligament which is inserted into the spine of the pubes, a process is given off, extending down- wards and outwards, and attached to the ligament of the pubes over the linea-ileo-pectinea; it pre- sents a concave edge towards the femoral vein, and is known under the name of Gimbernat's ligament. Fascia transversalis and iliacus.—Two fasciae are given off above from Poupart's ligament, one passing upwards between the peritoneum and transversalis muscle, which is called the fascia transversalis; a 63 second fascia extends between the peritoneum and iliacus, and psoas muscles, called the fascia iliaca. From another part of the fascia transversalis, a pro- cess passes down under Poupart's ligament, through the crural arch, to the sheath of the femoral ves- sels, forming its anterior part, and the fascia iliaca forms the commencement of the posterior portion. Sheath of the femoral vessels.—In this sheath are situated the femoral artery and vein, the anterior crural nerve not being included. The vein is placed most internal, and about five-eighths of an inch to the outer side of Gimbernat's ligament; the artery lies outside of the vein, and the nerve still more ex- terior. The artery and vein are separated by a septum. Fascia lata.-^—Under the superficial fascia of the groin, and extending from the inferior part of Pou- part's ligament, is a strong fascia, called fascia lata, which has two attachments above, but becomes united below. One portion is joined to Poupart's ligament from the spinous process of the pubes to the anterior superior spinous process of the ilium; and, passing downwards, covers the femoral artery and vein, the anterior crural nerve, and the muscles on the outer and fore part of the thigh. Falciform process.—From its origin at the spine of the pubes, a defined edge passes a little outwards and downwards, in a crescentic form, over the sheath of the femoral vessels, then curves inwards, and a little upwards, under the saphena major vein, and is united to the second portion. This second portion is connected above with the ligament of the pubes close to the insertion of the external oblique mus- cle; it then passes inwards and downwards upon the pectineus, adductor longus, and other muscles, to join that part which 1 described as passing under the saphena major vein. From the union of these 64 two portions, the fascia lata of the thigh results anteriorly. Between the free internal edge of the first, and the origin of the second portions, as low down as their junction under the saphena major vein, an opening is left, exposing a part of the femoral sheath. This space is filled above by absorbent glands; the absorbent vessels from which, here per- forate the sheath of the femoral vessels, to pass to the glands in the abdomen. At fhe lower part of the space, the saphena major vein penetrates the sheath to enter the femoral vein about an inch be- low the crural arch. If the fascia lata be entirely removed from the upper part of the thigh, the muscles and anterior crural nerve are exposed, but the femoral artery and vein remain enclosed in their proper sheath. Sheath funnel shaped.—On opening the femoral sheath, the artery and vein are exposed ; the former situated to the outer side of the latter, and about three inches from the symphisis pubes. The sheath, about two inches downwards, becomes intimately connected with a portion of the fascia lata. It has somewhat a funnel shape, being larger above, and contracted below, where it joins the facia lata. Epigastric artery.—The epigastric artery, in its course upwards and inwards from the external iliac, passes from one-half to three-fourths of an inch from the opening where the absorbents enter the abdo- men. There is, however, considerable variety in the origin of this vessel. Orifice of the sheath.—To view the orifice of the cru- ral sheath from above, the peritoneum, which covers it, must be taken off, when the relative situations of the vessels, entering the sheath, will be distinctly seen, as also the descent of the two portions of fas- cia to form the sheath, that from the fascia transver- 65 salis above the vessels, and that from the fascia ilia- ca beneath them. Difference in the male and female pelvis.—From the difference in the formation of the pelvis in the male and female, the space forming the opening to the femoral sheath is largest in the latter, on which ac- count they are more liable to the formation of femo- ral hernia. Commencement of the hernia.—When a femoral hernia commences, the patient's attention is first di- rected to the part on account of experiencing pain on suddenly straightening the limb, as in rising from a sitting posture. This is occasioned by the exten- sion of the fascia lata, and its pressing on the pro- truded parts. Appearance of the hernia.—On examining the seat of pain, a fulness is discovered at the upper and inner part of the femoral sheath, which disappears on pres- sure, or when the patient is recumbent. This ful- ness soon increases, so as to form a tumour about the size of a small walnut, which is situated immediately below Poupart's ligament, to the inner side of the femoral vessels, and to the outside of the spine of the pubes. As the swelling enlarges, it projects more forwards and upwards, turning up over Pou- part's ligament; as it meets with the least resistance in this direction. Like an enlarged gland.—When the tumour is small, from its situation and circumscribed feel, it has much the character of an enlarged inguinal gland. Direction of the hernia.—The direction of this her- nia is at first a little downwards in the femoral sheath, then obliquely inwards and forwards, and lastly up- wards ; sometimes, however, instead of turning up over Poupart's ligament, it takes a course down- 9 66 wards, in the direction of the saphena major vein; but this very rarely happens. Dissection of the hernia.—On dissecting a femoral hernia, the following appearances present themselves. On cutting through the integument, the fascia super- ficialis is exposed; this, in its natural state, is thin and delicate ; but frequently, when hernia exists, the fascia becomes dense and tough from pressure. Un- der this fascia a portion of the sheath of the femoral vessels is found, which closely envelopes the hernial sac itself; it is that portion which is perforated for the entrance of absorbent vessels. Fascia propria.—This covering I first became ac- quainted with in examining a patient in St. Thomas's Hospital, in the year 1800, and have since invariably found it, when operating for this form of hernia. It may be termed the fascia propria of the hernia. , Beneath this covering, and between it and the sac itself, there is generally some adipose matter situated, on separating which the sac is laid bare. This layer of adipose matter I have known to be mistaken for omentum. Mistaken for other diseases.—The femoral hernia is much less likely to be confounded with other dis- eases than the inguinal, on account of the much more frequent formation of various tumours in the situation of the latter; but still there are some diseases which I have known to be mistaken for femoral hernia, and in the discrimination of which much care is re- quisite. Enlarged gland.—In several instances, an enlarged gland in the groin has been mistaken for a femoral hernia; and, on the contrary, the hernia has been treated as an enlarged and suppurating gland; but such mistakes must arise from inattention to the pre- vious history of the case. Cases.—Some years ago, a man was admitted into 67 Guy's Hospital with a strangulated hernia, over which a poultice had been applied for three days before his admission, under the supposition that it was a bubo. The operation was performed, and the intestine found gangrenous. Mr. Bethune, surgeon, at Westerham, in Kent, assured me, that he saw a patient who had been the subject of a strangulated femoral hernia, which had been poulticed for some days, and at length opened, when air and feculent matter escaped, and the patient died ten days after. Hernia and enlarged gland.—When a femoral her- nia and enlarged gland exist at the same time, an at- tentive and minute examination is sometimes requi- site to ascertain the existence of the former. Case.—I once saw a lady with Mr. Owen, sur- geon to the Universal Dispensary, who had suffered from symptoms of strangulated hernia for nine days, and had been treated for inflammation of the intes- tines, as she had not mentioned the existence of a swelling in her groin. Mr. Owen discovered this swelling, and in consequence requested me to visit the patient, at the same time informing me, that the tumour had not the feel of a hernia, but that he sup- posed it must be one from the symptoms. Upon ex- amining the part, 1 found an enlarged gland, about the size of a walnut, very hard, and moveable; but be- neath this gland, and separate from it, was an elastic tumour, which I succeeded in reducing by the em- ployment of the taxis; and this relieved the patient from all the symptoms of strangulation. Psoas abscess.—Some of the symptoms attending psoas abscess resemble those of a femoral hernia, and might lead to mistake. Psoas abscess makes its ap- pearance in the groin in the same situation as a fe- moral hernia; it dilates when the patient coughs, and is less apparent when the person is in a recum- 68 bent posture, than when he is erect. It may, how- ever, be readily distinguished from hernia by the pain in the loins, which precedes the appearances of the swelling, by the general constitutional derange- ment attending it, by its more rapid increase, and by the absence of intestinal derangement. Inguinal hernia.—The error of most consequence respecting femoral hernia, is, that of mistaking it for inguinal hernia. Danger arises under such circum- stances, from the operation of the taxis, the direc- tion to make pressure in the femoral being quite dif- ferent from that proper in the inguinal; but the most serious mischief is likely to arise, if an operation be necessary, in the division of the stricture. Case.—I was once sent for to operate on a patient for a strangulated inguinal hernia, which, on examina- tion, I found to be femoral, and succeeded in reduc- ing it, by making the pressure in the proper direc- tion ; and I have known operations performed as for inguinal hernia, when the disease has been femoral. These mistakes arise from the femoral protrusion turning up over the crural arch or Poupart's liga- ment ; and much attention is often requisite in mak- ing an examination, before the surgeon can confident- ly decide on the true nature of the disease. The best marks of distinction which I have observed, are, that the neck of the femoral hernia is below and to the outer side of the spine of the pubes, while that of the inguinal hernia is above the spine ; also, by drawing down a femoral hernia, Poupart's ligament may be traced above it, which it cannot be, if the disease be inguinal. Varicose vein.—I have seen a case of enlargement of the femoral vein, which had somewhat the ap- pearance of a femoral hernia, but it was readily de- tected, by pressing on the iliac vein above, while the 69 patient was recumbent, when the tumour immediate- ly appeared. This hernia most frequent on the right side.—Fe- moral hernia is most frequent upon the right side, probably on account of the most persons employing that side in the greatest degree. Mothers liable to it.—Women who have borne many children are more liable to this disease than others, which arises from the extension of the abdo- minal parietes during gestation, causing a more relax- ed state of the parts; also, old persons are more fre- quently troubled with this disease than the young. Most frequently intestinal.—Most frequently the protruded part in femoral hernia is small intestine, very rarely only omentum, but occasionally both in- testine and omentum. 1 have seen the ccecum in a femoral hernia on the right side, and the ovaria have also been found in the hernial sac. Causes.—The femoral hernia is produced by the same causes as occasion the formation of inguinal hernia, except that I do not recollect a single in- stance in which this disease has been originated by a blow. Treatment of the Reducible Femoral Hernia. Danger of strangulation.—From the small size of the opening through which femoral hernia passes, the patient is in great danger from strangulation, unless proper means be adopted to prevent the de- scent of the viscera. Truss.—The employment of a truss is the only method by which the safety of a patient can be se- cured; but the truss required for femoral hernia must be of somewhat different construction to that which is required in inguinal hernia. The pad, instead of being continued nearly in a 70 straight direction with respect to the spring, as when required for inguinal hernia, should project down- wards, nearly at right angles, to the spring, that it may effectually press upon the opening through which the hernia protrudes under Poupart's ligament, and also upon the upper part of the thigh. To be constantly worn.—The truss should be con- stantly worn, as for inguinal hernia, to prevent the protrusion of the hernia, and also with the view of obliterating the mouth of the sac, and curing the disease. Does not cure.—It is very rare, however, that a cure is effected in femoral hernia by means of the truss, but still it is right that it should be constantly kept on. I have known many instances in which the constant application of the truss has not produced the smallest apparent alteration in this hernia; the reason is, because Poupart's ligament, and the fascia lata, support the pressure of the truss, and the con- stant variation in the tension of these parts on every movement of the body, prevents the steady pressure necessary to produce a gradual closure of the opening. In some cases, when the opening of the femoral sheath is large, it will be necessary to have a larger pad, and a stronger spring to the truss, and the pad may be more effectually kept in place, by means of a strap passed from it round the upper part of the thigh. ri r Double truss.—If a hernia exist on both sides, a double truss will be required, made upon the same principles as the single one. Salmon and Ody's truss.—The truss made by Sal- mon and Ody's, I have generally found best adapted to these cases. 71 Of the Irreducible Femoral Hernia. Causes.—Femoral hernia may become irreducible from adhesions of the protruded parts to the interior of the hernial sac ; from a growth of the protruded parts within the sac, so that they cannot repass the opening into the abdomen, or by a contraction at the neck of the sac itself, producing the same conse- quences. Treatment.—In either case, a truss should be ap- plied with a hollow pad, which is to receive the tu- mour, and prevent its increase. Case.—A gentleman consulted me, in consequence of his having an irreducible femoral hernia, which, upon examination, I thought only to contain omen- tum; I directed him to wear a truss, with a depres- sion in the pad, just large enough to receive the tu- mour. Two or three years afterwards, I saw this gentleman again, when I was gratified in learning, that his hernia had nearly disappeared. This was in consequence of absorption of the omentum having been produced by the pressure of the pad. Truss cannot always be worn.—If the hernia be en- tirely intestinal, this form of truss, with a hollow pad, cannot always be worn, as I have known it to create very severe suffering. Of Strangulated Femoral Hernia. Symptoms.—The symptoms of strangulation being the same as those I have already detailed in the lec- ture on inguinal hernia, I shall not again repeat them but merely observe, that in femoral hernia, they are usually more urgent on account of the smallness of the opening, through which the protrusion occurs, causing greater pressure. Severe.—The patients generally complain of more 72 pain from strangulated femoral than inguinal hernia in the same state, and they die sooner from the former than the latter disease. Medical treatment.—The medical treatment re- quired for strangulated femoral hernia, does not dif- fer materially from that necessary for the inguinal disease. Taxis.—In the first place, the taxis should be em- ployed, but in a different mode to that I have de- scribed as proper for the reduction of inguinal her- nia. The patient should be placed on a bed, with the shoulders elevated, and the thighs bent at right angles with the body, leaving only sufficient space be- tween them to admit the arm of the operator. The tumour is first to be pressed downwards, until it be below the level of Poupart's ligament, when it is to be kneaded upwards towards the abdomen. Difficulty.—The difficulty usually experienced in , attempting to reduce this form of hernia, arises from the pressure being made at first in an improper di- rection, viz. upwards, so that the hernia is forced over Poupart's ligament, instead of beneath it, and in this way the hernia never can be reduced. Pressure gentle.—As in the reduction of inguinal hernia, the pressure should be gentle and continued, avoiding violence, which may be productive of the most serious consequences. General treatment.—Should the taxis fail, the same general treatment as that directed for inguinal her- nia, should be pursued, as bleeding, the warm bath, opium, the application of cold, and the injection of the tobacco glyster. These remedies, however, have much less beneficial influence in femoral, than in the other forms of hernia; which I imagine*is ow- ing to the nature of the parts through which the protrusion occurs, and the smallness of the aperture through which it descends. 73 Symptoms urgent.—As the symptoms are usually very urgent in femoral hernia, and as the disease more rapidly destroys life, there is the greater ne- cessity for the early performance of an operation, when the usual means to effect reduction have been tried and have failed. I have known a patient die in seventeen hours after the symptoms of strangula- tion had commenced; and on the contrary, I have performed an operation with success, after the symp- toms had existed seven days; but in general, the pa- tients labouring under this disease do not survive the strangulation more than four days, if -the stricture remain; whereas, in inguinal hernia, under similar circumstances, they often live a week or more. Of the Operation for Femoral Hernia. Preparation.—The hair is to be removed from the surface of the tumour, and the bladder should be emptied. The patient should then be placed upon a table of convenient height, in a horizontal position, but his shoulders' should be a little raised, and the thigh bent towards the abdomen, in order to relax the abdominal muscles, &c. Operation.—The first incision should commence a little above the superior part of the.tumour, towards the umbilicus, and be extended downwards, some- what to the inner side of the prominent part of the swelling, as far as its middle ; a second incision should then be made from the inner to the outer side of the tumour, at right angles with the first incision, and joining it at the lower part, so that the two together form a figure resembling an inverted j_. The "angular flaps should then be dissected up, to allow of sufficient space for the other steps of the operation. Superficial fascia.—The superficial fascia which is 10 74 thus exposed, should next be divided to the same ex- tent as the integument, by which the covering form- ed of the sheath of the femoral vessels will come into view;* this should be carefully cut into, so as to admit of the introduction of a director under it, upon which it should be further opened, so as to freely expose the hernial sac. Layer of fat.—If the patient is fat, a layer of adi- pose matter may be found between this covering, formed of the sheath of the femoral vessels, and the sac itself. Sheath of the vessels.—I have known this covering, which I call the fascia propria, to be mistaken for the hernial sac, so that the surgeon who operated, supposed he had opened the peritoneal covering when he cut into the sheath, and after considerable difficulty, he succeeded in pushing up the protruded parts, but on the following day, the patient died ; and when examining his body, it was discovered, that the hernial sac had not been opened, but had been thrust up into the abdomen with its contents, which still remained in a strangulated state. Hernial sac.—The surgeon having exposed the hernial sac, should pinch up a small portion of its an- terior and lower part, between his finger and thumb, carefully excluding any portion of the contents of the sac, and then placing the blade of his knife horizon- tally, he should cautiously make a small cut into the elevated part, making an aperture of sufficient size to allow of the passage of a director, upon which he should further divide the anterior part of sac up- wards and downwards. Fluid.—A quantity of fluid usually escapes, when the sac is first opened, which varies greatly in quan- tity, and somewhat in colour, according to the period * There is usually a considerable vein between the super- ficial fascia, and the fascia propria, as well as absorbent glands. 75 that the strangulation has existed. It is not uncom- mon, however, for the fluid to be entirely wanting, even when there are no adhesions. If inflammation runs high, the peritoneal surface of the intestine is covered by adhesive matter. Division of the stricture.—The next and most im- portant step in the operation, consists in dividing the stricture, the situation of which should first be dis- tinctly ascertained by passing the point of the little finger into the hernial sac, on the fore and inner part of its contents. Seat of—If the hernia be large, the seat of strict- ure may be at or under the opening in the fascia lata, through which the covering formed by the sheath of the femoral vessels is protruded; but generally, the stricture will be found immediately beneath Poupart's ligament, in the mouth of the sac itself, where the hernia quits the abdomen. In either case, a director should be very carefully introduced into the sac, anterior to its contents, and gradually insinuated under the stricture, and upon its grove the hernia knife (before described) should be passed, with its cutting edge turned upwards, and a little inwards, towards the umbilicus, in which direc- tion the stricture should be divided. Two strictures.—In some cases when the hernia is large, strictures may be found both at the crescentic margin of the fascia lata, and under the crural arch of Poupart's ligament, and each will require division, that at the fascia lata must of course be first liber- ated. How treated.—When a stricture, therefore, exists at the crescentic margin, the surgeon, after dividing it, should make a careful examination, to ascertain if the passage to the abdomen be free, before he at- tempts to return the protruded parts, for should a second stricture exist, he may rupture the protruded 76 intestine in the violence he must employ in endea- vouring to return it. Direction of division.—In dividing the inner strict- ure, it has been recommended to cut in the direc- tion of Gimbernat's ligament, inwards towards the fuibes; but as the stricture is not occasioned by this igament, there cannot be any necessity for dividing it; I have known Gimbernat's ligament divided, from an idea that it formed the stricture, but the stricture still remained at the orifice of the fascia propria, or in the mouth of the sac itself, and the patient died.* Great caution necessary.—Great caution is requisite in dividing the stricture, if the protrusion be entirely intestinal, and the operator should not introduce the knife, until the intestine has been carefully placed out of danger by an assistant. Case.—Sometime ago, a case occurred in one of the Borough hospitals, in which the intestine was wounded, when the operator was dividing the strict- ure, which he did inwards, towards Gimbernat's ligament; feculent matter was extravasated into the cavity of the abdomen, and the patient died. On examining the parts after death, two openings were found in the intestine, close to the mouth of the sact Adhesions.—The treatment I have directed as proper in inguinal hernia, when the protruded parts adhere to the sac, or when the intestine or omentum are gangrenous, is also proper under similar circum- stances in femoral hernia. * It is curious, that Gimbernat's ligament should ever have been supposed to be the seat of stricture, as it exists only upon the inner side of the mouth of the hernial sac, and therefore could not influence the outer portion. If strangulated femoral hernia be examined in the dead body, and Gimbernat's Jigament be cut through, the hernia is not liberated by such a division, for the orifice of the fascia propria, or the neck of the sac itself, still girt the viscera as much as ever. t Cutting directly inwards is a most dangerous operation in femoral hernia, as the intestine is very likely to be wounded. 77 After treatment.—After the operation, the same mode of closing the wound, and indeed the after treatment generally, should be the same as in the inguinal disease. But little variety.—Very little variety is met with in femoral hernia, the most important one is that in which the obturator artery arises from the epigas- tric, and surrounds the neck of the sac. Dr. Barclay's preparation.—Dr. Barclay, a cele- brated teacher of anatomy at Edinburgh, was kind enough to send me a specimen of this variety, which was taken from a patient, whose previous history could not be ascertained. Mr. Wardrop has also met with this variety. Common course of the obturator.—Although the ob- turator artery frequently arises from the epigastric; it is very rarely found passing before the sac in fe- moral hernia, but usually takes a course to the outer side, and beneath the sac, as I have often witnessed when dissecting the parts of femoral herniae. My mode of avoiding injury to the epigastric or obtura- tor arteries, is to make a very slight division of the stricture with the knife ; and then, by pressure of the finger or of a director, to enlarge the opening. Fluid beneath the fascia propria.—In one instance I have met with a large quantity of fluid situated between the fascia propria and the hernial sac. The following is a short account of the case :— Case.—Miss-------, aet. 20, had been the subject of a femoral hernia on the right side for three or four years, which had acquired about the size of a pullet's egg. In June, 1825, the hernia became strangulated, and increased to a very large size. As she did»not mention the existence of the hernia to her medical attendants, it was not discovered until the third day from the commencement of the symp- toms, the continuance and severity of which led 78 to an examination. Mr. Wakefield, of Hatton Gar- den, who had attended her, immediately requested rae to visit her; when, after trying, without effect, the ordinary means to reduce the hernia, I operated. On opening the fascia propria, I was astonished at the escape of nearly a pint of transparent fluid, re- sembling that usually drawn off in hydrocele. The hernial sac, which then became exposed, was small; and, on opening it, a little of the usual dark-coloured fluid was discharged. A small portion of omentum, with a fold of small intestine, were protruded. Af- ter dividing the stricture, and returning the viscera into the cavity of the abdomen, I removed a large part of loose bag exterior to the sac. The patient recovered rapidly. 79 LECTURE XXXV. On Umbilical Hernia. Synonyme.—This form of hernia, which is also termed exomphalos, is next in frequency to the in- guinal. JYatural opening.—The protrusion takes place through the opening in the linea alba, which is form- ed in the foetal state for the passage of the vessels of the umbilical cord. How closed usually.—After the funis has been tied, this opening usually becomes closed by dense cel- lular tissue, and the remains of the umbilical veins and arteries, but not by a tendinous structure. The integument over it is adherent, and generally drawn in, forming the navel. Dissection of the parts.—Behind the navel, when these parts are dissected, the peritoneum is found, which adheres more firmly at this part than any other of the linea alba; it is connected above to the remains of the umbilical vein, and below to the liga- ment of the bladder and remains of the umbilical arteries. There is not any perforation in the peri- toneum behind the navel, as the vessels do not pene- trate it, but pass between it and the abdominal pa- ne tes. Commencement of the disease.—Umbilical hernia commences in a small protrusion about the size of a nut, which can be easily reduced, but which again appears immediately the patient coughs or exerts himself. If neglected, it soon increases in bulk ; and, as it augments, it gravitates; so that the larger part of the swelling is below the orifice of the sac, and in 80 some instances it acquires so great a size as to reach to the upper part of the thighs. Creates much suffering.—This disease, if intestinal, and not supported, is attended with much danger, and creates a considerable degree of suffering. The patient frequently feels so much weakness and sen- sation of sinking, as to be incapable of making an ex- ertion. The bowels are very irregular in their ac- tions, and the patient is much troubled with flatu- lence and nausea. Symptoms when intestinal.—Besides the frequent occurrence of these symptoms, the intestinal protru- sion may be distinguished by its elasticity, its uniform feel, and by the passage of the air, &c. through the canal, producing a gurgling noise. When omental.—When the protrusion is entirely omental, the patient experiences but little uneasiness or irregularity of the bowels. The feel of the swell- ing is uneven and doughy, and is but little tender un- der considerable pressure. When both.—Sometimes, if both intestine and omentum are contained in the hernial sac, they can be distinguished from each other by the above men- tioned marks. The omentum is in these cases usu- ally above, and the intestine below. But, most fre- quently, the quantity of omentum protruded is much larger than that of the intestine, and the latter is covered by the former, so that it cannot be at first distinguished. Common in infants.—The umbilical hernia is very common in infants soon after birth. Intestine is then generally protruded, and the shape of the swelling somewhat resembles the distended finger of a glove in shape ; the hernia is easily reduced, unless the opening in the linea alba is very small. Children, subject to this disease, suffer from grip- ing and a very irregular state of bowels, sometimes being constipated, at others being violently purged. 81 . Appearance in the adult.—When this hernia occurs in the adult, if the patient be thin, the shape of the tumour is pyriform and defined; but in fat persons, the hernia is sometimes scarcely perceptible on a superficial inspection, as it extends upwards and downwards, is flattened anteriorly, and has its cir- cumference blended with the adipose matter, so as not to present any defined edge. The tumour may be flattened in thin persons, but when so, its extent is always evident. Sac in part deficient.—Although, generally, the hernia has a peritoneal covering, or proper sac, yet, in a few instances, when the disease has been of long standing, and has acquired a very large size, I have seen the sac in part wanting. Two sacs.—1 have also known two sacs to exist at the same time ; one protruded by the side of the other, and only separated at their origin by a thin septum. Case.—Mr. Cline operated twice upon a woman in St. Thomas's Hospital, for strangulated umbilical hernia, in whom two herniae existed, having their commencement about half an inch apart, but the sacs lying in contact. Most frequent in women.—Women are much more liable to this disease than men, and the most frequent cause of it is pregnancy, the bowels being pushed up by the gravid uterus as it rises from the pelvis. Causes.—Another cause is the deposition of adi- pose matter within the omentum and mesentery, whereby their size is so much increased that the abdomen is hardly capable of containing them. Wo- men who become corpulent after having had many children, are often subject to this disease, on account of the lax state of the abdominal parietes, not afford- ing sufficient resistance to prevent such protrusions. The distension of the abdominal parietes, and pro- 11 82 trusion of the navel, which is sometimes met with in ascites, is said to be a cause of umbilical hernia ; but I am inclined to think that it is more frequently the consequence than the cause of this disease. Treatment of Reducible Umbilical Hernia. In infants.—In infants subject to this disease, the plan I usually adopt, is, after having reduced the her- nia, to apply half of an ivory ball sufficient to cover the opening, and to confine it in that situation by means of adhesive plaister. A linen belt should be applied, and secured round the body, but as soon as the child begins to walk, two straps must be fixed to the lower part of the belt, which should pass under the pelvis, between the thighs, to prevent the belt from slipping. In adults.—For the adult, or even for children, when the hernia is of small size, a spring truss may be employed, made on the same principle as that di- rected for inguinal or femoral protrusions. The pad of the truss should cover the opening through which the viscera escape; and the spring should pass from the pad to the back of the patient, a little beyond the spine; and a strap should be continued from the spring to the pad, to complete the circle. In very fat persons.—When the patient is very corpulent, so that the navel is deep, the portion of ivory may be advantageously placed under the pad of the truss, the more effectually to close the open- ing of the sac ; and this is much better than having a conical pad, which is liable to shift its position when the patient is in motion ; but the half globe of ivory does not follow the motions of the pad.* * The ivory ball with the adhesive plaister, will, in the adult, prevent the increase of a small hernia, so as to render a truss unnecessary. 83 When very large.—Very large hernias, accompa- nied with a lax state of the abdominal parietes, re- quire a different form of truss, as it is necessary to make a more extended pressure. The pad of the truss, therefore, instead of being only of sufficient size to cover little more than the orifice of the sac, must be of considerable extent, so as to press upon a large space round the hernial opening, and thus sup- port the parietes as well as the hernia, which will render the patient comfortable, although there is not any prospect of thus effecting a cure. Of the Irreducible Umbilical Hernia. Causes.—Umbilical hernia becomes irreducible from the same causes as the inguinal does; viz. ad- hesions of the intestines or omentum to the inner surface of the sac, or a growth of omentum, render- ing it too bulky to repass the opening by which it escaped. Becomes very large.—Under these circumstances, the hernia sometimes acquires an enormous size, more particularly in women, whose abdominal parie- tes have been weakened by frequent pregnancy; and I have in such persons seen the pudendum entirely covered by the hernial swelling. The umbilicus in these cases is brought nearer to the pubes than na- tural, by the constant weight and drag of the hernia. Danger of—With such a large hernia the patient is exposed to constant danger from blows or falls; besides the weight of the tumour, and an ulcerated state of integument, which often occurs, renders the patient incapable of following any employment re- quiring bodily exertion. Treatment.—When the hernia is irreducible, and not of very large size, a truss should be worn with a hollow pad, as recommended for irreducible inguinal 84 herniae. The hollow should be just sufficient to con- tain the swelling, and the edges should be rounded off so as to prevent any injury from pressure to the surrounding parts. The substance of the cup should be pewter, which should be covered with soft lea- ther. The spring should be of the same kind as that of the common truss. When very large.—In very large herniae of this de- scription, a truss cannot be worn; and all that can be done to relieve the patient is to support the swelling by bandages, passed over the shoulders so as to pre- vent the constant dragging of the tumour. Of Strangulated Umbilical Hernias. Symptoms.'—The symptoms, indicating strangula- tion in this form of hernia, are the same as those I have described as existing when inguinal or femoral herniae are in the same state ; but in the umbilical disease they are generally less urgent. Causes.'—Strangulation is frequently produced in these cases by the patient taking food not easy of digestion, or such as occasions flatulency ; persons having this complaint should therefore eat sparingly, and be careful to avoid all food difficult of digestion, or likely to create flatulence. Seat of stricture.—The seat of stricture is usually at the tendinous opening through which the hernia protrudes, but sometimes the neck of the sac itself is thickened, and prevents the reduction of the vis- cera. Treatment.—Taxis.—When strangulation exists, the surgeon should first endeavour to relieve the pa- tient by employing the taxis in the following manner. The patient being placed on the back, the shoulders should be elevated by pillows, also the pelvis a little raised, and the thighs bent at right angles with the 85 body. The surgeon should then grasp the swelling with his hand, and direct the pressure a little up- wards as well as inwards, because the opening to the abdomen is not usually in the centre of the swelling, unless the hernia is small, or projecting, when the pressure should be made directly inwards. If the neck of the sac can be distinctly felt, the surgeon should knead it with the finger and thumb of one hand, while he presses the hernia with the other. In very large herniae.—In very large, flat, and spreading hernia, when the tumour cannot be grasp- ed by the hands, the surgeon should make pressure by means of some broad surface, as the bottom of a wooden platter, which he should place on the sur- face of the swelling, and keep up a steady pressure upon it for twenty minutes or half an hour. General treatment.—Should the employment of the taxis fail in relieving the patient, the other means recommended for the femoral and inguinal herniae, under similar circumstances, should be tried; but the remedy which I have found most successful in this disease, and on which I place the greatest reliance, is the tobacco glyster, as it appears to produce much more beneficial effeets in this form of hernia, than in the others I have described. It should be used of the same strength, and with the same precautions I have before mentioned. In many instances I have known this remedy successful, after repeated trials of other means had failed to relieve the patient. Bleeding, and the application of cold, I have known to produce the desired effect after the taxis had failed; but the surgeon must be careful how he takes away blood, as women of delicate constitution, and lax fibre, are often the subjects of this disease, in whom the loss of blood, in large quantity, might prove destructive. Should the strangulation continue in spite of these I 86 trials to relieve it, the surgeon should proceed to li- berate the hernia by an operation, the performance of which is extremely simple, but requires a little caution. Operation.—The patient being placed upon a table of convenient height, in an easy position, with the abdominal muscles relaxed, the surgeon should com- mence the operation by making an incision across the swelling, and then a second cut at right angles with the first, in the direction of the linea alba; the transverse incision should be below, and should be joined at its centre by the lower part of the perpen- dicular cut, so that the two represent an inverted j^. The two angles should be dissected up to expose the superficial fascia, which the surgeon must next divide, but very carefully, as the hernial sac itself is sometimes wanting in part; and in such a case the protruded viscera would be immediately exposed. This covering should therefore be opened, as if it were the sac, by nipping up a small portion between the finger and thumb, in the manner I have already described. Hernial sac.—If the peritoneal covering be com- plete beneath the superficial fascia, it should be cut into, and divided further, upon a director, in the same way as when operating for other herniae. The escape of a small quantity of fluid usually indicates that the sac has been opened. Division of the stricture.—The protruded viscera being exposed, the operator should carefully pass his finger over their upper part to the opening of the umbilicus, and then introducing the hernia knife upon his finger, and insinuating it under the stricture, he should cut upwards towards the ensiform cartilage to such an extent as will make the opening sufficient- ly large to allow of an easy reduction of the pro- truded parts. 87 Return of viscera.—Having divided the stricture, the intestine, if in a fit state, should be first cautious- ly returned; and the omentum, if in large quantity, or if in a doubtful state, may be cut away, but if in a small quantity, and sound, it may be returned into the abdomen. After-treatment.—The edges of the external wound should be brought together by sutures, and the ap- proximation completed by strips of adhesive plaister; a compress of linen should be placed over this, and confined by means of a broad bandage passed round the body. It is of much importance, after this operation, to procure a closure of the wound by adhesion, as the direct communication with the abdomen increases the risk of peritoneal inflammation. Operation for large hernias,—For very large um- bilical herniae, when strangulated, I should recom- mend a different mode of operating, which should be performed in the following manner. A small open- ing should be made over the neck of the swelling, through the integument and superficial fascia, so as to expose the hernial sac at that part; then the opera- tor should pass his finger between the sac and edge of the umbilical opening, so as to guide the hernial knife, by which the umbilical opening should be dilated upwards without dividing the sac. Case.—I performed this operation upon a Mrs. Aaron, who had long been afflicted with a large irre- ducible umbilical hernia, which became strangulated. When I had divided the tendon, I was able, by very slight pressure, to return a portion of the protruded intestine, and she rapidly recovered. Adhesions.—In some cases the intestine adheres so firmly to the mouth of the sac, that great care is requisite to avoid wounding it. The separation of these adhesions in part must be effected with as lit- 88 tie violence as possible, by means of the finger, to allow of the safe division of the stricture. Strangulation from opening in the sac.—In some instances, where there has been an opening formed by absorption, or laceration of the hernial sac, the intestine, or omentum escape from the sac through the aperture, and become strangulated by the pres- sure from its edge. In these cases there is consider- able danger, unless the operation be very carefully performed, as the viscera are exposed immediately the superficial fascia is divided. Should the adhesions be extensive and firm, the surgeon must be content with liberating the stricture, and not attempt to return the protruded viscera. Part of the colon protruded.—The intestine gen- erally protruded in umbilical hernia, is a portion of the colon; the appendices epiploicae of which be- come more quickly altered than the intestine itself; and if much changed, they should be cut off rather than any risk incurred by leaving them to slough after the operation. Danger of the operation.—The danger in this operation is of wounding the intestine, as there is not any vessel of importance that can be injured. Of Ventral Hernia. Like the umbilical.—This hernia only differs from the umbilical in its seat, which is usually at the linea alba, or linea semilunaris; but any visceral protru- sion at the anterior, or lateral parts of the abdomen, except those already described, may be called ven- tral herniae. Symptoms.—The symptoms of this form of hernia are usually the same as those of the umbilical, ex- cepting when the hernia is formed between the um- bilicus and ensiform cartilage in the linea alba, and 89 contains a portion of the stomach, when peculiar symptoms will arise. Case.—1 once saw a gentleman with a hernia in this situation, who suffered constantly from indiges- tion, flatulency, and a distressing sensation of sinking at the scrobiculus cordis. His hernia was, however, reducible, and the application of a truss relieved all his unpleasant symptoms. Causes.—The following causes may give rise to this hernia:— 1. NA natural deficiency of tendinous structure, which I have known to a very considerable extent, in the linea alba or linea semilunaris. 2. The apertures for the passage of blood-vessels being unusually large. 3. Injuries by which the continuity of the parietes is destroyed. Coverings.—The coverings of ventral hernia are generally the same as those of the umbilical disease ; viz. the integument, superficial fascia, and peritoneal sac; but in some instances I have found another covering connected with the edge of the opening in the tendon through which the hernia escapes. When this hernia occurs in consequence of wound, the coverings must, of course, vary. Of the Reducible Ventral Hernia. Truss.—When seated in the linea alba, a truss, similar to that employed for umbilical hernia, should be worn; but, when low down in the linea semilu- naris, the truss applied should resemble that recom- mended for inguinal hernia, only that the pad must be turned somewhat upwards. When irreducible, the same form of truss, with a hollow pad, will be required. 12 90 Of Strangulated Ventral Hernia. Symptoms.—The symptoms indicating strangula- tion of this hernia are, in every respect, similar to those already described, as occurring when umbilical hernia is in the same state; and the means which should be tried, with a view of relieving the patient, should be of a like nature. Treatment.—As in the umbilical disease, the to- bacco enema has here a more powerful effect than in the inguinal or femoral herniae. Taxis.—In employing the taxis, ' the pressure should be made a little upwards as well as inwards, for the swelling, like the umbilical, has the greater part situated below the opening from the abdomen. Operation.—If an operation becomes necessary for the relief of the patient, it should be performed in the same mode as that described for umbilical hernia; but when the disease is seated low down in the linea semilunaris, the surgeon must bear in mind the course of the epigastric artery, and divide the stricture so as to avoid it. For large hernias.—In very large ventral herniae, the operation I have mentioned before, of merely exposing the neck of the sac, and dividing the strict- ure, without opening the sac itself, may be adopted with advantage. After-treatment.—In the after-treatment of these cases, nothing of importance is necessary beyond what I have already recommended for the other forms of herniae. Of the Thyroideal Hernia, or Hernia Foraminis Ovalis. The first example of this disease which I saw, was accidentally discovered in a male subject, in 91 whom an inguinal hernia also existed on the same side. The parts are preserved in the Collection at St. Thomas's Hospital. Course.—The hernia was protruded through the opening in the ligament of the foramen ovale, by which the obturator artery and nerve pass to the thigh ; the pubes was immediately before the neck of the sac, and the ligament of the foramen embrac- ed the other portion about three-fourths. The ob- turator vessels were situated behind, and somewhat to the inner side of the neck of the sac. The sac itself, not larger than a nutmeg, was placed under the heads of the pectineus and adductor brevis muscles. Two hernice in the same person.—I lately had an opportunity of seeing two specimens of this hernia in the same subject, one existing on each side, which were not discovered during life. Several cases of this form of hernia are related in the first volume of the Memoirs of the Royal Academy of Surgeons at Paris. Operation difficult.—The depth at which this her- nia is situated, would render an operation, in case of strangulation, extremely difficult; but, should such a step be necessary, I should recommend the divi- sion of the stricture inwards on account of the ob- turator artery, &c. Treatment.—If reducible, a truss, similar to that used for crural hernia, but with a thicker pad, would prevent its further descent. Of the Pudendal Hernia. Its seat.—This hernia appears in the external labium pudendi, about its middle. Course.—It commences at the side of the vagina, and passes into the labium between the vagina and 92 ischium; it has usually a pyramidal figure, and pre- sents the characters of other herniae, as elasticity, dilatation on coughing; also appearing in the erect, and disappearing when the patient is recumbent. The situation of the swelling, and its want of con- nexion with the abdominal ring, sufficiently distin- guish it from inguinal hernia, which also appears in the labium, but at the upper part. Treatment.—The increase of this disease may be prevented by the patient's constantly wearing a bandage to support the part; but a partial protru- sion cannot readily be checked, as from its situation, a pessary, unless of very large size, would not be of any service. When strangulated.—When strangulated, the usual remedies before mentioned should be tried ; and, if an operation becomes necessary, the sac should be carefully opened, and the stricture divided inwards towards the vagina, the bladder being previously emptied. Of the Vaginal Hernia. Its seat.—This hernia protrudes between the uterus and rectum, where the peritoneum is reflect- ed from one viscus to the other, at the posterior part of the vagina; sometimes, however, it appears at one side instead of the posterior part. It is only covered by the lining membrane of the vagina. Treatment.—The use of a pessary will prevent the protrusion of this disease. Of the Perineal Hernia. Its seat.—In the male, this hernia protrudes be- tween the bladder and rectum; and, in the female, between the rectum and vagina. 93 Case.—I have only seen one instance of this dis- ease, which was in the body of a male brought into the dissecting room. Dissection.—The reflected portion of peritoneum between the bladder and rectum, was protruded as far as the perineum, but no external tumour was perceptible ; Mr. Cutliffe, surgeon, at Barnstaple, has the parts preserved. Anterior to the sac were seated part of the blad- der, the prostate gland and terminations of the vesiculae seminales; behind was the rectum, and the mouth of the sac was about two inches and a half from the anus. The following curious case is taken from Mr. Bromfield's Chirurgical Observations :— Case.—" A lad, between six and seven years of age, was put under my care to be cut for the stone. The staff, in the attempt to introduce it into the bladder, met with resistance from a stone, which seemed to be lodged in the membranous part of the urethra, or a little lower down in the neck of the bladder. I made my incision, as usual, through the integument and muscles, to get at the grove of the staff; and then pressed the blade of my knife into the sulcus, at the extremity of the staff, being able to divide only the membranous part of the urethra ; and a very small portion, if any, of the prostate gland ; by the examination of the parts, with my fingers, I then found that this hard body was a pro- cess continued from the body of the stone contained in the badder; I therefore took the double gorgeret, without the cutting blade affixed, intending only to push, back the stone, and dilate the neck of the bladder, which I did by getting the beak of the gorgeret into the sulcus of the staff, and pressing it against the point of the stone, following its course with the instrument as the stone retired: but the 94 direction that the gorgeret took alarmed me, as it passed under the ossa pubis with great obliquity. I then concluded that the instrument had taken a wrong route, as I could not, in this case, have the advantage of the grove of the staff further than the extremity of the membranous part of the urethra; but, on withdrawing the upper part of the gorgeret, I introduced the fore-finger of my right hand into the bladder, by the under part of the instrument, which remained in the bladder, and was now no more than the common gorgeret; by which I was soon convinced that it was in the bladder, the situa- tion of which was raised much higher in the pelvis than usual. I then introduced my forceps, and, while I was searching for the stone, a thin diaphan- ous vesicle, like an hydatid, appeared rather below my forceps, which, in the' child's screaming, soon burst, discharged a clear water, as if forced from a syringe; the next scream brought down a large quantity of small intestines. I need not say, that this was sufficient to embarrass a much better ope- rator than myself; however, I proceeded in the operation with the greatest tranquillity, being con- vinced, that this very extraordinary event was not owing to any error in the operation : but the diffi- culty was to keep the intestine out of the cheeks of the forceps, when I should again attempt to lay hold of the stone; the extraction of which would be very difficult to effect, from the unusual situation of the bladder in this subject. The lower part of the gorgeret remaining in the bladder, the forceps were again easily introduced, which being done with the fingers of my right hand, I pressed back the in- testines, while I laid hold of the stone; but during the extraction the intestines were again pushed out by the child's screaming: nevertheless, as I had the stone secure in my forceps, I proceeded to extract 95 it, which I did very easily. Before I introduced the common gorgeret for the introduction of the forceps the next time, I got up the intestines a«-ain, and desired my assistant to keep them up till I got hold of a second stone, which, from its shape, ap- peared to be that which had got into the neck of the bladder. As soon as I was convinced by the examination, with my finger, that the bladder was freed totally from any pieces of stone, I again re- turned the intestines into the pelvis, and brought the child's thighs close together; a piece of dry lint was applied on the wound, and a pledget of diges- tive over it; he was then sent to bed, with no hope of his surviving till the next day; but, contrary to expectation, the child had a very good nigit, and was perfectly well in little more than a fortnight, without one alarming symptom during the process of cure; neither did the intestines once descend through the ruptured peritoneum after they had been returned when the operation was finished." The following are Mr. Bromfield's ideas of the nature of this case :— "After the incision of the integument and muscles was made, as usual, there soon appeared in the wound something like an hydatid, which proved af- terwards to be that part of the peritoneum wfrch is extended from the left side of the bladder and in- m testinum rectum to its attachment on the inside of the left os innominatum ; preventing the intestines from falling down too low into the pelvis; therefore, in this case, this expansion of the peritoneum must have been forced out of its usual situation. "Suffering daily more and more extension, it will at length permit the intestines to fall down to the very bottom of the pelvis, between the bladder and the rectum; therefore, when in the case above re- lated, the resistance of the integument and muscles 96 was taken off by the operation, the peritoneum was forced out, and at first was filled only with lymph, which gave it the appearance of an hydatid; but its thinness not being able to resist any longer the force of the abdominal muscles, pressing the viscera down- wards, it burst, and the intestines soon followed through the aperture. If this is allowed, we can easily account for the oblique course that the gorge- ret tock when first introduced, as the intestines had raised up the fundus of the bladder against the back part of the ossa pubis, so that my forceps could not be conreyed into the bladder, but almost in a per- pendicular direction; and I was obliged to press with my hand on the lower part of the abdomen, just above the pubes, to bring the bladder and its con- tents sufficiently low for the laying hold of the last stone with my forceps." Scarpa met with a case in which this hernia form- ed a tunour in the perineum. This form of hernia, and the vaginal, may become dangerois during gestation, and some cases illustrat- ing this are related in Dr. Smellie's cases on mid- wifery. Of the Ischiatic Hernia. Very rare.—This is an extremely rare form of henna; indeed, I have only seen one specimen of it, for which I am indebted to my friend Dr. Jones, whose name is well known by his excellent work oc haemorrhage. Case.—Dr. Jones having told me that he had in- spected the body of a patient who had died in con- sequence of the strangulation of a portion of intes- tine in the ischiatic notch, I became very anxious to obtain the parts; and, after considerable difficulty, we obtained permission to open the body a second 97 time, when I removed the hernia and surrounding parts. • Dr. Jones had been requested to visit the patient, a young man, about twenty-seven years of age, in consequence of his suffering from symptoms which resembled those produced by strangulated hernia. The patient stated that he had experienced a simi- lar attack before, which had been relieved by opium, followed by a dose of castor oil. Dr. Jones, there- fore, gave him some opium, and directed that he should take some pills composed of calomel and scammony, as soon as the stomach appeared tranquil. On the day following, Dr. Jones found that the patient had experienced relief for a short period af- ter taking the opium, but that the pills had been thrown up, and no evacuation had taken place from the bowels. The patient was also much troubled by eructations and flatulence, for which he took some spir: ammoniae comp: and spirit: lavendulae, with good effect. Dr. Jones, feeling confident that the symptoms were produced in consequence of the strangulation of some portion of the intestines, now examined the man carefully ; but could not detect any protrusion ; nor did the patient complain of any local pain, which could induce Dr. Jones to inspect the ischiatic notch, As no stools had been procured, some purgative glysters were thrown up, but without producing the desired effect. Other purgatives were subsequently given, and glysters were again thrown up, but with- out affording relief; also leeches and blisters were employed, but they produced only temporary bene- fit. On the sixth day from the commencement of these symptoms, they suddenly subsided, excepting that no evacuation from the bowels took place; and the patient felt himself so well, that he was desirous of going to business; but Dr. Jones advised him to 13 98 remain quiet for some days. Early on the morning of the seventh day the patient got up, and went down from his bed-room, which was in the fourth story, to the ground floor, but he soon returned, com- plaining of being very unwell; after which he gra- dually sunk, and expired on the same evening. Dissection.—On examining the body after death, a portion of the ilium was discovered passing by the right side of the rectum to the ischiatic notch, through which a fold of the intestine was protruded into a small hernial sac, to the inner surface of which the intestine was adherent. The strangulated part of the gut, and about three inches of it on each side of the stricture, was very much discoloured. The intestines between the stomach and protruded por- tion were distended with air, and had a few livid spots upon them. The intestines from the stricture to the rectum were very much contracted, particu- larly the arch of the colon. On carefully dissecting the parts after I had re- moved them from the body, I found a small orifice in the pelvis, anterior to, but a little above the scia- tic nerve, and on the fore part of the pyriformis muscle. This opening led to the hernial sac, which was situated under the gluteus maximus muscle, and in whicli the intestine had been strangulated, The orifice of this hernial sac was placed anterior to the internal iliac artery and vein, below the ob- turator artery, and above the obturator vein; its neck was seated before the sciatic nerve, and its fun- dus was covered by the gluteus maximus muscle. Below the fundus was the sciatic nerve, and behind it the gluteal artery; above, it was placed near the bone. Treatment.—Should the existence of such a hernia be ascertained, it might, if reducible, be prevented from protruding by the application of a spring truss; 99 but, should it become strangulated, and an operation be deemed advisable, I should recommend the divi- sion of the stricture to be made directly forwards. Of the Phrenic Hernia. Its seat.—Protrusions of the abdominal viscera through the diaphragm, may take place either at the natural apertures framed for the passage of the oesophagus, vena cava, aorta, &c, or through unna- tural openings, the consequence of malformation or injury. Symptoms.—When this hernia exists, the patient suffers much from interrupted respiration and cough, besides experiencing the symptoms of hernia already enumerated. Hernial sac.—This hernia has, or has not a proper sac, according to the circumstances of its formation ; when protruded through one of the natural aper- tures, it has a proper sac; when occurring from mal- formation, it sometimes has a peritoneal covering, and sometimes this covering is wanting; when the consequence of laceration or injury, the hernial sac is always deficient. Case.—I have never seen an hernia protruding through any of the natural openings of the diaphragm; but several cases are related by Morgagni, in which this form of hernia existed. He mentions the case of a young man who was attacked with symptoms of acute cardialgia and constant vomiting, under which he expired. On examining his body after death, the omentum, with part of the colon, the duodenum, some portion of the jejunum and ilium were found in the cavity of the thorax, having passed through the same opening by which the oesophagus descends; the lungs and the heart were compressed into a very small space. 100 From malformation.—The occurrence of phrenic hernia from malformation is not very uncommon. There are two preparations in the Museum at St. Thomas's Hospital exhibiting this disease. In one instance the opening is of sufficient size to admit nearly the whole of the small intestines through it; in the other specimen the large portion of the sto- mach was protruded through a much smaller aper- ture. In both cases the unnatural openings are in the left muscular portion of the diaphragm. Some cases of this form of the disease are also related in the first volume of Medical Observations and Inquiries, by Dr. G. Macauley. Danger.—When the unnatural aperture is small, the patient suffers frequently from the usual symp- toms of hernia, and is in danger of being destroyed by a strangulation of the protruded parts as in other hernia. In the year 1798, I published the history of an interesting case of this description, which I shall take the liberty of relating here. Case.—Sarah Homan, aet. twenty-eight, had, from her childhood, been afflicted with oppression in breathing. As she advanced in years, the least hur- ry in exercise, or exertion of strength, produced pain in her left side, a frequent cough, and very laborious respiration. These symptoms were unaccompanied with any other marks of disease ; and, as her appetite was good, she grew fat, and, to common observation, ap- peared healthy. The family with whom she lived suspected her of indolence, and her complaints being considered as a pretext for the non-performance of her duty, she was forced to undertake employments of the most laborious kind. This treatment she supported with patience, though often ready to sink under its consequences. 101 After any great exertion, she was frequently attack- ed with pain in the upper part of the abdomen, with vomiting, and a sensation, as she expressed it, of something dragging to the right side ; which sensa- tion she always referred to the region of the sto- mach. The cessation of these symptoms used to be sud- den, as their accession. After suffering severely, for a short time, all the pain and sickness ceased, and allowed her to resume her usual employments. As her age increased, she became more liable to a repetition of these attacks; and, as they were also of longer continuance than in the early part of life, she was at length rendered incapable of labouring for her support. Some days previous to her death, she was seized with the usual symptoms of strangulated hernia; viz. frequent vomitings, costiveness, and pain; the pain was confined to the upper part of the abdo- men, which was tense and sore when pressed. As these symptoms were unaccompanied with any local swelling which indicated the existence of her- nia, they were supposed to be produced by an inflam- mation of the intestines; but there were other symp- toms that could not be attributed to this cause, which occasioned much obscurity with respect to the true nature of the complaint, and seemed to indicate a disease in the thorax. She was unable to lie on her right side, had a constant pain in the left, a cough, difficulty of breathing, attended with the same drag- ging sensation of which she had formerly complained. The signs of inflammation of the intestines, with the addition of a troublesome cough, continued with- out abatement for three days, when she expressed herself better in these respects; but the morbid symptom in the thorax remained as violent as at first; and in the fourth day from their commence- ment she expired. 102 Dissection.—On examining the body after death, when the abdomen was opened, there appeared a very unusual disposition of the viscera. The sto- . mach, and left lobe of the liver, were thrust from their natural situation towards the right side. On tracing the convolutions of the small intestines, they were found to retain their usual situation; but lines of inflammation extended along such of their surfaces as lay in contact. This appearance the adhesive in- flammation assumes in its early stage; and it is high- ly probable, that, if the approach of death had been less rapid, these surfaces of the intestines would have been glued together by the effusion of coagulated lymph. When the large intestines were examined, the great arch of the colon, instead of being stretched from one kidney to the other, was discovered to have escaped into the left cavity of the chest, through an aperture in the diaphragm. The cce- cum and beginning of the colon were much distend- ed with air, and appeared therefore larger than na- tural ; but the colon, on the left side, as it descended toward the rectum, was smaller than it is commonly found. A small part only of the omentum could be dis- covered in the cavity of the abdomen, a considerable portion of it having been protruded into the chest, through the same opening by which the arch of the colon had passed. The displacement of the sto- mach, and left lobe of the liver, had arisen from the altered position of the colon and omentum; which, in their preternatural course towards the diaphragm, occupied the situation of each of these parts. When the chest was examined, the left lung did not appear of more than one third of its natural size; it was. placed at the upper part of the thorax, and was united to the pleura costalis by recent adhesions. The protruded omentum and colon were found at 103 the lower part of the left cavity of the chest, be- tween the lung and the diaphragm, floating in a pint of bloody-coloured serum. The colon, in colour, was darker than usual; in texture, softer, and dis- tended with feculent matter mixed with a brownish mucus. The portion of the intestine contained with- in the chest measured eleven inches. The omen- tum was also slightly altered in colour, being rather darker than natural; but, in other respects, this vis- cus was not changed; it adhered firmly to the edge of the aperture, and more than half of its substance was contained within the chest. The opening through which these viscera had protruded, was placed in the muscular part of the diaphragm, three inches from the oesophagus ; it was of a circular figure, and two inches in diameter ; its edge was smooth, but thicker than the other parts of the muscle. The peritoneum terminated abruptly at the edge of this aperture, so that the protruding parts were not contained in a sac, as in cases of common hernia, but floated loosely, and without a covering in the cavity of the chest, of which they occupied so large a space, as to occasion considerable pressure on the left lung, and to produce the diminution I have be- fore remarked. The right side of the chest, also the right lung and the heart, were free from disease. Could the precise nature of this disease be ascer- tained during the life of the patient, but little could be done for his relief; no more, than, perhaps, his own feelings would dictate, the refraining from all kinds of bodily exertion. From laceration.—The third cause of this form of hernia is wound, or laceration of the diaphragm, and the former inflicted with the small sword, has been the most frequent. The opening is at first prevent- ed from closing, by the pressure of the abdominal 104 viscera, which frequently protrude through it, in small quantity at first; but at length, should the pa- tient survive, very large portions escape. The only instance in which I have known this dis- ease produced by accident, has been from lacera- tion of the diaphragm, in consequence of the fracture of several of the ribs. Case.—William Rattley, aged thirty, was admit- ted into Guy's Hospital. About one o'clock on Feb- ruary 5, 1804, having fallen from the height of about thirty-six feet, by which six of the lower ribs on the right side were fractured. When admitted, he breathed with great difficulty, and complained of excessive pain; the crepitus from the fractured ribs could be distinctly felt, and there was slight emphy- sema. Soon after his admission, he vomited violent- ly, had frequent hiccough, and expired about eight o'clock on the following morning. Dissection.—The following appearances present- ed themselves on inspecting the body after death. A small wound at the inferior and posterior part of the right lung, with some slight but recent adhesions between the two portions of pleura. On pressing down the diaphragm, a portion of intestine was dis- covered, in the cavity of the chest on the right side, of a livid colour. On examining the cavity of the abdomen, this fold of intestine proved to be a part of the ilium, which passed upwards behind the liver, through the lacerated opening in the diaphragm, into the chest. The aperture in the diaphragm was situated about two inches from the cordiform tendon on the right side, in the muscular structure ; it was filled by the intestine, which was confined by a firm stricture. The laceration had been occasioned by the fractured end of the tenth rib. The other vis- cera of the abdomen were otherwise but little alter- ed; but near a quart of bloody serum was extrava- sated into the cavities of the chest and abdomen. 105 Of the Mesenteric Hernia. Cause.—This hernia occurs in consequence of a na- tural deficiency of one of the layers composing the mesentery, or from an accidental aperture being made. Formation.—The intestines force themselves into such an opening, and, quitting the proper cavity of the peritoneum, form a hernia, which may become of very large size, as the cellular union of the two lay- ers is not sufficiently firm to offer much resistance to the pressure of the protruding viscera. Case.—Mr. Pugh, of Grace-church Street, afforded me an opportunity of examining a hernia of this kind. The subject in which it was found, had been brought for dissection to St. Thomas's Hospital; and the man had been a patient under Mr. Forster, in Guy's Hospital, just previous to his death. Appearances.—On opening the abdomen, and rais- ing the omentum and colon, the small intestines were not to be seen, but a large swelling was discovered, situated over the lumbar vertebrae, and reaching to the basis of the sacrum ; which, on further examina- tion, proved to be a sac of peritoneum, containing the small intestines, and surrounding them complete- ly, excepting at the posterior part, where the aper- ture by which the intestines had escaped, was situated. From what I could collect of the previous history of the patient, he did not appear to have been much inconvenienced by this unnatural position of the vis- cera. Of the Mesocolic Hernia. The formation of this hernia is similar to that last described; and the first example I had an op- 14 106 portunity of examining, was, as the former, in a sub- ject brought to the Hospital for dissection. Appearances.—The abdomen having been opened, and the omentum and large intestines turned up, a tumour was discovered on the left side of the cavity, extending from over the left kidney, to the edge of the pelvic cavity, the lower portion being situated in the fold of the sigmoid flexure of the colon. The large intestines took their usual course, only that the caecum was nearer to the centre than in common. On the left side, the colon was raised by the tumour. The duodenum, a small part of the jejunum, and ter- mination of the ilium, were the only parts of the small intestines to be seen, on first opening the abdo- men, all the rest being situated in the sac, having pro- truded by an aperture on its right side, which was large enough to admit two folds of intestine in a dis- tended state. The sac was formed by the peritoneal layers of • the mesocolon. Dr. Jones's case.—Dr. Jones, of Barbadoes, sent me a drawing, exhibiting the larger part of the moveable viscera, between the layers of the peri- toneum, as found when examining the body of a patient he had attended. Of Strangulation of the Intestine within the Abdomen. This I have known to occur in several different ways. Causes.—First.—From the intestine protruding through an aperture in the omentum, mesentery, or mesocolon. Second.—From the same circumstance occurring when small openings are left in the adhesions formed in consequence of inflammation. Third.—From a membranous band formed at the 107 mouth of a hernial sac, becoming elongated, and en- tangling the intestine when it has been returned from the hernial sac. Fourth.—From the appendix vermiformis entang- ling the intestine. Cases.—Mr. R. Croakes, surgeon, of Barnsley, in Yorkshire, sent me the account of a case in which a portion of intestine had been protruded through an opening in the omentum, and had become stran- gulated. The patient was eighty years of age, and had been previously very healthy and active. The case terminated fatally, two days after the com- mencement of the symptoms; and on examination after death, the intestine was found in a gangrenous state. A case in which a portion of small intestine had protruded through an opening in the mesentery, and become strangulated, occurred under the care of Mr. Palmer, of Hereford. The symptoms were se- vere, but the patient survived until the ninth day from their commencement. Dr. Monro lias related a case of this nature in his work on crural hernia. Mr. Hodson, of Lewes, attended a young man who died in consequence of the strangulation of a fold of small intestine, which had protruded through an aperture lef[t in an adhesion of the omentum to the peritoneum. I have a very excellent specimen, showing the strangulation of intestine by elongated membranous bands. It was taken from the body of a patient of Mr. Weston's, of Shoreditch. The patient was eighty-five years of age, and resided in Hoxton Workhouse. He was seized with symptoms of strangulated hernia, in consequence of which Mr. Weston was sent for, who, on examining the man, found a hernia on the right side, which he soon re- 108 duced by the taxis. The symptoms, however, con- tinued, and the patient died. On examining his body after death, 1 found that the intestine had been re- turned into the cavity of the abdomen, but that two folds of it were entangled and strangulated by a long membranous band. Specimen in Guy's Museum.—In the Museum at Guy's Hospital is a beautiful preparation, showing a considerable portion of the small intestine, surround- ed and strangulated by the appendix vermiformis; but I am not acquainted with the history of the pa- tient from whom it was taken. As the precise nature of any of the above cases could not be ascertained during the lives of the pa- tients, no benefit could be derived from surgical aid. 109 LECTURE XXXVI. On Wounds. Of four kinds.—Solutions of continuity on the surface of the body are of four kinds, according to the manner in which they are produced; viz. In- cised, Lacerated, Contused, and Punctured. Incised, when produced by a cutting instrument; lacerated, when the parts are forcibly rent asunder; contused, when occasioned by some heavy body, or one passing with great velocity; and, punctured, if made by a pointed substance. This division of wounds is attended with advan- tage in the description of their treatment, as it must in some degree vary from the mode of their pro- duction. Of the Incised Wound. Character.—The lips of the divided parts are more or less separated according to the extent of the in- jury; and, the division of the muscles, which, by their contraction, lead to a gaping state of the wound, as in the cheek, the lips, or in transverse incisions in the limbs. The wound is covered with blood, which is florid or purple, as an artery or vein has been injured. If an artery, the blood flows by jets rapidly, and is of a florid colour; if a vein, the bleeding is slow, grad- ually filling the wound, and the blood is of a purple colour. Fainting is produced if an artery be cut, but rarely, if the bleeding be venous. Fainting also 110 results if the wound extends to parts of vital im- portance, even although the haemorrhage be very slight. Treatment.—When you are called to a case of in- cised wound, you are to make pressure upon its sur- face with a sponge to arrest the haemorrhage, and if the divided vessels be small, you will soon find it subside under a steady and continued pressure. But if an artery of any magnitude has been injured, it should be drawn from the surrounding parts by a pair of forceps, or raised by a tenaculum, and then tied with a very fine ligature ; one end of which should afterwards be cut off, that no more space than is absolutely necessary may be occupied by the thread or silk. So soon as the bleeding ceases, the coagulated blood is to be completely sponged away from the surface and edges of the Avound, the edges are to be brought together, and a strip of lint or linen moistened with the blood, is to be placed on the part in the direction of the wound, when the blood, by coagulating, glues the edges together in the most efficient and natural manner ; adhesive plaister is to be applied over the lint with spaces between to al- low of the escape of blood or serum. How closed.—In a few hours, inflammation arises, and fibrin becomes effused upon the surface and edges of the Avound, by which they become ce- mented. Organized.—In a few days, vessels shoot into the fibrin, effused by the inflammation; and it becomes organized with arteries and veins, and after a time, with absorbents and nerves; thus the structure of the part is restored. Wound of muscle.—If the wound be in a mus- cular part, more especially in transverse wounds of muscles, it is required that the position of the limb Ill be carefully attended to, that the wounded muscle may be relaxed as much as possible, and its sepa- rated portions approximated. Thus, if the biceps muscle were divided in the arm, the limb must be bent at right angles; and if the triceps be injured, extension will be necessary. Sutures required.—But if the wound has happen- ed in a muscular part, which is not supported, as in the cheek, a suture is required to preserve ap- proximation; the thread employed should be as fine as possible, and only as many as are absolutely ne- cessary, to produce the desired effect, should be in- serted. If a wound be angular, and of considerable ex- tent, a suture at the angle is desirable, or the edges will seldom be returned in their proper situation. Not injurious.—It is quite a mistake to suppose that sutures are injurious, and that they should be never used; for a wound often heals better with a suture and a cooling lotion, than with adhesive plais- ter. Indeed, adhesive plaister should not be appli- ed to the edges of wounds. Often have I seen it produce erysipelas, and sometimes the erysipelas followed by the death of the patient. After the removal of a large tumour from the breast, I often employ a suture to keep the parts in exact contact, and to prevent the edges from becoming inverted. Reproduction of parts.—When the wound is heal- ed, the parts wounded are generally reproduced. The cutis, and cuticle, easily ; the rete mucosum, more slowly. The cellular membrane is for some- time indurated, and requires the use and motion of the parts, to be completely evolved. A number of branches of arteries and veins are formed instead of the original trunks. Nerves are reproduced. Tendons are also again formed. Bones are united by bone. 112 Muscle not reproduced.—But some parts are not re- produced. There is a specimen in the Collection at St. Thomas's Hospital, in which a wound of a muscle is seen united by a tendinous structure. There is also a specimen of a cartilage of a rib united by bone, ( but in young persons cartilage is reproduced. Parts nearly separated unite readily.—Parts which are nearly separated readily unite, as the finger or the nose when it has been cut, or torn, and a suture is required to aid its union. Parts entirely separated will unite.—Parts entirely separated in other animals sometimes unite. Mr. Hunter removed the spur of a cock, and placed it in the comb by incision, where it not only adhered, but grew. He also removed the testis of a cock, and placed it in the belly of a hen, where it adhered. A tooth extracted from the human subject, and plac- ed in the comb of a cock, adheres there. The only instance in which I have seen a part re- moved entirely, and afterwards adhere, was in the following case :— I amputated a thumb for a patient in Guy's Hos-' pital; and, finding that I had not preserved a suffi- cient quantity of skin to cover the stump, I cut out a piece from the thumb which I had removed, and applied it upon the stump, confining it by stripes of adhesive plaister. On taking off the dressings a few days after the operation, 1 found, that the portion which had been completely separated, and after- wards placed upon the stump, was firmly united and organized. The most extraordinary instance of the union of a separated part has been related by Dr. Balfour, in the Edinburgh Medical and Surgical Journal, for Oc- tober, 1814, from which the following account is taken:— Case.—" On the 10th of June last, two men came 113 to my shop about eleven o'clock in the forenoon; one of whom, George Pedie, a house carpenter, had a handkerchief wrapped round his left hand, from which the blood was slowly dropping. Upon un- covering the hand, I found one half of the index fin- ger wanting. I asked him what had become of the amputated part. He told me that he had never looked after it, but believed that it would be found where the accident happened. I immediately de- spatched his companion to look for it, and to bring it to me directly he found it. During his absence I examined the wound, which began near the.upper end of the second phalanx on the thumb side, and terminated about the third phalanx on the other 6ide. The wound which had been inflicted with the hatchet was quite clean. " In about five minutes, the piece of the finger was brought; it was quite cold, and white in appearance, like a bit of a candle. I immediately exposed both surfaces to a stream of cold water, to wash the blood off the one, and any dirt that might adhere from the other. I then applied, with as much accuracy as possible, the wounded surfaces to each other, ex- pressing a confident opinion, that reunion would take place. " I endeavoured to inspire the patient with the same hopes, but he did not appear convinced of the possibility of such an occurrence. I informed him, that, unless pain or fuetor, or both, should occur, I would not remove the dressings for a week at least. I directed him to keep his arm in a sling, and not to attempt any kind of work; to which he promised obedience. He called on me the next day, when he was quite easy, but the wound had bled a little. Al- though he promised to call on me daily, I did not see him again till the fourth of July. I had conclud- • ed that he had applied to some other practitioner; 15 114 but, on the second of July, a gentleman called on me, and gave me the following account of the pa- tient :— " Two days after the accident the patient, under the influence of the ridicule of his acquaintance, for giving credit to my assurances, applied to another practitioner; who, on learning the history of the case, represented the impropriety of any one but myself intermeddling with it. But, prepossessed with the belief that he carried about a portion of dead matter tied to the stump of his finger, the man insisted upon having the bandages removed, which was according- ly done. Thus were nearly rendered abortive my attempts to produce reunion of the parts, and the profession deprived of a fact, which, as demonstrat- ing the powers of nature to repair injuries, is infe- rior to none in the annals of the healing art. For- tunately, however, nature had been too busy for even this early interference to defeat her purpose, —adhesion had taken place. " In consequence of the information I got from this gentleman, I found out the patient on the fourth, when reunion of the parts was complete. The fin- ger was in fact the handsomest the man had, and had recovered both heat and sensation. In the pro- gress of the cure, the skin was changed, and soon af- ter the accident the nail fell off. " From the account of persons present when the injury was inflicted, I am satisfied that twenty mi- nutes must have elapsed before the parts were re- placed; for the patient did not come to me imme- diately upon receiving the injury, but waited a con- siderable time in the building where the accideut happened. "The amputated part, as measured by the patient . himself, was one inch and a half long, on the thumb side, and one inch on the opposite side." 115 Adhesion prevents danger.—When adhesion of the incised wounds can be completely effected, the dan- ger ceases. An incised wound into the abdomen, exposing its different viscera, is not followed by dan- ger if the wound is made to unite. Wounds of the chest, even complicated with injury to the lungs, cease to be dangerous under the adhesive process. Wounds of the brain will unite by adhesion, and the patient recover. Adhesion prevented.—Union by adhesion is pre- vented by the following circumstances in incised wounds:— By sutures.— I. By the introduction of many, and of large sutures. It is therefore necessary to em- ploy the finest threads, and to cut off one of their ends, that they may occupy as little space as possi- ble ; and in from four to six days, they should be re- moved ; thus they are prevented from producing suppuration and ulceration. By too much inflammation.—2. By the inflamma- tion being suffered to run too high from want of bleeding generally, on-, locally, by leeches; or, from not employing cooling evaporating lotions. Spirits of wine and water, or acetate of lead and water, should be applied upon the wound, and around it. Purging is also often required. The adhesive inflammation is but a slow degree of action, and if it be not kept in bounds, suppura- tion will occur. By poisons.—If poisons be introduced into wounds, it will be wrong to attempt to produce adhesion; thus the bite of a rabid animal should be excised, as well as cauterized afterwards, to prevent the terri- bly dangerous consequences of such an injury. By caustics.—The use of caustic applications, whe- ther by potash, nitric acid, the actual cautery, &c. will necessarily prevent adhesions. 116 When an absorbent is divided.—When many ab- sorbent vessels are divided, the lymph poured out by them prevents adhesion, as I have seen in a trans- verse wound in the groin. Or a secretory gland.—When the secretory glands are wounded, their secretion prevents union. Case.—I was called to a gentleman who fell upon his face on an earthen plate, which he* broke; his face was dreadfully wounded ; I brought the parts together, and in ten days they appeared to be unit- ed, when I allowed him to eat; but the result was a profuse discharge of saliva from the wound, which was a very long time in healing, on account of the parotid duct having been cut across. By the surgeon's imprudence.—Union by adhesion, is often frustrated by the surgeon's impatience; he is anxious to see if union be effected or not, and most absurdly and mischievously raises the dressings, dis- turbing, and often breaking, the adhesions, and thus rendering the process of granulation necessary, when it might have been avoided. By state of constitution.—The adhesive inflamma- tion is often prevented by the state of the constitu- tion; if the patient be much out of health, or if he be extremely irritable, the inflammation will proceed beyond the bounds of adhesion, and suppuration will take place. In such persons, evaporating lotions to the wound, and opium internally, are the means of arresting the mischief which will otherwise ensue. Adhesion not always desirable.—It is not always an object to endeavour to produce adhesion; when there is much loss of substance, and the parts must be forcibly drawn together, much additional pain and irritation are occasioned by the attempt at adhesive union, and this is more especially the case in children, when the skin cannot well oear the application of the adhesive plaister. I therefore, when I remove 117 those marks which are called nevi materni, I do not attempt to bring the edges of the wound together; but only, after the bleeding has ceased, apply lint for twenty-four hours, and then a poultice to the.part by which much pain and irritation are avoided. The breast I often dress in the same manner, after the removal of tumours connected with much disease of the integument. Of Lacerated Wounds. Character.—These wounds bleed much less than the incised, for a reason which will he described when we speak of wounds of arteries ; but here it is sufficient to say, that the largest arteries of limbs may be torn through without any dangerous bleed- ing occurring. Differ from incised.—Lacerated wounds also differ from incised, in their often containing extraneous bodies. Those of the scalp are frequently filled with dirt, from the head ploughing the ground, and the utmost care is required to cleanse them with warm water, and to remove with a sponge all extraneous matter, as I have seen such a wound adhere, and afterwards suppurate in various places, for the dis- charge of the foreign bodies which the adhesive matter had at first confined. More disposed to inflame.—Lacerated wounds are more disposed to inflame, than the incised, and they require much more attention to the use of evaporat- ing lotions, and of leeches to suppress it. Affect the nervous system.—The nervous system frequently suffers severely from lacerated wounds. Spasms of the limbs, and tetanus, I have often seen follow these lacerations on the hand. Case.—I was sent for to see a young gentleman at Marlow, who had fallen into a hedge and torn his 118 hand with a thorn bush ; he died from tetanus. In the hospitals, from lacerated wounds of the fingers, made by machines for combing wool, I have several times known tetanus produced; the tendons and fas- cia in these cases had been much exposed and in- jured. Produce erysipelas.—Erysipelas is not an unusual effect of lacerated wounds, more especially if they are inflicted on the scalp, and they therefore require great attention, although they at first appear of trifling importance. Treatment.—The treatment of these wounds is the same as that which has been described for incised wounds; but more care is required in the use of cooling lotions, and the application of leeches, in quiel, and in the exhibition of opium under the first appearance of spasmodic symptoms. Patients with lacerated wounds, should not be much reduced by depletion, as it disposes to tetanic symptoms. 119 LECTURE XXXVII. Of Contused Wounds. Character.—These injuries differ from the incised and lacerated wounds, in being accompanied'with dis- organization : blood is extravasated, the cellular tis- sue is broken down, muscles are bruised, and many parts disorganized. Process of reparation.—The process of restoration is therefore quite different to that which takes place after incised or lacerated wounds. Sloughing.—Inflammation to a considerable extent must be produced ; the dead parts must be separat- ed by a process of ulceration, and granulatioi.s will arise to fill up the cavities occasioned by these sepa- rations. The surgeon, therefore, who treats these wounds as he would the incised or lacerated, has still to learn the fundamental principles of his profession. Contused wounds bleed but little, from the organi- zation of the parts being destroyed, and from the extravasation making pressure upon the vessels which are divided. Treatment.—The treatment of the contused wound in principle, consists in facilitating the separation of the contused parts, instead of approximation, as in the incised and lacerated wounds. To effect this object, and to expedite the process, fomentation and poul- tices are to be used, which lessen inflammation when too violent, and hasten the suppurative and ulcera- tive processes. If the inflammation be still con- siderable, leeches should be applied; but bleeding 120 ought not to be had recourse to from the arm? for all the powers of the constitution are required to assist in the process of separation, and of granula- tion. Medicines.—The bowels should be kept regular; but opium should be combined with the medicines given, to effect that object. If the constitution be- come much debilitated, the sulphate of quinine may be given; or ammonia, combined with opium. Applications.—When the sloughing, or separating process is completed, the fomentations and poultices are to be abandoned, and the parts may be approxi- mated by adhesive plaister, or simple dressing bf applied to the wound, treating it as a simple ulcer. / Of Punctured Wounds. Danger of—These wounds are produced by point- ed bodies, as needles, scissors, hooks, points of broken bones, &c: and the effects which follow them are often highly dangerous, by occasioning inflammation of the absorbents; or when tendinous structures or nerves are injured. Of their Effects upon the Absorbents. A slight wound through the skin into the cellular tissue, will be sometimes followed by severe pain in the part, a blush around it, and by the absorbent vessels forming red line-., from the wound to the ab- sorbent glands, in which they terminate. Consequences.—Of this effect I have seen very many examples, and 1 have been a sufferer from it myself. Abscesses sometimes form upon the absorb- ents, in their cou'?e to the axilla, or to the groin; and sometimes in the glands in which they termi- nate; and in very irritable persons death sometimes 121 ensues; and the following example of it I had an opportunity of inspecting. Cases.—A West Indian, studying at Guy's Hospital, wounded his finger, the absorbents of his arm be- came inflamed, and he laboured under excessive irri- tative fever; the veins seemed to suffer also from inflammation communicated to them, for his limbs became almost incapable of motion, from the violent pain produced by bending any of the joints, and the superficial veins of his limbs were very tender when Pressed. He died in six days after the attack, and inspected his arm. The absorbents of the limb were highly inflamed; and in the axilla matter was effused, not in a separate abscess, but in a sheet of suppuration in the cellular tissue, between and around the absorbent vessels. I was not permitted to inspect the body further. After an inflammation of this kind in myself, produced by wounding my finger when opening the body of a man executed on the same morning; my throat became sore as the inflammation in the absorbents of my arm subsided, and one»of my knees became stiff from rheumatism ; when this Avas sub- dued by a blister, the other knee became similarly affected. Poison absorbed.—It Avould seem that under cer- tain circumstances a poison is produced sufficiently strong to excite inflammation, even when there is no wound. Case.—Mr. Cook, surgeon, at Marsh-gate, West- minster Bridge, sent to me whilst he was labouring under the highest irritative fever, in consequence of having opened the body of a person wlio had died of puerperal fever. When I examined him, I found the extremities of his finger of both hands inflamed, as if they had been dipped in scalding water, and the absorbents of his arms red, hard, and knotted, 16 t 122 to the axilla; yet he had not any wound or abrasion of any kind upon his hands ; and it would therefore seem, that the fluid produced in the abdomen of this Avoman, in which his fingers had been frequent- ly immersed, Avas of a highly stimulating nature. Form of wound and state of constitution.—The effect of punctured wounds depends, however, very much upon the form of the wound, and the state of the constitution. When punctures have been made, by a clean needle, the tongue of a knee buckle, a fragment of bone, &c, nothing can be introduced of a poisonous nature, and the effect must depend upon the form of the Avound, and the structure injured. But the effect also depends upon the state of the constitution, as is evinced in our young students suf- fering in the Spring, after confinement in London, in the air of our dissecting room, and in the wards of our hospitals, and by their escaping these violent symptoms in the Autumn, when they have just quit- ted the country. I believe, therefore, that these effects arise from the form of the wound, and the state of the consti- tution ; also occasionally, but rarely, from the intro- duction of an irritating fluid, the result of peculiar inflammation, or the production of the first stage of putrefaction. Bites of dogs and cats.—I have knoAvn the bite's of cats, dogs, and rats, followed by high inflamma- tion, and constitutional irritation, many days after the injury has been inflicted ; and these cases unite the symptoms of punctured and contused wounds; the first effects upon the constitution arise from the punctures of their pointed teeth; but when the symptoms produced from this cause subside, from fifteen to tAyenty days after, I have knoAvn the in- jured parts inflame and slough; the constitution, as well as the part, undergoes great changes, and the patient becomes excessively reduced. 123 Treatment.—The treatment of punctured wounds consists in adopting the following plan :__ First.—A lancet should be used to extend the puncture to an incision. Second.—The surrounding parts should be press- ed to remove, -by the blood which issues, any ex- traneous matter which may have been introduced. If the finger is wounded, a piece of string or tape should be bound tightly round the injured finger, from its junction Avith the hand, as far as the wound, so as to force out blood from the opening Third.—The nitric acid, nitrate of silver, or caus- tic of potash, should be applied to the wound. Fourth.-—A lotion composed of the subacetate of lead; spirits of wine and water should be applied over the part, to prevent too much action when in- flammation begins. Fifth.—Leeches should be applied, and fomenta- tions with poultices employed, if the pain and in- flammation become considerable. Sixth.—Give calomel and opium at night, and a brisk purgative in the morning. Seventh.—Let the limb be supported on an inclin- ed plane, so that the blood shall gravitate toAvards the body; all stimulating food and drink should be avoid- ed ; a measure so absurd that a caution against it appears unnecessary; but an anatomist killed him- self by taking wine to oppose the putrefactive in- fluence of the matter he supposed to be absorbed. Inflammation returns.—The inflammation from fmnctures of the hand in dissecting, will continue a ong time, and be resumed when it seems to be at an end; attention to the general health, and to the part, must be therefore regarded closely, for a con- siderable period after the injury. 124 Of Punctured Wounds of Tendinous Structure. Danger of.—If fascia be punctured, alarming symp- toms will sometimes arise, in part from the form, of the wound, from the feeble power of the structure, and partly from the confinement of matter beneath the fascia. Form of the wound.—The form of the Avound produces these symptoms, because the parts are rather forcibly separated than actually divided, and consequently the adhesive process does not readily succeed. The structure of tendons and fasciae, from their little vascular organization, and difficult re- ^ storation, leads to much constitutional effort; and the form of fascia tends to confine the pus when it is secreted. Case.—A gentleman sat upon a rail, from which a nail projected, and it entered the middle and back part of his thigh ; great irritative fever folloAved, with redness and swelling of the thigh ; and, as fo- mentations and poultices, and calomel with opium, did not relieve him, 1 made an incision in the situa- tion of the puncture, and found that the nail had penetrated the fascia lata; I divided it freely, when some pus, which had formed under it, was discharg- ed. He quickly recovered. Early incisions.—When a puncture is made into a theca, suppuration is apt to ensue, when an early incision, by allowing the discharge of the matter, prevents the greatest mischiefs. If matter forms under the aponeurosis of the palm of the hand, an early incision is the only mode of relief, if the puncture which occasioned the suppura- tion is too small to admit of the escape of the pus. Treatment.—The treatment, therefore, of these wounds, consists in endeavouring to prevent suppura- tion by leeches, and evaporating lotions, in the first instance ; but, if matter does form, to open the ab- 125 scess early, both with a view of making the punc- tured an incised wound, and to give a free outlet for the escape of the pus. On the Effects of Punctured Wounds on the Nervous System. Tetanic symptoms.—The spasmodic and tetanic symptoms, which folloAV punctured wounds, are the effects of injury to tendinous, rather than nervous parts. Most of the cases of tetanus which I have seen occur from punctured wounds, have been when the hand or foot has been the seat of injury; the aponeurosis of the palm, or sole, or the tendons being hurt. I will not deny that an injury to a nerve will produce the same effect; but I cannot help doubting its being the usual cause. Cases.—I divided the posterior tibial nerve in a Mrs. Sabine, the wife of a surgeon at Dunchurch, for a painful tumour on it; and little constitutional irritation was produced by the operation. I removed a tumour from the median nerve of a gentleman, and cut away two-thirds of the thick- ness of the nerve, leaving one-third; tingling of the fingers, with some partial numbness, followed, but no constitutional irritation; and he did very Avell. I cut out five-eighths of an inch of the radial nerve, for aura epileptica; and no unpleasant symptom fol- loAved, but the patient got Avell. Mr. Key removed a portion of the cubital nerve, for aura epileptica; and, although it did not cure the Avoman, it produced no unfavourable symptoms. These instances, to which many more might be added, as well as the usual seat of the wound, Avhich produces tetanus, leads me to believe that it is rather the result of injury to tendinous than to nervous structures. Extensive injuries, by their sympathetic influence, 126 and by their severe shock to the nervous system, produce the destruction of life, even without vascu- lar re-action or inflammation. The symptoms which arise are sometimes only general spasm, sometimes trismus, and sometimes tetanus. Cases.—I once saw a body die, in a few hours, of the most violent spasms of most of the muscles of his body, from the pointed extremity of a broken thigh bone having penetrated the under side of the rectus femoris. I saw a person die from spasm, produced by a punctured wound in the triangular ligament of the pubes, from a sharp piece of wood; and I have seen a great number of such cases from injury to the hand and foot. Degree of spasm varies.—Sometimes, instead of this general spasm, the influence of the wound is particularly felt in the muscles of the jaAV, producing trismus, with the subsequent affection of the muscles of volition, and afterwards those of respiration, con- stituting tetanus. Sometimes the muscles of the posterior part of the trunk are more particularly affected, when the term opisthotonos is applied to the disease; and sometimes, on the contrary, the muscles of the anterior part are chiefly attacked, when the disease is named emprosthotonos. In the first case, the body is curved forcibly backwards; and, in the second instance, forwards. The muscles of the extremities become also extremely rigid and contracted, so that the joints cannot be moved; and, in the greater number of cases, life is destroyed in a few days. Tetanus, acute and chronic.—However, it may be observed, that there are two kinds of tetanus; one of an acute form, which generally terminates the patient's existence; and the other, of a chronic na- ture, which, after a time, is often recovered from. 127 Treatment.—The treatment which 1 have seen pursued in acute tetanus, has been, Warm bath.—The Avarm bath, which gives a temporary tranquillity, and slightly reduces the spasms ; but is not followed by any permanent good effects. Bleeding.—Bleeding, which hastens the patient's death ; it reduces the poAvers of the body; and, al- though the spasms are less violent, they destroy sooner. Opium.—Opium, I have generally seen given; but, in acute tetanus, never Avith any other advantage than a slight mitigation of the symptoms for a short period. 1 once saw Mr. Stocker give, at nine o'clock in the evening, half an ounce of tincture of opium, and at eleven o'clock an ounce more, without any permanent beneficial influence. To me, it appears to be absurd to resort to a treatment which has been repeatedly found to be inefficacious. Tobacco.—Tobacco injections I have seen used, but with no permanent advantage. Digitalis.—Digitalis I have knoAvn employed, but uselessly. Cold.—Ice I have seen extensively applied; but all these means, in acute instances, fail. Case.—Mr. Ward, of Gloucester, has lately pub- lished two cases, which were relieved by the hydro- cyanic acid. Treatment of chronic tetanus.—Chronic tetanus I have known relieved by calomel and opium,.by the cold and shoAver baths, by large doses of thetincture of muriate of iron; but I have also known persons recover who had scarcely taken any medicine; thus throwing a doubt upon the efficacy of those Avhich had, in other cases, been supposed to be beneficial. Trismus rarely fatal.—In every instance, in Avhich I have witnessed the existence of trismus, the patient has recovered. Calomel and opium are the best 128 medicines; and a blister to the head the most effica- cious local remedy.* * The following interesting case occurred in St. Thomas's Hospital, under the care of Dr. Elliotson and myself:— James Frazier, aet. thirty-nine, of florid complexion, and ro- bust appearance, employed in the London Docks as a porter, was admitted December 10. There were observed two small lacerated wounds on the inside of the ball of the left great toe. No crepitus indicative of fracture could be discovered. There was a slight degree of swelling, attended with violent pMn. He stated, that his toe had been dislocated, and thrown out- wards, across the other toes, by the fall of a piece of timber. It had been, however, forcibly reduced, by a person present, while he was in a fainting condition. He was brought to this Hospital immediately after. The edges of the wounds were brought together, a dossil of lint was placed over them, and afterwards covered by a light poultice: the foot elevated on a pillow. Cap: haust: purg : statim. December 11. Evening. He was restless, with a pain in hia head, back, and loins. Skin hot and dry; pulse full and hard, about eighty ; tongue furred in the centre, and red at the sides ; bowels costive. Venesectio ad 3 xij.----Repet: haust: purg. The dressings were removed from the foot, which was order- ed to be fomented all night. About an hour after the bleeding, the violence of the symp- tcms abated, and the man said he felt relieved. > December 12. Slept comfortably last night. Skin moist; pulse full and soft; tongue white ; bowels have been opened.. The foot is very painful; the wounds are beginning to suppu- rate ; the dorsum of the foot is red, tense, and swollen. Applic : Hirudin : xij. Capt: cal: gr ij opii gr 1-2 o. n. inf: rosae c mag : sulph : t. d. The blood abstracted yesterday neither cupped nor buffed. December 14. Was very restless. Skin dry ; pulse smaller and quicker ; bowels costive. Foot very painful; still red, tense, and swollen; wound suppu- rating. Repet. hirudin, xij.----Repet: haust: purg. December 19. Face flushed; skin moist; pulse small and quick ; tongue white and furred ; bowels relaxed. Foot very painful, so much so as to disturb his rest, the wounds suppurating, and the degree of inflammation less. Omit: calomel and opium. - 129 Capt. Tinct: opii gtt. xxx. Si opus sit. Foot to be fomented and poulticed as before. December 22. Diarrhoea subsiding; but he laboured under great irritation both of body and mind. December 24. Imperfect trismus came on yesterday after- noon, and increased towards this morning. He could not open his mouth more than three-quarters of an inch, nor protrude his tongue further than the teeth. Deglutition painful, and articu- lation difficult; pain in the back of the neck, and a want of free- dom in the motions of the head ; no rigidity of the muscles; coun- tenance anxious, and spirits very much dejected; skin bedewed with moisture; pulse quick, small, and compressible, 132; diar- rhoea had ceased. The wounds were suppurating healthily ; granulations at the bottom ruddy ; but perhaps the discharge was somewhat thin- ner ; tension and swelling on the dorsum of the foot remained, but the redness was less. Capt. ol : terebinth: gij station. Ferri: subcarb: 3 ss. 2nd qque hora (in treacle.) Applications to the foot as before. December 25. Took the same quantity of ol. terebinth, at 10$ last night, which was followed by five or six copious dejections, but he was not able to swallow more than one dose of the ferri subcarb. on account of its thickness. He therefore took five grains of musk every four hours; this he commenced at twelve o'clock last night, and took four doses of it. Mouth more closed ; a perfect inability to swallow any thing but liquids; complains of pain in the back; the other symptoms of trismus the same. Did not rest last night; face flushed; skin very moist; pulse the same. The foot remained the same. To omit the musk, and to take the iron mixed up with his beef tea, every two hours, as before ordered. Capt. vin. rub. 3 iv.----Strong beef tea, Ife iv. daily. December 26. Mouth more closed ; other symptoms of tris- mus the same ; belly rigid in a slight degree. Was restless last night; countenance anxious, and spirits much depressed ; face flushed and hot; pulse the same ; bowels open- ed twice during the night; troubled to-day with tenesmus and prolapsus ani. Foot very painful, and appeared the same as yesterday. December 27. The symptoms of trismus the same as yester- day ; the belly more rigid, and he complained of a stiffness in the back, and a shooting pain through the scrobic: cordis.; his face not so hot or flushed; had no stool for the last twenty-four 17 130 hours; tenesmus and prolapsus ani continued; perspires a good deal at night, and doses a little. Foot very painful. While removing the poultice this morn- ing, an abscess over the metatarsal bone of the great toe burst, and discharged an ounce or more of matter, of a greenish col- our, streaked with blood. Enema commune statim. This produced one or two small evacuations. Hitherto (ac- cording to the nurse's account,) the foeces have been of a natur- al colour, but to-day they presented the appearance of the ferri. subcarb. December 28. Morning. Mouth more closed; deglutition more difficult; articulation less distinct; the belly rigid, and there has been during the night convulsive movements in the muscles of the neck. Had no rest last night, and perspired a little ; his skin now cool; pulse 112, very weak and small; tenesmus has subsided. About half an ounce of pus was evacuated from the dorsum pedis, (near the metatarsal bone of the little toe,) there was a foetor arising from the wounds on the dorsum of the foot, while the original wounds were looking healthy. Afternoon of the same day, all the alarming symptoms abated ; his skin became moist; bis pulse fuller and softer, and his mouth more open, with an improved countenance. December 29. Mouth more open ; swallowing easier ; no pain in the back of the neck, nor any more convulsive move- ments about the muscles of that part; belly soft. Slept last night, and perspired a little, and had two motions from an enema; countenance improved; face not so flushed ; skin cool and dry; pulse fuller and softer, but still weak; appe- tite beginning to manifest itself. Tension on the dorsum pedis quite subsided. The surface is still inflamed, but the redness is of a darker colour. The two wounds on this part looking very unhealthy, and the discharge foetid and rather thin. The original wounds on the side of the great toe are beginning to cicatrize. December 30. Mouth more open ; less difficulty in degluti- tion, and a more distinct articulation ; no pain in the neck or back ; the belly however is rigid. Was very restless all last night, his foot being very painful; skin cool; pulse contracted and more distinct, about 120; dur- ing yesterday passed some small lumpy foeces. The foot tense, red, and swollen ; the discharge has ceased, and there was a foetor arising from the wounds, which were looking unhealthy, accompanied with severe lancinating pains. The original wounds, however, were healing. Foot to be fo- mented. Capt. ol. ricini Jss. 131 Enema cathart: si opus sit. Beef tea, fevj, instead of feiv. December.31. The castor oil operated five or six times, bringing away small lumpy foeces. The enema was not admin- istered. Opened his mouth readier, but not wider ; complained of pain running through the scrob. cordis, and of a dry cough, which arose, he said, from his not being able to breathe freely ; deglu- tition and articulation better. Slept better last night, and did not perspire ; countenance and spirits improved ; skin cool; pulse 120, softer, and not so con- tracted. Foot less tense and inflamed ; discharge from the wounds re- turned, but it is still too thin ; leg placed in a fracture box. January 1. Symptoms of tetanus quite subsided, those of tris- mus less violent. Much the same as yesterday ; pulse 108, soft and more full; bowels relaxed, with tenesmus; motions come away of a dark colour, and in very small quantities. Foot better; discharge more copious and healthy. Capt. ferr. subcarb. 3 ss. 4tu. q: q: hora, (in powder.) January 2. The same as yesterday; opened his mouth wider, but was still obliged to be very careful in swallowing. Foot looking better; the excess of inflammation quite subsid- ed ; the suppuration free and healthy. It was painful last night, and this prevented his sleeping. January 3. Much improved ; pulse ninety-nine, softer and fuller. Suffers very much from a collection of the iron in his rectum, a quantity of which was removed in a partially dry state ; this prevented his sleeping last night. Capt. ferr. subcarb. 6ta. q : q: hora, (in treacle.) Enema commune—pro re nata. Foot improving ; discharge healthy and free. The fracture box removed. January 4. Same as yesterday. January 5. Much improved; pulse eighty-eight, a great deal softer and fuller; has removed a very large quantity of iron from his rectum. From this period he gradually recovered, without any further relapse; he continued, however, for some time, to pass portions of the subcarbonate of iron with his stools. The sudden im- provement of the patient on the evening of the 28th, after the evacuation of the pus from the dorsum of the foot, cannot fail to strike any one, who may carefully peruse the above account; and I think it will require further trial of the iron before its efficacy in this formidable disease can be relied on.—T. 132 LECTURE XXXVIII. Of Wounds of Arteries. Incised.—These wounds we shall divide, as Avounds in general, into the Incised, Lacerated, Contused, and Punctured. When an artery is cut into, or divided, the imme- diate effect of such injury is to occasion an impetu- ous haemorrhage of florid blood, which, if the artery be large, whizzes through the wound. It flows in pulsation in obedience to the action of the heart. If the wounded orifice, nearest to the heart, be compressed, the blood from the opening most re- mote from the heart, flows in an uninterrupted stream, and is of a dark venous colour, owing to its having passed through capillary vessels. Fainting produced.—The brain soon ceases to be supplied with blood, and fainting is produced : sen- sation and volition become suspended ; and the action of the heart is in a great degree suppressed ; the flow of blood from the Avound becomes much dimin- ished, and sometimes entirely ceases. Recovery from fainting.—In a few minutes the pa- tient opens his eyes, and the power of the nervous system is restored. Modes of arresting the bleeding.—The mode by which bleeding is arrested may be either constitu- tional or local. Fainting is the constitutional mode, by suspending the voluntary and involuntary func- tions, more especially in the diminution of the action of the heart, so that the blood scarcely reaches the 133 wound, but it undulates in the heart, and large ves- sels under the fluttering of the heart.* Local means.—The local means consist in, first, the coagulation of the blood, which is effected in the cellular tissue around the artery, and also in the ex- tremity of the Avounded vessel, forming a plug; so that there is a continuation of coagulum from the outer surface to the orifice, and this sufficiently op- poses the issue of blood under the enfeebled action of the heart. Contraction of the vessels.—But this process is also aided by the contraction of the artery, not particu- larly at the divided part, but also to a considerable extent from the orifice. If the carotid artery, on one side, be cut across, and examined after the death of the animal, the ar- tery is found much smaller on the wounded side than on the other which has not been injured. This state of the vessel lessens the influence of the blood upon the Avound. Retraction of the vessel.—A retraction of the ar- tery also follows when the division of the vessel is complete ; and, by withdrawing itself into the cellu- lar membrane, the blood becomes effused around it, so as to compress its orifice. Thus, then, it appears that coagulation with contraction and retraction of the vessel, all concur to put a check to the bleeding. Process of inflammation.—These, then, are the immediate means; but it is required that a further process should take place, to render their effects permanent. Inflammation follows; and the clot of blood becomes glued to the inner surface of the ves- sel, whilst effusion into the surrounding parts creates pressure upon the artery so as to diminish its caliber; * The brain and nervous system are, however, sometimes so depressed, that without stimuli to the stomach and nose, the person will not recover. 134 this inflammation also usually produces a union of the edges of the wound, or otherwise granulations arise, fill it, and thus it becomes closed. Pressure.—The treatment, when an artery of not a very large size is divided in an extremity, is to ap- ply a tourniquet to compress the trunk from which it is supplied ; this, with gentle pressure on the wound, for a short time, will generally command the haemorrhage, Avhen the edges of the wound may be approximated, and union promoted, leaving on the tourniquet, so as to continue a moderate pressure on the trunk. M Application qja ligature.—But, if the vessel be large, it is necessary to make an incision in the direc- tion it takes, so as to expose the Avounded portions, when a ligature must be placed above and below on each portion of the vessel. The ligatures should be small, and one of the ends removed after their appli- cation. Dr. Vetch first recommended the removal of one of the threads. When an artery is not completely divided, its re- traction is prevented, and a coagulum, with difficulty, forms in it, and, when formed, is easily forced off* by the action of the heart. Hence, in a week or ten days after the injury, bleeding will sometimes occur; and repeated haemorrhage will destroy the patient if a ligature be not applied. 1 have known the tem- poral artery bleed eleven days after its partial di- vision, and when the wound in the integument was almost closed. The treatment of this injury consists in completely dividing the vessel, when its retraction enables a coagulum to form in and around it; but, if the artery be large, a ligature must be applied. 135 Lacerated Arteries. These bleed comparatively little. Cases.—A sailor, on board a Margate Packet, was bringing up his vessel in the river, and having his leg in a coil of the cable, the anchor was unexpectedly let go, when the cable caught his thigh, and lore cff his leg six inches above the knee, excepting thai a small portion of skin on the outer part still con- nected the parts; the bone was broken; the artery, vein, sciatic nerve, and muscles, were all completely separated. A handkerchief was bound around the wound, and he was brought to Guy's Hospital. The artery had ceased to bleed, but he had lost a con- siderable quantity of blood. I amputated his limb, and he proceeded favourably for ten days, Avhen he was seized with tetanus, and died. I have also seen the foot torn off above the ankle, and the bleeding stop Avithout the aid of tourniquet or ligature. Cheseldetfs case.—The case, related by Cheselden, of the arm being torn off at the shoulder without much haemorrhage, is known to every surgeon. Causes which prevent bleeding.—There are two causes which operate to prevent bleeding:— 1. The cellular tissue is sometimes drawn over the mouth of the vessel, and makes a ligature upon it, Avhich stops the blood. 2. Another state of the artery produces the same result, and in Avhich the mouth of the vessel remains open, the coats of the artery are excessively elon- gated, and its sides fall together so as to render its canals impermeable. Treatment.—The best treatment is to apply liga- tures upon lacerated arteries, if they be large; other- wise, when the powers of circulation are restored, there is a danger of haemorrhage. 136 Of Punctured Arteries. Consequences.—They produce different symptoms from the other wounds of arteries in this respect, that the external opening being small, the blood does not readily escape; and therefore coagulates in the cellular tissue, and forms a swelling there, which gradually increases in size as the blood issues from the wound in the artery; the impetus of the blood causes a pulsation; and the cellular membrane, around the extravasated blood, being condensed, forms a sac, Avhich impedes the evolution of the swelling. The external wound heals, and thus an aneurism is formed. It may be said that it differs from an aneurismal swelling in the mode of its production; and this is true, but it still has the other characters of the dis- ease, and requires the same treatment. Puncture in bleeding.—I have several times known it happen from bleeding in the arm ; in one case the radial artery was wounded, but in all the other cases, the brachial artery. Case.—The first case Avas in a patient at Guy's Hospital, a dresser of Mr. Lucas, senior, bled the man, and he came to me excessively alarmed, telling me what had happened, and that he had great diffi- culty in stopping the haemorrhage, but had at last succeeded, by applying a very tight bandage. A short time afterwards the man came to Gua's, and showed his arm to Mr. Lucas, who, seeing the aneu- rism, and hearing the cause, told the man that he must submit to an operation, which the patient re- fused. In walking home, he met an old acquaintance, to whom he told the circumstances; this friend, Avho occasionally bled and drew teeth, said he would cure him, and inviting him into his shop, he put a lancet into the swelling, and finding blood impetuously es- 137 cape, he as quickly escaped from his shop. The pa- - tient finding himself bleeding, fortunately put his hand upon the wound, and called for assistance. A bandage was bound tightly round his arm, and he went to St. Thomas's Hospital, where Mr. Cline operated upon him, when the radial artery, in con- sequence of a high division, was found to be the wounded vessel. Cases.—One of the apprentices at Guy's Hospital had the misfortune to wound the brachial artery in bleeding; he immediately perceived the nature of the mischief, but before he could arrest the bleed- ing, thirty-seven ounces of blood were lost. He bound up the arm extremely tight, and when the bandage Avas removed a few days after, an aneurismal swelling appeared at the fore part of the elbow, for which an operation Avas performed, of tying the ar- tery at the part, an operation Avhich was attended with great difficulty, and the patient died. I once assisted Mr. Chandler in performing the operation for brachial aneurism, produced by bleed- ing ; the sac was opened, and the orifices above and below Avere secured by ligatures, but still there was a free haemorrhage, from an anastomosing vessel, which it was necessary to secure. Treatment.—The treatment of this injury consists in the immediate binding up of the Avound, and ap- plying a tourniquet to the middle of the arm, which should press upon the artery, and upon the opposite side of the arm only, leaving the circulation by anastomosis as free as possible. If aneurism forms.—If an aneurism still follows this accident, the'tourniquet is to be continued, as de- scribed in the lecture on aneurism. Operation.—Should the tumour still continue to increase after this has been fully tried, it will be proper to make an incision upon the brachial artery, 18 138 about midway betAveen the elbow and shoulder joints, and place a ligature upon it, but upon no account cut down upon the Avounded vessel at the elbow. In one instance, after I had applied a ligature to the brachial artery, I Avas surprised to find the thread completely separated on the fifth day; but the ulce- rative process was probably accelerated by the in- flammation which existed previous to the application of the ligature. The patient recovered. Of Contused Wounds of Arteries. Danger of.—Gun-shot wounds and severe bruises sometimes destroy the vitality of a portion of artery. As it will afterwards slough, there is a remote dan- ger in such a Avound, which must be carefully guard- ed against. The slough will not separate until from eight to ten days, or more, after the wound has been inflicted; and then the patient, Avithout precaution, may lose an immense quantity of blood, and some- times be destroyed by the haemorrhage. The slough opens the vessel upon its side ; and, no retraction ensuing, the haemorrhage is unrestrain- ed by the coagulation of the blood. Treatment.—In these .cases, it is required that the patient should be kept at rest until the sloughing process be completed ; and he must be instructed in the tightening of a tourniquet, which must be ap- plied, and left constantly upon the limb, until all the sloughing has ceased. Case.—A gentleman received a shot through the calf of his leg, and was proceeding so well as to be suffered to sit up, and to put his limb to the floor; on the seventh day, he was seized with a severe bleeding, from the effects of which he sunk. 139 ON THE TREATMENT OF WOUNDS OF PARTICULAR ARTERIES. Arteries of the Scalp. Wounds of these arteries require in their treat- ment,—first, a complete division of the injured ves- sel ;—second, the application of pressure ;■—by the first, retraction is permitted, and future bleeding is prevented; by the second, the present haemorrhage is suppressed. Case.—I was called one night to see the son of Dr. Johnson, who was bleeding freely from the tem- poral artery, which had been opened by a leech. I did not like to make an incision, but advised the ap- plication of a small tourniquet, which completely succeeded, and this instrument I should advise in all wounds of arteries of the scalp, as the means of pres- sure. Of aneurism.—In aneurism, from wounds of the ar- teries of the scalp, I have, in each case that I have operated upon, been obliged to open the aneurismal sac, and to tie each communicating artery. The aneurisms Avhich I have seen on the scalp from injury, have been in the temporal and posterior aural arteries, and have arisen from wounds and con- tusions. Carotid Artery. Speedily fatal,—The wounds of this artery are usually so speedily fatal, that surgery is rarely able to preserve life. Securing the artery.—In tying the artery the pars vaga must be excluded from the thread, and although the dissection of parts from the artery cannot be made at the moment of securing the ligature, yet when the haemorrhage is stopped, a fresh ligature 140 may be placed upon the artery alone, instead of de- pending upon that which has been of necessity em- ployed at first. Subclavian Artery. Torn.—I have never seen this artery Avounded, but I have seen it torn through. Case.—A man was brought into Guy's Hospital with a fracture of the clavicle, in which accident the shoulder was very forcibly draAvn back to the spine. The dresser had to bleed this man in the injured arm, but little blood could be draAvn; and, thinking that he had not passed the lancet sufficiently deep, he plunged it so far as to wound the brachial arte- ry. The blood which issued from the wound, was of a venous character, but it required a very tight bandage to stop the haemorrhage. Great tumefac- tion succeeded about the shoulder, gangrene began in the arm, great constitutional irritation followed, and the man died. Upon examination of the body after death, it Avas found that after the fracture of the clavicle, the scapula was forcibly drawn back, so that the subclavian artery was torn through, but a cord of cellular membrane united its ends, so that the extravasation of blood had been very slight. Axillary. Mr. Key's case.—Mr. Key operated, and tied the subclavian artery, on account of an aneurism of the axillary artery which had been produced by a forci- ble extension of a dislocated os humeri. Brachial Artery. Wounded in bleeding.—This artery I have often known wounded in bleeding. 141 Treatment.—A slight bandage, and a thick dossil of lint as a compress, have succeeded in healing the artery. When an aneurism forms.—If aneurism forms, the tourniquet should be employed, as I have describ- ed ; and if this does not succeed, apply a ligature upon the brachial artery. Make an incision in the middle of the arm, on the inner side of the biceps, and take care to exclude the vein and median nerve from the ligature. Ulna Artery. The wounds of this artery are usually at the low- er part of the fore arm, Avhere the vessel is situa- ted, between the tendons of the flexor carpi ulnaris, and the flexor profundus ; it is accompanied by the cubital nerve, Avhich is placed close to the artery, and which must be carefully excluded from the liga- tures. On account of the free anastomosis between this artery and the radial; the application of two ligatures, one above, and another beloAV the open- ing into the vessel, is absolutely necessary to effect- ually stop the haemorrhage. Radial Artery. This artery is much more frequently wounded than the ulna, being in every respect more exposed. The application of tAVo ligatures is equally necessary, as in the ulna, and for the same reason. This ves- sel is readily found on the outer side of the flexor carpi radialis, and it is not accompanied by any nerve of magnitude. 142 Of the Palmar Arteries. Frequently Wounded.—Wounds of the palmar ves- sels are very frequent, but generally the bleeding may be stopped by steady and continued pressure, by means of a compress and bandage, and by a tourniquet onf the brachial artery; the application of cold, and attention to position, will materially as- sist. Should these means fail to arrest the bleed- ing, and if the openings of the divided vessel can- not be easily found, it will be necessary to secure the ulna, or radial arteries, or both ; as from the very free communication of these vessels, the secur- ing of one only, will not, in many instances, prevent further bleeding. It will be best, however, in Avounds of the superficial palmar arch, under such circum- stances, first to put a ligature upon the ulna artery, and then try pressure again, before the radial is taken up; which should not be done unless a trou- blesome haemorrhage continues. On the contrary, should the deep palmar arch be the seat of injury, and it become necessary to secure an artery, the radial should be first tied, and afterwards, provided the bleeding does not stop, the ulna should be like- wise secured. Of the Femoral Artery. High up in the groin.—If this artery be wounded high up in the groin, the finger must be thrust into the wound to stop the bleeding, until a compress can be applied upon the pubes, and the vessel be se- cured. In the middle of the thigh.—If it be Avounded in the middle of the thigh, in the mode Avhich I have described in the case of a relation of Mr. Sauma- rez, a large swelling will immediately form, and the 143 artery will be deeply situated, under a large coagu- lum. A free incision must be made to give the sur- geon ample room to proceed in securing the wound- ed vessel, a tourniquet being first applied. The di- rection of the incision will be that required in the operation for popliteal aneurism, only it must be more extensive. The coagulum, which is then ex- osed, must be scooped out from the wound by the ngers, and the parts be cleanly sponged. The tourniquet is then to be loosened, and the aperture in the vessel will be directly seen, when the tourni- quet is to be again tightened, and tAVo ligatures are to be placed in the artery, one above, and the other below the wound, an end of each thread being cut off; the edges of the Avound are to be approximated, so as to favour the union by adhesion. It is always right in these cases to divide the ar- tery, between the ligatures. Of the Popliteal Artery. Rarely wounded.—This vessel is so protected by the condyles of the os femoris, and so concealed be- hind the bone, that it is rarely lacerated, and when it is so, the Avound must be highly dangerous, as it will be probably complicated with a division of the sciatic nerve. It Avas a case of this accident which first attract- ed my attention to surgery, and Avhich taught me its value. Case.—A foster brother of mine, named John Love, aged about thirteen years, Avas playing and fell, as a wagon Avas passing, and one of the wheels of the wagon went over the back of his knee, as he laid with his face to the ground. The wagon Avas stopped, and Avhen he was drawn from under it, a stream of blood directly burst from his ham; a hand- I 144 kerchief was tied tightly over the Avound, and he was put upon the wagon, and was carried home in a fainting state. Different surgeons in the neigh- bourhood were sent for; but when they heard the nature of the case they all made excuses; one had a most dangerous case of fever, another was at a la- bour; a third with a pressing case of inflammation of the boAvels; they Avere all engaged, and could not come, or, like the hare and many friends,— " The first, the stately bull implored, " And thus replied the mighty lord ;— u Since every beast alive can tell, "That 1 sincerely wish you well; " I may without offence pretend, " To take the freedom of a friend. " Love calls me hence," &c. Tired of Avaiting, an old Avoman (who was deem- ed a sorceress in the village) was applied to, and she sent back the messenger, saying, that the bleed- ing Avould be stopped by the time they returned; and so it Avas, for John Love had expired.* This scene made a strong impression upon my mind, as it Avas the first death I had witnessed, and I Avas directly convinced how valuable a member of society a well informed surgeon must be, and Iioav great a curse an ignorant surgeon Avas. If the ar- tery could not have been tied, the limb might have been amputated. Danger in tying the artery.—In tying the artery in the ham, there is some danger of including the sci- atic nerve, as it is placed above the artery in cut- ting into the ham, and it must be carefully avoided; * This was forty-three years ago, when a man who had re- covered from the operation, for popliteal aneurism, was deemed a sufficient curiosity to be annually shown to the students at our Hospitals. 145 the artery must be draAvn from the vein where the large nerve is placed upon it. Mr. Cline once saAV the nerve included in a ligature in the operation for Eopliteal aneurism, and the patient died in a few ours. Of the Posterior Tibial Artery. Rare at the upper part.—These injuries at the upper part of the leg are very unfrequent, but they do sometimes occur. Case.—A man was brought into Guy's Hospital, who had fallen from a considerable height, upon a cart, and an iron peg in the cart had passed through the calf of his leg, betAveen the tibia and fibula; a profuse haemorrhage ensued, but by the application of a tourniquet it was stopped. In six days the bleeding recurred, when the tourniquet was tighten- ed, and the flow of blood was again suppressed ; but in tAVO days haemorrhage again took place. I tied the femoral artery at the usual place, and for a week the man went on well, but tnen the bleeding was renewed, and I was obliged to amputate the limb. On examining it after removal, it was found that the iron had passed through the posterior tibial artery, at the origin of the anterior tibial, and had penetrated betAveen the tibia and fibula. Immediate amputation.—An immediate amputa- tion would be the best course to pursue. In compound fracture.—I have several times known the posterior tibial artery wounded by the bone in compound fracture; once, in a patient of Mr. Chand- ler, and a piece of lint was forced into the wound, which stopped the bleeding, but it was followed by gangrene, of which the patient died. Cases.—In a case of Mi*. Lucas's, in Guy's Hospi- 19 146 tal, Mr. Pollard, his dresser, secured the artery, and the patient did well. A patient of Mr. Key's, a boy, upon Avhom a tourniquet Avas applied, had the bleeding restrained, and it did not return. In a patient of Mr. Travers's, it was Avounded by a* scythe, and was tied by Mr. Travers, in the Thea- tre at St. Thomas's Hospital; the patient did well. It is sometimes wounded by the employment of the adze. I Avas called to a case at Hunton Bridge, Herts, by Mr. Wingfield, surgeon, at Market Street. The wound was small, and the artery cut, but not divided; the injury had happened three weeks be- fore I saAV the man, the bleedings had been very frequent, and were restrained for a time by pressure on the wound, by means of a tourniquet. As the man had become excessively reduced by the last haemorrhage, and could not have survived another, as soon as I Avas called in 1 tied the artery; just as I had secured the vessel, the man fainted, and I thought he Avould have died, but he ultimate- ly recovered. Treatment.—In Avounds of this artery at the upper part of the limb, I should first apply a tourniquet, then place the limb in a bent position, so as to relax the gastrocnemius muscle, Avhich I should raise from its attachment to the tibia, so as to expose the artery and its accompanying nerve, Avhich I should be care- ful to exclude, whilst I put tAVo ligatures upon the wounded vessel, and afterwards should carefully close the wound and unite by adhesion. At the lower part.—At the lower part of the limb the artery is easily found, and secured behind the malleolus internus. It is accompanied by the poste- rior tibial nerve, Avhich lies on its fibular side, and which must be avoided. Interossial artery.—A wound of the interossial 147 artery I hare never seen; but in the case of such a wound I should cut upon the vessel from the outer part of the leg, and seek it between the tibia and fibula, close to the fibula. Of the Anterior Tibial Protected above.—This vessel is rarely wounded at the upper part of the limb, but frequently at the lower. Lying between the two bones above, it is much protected. How secured.—When wounded at the upper part of the limb, an incision must be made on the outer side of the tibialis anticus to find it: a tenaculum, or a pair of forceps, must be employed to raise the wounded artery, to remove it from the interosseous ligament; and then two ligatures are to be applied upon it. In compound fracture.—I have seen it wounded in compound fracture. First, in a brewer's servant, a patient of Mr. Birch's, in St. Thomas's Hospital; the artery being tied, the compound fracture pro- ceeded quite favourably. Case.—In a second case the result was singular. A man was brought into Guy's Hospital, Avith a com- pound fracture of the leg. A few days after his admission, he had a free haemorrhage from the wound, which Avas stopped by the application of the tourniquet; but at different intervals the bleeding was frequently renewed, and I was at length com- pelled to amputate his limb. Upon examining it afterwards, a spicula of bone was found penetrating the anterior tibial artery, and the opening into the vessel thus produced, had been enlarged by a pro- cess of ulceration, so as to give rise to the haemor- rhage. Operation.—When the anterior tibial artery is 148 Avounded low doAvn in the leg, it must, when it is tied, be completely raised from the tendons of the tibialis anticus, and extensor proprius pollicis, be- tween which it is placed; both ends must be se- cured. On the dorsum of the foot.—This artery is some- times Avounded on the upper part of the foot, where it is placed upon the navicular bone, and the middle cunieform, by a knife or chisel being dropped upon the foot. Each extremity of the divided vessel must be carefully tied, otherwise the haemorrhage will con- tinue, on account of the free anastomosis of this artery with the plantar. Of the Plantar Arteries. Treatment.—For a wound of either of these arte- ries, I should first try what the application of a bandage, with a compress upon the wound, and a tourniquet upon the thigh would effect, and should tie the posterior tibial artery, after an extended and unsuccessful trial of these means; for so deeply is the artery placed, and so situated amongst tendinous parts and nerves, that incisions should not be made at the Avounded part. Styptics. Wool.—In bleeding from small vessels on wound- ed surfaces, very fine wool laid down and confined by bandage upon the part is one of the best styptics. The wool may be dipped in flour to add to its ef- ficacy. Turpentine.—Turpentine is said to have power as a styptic, and 1 have seen bleedings stopped by it when it has been applied by lint, and with pressure; 149 but merely poured upon the wounded surface it ap- pears to me to be quite powerless. An old prescription.—There is an old prescription for a styptic in St. Thomas's Hospital, which I have seen useful. R. Pulv : Catechu Pulv: Bol: Armen: aa 3ij. Alum : ust: gj. Tinct: opii. q. s. at fiat pasta. This will stop the troublesome bleeding from leech bites. 150 LECTURE XXXIX. Of Wounds of Veins. Traverses paper.—Mr. Travers has published a very good paper upon the mode in Avhich they heal. In healthy persons not dangerous.—In a healthy constitution they are little dangerous, as the cellular tissue adheres over the apertures Avhich have been made in them, and inflammation speedily closes them. Case.—I once saw the axillary vein wounded in re- moving a scirrhous gland from the axilla, a dossil of lint was placed in the wound, and the arm Avas confined to the side, Avhen no bleeding of consequence ensued. In unhealthy persons dangerous.—In unhealthy con- stitutions they inflame and suppurate; they also ul- cerate, and sometimes life is destroyed, by bleeding, or by the inflammation extending to the large vein, and to the heart. Several cases of this kind I have witnessed; and in the greater number the wound of the vein had been made to abstract blood for inflammation of the lungs; and I have thought that the inflammation of the vein was the result of the impediment to the pul- monary circulation. Symptoms of inflammation.—The patient in a few hours after the bleeding, complains of tenderness in the arm, and requests to have the bandage loosened; he next finds great pain in extending the limb; the wound looks red, and its lips are separated. Then the plexus of veins on the fore arm become swollen, hard, and very painful; afterwards the basilic vein 151 of the upper arm feels as a solid body, and is much enlarged. High constitutional fever ensues. If the patient has sufficient power of constitution, abscesses form in the veins of the forearm; and by opening these early, great relief is afforded ; but if the habit be particularly feeble, the matter which is produced by the suppurative inflammation, does not point, but it remains in the veins, producing excessive constitution- al irritation, which destroys life. Appearances.—Upon inspecting the vein after death, it is found partly filled by adhesive matter, and in part by pus. There is in the collection at St. Thomas's Hospital, a beautiful specimen of abscess in the lon- gitudinal sinus of the dura mater. I have seen the jugular vein inflamed and adherent throughout the greater part of its course. Specimen.—We have, in the collection at Guy's Hospital, the femoral and iliac veins obliterated, taken from a patient who had phlegmatia dolens ; which disease has been extremely well described by Dr. Davis, in the " Medico Chirurgical Transactions." Division of the saphena.—But the worst cases of inflammation of veins which I have seen, have arisen from the application of ligatures to the vena saphena. Consequences.—First, I have seen a disease like phlegmatia dolens follow the division of this vein. Secondly, numerous abscesses form and break, sometimes destroying life, at others producing exces- sive irritative fever, from which the patient has been wijjh difficulty recovered. One patient became in- sane during the irritation, and did not aftenvards re- cover her mental faculties. Thirdly, they have died from suppurative inflam- mation, without any abscess appearing, and this is the cause of death after the operation of amputation, when it is performed during a very unhealthy state 152 of the constitution. I have seen, under these circum- stances, both artery and vein, in a stump, in a state of partial adhesion and suppuration. I saw, in Paris, in 1792, a case in which life was destroyed by suppuration of the femoral vein, after a gun-shot wound. Of the Treatment of Wounds of Veins. Position.—The first and greatest object is to emp- ty the veins as much as possible, by the position of the limb, which should be such as to allow of the gravitation of the blood to the heart. In the arm, an inclined plane; in the leg, the position for a frac- tured tibia. This prevents accumulation of blood, and distention of the vessels. Gentle pressure.—Secondly, a roller, from the ex- treme part of the limb, to the wound, wetted Avith the liquor plumbi subacetatis, and spirit should be applied to approximate the sides of the vein, and to make gentle pressure. Thirdly.—Leeches should be freely applied, and if suppuration be produced, fomentations. Wounds of the Abdomen. Two kinds.—These injuries are of two kinds: 1. Those in which the cavity is opened, but the viscera are not wounded. 2. Those in which some of the viscera suffer. First kind, often recovered from.—With respect to the first of these it is scarcely necessary to say, in the present state of surgical knowledge, that very extensive wounds of this description are often recovered from, as is proved by the operations for umbilical or ventral herniae, by the Cesarian section; 153 and, recently, by the removal of enlarged ovaria.* But the most curious circumstance in these wounds, is the manner in Avhich the intestines glide away from the sharpest instruments, and escape injury. I shall relate two cases:— Cases.—In the year 1785, my second year of be- ing at the Hospital, a gentleman came almost breath- less to the Hospital; and finding me the only per- son there, requested that I Avould immediately ac- company him. He took me to a house in the Bo- rough; and, leading me up stairs, showed me into a room, Avhere 1 found a female in her shift only, lying upon the floor, weltering in her blood. I with diffi- culty raised her, and placed her upon the bed she had just quitted. On examining her, 1 found four wounds in her throat; one of which was deep and extensive. These I closed by sutures; after which she was able to speak; and I then asked her what had induced her to commit the act; she made an in- coherent reply; but repeated the Avord stomach two or three times, which induced me to raise her linen, when I was surprised to find her bowels exposed by a Avound reaching nearly from the pubes to the ensiform cartilage of the sternum; for, after cutting herihroat with a razor, she had ripped up her belly with it, and let out her bowels, but the intestines were still distended with air; and I had a difficulty in returning them into the abdomen. They had not received the smallest wound. Dr. Key now came into the room, and I proceeded to sew up this ex- tensive opening ; but she died in nine hours. Mr. Tolman and myself were sent for to see a gentleman who had stabbed himself in several parts of his abdomen, with an old rusty dirk, and had for some time afterwards concealed himself from his * See cases by Mr. Liston. 20 154 family. When found, it was discovered, that a por- tion of omentum protruded through one of the open- ings; this was carefully returned; but, notwithstand- ing, the dirk still possessed its point, the intestines were not injured, and he recovered Avithout a bad symptom. The free motions of the intestines upon each other, independent of the peristaltic motion, is a great pre- servative in wounds of, and blows upon the abdomen. Peculiar symptoms.—There is another curious cir- cumstance in wounds into the abdomen; which is, that they immediately produce universal coldness and paleness, with nausea and faintness, excepting in the operation for strangulated hernia ; in which case the intestine has been accustomed to violence. Treatment.—In the treatment of these wounds, it is best to make interrupted sutures; the needle should penetrate the skin and muscles, but not the f>eritoneum. If the muscle be not included in the igature, a hernia is sure afterwards to form ; and, if the thread is introduced through the peritoneum, it adds much to the danger of abdominal inflammation. Between the sutures, strips of plaister, or of lint dipped in blood, should be applied, and the patient should be freely bled from the arm. If the local inflammation be great, leeches should be employed ; purgatives must be avoided, and food must not be given for several days. Of the Second Kind of Wound of the Abdomen. Rare.—Wounds of the abdomen, extending to the stomach, or intestines, are extremely rare. Dangerous.—There, danger is much lessened, if the wounded portion of the viscus protrudes through the opening in the parietes; for, if not, they are ge- nerally fatal. 155 Wounds of the Stomach. The best case which I have heard of, is related by Mr. Scott, in the medical communications, from which the following account is taken:— Mr. Scott's case.—" During the election for Wey- mouth, in March, 1784, Charles Thomas, a seaman, aged twenty-five, of a strong and healthy constitution, had the misfortune to receive a thrust with a small sword on the left side of his body. The sword pass- ed in between the second and third of the lower false ribs, and penetrated into the cavity of the ab- domen in an horizontal direction, to the extent of more than five inches, as appeared afterwards by the mark upon the blade. " 1 saw him about half an hour after the accident. His whole appearance was then much altered; his countenance being quite collapsed, and covered with a cold sAveat, while the pulse at his wrist was scarce- ly perceptible ; he had also a constant hiccough, a frequent retching and vomiting of blood, and a con- siderable discharge of blood, and other fluids, from the external wound. " From the place and manner in which the sword had entered, and the symptoms that followed, I was led to conjecture that the stomach was wounded; and that this was certainly the case, I was soon con- vinced, on examining the fluid discharged by the ex- ternal Avound, and finding in it several small pieces of meat in a soft digested state, together with some particles of barley. " He had complained of thirst, and some barley- water had been given him to drink; but this had been immediately thrown up after passing the oeso- phagus. Other mild fluids were now tried, as were likewise a common saline draught, in an effervescent state, and some thebaic tincture, but with no better 156 effect; and they Avere all instantly rejected, tinged with blood. "The retching and action of the stomach continu- ing to be very violent, and the patient complaining, at the same time, of a lump, or dead weight, as he termed it, in his inside, he Avas desired to drink some warm water; this was soon thrown up, accompanied Avith a good deal of barley in solid grains, with the surface slightly broken, and some pieces of meat in a half-digested state. More water being given him, it was quickly returned, tinged with blood, but, other- wise, nearly as pure as Avhen swallowed. " I now proposed that we should avoid giving any thing further by the mouth; but, as the spasms and hiccough Avere still very frequent, an emollient clys- ter Avas administered, by which a considerable quan- tity of foeces Avas discharged. Soon after this, an- other clyster, containing tAvelve ounces of barley- water, and 3ij of thebaic tincture, was thrown up, and the greater part of it retained. Warm fomen- tations were likewise applied externally; the surface of the wound was loosely dressed ; and he. was de- sired to lie as much as possible upon the injured side, with a view to favour the discharge. "On the first of April, the day after the accident, the symptoms were still very unfavourable. His pulse continued low and languid, with a great pros- tration of strength, and a coldness of the extremi- ties. He had had several rigours towards morning, and the spasms were sometimes very violent. He complained of extreme coldness over his whole body, and of a constant gnawing pain about the pit of his stomach, to which part Avarm fomentations Avere frequently applied. " A laxative clyster was again administered, Avhich was followed by a copious discharge ; soon after this, another clyster, consisting of fourteen ounces of veal 157 broth, and two drachms of thebaic tincture, was thrown up and retained. A similar clyster was re- peated in about four hours, with the same effect. Flannels, dipped in Avarm milk and water, were oc- casionally applied to his arms and legs, and hot bricks to the soles of his feet. He made a little water twice in the course of twenty-four hours; this was highly coloured, and deposited no sediment, though kept for a considerable time. " April 2. He had passed a restless night, and now coniplained of intense thirst. The hiccough and spasms were less frequent, but he suffered much from a constant burning pain in the lower part of his stomach. His pulse was small, and beat about 120 in a minute. The fomentations Avere applied as usual; and 3vj of the sal: cathart: amar: were dissolved in some broth, and throAvn up into the bowels as a laxative. This produced a considerable discharge of soft slimy foeces, in which were several small pieces of clotted blood enveloped in mucus. After this, in the course of the day, three clysters of broth and thebaic tincture were thrown up and re- tained. He was desired to use the pulp of an orange occasionally, to allay his thirst, and to wash his mouth frequently with barley water acidulated with lemon juice. "April 3. I was called to him early in the morn- ing, and told he was at the point of death. A cler- gyman had been sent for at the same time to per- form the last offices. The nurse informed me, that, whilst supported in bed to wash his mouth, he had been seized with a violent retching, accompanied with convulsions of the chest, but that nothing had been discharged from his stomach, except a small quantity of bloody fluid. When I saAV him, the spasms still continued; his forehead and breast were covered with a cold sweat; his pulse was low, and 158 intermitted; so that it could only be felt at inter- vals; and his strength seemed to be quite exhausted. Warm fomentations were immediately applied to the region of the stomach; and, as there was always some of the veal broth kept in readiness, I threw up about fourteen ounces of it, with 3ij of the the- baic tincture. The violence of the symptoms was soon moderated, and he appeared very languid, and showed a disposition to sleep. " When I saw him about four hours afterwards, I was told that he had enjoyed some rest. His pulse was now regular, but small and quick ; he was very Aveak, and just able to inform me, that, in washing his mouth, he had accidentally swallowed some of the liquor, and that this had thrown his stomach into violent action. About one pint of the broth was now injected Avithout any addition. This Avas likewise retained, and repeated at intervals of five or six hours. He now made water frequently, Avhich, upon standing, deposited a considerable quan- tity of sediment, of a light brick, or straw colour. "April 4. The hiccough, retching, and other un- favourable symptoms, were now entirely gone; but he still complained of a fixed pain in his stomach, accompanied with a sensation of heat, and of a sore- ness of the injured side, extending from the wound toward the middle of the abdomen. He was like- Avise troubled with thirst; his pulse Avas small, and about 110. The external wound had now begun to yield a discharge of good matter. "The same mode of treatment was continued, and the symptoms became daily more favourable. The broth was administered in clysters, to the amount of two quarts, or five pints a day. The fomentations were continued externally, and his feet and hands were frequently bathed in warm milk and water. He voided his urine regularly, and in about the pro- 159 portion of three pints in the twenty-four hours, though it sometimes considerably exceeded this quan- tity, and continued to deposit a great deal of sedi- ment. A little of the sal: cathart: amar: was occa- sionally added to the clysters in order to stimulate and cleanse the intestines; after the fourth day, how- ever, there Avas scarcely any fceculcnt matter dis- charged, but only a small quantity of viscid bile. " On the 10th day from the time of his being wounded, he appeared to be very sensibly relieved; his thirst and febrile symptoms were much abated, and his pulse Avas regular, and about ninety. As he was in good spirits, and expressed a wish that he might be allowed to swallow something, I procured some calf's-foot jelly, made luke-warra, of which he ate half a pint, Avithout feeling any bad consequences. The only remarkable circumstance that attended the first time of his sAvallowing, was, that it occasioned frequent eructations, and a great discharge of air; but this, according to his own account, produced ra- ther a grateful sensation than otherwise. Next day he was allowed some new milk for breakfast, and some chicken broth for dinner. The nutritious clys- ters Avere continued, however, till the 16th day, though less frequent than before. From that period, for about a fortnight, he lived wholly on bread and milk, and light broth. He was then allowed chicken, veal, and other meats easy of digestion. The exter- nal wound had been healed for some time, and he recovered his strength very gradually. The only inconvenience he suffered was. from costiveness, and a sense of soreness and stricture Avhich extended from the external wound towards the middle of the abdomen. This Avas particularly felt after a violent expiration, or any sudden extension of the body, when, to use his own expression, his side was drawn inwards and upwards. The costiveness was obviated 160 by mild laxatives, and gently stimulating clysters, and Avent off entirely as the intestines recovered their true and natural action. The other complaint which I apprehend to have originated from an adhesion of the inflamed stomach, to the peritoneum, seemed to go off gradually as he recovered his strength; though it was still felt in a certain degree in stooping, walk- ing quick, or any great exertion of the body. When I last heard of him, two months ago, he enjoyed good health."* " This case affords a striking instance of the re- sources and peculiar powers with which nature has endowed the animal machine, for its preservation, and for remedying any injury it may sustain. The treatment was such as was necessarily suggested by the symptoms. The wounded stomach Avas so extremely irritable, that even the mildest fluids increased the violence of its action, and were reject- ed ; for had any substance, Avhether of medicine or aliment been admitted, it would probably have in- terrupted the union of-the divided parts in the first instance, or afterwards, by the action necessary for its expulsion through the pylorus. " The liquid contents of the stomach had been chiefly discharged by the external Avound, though part of them must, no doubt, have passed into the cavity of the abdomen, and have been afterwards absorbed; but the wound of the stomach collapsing, the barley and indigested meat were left, which, in- creased the irritation, and occasioned the uneasiness and sense of weight he complained of, and which was, in a great measure, removed by the vomiting that took place upon his drinking the warm water. " He felt some relief after the retention of the * This was in the September twelve months following, as the paper is dated November 15, 1785. 161 first clyster, but at that time his strength Avas so re- duced, and the symptoms were altogether so unfa- vourable, that neither himself, nor those who saw him, entertained any hopes of his recovery. It is in- deed surprising what an extreme debility took place immediately after the accident, which could only arise from the nervous influence and general sympa- thy with a part so essential to life. " The accident that happened on the fourth day, induced me to persevere in the mode of treatment we had adopted. Indeed there Avas great encour- agement to continue it, as the broth clysters, were not only retained, but there was a proof of an ab- sorption having taken place, by the secretion and evacuation of urine, which then began to be consid- erable. It is a generally received opinion, that clysters seldom pass beyond the valve of the colon: the contrary has indeed been observed in the volvu- lus or iliac passion, but in that case the natural action of the intestines is inverted, and a violent degree of anti-peristaltic motion prevails; in this case, however, the broth was thrown up in a very gradual manner; and though, perhaps, it did not pass the valve of the colon, in the first instance, I am inclined to believe, from the sudden manner in Avhich the absorption was afterwards carried on, that a gentle degree of anti- peristaltic motion took place, Avhereby it (the broth) was impelled to the smaller intestines; this will ap- pear less surprising, Avhen we consider, that, in the natural action, the first impulse is communicate dby the stomach, in discharging the digested aliment at the pylorus, and continued through the intestines in determining the fceculent matter downwards: but here the natural action Avas suspended, the stomach was at rest, and there Avas no foreign matter to be discharged. " The advantages to be derived from throwing up 21 162 a supply of fluid, and supporting nature in this man- ner, in particular cases of morbid affections of the digestive organs, will readily occur to the attentive practitioner." Wounds of the Intestines. In operating for hernias.—In a small wound of the intestine, which I witnessed in strangulated hernia, under the operation, I pinched up the opening with a pair of forceps, and tied a thread around it; I then passed up the intestine to the mouth of the hernial sac, leaving the ligature to hang from the wound, and the patient recovered, but he had severe symp- toms for several days. Large wounds.-^-in a more considerable wound of the intestine, I should make an uninterrupted suture, and return the intestine into the abdomen, letting the end of the ligature hang from the external Avound, Avhich I should otherwise close with great care. I well know, that in experiments on animals, the ligature has been cut off close to the intestine, which has been returned into the cavity of the ab- domen, and the external wound has been afterwards closed, so as to leave the ligature to separate into the intestine. Now I do not clearly understand that this plan, in any way, adds to the patient's security; but, on the contrary, it increases his danger in my opinion, if the process of adhesion be deficient. Treatment.—In the treatment of these wounds, it is right, if the wound be in the small intestines, to keep the patient Avithout food, and support him by clysters of broth, &c. If it be in the large intestines, after a few days, a little jelly may be allowed. Per- fect quiet is to be observed; and, if there be much tenderness of the abdomen, leeches should be ap- plied. 163 Rupture of intestine.—Ruptures of the intestines from blows are more frequent accidents, arising from kicks of horses, falling upon projecting bodies, &c. The symptoms are, great depression, coldness, and paleness; the pulse is scarcely to be felt if the lace- ration be large, and the patient dies in from twelve to tAventy-four hours after the accident, quite sensi- ble to the last moment of his existence. But if the laceration be small, the symptoms are less violent; there is coldness, tension of the abdo- men, vomiting, costiveness, and not the least disposi- tion for food; there is subsequently great abdominal tenderness and great enervation. Case.—A patient was brought into Guy's Hospital, under the care of Mr. Forster; the man had been working in a gravel-pit, when the gravel fell in upon him. He vomited, his abdomen became tense, and as he made scarcely any urine, the case had been thought to be retention of urine. The man died six days after the accident, and, on examination after death, a rupture Avas found in the intestines. Treatment.—The treatment in these cases, is per- fect rest, to prevent any disturbance of the adhesive process, to apply leeches and fomentations to the ab- domen, to avoid giving any medicine, and to check the desire of friends in giving food for several days after the accident. Sometimes recovered from.—The intestines thus remaining for a length of time at rest,* and inflam- mation being kept within the adhesive bounds, I have seen (what I believe to have been) cases of this injury recovered from. * The peristaltic motion is greater or less as the intestines are full or empty. 164 Wounds of the Liver. Case.—I havetseen deep stabs, with a pen-knife, in the situation of this organ, recovered from, after great inflammation in the abdomen. The patient was bled generally, and by leeches, and fomentations were employed. Adhesive plaister had been ap- plied to the stabs, and on its being removed, a bloody serum was discharged from the wounds. Wound of the Gall Bladder. Case.—Mr. Edlin, of Uxbridge, informed me of the following case :—Two soldiers quarrelled, and one struck the other with his bayonet in the right side, just below the margin of the ribs. The Avounded man directly fainted and fell; Avhcn he recovered from his fainting state, he complained of agonizing pain in his abdomen, which became extremely tense and tender to the touch. In thirteen hours the man died; and, on examination of the body, the gall bladder Avas found to have been penetrated by the bayonet, and bile Avas extravasated into the abdomen. Mr. Edlin said, that wherever the bile rested, the peritoneum was highly inflamed. Wounds of the Spleen. Although this organ may be removed from the body, without the destruction of life, as is known from the case of the soldier, mentioned by Dr. Gooch, and by numerous experiments on animals, yet a very small wound of it is sometimes destruc- tive of life; the best example of Avhich I shall oive m trie iollowmg case :— Case.—A lieutenant of a press-gang was attempting to press a man, who resisted with much violence; a 165 scuffle ensued, and the lieutenant struck the man with his dirk, Avhich entered near the ensiform car- tilage, and its blade was nearly buried in the body. The man Avas brought to St. Thomas's Hospital, pale and extremely depressed, his abdomen became tense, and he died. Upon examining his body, it Avas dis- covered that the dirk had passed from the ensiform cartilage, under the margin of the chest into the ab domen, on the left side, and that its point had pene- trated the concave surface of the spleen; the cavity of the abdomen Avas filled with fluid blood. Wounded in tapping.—It is said, that the spleen has been often Avounded by the trochar, when tap- ping Avas performed on the left side, Avhich, under enlargement of this organ, might happen. Ruptured.—I have several times known the spleen ruptured by carriages going over the abdomen, and once by the horn of an ox. Each of these cases proved fatal. Cases.—TAvice have I knoAvn the spleen torn from its natural attachment to the diaphragm. The first instance, Avas in a patient of Drs. Babington and Let- som, a Miss Harris, who, having vomited violently, discovered soon after a SAvelling at the groin, and at the lower part of the abdomen. I was asked if it was hernia, and 1 declared it Avas not. She died after a week, vomiting constantly the liquids which she swallowed. When the abdomen was opened after her death, the SAvelling was found to arise from the spleen, Avhich had been detached from the dia- phragm, and Avas enlarged by the interruption to the return of blood from the veins, although the artery still contained blood. The spleen was turned half round on the axis of its vessels. The other case Avas that of a gentleman who Avas hunting in Surrey; he fell from his horse when going at full speed. He died the following day, or the 166 day after. Dr. Pitt, who attended him, examined the body after death, and found the spleen torn from the diaphragm. Treatment.—In wounds or ruptures of the spleen, I believe nothing can be done. If the case could be accurately ascertained, pressure by a roller on the abdomen would be the best treatment. Wounds of the Kidney. A wound of this organ is not fatal. Case.—A Boy called at my house, and showed me some chalky concretions Avhich he had coughed up from his lungs or bronchial glands. I said, " How long have you been subject to this complaint?" He answered, " Ever since I have passed blood with my urine." I asked him to explain himself further, when he told me, that Avhen quarrelling with an- other boy, he had been struck with a penknife in his back; that almost immediately he Avished to make water, when he passed a large quantity of blood. This continued for several days, but subsided by his remaining quiet in bed. The recumbent posture is / in such a case the very best security. Wounds of the Bladder. Danger from state of bladder.—These are dan- gerous, or not, as the bladder is full or empty, when the injury is inflicted. If full, urine is extravasated into the abdomen, or extensively into the cellular tissue, and death ensues. If empty, or nearly so, the danger is greatly lessened. The bladder is sometimes ruptured when the above observations are applicable. The cause of its laceration is generally a fracture of the pubes. Treatment.—The treatment of these cases, consists 167 in leaving a catheter in the bladder, and enjoining perfect rest. Wounds of the Chest. * Of two kinds.—These are also of two kinds:—• First, Wounds of the parietes. Second, Wounds of the viscera. Of parietes.—Wounds of the parietes are not at- tended with much danger. Cases.—A boy fell from a tree upon some pales, which entered his chest betAveen the seventh and eighth ribs, tearing his intercostal muscles freely. The air rushed violently into his chest at each res- piration, and was again expelled, Avhen the anterior surface of the lungs appeared at the Avound. The edges of the wound Avere brought together by ad- hesive plaister, a roller was applied tightly round the chest to confine the motion of the ribs, and he Avas bled very freely. He did extremely well. A man was brought into St. Thomas's Hospital Avho had been stabbed betAveen the cartilages of his ribs, he bled very profusely, and I thought the in- ternal mammary artery was wounded, but the bleed- ing soon subsided, and he recovered. Treatment in wounds of the parietes of the chest, is to promote as much as possible the adhesive in- flammation to close the wound externally. Haemorrhage.—If there be bleeding from the in- tercostal artery, the finger should be pressed upon the orifice of the vessel, until the disposition to hae- morrhage ceases. Case.—A man died in Guy's Hospital, who had been wounded through the intercostal muscles with an iron spindle, the wound healed, but tetanus super- vened, of which he died. Upon inspecting the chest after death, the lung was found to have assisted 168 in closing the Avound, by adhering to the injured pleura. Of Wounds of the Lung. Symptoms.—When this happens, the circumstance is known by the patient's coughing up florid and frothy blood ; by free bleeding from the Avound, if sufficiently large to permit its escape ; by considera- ble irritation and tickling in the larynx, and by dys- pnoea. Danger of—Danger in three Avays results from Avounds of the lung. First. From haemorrhage, if any large .branch of the pulmonary artery is wound- ed. If the vessel be wounded by a sword or knife, it bleeds very freely; but, if by a broken rib, very little, as it has the nature of a lacerated Avound. Treatment.—In either case, the patient must be freely bled, to prevent the continuance of the hae- morrhage from the wounded lung, and the opening must not be closed in the parietes until all bleeding from the lungs have ceased, otherwise the blood will remain in the cavity of the chest, and produce irri- tation and inflammation. Danger from inflammation.—The second danger is from inflammation of the lung, and effusion into the cavity of the pleura. The first is to be guarded against by large and repeated bleedings, determined by the dyspnoea and hardness of the pulse ; but there is little danger of bleeding too much in one of these cases, as it is an object not only to diminish the force of the circulation, but the quantity of the blood in the pulmonary vessels. If effusion follows, it is the result of neglected in- flammation, or of having closed the external Avound too early. In the one case, it is a purulent secre- tion; in the other, a bloody serum, which produces the dyspnoea some days after the accident. 169 Operation for effusion.—For effusion intb the che6t, it is right to perform the operation for paracentesis of the thorax, to draw off* the pus or bloody serum which has collected in the pleura. The mode of doing this has been already described. Effusion in old persons.—In old persons, there is great danger in fractured ribs Avith Avounded lung, and I always give a guarded opinion, for I have seen several die from effusion of fluid into the cel- lular tissue of the lung. The greatest care and quiet are therefore required in such a case, and it is better to give digitalis than to bleed very largely. Emphysema, the third consequence of wounded lung, is less dangerous than the others. It some- times extends to the face, covering the neck, and also a large part of the trunk. Treatment.—In the treatment, a bandage is to be placed so tight around the chest, as to prevent any rattling during a deep inspiration; the patient is to lie on the wounded side, and punctures may be made into the cellular tissue, where it is much loaded, but not so large as the wound made in bleeding. In all cases of wounds of the chest or lungs, rest is essentially necessary to recovery. Of Wounds of the Pericardium. Case.—Mr. Saunders told me the folloAving case, which occurred whilst he lived with Mr. Hills, of Barnstaple. Mr. Hills was called to attend a man, who, in a quarrel, had been Avounded by another with a reaping hook through the cartilages of the ribs. The wound was small, but deep, and the man had the appearance of one Avho had sustained a dangerous injury. In two or three days after, he in the region of his heart, a quick ; and in a few days more, he began 22 had^much pain ana's mall pulse 170 to swell, and could n&t lie down in bed. I forget exactly how long he lived, but I think for a fort- night or three weeks; and after his death, it was discovered that the hook had passed through the cartilages of the ribs into the pericardium, in Avhich there was an effusion of bloody pus. Wounds of the Heart. These wounds rarely occur, but in their conse- quences are so immediately fatal, as to preclude the possibility of affording relief. Two cases, hoAvever, of much interest, I have known, and of one there is a preparation in the museum of St. Thomas's Hos- pital. I will relate them. The first case is related in the second volume of the " Medico Chirurgical Transactions," and was sent to me by Mr. Featherton, who attended the patient. Case.—"Richard Hollidge, a private in the North- ampton regiment, while on duty on the 29th of March, 1810, with an unfixed bayonet in his hand, slipped down, and his bayonet entered his left side, between the sixth and seventh ribs, upon the supe- rior edge of the latter. He was some yards distant from the gate at which he was posted, and being challenged, he returned to open it, with the bayo- net still remaining in the wound; he was incapable of withdrawing it himself, but the person coming in extracted it for him. 1 was called to him within five minutes of the accident; he was then in a state of syn- cope, the extremities cold, and his pulse scarcely per- ceptible. In about the space of a quarter of an hour, he gradually revived, did not complain of any severe pain, and expressed, 'that he believed he was more frightened than hurt.' I examined the Avound with much diligence, but could not trace its extent further than one inch and a quarter, though it was evident 171 that the bayonet had penetrated two inches : the hae- morrhage was very inconsiderable. His wound was dressed; he was conveyed to the military hospital, and put to bed ; he was incapable of lying on his right side, but slept tolerably well. On visiting him the following morning, he complained of lancinating pains extending from the Avounded part across the chest, and of severe fugitive pains in different parts of the abdomen; his pulse Avas quick and thready, and tongue white and dry. These symptoms led to a suspicion, that the pleura costalis at least was Wounded, though no opening could be ascertained ex- tending into the cavity of the chest. 3xvj. of blood Avere taken from his arm, a solution of sulphate of magnesia administered, and fomentations applied to the abdomen. He was obliged to be supported in bed nearly in a sitting posture, as respiration became much impeded when perfectly horizontal: in this position he appeared to breathe with freedom. In the evening, he expressed himself in every respect much relieved ; his pulse was less quick, and had lost its thready sensation; tongue more moist; his medicine had operated moderately. On the follow- ing morning, I found he had passed a good night, his pulse was calm and steady, scarcely quicker than natural, and the tongue quite moist; the lancinating pains had subsided, and he merely complained of a trifling pain in the Avounded part; this was increas- ed by a slight cough, with Avhich he became affected only this morning, and which was unattended by any expectoration. His aperient draught was repeated, an emulsion ordered for his cough, and the antiph- logistic regimen strictly adhered to. Throughout the day he was walking about the ward, in very good spirits, quite jocular in his conversation with his felloAV patients, and expressed himself to them, that' low diet would not do for him any longer.' 172 He retired to rest about nine o'clock, and fell asleep; at eleven, he got out of bed to the commode, had" an evacuation, by no means costive; said, i he felt himself chilly, and a sensation that he should die;' returned to bed, and expired immediately; forty- nine hours from his receiving the wound. I examined the body on the following morning, in the presence of tAvo other surgeons. On opening the chest, the pleura was found slightly inflamed for some distance round the puncture, and an effusion of adhesive matter, emitting a small portion of the lung to the wounded part; the lung was not injured. At least tAvo quarts of blood were effused into the cavity of the chest; the pericardium was nearly filled with blood, and had a puncture through it, ex- tending three quarters of an inch into the muscular substance of the left ventricle, about two inches from its apex. A small coagulum was formed at the edge of the Avound through the pericardium. Upon opening the left ventricle of the heart, it was discovered that the bayonet had penetrated the substance of the ventricle, and had cut one of the fleshy columns of the mitral valve. On a revieAv of the case, I conceive it very curi- ous, that an organ like the heart, possessing such excessive irritability, a point to Avhich the most in- teresting of our sympathies are referred, and which is in some degree influenced by the most trifling, should be so materially wounded, and yet the sys- tem take so little cognizance of the injury. Death, in this case, it Avas perfectly evident, was not pro- duced from any alarm excited in the system by the wound, but occurred as a secondary consequence, from the haemorrhage increasing to such an extent, as to interrupt the actions of the heart and luno-s. That the haemorrhage proceeded chiefly from the heart, must be admitted: there was no symptom 173 whatever that indicated a wound of the lung; none could be found on the most deliberate examination; and the intercostal artery was entirely free from injury." . The second case has been published in the " Medi- cal Records and Researches," from which the fol- lowing particulars have been taken. It occurred during the time that Dr. Babington was employed as assistant surgeon at the Royal Hospital at Haslar, and by him the particulars were communicated:— Case.—" Henry Thomas, a marine, was received into the hospital, from his Majesty's ship Foudroy- ant, having a wound in his side. He had slipped from the gangway, where he had been placed as sentinel, to the deck below; and had fallen upon the point of his bayonet, which had penetrated his side a little below the false ribs, nearly in a perpendicu- lar direction, as far as the hilt of the instrument. Immediately after the accident he dreAV out the bayonet Avithout assistance, arose, took up his mus- ket, walked eight or ten steps, and then dropped down in a fainting state; from this state he soon re- covered, and was taken to the hospital about two hours after the receipt of the injury; he then com- plained of but little pain, Avas inclined to sleep, and when roused appeared in great distress. The wound was on the left side, about two inches above the ilium, and communicated with the cavity of the ab- domen ; but neither its direction nor depth could be ascertained. His body was cold, his pulse scarcely perceptible, but he had not apparently lost much blood. A portion of omentum, about 3ij in weight, protruded through the opening, this was cut off. A purgative enema was throAvn up, which procured a motion, without any appearance of blood. He drank freely of coltsfoot tea, and took his medicines; the fluids produced nausea, and attempts to vomit, but 174 he did not eject any thing from the stomach. The breathing was at first slow, but free, by degrees it became more oppressed, and at length grew ex- tremely quick and laborious, attended with a sense of weight on the right side of the thorax, which threatened suffocation. The expectoration was not bloody. Soon after the injury he began to complain of a pain in the chest, and at the pit of the stomach, which gradually increased, and towards midnight became almost insufferable. The upper part of the thorax had swelled a little, and the motion of the right arm much increased his sufferings. This tume- faction gradually augmented, and at eleven o'clock had reached the head and face ; it subsequently ex- tended all over the body before his death, which took place a little after two o'clock in the morning, apparently from strangulation. He retained his senses to the last minute. " On examining the body twelve hours after death, the following appearances were discovered:— " The triangular Avound from the bayonet, was seated on the left side, midway between the spine and the linea alba, having the last rib and the crista of the ilium at equal distances above and below it, it readily admitted the point of the finger. A por- tion of omentum still protruded, and appeared gan- grenous. The direction of the wound was oblique- ly upwards and inwards, and had penetrated the fol- lowing parts:—the integument, abdominal muscles, peritoneum, the colon near its termination in the rectum, again at its arch; the stomach inferiorly, two inches from the pylorus, and superiorly, under the left lobe of the liver, which was also wounded; the diaphragm in the centre of the tendon; after this the pericardium; the right ventricle of the heart in two places, first the inferior part, and again near the tricurped valve; next the lungs were 175 pierced; and last the anterior parietes of the right side of the thorax, between the cartilages of the second and third ribs, terminating in the substance of the pectoral muscle. The abdomen contained a little bloody serum; the pericardium a small quan- tity of blood; but the right cavity of the pleura had about two quarts of blood within it. "Although so many parts of importance Avere in- jured, but little was indicated of the extent of mis- chief from the symptoms which occurred during life. Thus the colon was twice perforated, but the stools were not tinged with blood, nor was there any foeculent matter in the cavity of the peritoneum. The stomach was also twice wounded, and yet vomiting did not take place, excepting once slightly, as he Avas brought to the hospital. The liver Avas opened to the extent of one inch, but yielded scarce- ly any haemorrhage. The heart had been pierced in two places, but yet its action continued regular, and supported circulation for above nine hours. The middle and upper lobes of the right lung were both wounded; yet he did not cough up any blood. The emphysema had originated under the pectoral muscle, and had gradually extended over the whole body." Wounds of the Throat. Parts injured.—Attempts to commit the act of suicide are the usual causes of these injuries, and usually one of the following parts suffer:—The pha- rynx, the larynx, the trachea, or the oesophagus. Description of parts.—If the chin be a little ele- vated, its distance from the sternum is about nine inches. First. Three inches below is the thyroid cartilage, and the space has the muscles of the os hyoides and tongue on the fore part. Second. In 176 the middle division is the larynx, with the pharynx behind it. Third. In the loAver part is the tracnea before, and the oesophagus behind. On the sides of these parts are situated the carotid arteries, which are divided near the os hyoides. The internal jugu- lar veins are also placed laterally. The pars vaga accompany the carotid arteries, and the grand sym- pathetic nerves are found somewhat nearer the ver- tebrae. Of the Wound above the Larynx. This is the most frequent seat of injury, which is inflicted whilst the chin is elevated. Symptoms.—Through the Avound, air and blood issue with frightful impetuosity, more especially when the patient coughs. A lighted candle brought near the aperture is immediately bloAvn out, and liquids, when attempted to be swallowed, are violently eject- ed from the wound. Hence, those ignorant of the structure of the parts, suppose that the air tube is injured, but the anatomist is aware that the wound has passed through the muscles of thejaw and tongue into the pharynx, being generally inflicted betAveen the chin and os hyoides. Arteries wounded.—The arteries Avhich bleed free- ly, are the sublingual, that pass just above the os hyoides on each side to the tongue; but sometimes the external carotid arteries are divided, Avhen, from the rapid haemorrhage, death is almost immediate. Treatment. The wound is generally in itself but little danger- ous ; and when persons die shortly after its infliction, it is frequently from the fever Avhich has led to the commission of the act, if it be not from haemorrhage. 177 Position.—Position in this wound is to be carefully attended to. If the chin be elevated, the wound gapes Avidely; but when the chin is depressed, the frightful aperture becomes closed; the head should therefore be brought down towards the chest, and confined in that position, in order to prevent a sepa- ration of the edges of the Avound. Sutures.—I have generally put three sutures in the integument only, the more effectually to guard ao-ainst any disturbance of the approximated edges, which may otherwise, from the constant motion of the pa- tient during irritability or delirium, be produced. Such sutures, through the integument only, are in this respect very useful, and are not ever disadvan- tageous. Enema.—The patient's mouth and tongue should be kept cool and moist, by the application of a por- tion of lemon dipped in water; but he should be chiefly supported by clysters of broth and gruel, to which opium should be added if they quickly return ; and when the fever has subsided, the addition of port wine should be made. I knew a lady who had a stricture in her oesopha- gus, who Avas supported forty-five days by clysters of broth and Avine, when she could not swallow even a drop of water. When food is given by the mouth, a small quanti- ty of solid matter excites less irritation than fluid; and a small portion of jelly is the best. The sutures should be removed in a week, and adhesive plaister be substituted for them. When the Avound is situated beloAV the os hyoides, as it sometimes is, the epiglottis is injured at its junc- tion with the thyroid cartilage. In a case of this kind to which I Avas called at Walworth, I put a thread through the frcenum, on the dorsum of the epiglottis, and fixed it again to the 23 178 thyroid cartilage. The man recovered; but whe- ther it was a post hoc, or a propter hoc, God knows! In general, these cases are fatal, in which the epi- glottis is separated from the thyroid cartilage, from a want of defence to the air tube. Of the Wound into the Larynx. Symptoms.—This wound is either into the thyroid or cricoid cartilages, or into the ligament which unites them. The air rushes out through the wound in expira- tion, and violently in coughing, and is also inspired through it. The person is not able to speak, unless the aperture be closed by pressure ; but the food does not pass out from it. A wound confined to the cartilages of the larynx, or to the ligament uniting them, is not dangerous, and by far the greater number of these cases, which I have seen, have done well. The treatment of them consists in approximation of the parts by posi- tion, and in the application of adhesive plaister to retain the edges in contact. When the wound is inflicted with excessive vio- lence, or by a stab, the pharynx may be Avounded, as it is situated behind the larynx, and then the treat- ment of the wound is to be similar to that of the wound above the larynx. Cases.—In a case of this nature, which was under the care of Dr. LudloAV, of Calne, he informed me that the thyroid cartilage, which was many Aveeks in healing, became ossified, and that portions of it exfo- liated. In a patient of mine in Guy's Hospital, the wound upon the thyroid cartilage remained fistulous, and I raised a piece of skin from the surface of the neck, above the opening, and turned it over the opening, 179 the edges of which I had previously pared: it united extremely well. Of the Wound below the Larynx. When the wound is inflicted within three inches of the sternum, it is more dangerous than in any other situation. The trachea is here on the fore part, the oesophagus behind, and the carotid arteries are si- tuated close to the trachea, more especially the right. The thyroid gland crosses the upper part of the trachea, and its veins cover the fore part. Symptoms.—If the trachea be cut, the air rushes through the Avound both in expiration and inspira- tion. The blood gets into the trachea, and excites a violent coughing, by which a bloody froth is for- cibly ejected, but the food or liquids do not pass out through the aperture. The external opening, in these cases, is generally small, as the wound often arises from a stab, and the consequence is, that the blood does not freely escape, but, lodging in the bronchia, adds excessively to the dyspnoea. Treatment.—In the treatment, the first object is to stop the bleeding; and if the Avound be not suf- ficiently large to lead to the easy discovery of the source of the haemorrhage, an incision should be made, in a longitudinal direction, to expose the mouths of the vessels. If the trachea be Avidely opened, pass a needle and ligature through the cellular tis- sue, upon its surface, Avhich, from its firmness, will support the ligature, and thus bring the edges of the aperture into contact; but do not penetrate the trachea itself Avith the needle. Thus securing the trachea, bring the edges of the external wound to- gether by bending the head fonvards; but do not apply adhesive plaister, as it prevents the escape of 180 air and blood in coughing, produces additional difficul- ty of breathing, and occasions emphysema. The ligature upon the cellular covering of the trachea, is to be separated by the ulcerative process, which will generally be effected in a week. A transverse wound in the trachea, will be follow- ed sometimes by a loss of voice, on account of the di- vision of the recurrent nerves. If one of the carotid arteries be opened, death is usually so instantaneous, that the patient cannot be saved. If a surgeon were present, or the wound was very small, and he could reach the patient be- fore he expired, he should thrust his finger into the wound, to stop the flow of blood, and then cut down upon the vessel, to expose it sufficiently, to place a ligature upon it, Avhich he can aftenvards better ad- just.* When the trachea is deeply cut, the oesophagus is sometimes Avounded; and, if the injury be exten- sive, death Avill generally ensue; but a stab into the oesophagus, or a small wound, may be recovered from. After an injury of this kind, the Avound into the trachea is to be treated as in the former instance, but which that in the oesophagus will be best approxi- mated ; all food, liquid or solid, must be avoided, and the patient is to be supported, as long as nature can bear it, by clysters. I object entirely to the intro- duction of tubes into the pharynx and oesophagus, as worse than unnecessary; for they are highly inju- rious by the cough Avhich they occasion, by their irritating the wound ; and, if adhesion or granulation have taken place to close the wound, such tubes tear it open again and destroy the process of restora- tion. * See case of wounded carotid. 181 LECTURE XL. Of Wounds of Joints. These accidents are but trivial, or very dangerous, as the surgeon is directed by proper principles, or is ignorant of the treatment which they require. Improper treatment.—If the patient has a poultice applied, or if the utmost attention be not paid to the immediate closure of the Avound, inflammation of the synovial membrane arises, and suppuration ensues. The most violent constitutional irritation succeeds,— shivering, heat, flushing, and profuse perspiration; generally, great swelling and excessive pain in the joint. Abscesses form in different parts of the joint, one succeeding another, until the strength becomes exhausted. In young or old persons.—In young and healthy constitutions, these Avounds in the largest joints are recovered from;' but, in aged and weak persons, they destroy life. Dissection of.—Upon dissection in the first stage, suppurative inflammation of the synovial membrane is found; in the second stage, the ligaments of the joint are thickened* and the synovial membrane in part ulcerated, in part granulating. The cartilages are absorbed; granulations arising from some parts of the bones, and exfoliation taken place from other portions. Anchylosis.—Recovery from these injuries, when inflammation has followed, is by adhesion, so as to destroy the synovial surface; or else by granulation, 182 when a partial or general ossific anchylosis is the result. Treatment.—All these effects may be prevented by an intelligent surgeon. When called to treat a Avound of from one to two inches extent into the knee joint, he will, with a fine needle and thread, passed through the skin only, (avoiding the ligaments,) bring the edges of the external Avound together; for a wound in the joint is different to most others, as the synovia has a constant tendency to force a passage outwards, and it is more abundantly secreted than usual, so that adhesive plaister is apt to be separated, and union prevented ; he will apply, therefore, lint dip- ped in blood over the surface of the AVound,and place the plaister over it; then cover the surface of the knee with soft linen, dipped into a lotion of the liquor : plumbi subacet : and spirit. Afterwards he will place a splint behind the limb to prevent all motion of the injured joint, and enjoin positive rest. Purgatives should be as much as possible avoided, and a rigid abstinence enforced. In eight days, the threads may be cut and drawn away, but the adhe- sive plaister and lotion should be continued. Three weeks should elapse before the patient be alloAved to quit the bed. If inflammation follow a wound into a joint, leeches and an evaporating lotion must be employed ; and if it run high, the patient should be bled freely from the arm. If suppuration be produced, fomentations and poul- tices are required locally; liquor : ammoniae acet: and opium internally. A fungous granulation forms at the wound, which must not be disturbed, as it is formed by nature to close the aperture ; fresh irritation is produced by disturbing it. When a limb is stiff from inflammation and adhe- 183 sion, early motion of the joint is required, and its use may generally be restored. A joint thus circum- stanced is not injured, but benefited by motion, whilst in a chronic or scrofulous inflammation of a joint, rest is most essential to its cure. In this case, there- fore, a patient should not only use the limb in com- mon exercise, but he should set upon a high table, and employ the muscles, for some length of time at once, in flexing and extending the limb. Partial anchylosis, when the joint is not altered in form, may, in young persons, be considerably re- lieved. Where ossific granulations have arisen from every part of the surface, permanent and complete anchy- losis must be the result. Removal of loose cartilages.—In removing loose cartilages from joints, it is proper first to draw down the skin to render the aperture afterwards valvular. The cartilage is fixed by an assistant, an incision is made over it, after the skin has been drawn an inch to one side, then as soon as the surface of the carti- lage is well exposed it jumps from its situation, the skin is let go, and then no direct opening remains communicating with the joint. The after treatment is the same as in simple in- cised wounds, only a suture is not required. Wounds of Tendons. Tendo achillis.—The division of the tendo achillis is most frequently occasioned by a Avound from an adze, and sometimes the injury arises from accident with a scythe. Effects of.—In Avhatever way it is produced, the immediate effect of the division of the tendon is a great separation of its divided portions, the upper one being drawn up by the action of the gastrocne- 9 184 mei, and a falling of the heel, the foot being influ- enced by opponent muscles. Sometimes the poste- rior tibial artery and nerve are also divided with the tendon ; where the surgeon should secure the former by a ligature as soon as possible, or else apply a tourniquet. Mischief of.—The mischief arising from this acci- dent depends in a great measure upon the treatment which may be adopted. If the edges of the wound be not approximated, and if the ends of the divided tendon are alloAved to remain at a distance from each other, inflammation arises, granulations are produced, and a union of the ends of the tendon takes place to the surrounding parts, destroying permanently the action of the muscles, and the motions of the tendon. But if the wound be united by adhesion, and the ends of the divided tendon brought into contact, or nearly so, the motions of the foot are generally re- stored. Treatment.—The principle in the treatment is to approximate the ends of the tendon by raising the heel, extending the foot, and bending the knee; the external Avound is then to be carefully closed, in or- der that it may be healed by the adhesive inflamma- tion. To effect this, a shoe with a heel one inch and a half in height is to be placed on the foot of the in- jured limb, and a strap is to be carried from the heel of the shoe, to the calf of the leg, then a roller is to be lightly applied upon the upper part of the leg, to confine the strap and to keep the foot extended. The edges of the external wound are to be brought together by a small suture, and all pressure at the part should be avoided, only an evaporating lotion be- ing placed upon it. The patient is to be confined to his bed until the wound be healed, and then he may be alloAved to Avalk a little with a high heeled shoe. This shoe is to have the heel gradually lowered until 185 it becomes of the same thickness as the heel of the shoe worn on the sound side. By this means, the muscle which had contracted, and the tendon Which had been injured are gently brought to their proper action. If the divided extremities of the tendon are allow- ed to remain separate during the union, an addition is made to the tendon in its length, and the power of the muscle acting upon it is thus reduced. Should much inflammation arise during the cure, the limb must be elevated to prevent all gravitation of blood, and leeches should be applied near the wound. Division of extensor tendons.—If the extensor ten- dons of the fingers be divided, the fingers should be kept extended during the cure, by a splint placed under the hand and fingers. Indeed it is only neces- sary to consider whether the divided tendon, in any case, belongs to a flexor or extensor muscle, to know Avhat is to be done to assist its union. Punctured Wounds of Tendons. Dangerous.—These are dangerous accidents, being often productive of tetanus. Several times within my knowledge, this has occurred from persons tread- ing upon a nail, which has penetrated the shoe, and wounded the tendinous aponeurosis of the sole of the foot; also an accident of a somewhat similar nature to the palm of the hand, I have seen productive of a similar effect. Tetanus.—Tetanus seems to be the result of a wound of a structure difficult to heal, and requiring great constitutional efforts to produce the effect; and these efforts in a very irritable constitution pro- duce the highest nervous excitement. Treatment.—In these injuries, I have observed that 24 186 it is best to foment and poultice the parts, so as to sooth and tranquillize them ; also to carefully avoid depletion, even from the first to any great extent, either locally or constitutionally. The patient should be allowed his common diet, and "if he be restless or complain of much pain in the wound, opium should be given. Lowering the patient only adds to his irritability. Of Laceration of Tendons. Of tendo achillis.—The tendo achillis, and some- times, but not so frequently, other tendons are torn through. This accident to the tendo achillis is produced either by a violent effort of the muscles as in jump- ing or dancing, or by an unexpected extension of the tendon ;—as for instance, by treading unawares with the toe only upon an elevated substance. Dr. Curry, late physician to Guy's Hospital, informed me that he tore his tendo achillis by catching his toes upon a scraper, Avhen walking in a dark street; being at the time unprepared for such an occurrence. Treatment.—In whatever way the accident may be produced, the treatment required will be to extend the foot, and bend the knee to allow the ends of the lacerated tendon to approximate. In this way the tendon soon unites by the adhesive process, and the use of the limb is afterwards gradually restored. Some degree of thickening of the tendon for a long time remains, and the patient halts a little in rapid motion. The position of the foot and leg is to be maintain- ed in the same way as when the tendon is divided by incision, and an evaporating lotion should be em- ployed. After the union, the same precautions are to be observed with respect to the employment of the high heeled shoe. 187 Of Partial Laceration of the Tendo Achillis and Gastrocnemius Muscle. Cause of.—A person in running or walking fast, or if his foot slips backAvards when it has been ad- vanced, sometimes feels as if he had received a se- vere bloAv upon the back of his leg, and is immedi- ately unable to Avalk, but with the greatest difficulty, and with the foot extended. The cause of this feeling is a laceration of some fibres of the tendo achillis, or of the gastrocnemius muscle, Avhere it joins the tendon. There is great tenderness upon pressure on the following day, with some ecchymosis, which daily increases, until the limb becomes considerably discoloured. The least attempt to bend the foot is accompanied with great pain, and folloAved by swelling of the leg and ankle. From a belief that the injury is slight, and from negligence in treating it, the lameness which results from this accident is often of very long continuance; but, if properly attended to from the first, it is in general soon recovered from. A similar treatment to that recommended for di- vision or laceration of the tendon, is requisite for the cure of this injury, and Avhen the patient can bend the foot Avithout producing pain, then the high heeled shoe must be worn, and the heel be grad- ually lowered, as in the previous cases. From three to six weeks are required to effect a cure. Of Wounds of the Nerves. Effect of.—The immediate effect of the division of a nerve of a limb, is the loss of volition in those muscles to Avhich the nerve is distributed, and the antagonist muscles being unopposed, gradually con- 188 tract. If the nerve supplying the flexors is divided, the limb becomes extended; if that distributed to the extensors is separated, the opponent muscles keep the extremity flexed. This arises from the tenden- cy a muscle possesses to occupy the smallest space possible, and which differs from voluntary or invol- untary contraction, as the latter can only continue for a time; but the former is permanent, or as long as the antagonist muscles are paralysed. The second effect of the division of a nerve is the diminution of sensibility ; I call it diminished, be- cause I do not find that the division of the branch of a nerve, although it benumbs the parts, entirely deprives them of sensation. In the division of the infra orbitar nerve, or of one of the nerves of the fingers, some sensation re- mains, but numbness is produced; when, however, all the nerves passing to an extremity are divided, sensation is entirely destroyed. Case.—I once saw a case, in which one of the branches of the median nerve was divided in the palm of the hand; and if pressure was made on the radio spiral nerve at the elbow, it produced a ting- ling sensation in the benumbed finger.* The temperature of the part to which the nerve is distributed, if it be covered so as to prevent the access of a colder medium, is greater than that of arts similarly covered ; but if it be left altogether are, it then has less power of resisting diminished temperature than the surrounding parts. I have seen severe chilblains, and, during the winter, in- curable ulceration folloAV the division of the median nerve. * It appears, therefore, as if nervous influence is supported in a degree by anastomosis. 189 Divided nerves unite.—When a nerve" has been divided, if its extremities are brought together, it unites, and the function of the nerve becomes grad- ually restored. Dr. Haighton's experiments.—Dr. Haighton divid- ed the pars vaga on one side of the neck of a dog, and, after some time, he cut through the nerve on the other side : the dog lived, Avhich he Avould not have done, had both the nerves been divided at the same time. When he had allowed time for the union of the second, he divided both at once, and the ani- mal died under the same circumstances as would have occurred, had no previous experiment been made. The time required for the union and restoration of function, appears to depend upon the size of the nerve. Cases.—A young gentleman Avho had injured the external condyle of the os humeri, had numbness in the direction of the radial nerve, and he recover- ed the sensibility of the parts in four months. The numbness sometimes produced by bleeding is recovered from in three months. In a fracture of the thigh bone, by which the sciatic nerve Avas injured, so as to produce numb- ness in the limb below, the person recovered in nine months. Koschiusko, the Polish ^General, had his sciatic nerve injured by a pike, and when in this country, many months after receiving the Avound, he had not got rid of the effects; and I have heard since, that he remained lame. At the place of union, after the division of a nerve, there is the appearance of a ganglion, as may be seen in a preparation I made from the finger of a person brought into the dissecting room at St. Thom- as's Hospital, a cicatrix covered the ganglion. 190 Independent of the size of a nerve, the time in which union will be complete, must also depend much on the position and approximation of the ends. Treatment.—In the treatment of a wounded nerve, the only objects are the approximation of its ends and union by adhesion. Many bad symptoms have been attributed to the partial division of a nerve; but I have, in part, cut through the sciatic nerve of a dog, without produc- ing any other symptom than partial paralysis. Cases.—I removed from the median nerve, a tu- mour for a gentleman, and took away two thirds of the nerve with it, and numbness with tingling Avere the only unpleasant symptoms following.. A Mr. H. called at my house, who had a partial division of the median nerve, affecting the fore, mid- dle, and ring fingers, but not the thumb; he had tingling with the numbness, but no other bad symp- tom. A nerve divided in part, therefore, occasions ting- ling and numbness ; one completely separated, only numbness ; the treatment of the former is as that of the latter. Ligature on a nerve.—If a ligature be applied upon a nerve of magnitude, the consequences are some- times fatal, and sometimes productive of lingering suffering. Cases.—Mr. Cline informed me, that in a case of popliteal aneurism, operated upon in the old way, by opening the tumour in the ham, the popliteal nerve was included in the ligature with the artery, and that the man died in a few hours. In a case of amputation at Guy's Hospital, I saw the whole sciatic nerve included in a ligature, which was applied to suppress haemorrhage from the ar- tery which accompanies the nerve. In four days, the man was seized with violent spasms in the stump. 191 On the fifth day, spasms affected the limb, and from thence extended to the other muscles of the body. On the seventh day, he died. If a nerve be included in a ligature, Avhen tying an artery, the process of ulceration is extremely sIoav, and the slightest drawing of the ligature pro- duces agonizing pain. Lord Nelson suffered excessively from this cause after his limb had been amputated ; and with all his heroism, he could not bear the least touch of the ligature, without uttering the most violent expres- sions. After amputation, then it is right to avoid, with the greatest circumspection, any nerve, or portion of a nerve, in placing the ligatures on the vessels. The division of a nerve, or even pressure upon the spinal marrow, so as to destroy volition and sen- sation, does not prevent the involuntary action of the limb or limbs from proceeding. The circula- tion still proceeds, and the irritability of the part remains as is shown in the application of a blister, Avhich produces the usual vesication; also, a Avound heals by the adhesive process. Friction and electricity seem to have some influ- ence in restoring action in a divided nerve, or of one which has partially lost its power from any other cause. Pressure upon a nerve, occasions the sensation of a part being asleep; striking the cubital nerve at the elbow, occasions violent tingling in the little fin- ger, and half the ring finger. Of Sprains. Definition.—A sprain is an injury occurring to the ligaments or tendons surrounding a joint, which are either forcibly stretched or lacerated. How produced.—It usually happens from the sud- 192 den extension of the joint in a direction Avhich the muscles are unprepared for; in the same manner as when a dislocation is produced, only that the vio- lence is not sufiicient to occasion a displacement of the bones. Common seat of.—The most common situations of these accidents are either at the wrist or ankle, aris- ing from sudden falls, by which joints are unexpect- edly and forcibly bent. Symptoms.—These injuries are attended with con- siderable pain at the time of the accident, and the part soon becomes SAVollen and tender; the former symptom arises from the effusion of blood in the first instance, out of the lacerated blood vessels, and be- comes subsequently much increased from inflamma- tion ; the tenderness and pain are generally in pro- portion to the tumefaction. At first the surface of the skin presents its natu- ral appearance, but after a short time, as the effus- ed blood coagulates, it becomes much discoloured. Sensation of crepitus.—When inflammation has been set up, and given rise to effusion of fibrin, a sensation of crepitus is experienced on examining the injured part, Avhich might, by an ignorant surgeon, be mistaken for the crepitus of fractured bone ; but it never gives that distinct grating feel which occurs from the rubbing of one portion of broken bone upon another. Motion of joint destroyed.—Immediately after the receipt of the injury, the ordinary motions of the joints can be readily performed; but as the swelling takes place, these motions become much impeded, and ultimately cannot be performed Avithout pro- ducing acute pain, and increasing the mischief. Treatment.—In the treatment of these cases, the first object is to arrest the haemorrhage from the lacerated vessels, and then to prevent the occur- rence of severe inflammation; afterwards to pro- 193 mote the absorption of the effused matter, and sub- sequently to restore the motions of the injured parts. Cold and position,—In the first instance, the ap- plication of cold by means of evaporating lotions, and attention to the position of the limb, will effect much in arresting the effusion, and preArenting acute inflammation. The position should be such as to relax those muscles which act on the injured ten- dons, and at the same time such as will favour the return of blood to the heart. Bleeding.—Should the pain and tumefaction in- crease in spite of these means, leeches should be freely employed over the seat of mischief, and the bleeding encouraged by tepid applications; purga- tives should also be administered; and in very robust persons, Avhen the injury is extensive, general blood letting, and other constitutional remedies must be had recourse to. After effects.—When the inflammation is subdued, and the patient is free from pain, still the surgeon has much to do in effecting the absorption of the effused matter, and this he should be careful to re- move, as it is from neglecting this stage of the injury that other and more important disease originates, this more particularly in persons suffering from any constitutional disease, as in those affected with scro- fula. In healthy persons.—In persons free from consti- tutional disease, these injuries, if not very extensive, are rapidly recovered from; the effusion quickly subsides, and the motions of the joint are restored ; but in no case should the patient be allowed to ex- ercise the part as usual, until all pain has ceased, and the part has nearly regained its original form. Too early motion.—By a too early use of the part, the effects of the injury are kept up, so that weeks, months, or even years may elapse ; and the 25 194 patient still suffer from them; Avhereas a little more attention to the disease in the first instance, would have completely removed all the suffering and danger. In unhealthy persons.—In persons suffering from constitutional disease, a chronic form of inflamma- tion is often set up, which terminates in suppuration, and often affects the bones, which become carious, and make it necessary for the surgeon to remove the diseased part by amputation, in order to save the patient's life. Therefore, after the acute symptoms have been removed, be careful to get rid of all the effects of the injury before the patient be allowed to employ the limb, as previous to thfe accident. Treatment of chronic stage.—Rest, position, and the use of mild stimulants, with friction and mode- rate pressure, are the best means of producing the desired effect. The liniment: ammoniae; liniment: hydrargyri; liniment: saponis, may either of them be rubbed over the affected part, night and morn- ing, afterwards making pressure by the application of a roller ; or the part may be enveloped in strips of one of the folloAving plaisters :—Empl: ammon: —Empl: ammon : c hydrarg: Empl: Galbani, over which the roller should be placed. I have also known good effects produced from the pouring a continued stream of cold water on the part from a pump or large pitcher. Should the disease prove obstinate, and be at- tended Avith occasional pain, the aid of counter ir- ritation may with great advantage be produced, either in the form of blister, or the Ung: Antimon: Tartarizat: I have known many cases quickly cured by these means. Exercise.—When the marks of disease have been removed, the motions of the parts should be pro- moted by moderate, but regular exercise. 195 LECTURE XLI. On Dislocations. Definition.—A dislocation is the displacement of the articulatory part of a bone, from the surface on which it was naturally received. I shall first make some general observations on these accidents, and afterwards describe the par- ticular dislocations. Require immediate assistance.—There are few ac- cidents to Avhich the human body is liable, that are more likely to endanger the reputation of the sur- geon, than dislocations, as the restoration of the in- jured parts depends very much upon his decision and immediate assistance ; for, if much time escape before the parts are restored to their natural posi- tions, the reduction is rendered proportionably diffi- cult, and may become perfectly impracticable; when the patient becomes a living memorial of the sur- geon's ignorance. Consequences of neglect.—I have known several instances in which the Avant of professional know- ledge or inattention, on the part of the surgeon, to these accidents, has been the occasion of irrecover- able deformity in his patient, and of the loss of his own professional character. Anatomical knowledge requisite.—An accurate know- ledge of the anatomy of the joints is necessary, to enable the surgeon readily to detect the nature of many dislocations, as also to adopt the best means of reducing them. Let me, therefore, entreat you to examine and study well the structure of the different 196 joints, the forms of articulation, the bones and carti- lages composing them, the ligaments connecting them, and the action of the muscles moving them ; as, Avith- out this knowledge, you cannot practice your pro- fession Avith credit to yourselves, or to the advantage of those Avho may come under your care. I have known a case of fracture of the neck of the thigh bone treated as a dislocation, and the pul- leys applied to the limb, by a hospital surgeon, who was deficient in anatomical knowledge. Sometimes difficult to detect.—In some cases, how- ever, so much tumefaction arises from extravasation of blood, or the parts become so tense from the effu- sion, in consequence of inflammation, that the best surgeon will not be able exactly to ascertain the pre- cise nature of the injury during the first few days af- ter its receipt; it would be, therefore, extremely il- liberal and unjust to attribute ignorance to a surgeon who might have given an incorrect opinion under such circumstances. Immediate effects.'—The immediate effects of a dis- location are, to produce an alteration in the form of the joint, in the length and ordinary position of the limb; also, after a short time, when the muscles have contracted, to destroy the motions of the joint. At first, much motion.—Case.—In the first few minutes, however, after the injury, the degree of motion is considerable, which I had an excellent op- portunity of seeing in a patient brought to Guy's Hospital, with a dislocation of the thigh bone into the foramen ovale, which had occurred only a few minutes before his admission. The nature of the injury Avas extremely Avell marked, only there was great mobility of the limb at first, but in less than three hours it became firmly fixed by the contrac- tion of the muscles. Limb lengthened or shortened.—In dislocation of the 197 extremities, the limb is usually shortened; but when the femur is displaced into the foramen ovale, or the humerus into the axilla, the limbs are lengthened. Pain,—A dull pain is felt from the pressure of the dislocated bone upon the muscles, but the pain is sometimes severe when the bone rests upon a large nerve or nerves, as when the femur is dislocated into the ischiatic notch, or the humerus into the axilla; and, from the same cause, numbness and a partial paralysis of the limb are also produced. Vessels injured.—The large blood vessels also, occasionally, receive much injury from these acci- dents. I have knoAvn the subclavian artery so much compressed by a dislocation of the sternal extremity of the clavicle backAvards, as to stop completely the pulsation at the wrist. In another case, the axillary artery Avas so much injured by a dislocation of the humerus into the axilla, as to give rise to aneurism, for the cure of which the subclavian artery Avas tied. Head of bone felt.—If there be not much extrava- sation or effusion, the head of the displaced bone may be easily discovered in its new situation, and may be distinctly felt to roll, if the limb be rotated. In some instances, the usual prominence of the joint is lost, as when the humerus is dislocated into the axilla, or an unnatural projection occurs, as in dis- locations of the elbow. Remote effects.—The remote effects of these in- juries are,—First. The sensation of crepitus, which occurs a day or tAvo after the accident, from the effusion of fibrin into the joint or bursoe, although it does not give that grating feel Avhich arises from the motion of the fractured ends of a bone upon each other; yet, I have knoAvn medical men, not aware of this circumstance, suspect a fracture Avhen none existed. Inflammation.—In general, the degree of inflamma- 198 tion arising from these injuries is very slight. Some- times, however, it is considerable, causing, together with the extravasation, great tumefaction of the sur- rounding parts, and rendering it difficult to ascertain the nature of the injury. I have knoAvn, in a few instances, so high a degree of inflammation to follow the receipt of these injuries, as to destroy the pa- tient. Case.—A master of a ship who had dislocated his thigh upwards, a few days after its reduction, had extensive suppurative inflammation take place in the thigh, under which he sunk. Mr. Howden, a surgeon in the army, has given the history of a somewhat similar case to the Physical Society of Guy's Hospital. Dissection of parts.—On dissecting the injured parts in those who die shortly after a dislocation from vio- lence, the capsular ligament is found torn transverse- ly to a great extent, and the peculiar ligaments of the joint are also ruptured, the head of the bone being removed from its socket. In dislocations of the hip, I believe the ligamen- tum teres is always torn through, or separated from its attachment, sometimes with a piece of cartilage, or even of bone. When the humerus is dislocated, however, the tendon of the biceps, which answers the purpose of a ligament, is, as far as I have had an opportunity of witnessing, uninjured,—although I do not mean to deny the possibility of its being ruptured. Tendons and muscles injured.—The muscles and ten- dons surrounding the joint are frequently much injur- ed, as for instance, the tendon of the subscapularis muscle, when the head of the humerus is displaced into the axilla, or the pectineus and adductor brevis muscles, in dislocation of the femur into the foramen ovale. 199 When unreduced.—When a dislocation has remain- ed unreduced for a length of time, some degree of motion is gradually restored, but the power and mo- bility of the limb are never completely regained ; and, in the dislocations of the thigh, the patient is ever after lame. Dissection of—In dissecting cases of this kind, the head of the bone is found much altered in figure; this alteration, hoAvever, does not depend very much upon the length of time that the bone has been dis- placed, but more upon the structure which the head of the bone presses on, whether bone or muscle. If the bone rests on muscle.—If it rest upon muscle, the bone undergoes but little change, its articular cartilage remains, and a new capsular ligament forms around it, from the thickening and condensation of the surrounding cellular tissue. If on bone.—If, on the contrary, it presses upon bone, an extraordinary change is produced, both in the head of the dislocated bone, and in the osseous surface on Avhich it rests. The articular cartilage becomes absorbed from the dislocated extremity, and the periosteum of the bone on which it presses is removed in the same manner, so that a smooth hol- low surface is formed, to which the head of the dis- placed bone becomes adapted. At the same time that the holloAv is formed at that part on Avhich the head of the dislocated bone immediately presses, a deposite takes place from the surrounding periosteum, betAveen it and the surface it naturally covers, by which a ridge or lip is produced, forming with the depression a deep cup to receive the head of the bone ; also, the tendons or muscles which were lace- rated, are united, and the latter accommodate them- selves to their altered positions, so that, by a beau- tiful and gradual change in the injured parts, a new articulation is established. 200 On account of the great change which thus occurs Avhen a dislocation has remained unreduced for a length of time, it becomes impossible to restore the bone to its original position, and after the expiration of many weeks, such an attempt Avould not only be absurd, but attended with much risk to the patient. Case.—In an attempt to reduce a dislocation of the humerus, Avhich had existed only six Aveeks, so much injury was done to the muscles by the violence employed, that the patient died in consequence. Dislocation from effusion.—But although disloca- tions are generally occasioned by violence, and are accompanied by laceration of the ligaments, yet they occasionally arise from relaxation of the liga- ments only, the result usually of a morbid accumula- tion of synovia in the joint. Of patella.—I have seen the patella frequently displaced from this cause ; and, in the year 1810, 1 admitted a girl into Guy's Hospital, who Avas the sub- ject of such dislocation. The patella was suddenly and frequently thrown outwTards in Avalking, which occasioned her to fall, and it required considerable force to reduce it. By the application of some strips of plaister, and a bandage, the bone was readily kept in its proper situation. Case.—I once saAV a girl who had the power of throwing the patella outwards at will,—she had been brought up as a dancer or tumbler. From paralysis.—The loss of power in muscles surrounding a joint, either from paralysis, or from being kept a long time upon the stretch, allow of the joint being easily dislocated; but, under such circumstances, the reduction is effected Avithout dif- ficulty. Cases.—A young gentleman who had become pa- ralytic on one side during dentition, would readily dislocate the head of the humerus, throwing it over 201 the posterior edge of the glenoid cavity, from whence it could be replaced with facility. The loss of muscular power, arising from conti- nued extension, is well illustrated by the following case :— Case.—A junior officer, on board of one of the Company's ships in India, was punished by one of the mates, during the absence of the captain, in the following manner:—His foot Avas placed upon a small projection on the deck, and his arm was tied and forcibly drawn toward the yard of the ship; in this position he was kept for one hour. After this, the muscles of the arm gradually wasted, and the bone could be dislocated merely by his raising the extre- mity to his head, but was easily replaced by slight extension. Muscles prevent dislocation.—These cases prove also, that the muscles in a healthy state must have considerable influence in preventing displacement from violence, as also of resisting the reduction when dislocation has occurred. From ulceration.—Another more frequent cause of dislocation, is ulceration, by which the attach- ments of the ligaments are destroyed, when displace- ment of the joint takes place, either from the action of the muscles, or from there not being sufficient sup- port to counteract the weight of the bone. Thus, in long continued ulcerative disease of the hip joint, we find the head of the femur drawn up on the dor- sum of the ilium; and, in the same affection of the knee, I have seen the tibia sink off the condyles of the femur. Case.—There is in the Museum at St. Thomas's Hospital, a preparation, showing an anchylosis of the tibia, at right angles with the fernur, after a disloca- tion from ulceration. Dislocation with fracture.—It frequently happens 26 202 that a fracture occurs at the same time with a dis- location ; this is more especially the case in the dis- placements of the ankle joint, which seldom take place without fracture. The acetabulum is -some- times broken in dislocations of the hip, and the coro- noid process of the ulna is occasionally separated when that bone is dislocated, which renders it scarce- ly possible for the surgeon to preserve the parts in their natural position during the treatment. Case.—A preparation in St. Thomas's Museum, shows a fracture of the head of the humerus, occur- ring with displacement. Treatment.—When dislocation and fracture of a bone occur at the same time, the dislocation should, if possible, be reduced immediately, taking care to prevent further injury to the fractured part, by the application of bandages and splints. For, if the frac- tured bone be allowed to unite before attempting to replace the dislocation, such union Avould most prob- ably be destroyed by the additional violence neces- sary to reduce the bone, after having remained so long out of its natural situation. So also, if a bone in one limb is dislocated, and in another fractured, the dislocation should be reduc- ed as soon as the fractured bone has been support- ed and secured from injury. Dislocations not complete.—Dislocations are not al- ways complete; but in some instances a partial dis- placement of an articulating surface occurs. A pre- paration in St. Thomas's Museum, dissected by Mr. Tyrrell, shows an imperfect dislocation of the ankle; the end of the tibia rests still in part upon the astra- galus, but the greatest portion is seated on the os naviculare. Of the knee.—The knee joint, on account of the extensive articular surfaces, is seldom completely displaced. 203 Of the humerus.---The humerus is sometimes thrown upon the anterior edge of the glenoid cavity, but is easily replaced. Of-the elbow.—The elboAV joint is liable to partial displacement, both of the ulna and radius. Supposed dislocation of vertebras.—The injuries to the spine, Avhich are sometimes called dislocations, and are producing paralysis of the part of the body below the seat of mischief, are really fractures Avith displacement of the broken bone. Simple disloca- tion of the vertebrae, I believe to be an exceedingly rare accident, if we except that which is said to oc- cur sometimes between the first and second cervical vertebrae. Causes, violence.—Violence is usually the cause of dislocations, and is generally applied unexpectedly, when the muscles are not prepared for resistance, and when the bone is in an oblique position with re- spect to its socket. Under these circumstances, very slight force will produce the displacement which could not otherwise be occasioned, but by great violence. Execution of Damien.—The power of the muscles in resisting excessive force, when prepared for its application, is well illustrated by what occurred in the execution of Damien, for an attempt to murder Louis the XVth. Four young horses Avere fixed, one to each limb, and were then compelled to draw in different directions, for the purpose of tearing the limbs from his body; but this could not be effected, and after fifty minutes trial, the executioners Avere obliged to cut through the muscles and ligaments, before the limbs could be separated. Dislocation rare in old persons.—Old persons are much less liable to dislocations than those of a mid- dle age, as from the difference in the, firmness of their bones, those of the former are much more easily broken than displaced. 204 In very young.—In very young persons also, dislo- cations are rare, as the bones break, or the epiphy- ses give way under the violence Avhich would other- wise displace them. I have, however, known an in- stance of dislocation in a child of seven years of age. Displacement often occurs in children from ulcera- tion, as I have already described, and is most fre- quent at the hip joint. I have seen several cases X I v . /* l 11 which have been supposed dislocations of the elbow joint in children, but were really oblique fractures of the condyles of the humerus, in which one or both bones of the fore-arm were drawn backwards with the portion of the condyle. Compound dislocation.—In a compound dislocation, besides the displacement of the articulating surfaces, the cavity of the joint is opened by a division of the exterior soft parts, as the integument, capsular liga- ment, &c. so that the synovia escapes through the wound. Danger of.—This injury is usually attended with considerable danger, on account of the inflammation which occurs in the synovial membrane, and lacerat- ed ligaments; the former being of the mucous kind, quickly takes on the suppurative inflammation, and thus a profuse discharge rapidly ensues. The ar- ticular cartilages covering the extremities of the bones are gradually destroyed by an ulcerative process, and the bone inflames; granulations are throAvn out from the extremities denuded of cartilage, so as to fill up the cavity. Generally these granulations unite, and become ossified, producing anchylosis, but occasionally some degree of motion is gradually re- gained. Often require amputation.—To effect all this, great constitutional powers are necessary, and per- sons naturally weak are often, under these circum- stances, obliged to submit to the removal of the limb to preserve life. 205 Rare in some joints.—Compound dislocation occurs but very rarely in some joints, as the hip, shoulder, and knee ; but is often met with in the ankle, elbow, and wrist. Judicious treatment.—Much may be done in these cases by judicious treatment in the first instance, when the object should be to promote adhesions of the external wound, and thus render the dislocation simple. Instead of applying emollients, therefore, to encourage suppuration, Avhich is productive of so much mischief, the edges of the wound should be carefully approximated by strips of plaister, and evaporating lotions should be applied over the limb, which should be left undisturbed for several days. I shall, hoAvever, enter more fully into the treat- ment of these injuries, Avhen describing the particu- lar dislocations. Treatment of Simple Dislocations. Reduction.—The first and principal object is the reduction of the dislocated bone, Avhich I have men- tioned, becoming difficult in proportion to the time allowed to escape after the receipt of the injury. Difficulty increases as time elapses.—If the muscular power be great, great force will be required to over- come the contraction of the muscles, and this diffi- culty will increase in proportion to the length of time allowed to pass by between the injury and the attempt to reduce the dislocation. In very muscular persons, therefore, no endeavour should be made to reduce a dislocation of the arm, after a lapse of three months from the receipt of the injury; but in per- sons with little muscular power, reduction may be effected before the expiration of four months after the accident. In displacement of the thigh, two months in stout persons, and a few days more in those of relaxed fibre may be allowed as the period 206 lifter which it would be wrong to employ violent means to endeavour to reduce the dislocation. From contraction of muscles.—The difficulty in re- ducing dislocations is chiefly owing to the contraction of the-muscles, which is involuntary, and Avhich be- comes greater in proportion to the length of time which has elapsed after the injury. The muscles have a power of contraction independent of the voluntary or involuntary action, which are common to them, and the former of which cannot be main- tained but for a very limitetl period. Effect on muscles.—When the poAver of a muscle is destroyed, the antagonist muscle immediately con- tracts, and this contraction is permanent, or as long as the power of the other muscle is wanting. This may be seen in those persons who have suffered from paralysis of the muscles on one side of the face, the opposite side being draAvn up and disfigured by the contraction of the opposing muscles. In the same way when a dislocation has taken place, the muscles soon contract and fix the bone in its new position, and this contraction becomes firmer and more difficult to overcome, the longer the time al- lowed to elapse before any attempt be made to re- place the bone. The reduction should therefore be made as soon as possible after the receipt of the injury. Other causes creating difficulties.—But independent of the muscular contraction, other circumstances give rise to difficulty in attempting to reduce a disloca- tion of long standing, and often render the reduc- tion impracticable. The head of the bone becomes adherent to the surrounding parts, so that when the muscles have been divided in dissecting the injured joint, the bone cannot be replaced ; this I have ob- served in the dislocation of the humerus, and also of the radius. After a time the original cavity be- 207 comes filled with new matter, and sometimes a new articular socket is formed for the head of the dislo- cated bone; under these circumstances the possi- bility of the reduction is destroyed. Form of joints.—In recent dislocations, the form of the joint may in some instances afford an obstacle to the reduction; as, Avhen the articular cavity is surrounded by a projecting edge as in the hip, in which case the head of the bone requires to be lifted over the edge when reducing the displacement. If the head of the bone be much larger than its cervix, as in the radius, it affords an impediment to the reduction. Capsular ligament.—Some persons have supposed that the return of a dislocated bone to its natural position, might be impeded by the smallness of the aperture in the capsular ligament; but this cannot happen, as the ligament is inelastic, and an aperture admitting the dislocation would as readily admit of the reduction. The capsular ligaments possess, in fact, but little power of preventing dislocations, and the protection is principally afforded by the peculiar ligaments and tendons covering each joint. Constitutional means.—Constitutional, as Avell as mechanical means, are often necessary to assist in the reduction of dislocations; and in many cases, the employment of force only, is very improper; as, unassisted by constitutional means, much greater vio- lence must be exercised, and consequently the imme- diate suffering, and subsequent inflammation, will be proportioned to this violence. Bleeding, o>c.—Bleeding, the Avarm bath, and such medicines as create nausea, are the best means of assisting constitutionally in the reduction of disloca- tion, as they most readily produce a state of faint- ness, during which the muscular power is greatly diminished. Bleeding is the most powerful, and at 208 the same time the most speedy method of the three, if the blood be drawn from a large orifice, and the Eatient be kept in the erect position; it cannot, owever, be resorted to in all cases, and might be highly injurious in very old or debilitated persons; but in the young and robust it may be employed with safety and advantage in the mode I have pro- posed. Warm bath.—In using the warm bath, the tem- perature should be from 100° to 110°; and the heat should be kept up until the patient feels faint, when he should be taken out, and the mechanical means should be immediately resorted to. The desired effect is much sooner produced by abstraction of blood, during the time that the patient is in the bath, than by bleeding, or the bath singly. Creating nausea.—The third mode, viz. that of exciting nausea by the exhibition of tartarised anti- mony in small doses, is not so certain as the former modes, but it is exceedingly useful in keeping up the state of faintness produced by bleeding or the Avarm bath, Avhen the dislocation has been of longstanding and likely to require a continued application of me- chanical means for its reduction. Opium.—Opium might, perhaps, be serviceable in large doses, as it greatly diminishes muscular poAver. I have not yet tried it. Mode of reduction.—When the power of the mus- cles has been lessened, the reduction of the dis- location should be attempted, by fixing one bone, whilst the extremity of the other is drawn towards the socket by extending the limb. Inattention to this point is one of the great causes of failure in attempting to reduce dislocations; for if the bone in which the socket is situated be not fixed, the reduction cannot be accomplished. If, for in- stance, in attempting to reduce a dislocation of the 209 humerus the scapula be not fixed, it is necessarily draAvn doAvn with the os humeri, and the extension is unavailing. If one person holds the scapula, whilst tAvo extend the humerus, the extension will still be very imperfect: the one bone must be firmly fixed, at the time that the other is extended, to render the force effectual. The extension should be gradually and carefully made, and continued rather to fatigue than extend the muscles by violence. Violence is as likely to lacerate sound parts as to reduce the dislocation, and this I have known to occur. Use of pulleys.—The force required may be appli- ed by the aid of assistants, or by compound pulleys, and in cases of difficulty the latter is much the more preferable mode, as the extension can be thus made gradually and continued; whereas that made by as- sistants, is usually irregular, and often ill timed, being more likely to tear the soft parts than to restore the bone to its natural situation. In all dislocations of the hip, and in those of the shoulder, of long standing, pulleys should always be employed, in preference to any other mode of exten- sion, although I do not deny the possibility of reduc- ing these dislocations by the aid of assistants only. Relaxation of muscles.—In endeavouring to reduce a dislocation, the position of the limb should be such as to relax as much as possible, the larger muscles, by Avhich the reduction may be greatly facilitated. Points for extension.—A difference in opinion ex- ists, whether the extension should be made from the dislocated bone, or from the limb below. M. Boyer, Avho has had great experience in surgery, prefers the latter, but in my OAvn opinion it is best to apply the force to the bone which is dislocated, although in re- cent dislocations of the humerus, I usually make ex- tension from the wrist, drawing the arm in a line 27 210 with the side of the body, at the same time placing my heel in the axilla. Effect of will.—Much may be done in these cases, at the time the surgeon is attempting the reduction by drawing the patient's attention from the accident, as the muscles are affording much resistance in obe- dience to the will, as long as the mind is directed to them ; but this subsides as soon as any other circum- stance engages the patient's attention. Thus I have reduced a dislocation of the humerus, by directing a patient to rise, at the time I was making extension by the wrist, having my heel in the axilla, after hav- ing made various unsuccessful efforts, whilst he was recumbent. In attempting to rise, the mind was di- rected to other muscles than those opposing the re- duction ; and thus the force they had previously ex- ercised, was so far diminished as to allow of the re- duction. Mode of applying the pulleys.—Before applying the pulleys, a wetted roller should be put round the limb, and the leather to which the rings are fixed to re- ceive the hook of the pulleys, should be buckled on over this roller; this will prevent it from slipping during the extension. The cord should at first be drawn very gently, until the resistance of the mus- cles is felt, when the surgeon should rest for tAvo or three minutes, and then gradually and carefully ex- tend again, and so on until he perceives the muscles quiver; after which a very little more extension will accomplish the desired purpose. When reduced.—The surgeon may knoAV when dis- location is reduced, by the restoration of the natural figure of the articulation. After treatment.—For some time after the reduc- tion of the dislocation of the shoulder of long stand- ing, bandages are required to retain the bone in its proper situation; and the same treatment must be 211 adopted after similar accidents to those joints in. Avhich the articular cavity is shallow. In all cases after reduction, rest is necessary, to alloAV of the union of the ruptured ligaments; eva- porating lotions should be employed to prevent ex- cess of inflammatory action, and leeches should be applied if the inflammation run high. Subsequently friction will be found of great service in restoring the natural functions of the joint. The injuries to the spine, commonly described as dislocations, have been already treated of in a former lecture. I shall noAV, therefore, proceed with the description of these injuries to the other articula- tions, and commence with those taking place at the junction of the ribs. Of Dislocation of the Ribs. Three forms.—Three forms of dislocation are men- tioned as occurring to the ribs and their cartilages; viz.—First, a displacement of the posterior or verte- bral extremity fonvards on to the body of the ver- tebrae. Second, a separation of the anterior ex- tremity of the rib from its cartilage. Third, a simi- lar injury between the cartilage and the sternum. Cause of first form.—The dislocation of the ver- tebral extremity might occur from a person falling backward on some pointed substance, so as to drive the head of the rib from its natural situation; such accidents are, hoAvever, very rare. Signs of.—This injury Avould produce symptoms nearly similar to those from fracture of the rib, as pain on motion, and difficulty of respiration. Treatment.—The same mode of treatment would be also proper in either case ; as bleeding to prevent inflammation, and the application of a roller to con- fine the motions of the ribs. 212 Displacement of cartilage.—When a cartilage has been separated and displaced either from the rib or from the sternum it may usually be replaced Avith ease, if the patient will take a deep inspiration, so as to enlarge as much as possible, the diameter of the chest; for under these circumstances very slight pressure will return the parts to their original posi- tion. Treatment.—After the reduction, a small compress confined over the seat of injury by a bandage, as applied for fractured rib, will be requisite to prevent any future displacement. Deformity of ribs.—In sickly and weak children, an alteration sometimes takes place in the form and direction of the cartilages of the ribs, Avhich might be mistaken for a dislocation. It most frequently occurs at the cartilages of the sixth, seventh, or eighth ribs, and is accompanied with some alteration in the course of the ribs themselves. Dislocation of the Clavicle. Articulations strong.—The articulations of the cla- vicle Avith the sternum, and with the scapula, are so firm as to render displacement of either extremely rare, when compared with the dislocation of some other joints. Dislocations of the Sternal Extremity. Two kinds.—The sternal end of the clavicle may be displaced in two ways;—first, when thrown ante- rior to the sternum, or fonvards;—second, back- Avards, or behind the sternum. Anteriorly.—In the anterior dislocation, a SAvelling is readily perceived on the anterior and upper part of the sternum ; and if the finger be carried on the surface of the sternum upwards, this projection stops 213 it. On placing the knee between the scapulae and drawing the shoulders backwards, the swelling dis- appears ; but it reappears Avhen the shoulders are again allowed to advance. If the shoulder be ele- vated, the SAvelling descends, and if the shoulder be depressed, the projection ascends towards the neck. Pain from motion.—The patient experiences much difficulty in moving the shoulder, and the attempt creates pain; but Avhen at rest, he suffers but little pain or inconvenience. In very thin persons, the nature of the accident is at first view easily detect- ed, but some difficulty may occur in ascertaining its nature in very fat people. Cause.—This injury is generally occasioned by a fall, either on the point of the shoulder, Avhich drives the clavicle inwards and forwards, or upon the elbow, at the time that it is separated from the side, which produces the same effect. Sometimes a partial displacement.—Sometimes this dislocation is only partial, the anterior part of the capsular ligament alone being lacerated; in this case the projection is but slight, but most frequently all the ligaments are torn through, and the bone with the interarticular cartilage is completely displaced. Treatment.—This dislocation is easily reduced by drawing the shoulders backAvards, by Avhich the cla- vicle is drawn off the sternum, wheff it falls into its natural situation; but the shoulders must be kept in this position to prevent a recurrence of the displace- ment, and the arm must be supported, or its weight will affect the position of the bone. The application of the clavicle bandage and pads in the axillae will effect the first object, and the sec- ond will be gained by placing the arm in a short sling. Posterior dislocation very rare.—I have never seen, or knoAvn of an instance, in Avhich the disloca- tion backwards has been produced by violence; yet 214 I conceive that it might happen from a blow on the fore part of the bone. From deformity.—The only case of this form of dislocation that I have known, was occasioned by great deformity of the spine, from which the scapula was thrown so much forwards, as not to leave suffi- cient space for the clavicle between it and the stern- um : in consequence of this the clavicle was gradually forced behind the sternum, where it pressed upon the oesophagus, and gave rise to so much inconve- nience, as to occasion a necessity for the removal of the extremity; the trachea from its elasticity escap- ed pressure, being pushed to one side. This case was under the care of Mr. Davie, sur- geon, at Bungay, in Suffolk, from Avhom I had many of the particulars. He deserved great praise for suggesting the mode of relief; and the skill with which he performed the operation was a proof of the soundness of his professional knowledge. Case.—Miss Loffty, of Metfield, in Suffolk, had very great distortion of her spine, by which the sca- pula was gradually thrown so much forwards, as to displace the sternal extremity of the clavicle, forcing it inwards behind the sternum, so as to press upon the oesophagus, and occasion great difficulty in swal- lowing. She had became very much emaciated. Mr. Davie thinking that he could relieve the suf- ferings of the patient, and prevent the threatened destruction of life, by removing the sternal extremity of the clavicle, performed the following operation :— He first made an incision of between two and three inches in extent, over the seat of the dislocation, in a line with the direction of the clavicle. After divid- ing the soft parts surrounding the bone, he placed a portion of stiff sole leather behind it, whilst he care- fully sawed through it, about one inch from its end, 215 with Hey's saw; he then elevated it, and separated it from the interclavicular ligament. The wound aftenvards healed quickly, and the patient Avas again able to swallow without difficulty. She lived six years after the performance of the operation. Dislocation of the Scapular Extremity. Upwards.—I have not ever seen any other dislo- cation of the scapular extremity of the clavicle, than that in which the end of the clavicle is thrown above the acromion process; and I should conceive it very unlikely for any other form to occur; but I do not mean to deny the possibility of a displacement be- neath the acromion process of the scapula. This extremity is more frequently dislocated than the sternal end, and may be detected by the follow- ing signs:— Signs of.—The shoulder of the injured side ap- pears depressed, and drawn nearer to the sternum, than the sound one. This arises from the scapula having lost the support of the clavicle. On exami- nation, the nature of the injury is readily ascertained, by passing the finger along the spine of the scapula, so as to trace the continuation of the acromion with it; in doing this, the finger is stopped by the extre- mity of the clavicle, which projects above the acro- mion, and pain is experienced when this elevation is pressed. The swelling disappears when the shoul- ders are draAvn backwards, but rises again if they are allowed to come forward. Pressure upon the end of the dislocated bone causes pain; but when at rest, the patient suffers but little. Causes.—This injury is most frequently occasioned 216 by a fall upon the shoulder, by which the scapula is forced inwards towards the chest.* Treatment.—The reduction of the displaced bone in these cases, may be, in most instances, readily ac- complished, by placing the knee between the scapu- la of the patient, and then drawing his shoulders backwards and upwards. After the reduction, a pad or cushion should be placed in each axilla, for the purpose of elevating the scapulae, keeping them from the side of the thorax, and to defend the soft parts from the bandage, which should next be applied, as in the former case, only it should be broad, and made to press over the seat of injury. The employment of a short sling is likewise of essential importance. Not perfectly recovered from.—It rarely happens that these accidents to the clavicle are perfectly re- covered from; some degree of deformity usually re- mains, and of this the patient should be informed at the commencement of the treatment, otherwise he may attribute it to the negligence or ignorance of the surgeon; but this deformity Avill not interfere with the future motions of the joint. Dislocation of the Os Humeri. Four directions.—The head of the humerus may be displaced from the glenoid cavity of the scapula, in four directions;—three of the dislocations are com- plete, and one not perfectly so. The first is doAvnwards and inwards into the axilla. The second is forwards, under the pectoral mus- cle, below the clavicle. The third is backAvards, on the dorsum of the scapula, below the spine. * I have known this dislocation arise from a blow, by the falling of a heavy piece of timber upon the extremity of the shoulder.—T. 217 The fourth is only partial, when the head of the bone rests against the external side of the coracoid process of the scapula. Of the Dislocation in the Axilla. Signs of—This dislocation may be known by the following signs :—The rotundity of the shoulder is destroyed, and a hollow may be felt below the acro- mion process of the scapula, in consequence of the head of the humerus being displaced from the gle- noid cavity, by which the deltoid muscles lose its support, and is dragged down with the depressed bone. The arm is lengthened, as the superior ex- tremity of the humerus is placed beneath its natural articular surface. The elbow is separated from the side, and cannot be made to touch it, but with diffi- culty, as the effort presses the head of the bone upon the axillary nerves, occasioning severe pain, and the patient generally supports the arm with the hand of the sound limb, to prevent the Aveight from pressing on these nerves. If the elbow be far removed from the side, the head of the os humeri can be easily felt in the axilla, but not so if the arm be alloAved to re- main nearly close to the side ; raising of the limb throws the head of the bone doAvnwards, and to the lower part of the axilla, so that it can be more readi- ly felt. The motions of the joint are in a great de- gree destroyed, especially upwards and outwards, and the patient cannot raise his arm by muscular ef- fort; for this reason, it is usual, when wishing to de- tect a dislocation, to ask the patient if he can raise his hand to his head. The answer invariably is, that he cannot, if a dislocation exists. The arm cannot be rotated, but a slight degree of motion backAvards and fonvards still remains. 28 218 Motion sometimes considerable.—In very old per- sons, and in those having a relaxed state of muscles, the degree of motion is occasionally but little inferior to that which exists Avhen the bone is in its natural state. Crepitus.—Some time after the accident, a crepi- tus may be often felt, occasioned by inflammatory effusion, and from the escape of synovia ; but it is never so distinct as that produced from fracture. There is frequently a numbness of the fingers, from the pressure of the head of the bone upon the axillary nerves. Thus it will be found, that the principal marks of the accident are, the loss of the rotundity of the shoulder, the presence of the head of the bone in the axilla, and the destruction of the natural motions of the joint. But often these marks are but little apparent in a few hours after the receipt of the in- jury, from the extent of swelling which occurs, on account of extravasation; they, hoAvever, become again distinct when the tumefaction and inflammation have subsided. Under these latter circumstances it is, that the London Surgeons are generally consulted, when the nature of the injury cannot be mistaken; whereas, the general practitioner is called upon dur- ing the state of tumefaction and inflammation, to form his opinion, and should he then overlook a dis- location, it is our duty, injustice to the general prac- titioner, to inform the patient that the difficulty of ascertaining the true nature of the accident is very greatly diminished by the cessation of swelling and inflammation. The readiness with which the injury may be de- tected, will also differ much in very thin and ema- ciated persons, or in those loaded Avith fat, and pos- sessing large and powerful muscles. Causes.—The most common causes of this acci- 219 dent, are falls upon the hand, when the arm is above the horizontal line, or upon the elbow, when the arm is raised from the side ; but more especially by a fall upon the shoulder itself, when the muscles are unprepared to resist the violence. Liability to recur.—When the arm has been once displaced, it is much more liable, after the reduction, to be again dislocated, unless great attention be paid to the injured joint; and very slight causes Avill often produce a recurrence of the injury, which I have known take place merely from the action of lifting up the sash of a window. Case.—When an apprentice at St. Thomas's Hos- pital, as I was one morning going through the wards, I was called to visit a man who had dislocated his shoulder in the ordinary effort of stretching himself, and rubbing his eyes, when he first awoke. Proper mode of preventing.—To prevent as much as possible this disposition to future dislocation, the limb should be kept perfectly at rest for three weeks after the reduction, during which time, a pad should be fixed on the axilla, and the arm bound to the side; thus the lacerated parts will have time and opportunity to unite, Avhich they cannot well do if the usual motions are permitted. Dissection.—I have had opportunities of dissect- ing two recent cases of the dislocation downwards, in which I found the following appearances :— Cases.—rln the first case, the axillary vessels and nerves were forced backwards upon the subscapula- ris muscle, by the head of the dislocated humerus. The deltoid muscle was draAvn down, and the supra and infra spinati muscles were stretched over the glenoid cavity, and inferior edge of the scapula. The head of the bone was seated between the cora- co brachialis and axillary plexus. The capsular li- gament was extensively lacerated on the inner side 220 of the glenoid cavity, as was also the tendon of the subscapularis muscle, Avhere it covers the ligament. In the second case, violent attempts had been made to reduce the dislocation five weeks after its occurrence, but without success, and the patient died from the effects of the violence used in the extension. The pectoralis major was slightly lacerated, the su- pra spinatus very much so; the infra spinatus and teres minor Avere also torn, but not to any great ex- tent ; the deltoid and coraco brachialis had also suf- fered a little. The capsular ligament had given way between the teres minor and subscapularis tendons, the latter being separated from the lesser tubercle of the humerus. Muscles affording resistance.—In these dissections, I found that the supra spinatus and deltoid muscles were those which afforded the chief resistance to the reduction of this dislocation ; therefore, in order to effect the reduction, the best direction in which the arm can be extended, is at a right angle with the body. The biceps should be at the same time re- laxed by bending the elbow. In examining a dislocation Avhich has existed for several years unreduced, the head of the bone is found much altered in form, being flattened on that side next the scapula, but it is perfectly covered by a capsular ligament. The glenoid cavity is complete- ly filled by a substance of a ligamentous nature, with some small portions of osseous matter suspended in it, and a new articular surface is formed for the head of the dislocated bone, on the inferior costa of the scapula. Of the Reduction of the Dislocation in the Axilla. Modes of reduction differ.—The means employed for the reduction of the head of the humerus when 221 dislocated downwards into the axilla, must differ ac- cording to the circumstances attending the accident; but in all recent cases, I generally attempt the re- duction by the heel in the axilla, which may be done in the following manner:— By the heel in the axilla.—The patient should be placed on a sofa, or table, near the edge, in a recum- bent posture, and a Avetted roller should be bound round the arm, just above the elbow, over Avhich a handkerchief or towel should be fastened ; the elboAV being then separated from the side, the surgeon places the heel of one foot in the axilla, and rests the other upon the ground, as he sits by the patient's side. The heel should be placed far enough back to receive the inferior edge of the scapula, and pre- vent its descent at the time that the arm is extended. The extension is to be made from the handkerchief or towel, and continued steadily for four or five minutes, in which time usually the head of the bone slips into its proper cavity. The force of two or more persons may be employed in extending, by means of the towel, if required. If of some standing.—If, however, the accident is of several days' standing, and if the muscles have been fixed and rigid, more force than can be applied as above will be required to effect the reduction, and the following means must be resorted to :— Second mode.—The patient must be placed in a chair, and the scapula fixed by a bandage with a slit in it, which admits the arm through it; this must be tied over the acromion, so as to keep it well in the axilla. Next, place a wetted roller round the arm immediately above the elbow, to pro- tect the skin, and upon it fix a very strong worsted tape, by Avhat is termed the clove-hitch. Then raise the arm at right angles with the body, or a little above the horizontal line, to relax the deltoid and 222 supra spinatus muscles. Tavo persons then holding the scapula bandage, should keep it fixed, whilst two others draw from the bandage affixed to the arm with a steady, equal, and combined force. Af- ter the extension has been kept up for a few min- utes, the surgeon should place his knee in the ax- illa, resting his foot on the patient's chair ; he should then raise his knee by extending his foot, and at the same time, with his right hand, push the acromion downwards and inwards, by Avhich the reduction will be generally accomplished. Whilst the extension is kept up, a gentle rotato- ry motion will diminish the counteracting power of the musclesj and materially expedite the reduction ; but should the force applied in this way not be suf- ficiently steady and continued, then we must apply the pulleys, not with a vieAV of exerting greater force, but to enable the surgeon to employ it more equally and gradually. Use of pulleys.—The bandages, &c. being applied, as in the last instance, the patient is to be seated between two staples, which are to be fixed in the walls of the apartment, so that the force can be em- ployed in the same direction as before-mentioned. The surgeon should first draw gently and steadily until the patient complains of pain, when he should stop, but not relax the extension. Much advantage may be gained now by conversing with the patient, and directing his attention to indifferent subjects. In two or three minutes he may carefully extend a little more, and then cease again, and so on, until he has made as much extension as he thinks correct, but he should at intervals slightly rotate the limb. Then giving the string of the pulley to an assistant, desiring him not to relax, he should place the knee in the axilla, and press the acromion as before de- scribed, when the bone glides into its proper situa- 223 tion, not however with a snap, as Avhen the other means are employed. Hospital treatment.—In the hospital practice, I usually order the patient to be bled, and put into a warm bath at the temperature of 100° to 110°, giv- ing him a solution of tartar emetic until he becomes nauseated and faint, when he is immediately taken from the bath, and extension applied before he re- gains muscular poAver. This plan obviates the ne- cessity of using any great force. By the knee in the axilla.—In very old relaxed per- sons, or in very delicate females, another mode of reducing this dislocation may be resorted to, by plac- ing the knee in the axilla in the following manner: —The patient should be seated upon a low chair, when the surgeon should separate the injured arm from the side, and then resting his foot upon the chair, should place his knee in the axilla, and holding the arm Avith one hand over the condyles of the humerus, and pressing the acromion of the scapula Avith the other, he should then depress the elbow, by Avhich the dislocation will be reduced. When often dislocated, easily reduced.—Case.—Af- ter frequent displacements of the shoulder, but very slight force is necessary to reduce any future dislo- cations. A gentleman in the country, of my ac- quaintance, Avho has frequently dislocated his shoul- der, has often reduced it himself in the following Avay,—by leaning "over one of the common field gates, and laying hold of one of the lower bars, then allowing his body to Aveigh down on the other side ; —this is on the same principle as placing the heel in the axilla, which will effect the reduction of three- fourths of the recent dislocations. 224 Of Dislocation forwards under the Pectoral Muscle. Easily detected.—This dislocation is much more readily detected than the former. The depression beneath the acromion process of the scapula is greater, and the process itself appears more promi- nent. The head of the os humeri can be distinctly felt, and, in thin persons, may be seen forming a SAvelling beneath the clavicle, Avhich moves when the elbow is rotated. Signs of.—The head of the bone is situated in- ternal to the coracoid process, between it and the sternum, and is covered by the large pectoral mus- cle. The arm is shortened, and the elbow is sepa- rated from the side, being forced outwards and back- Avards ; the motions of the arm are more affected than in the former dislocation, the head of the bone being fixed, by the coracoid process and neck of the scapula on the outer side, by the clavicle above, and by the muscle on the fore part, as well as by the action of the teres minor with the supra and infra spinati muscles, which are rendered very tense. The pain occasioned by this injury is not so se- vere as in the dislocation into the axilla, because the axillary vessels and nerves are less compressed. Chief marks.—The chief diagnostic marks, are the position of the limb, the elbow being carried from the side and backAvards; the head of the bone being readily felt below the clavicle, and its moving when the arm is rotated. Dissection of.—There is in the Museum at St. Thomas's Hospital, a beautiful preparation, showing a dislocation of this kind of long standing, Avhich presents the folloAving appearances :—The head of the humerus rests upon the neck and part of the venter of the scapula, just below the supra-scapu- lar notch; the subscapularis muscle has in part been 225 raised so that the head of the bone rests on the scapula; the subscapularis and serratus magnus mus- cles being between the extremity of the humerus and the surface of the ribs. The tendons of all the muscles attached to the tubercles, as also that of the long head of the biceps muscle remain per- fect. The glenoid cavity is filled with a ligamen- tous substance, but its general figure is not much altered; and to this ligamentous structure the ten- dons of the supra and infra spinati, and of the teres minor muscles are adherent, having however a sesa- moid bone formed in them: a new socket has been formed, Avhich extends from the glenoid cavity, to the venter of the scapula, occupying about one third of its width, it has a complete lip, and is irregularly covered with cartilage ; the head of the humerus is a good deal altered in form, and its cartilage has been in many places removed by absorption: a per- fect capsular ligament has been formed. Causes.—Violent bloAVS upon the shoulder, or falls upon the elbow, Avhen it is thrown behind the line of the body, are the usual causes of this dislo- cation. Of the reduction of the Dislocation forwards. When recent.—In recent dislocations of the kind, the reduction may be accomplished by placing the heel in the axilla, and making extension from the arm as before described; the foot should, however, be placed rather more forwards, to press on the head of the bone, and the arm should be drawn a little backwards as Avell as doAvnwards. When of long standing.—When the dislocation has existed for some days, it will be best to use the pulleys, as continued and steady extension will be required to reduce it. 226 Mode of reduction.—The scapula must be fixed by the same bandage as formerly described, and the wetted roller, with a strap for the pulleys, fixed on in the same manner above the elbow. The fore- arm should be bent to relax the biceps muscle. Direction of extension.—The most important cir- cumstance, is the direction in which the extension is to be made, which must be outwards, a little down- wards and backwards ; for if it be made horizontal- ly, as in the former case, the coracoid process of the scapula prevents the head of the humerus from passing outwards in its proper situation. When the head of the bone has been brought below the coracoid process, by the extension, the surgeon should, with his knee, press it backwards and upAvards to the glenoid cavity, at the same time pulling the arm forwards from the elbow, by which means he will expedite the reduction. As the re- sistance is greater, the extension must generally be continued longer than that required to reduce the dislocation into the axilla. Of the Dislocation backwards on the Dorsum of the Scapula. Situation of bone.—In this dislocation, the head of the humerus is throAvn upon the dorsum of the scapula, below the spine, where it forms a projection at once perceptible to the eyes of the surgeon, and this enlargement may be seen and felt to move when the elbow is rotated. The motions of the arm are less confined than in either of the former dislocations. Very rare.—Only tAvo cases of this kind has oc- curred in Guy's Hospital during thirty-eight years. One was during my apprenticeship, and was under the care of Mr. Forster. The nature of the injury 227 was scarcely to be mistaken, on account of the pro- jection formed by the head of the bone upon the posterior part of the scapula. The bandages were applied, and the extension made in the same Avay as for the dislocation into the axilla, and the reduction was quickly accomplished. The second case Avas reduced in the same manner by the dresser: it occurred some years after the former. Of Partial Dislocation of the Os Humeri. Of common occurrence.—This is an accident of fre- quent occurrence. The head of the humerus is displaced fonvards, and rests against the coracoid process of the scapula; there is a depression under the back part of the acromion, the axis of the arm is directed imvards and fonvards, and the under mo- tions of the arm can still be made, but it cannot be elevated as the head of the bone strikes against the coracoid process, over Avhich it forms an evident projection, moving Avhen the arm is rotated. Case.—Mr. BroAvn, aged fifty, Avas throAvn from his chaise and injured his shoulder, which upon ex- amination was found to have lost its roundness, and a depression was perceptible under the acromion process ; the arm could be moved readily, except directly upwards. The only opportunity which I have had of seeing the dissection of this accident, was through the kindness of Mr. Paty, surgeon, Bouverie Street, he had the subject brought to him for dissection at St. Thomas's Hospital. The following is Mr. Paty's account:— Mr. Paty's dissection of—Partial dislocation of the head of the os humeri, found in a subject brought for dissection to St. Thomas's Hospital, during the latter part of the year 1819. 228 The appearances were as follows:—The head of the os humeri, on the left side, Avas placed more forwards than is natural, and the arm could be drawn no further from the side, than the half-way to the horizontal position. Dissection.—The tendons of those muscles which are connected with the joint Avere not torn, and the capsular ligament Avas found attached to the cora- coid process of the scapula. When this ligament Avas opened, it was found that the head of the os humeri was situated under the coracoid process, which formed the upper part of the new glenoid cavity; the head of the bone appeared to be thrown upon the anterior part of the neck of the scapula, which was hollowed, and formed the loAver portion of the new glenoid cavity. The natural rounded form of the head of the bone was much altered, it having become irregularly oviform, with its long axis from above dowmvards; a small portion of the ori- ginal glenoid cavity remained, but this Avas rendered irregular on its surface, by the deposition of cartil- age ; there were also many particles of cartilaginous matter upon the head of the os humeri, and upon the hollow of the new cavity in the cervix scapulae, Avhich received the head of the bone. At the up- per and back part of the joint, there was a large piece of the cartilage, which hung loosely into the cavity, being connected with the synovial membrane at the upper part only by two or three small mem- branous bands. The long head of the biceps muscle seemed to have been ruptured near to its origin, at the upper part of the glenoid cavity; for at this part the tendon Avas very small, and had the appearance of being a new formation. Causes of—The same causes which produce the dislocation under the clavicle, only with less vio- lence, will occasion this displacement. 229 Reduction of.—The reduction in these cases may be accomplished by the same means as those direct- ed to be employed for the dislocation forwards; but in addition, it is necessary to draw the shoulders backAvards, and after the reduction, a bandage must be applied to keep the head of the bone in its proper situation, and to prevent the motions of the scapula forwards, or otherwise the bone will again slip out of the glenoid cavity. Of Compound Dislocation of the Os Humeri. Forwards.—In the dislocation of the os humeri fonvards, the head of the bone may, by excessive violence, be forced through the exterior soft parts. Treatment of—In such a case, the reduction of the displaced bone should be immediately effected by the means I have already recommended for the simple dislocation; and when replaced, the edges of the external wound should be approximated by a suture, and then lint dipped in blood should be applied o\-er the wound, Avhich is to be further sup- ported by strips of adhesive plaister. The limb must be fixed to the side, by a roller passed round it and the body, this will prevent any motion of the limb, and thus there will be less risk of the suppu- rative inflammation occurring, Avhich Avould greatly endanger the patient's life. Mr. Dixon's case.—Mr. Dixon, of NeAvington, kindly furnished me with the following particulars of a case which was under his care :— Robert Price, aged fifty-five, fell, when in a state of intoxication, upon his shoulder, which produced a dislocation of the humerus, and forced the head of the bone fonvards, through the integuments of the axilla; and I found it situated on the anterior part of the thorax, over the large pectoral muscle. The \ 230 reduction was accomplished with great ease, after which he was placed in bed, and an evaporating lo- tion Avas applied. The following morning he com- plained of great pain, and considerable swelling had taken place, for this he was bled and purged freely, the injured part was poulticed, and anodynes were given to relieve pain and procure rest. For several days afterwards, leeches were repeatedly and free- ly applied over the joint, until after about two weeks from the receipt of the injury, when the wound began to discharge very freely a healthy pus. This continued for ten or twelve weeks, during Avhich time his constitution suffered much, he was restless, irritable, and became emaciated. Afterwards, a number of small abscesses formed in the surrounding cellular tissue, occasioning sinuses, some of which were exceedingly troublesome, requiring dilatation. This was kept up for twelve months, Avhen all dis- charge ceased, but the joint was completely anchy- losed. He retained, however, perfect use of the fore arm and hand. Of Injuries near the Shoulder Joint liable to be mis- taken for Dislocations. Fracture of the Acromion. Signs of—When this process of bone is broken off, it is drawn down by the Aveight of the arm, the deltoid muscle having in part lost its support, allows the head of the os humeri to sink as far as the cap- sular ligament will admit of its doing so, and the roundness of the shoulder is consequently destroyed. On tracing the finger along the spine of the scapula, towards the acromion, a depression is felt at the point of natural junction between these two parts. If the arm be raised from the elbow, so as to carry 231 the head of the humerus upwards, the shape of the shoulder is immediately restored, as the acromion process is returned to its original position, but as soon as the arm is allowed again to hang down, the de- formity recurs; when the arm has been elevated, a crepitus may be distinctly felt, by pressing one hand over the seat of injury, and at the same time rotat- ing the elbow. Treatment of—In the treatment of this accident, the os humeri is to be made the splint, to keep the fractured bone in its proper position; and to effect this, the elbow is to be raised, and the arm fixed, but a thick pad or cushion must be placed between the elbow and side, to separate the former from the latter, and thus relax the deltoid muscle, otherwise the broken extremities of the bone will not be in contact. The pad having been placed betAveen the side and elbow, the arm should be bound firmly to the chest by a roller, and a second bandage, or a short sling should he applied to support the elbow, and this position should be maintained for three weeks. Union by ligament.—Very little inflammation usu- ally follows this injury, and the disposition to ossific union is very feeble; thus, unless the fractured ends of the bone be placed in close contact, and if they be not kept perfectly at rest during the time requir- ed for such union, the junction will be by a ligamen- tous structure, instead of by bone. Fracture of the Neck of the Scapula. Like dislocation.—This accident is much more likely to be confounded Avith dislocation than any other of the injuries to the shoulder joint. The fracture takes place through the narrow part of the neck of the scapula, opposite the notch of the supe- 232 rior costa; and the glenoid cavity falls with the head of the humerus into the axilla. The rotundity of the shoulder is therefore destroyed, a hollow exists be- Ioav the acromion process ; and the head of the os humeri can be fell in the axilla, as when the dislo- cation into the axilla occurs. Signs of.—In these cases the deformity of the shoulder is easily removed by raising the arm ; but when the support is withdrawn, the appearances of dislocation again present themselves; and by grasp- ing the shoulder so that the fingers rest upon the coracoid process, a distinct crepitus may be felt when the arm is rotated. Thus the ease with which the form of the shoulder is restored, the re-appearance of dislocation Avhen the support is withdrawn ; and the perception of crepitus in the situation of the co- racoid process, are the principal diagnostic marks of the fracture of the neck of the scapula.* * The above account is that which I have given for many years in my lectures, and which 1 thought fully to explain the nature of the symptoms attending this accident, although it had never been confirmed by any subsequent dissection of the parts. Two cases have lately offered themselves, in which I have had opportunities of carefully examining the shoulder joint, after the receipt of injuries, which, at the time, produced the above described symptoms, and which had been considered as fractures of the cervix scapulae. The first case was that of a Mr. B. a West India Merchant, who, at my request, bequeathed to me the joint in which this accident was supposed to have occurred ; his executors resisted my claim, but after some little difficulty I obtained my legacy. On exposing the cavity of the axilla, I there found the head of the os humeri separated from the shaft of the bone; it was seated just below the cervix of the scapula, and was united by a ligamentous matter to the venter of the scapula, close to the anterior costa. The fracture had taken place between the ar- ticular surface of the humerus, and its tubercles ; the capsular ligament had been lacerated, so as to permit the separated por- tion to escape into the axilla; and the upper part of the shaft of the bone with the tubercles, had fallen in upon the glenoid 233 Treatment.—In the treatment of this injury, tAvo principal points must be attended to. First, to ele- vate the head of the humerus; and, Secondly, to carry it outAvards ; the latter object will be effected by putting a thick compress on the axilla; and the former, by elevating the arm and confining it in a short sling. Of Fracture below the Tubercles of the Humerus. Rare in middle aged persons.—This injury some- times occurs in the young and old, but rarely in the middle aged. In the young the separation takes cavity, by which the roundness of the shoulder had been de- stroyed ; the glenoid cavity was but little altered, and the pa- tient had before his death, acquired a free motion of the joint in every direction, excepting as a sword arm, for he could not raise his elbow above the horizontal line. The parts are pre- served in the museum at St. Thomas's Hospital. In the second, that of a gentleman in Gainsford Street, a pa- tient of Mr. Greenwood's, in whom a fracture of the cervix scapulae was supposed to have occurred, and who died in conse- quence of retention of urine, I discovered, on inspecting the in- jured joint, nearly the same appearances as in the former dis- section. Having thus ascertained the true nature of this injury, by the only accurate mode, viz. that of dissection, I have since been able readily to trace it in the living subject. Mr. B. the medical attendant of Lord Y. whilst travelling with his lordship in the Isle of Wight, had his shoulder injured in consequence of the carriage being overturned. Sometime after I saw him in London, in consultation with several medical gentlemen, and on examining the shoulder I found a depression beneath the acromion process; and could distinctly feel the head of the humerus in the axilla. The rotundity of the shoul- der could be easily restored by elevating the arm so as to carry the upper portion of the bone upwards and outwards; but whilst the humerus was supported in this position, I could still plainly feel the head of the humerus in the axilla, separated from the shaft of the bone. I must confess, that I now doubt the very frequent occurrence of the fracture of the cervix scapulae. 30 234 place between the epiphysis and shalf of the bone, and in the old, near the same spot, from the weak- ness of the bone at that part. In these cases the head of the humerus remains in the glenoid cavity, but the body of the bone sinks into the axilla, draw- ing down the deltoid muscle so as to lessen the round- ness of the shoulder. Case.—I made the following notes respecting the case of a child about ten years of age, brought into Guy's Hospital with this injury. The limb could not be moved Avithout creating great pain: if the upper part of the bone Avas fixed, the lower portion could be tilted out so as to be felt, and to form a visible projection, and in doing this a crepitus was dis- tinctly perceived, which could not be felt whilst the bone remained depressed into the axilla. The head of the humerus did not obey the rotatory motions of the elboAV. Treatment.—In treating this accident, a roller should be applied from the elboAV to the shoulder; and then a splint must be placed on the inner, and another on the outer side of the arm, with proper pads, and these must be fixed on with tapes, or a roller. A cushion should be put in the axilla, to throAV out the upper part of the bone, and the limb should be gently supported in a sling, but not at all forced up, or the bones will overlap. 235 LECTURE XLII. Dislocations of the Elbow Joint. The elbow may be dislocated in five different ways. 1st. The ulna and radius backwards. 2nd. The ulna and radius laterally. 3rd. The ulna separately from the radius. 4th. The radius alone forwards. 5th. The radius alone backAvards. Of Dislocation of the Ulna and Radius backwards. Signs of.—This injury is strongly marked by the great change in the figure of the joint, and by the destruction of its principal motions. The ulna and radius form a considerable projection above the natu- ral position of the olecranon posteriorly, with a de- pression on each side; on the fore part, the extremi- ty of the humerus occasions a SAvelling, behind the tendon of the biceps muscle. The flexion of the joint is almost destroyed, and the fore arm and hand are fixed in a supine position. In the museum at St. Thomas's Hospital is a pre- paration showing the effects of a compound disloca- tion of this kind, which I had an opportunity of dis- secting. Dissection of.—The olecranon projected one inch and a half above its usual position, posteriorly, and the coronoid process of the ulna rested in the pos- terior fossa of the humerus ; the radius was throAvn 236 upon the back part of the external condyle of the humerus; the condyles themselves formed a large swelling anteriorly. The capsular ligament was lacerated extensively on its fore part, but the coro- nary ligament remained entire. The brachialis an- ticus muscle was greatly stretched, and the biceps moderately so, by the altered position of the radius and ulna. Cause.—The mode in which this accident is pro- duced is by a severe fall, when the person puts out the hand to save himself; but the whole weight of the body being received upon the limb before it is Perfectly extended, the radius and ulna are forced ackwards and upwards behind the humerus. Mode of reduction.—The reduction of this dislo- cation may be readily accomplished by the folloAving means. The patient being seated on a chair, the surgeon should lay hold of his wrist and place his knee on the inner side of the elbow joint, then press- ing down the ulna and radius Avith his knee, so as to separate them from the humerus; he should at the same time bend the arm gradually and firmly; the coronoid process is thus removed from the posterior fossa of the humerus, and the action of the muscles draws the bones into their proper situations. Bend- ing the arm around a bed post, or over the back of a chair, will also effect the reduction. After treatment.—After the reduction the arm should be bandaged in the bent position, at rather less than a right angle Avith the upper arm; the bandage should be kept wet with an evaporating lotion, and the limb supported by a sling. Of Dislocation of the Ulna and Radius laterally. External or internal.—This dislocation may take place either externally or internally ; in one case the i I 237 ulna is thrown upon the external condyle of the hu- merus, and in the other instance, upon the internal condyle. Signs of external.—In the external displacement, the olecranon forms a greater projection than in the dislocation backAvards, as its coronoid process is seat- ed upon the external condyle of the humerus, instead of being placed in its posterior fossa; the head of the radius is thrown to the outer side, and behind, where it forms a SAvelling, which moves Avhen the hand is rotated. Of internal.—When dislocated internally, the ole- cranon projects equally as in the former case, but the head of the radius falls into the posterior fossa of the humerus; the external condyle forms a large protuberance on the outer side. Cause.—This accident is produced in the same way as the former, only that the direction of the limb at the time varies. Reduction.—The reduction in these cases may be effected by the method described as proper for the dislocation backAvards; it is not necessary to move the fore-arm outwards or inwards, as the actions of the biceps and brachialis anticus muscles draw the bones into their natural positions, immediately that they are separated from the extremity of the hu- merus. Case.—In a recent case of this dislocation in a lady, I speedily reduced it by forcibly extending the arm; when the tendons of the biceps and the bra- chialis anticus muscles acted as strings from a pul- ley, and forced the condyles of the humerus back- wards. 238 Of Dislocation of the Ulna backwards. Signs of.—When the ulna is thrown backAvards upon the os humeri, and the radius remains in its natural situation, the olecranon forms a projection behind, and the fore-arm and hand are tAvisted in- wards. The fore-arm cannot be brought to more than a right angle with the upper arm, without con- siderable force. It is not so readily detected as the former inju- ries; but its chief diagnostic marks are the projec- tion of the ulna, and the turning of the fore-arm inwards. Dissection of.—A preparation in the museum at St. Thomas's hospital affords an excellent opportu- nity of viewing the nature of this dislocation. The displacement had existed for a long time unreduced. The coronoid process of the ulna rests in the poste- rior fossa of the humerus ; the olecranon projects be- hind ; the head of the radius has made a considera- ble depression in the external condyle. The coro- nary, oblique, and a small portion of the interosseous ligaments have been torn through. Cause.—This dislocation is produced by the appli- cation of violence in the direction of the lower ex- tremity of the ulna, which forces it suddenly up- wards and backwards. Reduction of—The reduction is in this case much more readily made than Avhen both bones are dis- placed, and by the same means. The radius assists the return of the ulna to its proper position, by push- ing the condyles back, when the fore-arm is bent, and the brachialis anticus acts at the same time in drawing the ulna forwards. 239 Of Dislocation of the Radius forwards. Situation of bone.—The radius is sometimes sepa- rated from its attachment to the coronoid process of the ulna, and is displaced into the depression above the anterior part of the external condyle of the hu- merus, and also above the coronoid process. Signs of—I have seen several cases of this injury, which exhibits the following marks. The fore-arm is a little bent, but cannot be either completely flex- ed or extended. When an attempt is made to bend the fore-arm, the motion is suddenly stopped by the striking of the radius against the humerus, and the surgeon is immediately convinced that this check to the flexion is by the striking of one bone upon an- other. The hand is nearly in a state of complete pronation, but cannot be rendered entirely so, nor can it be placed in a supine position. The head of the radius may be felt on the fore and upper part of the elbow joint, and its movements are perceptible Avhen the hand is rotated. The sudden stop to the flexion of the fore-arm, and the situation of the head of the radius are the most distinguishing marks of this injury.* Dissection of—On dissecting this injury, the head * A sailor about thirty years of age, applied at St. Thomas's Hospital with a dislocation of the radius forwards, which had existed above six months. I could readily feel the head of the radius above the external condyle, particularly when 1 bent the arm as much as possible, and flexed the hand towards the fore- arm. The hand was half supine, and could not be placed en- tirely in the supine or prone positions, if the humerus was fixed. A sudden stop was experienced when bending the arm, by the head of the radius striking upon the humerus. The man had regained a great degree of motion, yet was extremely anxious for me to attempt the reduction, which I declined, and urged him not to allow any one to make the trial, as I was confident it would have been useless.—T. 240 of the radius is found resting in the depression above the external condyle of the humerus. The corona- ry, the oblique, with part of the interosseous, and the anterior portion of the capsular ligaments are lacerated. The biceps muscle is shortened. Cause.—The dislocation is occasioned by a fall upon the hand when the limb is fully extended, the weight of the body being received upon the infe- rior extremity of the radius. Cases.—The first case I had an opportunity of seeing of this accident, occurred under the care of Mr. Cline, during my apprenticeship to him, at St. Thomas's Hospital. The most varied attempts, Avhich his strong judgment could suggest, were made to reduce the displacement, but without success; and the woman Avas discharged with the bone still displaced. The second case which I witnessed was in a lad, whom I was asked to visit by Mr. Balmanno, in Bi- shopsgate Street; but I could not succeed in reduc- ing the dislocation, although I persevered, with va- ried modes of extension, for more than an hour and a quarter. In the third case, I succeeded in replacing the bone during the time that the patient Avas in a state of syncope; by resting his olecranon upon my foot, (as he lay upon the floor,) to prevent the ulna from receding, and then extending the fore-arm. Another case which I attended with Mr. Gordon, was reduced by placing the arm over the back of a sofa, thus fixing the humerus, whilst we made exten- sion from the hand so as to act alone on the radius. Best mode of extension.—One evening after I had lectured upon this subject, and had explained the difficulties of reduction, Mr. Williams, one of my pu- pils, told me that he had known this dislocation re- duced by extending the hand only. This I soon con- 241 vinced myself was correct, by experiments on the dead body. The connexion of the hand with the radius, allows of the application of force to extend this bone without including the ulna. In making the extension the humerus should be fixed, and the hand rendered as much as possible supine, to remove the head of the radius from the upper part of the coro- noid process of the ulna. Of Dislocation of the Radius backwards. Very rare.—The only instance in Avhich I have seen this dislocation, was in a subject brought to St. Thomas's dissecting room, in the year 1821; the dis- placement had existed some time. Signs of.—The head of the radius Avas thrown be- hind, and to the outside of the external condyle of the humerus, where it formed a projection Avhich could be readily seen as well as felt, when the arm was extended. The oblique and coronary ligaments Avere torn through, and the capsular ligament Avas partially lacerated. Of the cause of this accident I am ignorant, as I have never seen it in the living subject. Reduction.—The reduction, I should imagine, would be easily effected by bending the arm, after which it would be proper to support the bone in its proper position, by means of bandages, and keep the arm bent at right angles, for three or four weeks, until the ligaments have had lime to unite. 31 242 Accidents at the Elbow Joint likely to be confounded with Dislocations. Fracture above the Condyles of the Humerus. Like the dislocation backwards.—When the con- dyles of the os humeri are obliquely fractured a little above the elbow joint, the appearances presented are so like to those occurring from the dislocation of the ulna and radius backwards, that the two injuries might be readily confounded; in the fracture, how- ever, all marks of dislocation are easily removed by extension, but return again as soon as the extension is withheld, and by rotating the fore-arm upon the humerus, a distinct crepitus can be usually felt. Case.—In July, 1822, a boy about nine years of age Avas admitted into Guy's Hospital, having fallen from a cart upon his elbow. The arm Avas a little bent, and the ulna and radius appeared to form a large projecting behind the elboAV joint: when the fore-arm Avas extended, the appearances of disloca- tion subsided, but they returned immediately that the extension was discontinued. The arm was se- cured in splints, Avhich Avere removed in ten days, when passive motion was carefully employed;.the lad recovered. Frequent in children.—This injury is much more frequently met with in children than adults; but I have known it to occur at nearly all ages. Treatment.—In treating this accident, the arm should be bent, and the fore-arm drawn forwards to replace the fractured portions, and should be then secured by a bandage. A splint having two portions joined at right angles, is best adapted to this case ; the upper portion is to be placed behind the upper arm, and the loAver part under the fore-arm; a splint will be also required on 243 the fore part of the upper arm; these should be well secured by straps, the arm should be supported by a sling, and evaporating lotions kejft applied. Passive motion.—After the lapse of a fortnight in the young patient, and of three Aveeks with the adult, passive motion should be carefully employed to pre- vent anchylosis, which may othenvise take place. In some of these cases, the loss of motion in the joint is considerable, even after the greatest care and at- tention on the part of the surgeon. Of Fracture of the Internal Condyle of the Humerus. Signs of.—When this accident occurs the ulna projects backwards, from having lost its support. The injury may be distinguished from others by the crepitus, which can be felt upon bending and straight- ening the arm, and from the hand being turned to- wards the side during the extension. Treatment.—The same mode of treatment as that directed for the fracture above the condyles, will bo proper in this case; passive motion must be employ- ed early, when the recovery will be complete. Of Fracture of the External Condyle of the Humerus. Signs of.—This injury produces swelling over the external condyle, and pain is experienced at the part on pressure, or during the flexion and extension of the arm; but it is best distinguished by the crepitus, which can be readily fell during the rotatory mo- tions of the hand. If the portion of bone detached be large, it is displaced backwards, and the head of the radius accompanies it. Dissection of.—Two preparations in the museum at St. Thomas's Hospital, exhibit specimens of this fracture; one is oblique, and the other transverse 244 at the extremity of the condyle. There is not any ossific union in either, but the fractured portions are joined by a ligamentous substance, and this appears to be the case in all instances of fracture with a cap- sular ligament. Frequent in Children.—Children are generally the subjects of this accident; it is seldom met with in adults, and very rarely in advanced age ; and it is occasioned usually by a fall upon the elboAV. Treatment.—The best mode of treatment in this injury, is to place a roller around the joint, which should pass also above and below it, then to support the limb in the splint, having two portions at right angles, as in fracture above the condyles; and to this, the upper and lower arm are to be well secur- ed. In young children, a portion of stiff paste board, applied Avet, and bent to the shape of the elbow, will answer best, as Avhen dry it adapts itself to the form of the limb, and affords an excellent support. Passive motion.—After three Aveeks, the surgeon should yery cautiously commence the passive motion. Bony union.—If the fracture in these cases extends without the capsular ligament, a bony union may with care be effected; but when entirely within the capsule, the union, as far as I have seen, is always ligamentous. Of Fracture of the Coronoid process of the Ulna. The following case which I have for many years related in my lecture, was considered as a fracture of the coronoid process, and will show the symptoms produced by such an injury. Case.—A gentleman in the act of running, fell upon his hand, which he extended to break his fall, and immediately afterwards he discovered that the mo- tions of his elbow joint were greatly diminished, as 4» 245 he could bend the arm but little, nor could he en- tirely straighten it. His medical attendant in the country, to whom he applied, found the ulna pro- jecting backAvards, but that on forcibly bending the arm, the figure of the joint became immediately re- stored. A splint and bandages were applied, and the arm supported by a sling. Several months af- terwards the gentleman came to town, Avhen 1 saw him; his ulna still projected behind the condyles of the humerus; but could with little violence be re- stored to its situation by bending the arm. Union ligamentous.—Case.—Some time after I had seen this gentleman, I had an opportunity of dissect- ing a case of this injury, in a subject brought to St. Thomas's anatomical theatre. The coronoid pro- cess of the ulna had been broken off within the joint, and had only united by ligament, so as to move free- ly on the ulna, and to alloAV the ulna to be carried back between the condyles, when the arm was ex- tended. Reason of.—I am doubtful if the most, careful treatment would effect a perfect cure, as the coro- noid process loses its ossific nourishment, and has only a ligamentous support. The vitality of the fractured process of bone is only supported by the vessels of the reflected portions of the capsular liga- ment, which do not appear sufficient to create a bony union. Treatment.—In the treatment of this accident, the arm should be kept steadily in the bent position for three AVeeks, to allow time for the ligamentous union, and to make it as short as possible. Of Fracture of the Olecranon. Signs of.—The marks of the injury are generally so evident, that it can scarcely be mistaken. A *± 246 swelling takes place at the back of the elboAV, Avhich, when pressed, feels soft, and allows the finger to sink in towards the joint; this is betAveen the tAvo extremities of the fractured bone ; the detached por- tion is draAvn upwards from the head of the ulna, to the extent of from half an inch to two inches; it can be readily moved from side to side beneath the integument, and becomes further separated from its former connexion Avhen the arm is bent. The pa- tient can bend the arm Avith ease, but he cannot ex- tend it Avithout great difficulty, and the attempt gives him much pain : without exertion it remains semi- flexed. No crepitus can be felt; and the rotatory motion of the radius upon the ulna are perfect. Considerable tumefaction from effusion of blood usu- ally folloAVs this accident, and in a feAV days the sur- rounding parts are much discoloured from ecchymo- sis. The fracture generally occurs about the centre of the process, transversely ; but I have seen the bone obliquely fractured. Dissection.—In dissecting the injured parts, some time after the occurrence of the accident, the por- tion of the olecranon, still connected to the ulna, exhibits some evidence of ossific deposite, and some- times the detached part has some slight marks of a similar character; the cancellated structure is filled with new ossific matter. The capsular ligament is lacerated posteriorly on each side of the olecranon. It appears, therefore, that as soon as the fracture takes place, the action of the triceps muscle draws up the extremity of the process, from half an inch to two inches, according to the extent of laceration of the capsular ligament, and the ligamentous band naturally connecting the olecranon to the coronoid process. Experiments.—To satisfy myself Avhether this pro- cess when broken would again unite by bone, I tried 247 several experiments upon dogs and rabbits, when I found that if the fracture was transverse, and such as to allow of separation between the fractured ends, by the action of the muscles, the union Avas always ligamentous; but if the fracture was oblique, and not admitting of separation, the parts were readily united by ossific deposite. The want of bony union, appears, therefore, to depend upon a want of adap- tion of the broken surfaces, and not upon any defi- ciency of support, as in the case Avith the fractures of processes within the capsular ligaments of joints. Causes.—This fracture may be occasioned by fall- ing upon the elbow, Avhen the arm is bent, or it may take place from the action of the triceps muscle only, during any violent and sudden exertion. Treatment.—The principle of treatment in these cases is to render the separation of the fractured extremities of the bone as slight as possible, as the limb is weakened in proportion to the length of the ligamentous union, from the diminished power of the triceps muscle. The arm, if possible, should be placed and fixed in a straight position, and if much swelling and pain exist, leeches and evaporating lo- tions must be employed for two or three days; and immediately the tumefaction has subsided, a bandage must be applied above the elbow, and another be- Ioav, having a portion of linen or broad tape placed beneath them longitudinally on each side of the joint; the ends of these pieces of linen or tapes are then to be tightly tied over the rollers, so as to ap- proximate them, and thus,bring the broken surfaces together. A splint Avell padded must be placed on the fore part of the arm and joint, and confined by rollers, so as completely to prevent any flexion of the limb. The bandages about the seat of injury should be kept wetted with the evaporating lotion. This is the only injury to the elbow joint, in which the straight position is proper. 248 Passive motion.—Passive motion should be very carefully employed about a month after the accident, but not sooner. Whencompound.—When this fracture is compound, union by adhesion should be effected if possible, by approximating the edges of the external Avound with adhesive plaister, and placing over this, lint dipped in blood; the treatment in other respects, will be the same as in the simple injury. Fracture of the Neck of the Radius. Very rare.—This injury, Avhich is said by some surgeons to be of frequent occurrence, I have never seen ; but I do not mean to deny that it sometimes happens. When it exists, 1 should imagine that it would be readily detected by the crepitus, which the rotating of the radius Avould occasion. Treatment.—The same mode of treatment as that already recommended for fracture of the external condyle, would in such cases be most proper. Of Compound Fractures, and Dislocations of the El- bow Joint. Not dangerous.—I have known several cases of this nature recover, Avith a partial anchylosis of the joint; if properly treated, the constitutional de- rangement in consequence of the injury, is not pro- ductive of any serious mischief. Case.—A brewer's servant Avas admitted into Guy's Hospital, on account of a compound fracture of his elbow joint, attended with considerable comminution of bone. The extent of injury was so great as to induce me to recommend immediate amputation, but I could not by any means persuade the patient to 249 submit to the operation. The limb Avas therefore laced upon a splint, in a bent position, the bones eing easily reduced; the edges of the exterior wound were carefully approximated. He recovered without any untoward symptoms, and retained suf- ficient motion of the joint, to enable him to resume his former employment. I have known several other cases in which the patients have recovered, without any severe con- stitutional sufferings. Treatment.—In the treatment of this injury, the limb should be kept in a flexed position, as anchy- losis to some extent is sure to be the consequence of it, when the position Avill lessen the inconve- nience attending it. If attended with much commi- nution of bone, the loose portions should be remov- ed before the external Avound is closed. In elderly persons, or in those not possessing sufficient poAver of constitution to support the suppurative process, the limb should be amputated in the first instance. Otherwise, the edges of the wound should be brought together by adhesive plaister, then covered with lint dipped in blood, and afterwards supported by a bandage moistened with an evaporating lotion. Of Dislocations of the Wrist Joint. Dislocations of this articulation may occur in three ways :— First.—Dislocation of the ulna and radius to- gether. Second.—Dislocation of the radius alone. • Third.—Dislocation of the ulna alone. I 32 250 Dislocation of the Ulna and Radius. Forwards or backwards.—These bones may be displaced from the connexion with the carpal bones, either forwards or backwards. If a person in fall- ing has the Aveight of the body received upon the palm of the hand, so as to occasion a dislocation, it will be forwards ; the radius and ulna resting upon the anterior annular ligament of the carpus ; should the fall, however, be upon the back of the hand, the contrary displacement may be produced. Signs of—In each of these cases, two projections are perceptible, anteriorly and posteriorly, one from the extremities of the radius and ulna, the other from the bones of the carpus, which render the de- tection of either injury easy. Injury resembling dislocation.—The effusion which so frequently folloAVS sprains of the tendons, fre- quently produces an appearance somewhat similar to that resulting from dislocation; it may, however, be distinguished from that occasioned by the dislo- cations, as it takes place gradually, and is rarely found on both sides,—whereas, in the displacement, the projections immediately folloAV the accident, and appear both anteriorly and posteriorly. Reduction.—These dislocations may be easily re- duced, by fixing the fore and upper arm, whilst ex- tension is made from the hand; immediately that the ends of the bones are separated from each other, the actions of the muscles restore them to their proper situations. When replaced, they must be supported by bandages, and two splints, one placed before and another behind the articulation, reaching from the elbow to the ends of the meta- carpal bones, to prevent motion, as Avell as to pro- tect the injured parts. The fore-arm and hand should be placed in a sling. 251 Dislocation of the Radius alone. Forwards.—The radius is sometimes thrown from its articular surface anteriorly, so as to rest upon the scaphoid and trapezium, where it forms a projec- tion ; the hand is twisted, the inner side of the palm being placed forwards. Cause of.—A fall upon the hand, Avhen it is bent back, is the common cause of this injury. Reduction,—It may be reduced by the same means as the former dislocation, and will require the same after treatment. Dislocation of the Ulna alone. Backwards.—The displacement of the ulna alone, occurs much more frequently than that of the radius alone; the mode in Avhich the former bone is ar- ticulated by means of an inter-articular cartilage, and its not forming a part of the Avrist joint, allows of its being more readily thrown from its natural position. It usually projects backwards, and is at- tended with laceration of the sacciform ligament. It may be easily pressed into its proper situation, but immediately the pressure is discontinued, it again protrudes, as the support of the ligament is de- stroyed. Treatment.—In the treatment of the injury, it is, therefore, necessary to employ a compress over the extremity of the ulna, and then to support the bone in its natural position, by bandages and splints, as in the former dislocation. 252 Of Dislocations of the Ulna, with Fracture of the Radius. The ulna is often dislocated fonvards, the radi- us being at the same time fractured obliquely about an inch above the articulation. Signs of.—The hand is, in these cases, throAvn backwards, as in the dislocation of both bones for- wards; the extremity of the ulna can be felt just above the pisiform bone, beneath the tendon of the flexor carpi ulnaris, and the fractured extremity of the superior portion of the radius is situated under the flexor tendons of the hand. Reduction.—The reduction in these cases is usual- ly very difficult, requiring powerful extension; and there exists a further difficulty in preserving the pro- per position, when the reduction has been effected, as the bones are again displaced from the slightest cause, unless confined by bandages, &c. The exten- sion should be made as in the former cases, and when the bones have been drawn into their natural situa- tions, two cushions must be placed, one before and the other behind the articulation, and there firmly bound down by a roller; over these, splints, lined with pads, should be placed, to reach from the elboAV to the hand, and secured by a long roller. The arm must be placed in a sling for three weeks, if the pa- tient be young; or from four to five weeks if aged, before passive motion be resorted to for the purpose of restoring the motions of the joint, which will not be perfectly effected under four or five months. Of Compound Dislocation of the Ulna, with Fracture of the Radius. Consequences.—The consequences of this injury are serious or not, according to the degree of surround- 253 ing mischief, and the extent of the fracture ; if com- minuted, the subsequent inflammation is severe, but othenvise of trifling extent, when judicious treat- ment is adopted. Reduction.—The reduction is to be accomplished as Avhen the simple dislocation and fracture occur; the edges of the wound must be carefully approxi- mated, and every means taken to promote adnesive inflammation, and to keep it within bounds by evapo- rating lotions, and the employment of leeches if ne- cessary. The arm must be laid on a splint, and sup- ported by a sling. The dressings should not be dis- turbed so long as the patient remains free from suf- fering, or until the Avound has united ; should symp- toms of suppuration occur, the removal of part of the dressings may be sufficient to allow the escape of the pus, Avithout taking off the Avhole. Dislocation of the Carpal Bones. Very rare.—This injury is of very rare occurrence. Case.—An elderly Avomanwas admitted into Guy's Hospital, in consequence of an accident to her wrist, produced by a fall upon the back of her hand; the radius was found to be fractured obliquely through its inferior extremity, and the part thus separated from the shaft of the bone, was thrown backAvards upon the carpus Avith the scaphoid bone. The fin- gers could be extended, but not entirely flexed. The reduction was readily accomplished by exten- sion and steady pressure, and the part supported by splints. Leeches and evaporating lotions were em- ployed at first, to subdue the inflammation and tumefaction which folloAved the injury, and after- wards, further support Avas given by strips of soap plaister. Ganglia.—I have known ganglia, which so fre- 254 quently form about this part, several times mistaken for displaced bones, but a little attention to the his- tory of the case Avill readily explain the difference. Partial dislocation,—Relaxation of the carpal liga- ments will sometimes admit of a partial dislocation of some of the bones, when the joint is forcibly flex- ed; and this state is generally accompanied with great debility of the part, preventing the patient from any continued exercise of it. Treatment.—Moderate pressure and support are the best means of relieving such complaints, the use of friction and of cold Avater poured from a height upon the part, 1 have knoAvn of service. Of Compound Dislocation of the Carpal Bones. Causes.—This frequently happens from the burst- ing of guns, or from the hand and wrist being caught in machinery, and in such cases, one or two of the carpal bones may be removed, and a considerable de- gree of motion be afterwards preserved in the articu- lation ; but, if attended with extensive surrounding mischief, amputation should be performed. Case.—The folloAving case occurred under the care of Mr. Forster, in Guy's Hospital. Richard Mitchell, aged 22, Avas admitted into the Hospital in conse- quence of an extensive wound into the wrist joint, inflicted by a wool combing machine. Two-thirds of the joint was opened, and the surrounding soft parts had suffered considerably. The scaphoid bone was dislocated backwards, and nearly separated from its usual connexions; the extensor tendons of the thumb, of the fore and middle fingers Avere torn through, as was also the radial artery, which, however, did not bleed much. The scaphoid bone was removed, and the edges of the wound were approximated by su- tures, and adhesive plaister applied in strips; the 255 whole was covered by lint dipped in blood, and sup- ported upon a splint to prevent any motion of the joint; a small quantity of blood was taken from the arm, and the seat of injury kept moistened with an evaporating lotion. In tAvo or three days it became necessary to remove these dressings in consequence of suppuration, Avhen a poultice was applied. A small slough Avhich had formed, separated kindly, and the process of granulation went on without a check, so as to fill up the wound in the course of three weeks. His recovery was somewhat retarded by the occur- rence of a pulmonary affection, requiring the use of leeches, diaphoretics, &c. to which it yielded. He left the Hospital, with but little motion of the fingers, but this appeared to be gradually increasing. Dislocation of the Metacarpal Bones. Articulation strong.—The articulation of these bones with the carpal is so strong, that great violence is requisite to separate them. I have seen them dis- placed from the bursting of guns, or the passage of a heavy laden carriage over the hand. Removal of bones.—In these cases, one or more of the metacarpal bones may be removed without am- putating the whole hand. Cases.—1 amputated the middle and ring fingers, with their metacarpal bones, from the hand of a Mr. Waddle, of Cheapside, in consequence of their being extensively injured by the bursting of a gun. I brought the edges of the wound together by sutures, and approximated the fore and little fingers by a roller; the wound united readily, and he had after- wards a very useful extremity. A boy Avas admitted into Guy's Hospital with a very severe injury to the hand, from the bursting of a gun, by Avhich all the metacarpal bones, excepting 256 that of the fore finger, were so shattered, as to ren- der it impossible to save them. The thumb had been entirely separated, with its metacarpal bone, and the trapezium was so much injured, that I thought it proper to remove it; I therefore took it away, as well as the metacarpal bones of the mid- dle, ring, and little fingers, with the fingers them- selves; thus only leaving the fore finger with its metacarpal bone. He recovered quickly, and could use this finger as a hook with the greatest facility and advantage.* Fracture of the Head of the Metacarpal Bone. Seat of—The digital extremity of a metacarpal bone, Avhich is called the head, is sometimes broken off, and gives rise to an appearance of dislocation, but the crepitus, on examination, makes the nature of the accident very evident. Treatment.—In the treatment of this accident, the patient should be made to grasp a large ball of firm materials, and over this his hand should be confined by a roller; this is the best method of restoring the fractured bone to its natural position. Dislocations of the Fingers. Common seat of.—The most frequent seat of this displacement is between the first and second pha- * A case somewhat similar to the above, occurred under my care in St. Thomas's Hospital, in which I was obliged to ampu- tate the little and ring fingers from the injured'hand, with their metacarpal bones. I also removed the unciform bone, and the middle finger, with two-thirds of its metacarpal bone. The re- covery was gradual, but complete, and the patient can now use his thumb and fore finger very expertly.—T. 257 langes ; but it is not an accident of common occur- rence. Nature of.—The dislocation may occur either backwards or fonvards, Avhen the projections formed by the ends of the bones plainly indicate the nature of the injury. Reduction.—If recent, the reduction may be easily accomplished, by making extension with a slight in- clination forwards, to relax the flexor muscles; if of some days standing, a long continued and steady ex- tension is necessary to replace the bones. It has been recommended, in cases of difficulty, to divide the ligaments or tendons, but I have seen too much mischief result from injuries to these parts, ever to advise such a practice. Remarks apply to injuries of toes.—The same ob- servations are applicable to the dislocations of the toes, but rather more difficulty is experienced in the reduction, on account of the shortness of the pha- langes. Of Dislocation from Contraction of the Tendon. Cause.—The phalanges are sometimes drawn out of their proper positions, by the contraction of a flexor tendon and its theca, in consequence of a chro- nic inflammation, induced by excessive employment of the hand in rowing, ploughing, hammering, &c.; nothing can be done to relieve these cases, but when merely a single band of fascia is thickened, and pro- duces this deformity, it may be divided with much advantage by a narroAV bistoury, introduced by a small opening through the skin. A splint must afterwards be applied, to keep the finger straight during the healing of the wound. In the toes.—A similar contraction also occurs in the tendons of the toes from the wearing of tight 33 258 shoes; the projection of the first and second pha- langes, in these cases, often gives rise to so much suffering and inconvenience, as to make it necessary to amputate the toe, otherwise the patient cannot take necessary exercise, and is deprived of many en- joyments. The cases in which I have performed the operation, have generally done extremely Avell, and restored the patients to comfort. Dislocations of the Thumb. Muscular connexion strong.—The number of strong muscles connected Avith the bones of the thumb, render the reductions of their dislocations very diffi- cult, especially when much time has been allowed to elapse from the receipt of the injury. Dislocation of the Metacarpal from the Carpal Bone. Form of.—In the majority of cases in which I have witnessed a displacement of the metacarpal bone of the thumb from the trapezium, the former has been thrown inwrards towards the metacarpal bone of the fore finger. The thumb has been bent backwards, and the extremity of the bone has formed a projec- tion in the palm of the hand ; it has been attended with considerable pain and tumefaction. Reduction.—In making the extension for reduc- tion, it is particularly necessary to attend to the re- laxation, as far as possible, of the most powerful muscles, Avhich are the flexors; thus the thumb must, during the process, be inclined toAvards the palm of the hand. The force applied must be continued and steady, as violence Avill not effect the desired object. If simple extension does not succeed in reducing the dislocation, the part must be left to the degree of recovery which nature will effect, as it would be 6 259 improper to attempt relief by any division of mus- cles or tendons. Compound dislocation.—A compound dislocation may be produced at this articulation by the bursting of a gun, and in such a case, if the tendons are not lacerated, the dislocation should be reduced, which it can be easily, and the edges of the external Avound should be brought together by suture, when, with careful treatment, a good cure may be effected. Case.—A case of this kind occurred at Brentford, under the care of Mr. George Cooper, in a young gentleman, aged thirteen ; the injury was occasioned by the bursting of a powder flask in his hand: The mass of muscle connecting the thumb to the hand was torn through, but the tendons of the long flexor, and of the extensors were not injured. The dislo- cation was reduced, and the wound closed by sutures and adhesive plaister, over which an evaporating lotion was applied. The wound united in part rapidly, and the remaining portion healed kindly by granulation. Tavo weeks after the receipt of the injury, Mr. Cooper began the use of passive motion, and the patient ultimately gained perfect motion in the joint. Amputation required.—Should, however, the ten- dons be lacerated, or much surrounding mischief ex- ist, amputation will be required; and I have found it necessary, in such a case, to remove the articular surface of the trapezium, Avhich I think may be done with advantage, especially Avhen there is a scarcity of superficial soft parts. Dislocation of the First Phalanx. Simple.—In the simple dislocation at this articula- tion, the first phalanx is throAvn back upon the me- tacarpal bone, forming a projection there, whilst the 260 end of the metacarpal bone protrudes towards the palm of the hand; the motions of the joint are de- stroyed, although the thumb can be made to ap- proximate the fingers by the movements of the carpometacarpal articulation. Reduction.—The mode of applying the extension for the reduction of this dislocation, should be as fol- lows, and the direction should be towards the palm of the hand, to relax the flexor muscles. The hand should be soaked in warm Avater for a considerable time, to relax the soft parts as much as possible, then a piece of soft leather Avetted, should be placed closely around the first phalanx, and over this a por- tion of tape, two or three yards in length should be fixed by the clove hitch, (a knot, so called by sailors.) An assistant should next firmly hold the metacarpal portion of the thumb, by passing his fore and middle finger between the patient's fore-finger and thumb, whilst the surgeon draws the first phalanx from the metacarpal bone, in a direction somewhat imvards to the palm of the hand. Another method.—If the above plan does not suc- ceed, the folloAving should be adopted:—The leather and tape being applied as before, a strong worsted tape should be passed betAveen the patient's fore- finger and thumb, and this should be tied to a bed f>ost, around which the arm should be bent; a pul- ey being then fixed to the tape connected to the first phalanx, a gradual and steady extension should be made, Avhich will generally effect the reduction. Sometimes not reduced.—When the above describ- ed means have been fairly tried, without success, it will be best to leave the case to nature, when the patient will, after some time, acquire a great degree of motion. When compound.—In cases of compound disloca- tion, should the reduction be difficult, a part of the 261 extremity of the bone may be removed by amputa- tion ; and the patient may afterwards obtain a use- ful joint, by the early employment of passive motion. Of Dislocation of the Second Phalanx. Easily detected.—In a simple dislocation of this kind, the nature of the injury can scarcely be mis- taken, and the reduction may be accomplished in the following way :—The surgeon should grasp the back of the first phalanx with his fingers, and apply his thumb upon the fore part of the dislocated pha- lanx, and then flex it upon the first as much as pos- sible. Treatment of compound.—The treatment of the compound dislocation of this articulation, is the same as that recommended for a similar accident in the first phalanx; but the ends of the tendon should be made smooth by the knife, when, by careful ap- roximation they will unite. Passive motion may e used in two or three Aveeks. 262 LECTURE XLIII. Dislocations of the Hip Joint. The head of the femur may be throAvn from the acetabulum in four directions. First.—UpAvards, upon the dorsum of the ilium. Second.—Downwards, into the foramen ovale. Third.—Backwards and upwards, in the ischiatic notch. Fourth.—Fonvards and upwards, upon the body of the pubes. A fifth form.—A displacement dowmvards and backwards has been described by some surgeons, but 1 have never had an opportunity of witnessing it, and I am inclined to believe that some mistake exists about this injury, although I do not mean to deny the possibility of its occurrence. Dislocation Upwards and Backwards on the Dor- sum Ilii. The most common.—This is the most common of the displacements of the hip joint, and is marked by the following signs :— Signs of.—The limb on the injured side is from one inch and a half, to two inches and a half shorter than the sound limb. The knee and foot are turn- ed imvards; the knee being a little advanced upon the other, and the great toe resting upon the tarsus of the other foot. The motion outwards is destroy- ed, so that the leg cannot be separated from the 263 other, but the thigh may be a little bent across the sound limb. The head of the bone may be felt, and seen to move, upon the dorsum of the ilium, if the knee is rotated imvards; excepting Avhen the injury gives rise to extensive extravasation of blood; the trochanter major is throAvn much nearer than usual to the anterior superior spinous process of the ilium, so as to render the rotundity of the injured hip much less than that of the sound side. The chief marks will therefore be, difference in length, change of position, diminution of motion, and loss of projection or rotundity from the altered position of the trochanter major. Fracture of the cervix.—The accident with which this dislocation is most liable to be confounded, is the fracture of the neck of the thigh bone Avithin the capsular ligament. The distinguishing marks are, hoAvever, sufficient to prevent any mistake, if com- mon attention be paid to the case. In the fracture of the neck of the thigh bone, the knee and foot are usually turned outwards, and the trochanter is draAvn upwards and backwards upon the dorsum of the ilium; the limb Avhich is shortened one or two inches by the contraction of the muscles, can be re- stored to the same length as the other by slight ex- tension; but the shortening immediately recurs Avhen the extension is abandoned; and the limb may be readily flexed, although it creates much pain. On rotating the limb, Avhen extended, a crepitus can be felt, Avhich is not perceptible whilst the limb is draAvn up. This fracture rarely happens, but in old persons, and is generally the effect of a very trifling injury; it occurs, however, much more frequently than the dislocation. Thus the greater mobility of the joint, the ease Avith which the length of the limb is restored; and the perception of crepitus during rotation, when the 264 limb is extended, furnish ample marks of distinction between the two injuries. Diseased hip.—The alterations in the figure of the joint produced from inflammation and ulceration, can hardly be mistaken for dislocations from vio- lence, excepting by persons ignorant of anatomy, and but little attentive to their professional duties. The gradual progress of the symptoms, the pain in the knee, the increased length of the limb at first, and the marked shortening afterwards; the extent of motion, and the sufferings created by any extreme movement, are differences which would hardly es- cape the notice of the most careless observer. The consequences of this disease, when of long standing, are ulceration of the head of the bone, ligaments, and acetabulum, accompanied with such a change of situation of the parts, as sometimes to present the appearances of dislocation, but the history of the case will readily inform the surgeon of its true na- ture. State of muscles.—In the dislocation upon the dorsum of the ilium, the pyriformis and glutei mus- cles, the triceps, the pectineus, the psoas magnus, and iliacus internus, the rectus, the semitendimosus, and membranosus, the obturator externus, and one head of the biceps are all shortened. The obtu- rator internus, the gemini, and quadratus fenioris are all stretched. The triceps and glutei chiefly oppose the reduction. Cause.—This dislocation is occasioned by a fall or Woav when the limb is turned inwards. Mode of reduction.—The reduction may be ac- complished in the following manner: bleed the pa-- tient to the extent of from twelve to twenty ounces, or even more if he be very robust, then place him in a warm bath, at the temperature of 100°, and gra- dually increase the heat to 110°, until he faints: and 266 to accelerate the faintness, give him in solution a grain of tartarized antimony every ten minutes, until nausea is excited. When faint, remove him from the bath, envelope him in blankets, and place him between tAvo strong posts, about ten feet asunder, and in which two staples are fixed; or rings may be fixed in the floor, and the patient laid between them. He should be placed upon his back, and covered well with blankets. A strong girt should then be passed between the thighs, close to the upper and inner part of the injured limb, and the ends of this should be fastened to one of the staples. A wetted roller should next be placed •ghtly on the lower part of the thigh, just above the knee of the injured limb, and upon this a leather belt, with straps and rings affixed for the attachment of the pulleys, should be closely buckled. The knee should be slightly bent, and the thigh directed across the sound one just above the knee. The pulleys must be attached to the straps of the belt, and to the other staple. The surgeon now should gradually and carefully com- mence the extension, and continue it until the pa- tient begins to complain of pain, when he should rest a little, without relaxing, so^ts to fatigue the muscles; having waited a short time, he should again draw the cord, and when the patient again complains, he should again suspend the extension, and so on, until the mus- cles yield, and he finds the head of the bone is brought near to the acetabulum, when he should give the string of the pulleys in charge to an assist- ant, with directions to keep up the extension, whilst he himself rotates the knee and foot gently, under which motion the reduction Avill be usually accom- plished. When the pulleys are used, the head of the bone does not generally return into the acetabulum with a snap, as the muscles, from continued exten- sion, have not sufficient poAver remaining to allow of 34 266 any poveerful contraction; thus the surgeon can only be assured of the accomplishment of the reduction, by the restoration of the figure of the part, and by loosening the pulleys and examining the joint. It sometimes happens, that the bandages get loose before the extension is sufficient, Avhen they should be carefully re-applied, but in as short time as possi- ble, to prevent the muscles from recovering their original tone. Head of bone lifted.—When the head of the femur has been brought by the extension to the edge of the acetabulum, the rotatory motion above mention- ed, is not always suffici#t to promote the reduction, but the head requires to be lifted over the lip of this cavity; this may be performed by passing a towel or napkin as near to the joint as possible, at the upper part of the thigh, and by it an assistant may raise the upper part of the bone from the surface of the ilium. When the reduction has been accomplished, the patient must be very carefully removed to bed, in consequence of the risk of further displacement, from the very relaxed state of the muscles. In recent cases.—The reduction of this dislocation may be completed, in a very recent case, before the muscles have had time to contract, by extension made in a direction, not under other circumstances, well adapted for this purpose ; and I have seen it thus effected :—The mode described by Mr. Hey, if I understand it correctly, appears to me but little cal- culated to succeed, unless in a very recent case; but I state this Avith great deference, as no one can have a higher opinion of the talents and professional ac- quirements of Mr. Hey, than myself, and I am not certain that I do understand, in all respects, the de- scription of the method which he adopted. Result of experience.—The plans which 1 have re- 267 commended, are the result of considerable experience, both in public and private practice; they have rare- ly failed even under the most unfavourable circum- stances; some slight deviation from them may be occasionally required, from some difference in posi- tion, but this will only be an exception to a general rule, and will occur but very seldom. I shall relate some cases in confirmation of what I have advanced. These first cases not only illustrate the mode of treatment detailed in the preceding observations, but particularly explain the benefits to be obtained by the employment of the pulleys, and the assistance of constitutional treatment. Case.—I am indebted to Mr. Bennet, surgeon, at Chester, for the history of the following case. John Forster, aged twenty-two years, had his thigh dislo- cated in consequence of a cart passing over his pel- vis, and was admitted into the Chester Infirmary July 10, 1818, soon after the receipt of the injury. The nature of the injury was Avell marked. The patient being placed upon a table, extension was made by pulleys for fifty minutes Avithout success. He was then placed in the warm bath for tAventy minutes, after which the extension was repeated for a quarter of an hour, but still without the desired effect. He was then bled to the amount of twenty- four ounces, and he took forty drops of tincture of opium, but as this did not create faintness, the solu- tion of tartar emetic was exhibited in small and fre- quent doses ; this soon produced nausea and faintness, during which a steady extension for ten minutes ac- complished the reduction. Mr. Nott, of Collumpton, Devon, sent me the fol- lowing particulars:— Case.—John Lee, aged thirty-three, a very stout man, dislocated his left hip by a fall, October 9,1819, 268 . but was not seen by Mr. Nott until the 4th of De- cember following, just eight weeks after the acci- dent, the effects of which still remained, exhibiting distinctly the usual appearances. The bandages and pulleys being applied, extension Avas gradually made, and at the time of its commencement, the solution of tartar emetic was given him, and repeated every ten minutes, but without creating much nausea. The extension still being continued, he was bled to the extent of sixty ounces, but Avithout producing syn- cope. The extension Avas kept up for tAvo hours, when an evident alteration was perceptible in the injured limb; the head of the bone was elevated by means of a toAvel under the upper part of the thigh, and the limb was rotated; soon after this period a grating was heard from the situation of the head of the bone, and the man immediately exclaimed that the limb was reduced; and this, on relaxing the pul- leys, we found to be correct; before removing him to bed his legs were bound firmly together to pre- vent any recurrence of the displacement, and a large blister was applied over the trochanter. When he Avas first allowed to rise from his bed, a bandage was applied upon the thigh and pelvis; passive motion was previously employed. In five weeks after the reduction he walked nearly twenty miles without in- convenience. The above case shows that the reduction may be effected by skilful management a considerable time after the receipt of the injury. And this is further confirmed by cases related by Mr. Mayo, and Mr. Tripe, of Plymouth, in each of which the disloca- tions had existed seven weeks before the reductions Avere accomplished. Without pulleys.—The following cases prove that this dislocation may be replaced without the use of 269 the pulleys, but at the same time show how desira- ble their assistance would have been. Cases.—Mr. Holt of Tottenham requested me to visit, Avith him, Mr. Piper, aged twenty-five years, who was the subject of dislocation of the thigh upon the dorsum of the ilium, but which had existed a month previous to his coming under the care of Mr. Holt. Mr. Holt and myself, assisted by five power- ful men, used our utmost exertions to replace the bone, and we Avere several times obliged, from fa- tigue, to relax, and renew our attempts. After re- pealed trials, for fifty-two minutes, we succeeded in effecting the reduction, when we had determined to make but one more effort. Another case, which I attended with Mr. Dy- son of Fore-street, Avas reduced without the use of pulleys, but Avith so much violence, and such une- qual extension, that I am sure no surgeon, Avho had seen the pulleys employed in reducing this form of dislocation, would have recourse to any other method. Mr. Oldnow, of Nottingham, sent me the particu- lars of a case in Avhich the reduction was effected without the assistance of pulleys, but in which an extension was made from the ankle, the pelvis being secured by towels. The dislocation Avas recent, and the reduction easy. Dislocation downwards, or into the Foramen Ovale. Signs of.—The displacement of the head of the os femoris into the obturator foramen, occasions an immediate lengthening of the limb, to the extent generally of two inches. The projection of the trochanter major is lessened, and the body is bent forwards from the stretching of the iliacus internus and psoas muscles. When the patient is erect the knee of the injured limb projects forwards, and the 270 . thigh is widely separated from the sound one from the action of the glutei and pyriformis muscles, and it cannot be made to touch the knee of the perfect extremity without great violence. The foot is also widely separated from the other, but the toes are not either everted or inverted, but are usually di- rected forwards. In very thin subjects, the head of the bone may be felt, by firmly pressing the fingers upon the inner and upper part of the thigh, to- wards the perineum. The chief diagnostic marks are, therefore, the increased length of the limb, the separation of the legs, and the bent position of the body. Situation of the bone.—The head of the bone is thrown below, and rather anterior to the axis of the acetabulum; and a depression exists below Pou- part's ligament. Cause.—The dislocation is produced by a fall or blow when the legs are much parted from each other. Dissection of.—The mischief occasioned by this injury is extremely well shown by a preparation in the Museum of St. Thomas's Hospital which I dis- sected many years ago. The head of the os femo- ris rested in the foramen ovale, which is entirely filled by bone, the external obturator muscle and the ligament, naturally occupying this space, being ab- sorbed ; bony matter had been also, extensively de- posited around the edge of the foramen, so as to form a deep socket, which enclosed the head of the bone, so that it could not be remoAred without break- ing the cup, but still allowing of considerable motion; the interior of this socket was perfectly smooth. The acetabulum Avas half filled with ossific matter, and so much altered as not to be capable of contain- ing the head of the thigh bone, which Avas but little changed, its articular cartilage still remaining perfect. 271 The ligamentum teres was completely torn through, and the capsular ligament partially lacerated? The pectinalis and adductor brevis muscles had been torn, but*had united by tendon, the psoas, iliacus internus, and pyriformis muscles, Avere all stretched. Ligamentum teres torn.—It has been supposed that the ligamentum teres Avas not lacerated in this dislo- cation, because, in the dead subject, the head of the bone can be drawn over the lower edge of the ace- tabulum, if the capsular ligament be divided whilst the round ligament remains uninjured; but as the dislocation occurs when the thighs are wide apart, and the ligament is upon the stretch, when the head of the bone is thrown from the acetabulum the liga- ment is torn through before the dislocation is com- plete. Reduction if recent.—In recent cases the reduction of this dislocation may be easily accomplished by the following means. The patient being placed up- on his back, and his thighs being separated as widely as possible, pass a girt between the upper part of the injured limb and the pudendum; and let the ends be fixed to a staple in the wall of the room; then grasp the ankle of the dislocated extremity, and draw the limb over the sound one, and thus the head of the bone will slip into its proper cavity. Placing the patient upon a bed, so that one of the bed-posts is received between the upper part of the thighs, and then forcing the injured limb across the sound one, will also effect the same purpose. Some- times, hoAvever, it will be found necessary to place a second girt or bandage round the pelvis beneath that Avhich I have already described, and the ends of this second girt should be fixed to a hook or sta- ple on the sound side of the patient, to prevent any lateral motion of the pelvis at the time that the in- jured extremity is drawn across the sound limb, oth- 272 erwise the motion of the pelvis following that of the lirflb may prevent the reduction. Of longstanding.—Should the dislocation have ex- isted for three or four Aveeks before any attempt is made to reduce it, the patient should be placed upon the sound side, and his pelvis fixed by one bandage, whilst another is placed under the upper part of the dislocated thigh, and connected to the pulleys above so as to> act perpendicularly; the surgeon should then press upon the knee and leg to prevent their being drawn up with the superior portion of the thigh bone, at the same time that an assistant elevates this latter part, by drawing the cord at- tached to the pulleys. Great care must be taken not to press the leg and knee too much, or the head of the femur will be forced backAvards into the ischiatic notch, for the power of the lever which is employed is very great. The folloAving case was communicated to me by Mr. Daniell. Case.—Mr. Thomas Clarke, aged fifty, received an injury to his hip in consequence of a fall from his cart in endeavouring to stop the horse, which had run way with him. Between two and three weeks after the accident, Mr. Potter, of Ongar, in Essex, was requested to visit the patient, and Mr. Daniell, being on a visit to Mr. Potter at the time, accom- panied him to see the case. On examining the injured limb, it was found to be three inches longer than the sound one, the knees were separated, and the foot turned a little outward; when the patient endeavoured to stand, his body was bent forwards. The nature of the injury being thus extremely evident, the following means were resorted to effect the reduction of the dislocation. The patient being robust, some blood Avas first taken from his arm, but 273 as this did not sufficiently reduce his powers, a solu- tion of the tartar emetic was given to him. He was then placed on his side, near to the edge of the bed, and a girt being passed round his pelvis, was carried through the frame of the bedstead and fixed, so as to prevent any movement of the body; a second girt was passed between the thighs, and fixed to the pulleys above the upper part of the injured limb. Whilst the extension Avas making Mr. Potter rotated the limb, and dreAV the knee toAvards that on the sound side. When these means had been continued for about ten minutes, the effects of the tartar emetic became excessive, and in five minutes after- wards the head of the bone returned to its original socket with a snap; the patient was then placed in bed, and the injured parts supported by a roller. He speedily recovered the use of his limb. Of the Dislocation backwards, or into the Ischiatic Notch. Common description wrong.—In describing this dis- location, some surgeons have considered the head of the os femoris as being thrown backwards and down- wards ; Avhich must have arisen from their not re- collecting the natural position of the os innominatum in the skeleton. This notch which gives passage to the pyriformis muscle, and also to the gluteal, ischiatic and internal pudendal arteries, with the sci- atic nerve, is naturally situated a little above, as well as behind the acetabulum, so that the head of the thigh bone Avhen displaced into this space, is placed upwards as well as backwards, with respect to the acetabulum ; and this you must carefully bear in mind. Situation of bone.—The head of the os femoris in this dislocation is situated on the pyriformis mus- 35 274 cle, between the edge of the bone which forms the upper part of the ischiatic notch, andthe sacro scia- tic ligaments. Difficult to detect.—Of all the dislocations of the thigh, this is the most difficult to detect, because the length of the limb is but little altered, and the change in the position of the knee and foot is not so marked as in the dislocation upAvards. It is also more difficult of reduction because the head of the bone is placed deeply behind the acetabulum, and requires to be lifted over the edge, as well as drawn towards it. Signs of.—The dislocation is marked by the fol- lowing signs:—The limb is from half an inch to one inch shorter than the sound one, but rarely more than half an inch. The natural projection formed by the trochanter major is diminished, and is inclin- ed towards the acetabulum, but still remains at right angles with the ilium. The head of the bone can only be felt in very thin persons, and then not very distinctly. The knee and foot are turned inAvards, and the great toe rests against the ball of the great toe of the sound limb. When the patient is erect the toe touches the ground, but the heel does not quite reach it, and the knee is bent and projects a little forwards. The motions of the joint are in a great degree prevented, admitting but of slight flex- ion and rotation. Dissection of.—There is in the collection at St. Thomas's Hospital, an excellent specimen of this in- jury, which I met with accidentally in the dissecting room. The original acetabulum is entirely filled by a ligamentous substance, so that it could not have again received the head of the femur; the capsular ligament is torn anteriorly and posteriorly ; the round ligament is torn through; the head of the bone rests in the situation I have before described; but there 275 is not any appearance of an endeavour to form a neAV socket for its reception. A new capsular ligament surrounded the head of the bone, but it has been opened and turned doAvn to exhibit the head, with the lacerated-portion of the ligamentum teres con- nected to it. Cause.—This displacement occurs from the ap- plication of violence'when the thigh is bent at right angles with the body, so that the knee is forced in- wards. Reduction.—The reduction, Avhich is extremely diffi- cult, is best effected in thefolloAvingmanner:—Place the patient on a table upon his sound side, and fix the pelvis by passing a girt between the pudendum and inner part of the thigh, and making it fast to some firm point; then apply a wetted roller round the limb above the knee, and over it buckle the leather strap, and place a towel under the upper part of the injured thigh. The extension should then be commenced Avith the aid of the pulleys, so as to draAV the dislocated thigh forwards in a direction over the middle of the sound one, measuring from the pubes to the knee ; when this has been contin- ued for a short time, an assistant should elevate the upper part of the bone, by drawing the towel with one hand, whilst he presses on the pelvis Avith the other; and by this means he will lift the bone over the brim of the acetabulum. A round toAvel passed under the upper part of the thigh, and over the shoulders of the assistant, will allow him to employ more force for this purpose, by raising his body at the same time that he rests both hands upon the pelvis of the patient. Another mode.—I have knoAvn another method succeed in effecting a reduction of this dislocation, although the one I have described is the best. Case.—A man, aged twenty-five, was admitted 276- into Guy's Hospital, under the care of Mr. Lucas, on account of a dislocation of his thigh backAvards. An extension Avas made by means of the pulleys, draw- ing the limb in a line with the body, and at the same time thrusting the trochanter major forwards with the hand; the reduction Avas accomplished in about two minutes. Signs of reduction.—The reduction is generally in- dicated by a snap which takes place Avhen the head of the bone returns into the acetabulum ; but when the muscles have been some time contracted, and when an extreme state of nausea has been produced by bleeding, and the tartar emetic, the reduction is not accompanied by any noise, as in the following case, the particulars of Avhich were given to me by Mr. Worts, a dresser to Mr. Chandler, at St. Thom- as's Hospital. Case.—James Hodgson, aged thirty-eight, a strong muscular man, was admitted into St. Thomas's Hos- pital, on Tuesday, February 8, 1820; his left thigh being dislocated backwards. On account of the great swelling which existed at the time of his admission, the nature of the injury was not considered suffi- ciently evident, and merely evaporating lotions were applied. On the 12th the patient Avas seen by Mr. Chandler and Mr. Cline, and the latter thought it a case of dislocation. On the 14th Mr. Chandler re- quested me (Sir Astley) to see the case, Avhen I im- mediately declared it to be a dislocation into the is- chiatic notch, and directed that the man should be bled, as he suffered considerable pain, and the ten- sion about the injured part was still very great. On Saturday the 19th, the pain and swelling having sub- sided, means were employed to effect the reduction. After bleeding the patient largely, and giving him the tartar emetic, the bandages and pulleys Avere ap- plied as I have already directed, and the extension 277 conducted in the same manner. The extension was continued for about ten minutes before any attempt was made to raise the head of the bone, but it was then tried, and at the same lime the limb was rotat- ed by turning the knee outwards. After the expi- ration of a quarter of an hour, the appearance of the hip became much altered, and of its natural shape; but as no snap had been heard, the same means were continued for tAventy-five minutes long- er, Avhen, in consequence of the strap above the knee becoming loose, the pulleys Avere removed, and it was then discovered that the reduction was ac- complished ; but it had occurred Avithout either the by-standers or the patient being aAvare of it. Of the Dislocation on the Pubes. Easily detected.—This is more readily detected than any other of the dislocations of the thigh. Cause.—It generally happens by the foot slipping unexpectedly into some holloAV, whilst a person is walking, the body being at the time bent backAvards, so that the head of the os femoris escapes fonvards. Signs of—The folloAving signs usually indicate this displacement; the injured limb is an inch shorter than the sound one; the knee and foot are turned outAvards ; but what renders it so evident, is the readiness with Avhich the head of the bone can be felt a little above the level of Poupart's ligament, upon the pubes, on the outer side of the femoral ar- tery and vein, it there forms a round hard swelling, which moves when the thigh is bent. Mistaken.—Although so easy to distinguish, yet 1 have knoAvn three cases in Avhich the injury has been overlooked, until too late to afford relief; this could only have arisen from great carelessness, or excessive ignorance. 278 Dissection of—A preparation from one of these neglected cases, which I had an opportunity of dis- secting, is preserved in the museum at St. Thomas's Hospital. It presents the folloAving appearances:— The acetabulum is in part filled by a new deposite of bone, and is in part occupied by the trochanter ma- jor, but both are very much altered. The capsular ligament is very extensively torn, and the ligamen- tum teres entirely divided. The head of the bone is placed on the pubes under Poupart's ligament, Avhich has been thrust up by it; the iliacus internus and psoas magnus muscles, are stretched over the neck of the bone, and upon them is the anterior cru- ral nerve. Both the head and neck of the bone are flattened, and the latter rests in a neAv articular ca- vity formed for it upon the pubes, above the level of Avhich the head of the femur is situated. The edges of the neAv acetabulum project upon each side of the neck of the bone, so as to confine it laterally, whilst Poupart's ligament confines it upon the fore part. The femoral artery and vein pass close to the inner side of this cavity, for the cervix of the femur. This injury might be mistaken for a fracture of the neck of the bone, but only through great carelessness and inattention. Reduction of.—The reduction of the dislocation may be accomplished in the following Avay:—Place the patient upon a table on his sound side; then pass a girt between the pudendum and the upper and in- ner part of the injured limb, and fix this to a staple rather before the line of the patient's body. The wetted roller, strap, buckles and pulleys, should then be placed above the knee, as before described for other displacements. The extension is to be made backwards and dowmvards. The application of the towel at the upper part of the thigh, and lifting the head of the bone by it, over the edge of the aceta- 279 bulum, is also necessary in reducing this form of dis- placement. The following case, which will illustrate the mode of reduction, occurred under the care of Mr. Tyrrell, at St. Thomas's Hospital. Case.—Charles Pugh, aged fifty-five, Avas admitted into St. Thomas's Hospital on the 23rd of January, 1823, with a dislocation of the right thigh, which had been produced by a bloAv upon the back part of the thigh, from a cart wheel, at the time he was making water at the corner of a street, and unpre- pared to resist the violence. The head of the bone could be distinctly felt below Poupart's ligament, immediately to the outer side of the femoral vessels. The foot and knee were turned outAvards, Avith very little alteration in the length of the limb. The thigh was not flexed towards the abdomen, and was nearly immoveable, admitting only of slight abduc- tion and adduction, also a little rotation outwards, but not at all inwards. It was speedily reduced by the following means :—The patient was placed on his left side, a broad band Avas placed betAveen his thighs, and being tied over the crista of the ilium on the right side, Avas made fast to a ring in the wall. A wet roller having been put on above the right knee, a bandage was buckled over it, and its straps attached to the hooks of the pulleys, by which a gradual extension Avas made, draAving the thigh a lit- tle backAvards and doAvnwards. When this exten- sion had been kept up a short time, another bandage was applied round the upper part of the thigh, close to the perineum, by means of which the head of the bone was raised, and in the course of a few minutes the reduction was easily accomplished. The patient had not been bled nor taken any medicine ; he suffer- ed but little after reduction, and Avas able to walk without pain or inconvenience five or six days after- wards. 280 Frequency of the different dislocations.—From what I have observed respecting the comparative fre- quency of the dislocation of the thigh, I should think the proportion in tAventy cases about as follows:— tAvelve on the dorsum ilii; five in the ischiatic notch; two in the foramen ovale; and one on the pubes. Formerly overlooked.—Considering the frequent occurrence of these dislocations, it is extraordinary that they should have escaped the observations of former surgeons; it can only be accounted for by the difficulties Avhich existed in the pursuit of morbid anatomy. I Avas informed by Mr. Cline, that Mr. Sharpe, a surgeon of Guy's Hospital, possessing con- siderable eminence, and author of a " Treatise on Surgery," did not believe that these displacements ever took place. Now readily recognised.—There is great pleasure in contrasting the present state of professional in- formation with that which existed fifty years ago. Our provincial surgeons now readily detect these in- juries, and generally succeed in reducing them. Let us never, however, forget that it is to the knowledge of anatomy, and more especially, of morbid anatomy, that Ave are indebted for this superiority; and there- fore Ave should never neglect or lose an opportunity of pursuing our investigation on these points, if we Avish to increase our reputations as surgeons, and practice our profession Avith credit. Injuries liable to be mistaken for Dislocations of the Hip. Of Fractures of the Os Innominatum. In these cases the application of the force neces- sary to reduce a dislocation, increases excessively the patient's sufferings, and destroys the probability of recovery, if any previously existed. 281 Signs of.—When a fracture occurs of the os in- nominatum, Avhich extends through the acetabulum, the head of the os "femoris is drawn upwards, and the trochanter major is turned a little forwards ; thus the leg is somewhat shortened, and the knee and foot are a little inverted, resembling the ap- pearances produced by a dislocation into the ischi- atic notch. When the sacro iliac junction is broken through, and the pubes and ischium are fractured, the limb is in a great degree shortened ; but the position of the knee and foot is not altered. Differ from dislocation.—These injuries do not affect the motions of the hip joint so much as dislo- • cations, and a crepitus can be felt if the limb be moved whilst the hand rests upon the crista of the ilium. I have seen three cases of fracture of the os in- nominatum, somewhat resembling dislocations, two in which the injury extended through the acetabu- lum, and one in which this cavity remained uninjur- ed ; the following are the principal features of these cases. Cases.—In the year 1791, a man was admitted into St. Thomas's Hospital, on Avhom a hogshead of sugar had fallen. When examined, his right leg and foot Avere found inverted, and the limb appeared shorter than the left by tAvo inches. Whilst making a gentle extension to endeavour to bring the injured limb to an equal length with the perfect extremity, a crepitus was discovered in the os innominatum. The patient was' exceedingly pallid, his muscular power extremely feeble, and he appeared rapidly sinking. He expired the same evening. The fol- loAving appearances presented themselves when the body Avas examined:—The deep part of the ace- tabulum Avas broken off, so as to allow of the escape 36 282 of the head of the thigh bone from the cavity; the neck of the bone Avas firmly embraced by the tendon of the obturator internus, and by the gemini; the junction of the pubes at the symphysis had been se- parated, and the bones Avere nearly an inch apart; the ilium, ischium and pubes Avere fractured, and the fracture extended through the acetabulum ; the left kidney was much injured, and about a pint of blood was found extravasated into the cavity of the abdo- men. In the second case, which also was in St. Tho- mas's Hospital, the appearances of a dislocation backwards existed. The patient died upon the fourth day after the receipt of the injury; and on examination after death, an extensive fracture of the innominatum was discovered, passing through the acetabulum and dividing it into three parts ; the head of the os femoris was deeply sunk into the cavity of the pelvis. The third case in which the acetabulum escaped was brought into Guy's Hospital in the year 1817, August the 8th. Mary Griffiths, aged thirty, had her pelvis caught between a cart wheel and a post; —when admitted into the hospital, she Avas pale, feeble, and her far-ces passed off' involuntarily. On grasping the right os innominatum a distinct motion and crepitus could be perceived, and the posterior superior spinous process projected much above its natural situation. The pubes appeared driven in toAvards the cavity of the pelvis. An extensive ec- t chymosis existed upon the right side below the last rib. The pelvis was fixed by a broad bandage, and some opium was administered. She lived until the evening of the 24th, and appeared to sink from the effects of a large slough, which formed over the seat of extravasation upon the right side. Examination.—The body was inspected the next 283 day, when an extensive fracture was found extend- ing through the body of the pubes and the ramus of the ischium on the left side ; the right ilium Avas separated from the sacrum at the sacro iliac sym- physis, Avith a portion of the transverse processes of the sacrum which Avere torn from the sacrum with the ligaments; the left sacro iliac junction had also given way, but only to a sufficient extent to admit the narrow extremity of the handle of the scalpel between the bones. I have known several cases of simple fracture of the innominatum recover. Of Fractures at the upper part of the Thigh Bone. Mistaken^for dislocation.—These injuries have been frequently mistaken for dislocations of the hip, and the distinguishing marks are sometimes with dif- ficulty detected. Three species of.—Three species of fracture dif- fering in their nature and result, and requiring dis- tinct modes of treatment, are met with at the upper part of the femur, and have been generally classed under the indiscriminate appellation of fracture of the cervix femoris. Want of proper anatomical in- vestigation by dissection, has given rise to this con- fused classification, and has led to the disputes re- specting the processes Avhich nature employs to effect a cure. Thus one surgeon declares that they cannot be united, whilst another asserts that the cure is as easily performed as in fractures of other bones. The opinions I am about to offer to you, are the result of extensive observation on the living, who have suffered from these injuries; of numerous ex- aminations of the dead body; and of many experi- ments which I have performed upon inferior animals. 284 Of frequent occurrence.—These accidents are of such frequent occurrence, that the wards of our hospitals are seldom without an example of them; whilst scarcely two cases of dislocation happen there in the course of the year, although the buildings contain about nine hundred patients. The different species of injury are as follow :— First.—That which takes place through the neck of the bone entirely within the capsular ligament. Secondly.—A fracture through the neck of the thigh bone at its junction Avith the trochanter major, external to the capsular ligament. Thirdly.—Fracture through the trochanter major, beyond the cervix femoris. Of Fracture of the Neck of the Thigh Bone within the Capsular ligament. Signs of limb shortened.—The following appear- ances are usually produced by this fracture :—the limb becomes shortened one or tAvo inches; this arises from the connexion between the head of the bone and the trochanter major being destroyed, so that the latter loses its support and is drawn up by the action of the glutei muscles, as far as the cap- sular ligament will admit of; and it therefore rests upon the edge of the acetabulum, and a little upon the ilium above it. This difference in length is readily detected by placing the patient in a recum- bent posture and comparing the situation of the malleoli; the heel of the injured extremity is usual- ly found resting in the holloAv between the internal malleolus and the tendo achillis of the sound limb; but this is not always the case. For a short period after the receipt of the injury, this shortening may be made to disappear by a very slight extension of the limb, but it again re-appears immediately that the 285 extension is discontinued. This may be again and again effected, until the muscles acquire a fixed con- traction, which cannot be subdued but by very great force. Limb everted.—Another indication of this accident is the eversion of the knee and foot, from the action of the powerful and numerous rotators outwards^ which have but very feeble opponents; the obtu- ratores, the gemini, the pyriformis, the quadratus, the gluteus maximus, the pectinalis, and the triceps, all assist in the rotation of the limb outwards; whilst only a part of the gluteus medius, with the minimus and the tensor vaginae femoris act as antagonist mus- cles, or rotators inwards. The eversion is by some considered as depending on the weight of the limb, and not upon the muscular contraction; but the re- sistance afforded by the rotators outwards, when an endeavour is made to turn the limb inwards, suffi- ciently prove the true cause of the eversion. The inversion is also in some.degree prevented by that portion of the neck which remains attached to the trochanter major, and which rests against the ilium. Principal marks.—The shortening of the limb, and the eversion of the knee and foot, are the two principal marks which attract the attention of the surgeon. How produced.—When the femur is dislocated upwards, eversion of the knee and foot is prevented by the head and neck of the bone; but the separa- tion of these from the trochanter in the case of fracture,, allows of a ready eversion. I have known the limb inverted in a case of fracture of the cervix femoris, but this must be regarded as an extremely rare circumstance. Symptoms not well marked at first.—The nature of this injury is not well marked until some few hours after the receipt of the injury, as the muscles do not acquire a fixed contraction for some time ; it 286 is from this circumstance that the injury has been mistaken for dislocation, and that the patients, even in the large hospitals, have been submitted to use- less and painful attempts to reduce the displacement. Degree of suffering.—After the receipt of this in- jury, the patient suffers little or no pain whilst at rest in the recumbent posture, but rotation of the limb, more particularly inwards, creates much suffer- ing from the fractured end of the bone rubbing upon the synovial membrane, Avhich lines the capsular ligament. The pain is most acutely felt at the up- per and inner part of the thigh, near the insertion of the psoas and iliacus internus muscles, into the trochanter minor. The limb can be moved in all directions, but the flexion creates pain, and is accomplished with diffi- culty, particularly if the thigh be directed towards the pubes ; if the knee be carried outwards when the thigh is flexed it is accomplished with more ease, and without producing much pain. Trochanter major projects less.—The trochanter major of the injured side projects less than that of the sound side, as it has lost the support of the neck ; it is also drawn up towards the ilium, and is there- fore higher than that of the perfect limb. Patient examined erect.—To be perfectly satisfied of the nature of the injury, the patient should be examined in the erect as Avell as in the recumbent posture ; he should be made to stand, which he can do Avith assistance, and endeavour to bear his weight upon the sound extremity, Avhen the shortening of the injured limb is distinctly seen, the knee and foot are everted, and the prominence of the hip is less- ened. Pain on standing.—In attempting to rest upon the unsound limb, the patient experiences great pain in consequence of the stretching of the psoas, iliacus 287 internus and obturator externus muscles, as well as by the pressure of the fractured portion of the cer- vix upon the capsular ligament. Crepitus.—The fracture is not indicated by a cre- pitus on motion whilst the patient is recumbent, as in other fractures, but it can generally be felt, when the limb is extended to the original length and then rotated ; the crepitus may sometimes be discovered on the mere elongation of the extremity, but it is most distinct if it be turned inwards. Most frequent in females.—Females are more liable to this accident than males, which may be accounted for by the powers of the constitution being generally weaker, and the natural position of the neck of the thigh bone more horizontal. In old age.—The period of life at Avhich this in- jury occurs, is another circumstance Avorthy of con- sideration, as it seldom takes place but at an advanced period of life. We find it described as happening in young persons, but in these cases the injury has not been really confined to the cervix Avithin the capsular ligament, and thus so much confusion has arisen with respect to the true character of the ac- cident. During a period of forty years, for which I have attended St. Thomas's and Guy's Hospitals, and in my private practice, which has been more than my share, I have seen between two and three hundred cases of fracture of the cervix femoris, with- in the capsular ligament; yet in very few instances have I known it take place in persons under the age of fifty years. It is most frequently met with be- tAveen the ages of fifty and eighty, at a time of life when dislocation very rarely takes place. I have, however, seen a case of the fracture at the age of thirty-eight, and a case of dislocation at sixty-two. Reasonsfor.—The liability to the different forms of injury at the different periods of life, is OAving to 288 the changes which are taking place in the bones as well as in the other structures of the body, ac- cording to the balance of the arterial and absorbent systems; during youth the action of the former pre- ponderates, and hence the source of growth; in middle age the two preserve an equilibrium of ac- tion, and thus but little alteration occurs; in old age the absorbents exceed in activity the arteries, from which a diminution arises, but this is rather from a disease of power in the arteries than an increase in the absorbents. Change in bones.—Thus the increase of the bones takes place in youth, until they acquire that bulk, weight, and compactness which characterizes them at the adult period, and which they for some time retain, until they become gradually light and soft in the advanced period of life : even the neck of the thigh bone undergoes a considerable change from an interstitial absorption, by which it becomes shorten- ed, and altered in its angle with the shaft of the bone, the head often sinking beneath the level of the trochanter major, instead of being above it. This alteration gives the idea, upon a superficial in- spection, of there having been formerly a fracture which had united. Period of change varies.—The period at which these alterations take place, vary in different indi- viduals, as we find the general appearances do, which indicate old age, and which are as strongly marked in some at sixty, as in others at eighty years of age. It is from these changes, however, that the nature of injury varies generally at the different periods of life, as from the different states of the bones, that violence which would produce dislocation in the adult, occasions fracture in the old person; and when dislocation does occur at an advanced period of life, it is in those persons who have particularly strong 289 constitutions, and in whom the bones have not under- gone the changes I have described. Causes very slight.—The very slight causes which often occasion fracture of the bones in old persons, is a proof Iioav much this altered state predisposes to such injury. The most frequent cause of the fracture of the neck of the thigh-bone, in London, is a sudden slip from the foot to the carriage pave- ment ; Avhich, although only a fall of a few inches, yet it is sufficient to produce this serious accident. It is also often occasioned by a slight fall upon the trochanter major; and I have known it produced by the toe catching in the carpet, or against some pro- jection in the floor, at the time that the body was suddenly turned to one side. It is particularly ne- cessary to recollect the very slight causes Avhich give rise to this injury, and to be on your guard re- specting it, otherwise it could hardly be supposed that an accident of so serious a nature could be so easily produced. Opinions on mode of union.—With respect to the mode in Avhich these fractures of the neck of the thigh bone within the capsular ligament unite, much difference of opinion exists ; it is asserted by some surgeons, that thesef ractures unite like those occur- ring in the other bones of the body ; but from the numerous dissections Avhich I have had an opportu- nity of performing in these cases, I firmly believe that, as a general rule, the transverse fracture of the cervix Avithin the capsule does not unite by bone ; such is the opinion I have delivered in my lectures for these thirty years, and which has been from year to year strengthened by further observations and fresh dissections. Want of bony union,—In all the examinations which I have made of these cases, I have seen but one in Avhich a bony union had followed a transverse frac- 37 290 ture of the neck of the bone within the capsular ligament. I do not, however, mean to deny the pos- sibility of a bony union, or to maintain that it cannot take place, but it is an exceedingly rare circumstance. Considering the various modes in Avhich a fracture may take place, the degree of violence which may occasion it, and the extent of mischief to the sur- rounding parts, which may accompany it, it would be presumptuous in any one to maintain the impossibility of a bony junction; the bone may be broken with- out the fractured ends being separated from each other, or Avithout any laceration of its periosteum, or the reflected ligament which covers its neck; and again, the fracture may be in part within, and in part without the capsular ligament; under this latter cir- cumstance, I Avell know that an ossific union might be produced; and I have had the opportunity of seeing more than one. Causes preventing bony union,—I shall now point out several circumstances Avhich in my opinion tend to prevent an ossific union after a transverse fracture of the neck of the thigh bone within the capsular liga- ment. Want of apposition.—In the first place, a Avant of proper apposition of the fractured extremities of the bone may in many cases have considerable effect in preventing the union by ossific matter, as we find that a proper junction does not take place between the broken portions of bone, in any part of the body, when the extremities are much separated from each other. Cases.—In the case of a boy, from whom a por- tion of the tibia was removed in consequence of its protruding from compound fracture, but in whom the fibula remained uninjured, so that the ends of the divided tibia could not be brought into contact, no bony union took place. 291 A case someAvhat similar occurred in the Bristol Infirmary, under the care of Mr. Smith. A portion of diseased tibia, between Iavo and three inches in length was removed, leaving a space to that extent between the ends of the bone; and six Aveeks after the operation the boy was able to walk about with- out much difficulty, and it was supposed the ossific union had taken place; but in consequence of his death from small pox, an opportunity occurred of examining the limb, when the larger part of the for- mer space was found to be occupied by a thin liga- mentous substance, without any bony deposite. Experiments.—This is also confirmed by experi- ments which I have made on other animals. I took out a portion of the radius of a rabbit measuring seven-eighths of an inch in length, after which the ends of the bone did not unite to each other, but formed connexions to the ulna; in a second experi- ment, I removed a portion of the radius from anoth- er rabbit, measuring only one-ninth part of an inch, but with the same result. Also a portion of the os calcis being separated and drawn above its natural situation by the action of the gastrocnemius muscle, only united by ligament. Motion of the part.—In the fracture of the cervix femoris it is extremely difficult to keep the limb in a proper and steady position, as the most trifling change in position produces some motion of the part from the contraction of the powerful muscles which pass from the pelvis to the thigh. Were this, however, the only difficulty, it might possibly with much care and attention, be in a great measure obviated. Want of continued pressure.—Even in those cases in which the length of the limb is properly preserved, another circumstance I conceive may operate to pre- vent the bony union, which is the want of pressure of one portion of bone upon the other, when the 292 capsular ligament remains entire. This arises from the secretion of a large quantity of synovial fluid into the capsule, Avhich distends the ligament, and prevents the proper contact of the tbroken bones. After the inflammatory process has subsided, and the effusion of ligamentous matter has taken place from the synovial membrane, then this fluid becomes ab- sorbed. How prevented.—In other fractures where the bones are surrounded by muscles, the broken extre- mities are kept pressed together by the action of these muscles; but in the fracture taking place through the neck of the thigh bone, the muscles can only act upon one portion, and that in such a Avay as tends to separate one from the other. Pressure essential.—That pressure is essential to the bony union, is proved by the examination of those cases in Avhich the fractured ends of the bone overlap each other, Avhen a proper ossific deposite is found on that side where they press upon each oth- er ; whilst on the opposite sides, where no pressure exists, scarcely any alteration can be perceived. Again, in those cases Avhere the actions of the mus- cles separate the fractured ends of a bone, as Ave frequently find, union does not take place until the surgeon produces the necessary pressure by artificial means; as .by the application of a belt, which buc- kles tightly round the limb. Deficiency of ossific inflammation.—A third circum- stance, hoAvever, tends principally to explain the want of bony union ; in these cases, it is the deficien- cy of ossific inflammation in the head of the bone, when separated from the cervix; it is then only sup- ported by the vessels passing from the ligamentum teres, which are minute and feAV in number. In the perfect state, the head and neck of the femur are chiefly supplied with blood by the vessels of the 293 cancelli of the cervix, and by those of the reflected membrane which covers it* If, therefore, in cases of fracture the reflected membrane be torn through, which it generally will be, the chief source of sup- ply to the head of the bone, and that portio'n of the neck connected with it, is cut off, and there is not sufiicient organic poAver remaining to produce ossific matter; thus we find that scarcely any change takes place in the head of the bone," similar to that occur- ring in other bones when fractured; there is merely a layer of ligamentous substance thrown out, and covering the surface of the cancellated structure. Dissection.—On examining these injuries by dissec- tion, we usually find the folloAving appearances:— The head of the bone remains in the acetabulum connected by the ligamentum teres. There are upon the head of the bone, very small white spots, covered by the articular cartilage. The cervix is sometimes broken directly transversely, at others with obliquity. The cancellated structure of the broken surface of the head of the bone, and of the cervix, is holloAved by the occasional pressure of the neck, attached to the trochanter, and consequent ab- sorption; and this surface is sometimes coated par- tially with a ligamentous depositc. The cancelli are rendered firm and smooth by friction, as we see in other bones Avhich rub upon each other when their articular cartilages are absorbed, giving the surface the appearance of ivory. Portions of the head of the bone are broken off, and these are found either attached by means of ligament, or floating loose- ly in the joint, covered by a ligamentous matter; but these pieces do not act as extraneous hodies, so as to excite inflammation, and thus produce their dis- charge; not more than those loose portions of bone covered by cartilage, Avhich are found so frequent- ly in the knee, ana sometimes in the hip and elbow 294 joints. With respect to the neck of the bone Avhich remains attached to the trochanter major, the most remarkable circumstance is, that it is in a great de- gree absorbed, but a small portion of it remaining; its surface is yellow, and bearing the character of ivory, if the bones have rubbed against each other. Some ossific deposition I have seen manifested around this small remaining part of the neck of the bone, and upon the trochanter major, and thigh bone be- low it, in some examples of this fracture. Capsular ligament thickened.—The capsular liga- ment, enclosing the head and neck of the bone, be- comes much thicker than natural; but the synovial membrane undergoes the greatest change from in- flammation, being very much thickened, not only upon the capsular ligament, but also upon the reflect- ed portion of that ligament upon the neck of the bone, as far as the edge of the fracture. Increase of synovia.—Within the articulation, a large quantity of serous synovia is found; by which term I mean to express, that the synovia is less mu- cilaginous, and contains more serum than usual; this fluid by distending the ligament, separates for a time one portion of bone from the other; it is produced by the inflammatory process, and becomes absorbed when the irritation in the part subsides. I do not knoAV the exact period at which this change takes place, but I have seen it in the recent state of the injury. Into this fluid is poured a quantity of liga- mentous matter, by the adhesive inflammation ex- cited in the synovial membrane, and flakes of it are found proceeding from its internal surface, uniting it to the edge of the head of the bone. Thus the ca- vity of the joint becomes distended, in part by an in- creased secretion of synovia, and in part by the solid effusion which the adhesive inflammation produces; the membrane reflected on the cervix femoris is 295 sometimes separated from the fractured portions, so as to form a band from the fractured edge of the cervix to that of the head of the bone ; bands also of ligamentous matter pass from the cancellated structure of the cervix to that of the head of the bone, serving to unite, by this flexible material, the one broken portion of bone Avith the other. Ossific deposite on the body of the bone.—The tro- chanter is draAvn up more or less in different acci- dents; and in those cases in which it has been very much elevated, I have known a considerable ossific deposite take place upon the body of the thigh bone, between the trochanter major and the trochanter minor. When the bone has been macerated, its head is much lighter and more spongy than in the healthy state, excepting on those parts most expos- ed to friction, Avhere it is rendered smooth by the attrition, which gives it a polished surface. Inmost cases no ossific union,—It may,therefore, be considered as a general principle, that ossific union is not produced in these cases; nature makes some ef- forts to effect it on that portion of the fracture at- tached to the body of the bone, but scarcely any upon the head and portion of the cervix separated with it. Not only in the hip joint.—This want of ossific union does not appear to be merely confined to the frac- ture of the cervix femoris, but also occurs in the fractures of the condyles, of the os humeri and co- ronoid process of the ulna, and other articular pro- cesses, when broken off entirely within the capsular ligament. These opinions, Avhich I have for many years de- livered in my lectures, have been confirmed by many cases in Avhich I have had an opportunity of dissect- ing the injured joint, and also by the result of the experiments which I have performed on other ani- 296 mals, and in which I found only a ligamentous union occur Avhen the fracture Avas confined to within the capsular ligament. Confounded with dislocations.—The cases of frac- ture of the cervix femoris may be confounded with those dislocations of the hip in which the limb is shortened; viz. those occurring on the dorsum ilii, the ischiatic notch, and on the pubes ; the eversion of the knee and foot, with the greater mobility of the limb will distinguish them from the two former; and in the latter instance, the readiness with which the head of the bone can be felt in the groin, renders the case sufficiently obvious. With other fractures.—They may be also confound- ed with the cases of fracture external to the capsu- lar ligament; but if the surgeon be sufficiently atten- tive to the following points, he will readily distin- guish the difference :—the age of the patient, the length of the limb, the cause of the injury, the feel- ing of crepitus, the great extravasation of blood, and the degree of suffering; for the fracture of the cervix generally occurs at an advanced age; the limb is shortened, the cause of the injury very slight, there is not any perception of crepitus until the limb be* elongated, and the degree of suffering is very tri- vial. Various modes of treatment.—In the treatment of the fractures of the neck of the thigh bone, within the capsular ligament, I have tried numerous and various means, to endeavour to effect a bony union, and I have known other surgeons adopt many inge- nious plans Avith the same vieAV, but all without suc- cess. The double inclined plane has been employed Avith numerous contrivances to keep the injured limb extended, and to support the fractured portions in contact, also to prevent as much as possible, the mo- 297 tions of the pelvis. The straight position with va- rious modifications, has likewise been employed; in- deed, I scarcely know any form of mechanical treat- ment which could be adopted, Avhich has not been tried, for the purpose of aiding the bony union in these cases. I have not, however, yet witnessed one single example of such a union, which was not doubt- ful, as to its being entirely within the ligament. Case.—In a convict at Sheerness, who could be completely controlled, the limb was kept steadily extended for six months, yet it united only by liga- ment. I am aware that instances of success have been published; but I cannot give credence to such cases, until I see that the authors are aware of the distinc- tion between fractures within, and those without the capsular ligament; and that they are likewise ac- quainted with those changes in the head and neck of the bone, which occur in advanced age. Treatment recommended.—Not having found or known any mode of treatment succeed in effecting an ossific union in these cases, and having repeatedly seen the patient's health much injured by the trials which have been made, all that I now direct to be done, is, that a pillow should be placed under the limb for its whole length, and a second rolled up, put under the knee, and that the limb should be allowed to remain upon these for ten days or a fortnight, until pain and inflammation have subsided; the pa- tient should then be allowed to rise and sit in a high chair, to prevent much flexion of the limb, which would be painful. In a few days more he should begin to walk with crutches, and after a time a stick should be substituted for the crutches, and in a few months he will be able to use the limb Avithout any adventitious support; when he commences to bear the Aveight of the body on the limb, he should be 38 298 provided with a high heeled shoe, which will much assist him. Degree of recovery.—The period and degree of re- covery in these cases, depend much upon the bulk of the patient; as the very corpulent patient will, for a long time, require the aid of crutches, in others less bulky, a stick only will be required; and in very spare persons such assistance is only necessary for a very short period; but unless a shoe be worn having a sole sufficiently thick to remedy the diminished length of the limb, the patient has a considerable degree of lameness. In doubtful cases.—Should any doubt exist as to the fracture being situated external or internal to the capsular ligament, the case should be treated as for the former injury, Avhich I shall presently de- scribe, and in Avhich ossific union may be procured. A cautious opinion necessary.—The surgeon should be very cautious in the opinion he gives respecting the result of these injuries, as when the fracture is transverse, lameness is certain to follow; but in va- rious degrees, which cannot at first be estimated. Sometimes fatal.—In very aged and infirm persons* this accident sometimes produces fatal consequences, from the exhausted state of the constitution, and from the confinement in the attempts at union. Of Fractures of the Cervix Femoris, external to the Capsular Ligament. Difficult to distinguish.—The symptoms produced by this injury, are, in many points, so similar to those accompanying the former injury, that great attention is necessary to distinguish them. Such a distinction, is, however, highly important, as the result differs so materially, an ossific union being readily produced when the injury is external to the capsular ligament; 299 whereas, in that which I have already described, such a union rarely, if ever, takes place. Signs of—When the fracture occurs external to the ligament, the injured limb is but little shorter than the other; the foot and knee are everted, the rotundity of the hip is lost, and the patient experi- ences much pain at the hip, and about the upper and inner part of the thigh. These marks are also found when the fracture takes place internal to the capsular ligament. Distinguishing signs of.—The following are the principal signs by which the nature of these injuries may be detected :—1st. The fracture external to the capsule occurs frequently at an earlier period of life than that which takes place internal to the joint; although I have known it produced after fifty years of age, yet it is usually found under that age. 2nd. The injury is generally occasioned by much greater violence, as by severe bl*ws or falls, or the passage of laden carriages over the pelvis, whereas the in- ternal fracture is the consequence usually of very slight cause. 3rd. The crepitus in the fracture ex- ternal to the ligament, is readily felt when the limb 'is slightly moved, and generally Avithout drawing it down. 4th. The degree of suffering is much greater, especially on moving the limb, if the injury be ex- ternal to the capsule, as the rough extremity of the bone penetrates the surrounding muscles; the limb v also is much more sAvollen, and the constitutional ir- ritation is considerable. 5th. There is great extra- vasation of blood, generally, in these cases. Dissection of.—In dissecting these cases, the frac- ture is generally found at the root of the neck of the bone, external to the capsular ligament; but its seat and extent varies very much in different exam- ples, and the degree of shortening of the limb, de- pends upon the form of the fracture, and upon the 300 extent of laceration of the surrounding soft parts, so as to admit of retraction. Complicated.—Sometimes the fracture external to the capsular ligament, is complicated with injury of the trochanters. Case.—Mr. Travers has an excellent specimen of this form of injury taken from a patient who was under his care in St. Thomas's Hospital. Richard Norton, aged sixty, was admitted into the Hospital on the 24th of January, 1818, in conse- quence of severe injury of his left hip, occasioned by a fall upon the curb stone of the foot pavement. The limb of the injured side Avas shortened, and the knee and foot everted; the swelling about the hip was very great; the limb could be moved freely in all directions, but not without creating much suffer- ing; and Avhen moved a crepitus could be distinctly felt in the situation of the trochanter major. When the swelling had in great measure subsided, the limb Avas confined by the application of the long outer splint, and two thigh splints Avell bedded. In March the splints were removed, when the limb was found to be a little shortened, but the hip had regained its natural appearance. About a month after this, he began to use his limb, walking with the aid of crutch- es. He Avas afterwards placed under the care of the physician, on account of his general health being defective, and he died suddenly, being seized with spasms in his chest. Dissection.—On examining the hip after his death, the fracture was found to have extended through the trochanter, some way down the bone, and it had apparently united with very slight deformity, but on macerating the bone, the head and neck became loose on the body of the femur; they could not, however, be perfectly separated, as a shell of bone had formed, confining the head and cervix. 301 The preparation which Mr. Travers was so kind as to send me, presents the following appearances: the head and cervix of the bone had been separated from the trochanter major and body of the femur. The upper part of the bone had been obliquely split, so as to receive the cervix into its cancelli. This fracture had divided the posterior portion of the trochanter major from the body of the thigh bone, and the trochanter minor had been removed with it. Union had taken place between the frac- tured portions of the trochanter, at a slight distance from each other, and thus a hollow was left into which the cervix femoris was received, but it had not been united by ossific deposite, as it became loose from the maceration. Mr. Oldnow's cases.—Mr. Oldnow of Nottingham sent me tAvo specimens of this fracture, in which the necks of the bones were fractured at their junc- tions with the trochanter major. The trochanter major itself had been broken off, and the trochanter minor formed a distinct fracture. The bones had become re-united, the cervix femoris to the shaft of the bone, and the trochanter minor a little higher than its natural attachment. The trochanter major was in one specimen re-united to the body of the bone, but not in the other. Thus the thigh bone was at its upper part divided into four parts; the head and neck of the bone formed one part; the trochanter major a second; the trochanter minor a third, and the body of the bone the fourth. Thus this fracture unites by bone in a similar manner to the fracture of other bones external to the capsular ligaments, because the bones can be brought into apposition, and are confined together by the surrounding muscles, and the nutrition of each extremity of the bone is well supported by the vessels which proceed to it from the surrounding parts. 302 Difference of opinion accounted for.—This in some measure explains the difference of opinion respecting the union of the fracture of the neck of the thigh bone. In the internal fracture, the bones are not applied to each other, and the nutrition of the head of the bone being imperfect, no ossific deposite is produced; but in the external injury, the bones are field together by the pressure of the ^surrounding soft parts, and are easily kept in apposition by ex- ternal bandages and splints. Generally a long period is required to produce a perfect union in these cases, and many months elapse before the patient acquires a free use of the limb. Fracture through the Trochanter Major. Nature of.—An oblique fracture sometimes occurs through the trochanter major, without any injury to the cervix of the thigh bone. This accident takes place at all periods of life, and its symptoms are as follow. Signs of—The limb is but little shortened, and sometimes its length is not altered; the foot is gen- erally benumbed; the patient cannot turn himself in bed without assistance, and any attempt to do so creates excessive pain. The portion of the tro- chanter connected to the shaft of the bone, is either drawn forwards towards the ilium, or it falls to- wards the tuberosity of the ischium, being, in gen- eral, widely separated from the superior portion, or that which remains connected to the neck of the bone. The foot is greatly everted, and the patient is unable to sit on account of the violent pain pro- duced by the position. From the separation of the fractured extremities of the bone, crepitus cannot often be detected, unless the limb be very freely moved. 303 Most important signs.—The eversion of the foot, and the altered position of the trochanter major, are the chief distinguishing marks of the injury. Unite by bone.—Ossific union readily takes place in these cases, more quickly than in the fracture through the cervix femoris, and the patient recovers a very good use of the limb. Cases.—The first case Avhich I recollect seeing of this injury, was about the year 1786, in St. Tho- mas's Hospital, under the care of Mr. Cline. The limb was extended over a pillow, rolled under the knee, and splints were applied on each side of the limb; a firm union took place, and the man was able to Avalk extremely well. After being dismissed from the hospital, he was attacked Avith fever, of which he died. On examining the seat of injury after death, the fracture which had extended through the trochanter major, was found firmly united with very little deformity. The following are the particulars of a case which I attended with Mr. Harris, of Reading. July 20th, 1821, Mr. B., aged 51, a gentleman residing about six miles from Reading, fell from his horse, and injured his left hip; he got up imme- diately, and walked a few steps, but soon found that he was incapable of bringing his left leg forward, and he felt a severe pain in the hip. He was con- veyed home in-a cart, a distance of about four miles, and Mr. Harris visited him about two hours after the accident, Avhen the folloAving circumstances were noticed. He could not discover any crepitus on ro- tating the limb; it was of equal length with the sound one ; the foot Avas not turned inwards or out- wards, and the patient could retain it in any posi- tion in which it Avas placed. A good deal of sAvell- ing existed about the hip, and Mr. B. complained of some pain; he could bear the limb to be moved 304 without much increase of suffering, excepting when the injured limb was drawn across the sound one, when the pain was greatly augmented. Under these circumstances, Mr. Harris gave it as his opinion, that there was not either a fracture or a dislocation. On the 22nd, Mr. Ring, of Reading, saw Mr. B., and on examining the limb, confirmed the opinion of Mr. Harris. The patient Avas kept at rest, and leeches, with evaporating lotions, were employed to reduce the swelling of the hip. On the 26th, an acute attack of hepatitis, render- ed active treatment necessary ; and during this time, the limb remained much in the same state. August 14. Mr. Ring again examined the limb, and whilst moving it, thought he felt a crepitus. On the folloAving day, Mr. Harris also felt and heard the crepitus. The case being, however, still obscure, Mr. Brodie was sent for; on his arrival, the particulars of the case were communicated to him, and he minutely examined the injured limb, but for some time was doubtful as to there being a fracture, until, upon ro- tating the limb very extensively, he distinctly felt the crepitus; he was, however, much surprised to see, that the patient could, when standing, bear very considerably upon the injured limb, and he consider- ed the case as very obscure, the usual symptoms of fracture, except the inability to move the limb, being but little marked or entirely wanting. Mr. Brodie applied a long splint, with a bandage from the toes to the hip, which he directed to be worn for a month ; and at the same time, ordered the limb to be kept perfectly at rest. But little alteration having taken place in the case at the end of the month, Sir Astley Cooper was requested to visit Mr. B. After hearing the 305 history of the case, he proceeded to examine the limb. First, looking to the relative position of the ex- tremities, as the patient lay upon his back, he placed his hand under the trochanter major, Avhich he found had dropped from its natural situation, and raising it toward the cervix, he readily detected the crepitus, and agreed with Mr. Brodie and Mr. Harris, as to the nature of the injury, viz. a fracture of the cervix femoris, where it unites with the trochanter major. The folloAving plan of treatment was adopted by Sir Astley, with a view of retaining the trochanter in its proper position, whilst the patient could re- main perfectly at rest in the horizontal posture. A mattress was made of horse hair, about five inches thick, very smooth, and this Avas covered with a sheet. A part of the mattress Avas made to draw out on the opposite side to the fracture, so that when the natural evacuations took place, there still should be no motion of the body; before draw- ing out the piece of mattress, a board of two feet long, and six inches wide, shaped like a wedge, was insinuated under the buttock of the right side, the two ends of the board resting on the mattress, there- by preventing the nates from sinking, at all, into the opening, Avhen the piece of mattress was removed, the board was of course taken away, when the por- tion of the mattress Avas replaced. Upon the bed- stead, was first placed a thick smooth board, suffi- ciently large to cover the bottom of the bed, and on that Avas placed the mattress, thereby prevent- ing any sinking by the weight of the body. A bandage, made in the following manner, Avas applied to support the trochanter:—a broad web, sufficient to go round the body, over the hip, was furnished with two straps and buckles to fix it with, and the belt was made of a greater width at that part, which Avas to be placed under the injured tro- 39 306 chanter; the Avhole was lined with chamois leather, and stuffed; a pad of the same leather Avas made, about six inches long, three broad, and three thick, gradually tapering to a point; this pad was placed immediately under the injured trochanter, so that when the bandage Avas buckled on, it passed into the holloAV beneath that process, forcing it upwards and forwards into its natural position. Another thick pad, about eight inches square, of a wedged shape, Avas provided, and this was placed under the upper part of the thigh of the injured side, after the application of the bandage. The patient Avas placed on his back, the limb resting on the heel; and to prevent the possibility of any motion of the foot, and of the body, a wide board was fixed to the bed posts, at the foot of the bed, with two pieces of Avood padded and fastened to it; between these the foot was received, and the least lateral motion prevented. A cushion was plac- ed betAveen the foot board, and the sole of the sound foot, so that by gentle pressure, the patient could prevent his body from slipping down in the bed. This mode of treatment Avas steadily pursued for a month, without much inconvenience or suffering to the patient; the bandage being from time to time tightened. Until the expiration of three weeks, the patient said he could occasionally still feel the crepi- tus, but after that period, this sensation entirely dis- appeared; he complained of some pain in the di- rection of the trochanter, and the limb became somewhat oedematous. Sir Astley Cooper again visited Mr. B. a little more than a month from his first seeing him, when he was of opinion that union had begun, and direct- ed a continuance of the same treatment, Avhich was therefore persevered with for a further period of about ten weeks; Sir Astley seeing the patient once in this time. 307 It was not until fourteen or fifteen weeks from the commencement of this treatment, that the band- age was removed for more than a few minutes, or that any material alteration was made in the plan. It was then taken off for about two hours; when the trochanter was found to retain its position, and from examination of the parts, a considerable thick- ening could be discovered about the trochanter. After this, Sir Astley desired that the bandage should be re-applied every day for an hour, and di- rected friction to the limb from the foot upAvards. Mr. B. from this time, rose every day, and was soon able, Avhen supported by his crutches, to move his hip joint freely; but the limb continued much swoll- en, and the motions of the knee joint Avere extreme- ly limited. By steadily persevering with friction, and passive motion, Mr. B. has since obtained a free use of the extremity. Fracture of trochanter.—A peculiar form of frac- ture of the trochanter major, in Avhich this process was separated at the part at Avhich it is naturally united by cartilage as an epiphysis, occurred under the care of Mr. Key. Case.—The patient, a girl about sixteen years of age, fell in crossing the street, and struck her hip against the curb-stone. She rose directly, and Avalk- ed home without much suffering or difficulty, but experiencing afterwards considerable pain, she was taken to Guy's Hospital on the sixth day after the accident. On account of her constitutional symp- toms being much more severe than those usually at- tending injury to the hip, she was placed under the care of Dr. Bright, at Avhose request Mr. Key ex- amined the limb, which he found considerably evert- ed, and in appearance about half an inch longer than the sound extremity; it could be moved in all di- rections, but abduction caused great pain; not any 308 crepitus or displacement could be discovered, and her having walked both before and after her ad- mission into the hospital, gave rise to a supposition that fracture did not exist. Her constitutional suf- fering rapidly increased, accompanied with general uneasiness about the abdomen, and she died on the ninth day from the receipt of the injury. After death, Mr. Key first examined the seat of injury externally, with attention, but could not dis- cover any deviation from the natural state. Dissection.—On exposing the capsule of the joint afterwards, a cavity Avas discovered by the side of the pectineus muscle, passing backwards and doAvn- wards towards the trochanter minor, and containing some pus : it extended behind the bone to the large trochanter. On cutting through the ligaments, and dislocating the head of the bone, a fracture was first perceived at the root of the trochanter major. This fracture had separated the trochanter from the neck and body of the bone, without the tendons attached to the outer side of the process having been injured, so that a separation of the fractured portions could not take place, on which account the nature of the accident had not been detected during the life of the patient. Of Fractures below the Trochanter. Difficult to manage.—When the thigh bone is broken just below the trochanter major and minor, much difficulty exists in effecting a good union, and if the treatment be ill-managed, great deformity is the consequence. The fractured extremity of the superior portion of the bone is drawn upAvards and forwards by the action of the psoas, iliacus internus, and pectineus muscles, and any attempts by pressure to obviate this position of the bone, only increases 309 the suffering of the patient, without effecting the desired purpose. Treatment.—In the treatment of such a case, two principal circumstances require attention: first, to elevate the knee, by placing the limb over a double inclined plane, and secondly, to raise the body so as to place the patient in nearly a sitting position; the degree of elevation of the limb or of the body must depend on the approximation of the fractured ends of the bone, and the surgeon must carefully as- certain that the proper relative position of the fe- mur is restored, before he proceeds to apply the splints and bandages to retain them in this state. A strong leather belt lined with some soft material, and made to buckle rouqd the limb, answers better in these cases, than the common splints. Specimen of.—A preparation in the museum at St. Thomas's Hospital exhibits the mode of union in an ill-treated case of this kind, and illustrates the neces- sity of careful attention to the points I have men- tioned, viz.: the relaxation of the psoas, iliacus in- ternus, &c. by elevating the body, and the raising of the inferior portion of bone to a line with the su- perior. 310 LECTURE XLIV. Of Dislocations of the Knee. Structure of joint.—The frequent and great vio- lence to which this joint is exposed, also the form of the articulation, the cavities on the head of (he ti- bia being very shalloav, Avould render it extremely liable to displacement, Avere it not for the extent of articulating surface, and the existence of numerous strong ligaments, Avhich connect the os femoris, the tibia, and the patella. Dislocations do, however, sometimes occur from excessive violence, or from great relaxation of the connecting ligaments. Of Dislocation of the Patella. Three forms of—The patella may be dislocated in three directions;—viz. outwards, inwards, and upwards. External.—The external displacement is the most common; in Avhich case the patella is thrown upon the outer condyle of the os femoris, where it occa- sions a great projection, which circumstance, and the incapacity of bending the knee joint, sufficiently mark the nature of the injury. Cause of.—Persons who have naturally an incli- nation of the knee inwards, are most liable to this injury, and it is usually produced by a fall at the time that the knee is turned inwards and the foot 311 outwards, so that the action of the muscles, in en- deavouring to prevent the fall,draAV the patella over the external condyle of the thigh bone. Internal.—The displacement of the patella upon the internal condyle, is much less frequent, and gen- erally happens from a fall upon a projecting body, by Avhich the patella is struck upon the outer side, and forced inwards at the time that the foot is turn- ed in the same direction. Ligament torn.—Unless the ligament has been re- laxed from previous disease, it will be torn in either of these dislocations. The reduction, in either case, may be accomplish- ed in the folloAving manner:— Treatment.—Place the patient in the recumbent posture, and let the leg be raised, by lifting it at the heel, so that the extensor muscles of the thigh may be relaxed as much as possible ; then press down firmly the edge of the patella, furthest from the articulation, by which the opposite edge will be raised over the condyle, when the action of the muscles will quickly restore the bone to its na- tural situation. Case.—The following plan was adopted by Mr. George Young, in a case of the external dislocation, which he could not succeed in reducing by other means. He placed the ankle of the limb upon his shoulder, which gave him considerable power in ex- tending the knee joint; when grasping the patella with the fingers of his right hand, he pressed the outer edge of the bone with the ball of his left thumb, and thus forced it into its place. A^tcr treatment.—After the reduction, the limb must be kept at rest, and the part kept moist with an evaporating lotion; after three or four days, ban- dages may be employed. The motions of the joint 312 are soon restored, but a degree of Aveakness remains for some time. From relaxation.—Very slight causes produce the lateral dislocation, when much relaxation exists, but the reduction is very easily accomplished, and it is ne- cessary to employ a laced knee cap, with a strap and buckle above and below the patella, to prevent a recurrence of the accident. Of the Dislocation of the Patella upwards. Nature of.—In this displacement, the ligamentum patellae is torn through, and the patella is drawn up- wards upon the fore part of the thigh bone. Signs of.—The nature of this injury is extremely well marked, by the elevation of the patella, the freedom of its motion laterally, and the depression above the tubercle of the tibia from laceration of the ligament : the patient cannot support himself upon the limb, as the knee immediately bends Avhen he attempts to do so. The accident gives rise to a considerable degree of inflammation. Treatment.—The treatment required for this in- jury, in the first place, will be to reduce the inflam- mation, by the application of leeches and evaporat- ing lotions, at the same time that the limb is kept extended, and the body elevated, to relax the mus- cles, and prevent as much as possible the elevation of the patella; after from four to seven days, a roll- er should be placed upon the limb, from the toes to the knee, to prevent swelling, and a splint should be fixed behind the knee, to prevent any motion of the joint; a leather strap should then be buckled around the loAver part of the thigh, just above the patella, and to this should be attached another strap, which should pass on each side of the leg, under the foot, hy which the circular strap may be draAvn doAvn so 313 as to restore the patella as near as possible to its natural position, and thus approximate the laoerated ends of the ligament, to allow of union. With attention, union perfect.—With great atten- tion, the union will be perfect; passive motion may be carefully employed at the expiration of a month. Degree of recovery.—The degree of recovery de- pends upon the length of the ligamentous union, being perfect when the lacerated extremities are kept in contact during the union, and the powers of the limb being diminished in proportion to their sep- aration. Dislocation downwards.—A dislocation of the pa- tella downwards has been mentioned by some sur- geons, but I have not seen any injury deserving such a title. Sometimes the tendon of the rectus muscle is torn through, in which case a depression can be felt above the patella, but the bone itself retains its natural situation. The same position of limb and body is necessary in the treatment of this injury, as in the dislocation upwards, and a pad should be ap- plied over the ligamentum patella, and confined there by a roller.* Of Dislocation of the Tibia at the Knee Joint. Four forms of—The superior extremity of the tibia may be displaced in four directions, viz.: out- wards, inwards, backwards, and fonvards, but only the two latter are complete dislocations, as in the two former instances the articular surfaces of the * In a case of this nature, which came under my care in St. Thomas's Hospital, 1 found considerable advantage from the application of a pad over the upper portion of the rectus muscle, it was confined by a roller, and assisted materially in approxi- mating the lacerated ends of the tendon ; the patient recovered with perfect use of the limb.—T. 40 314 tibia, and of the condyles of the os femoris are still partly in contact.' These lateral dislocations occur but seldom. Inwards.—When dislocated inwards, the head of the tibia forms a large projection on the inner side of the joint, the internal condyle of the femur rests upon the external semilunar cartilage, and the ex- ternal condyle projects to the outer side. Case.—The first case of this injury which I recol- lect seeing, was brought into St. Thomas's Hospital, during my apprenticeship there, when I remember being struck with three circumstances respecting it; first, the great deformity of the joint—second, the little force necessary to reduce the displacement— third, the slight degree of local or constitutional suffering which followed, the recovery being com- plete in a few weeks. Outwards.—When displaced outwards, the tibia projects upon the outer part of the joint, the inter- nal condyle upon the inner side, and the external condyle rests upon the internal semilunar cartilage, the deformity produced being as great as in the for- mer case. Reduction.—The reduction in either instance may be readily effected by direct extension, and but little diminution of power in the joint follows. I believe that, in both these dislocations, the tibia is rather twisted upon the femur, than forced merely inwards or outAvards, so that the condyle of the os femoris is thrown someAvhat backwards with respect to the head of the tibia, as well as laterally. After treatment.—When the patient is first allow- ed to use the limb after an accident of this kind, the joint should be supported by a bandage or a knee cap, as frorn the injury to the ligaments, it remains feeble for some time, although the recovery ultir mately is nearly perfect. 315 Dislocation of the Tibia forwards. Signs of.—When this accident occurs, the follow- ing appearances will be presented, when the patient is in the recumbent position. The head of the tibia projects forwards, and the inferior part of the thigh bone is depressed, being thrown a little to one side as well as backAvards: the patella is drawn up by the action of the rectus muscle. The circulation through the popliteal \ressels is obstructed by the pressure of femur posteriorly, so that arteries below cease to pulsate, and the foot feels numbed from pressure upon the nerves. Case.—A man named Briggs Avas admitted into Guy's Hospital, in the year 1802, under the care of Mr. Lucas. He had a dislocation of the tibia for- wards, in one extremity, which presented the marks I have described, and a compound fracture of the tibia, with a dislocation of the head of the fibula ex- isting in the opposite limb. The extent of mischief attending the compound fracture, rendered it neces- sary to amputate that extremity. The dislocation in the other extremity was easily reduced, by ex- tending the thigh from above the knee, and by drawing the leg from the thigh, inclining the tibia a little downwards. The patient recovered. Dislocation of the Tibia backwards. Signs of.—This injury occasions the following marks. A projection of the condyles of the os fe- moris anteriorly, a depression of the ligamentum pa- tellae, the head of the tibia is seated behind the con- dyles, and the limb is shortened, the leg being bent forwards. My friend, Dr. Walsham, sent me the following particulars of a case which was under his care. 316 Case.—Mr. Luland, a very robust and muscular man, had his shoulder and knee dislocated in conse- quence of being throAvn from his cart, in January 1794. The head of the tibia Avas completely dislo- cated backwards, reaching behind the condyles of the femur into the ham ; the tendinous connexion of the patella to the rectus muscle was ruptured ; the ex- ternal condyle of the os femoris was very protuber- ant ; »the leg was bent forward and shortened, and there was a depression just above the patella. The patient felt most excruciating pain when the limb was moved, but there was not any considerable suf- fering when it was at rest. It was reduced by the following means :—Two men extended upwards, one from the groin, another from the axilla, whilst two others extended the leg fro'm a little a^ove the an- kle, in -fehe oppo'site direction; and they gradually increased the force of their extension, tiH the»bone was reduced. At the time of extension, Dr. Wals- ham directed the head of the bone to its natural situation. A roller was afterwards placed over the knee, the limb was laid upon a pillow, and an evapo- rating lotion Avas constantly applied. In this state, the patient remained for a fortnight free from pain, when the Doctor gently moved the joint every other day, as far as he could, without creating pain. In about a month, Mr. Luland began to Avalk on crutches, in ten weeks he Avas able to sit at the din- ner table, and in five months had perfectly recover- ed the use of his limb. Of Partial Luxation of the Thigh Bone from the Semilunar Cartilages. Reason of.—The ligaments of the knee joint some- times become so much lengthened from extreme re- laxation, or from an increased secretion into the joint, 317 as to permit the semilunar cartilages to glide upon the surface of the tibia, when pressure is made by the femur on the edge of the cartilage. First described by Mr. Hey.—The nature of the accident was first accurately described by Mr. Hey, of Leeds, who was so justly celebrated for his high professional attainments; he also suggested an inge- nious and scientific mode of treatment, which is gen- erally successful. Causes of—The displacement is most frequently occasioned by a person Avhen walking catching the toe against some projecting body; whilst the foot is everted, pain is immediately felt in the joint, and the limb cannot be straightened. I have known it also produced by the bed clothes obstructing the motion of the foot, when a person has been turning in bed. The explanation of the accident is as follows :— Explanation of.—The semilunar cartilages, which receive the condyles of the femur, are united to the tibia by ligaments; and when these ligaments be- come extremely relaxed or elongated, the cartilages are easily pushed from their situation by the con- dyles, which are thus placed in contact with the head of the tibia, and when an attempt is made to extend the limb, the edges of the semilunar cartila- ges prevent it. Reduction.—The mode of reduction is, to bend the limb as much as possible, so as to enable the cartilage to slip into its natural position from the pressure of the femur: the cartilage being thus replaced, the limb can be again properly extended, and the con- dyles are again received upon the cartilage. I have, however, known this plan to fail in effect- ing the desired object, as the following case will show. Case.—A lieutenant in the army, who had been repeatedly the subject of this injury, and who had 318 been as often relieved by the means above recom- mended, had a recurrence of the accident whilst turning in his bed ; he came to town, but the former mode of treatment, although repeatedly tried, did not succeed in reducing the dislocation; he after- wards went to Mr. Hey, of Leeds, but Avithout ob- taining relief. After treatment.—A knee cap, made to lace closely upon the joint, will generally prevent any further displacement; but, in some cases, this is not suffi- cient. Cases.—Mr. Henry Dobley consulted me, in con- sequence of his suffering frequently from this acci- dent, which could only be prevented by the addition of straps to the knfce cap, one of Avhich, of consid- erable strength, passed just below the patella. In another case, that of a young lady, also fre- quently the subject of this dislocation, the accident could only be prevented by a linen bandage, having four rollers attached to it, Avhich were tightly bound above and beloAV the patella. Effects of.—I have seen some cases of this kind, in which a very great alteration has taken place in the form and size of the joint, in consequence of a chronic inflammation attending them. The follow- ing is an account of one :— Case.—Lady D. in falling, twisted her thigh in- wards, so as to occasion great pain in the knee joint. On attempting to extend the limb, she could not move the knee joint; but, after pressing the thigh outwards and leg inwards, with some force, she found herself capable of straightening the extremity. For a fortnight after the accident, the joint was ex- tremely weak, and she could hardly bear it to be moved. She then began to stand upon the limb, supporting herself by crutches; but when she bore much upon the injured limb, it suddenly bent back, 319 and this produced considerable pain and swelling, at the time she felt the condyles slip from the semi- lunar cartilages upon the head of the tibia. This occurred repeatedly during a period of fifteen months after the accident, and each time greatly retarded her recovery. Three months after this, she had so far improved, as to be able to walk with the aid of a stick only, when, in endeavouring to raise herself from a sofa, her left knee gave Avay, as if the bone had slipped from its place; the thigh bone being at the same time twisted outwards; this produced great pain and SAvelling, and she was again unable to stand upright. Her joints Avere all remarkably flexible, and when a girl, she often experienced a sensation of having dislocated her knees, but from this she soon recovered. When 1 saw her, both knees were much enlarged from effusion of synovia into the cavi- ties of the joints, she could not stand without sup- port, and was unable to straighten the limbs. To relieve her, blisters were applied, and for some time kept discharging; after they were allowed to healT pressure was employed by means of bandages, which were occasionally removed, to allow of friction. She derived most benefit from the internal use of the pilul: hydrarg : submuriat: comp: and the decoct: sarsaparillae comp: and externally from the friction. Dissection of these joints.—In the dissection of these cases, the ligament is found extremely thick- ened ; small ligamentous and cartilaginous bodies are hanging from it; part of the articular cartilage is absorbed, and part presents a thick projecting edge* After maceration, the edges of the condyles are found to be much increased by deposite of bony mat- ter. 320 Of Compound Dislocations of the Knee. Very rare.—This accident is of very rare occur- rence ; I have only once seen such a case, which re- quired immediate amputation; and I scarcely know any form of injury which Avould so urgently call for operation. Case.—On the 26th of August, 1819, I was sent for by Mr. Oliver, of Brentford, to see a Mr. Pritt, in consequence of severe injury to the knee, occa- sioned by a fall from the coach box of one of the mails. On examining the limb, I found a large aper- ture in the integuments, on the outer side of the knee joint, through Avhich the external condyle of the femur projected, so as to be on a level Avith the edges of the skin. The inferior part of the os fe- moris was throAvn behind, and to the outer side of the head of the tibia, the bone was twisted out- wards, so that the internal condyle was situated upon the head of the tibia, whilst the external condyle was turned backAvards and outwards. We succeed- ed in replacing the bones with much difficulty, but as soon as the extension ceased, they returned to the same position as I have above described. In consequence of the great severity of the injury, the difficulty of retaining the bones in their nat- ural situation, and the patient being of a very irrita- ble disposition, I immediately proposed and Avith his consent performed the operation of amputation. Great constitutional suffering followed the operation, but under the judicious treatment of Mr. Cline, who visited him during my absence from toAvn, he gradu- ally recovered. Dissection.—On dissecting the limb after the ope- ration, I found great extravasation of blood into the cellular tissue surrounding the joint; the vastus in- ternus was extensively lacerated, just above its con- 321 nexion with the patella; the tibia projected for- wards, and the patella Avas situated to the outer side of the knee. On the posterior part, both the heads of the gastrocnemius externus muscle Avere torn through, and the capsular ligament so complete- ly divided, as to admit both the condyles of the fe- mur through it. Attempt to save the limb.—Should a case of com- pound dislocation of the knee occur, in Avhich a very small wound only existed, admitting of ready closure, it would be right to attempt the preservation of the limb. Of Dislocations of the Knee from Ulceration. Cause of—From the chronic diseases of joints, not only the synovial membrane and articular car- tilages suffer from ulceration, but in some cases the capsular, and also the peculiar ligaments become ulcerated, so that the connexion between the bones is in a great measure destroyed, when the muscles which participate in the irritation, contract and grad- ually displace the bones producing great distortion of the limb. This is most frequently seen in the hip joint; but it is not uncommon to find at the knee the tibia drawn out of its proper line, with respect to the fe- mur from the same cause. Extraordinary distortion.—Case.—Occasionally, the distortions thus produced are very remarkable. Mr. Cline amputated a limb in St. Thomas's Hospi- tal, in which the following alteration had taken place from chronic disease in the knee joint. The leg was placed forwards, at right angles with the thigh, so that, prior to the operation, it projected before the patient when he was standing. On examining the joint, the patella was found anchylosed to the 41 322 femur, as also the tibia to the fore part of the con- dyles of the thigh bone. Mode of preventing.—Much may be done in the early stage of this disease, to prevent deformity, by the application of splints, and the use of internal remedies, as the pulv: ipecacuanha? comp: to di- minish general irritability. Of Fractures of the Knee Joint. I shall now proceed to describe the fractures which occur in tne bones forming the knee joint. Fractures of the Patella. Forms of.—The most common fracture of this bone, is transversely; sometimes, however, it is brok- en longitudinally; these fractures may be either sim- ple or compound, but the latter rarely happens. Transverse.—When fractured transversely, the superior portion of bone is separated from the in- ferior being drawn up by the action of the rectus vasti and crureus muscles, which are inserted into it. The lower portion of the bone remains in its nat- ural situation, connected to the ligamentum patellae. Extent of separation.—The degree of separation will be found to vary from half an inch to five inches, and it depends upon the extent of laceration of the capsular ligament, and tendinous aponeurosis covering it. Signs of—The nature of the injury is readily re- cognised, on examination, by the fingers, when press- ed between the two portions of bone, sinking nearly to the condyles of the femur; by the situation of the upper portion of bone, and by its free lateral motion upon the fore and lower part of the thigh bone; the patient cannot extend the limb, nor can 323 he support the weight of the body upon it when standing, as the knee immediately bends forwards from the loss of the support of the extensor muscles. The injury, if simple, is attended with but little pain, and is not productive of much constitutional suf- fering. Consequent swelling.—A feAV hours after the re- ceipt of the accident, the part becomes tumid from extravasation of blood, and the surface presents a discoloured appearance from ecchymosis, this, how- ever, subsides in a few days, but the joint enlarges from an increased secretion of synovia, and from ef- fusion in consequence of inflammation. As the por- tions of the bone are separated, no crepitus can be felt, as is usual in other fractures. Causes.—Two causes are found to produce this injury :—First, falls upon the knee, or blows upon the patella, when the patient is erect. Second, the action of the extensor muscles upon the bone, in any sudden effort to prevent a fall. Cases.—1 Avas called to attend a gentleman, who had fractured his patella by an effort he made to save himself from falling, after having leaped over a broad ditch. I also saw a lady, who met with the same acci- dent, in endeavouring to save herself from a fall, when descending some stairs, having placed her heel too near to the edge of one of the steps. Explained.—It may appear extraordinary, that the action of the muscles alone is sufficient to produce fracture, but a little attention to the structure and mode of action easily explains the fact. When the knee is bent, the patella is drawn doAvn on the end of the condyles of the femur, and the upper edge of the bone projects forward, so the muscles do not act in a line with the patella, but at right angles with it, and more particularly upon its upper portion. 324 Mode of union.—The union in these cases is gen- erally ligamentous, whether the portions of the frac- tured bone be nearly approximated, or widely sepa- rated. Soon after the accident, bloo,d is poured out, and fills the space between the lacerated liga- ment and broken pieces of bone, but this soon be- comes absorbed, and its place is occupied by adhe- sive matter thrown out in consequence of inflamma- tion ; this soon becomes organized by vessels from the edges of the injured ligament, and a structure, similar in its character to ligament, is thus produced, by which the parts divided by the injury are again united. Sometimes this new structure does not com- pletely fill up the space formed by the separation of the portions of bone and ligament, but it has aper- tures in it; but this most frequently occurs when the separation is very great, or when the limb has been moved too soon after the accident. Dissection.—On examining the seat of injury, some time after the accident, I find that the patella itself undergoes but little change, the inferior por- tion has its broken surface very little altered, being only rather smoothed; the upper portion has its fractured surface covered with some ossific deposite, so that there is more ossific action in the superior than in the inferior portion of the bone. The ar- ticular surface maintains its natural appearance. Experiment.—By experiments on the rabbit, I have been able to trace the mode in which this injury is repaired; in each experiment I divided the patella, by placing a knife on the bone, and striking it gently with a mallet, having first cut through the integu- ments, which I drew as much as possible to one side, so that when allowed to resume their natural situa- tion after the division of the patella, the wound was not opposite the fracture. Appearances forty-eight hours after.—Examining the parts forty-eight hours after the division, I found 325 the portions of bone separated to the extent of three quarters of an inch, and the intervening space filled with coagulated blood. Eight days after.—In a second experiment, exam- ined eight days after, most of the blood was absorb- ed, and adhesive matter deposited in its place. Fifteen days after.—A third, examined on the fif- teenth day, the adhesive matter had become smooth and someAvhat ligamentous. Twenty-two days after.—A fourth, examined on the twenty-second day, the new ligament was per- fect. Five weeks after.—A fifth examined at the expi- ration of five weeks, and injected, showed the or- ganization of the neAV ligament, which was chiefly supplied by vessels from the original ligament, and by a very few vessels from the bone. Union by ligament.—In repeating these experi- ments upon the rabbit and dog, I could not succeed in producing a bony union, although I could keep the fractured pieces in perfect contact. Bony union.—I believe, hoAvever, that ossific union may now and then be produced; in a case Avhich I saw with Mr. Chopart at Paris, there was every ap- pearance of such a junction, and Mr. Fielding of Hull has published another case. Although in a large majority of these cases, I be- lieve the union to be ligamentous, yet it is extremely desirable to make the ligament as short as possible, as the degree of recovery of the power of the limb is in proportion to the approximation of the fractur- ed portions of the patella, or according to the short- ness of the neAv ligament, for as the superior por- tion of the bone is separated from the inferior by the action of the rectus muscle, so the muscle be- comes shortened, and its power consequently dimin- ished. When, therefore, the intervening ligament 326 is very long, the person cannot walk fast without a halt, and is in constant danger of falling. Treatment.—In the treatment of the transverse fracture of the patella, the patient should first be placed in bed upon a mattress, with the injured limb extended, behind which a hollow splint, well padded, should be applied; the heel should be elevated a little, and the body raised, in order to relax, as much as possible, the rectus muscle, and thereby prevent it from drawing up the superior portion of the frac- tured bone. The limb should be fixed to the splint to prevent its slipping, and the surface of the joint should be kept constantly moist, with an evaporating lotion. If there be much tension or pain succeeding the injury, the application of leeches will be neces- sary, with a continuance of the evaporationg lotion. In a few days, the SAvelling and pain Avill subside, under this plan of treatment, after which the band- ages may be applied to approximate the portions of bone. The surgeon should be very careful not to apply the bandages before the tension has been re- duced; I have known severe suffering and inflam- mation produced by their too early application, so much so in some cases as to threaten a sloughing of the integuments. Common bandage.—The most common mode of using the bandages is as follows : a roller is first ap- plied from the toes to the knee, to prevent swelling of the leg; two pieces of broad tape are then pla- ced on each side of the patella, in the direction of the limb, and two rollers are next bound round the extremity, one above, and the other below the knee joint, confining the pieces of tape, and having the tAvo portions of bone between them; the- ends of tape on each side are afterwards turned over the rollers, and tied so as to bring the rollers nearer to each other, and thus press the portions of the frac- 327 tured bone as near as possible together; the splint is again applied and fixed to the limb, to prevent any flexion of the joint, the heel is still raised, and the body supported nearly in the sitting posture. Another mode.—I usually adopt a mode rather different, which I think preferable, and Avhich con- sists in buckling a leather strap around the lower part of the thigh, immediately above the superior portion of the patella, and having another strap attached to the former on each side, long enough to pass under the sole of the foot, by which the circular strap can be drawn down, and with it that part of the broken bone connected to the tendon of the rectus muscle; the splint and the position are attended to as above mentioned. Period of confinement.—It is necessary in the adult to continue this treatment for five weeks, and in el- derly persons for six weeks, before any motion is al- loAved; it may then be employed passively, but very cautiously, until it be ascertained that the union is sufficiently firm to bear it without risk, when it may be continued from day to day until the joint can be completely flexed. Passive motion essential.—Passive motion is very essential to promote the return of poAver in the muscles and joint, as without it many months will elapse, and the patient still be incapable of flexing the limb. When passive motion is to be employed, the patient should be seated upon a high stool or ta- ble, in such a manner that the edge of the seat reaches as far as the ham, so that the leg can be depressed without the thigh; this is to be done with consider- able care at first, until a slight degree of motion has been acquired, when the patient may, by sAvinging the leg, and directing his mind to the contraction of the rectus and exterior muscles, gradually restore the functions of the joint. If the union has taken 328 place with a shortened state of the rectus muscle, and the portions of bone are joined by a long inter- vening ligament, the muscle does not recover its voluntary power until it has been again elongated, which is done by bending the knee. Case.—A young woman who had suffered from transverse fracture of both patellae, was brought to my house in consequence of not having recovered any poAver of flexing the limbs. Passive motion was employed, and she Avas directed to extend the limbs, when they had been flexed by the surgeon; in this manner, after persevering for some time, she gradu- ally recovered the use of the joints. The pain cre- ated by the passive motion, and the very gradual benefit derived from it, make patients averse to its continuance, but it is perfectly essential to recovery. Of the Perpendicular Fracture of the Patella. This injury, as the former, is attended with con- siderable effusion and swelling of the soft parts. Union by ligament.—Having seen several cases in which the union had only been effected by ligament, and not being aware of any circumstance that should prevent ossific junction, I made several experiments upon dogs and rabbits, the result of which was as follows :— Experiment.—Having produced fractures in a man- ner somewhat similar to that already described, for occasioning the transverse division of the bone, suffi- cient time was alloAved for the process of cure to be completed, when the bones were examined, and found to be joined only by ligament, and the two portions considerably separated from each other, from the pressure of the condyles of the femur upon the inner surface of the patella Avhen the knee Avas bent. I therefore made another experiment, and divided 329 the patella in a dog, but in such a manner, that the tendon above, and the ligament beloAV, remained un- injured, so that there could be no separation of the fractured portions; in this case, I found that a per- fect ossific union took place. Union by bone.—It appears then, that in either the longitudinal or transverse fractures, when the portions of bone are separated, that a ligamentous union takes place; but if these portions remain in contact, that they may be united by bone. Case.—Mr. Marryat had his patella broken into three portions, by a fall from his gig, the bone was divided by a transverse fracture, and the lower piece again divided by a perpendicular fracture ; the trans- verse fracture united by ligament only, whilst the perpendicular fracture joined by bone. Experiment.—I fractured the patella of a dog, separating it into four portions by a crucial division, no union took place between the two superior pieces, neither to each other, nor to the inferior, but the in- ferior portions became united to each other by bone. Treatment.—The treatment of this accident, con- sists in placing the limb in an extended position, with a padded splint posteriorly, to prevent any motion of the knee joint; in applying an evaporating lotion un- til the SAvelling and pain have subsided, after which, a knee-cap padded on each side of the patella should be buckled around the joint, the straps passing above and below the patella. Of Compound Fracture of the Patella. Extent of mischief.—When this accident is attend- ed with extensive laceration, and much contusion of the surrounding soft parts, it Avill be right immediate- ly to amputate the Hmb; but should the wound be small, so that its edges can be readily approximated, 42 330 and not accompanied with such mischief as is likely to occasion sloughing, an attempt should be made to preserve the extremity. Treatment.—The principal object in the treatment, is to produce adhesion of the edges of the wound; to effect Avhich, all our efforts should be directed. The application of sutures is necessary, not only to assist in the immediate approximation of the edges of the wound, but to prevent their after separation, which is otherwise liable to take place from the escape of synovia, and the lax state of the integument; besides the sutures, strips of adhesive plaister should be placed, and the part kept cool, by the evaporating lotion. Poultices or fomentations must not be used, as they prevent the adhesive process. Cases.—A man in St. Thomas's Hospital, under the care of Mr. Birch, had fomentations and poul- tices employed, after an injury of this nature, in which but a small wound communicated the joint,-—he died in consequence of excessive constitutional irritation, produced by suppurative inflammation, which took place in the joint. The following case, which was under the care of Mr. Dixon, of Newington Butts, will fully explain the mode of treatment I would recommend. Mr. Redhead, aged 39, of a spare habit, was thrown from his gig, June 18, 1819, Avhen his knee, striking against the wheel of a cart, produced a com- pound' fracture of his patella. At Mr. Dixon's re- quest, I visited the patient in the afternoon of the day on Avhich the accident had occurred, and on ex- amining the joint, I found a wound on the fore part, which readily admitted my finger into the joint; the patella Avas broken into several pieces, one of Avhich being detached, I removed. From the habit of the patient, and his not having an irritable constitution, we determined on attempting to preserve the limb. 331 1 accordingly brought the edges of the wound to- gether by the application of a suture, taking care not to include the ligament; I then further secured the closure of the wound by strips of adhesive plais- ter, and over the Avhole, I placed a roller very light- ly, which was to be kept constantly moistened with spirit of Avine and water. The leg Avas placed in an extended position, and he was ordered to live on fruit. The suture was not removed until the 30th of June, as he did not at all complain. At the ex- piration of a month, Mr. R. Avas allowed to leaA'e his bed; and in five weeks from the accident, pas- sive motion was commenced. He gradually recover- ed the perfect use of his limb. In the year 1816, a case happened in Guy's Hos- pital, in Avhich the knee joint Avas opened by ulcera- tion, some time after the occurrence of a transverse fracture of the patella, which had united by a liga- ment about three inches in extent; the patient, a woman, was admitted into the hospital, in conse- quence of having numerous ulcers on various parts of her body, one of Avhich was seated in the integument, immediately over the new formed ligament, uniting the broken patella; this ulcer became sloughy, and extended through this ligament into the joint, in Avhich excessive inflammation and suppuration occur- red, which destroyed the patient. Of Oblique Fractures of the Condyles of the Os Fe- moris into the Knee Joint. Signs of.—Either the external or the internal con- dyle of the femur may be separated by fracture from the rest of the bone, producing much deformity of the knee joint, and giving rise to great SAvelling, Avhich circumstances, together with the feeling of crepitus when the joint is moved, indicate the na- 332 ture of the injury. In either case, the same mode of treatment is required. Treatment.—The injured limb is to be placed upon a pillow in the extended position ; leeches and evapo- rating lotion are to be employed, until the inflamma- tion is subdued ; after Avhich, a piece of stiff paste- board, about a foot and a half in length, and of suffi- cient width to envelop the posterior and lateral parts of the knee joint, as far as the sides of the patella, is to be applied Avet, and secured by a roller; this, when dry, adapts itself to the form of the joint, and best confines the fractured portion of bone. In five weeks, passive motion should be employed to facilitate the recovery of the motions of the articulation. Compound fracture.—Compound fracture of the condyles of the os femoris is a rare accident; and in the'old, or irritable, is most likely to be attended Avith fatal consequences, unless the limb be removed. In young persons, or in those not of an irritable consti- tution, a cure may be effected, unless the opening be very extensive, or attended with much surrounding mischief. Case.—A boy was admitted into St. Thomas's Hospital, in September 1816, under the care of Mr. Travers, having a transverse fracture of the femur, just above the condyles, and an oblique fracture of the external condyle, with which a small wound com- municated; the limb was placed in a fracture box in the semi-flexed position. The patient suffered but little from constitutional disturbance, although the integuments over the injured condyle ulcerated, so as to expose the bone, which Avas removed in No- vember, in consequence of its losing its vitality. Af- ter this, the limb was placed in the straight position, as anchylosis was deemed unavoidable, but the lad recovered with a perfectly useful joint. 333 Of Oblique Fracture of the Femur, just above the Condyles. Consequence.—The consequences of this injury are often very lamentable, producing great deformity of the limb, and destroying, in a great measure, the mo- tions of the knee joint. Causes.—The injury is generally produced by a fall from a height upon the feet, or upon the knee when the joint is very much flexed. Specimen of examined.—Mr. Paty, surgeon of Bou- verie Street, Fleet Street, has a preparation, shoAV- ing the great deformity consequent on this injury, it was taken from a subject brought into the dissecting room at St. Thomas's Hospital. Before dissecting the parts, it appeared that the femur had been frac- tured just above the condyles, and that the inferior part of the superior portion of the bone projected as far as the upper part of the patella, being only co- vered by the skin; the size of the bone was much increased. On examining the seat of injury, the end of the superior portion of bone was found to have pierced the rectus muscle, through which it contin- ued to project. The patella could not be drawn up- wards, as it was stopped by the extremity of the bone. The condyles of the femur and the inferior portion of bone had been draAvn upwards and back- wards by the action of the muscles, behind the inferior part of the superior portion, and had united to it very firmly. Independent of the deformity in this case, the mo- tions of the knee joint must have been very limited, as the rectus muscle was hooked upon the projecting extremity of bone anteriorly, Avhich also prevented the ascent of the patella. Best mode of treatment.—The best mode of'treat- ment to obviate these great evils, is first to flex the 334 joint as much as possible, to liberate the rectus mus- cle, at the same time supporting the condyles over some fixed body, to prevent their receding, and af- terwards the limb must be firmly extended, to pre- vent retraction. The folloAving cases will explain the difficulty of effecting these objects; the first was under the care of Mr. Welbank, junior. Case.—A gentleman of middle age, a tall and powerful man, was thrown from his gig in June 1821. The medical attendant, who was called to see him, found him lying on a bed, to Avhich he had been carried, with his right leg bent across the left at an angle. At first view, it appeared that there was a lateral dislocation of the knee, a deep hollow was seen on the outer side, in the situation of the condyles, and above it a sharp projection. On exam- ining more attentively the seat of injury, an oblique fracture of the femur was found just above the con- dyles; considerable effusion existed in front of the joint, around the patella, which could not be dis- tinctly felt. After the fracture had been reduced, which was readily effected by slight extension,* a ridge could be felt just above the patella, Avhich, upon a superficial examination, might have been mis- taken for a transverse fracture of that bone^ If the limb was flexed, a great deformity resulted from the projection of the upper portion of the fractured bone, which disappeared again on extending the limb. The sensation of crepitus was very indistinct. The extremity was placed in an extended position, and secured by the application of short splints, for the space of a week, during which time means were employed to reduce the inflammation of a capsule, consequent on the injury. After this, a long splint was applied on the outer side of the limb, from the trochanter major to the foot, and a shorter one on the inner side, from the middle of the thigh to the 335 middle of the leg; these were firmly confined by bandages, and the limb Avas supported upon an in- clined plane. In consequence of frequent variation in the projection of the upper portion of bone, weights were subsequently appended to the foot, to keep up a constant extension, Avhich appeared to be advantageous. In September folloAving, the union Avas thought to be sufficiently firm, and the patient was carefully re- moved to Eastbury, Herts, in a litter-carriage, with his limb still in the same position. It being found, however, that alteration of posture, or any attempt to flex the limb, produced a greater projection at the seat of fracture, the former plan of treatment was continued for another fortnight. Upon a further ex- amination after this period, a degree of lateral mo- tion could yet be felt, and the projection of the frac- tured bone Avas still increased by bending the knee, indicating that the union Avas not yet firm, in conse- quence of which the limb was again placed at rest, and a circular belt was tightly buckled around it at the seat of injury, to press the fractured parts to- gether, and to maintain them in firm apposition. In the middle of October, the patient was first alloAved to get up, the union being then complete, and he has since gradually recovered the use of the limb, so as to be able to Avalk Avithout assistance, but he has lit- tle power of bending his knee, the upper part of the patella being caught against the projecting por- tion of the femur, Avhich is still evident. The limb is someAvhat shortened, and the thigh inclined out- wards. Case.—Mr. Kidd, Avho Avas tall, muscular, and in weight fifteen stone, fell from a height of twenty-one feet, and by the severity of the concussion, fractured his thigh bone obliquely, just above the condyles, and the lower part of the superior portion of the bone penetrated through the rectus muscle and inte- 336 guments, appearing just above the patella. He was immediately carried home, and I Avas requested to see him by Mr. Phillips, Surgeon to the King's Household, who had been called to him. The pro- jecting extremity of the superior portion of bone was saAvn off, and the fracture reduced, when the edges of the wound were carefully brought together, and the limb was placed over a double inclined plane. The wound healed Avithout difficulty, which was extremely favourable. The accident occurred on the 9th of November 1819, and on the 30th, splints Avere applied to press the bones together. December 23, the limb was placed in an extended position, Avhich was continued until the beginning of February. The patient was then allowed to sit up; but on a careful examination of the limb, the union of the fracture Avas ascertained not to be complete, and a leather bandage was therefore placed around the injured part, and tightly buckled, to secure the bones in a proper position. On the 3rd of May, the union was found to be complete, and a few days after the bandage Avas removed, the limb being supported by a pillow. He was still unable to leave his bed in consequence of the great swelling of the leg, and some' degree of superficial ulceration from the ap- plication of the leather bandage. On the 19th of July, he was removed from London to Kensington upon a litter. A considerable period elapsed before the swelling of the limb subsided, or before he was able to be moved to a sofa. At the end of January, he was on crutches for the first time, and took his first walk out of doors, near the close of the follow- ing month. After union Avas complete, the inferior part of the upper portion of the bone, Avhich had been broken, continued to project, its size Avas very much increas- ed, and the patella was fixed to its extremity, to which also the skin adhered. 337 Apparatus for extension.—I have had an apparatus constructed, which I think better calculated to pre- serve the limb in a constant state of extension, than that employed in either of the above cases. It consists of a straight splint, long enough to reach from the upper and inner part of the thigh, as far as several inches below the sole of the foot; the upper extremity is hollowed and padded, so as to fit in between the scrotum and thigh, against the side of the pubes; and the loAver part resembles that described and employed by Boyer; having a boot Avhich fixes by the sole to a bolt projecting at right angles from the splint; the bolt is connected with a screw, let into the lower part of the splint, and on turning this screw, the bolt is carried up- wards or downwards, according as the screw is mov- ed to right or left. After having liberated the rec- tus muscles from the broken, extremity of bone, by bending the knee as before directed, the limb is to be extended, and the apparatus applied on the inner side of the limb, in the following manner :— The upper padded end being placed between the scrotum and thigh, against the side of the pubes; the foot is to be received into the boot, and confin- ed there by closing the front with a lace in the usual manner, or with straps and buckles; then by turn- ing the screw, the bolt connected with the sole of the boot, and consequently the boot and foot are made to descend, thus a powerful mode of exten- sion is afforded, the upper part of the splint being fixed against the pelvis, the Avhole force of the in- strument is exerted upon the limb. Of Fracture of the Head of the Tibia. Nature of—A fracture sometimes occurs oblique- ly through the head of the tibia into the knee joint, 43 338 in which a mode of treatment very similar to that recommended for the oblique fracture of the con- dyle of the femur is necessary; viz. an extended position of the limb, in which the extremity of thigh bone tends to keep the fractured bone in its proper situation; the application of a piece of AVetted paste board, and a bandage. Passive motion should be employed early. If not connected with the joint.—Should the frac- ture not extend so high as the joint, the semi-flexed position of the limb over a double inclined plane will be best, as the weight of the leg then counter- acts the efforts of the muscles, which would other- wise draw up the inferior portion of the broken bone. Of Dislocation of the Head of the Fibula. Causes.—This accident may occur from violence or relaxation of ligament. I have only seen one case from the former cause, which was accompani- ed Avith a compound fracture of the tibia, requiring the removal of the limb. From relaxation.—The displacement in conse- quence of relaxation is more frequent; if the head of th« bone slips backwards, it can be easily replaced ; but unless confined in its proper situation, it is direct- ly dislocated again. Treatment.—The first object in the treatment is to promote the absorption of an effusion of synovia which exists in the joint; this may be effected by repeated blistering, and afterwards a strap should be employed to buckle around the upper part of the leg, Avith a small pad attached to it, Avhich should press behind the head of the bone, to retain it firm- ly in its natural situation. 339 LECTURE XLV. On Dislocations of the Ankle Joint. Strength of the joint.—This articulation, which is* formed by the tibia, fibula, and astragalus, with their cartilages, and synovial membrane, is so strongly pro- tected by the form of the joint, and the numerous ligaments connecting these bones, that great violence is necessary to produce a dislocation, and Avhen this does occur, it is generally accompanied with frac- ture, the ligaments often affording more resistance than the bones. Three forms.—The tibia may be dislocated in three different directions, viz. inwards, fonvards, and outwards; a displacement backAvards is also said sometimes to take place. Cases have likewise oc- curred in Avhich the foot has been thrown upwards, the astragalus being received between the tibia and fibula, in consequence of the ligament, which unites these bones, giving way; but this is only a severe form of the internal dislocation. Of Simple Dislocation of the Tibia, inwards. Appearances.—This is the most common of the dislocations of the ankle. The malleolus internus forms a projection under the skin, on the inner side of the foot, and the integument is so much distended as to appear in a bursting state;—the foot is turned outAvards, so that its inner edge rests upon the ground, when the patient is erect,—a depression 340 exists above the outer ankle, but there is otherwise much swelling; a crepitus can be usually felt about three inches above the external malleolus on moving the foot, Avhich can be done laterally Avithout diffi- culty, but the motion creates violent pain. On dissection.—The appearances upon examining the seat of injury by dissection, are the following: —the end of the tibia rests upon the inner side of the astragalus; instead of on its upper articulatory ♦surface; and if the accident has occurred from a person jumping from a considerable height, the low- er end of the tibia where it is connected to the fibula by ligament, is broken off, and remains attach- ed to the fibula, Avhich is also fractured from tAvo to three inches above the malleolus, and the end of the superior portion of the fibula is carried down upon the upper surface of the astragalus, occupying the natural situation of the tibia; the inferior por- tion of the fibula with its malleolus remains in its natural position, and the ligaments connecting it to the tarsal bones are uninjured. Causes.—The most frequent cause of this acci- dent is jumping from a great height, or it is some- times produced by the foot being caught whilst a person is in the act of running, with the foot turned out, so that the foot is fixed whilst the body is car- ried forwards. Reduction.—The reduction of this dislocation, which should be effected as soon as possible, may be accomplished in the following manner:—place the patient upon a mattress, properly prepared, on the side Avhich corresponds to the injured limb, and bend the leg at right angles with the thigh, so as to relax the gastrocneraii muscles; then fix the thigh whilst an assistant draws the foot gradually in a line with the leg, and at the same time press the lower ex- tremity of the tibia outwards towards the fibula, to 341 force it upon the articulatory surface of the astraga- lus. Reason of failure.—Great violence will often fail in reducing this dislocation, if the limb be kept ex- tended; when, in the same case, the replacement may be very readily effected after the leg has been bent in the mode I have described. The difficulty in the former instance is from the powerful resistance of the gastrocnemii muscles. Treatment.—After the reduction, the limb is still to be kept upon its outer side, being surrounded by a many tailed bandage, and supported upon a well padded splint Avhich has a foot piece ; a second splint also furnished with a foot piece is to be placed on the opposite side of the limb, or that which is upper- most ; and these splints are to be so secured as to prevent eversion of the foot, and to preserve it at right angles with the leg. The bandage is to be moistened with an evaporating lotion. The subse- quent inflammation must be kept within bounds by local or general bleeding as necessary, and the secre- tions must be attended to. Period of care.—About five or six weeks after the accident, the patient may be allowed to leave his bed, having the joint Avell supported by the applica- tion of straps of plaister around it. After eight Aveeks, passive motion and friction should be em- ployed to restore the motions of the joint. Of Simple Dislocation of the Tibia, forwards. Appearances.—This accident produces the folloAV- ing appearances :—the foot seems much shortened, the toes are pointed doAvnwards, and the heel pro- jects. The inferior extremity of the tibia forms a large projection upon the middle and upper part of the tarsus, under the extensor tendons, and a depres- sion exists before the tendon achillis. 342 On dissection.—When examined by dissection, the tibia is found to rest upon the upper surface of the navicular and internal cunicform bones, but a small part of its articular surface still is in contact Avith the articular surface of the astragalus. The fibula is broken, and the superior portion of the bone is carried fonvards with the tibia; whilst the mal- leolus externus, with two or three inches of the loAver part of the fibula remains in its proper situation; the capsular ligament is lacerated extensively on its fore part, and the deltoid ligament is partially torn through. Causes.—The most frequent causes of this injury are, a fall backwards at the time that the foot is con- fined, or jumping from a carriage in rapid motion, whilst the toes are pointed forwards. Reduction.—To accomplish the reduction, the pa- tient should be placed on his back upon a mattress, and the thigh being elevated towards the abdomen, the leg is to be bent at right angles with the thigh; the foot is then to be extended in a line a little be- fore the axis of the leg, the thigh being fixed, and the tibia pressed backwards to its natural position. Treatment.—When the reduction has been effect- ed, the many tailed bandage, and padded splints are to be applied as in the former case, and the same means adopted to prevent excess of inflammation. The position of the limb should be upon the heel, with the knee bent, and the foot well supported. After five weeks the patient may be alloAved to get up, as the fibula will then be united; and passive motion may be carefully used. Of the partial Dislocation of the Tibia, forwards. Nature of—In this accident, the tibia does but half quit the articular surface of the astragalus, resting in 343 part upon the navicular bone, and in part on the as- tragalus. Signs of.—The signs of the injury are, the point- ing of the toes, the elevation of the heel, a great difficulty in placing the foot flat upon the ground, and a considerable loss of power in the movements of the joint. The shortness of the foot, or the pro- jection of the heel, are not very remarkable; the fibula is broken. Case.—The first case of this injury Avhich I saw, was in a very stout lady at Stoke Newington, Avho supposed that she had sprained her ankle by a fall. The toes were pointed, and the motions of the ankle joint entirely destroyed. I attempted to draw the foot forwards, and to bend the ankle joint, but I could not succeed. Some years after, 1 saAV this lady walking upon crutches, the toes Avere still point- ed, and she could not place the foot flat upon the ground. Dissection.—I was not, however, perfectly ac- quainted with the precise nature of the injury she suffered from, until my friend, Mr. Tyrrell, showed me a foot which he had dissected at Guy's Hospital, and Avhich he was so kind as to give me. It pre- sents the following appearances: the articular sur- face of the lower part of the tibia is divided into two, the anterior part is seated on the navicular bone, the posterior upon the astragalus; these two articular surfaces formed at the lower extremity of the bone have been rendered smooth by friction; the fibula had been fractured. Reduction.—The mode of reducing this partial dis- placement should be in every respect similar to that recommended for the complete dislocation, the same directions for the after-treatment should also be adopted. As the signs of the injury are not very well marked, great attention will be required in the examination, and the surgeon should not rest satisfied 344 until the motions of the joint are in a great measure restored. Of simple Dislocation of the Tibia, outwards. This injury is usually attended with much more surrounding mischief than either of the former, as it is produced by greater violence ; there is more lace- ration of ligaments, and more contusion of the in- tegument. Appearances.—The sole of the foot is turned in- wards, and its outer edge rests upon the ground, when the patient is standing; the foot and toes are f>ointed somevvhat doAvnAvards, and the external mal- eolus forms so decided a prominence upon the outer side, by protruding the skin, that the nature of the accident can scarcely be mistaken. On dissection.—Upon dissection, the malleolus in- ternus of the tibia is found obliquely broken from the shaft of the bone; the inferior portion of the shaft of the tibia is thrown forwards and outAvards upon the astragalus before the malleolus: the deltoid ligament remains entire. If the fibula is perfect, the three ligaments naturally coajp^jjting it to the tarsus are ruptured; but whfte ribul^nca is fractured, Avhich often happens, t^^amer^^-rrl^re not injured. The astragalus is so 1^e!ga&*rbroken, and the capsular ligament is lacerlFea. The injury may be occasioned either by a fall or jump from a height, the foot being twisted inAvards, or by the passage of a carriage wheel over the ar- ticulation. Reduction.—To effect the reduction, place the pa- tient upon his back, elevate the thigh towards the abdomen, and bend the leg at right angles with the thigh; then fix the upper part of the leg and thigh, Avhilst an assistant extends the foot in a line with the 345 leg, and at the same time press the tibia inwards to- wards the astragalus. Treatment.—When reduced, apply the many tailed bandage and padded splints with foot pieces, as in the former cases; but in addition, place a pad over the fibula, just above the outer malleolus, so that when the limb is laid upon the outer side, which is the best position, the portion of bone above the pad may be raised, and the pressure of the outer malleolus upon the injured integument may be pre- vented. A similar mode of after treatment to that des- cribed for the other dislocations, will be proper, but more depletion will usually be required after this injury, as the inflammation is generally more violent. Passive motion should be employed after six weeks from the accident. Of Compound Dislocations of the Ankle Joint. Nature of.—The only difference between these injuries and those already described is, that in these cases the integuments and ligaments are divided, ei- ther by the bone, or by the pressure of some uneven and hard body, on which the limb may have been thrown, so as to expose the joint from which the synovia escapes through the wound. Consequences.—The consequences of these injur- ies are, however, very different from those occa- sioned by the simple dislocations; usually the folloAV- ing effects are produced. The synovia at first es- capes through the wound, and in a short time after the accident, inflammation commences; this inflam- mation extends to the ligaments as well as to the extremities of the bones forming the joint, and the secretion from the joint becomes much increased. In about five or six days, suppuration commences; 44 346 at first the discharge of matter is small, but it soon becomes very profuse. Under this process of sup- puration, the articular cartilages become partially or wholly absorbed, but in general only partially; the ulceration of the cartilage is a very slow process, usually attended with much constitutional suffering, and is often folloAved by exfoliation of bone. When the cartilages have been removed, granulations arise from the extremities of the bones, and from the ligaments, which inosculate and fill the cavity of the joint. In some cases, adhesive inflammation occurs in the commencement, and the articular surfaces be- come united Avithout any absorption of the cartila ges; this often occurs in part, but I have seen it extend to the Avhole surfaces. Anchylosis does not always follow.—But neither the adhesive union, nor the inosculation of the gran- ulations entirely destroy the motions of the joint, if passive motion be employed sufficiently early and carefully; and I have seen, in some cases, the mo- bility of the articulation restored to nearly its orig- inal extent; otherwise, the other joints of the tarsus acquire such an increase of motion, as to render the deficiency in that of the ankle hardly perceptible. When the powers of the joint are completely de- stroyed, it is by a deposite of cartilage, and a subse- quent formation of phosphate of lime, as is usual in the reparation of fracture of bones. Constitutional symptoms.—The various local effects which I have described are accompanied usually with much constitutional suffering. About twenty- four hours, or in tAvo or three days after the receipt of the injury, the parent begins to complain of pain in the head and back, showing the influence of the accident upon the brain and spinal marrow. Loss of appetite, nausea, and often vomiting, indicate dis- order of the stomach; the tongue is white, yellow- 347 ish, or brown, according to the degree of irritation; the bowels generally become inactive, from a pau- city of the secretions, not only from their mucous surface, but from the glands, connected Avith them, as the liver, pancreas, &c.; the secretion of the kid- neys is much diminished, and of a deep colour ; the skin becomes hot and dry, ceasing to pour out the perspirable matter. The action of the heart and arteries is accelerated, the pulse becoming hard, and in severe cases it is often irregular or intermittent. The respiration is hurried in sympathy with the quickened circulation. When the irritation is great, the nervous system becomes further affected, the patient is restless and Avatchful, and as the severity of the case increases, delirium subsultus tendinum, or tetanus occur. Such are the usual effects of local irritation upon the constitution, but the degree in which they are developed depends upon the irritability of the sys- tem, the powers of reparation, and the extent and violence of the injury. Cause of symptoms.—The cause of the severity of the local and constitutional symptoms in these cases appears to be the exposure of the joint, and the great efforts necessary for the reparation of the injury under such circumstances, as the simple dislo- cations very rarely occasion these distressing effects, but the adhesive process repairs the mischief, with- out giving rise to either much local or constitutional disturbance. Thus the first principle in the treat- ment of the compound dislocation is clearly pointed out, viz.: the closure of the wound, and the aiding, by all means in our power, its union, by adhesive in- flammation; so as to prevent suppuration in the cavity of the joint. Amputation formerly performed.—Formerly, and within my recollection, it was thought expedient for 348 the preservation of life, by many of our best sur- geons, to amputate the limb in these cases ; but from our experience of late years, such advice would in a great majority of instances be now deemed highly injudicious. The mode of treatment to be adopted in these cases is as follows, and will apply generally to either form of dislocation. Treatment.—The first object will be to suppress haemorrhage, if any of consequence exists. Of the two arteries, the anterior and posterior tibial, Avhich are likely to be wounded, the former will be found most frequently injured, the latter generally escaping; but in case of bleeding from either, it will be neces- sary to apply two ligatures, one above and another below the aperture from which the bleeding occurs. The projecting extremities of the bones are often covered with dirt, having been thrust against the ground; when the next step will be to cleanse them thoroughly from every particle of extraneous mat- ter, otherwise it Avill afterwards excite suppurative inflammation in the joint. Should the bone be com- minuted or shattered, all the detached portions must be carefully removed, and if the wound is not suffi- ciently large to allow of their being taken out with- out much difficulty, it should be enlarged with a scalpel, but the incision should be made in such a direction, as will avoid further exposure of the joint. The wound will sometimes require dilatation, if the integuments are nipped into the joint by the pro- jecting bone, as they cannot be in many instances liberated without. The reduction of the dislocation is to be accom- plished by the same means as already described in the simple displacements, and Avhen reduced, the edges of the wound are to be very carefully ap- proximated by sutures and strips of plaister, over 349 which a piece of lint, dipped in the patient's blood, is to be placed; this, when the blood coagulates, forms, as far as I have seen, the best covering for the Avound. The part is to be further supported by the application of separate pieces of linen, in the same way as the many tailed bandage, but each por- tion being unconnected with the others, so that any one piece can be removed, and another substituted for it, by tacking the ends of the old and new strips together, before the former is draAvn from its situa- tion ; in this way the limb is not disturbed by the change. This bandage is to be moistened by an evaporating lotion. The padded splints are lastly to be employed with foot pieces, as recommended in the simple dislocation, but a portion of that one situated on the wounded side of the limb should be cut out, in order to enable the surgeon to dress the wound without removing the splint. The position in which the extremity should be placed is the same as in the simple injury, but must be occasionally va- ried a little according to the seat and extent of the wound. Constitutional remedies.—The next object will be to prevent or diminish the constitutional suffering likely to ensue; in some cases it will be necessary to take away blood generally, but this should be done with the utmost caution, as great power is required to support the after process of restoration, which will fail altogether if the patient be rendered feeble by the loss of blood or other means. Purgatives should also be administered with great care, as the frequent change of position which the action on the bowels necessarily occasions, tends very much to in- terrupt or destroy the adhesive process, which it is our chief object to promote. I am confident that 1 have seen many cases of compound fracture prove destructive under such circumstances. The bowels 350 should be emptied as soon as possible after the ac- cident, before the adhesive inflammation is set up, after Avhich a mild aperient may be given at in- tervals. After treatment.—Should the patient remain free from pain, this mode of treatment should be perse- vered in until the adhesive process is complete; but should he complain of suffering in the injured joint, the dressings must be cautiously raised, so as to ex- pose a very small part of the wound, to allow of the escape of any matter which may have formed, but not to disturb any adhesions which have taken place. If the suppurative inflammation has commenced, the first dressings may be removed, and the surface of the Avound be merely covered with some simple dressing. Should much surrounding inflammation arise, it will be necessary to apply poultices on the wound, and leeches upon the limb, at a little distance from it, and aftenvards to continue the use of the evaporating lotion over the inflamed surface not cov- ered by the poultice. When the inflammation has subsided, the use of the poultices should be discon- tinued, as they relax the vessels too much, and retard the progress of cure. Period of recovery.—In favourable cases, the wound heals in a few weeks with but little suppuration. In those less favourable, the discharge is very copi- ous, and portions of the extremities of the bones ex- foliate, rendering the recovery very tedious. Even in the most favourable instances, the patient cannot venture to use crutches before the expiration of three months, and often not until a much more dis- tant period. I shall now relate a few cases, Avhich will further explain the best mode of treatment, and also show the impropriety of recommending amputation indis- criminately in these cases. 351 Cases.—In the year 1797, I attended a gentleman with Mr. Battley, who then practised as a surgeon. This gentleman had, in a fit of insanity, jumped from a tAvo pair of stairs window into the street, by which he caused a compound fracture of the ankle joint; he, nevertheless, got up without assistance, and hav- ing obtained admission into the house, he ascended the stairs to his bed-room, and having fastened the door, got into bed. The door was forced open, as he would not unfasten it. When I examined the injured limb, I found that the tibia was dislocated inwards, and that the astragalus was broken into many pieces, many of which being detached, I re- moved. We then reduced the displaced bone, and having approximated the edges of the wound, cov- ered the whole with lint wetted with the patient's blood. The limb was placed on the outer side, with the knee flexed, and an evaporating lotion was freely applied. In three or four days after, considerable inflammation took place, but this was subdued by general and local bleeding, with emollient applica- tions to the wound ; extensive suppuration followed, and continued very profuse for nearly tAvo months, when the surface was covered by granulations ; at the same time an improvement took place in his mental affection, which became less and less as the wound closed; between four and five months from the accident, the healing-process was complete, and the state of his mind natural. At the expiration of nine months he returned to his employment, but could not walk Avithout the aid of a stick for many months. In October, 1817, I Avas called by Mr. Clarke, a surgeon, residing in Great Turnstile, Lincoln's Inn Fields, to visit Mr. Caruthers, a young gentleman who had a compound dislocation of the ankle joint inwards, occasioned by the overturning of a stage- 352 coach at Kilburn, from which place he had been re- moved to Lambeth where he resided. The extrem- ity of the tibia projected to the extent of between two and three inches from a wound through the in- teguments on the inner side. The tibia was broken, a small portion of it remaining attached to the joint by the ligaments; the fibula was also fractured bad- ly. I found it necessary to enlarge the aperture in the integuments, before I could replace the dislocat- ed bone. After the reduction, simple dressings were spread over the Avound; these Avere confined by a many tailed bandage, moistened with an evaporating lotion, and the limb was supported by the padded splints, and placed in a semi-flexed position upon a quilted pillow. The patient was bled, and took mild purgatives, with saline medicines. Considerable lo- cal and constitutional suffering followed, which great- ly exhausted the patient; abscesses formed in the leg, and some exfoliation took place, much retarding the progress of cicatrization. These abscesses Avere freely opened, and the parts supported by strips of plaister; the limb was kept cool by the use bf evaporating lotion, and the strength was support- ed by giving bark and wine. In the January 1819, the last exfoliation occurred, after which the wound healed rapidly, and the patient recovered his health. Mr. Caruthers has since obtained very considerable use of the limb, being able, he told me, to walk six or eight miles if necessary. Mr. Abbott, of Needham Market, Suffolk, sent the particulars of the folloAving interesting case, which occurred under his care. Mr. Robert Cutting, aged seventy, corpulent, in- temperate, and of a gouty habit, had his ankle dis- located in consequence of being thrown doAvn in a quarrel: the end of the tibia Avas forced through the integuments, and protruded about four inches; 353 the fibula Avas fractured a few inches above the joint, and the foot Avas turned outAvards. Immedi- ately he got up, and in struggling to stand, he cover- ed the end of the bone with dirt and sand, of Avhich also a considerable quantity got into the joint. He was conveyed home about four miles in a cart, and Mr. Abbott saAV him about five hours after the ac- cident, and recommended amputation in consequence of the extent of injury, and the disordered state of the patient's constitution; but this the patient could not be induced to submit to, therefore the injured parts were carefully and thoroughly cleansed Avith warm water, the dislocation was reduced, and the edges of the Avound were nearly brought into appo- sition by strips of linen dipped in the tinctura Ben- zoini composita, without sutures or adhesive plaister; a thin board, hollowed to receive the leg, and with an opening in the situation of the outer ankle, being well padded, Avas placed under the outer side of the limb, which was enveloped in a folded flannel band- age, from the foot to the knee ; the leg was laid in a flexed position, with the foot a little raised. The patient was bled to 3xij, and ordered a mild saline purgative every two hours, until the bowels Avere relieved, with milk broth for his food. The accident happened on the 25th of April, 1802; and he proceeded very favourably until the 27th, when he complained of darting pains in the injured limb, and he Avas restless, yet his skin and bowels Ave re acting properly. Upon unfolding the flannel, some swelling appeared about the joint, and some glecty discharge escaped from beneath the dressing; the inflammation did not appear much more than necessary, but six leeches were applied at a little distance from the seat of inflammation, Avhich relieved the pain, and the wound Avas dressed as be- fore. This plan of treatment was continued, and 45 354 the case proceeded most favourably; on the 2d of May, a small quantity of matter Avas discharged, but without augmenting the symptoms. After ten weeks, he was moved daily from the bed to a sofa, and about this time the Avhole of the dressings were ta- ken off for the first time, Avhen the wound was found to be completely cicatrized ; previously, only small portions had been elevated at a time, and fresh pieces put on to keep the covering perfect. When exposed, the exterior of the joint presented its usual appearance, excepting a slight enlargement in the situation of the cicatrix; but this Avas not more than could be expected. At the end of five months, he was allowed to go on crutches, and bear as much Aveight on the limb as his own feelings suggested to be proper. Being a butcher by business, he after- wards rubbed the limb with the fluid obtained from the joints of animals, and also frequently placed his foot and ankle in the Avarm paunch of an ox. Be- fore the expiration of tAvelve months, he could walk Avithout the assistance of a stick, and for many years before his death could walk with perfect ease and freedom. He lived to the age of eighty-three. The folloAving are the particulars of a case sent to me by Mr. Scarr, Surgeon, at Bishop's Storford; he also sent the patient for my inspection, after his re- covery, so that I had an opportunity of witnessing the happy result of Mr. Scarr's skill. Case.—John Plumb, aged 38, had descended on a ladder, about ten feet from the ground, Avith a sack of oats upon his shoulders, Avhen the ladder slipped from under him, and he fell to the ground upon his feet, still retaining the load of oats. Mr. Scarr Avas passing at the time, and immediately attended to the man. When his stocking had been removed, the tibia and fibula were found projecting through the skin at the outer side of the ankle, and the astraga- 355 lus was exposed through an opening on the inner side ; both the wounds were clean, and without much surrounding mischief. Mr. Scarr therefore imme- diately reduced the displacement, and closed the Avounds by the application of adhesive straps, and placed the patient in bed, with the limb flexed, and laid upon the outer side. The limb was moistened with a lotion of acetate of lead. About 3xvj of blood were taken from the arms; some saline medi- cines administered ; and the antiphlogistic treatment persevered in, with due regard to his constitutional powers ; some abscesses formed, which Avere opened in the most favourable points, and the patient be- came gradually convalescent in about six months, Avithout any very urgent symptoms. At the end of twelve months, he was able to resume his laborious occupation as before the accident. Removing a portion of bone.—It has been recom- mended in the treatment of these cases, to remove Avith a saw the projecting extremity of the tibia, be- fore the reduction of the dislocation is attempted; there are some instances in which such a proceeding is absolutely necessary, and many reasons are given for adopting this practice in general. When necessary.—The cases in Avhich it must be necessarily adopted are the folloAving: First, Avhen the dislocation cannot be othenvise reduced Avithout great violence. Secondly, Avhen the extremity of the bone is frac- tured obliquely, so that if reduced it immediately slips from its proper situation, Avhen the extension is discontinued; but after the removal of the point by the saAV, it rests readily upon the astragalus. Reasons for, generally.—The reasons assigned for adopting this plan in all instances are, First, That the shortening of the bone relaxes the muscles, and diminishes the tendency to spasmodic 356 contractions, Avhich so frequently occur when much force has been used to replace the bones. Secondly, That the adhesive process goes on much more readily from the sawn extremity of the bone than from the natural articular surface, consequently the local irritation is less. Thirdly, That Avhen the suppurative inflammation does occur, it is rendered 'much less, as there is not the same extent, by nearly one half, of cartilagi- nous surface to be removed^by ulceration, and thus by the diminution of the ulcerative and suppurative process, the constitutional irritation is much lessened. Fourthly, It has been remarked, that those cases have usually recovered quickly, in which the extre- mities of the bones have been broken into many small pieces, and separated so as to render their re- moval necessary. Fifthly, I do not recollect any instance of unfavour- able termination, when this practice had been pur- sued ; but I have known many unsuccessful in which it had not been adopted. Objections to.—The objections made to this treat- ment are, first, that the limb must be shortened by the removal of the portion of bone, and, secondly, that the joint must afterwards become anchylosed. Not important.—Provided Ave admit that the dan- ger of the case is lessened, Avhich I believe, by the sawing off the extremity of the tibia, the first objec- tion cannot be considered of much Aveight, more es- pecially as the defect is so easily remedied after- wards, by increasing the thickness of the sole of the boot or shoe. With regard to the second objection, I do not imagine that anchylosis is at all a necessary consequence, having seen cases in Avhich considerable motion remained after the removal of bone, and re- covery of the patient. I know that anchylosis is lia- ble to take place in either mode of treatment, but 357 even then the patient, after a time, walks with very little halt, as the other tarsal joints acquire so much increase of motion. Treatment adapted to the case.—It appears to me, hoAvever, that either plan may be adopted, accord- ing to the features of the case, and I should not Avish it to be supposed that I recommend the one to the entire exclusion of the other. General principles.—When the dislocation can be reduced without much force, and the bones retain their proper situation readily, Avithout the occurrence of spasmodic muscular action; and if the patient be not very irritable, an attempt should certainly be made to effect a cure, without removing the ends of the bones; but if the bones be shattered, or fractur- ed obliquely, so that it will not retain its proper po- sition Avhen reduced, the saAV should be employed, in the first instance, to smooth the ends of the bones, when the small separate pieces have been taken away, and in the second place, to make a surface to rest" upon the astragalus. I would also rather use the saAV, than employ great violence to reduce the dislocation otherwise; likeAvise in those cases where the spasmodic contraction of the muscles renders it extremely difficult to keep the injured joint in its na- tural position. I shall noAV relate some cases, Avhich Avill afford an opportunity of judging better of the propriety of what 1 have stated. Cases.—Nathaniel Taylor, aged thirteen, was ad- mitted into Guy's Hospital, in consequence of his having a compound fracture of his ankle joint. The injury had been occasioned by a boat falling upon his leg. The end of the tibia and the fractured extre- mity of the fibula projected through an extensive opening at the outer ankle ; the malleolus externus retained its natural situation and ligamentous con- 358 nexions. The foot Avas turned inAvards, and hung so loosely, that the sole could be placed against the side of the leg. I tried to reduce the bones to their proper situations, but could not effect it, but by very great force, and as soon as the extension was discontinued, they again slipped from their places. Under these circumstances, those around me urged me to ampu- tate the limb; but considering my young patient to be otherwise in good health, and not of an irritable habit, I determined to preserve the limb if possible. On a further examination, I discovered that the mal- leolus externus and inferior part of the fibula connect- ed to it, although in its natural position, was very loose, and I therefore removed it, by dividing the ligaments Avith a scalpel, and I after Avards sawed off about half an inch of the end of the tibia. I then found that I could easily replace the bones, and that they retained their positions without difficulty. Hav- ing approximated the edges of the Avound, I covered it with lint dipped in the patient's blood, and by strips of adhesive plaister; the limb was placed upon the heel, and supported by padded splints. Scarcely any constitutional suffering occurred, but little suppuration took place, and the wound grad- ually healed. One abscess formed over the tibia, but did not give rise to any severe symptoms. He was allowed to get up, and to use his crutches after about two months, and at the expiration of four months he could Avalk very well. There appeared to be some motion at the ankle, but the tarsal joints had evidently acquired much increase of motion. In December, 1818, I Avas called upon to attend, with Mr. Jones, of Mount Street, a Mr. West, aged forty, who had severely injured his left ankle, by jumping from a one horse chair, alarmed at the horse's kicking. When I first saw him, the extremity of the tibia 359 projected through a Avound in the integuments, at the inner side of the ankle, and a portion of skin Avas nipped into the joint by the bone, the foot was turned outwards, but hung loosely. Finding that our patient Avas of a most irritable constitution, and seeing that great violence must be employed to re- duce the bone, and that to effect the reduction it would be necessary to enlarge the wound consider- ably, I considered it much better to remove the ex- tremity of the tibia, in order to avoid those evils. I therefore sawed off a portion of the bone, and then effected the reduction without difficulty, nor was there any disposition to further displacement from muscular contraction. The edges of the wound Avere next secured in contact, by the insertion of a fine suture, and the part Avas covered with lint wet- ted with blood, and a many tailed bandage. The limb was secured by the padded splints, and placed upon the outer side, in a semi-flexed position. The patient Avas bled to the extent of 3x, some opium was given him, and the spirit lotion Avas freely ap- plied to the extremity. On the third day, the foot exhibited slight vesications, and he complained of tension, and some pain, but this soon subsided. About the sixth day, the wound began to discharge a se- rous fluid, mixed with red particles ; poultices Ave re employed ; the secretion soon became purulent, and continued to increase until the end of a month, when it gradually subsided. At the end of two months, the patient Avas alloAved to get on to his sofa, as the joint appeared firm ; a small wound still, howev- er, existed, from which it was evident some small exfoliation would take place; this did not happen for several months. During the progress of the case, Dr. Pemberton Avas consulted in consequence of the patient's having an extremely disordered state of stomach ; but, notwithstanding, the symp- 360 toms produced by the accident Avere not more se- vere than those usually occurring in a common case of compound fracture. Dr. Rumsey, of Amersham, Avas so kind as to send me the account of an excellent case of compound dislocation of the ankle, complicated with simple fracture of the thigh bone of the same limb; the folloAving are the particulars : Mr. Tolson, aged forty, was thrown from a cur- ricle, on the 21st of June 1792, and in falling, dis- located his left ankle joint. Dr. Rumsey saAV him about two hours after the accident, Avhen he found a large wound at the outer ankle, through which the extremities of the tibia and fibula, with a por- tion of the astragalus, protruded ; for the astragalus had been fractured, and one portion of the bone still remained attached to the tibia and fibula, the foot was turned inwards and upAvards, and the skin of the outer side, beneath the Avound, Avas very much confined by the dislocated bones. Dr. Rum- sey, deeming further advice necessary, sent for Mr. Pearson, of London, and Mr. Henry Rumsey, his brother, a surgeon at Chesham ; and during the ab- sence of the messengers, the patient directed Dr. Rumsey's attention to his thigh, which Avas then as- certained to be fractured at the superior part. This circumstance being considered by Dr. Rumsey and his brother as a decided obstacle to amputation, they determined on endeavouring to preserve the limb. Finding that they could not replace the bones without excessive force, Dr. Rumsey determined upon removing that part of the astragalus which was attached to the dislocated bones. Upon separating this portion of bone, it was found to be as near as possible the superior half, the fracture having been horizontal through its centre. After this had been taken away, Dr. Rumsey still found it necessary to 361 divide a portion of the integuments, which had been confined by the dislocated bones, before he could readily effect the reduction. The bones being re- placed, some lint dipped in tincture of opium was laid over the Wound; the whole was covered with a poultice made of oatmeal and stale beer, and the leg Avas secured Avith padded splints. On Mr. Pear- son's arrival, he perfectly approved of the course Avhich had been adopted. In the night following, the patient became deliri- ous, vomited, and his pulse was full and frequent; he was bled to 3x, and ordered to take a common saline draught with antimonial wine and tincture of opium every four hours; the tartrate of potash and manna were given in sufficient quantity to relieve the bowels. He also experienced considerable pain in the ankle and thigh. On the 24th, these un- pleasant symptoms had in a great measure subsided, and a discharge commenced from the wound; he continued the same plan of treatment, with the omission of the antimony, as his stomach was irrita- ble. He continued doing well until the 28th, when the discharge became thin, and he Avas much troub- led Avith pain and flatulence in the bowels; it Avas therefore considered necessary to alter his diet, and on the 29th, he Avas allowed a small quantity of an- imal food, some table beer, and port wine ; the bark Avas also freely taken in substance and in decoct/on ; he Avas much benefited by this change. The dis- charge soon became very copious, in consequence of Avhich the wound Avas obliged to be cleansed fre- quently ; the limb Avas therefore placed upon the heel, as the dressing could not be effectually accom- plished without considerable disturbance, whilst it continued on the outer side. After the alteration of position, much more attention was required to pre- vent further displacement, as the foot had a tenden- 46 362 cy to incline inwards, causing the end of the fibula to project at the wound ; this Avas however obviat- ed, by placing some small wedges between the foot and the fracture box, on the inner side, and others betAveen the calf of the leg and the box on the outer side. About the 30th, the use of the poultice Avas discontinued, and the Avound was dressed with dry lint, over which a pledget, spread with the ce- rat: plumbi superacetatis, was placed, and confined by a bandage to keep up moderate pressure. The bark and opium were continued until the beginning of August, and the wound gradually healed with only one check from the confinement of matter, the cicatrization being completed about the middle of September. The union of the thigh bone also went on well, but as the state of the leg prevented the possibility of keeping up sufficient extension, a de- gree of curvature was produced by the junction. The patient was soon able to walk about with the aid of a stick only, and acquired a power of motion in the injured joint nearly equal to that of the sound limb. Another excellent case occurred, under the care of Mr. Cooper, of Brentford, formerly my dresser, who obliged me by sending the particulars from which the following account is taken. Thomas Smith, aged thirty-six, a painter, dislocat- ed his ankle outwards, by a fall with a ladder, his foot being caught between two of the steps. Mr. Cooper was fortunately passing at the time, and im- mediately attended to the patient. On examining the limb, he found that the fibula Avas broken about five inches above the outer malleolus, and the tibia fractured longitudinally three inches from the joint; the small inferior portion remained attached Avith the inner malleolus. About an inch and a half of the inferior part of the shaft of the tibia, and the 363 broken end of the fibula projected through a wound in the skin, rather anterior to the malleolus exter- nus. Mr. Cooper finding that moderate force was not sufficient to replace the bones, he divided a portion of integument, which was pressed in by the protruding bones, and he also removed, with a me- tacarpal saw, an inch of the tibia, and a small piece of the fibula, after which the reduction Avas easily accomplished. The edges of the wound Avere brought together by tAvo sutures, and further secured by strips of adhesive plaister; over this the many tail- ed bandage, and the padded splints Avere placed to support the limb, Avhich was placed on the heel, and kept cool by an evaporating lotion. In the even- ing, an opiate was given, and he Avas ordered some aperient for the next morning. Some slight bleed- ing occurred during the folloAving night, but not sufiicient to require a removal of the dressings, which were not, therefore, disturbed until the fourth day, when they Avere taken off, and the appearance of the Avound Avas then favourable. On the eighth day, a slough had formed, about five or six inches in circumference; a poultice was therefore applied to the foot, and the evaporating lotion continued to the limb above; he also took port wine and bark, to support him under the profuse suppuration which followed. The slough separated on the thirteenth day, exposing a healthy granulatory surface, after which merely simple dressing Avas applied. In five weeks from the accident, the wound was perfectly healed; and in a little more than two months, the fractured bones had become so firmly united, that the patient was able to sit up. In three months he began the use of crutches, and eventually obtained almost a perfect limb. This man had suffered frequently from colica pic- tonum, and had an extremely irritable stomach, he 364 was also naturally, of a nervous temperament, there- fore but ill calculated to support the consequences of so severe an injury. He derived considerable benefit from the occasional use of the saline effer- vescent mixture, and from the free exhibition of opium at night* * Although it is perfectly unnecessary to state more cases in confirmation of the correctness of Sir Astley's opinions respect- ing the treatment of these injuries; yet 1 think the following account of sufficient interest to warrant its relation :— Timothy Holland, a very stout muscular man, aged about thirty-five years, employed as a labourer at the London Docks, was standing on the quay, close to one of the swing bridges, when the bridge was forcibly and unexpectedly swung round, and struck his right leg on the outer side, a little above the ankle, occasioning a severe compound dislocation inwards, for which he was brought to St. Thomas's Hospital, soon after the accident, on the 23rd of August, 1826. 1 was immediately sent for, and on my arrival at the Hospital, found the patient placed upon a bed, with the injured limb in the following state :—About two inches of the inferior extremi- ty of the tibia projected through an extensive wound on the inner side of the joint; the internal malleolus was broken off, and remained loosely attached by the deltoid ligament. The wound extended in two directions, one reaching from about three inches above the joint, a little to the outer side of the course of the anterior tibial artery, to the centre of the meta- tarsal bone of the great toe; the artery was completely expos- ed for more than three inches, but had not been wounded; the second portion of the wound extended from the former, imme- diately over the articulation, round the anterior and inner parts of the joint, as far as the back of the tendo achillis ; the posterior tibial artery and nerve were also exposed to the extent of an inch, but otherwise uninjured. A portion of the integument, about four inches in circumference, near the inner side of the joint, appeared to have suffered considerably, but retained its sensibility. The fibula was fractured about three inches above its malleolus.—Notwithstanding the formidable appearance of the case, 1 found my patient cool, and willing to submit to any thing I proposed. His composure and time of life, when the constitutional powers are great, determined me to attempt the preservation of the limb. On endeavouring to replace the bones, I found it could be effected without much violence, but that they became again dislocated immediately the extension 365 These cases I think quite sufficient to show, that in very many instances, not only the life of the pa- tient may be preserved without the removal of the was discontinued, I therefore removed, with a saw, nearly an inch of the end of the tibia, and likewise took away the mal- leolus internus, which was but slightly connected by ligament. The reduction was then easily accomplished, and the disposition to further displacement no longer existed, excepting that the end of the tibia advanced a little forwards. This I easily reme- died, by placing a long narrow splint on the posterior part of the limb, from the upper projecting part of the calf of the leg to the heel, and then fastening a broad piece of tape around the splint and leg, a little above the seat of injury, so as to press the heel forwards, and the end of the tibia backwards. The edges of the wound were brought together and secured by su- tures and strips of soap plaister, over which, the many tailed bandage and splints were applied ; the limb was placed upon the outer side, in a semi-flexed position ; the bandages were kept wet with a splint lotion ; the patient passed a sleepless night, but was free from pain, his tongue was slightly furred, and his pulse quickened. These symptoms became alleviated by the action of some aperient medicine, and he proceeded very favourably until the 30th, when he complained of consid- erable pain in the ankle, and exhibited a good deal of constitu- tional derangement. The dressings being removed, that por- tion of the skin which had been so much injured at the time of the accident was found to be sloughing; otherwise the appear- ance of the wound was favourable. Some fresh strips of plaister were lightly applied, and covered by a poultice, and he was ordered some saline effervescing medicine. On the 5th of Sep- tember, the suppuration had become profuse ; the poultice was discontinued, and the wound was dressed with the nitric acid lotion over the slough, and simple cerate to cover the whole; the same position was observed, and he was allowed some meat and porter for the first time. From this period, only a slight check occurred in the cure, by the burrowing of some matter up the leg, which was relieved, by altering the position a little, and applying a small compress in the direction of the sinus. The wound was completely closed by the end of October; he was then allowed to sit up, but did not venture to bear at all upon the limb until some weeks after. He was discharged from the Hospital on the 23th of February, 1827, having re- gained a perfect use of his limb, wearing a shoe with the sole thick, in proportion to the shortening of the leg, with which he 366 injured limb, but that the extremity is, afterwards, infinitely more useful than any artificial one could be, and that it may become nearly as perfect as previous to the accident. Amputation sometimes necessary.—There are some circumstances, however, which render the operation of amputation absolutely necessary, and these I shall now briefly point out. In old persons.—First, the advanced age of the patient, when the poAvers of the constitution are not sufficient to support the extensive suppurative in- flammation likely to folloAV the injury, but Avhich the operation of amputation does not expose the patient to. For very extensive wound.—Secondly, A very ex- tensive lacerated wound, with much haemorrhage, will render it imprudent to attempt to preserve the limb. For extensive fracture.—Thirdly, Extensive com- minution of the tibia or of the tarsal bones, as the astragalus and calcis, will give rise to a necessity for amputation. When only some small portions of bone are broken off, they should be carefully re- moved, and the end of the bone be smoothed by a saw. Fourthly, The dislocation of the tibia outwards, as it is generally accompanied with extensive injury to the soft parts, as well as to the bones, will often require the performance of amputation. Wound of a large artery.—Fifthly, The division of a large artery with an extensive wound, might render the operation necessary ; but I should not, in all cases, recommend amputation on this account, walked quite free from any lameness. 1 repeatedly examined the joint which had been injured, and could discover but a very trifling difference between its motions and that of the sound ankle.—T. 367 more especially if the injured vessel was the ante- rior tibia, as I have known more than one instance of recovery, in which this vessel has been secured, and the limb saved. Division of the posterior tibial artery could hardly take place without injury to the large accompanying nerve, which would increase the necessity for removing the limb. Extensive contusion.—Sixthly; extensive contusion of the surrounding soft parts, likely to occasion the formation of large sloughs, would be a reason for am- utating; this will generally happen when the injury as been occasioned by the passage of the wheels of a heavy laden wagon over the joint; or from the falling of a Arery heavy weight upon the limb. These are the principal circumstances which ren- der an immediate performance of amputation neces- sary; but there are others Avhich may make it equal- ly proper at a more distant period from the accident. Mortification.—If mortification ensues, the opera- tion will be required; it is, however, best in such a case, to wait until the extent of the mortification is clearly defined, before the amputation be performed, although I conceive, that when the mortification re- sults from the division of a blood vessel, or from other local injury in a healthy constitution, a different practice may be adopted to that which would be proper if the disease arose from constitutional causes. I have known the arm amputated in consequence of mortification produced by a division of the brachial artery at the elboAV; the mortification Avas extending at the time, but the patient did well, the limb being removed above the elbow. In another instance, where death of the foot had occurred in a case of large popliteal aneurism, the limb was amputated above the swelling, Avhilst the mortification was still proceeding up the leg, and the man recovered. Excessive suppuration.—Should the suppuration 368 from the joint be greater than the constitution can support, as I have seen it, amputation will be requir- ed to save the life of the patient. Large exfoliation.—Again, when considerable por- tions of bone are exfoliating, and keeping up a con- tinued state of irritation, if they cannot be removed without inflicting great injury, the operation of am- putation should be performed. Deformity of limb.—Excessive deformity may re- sult from negligence on the part of the surgeon, dur- ing the union of the wound, so as to make the limb Avorse than useless to the patient, Avhen it will be ne- cessary to remove it. Case.—Mr. Norman, of Bath, amputated the leg of a man in consequence of such deformity. The patient had suffered from a compound dislocation of his ankle inwards, accompanied with displacement of the astragalus, which Avas removed. After the union of the Avound, it was discovered that the os calcis had been drawn up against the posterior part of the tibia, and had there become firmly united to it, the toes being pointed downwards, rendering the limb useless. When tetanus occurs.—It has been recommended to amputate when tetanus occurs after this injury, but as far as my OAvn experience goes, I believe that the operation only hastens a fatal termination. I have only seen one case of tetanus following compound dis- location of the ankle joint, which, in spite of every attention on the part of Dr. Relph, who attended the patient with me, destroyed life. Not advisable.—Although I have not witnessed the performance of the operation after the appearance of tetanic symptoms, when the injury has occurred in the ankle, yet 1 have knoAvn it tried in several in- stances, when this formidable affection has been pro- duced from other injuries, and it appeared rather to hasten the progress of the disease than to relieve it. 369 Cases.—In a case of compound fracture just above the ankle joint, producing tetanus, the limb was am- putated; the tetanic symptoms increased, and speedi- ly destroyed the patient. In another instance, Avhen tetanus had folloAved in- jury to the finger, amputation was performed, but without alleviating the symptoms, and the man died. I could relate other cases, all shoAving: how unavail- ing the operation is under these circumstances. Chronic tetanus.—I have known a form of tetanus succeeding injuries, in Avhich the symptoms have never been very severe, and Avhich has been termed chronic tetanus; this is sometimes gradually recov- ered from, although but little be done by medicine, and nothing at all by surgery. The medicine which I have seen most advantage from, has been calomel and opium; and opium should be applied to the wound. Excessive irritability.—There are some persons who are naturally so excessively irritable, that the slightest injuries produce fatal consequences ; and in others again, possessing originally good constitutions, this extremely irritable state may be induced by ex- cess of mental exertion, by intemperance, by great indolence, or other causes, so that very trifling acci- dents will destroy them. Those persons also, who are much loaded Avith fat, and especially those who, under such circumstances, are extremely indolent, generally bear important accidents or operations very ill, and frequently perish in spite of the most cau- tious and attentive treatment. Of Fractures of the Tibia and Fibula near the Ankle Joint. Of fibula.—Fracture of the fibula frequently oc- curs about three inches above the outer malleolus. 47 p-.--- 370 Symptoms of.—The patient immediately experien- ces pain at the seat of the injury, which is much in- creased by any attempt to bear the weight of the body upon the limb; and in endeavouring to stand, he does not place his foot flat upon the ground, but rests it upon the inner side, to receive the weight chiefly on the tibia; the flexion or extension of the foot also augments his suffering. An inequality of the surface of the limb over the seat of fracture often exists, and a crepitus is readily distinguished, by placing one hand over the injured part, and by ro- tating the foot at the same time with the other hand. Causes of.—This fracture is produced by a blow upon the inner side of the foot, which forces it out- wards against the lower part of the fibula: also, by a sudden and violent twist of the foot inwards. It is, perhaps, most frequently occasioned by a lateral fall, when the foot is confined. I broke my right fibula by falling on my right side, Avhilst my foot was confined betAveen two pieces of ice : I felt a snap in the bone at the time of the accident, and experien- ced pain from every jolt of the carriage in Avhich I was conveyed home. Treatment.—The treatment necessary for this in- jury, consists in applying the many tailed bandage, and to keep it wet for a few days with the spirit lotion; over this bandage, the padded splints with foot pieces are to be placed and secured, so as to support the great toe in a line with the patella. The limb should be laid upon a pillow on its side in a semi-flexed position. Consequence of neglect.—Although no great de- formity can arise from this accident, on account of the support afforded by the tibia, yet a considerable degree of lameness may result, if the case be neg- lected. Dr. Blair, a naval physician, who had frac- 371 tured his fibula, and had not paid proper attention to the case, became in consequence unable to walk on flat ground Avithout a lameness; as the foot was twisted by the irregular union of the broken bone. Of tibia.—Fracture of the tibia often occurs at its inferior part, either extending into the joint, or seat- ed immediately above it. If the fracture enters the joint, but little deformity is produced; but if above the articulation, the lower part of the upper portion of the bone usually projects a little. The foot is generally inclined someAvhat outwards, but the injury is easily detected by the crepitus, which can be felt when the foot is freely moved. Treatment.—This injury should be treated in every respect as the former, but great care must be taken to prevent the inclination of the foot outAvards, and to keep the great toe in a line with the patella. When the fracture takes place obliquely from with- in to without into the joint, the foot will be turned slightly inAvards, and the malleolus externus will pro- ject more than usual; it will be necessary therefore, in the treatment, to attend to this point, othenvise it will be the same. By placing the limb upon the heel, the proper position of it is more readily ob- served, but the case will do equally Avell, with atten- tion, if the extremity be laid upon the outer side. Compound fracture.—The observations respecting the compound dislocations of the ankle joint, will be found generally applicable to the cases of compound fracture communicating with the articulation. Of Dislocations of the Tarsal Bones. Of astragalus.—From the situation of the astraga- lus, and its very firm ligamentous connexion to the tibia, fibula, calcis, and navicular bone, we could scarcely suppose its displacement possible, and al- 372 though it is occasionally dislocated, yet the injury very rarely if ever occurs, without a fracture of one or more of the surrounding bones. Reduction difficult.—-When dislocated, it is ex- tremely difficult to reduce, and if this be not effected, lameness to a considerable extent must be the con- sequence. I had an opportunity of seeing a patient who was under the care of Mr. James, of Croydon, in conse- quence of an injury to the tarsal joint. Cases.—I found that the tibia was fractured ob- liquely at the inner malleolus, and that the astraga- lus was dislocated outwards. Every means which Mr. James could suggest had been tried to replace the bone, but it still continued to project upon the upper and outer part of the foot; so much force had been employed in making extension, that the in- tegument sloughed in part. Considerable deformity resulted; the toes were pointed inwards and down- wards, and the motions of the joint were in a great measure destroyed. I attended the following interesting case, with Mr. West, of Hammersmith, and Mr. Ireland, of Hart Street, Bloomsbury. Mr. DoAvnes fell from his horse on the 24th of July, 1820, and dislocated his astragalus. Mr. West, who first saw him, endeavoured to replace the bone, but could not succeed; he therefore placed the limb in splints, and kept the part moistened with goulard lotion. The patient Avas bled largely, and took some anodyne medicine. On the 25th, I visited Mr. DoAvnes, with Mr. Ireland and Mr. West, when I found the astragalus displaced fonvards and in- wards, accompanied with a fracture of the fibula a little above its malleolus. All my attempts to re- duce it proved ineffectual. The skin over it ap- peared in a bursting state, so much so, that I felt in- 373 clined to divide it and remove the astragalus; but knoAving the resources of nature in accommodating parts under injuries, and of restoring the usefulness of the limb, I declined interfering, and the previous treatment was therefore continued. On the 28th, the skin over the bone began to inflame, and not- withstanding the employment of leeches and evapo- rating lotions, it sloughed on the 16th of August, ex- posing the astragalus, which gradually became loos- ened and dislodged. A profuse discharge attended this process, but bark and wine freely given kept up the constitutional powers ; the wound was poulticed. On October the 5th, I removed the astragalus, hav- ing only to divide some few ligamentous fibres. Af- ter this, the wound was dressed Avith soap plaister, and the patient gradually recovered, being able to walk Avithout the aid of a stick. Compound dislocation.—In compound dislocation of the astragalus, the plan of treatment to be pursued has been already pointed out in the history of the compound dislocations of the ankle joint, from Avhich it is evident, that the Avhole or a part of the astraga- lus may be removed, and yet the patient recover a very useful limb. If, however, the astragalus should still remain firmly attached, and can be replaced; such treatment should be adopted in preference to taking it away. Case.—Mr. Henry Cline had the folloAving case under his care in St. Thomas's Hospital. On the 21st of June, 1815, Martin Bentley, aged 30, Avas admitted into the Hospital, having been se- verely injured by the falling of some heaAry stones upon his legs. An extensive compound fracture of the tibia and fibula existed in the left leg, near the middle, attended Avith so much mischief to the sur- rounding soft parts, that Mr. Cline amputated the limb below the knee. On the right side, a disloca- 374 tion of the astragalus ha > > >