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BY M. P. QUERSANT, HONORARY SURGEON OF THE HUPITAL DES ENFANTS MALADES, PARIS ; HONORARY MEMBER OF THE SOCi£t£ DE CHIRCRQIE, ETC. TRANSLATED FROM THE FRENCH BY RICHARD J. DUNGLISOX, M.D. &wi? PHILADELPHIA: HENEY 0. LEA. 1873. 100 \Sri^ Entered according to the Act of Congress, in the year 1872, by HENRY C. LEA, in the Office of the Librarian of Congress. All rights reserved. PHILADELPHIA! COLLINS. FEINTER, 705 JAYNE STREET PREFACE. My object in publishing these notes on the surgical diseases observed in children has not been to embrace the entire domain of infantile surgery. I have wished only to sum up my views on cases which I have most frequently met with, and which particu- larly served as subjects for my clinical lectures at the Hopital des Enfants from 1840 to 1860. I have wished to make known the results of my practice, and to point out both my successes and my reverses. If I have omitted several points, it is because I have hesitated to speak of very rare malformations, which I have scarcely ever met with, or of diseases which are very rarely ob- served in children, as aneurisms of the arteries, varix, or varico- cele, of which I have seen but one example operated upon with success by the plan of M. Ricord. The same may be said of congenital luxations, which I have seldom seen, except luxation of the coxo-femoral articulation, that of the superior extremity of the radius, and of the clavicle, and a few others that I have scarcely been able to observe sufficiently. I have rather preferred not to speak of those subjects on which I could not base very practical opinions; and I have limited myself iv PREFACE. to offering to students and practitioners, in concise descriptions which doubtless leave much to be desired, what I have learned by examination and study, what I have done, and what I have observed in a large number of cases in my experience with little patients. NOTE BY THE TRANSLATOR. In offering to the American reader a translation of the valuable work of M. Guersant, it has been deemed expedient to preserve, without note or comment, the original text of one whose authority on the surgical affections of early life is so generally recognized. As allusion is liberally made by the author to the experience of other French writers and practitioners on almost all the subjects discussed, this treatise on the Surgical Diseases of Children may be justly regarded as a reflection of the views of the most distin- guished surgeons of that country, in the very interesting class of cases embraced in it. Philadelphia, Nov. 1872. CONTENTS. PAGE CHAPTER I. Surgical Operations - ........17 CHAPTER II. Cervical Adenitis...........23 CHAPTER III. Phimosis.............27 CHAPTER IV. Fractures...........• . 31 CHAPTER V. Tracheotomy in Croup..........47 CHAPTER VI. Hypertrophy of the Tonsils.........61 CHAPTER VII. Polypus of the Rectum..........68 CHAPTER VIII. Vascular Tumours and Spots—Nsevi Materni......71 CHAPTER IX. Cysts and Encysted Tumours.........79 CHAPTER X. Vesical Calculus—Lithotomy—Lithotrity......83 CHAPTER XI. Hydrocele.............98 CHAPTER XII. Prolapsus Ani............103 CHAPTER XIII. Chronic Arthritis...........106 CHAPTER XIV. Burns . ...........119 CHAPTER XV. Harelip.............124 Vi CONTENTS. PAGE CHAPTER XVI. Coxalgia.............133 CHAPTER XVII. Irrigation of the Pharynx.........145 CHAPTER XVIII. Vulvitis of Young Children.........1^' CHAPTER XIX. Foreign Bodies in the Ear.........151 CHAPTER XX. Cataract.............153 CHAPTER XXI. Abdominal Hernia...........157 CHAPTER XXII. Leucorrhoea............165 CHAPTER XXIII. Torticollis.............168 CHAPTER XXIV. Malformations of the Fingers and Toes.......173 CHAPTER XXV. Caries of the Vertebrae..........177 CHAPTER XXVI. Congenital Imperforation of the Anus and Intestines .... 188 CHAPTER XXVII. Traumatic Luxation of the Femur........194 CHAPTER XXVIII. Foreign Bodies in the Air-Passages........200 CHAPTER XXIX. Purulent Ophthalmia of the New-Born.......205 CHAPTER XXX. Incontinence of Urine..........210 CHAPTER XXXI. Cancer of the Eye...........214 CHAPTER XXXII. Club-Foot............ 217 CHAPTER XXXIII. Cancer of the Testicle......... 227 CHAPTER XXXIV. Encephalocele, or Hernia Cerebri........230 CHAPTER XXXV. Cephalaematoma.........• , 232 CONTENTS. Vll PAGE CHAPTER XXXVI. Hypospadias and Epispadias.........234 CHAPTER XXXVII. Ranula.............237 CHAPTER XXXVIII. Inflammation of the Breasts......... 239 CHAPTER XXXIX. Osteitis.............240 CHAPTER XL. Caries.............242 CHAPTER XLI. Necrosis.............244 CHAPTER XLII. Oculo-Palpebral Conjunctivitis........250 CHAPTER XLIII. 'I'raumatic Lesions of the Cornea........256 CHAPTER XLIV. Chilblain.............259 CHAPTER XLV. Traumatic Dislocations..........261 CHAPTER XLVI. Erysipelas.............265 CHAPTER XLVII. Sprains.............270 CHAPTER XLVIII. Ozoena.............274 CHAPTER XLIX. Lachrymal Fistula...........276 CHAPTER L. Anaesthesia............2i9 CHAPTER LI. Phlegmon.............281 CHAPTER LII. Ceratitis.............284 CHAPTER LIII. Strabismus............287 CHAPTER LIV. Cynanche Parotidaea..........292 CHAPTER LV. Spiua Bifida............294 Vlll CONTENTS. PACK CHAPTER LVI. Tongue-tie............29* CHAPTER LVII. Prolapsus of the Urethra..........301 CHAPTER LVIII. Pemphigus ........•••• 303 CHAPTER LIX. Thoracentesis............30o CHAPTER LX. Ectropion.............309 CHAPTER LXI. Entropion.............31-j CHAPTER LXII. Trichiasis............. 31o CHAPTER LXIII. Naso-Pharyngeal Polypus.........316 CHAPTER LXIV. Onychia.............320 CHAPTER LXV. Abnormal Cicatrices........... 323 CHAPTER LXVI. Diseases of the Umbilicus.........328 CHAPTER LXVII. Epiphyseal Separations .......... 331 CHAPTER LXVIII. Cutaneous Tumours........... 332 CHAPTER LXIX. Crushed Fingers...........335 CHAPTER LXX. Lancing of the Gums..........338 CHAPTER LXXI. Abscess of the Nasal Septum.........340 CHAPTER LXXII. Congenital Luxations..........342 CHAPTER LXXIII. Foreign Bodies in the (Esophagus........346 THE SURGICAL DISEASES OF CHILDREN. CHAPTER I. SURGICAL OPERATIONS. Having been connected with the surgical service of the Chil- dren's Hospital for twenty years, we have had sufficient experience with surgical operations on children to induce us to present, as the result of our own practice, some general reflections on the manner of performing operations on the young. The three subjects we propose to discuss in this section are, 1. The preparation of the pa- tient ; 2. The performance of the operation; and 3. The after-treat- ment. 1. Preparation of the Patient.—Certain vices of conformation, especially imperforate natural openings, should be operated upon at birth without any preparation. Others, which offer no obstacle to the performance of the functions and to the development of the child, may be deferred to a somewhat more remote period. This last class includes club-foot, phimosis, webbed or supernumerary fingers, complicated harelip, cleft palate, etc. We are of the opinion that, as a general rule, operations, even in those cases seeming to demand early treatment, are much more likely to suc- ceed fifteen days, three weeks, or a month after birth, when full time will be afforded the surgeon to know if the infant thrives, and if its functions are properly executed—in a word, if it is healthy —than if attempted a day or two after birth. This delay will also afford an opportunity, if there be reason to fear a variolous attack, to vaccinate the child several days before resorting to a surgical operation. * If the operation is not urgently demanded, and can be post- 2 18 SURGICAL OPERATIONS. poned to a period still more distant, good surgery would suggest the propriety of choosing, either in hospital or in general practice, a time of the year most exempt from diseases, and especially when epidemic affections, such as smallpox, measles, scarlet fever, and diphtheria, are not prevalent. Rarely would it be advisable to operate in the spring, as has been sometimes suggested; generally we should prefer the months of June, July, August, September, and even October, which ordinarily present a more regular and less variable temperature than any other period of the year. In these cases it will be better, first of all, to vaccinate the little pa- tient, if this has not already been done, and even to revaccinate, by way of precaution, those who have attained the age of fifteen or sixteen. Without such preparatory attention, we may see our patient die of smallpox just as he is recovering from the suc- cessful operation to which, he has been subjected. We had occa- sion, in a child five years of age, to make a disarticulation of the thigh for osteosarcoma of that region (the pathological specimen being afterwards deposited in the Muse"e Dupuytren); the wound was nearly cicatrized and the cure seemed assured, when the child, which unfortunately had not been vaccinated, was attacked with smallpox, and died thirty days after the operation. It is of the highest importance, before deciding to operate, that the surgeon should act also as a physician, and examine the case with the most scrupulous attention, in order to be thoroughly con- fident of the non-existence of any internal disease, or of any special disposition which might affect the result of the operation and the life of the patient. It is also expedient to know if the child is sub- ject to convulsions, or if it has a constitutional tendency to hemor- rhage. It is a well-known fact that in certain individuals the slightest wounds are attended with hemorrhages that are extremely difficult to arrest, and we have on more than one occasion met with this predisposition in children. In one case of this kind, we were compelled to postpone an excision of the tonsils in a little patient who had purpura hemorrhagica, and he was under treatment for two months with astringents, iron, etc., before we decided to ope- rate. In spite of this precaution, after the removal of the tonsils a hemorrhage followed which gave us much uneasiness. We deem it best, therefore, to prepare children subject to hemorrhage by administering the perchloride of iron internally, in divided doses fifteen to thirty grains daily, for at least eight days. In another PERFORMANCE OF THE OPERATION. 19 instance, we lost from convulsions, also after excision of the ton- sils, a child subject to that nervous affection, on whom we had very frequently practised cauterization of those glands for the cure of the hypertrophy of which they were the seat. We may also add that preparation of the young patient is some- times indispensable from the very nature of the operation to be performed upon him. When, for example, we are about to estab- lish an anus in an imperforate rectum, we must first empty the bladder; when we are about to perform lithotomy, we must evacuate the rectum. In all operations, we should take care that digestion is properly accomplished, and that the bowels are freely opened. So far as the moral preparation of the patient is concerned, we are not usually required to interfere. Those, however, who are old enough to listen to reason should be brought to the operation by explanation of its necessity, and be made to understand, that if they suffer pain, it is with the view of curing them. But the ma- jority of children should be operated on by surprise. In every case it is indispensable that the surgeon should be surrounded with assistants capable of exerting a firm hold on the patient, and of displaying a force proportioned to that of the child. Some- times, even in a simple examination of the case, in inspecting the throat especially, we must act promptly and by surprise, boldly carrying the tongue-depressor over the base of the organ. Some- times, if we propose to administer chloroform, it will be necessary to attempt its use before the day of the operation. 2. Performance of the Operation.—In quite a large number of sur- gical cases, we can dispense with the use of anaesthetics. We gen- erally operate without chloroform in opening abscesses, in sounding the bladder, and in touching the rectum and removing a small polypus from that region. There are some operations, indeed, in which we should absolutely reject the use of that agent; those, for instance, performed on very nervous and excitable patients. In some cases, too, we may resort to local anaesthesia by means of chloroform, or, what is still better, of ice applied for a certain time on the point selected for operation. There are other opera- tions, again, in which anaesthetics are wholly inadmissible, such as excision of the tonsils, tracheotomy, etc. There is a very large number of cases in which the use of chlo- 20 SURGICAL OPERATIONS. roform has appeared to us to be strongly indicated ; and we may truly say, that having used it with more than five or six thousand children, we have no dread of the employment of anaesthetics. We always have recourse to Charridre's instrument, as suggested by Robert, with which we have been sometimes able to chloro- formize our patients in spite of their resistance. A mushroom - shaped sponge may be used, presenting an opening sufficiently large to allow a free passage of air when it is held before the mouth. We have never had to deplore a single accident from its employ- ment. Extreme infancy is not a contra-indication. We have used chloroform in the youngest subjects; among others, for two cases of strangulated hernia in children of less than four months. Solely with the view of more conveniently examining diseased organs, we have in this way frequently put children to sleep, who, suffering with affections of the eye, obstinately refused to open their lids. We have resorted to the same means in investigating some cases of very painful coxalgia. Finally, we must express our great appreciation of the use of chloroform in certain operations which are accompanied with se- vere pain, and which especially demand precision in their execu- tion ; lithotomy, for example. Once the young patients are asleep, whether they be so partially or perfectly, we must take every pre- caution to hold them securely while we proceed with the opera- tion ; for, though insensible and not conscious of pain, they may nevertheless make sudden movements and thus disturb the operator. It is worthy of remark that at the moment of the execution of the operation on children the task claims from the surgeon the most exact knowledge of anatomy, for the region being of less extent, and the spaces smaller, we are often obliged to limit the incisions, and to give them only such dimensions as are absolutely necessary. The neck of a child of two years, for example, upon whom trache- otomy is to be performed, does not allow of the same field for action as in the adult. The incision of the perineum, in a patient of the same age, demands more care on the part of the surgeon in the performance of lithotomy. We should, in short, be well persuaded of a fact, of which many persons seem ignorant, that operations are more difficult in children than at a more advanced age. In some cases, we must deviate from the principle that recom- mends us to operate slowly, for children do not bear pain for as long AFTER-TREATMENT. 21 a time as adults, and loss of blood is generally more dangerous. It is almost always advisable, therefore, to remove the tonsils very ra- pidly. Sometimes it is of importance to perform tracheotomy speed- ily to prevent the patient from dying on the surgeon's hands, espe- cially if the veins are opened and serious hemorrhage results. For these reasons, the anatomical knowledge of the operator should be positive, in order to allow him to act with perfect confidence. 3. After-treatment.—The first local attention to be given to those operated on includes the application of the ligature and torsion of the vessels. When but few ligatures or but little torsion have been used after a large amputation or the extirpation of a tumour, which has involved a large loss of substance, we believe that it will be best—as confirmed by our own experience—at our leisure, to make the dressing a half hour or an hour after the operation. This rule, laid down by Dupuytren, has the great advantage of affording time to the circulation to re-establish itself, and prevents hemorrhages, which so often come on a considerable time after the dressing, and necessitate changes in it—a very painful procedure for adults, and still more painful for children. If, after certain operations, we should consider it advisable to tampon the wound with perchloride of iron, it should be combined with equal parts of water, to avoid gangrene of the wound. We should invariably aim, in all our operations, to secure union by the first intention. Faithful to a rule suggested in the first instance for certain ope- rations by Dupuytren, and afterwards generalized by Lisfranc, we have nearly always dressed our patients afresh the day following the operation. This practice, in which only the charpie and the linen covering the wound are removed, and the bandages and the stitches are left undisturbed, obviates numerous accidents, such as, in the first place, erysipelas, by not allowing the charpie, im- pregnated with blood and serum, to remain in contact with the skin; the retention between the edges of the wound of the suppu- rative discharge, if it has been already formed ; and the contraction of the wound, if the points of union are too numerous or too tightly pressed together, for we can then raise or loosen them. By this half-dressing, made on the day after the operation, we may often dis- cover the cause of a fever, for whose presence we may not otherwise be able to account. If there be erysipelas, we may use collodion, which, in the traumatic form of the disease in children, has often 22 SURGICAL OPERATIONS. proved successful in our hands. This application, employed exter- nally at once, with the internal use of the alcoholic tincture of aconite-leaves in divided doses, fifteen to twenty drops in the twenty-four hours, has sometimes prevented purulent absorptions, an accident of sufficient rarity, it is true, in children, but one which has come under our observation. If the wounds become pale and grayish, the application of charpie steeped in solution of chlorinated soda has been found of service. Pure lemon-juice has succeeded in giving by the next morning a healthy appearance to a wound of an unpromising character. But if the local treatment we have just indicated, and the fre- quent or occasional renewal of the dressings, according to the increase or diminution of suppuration, be of great importance to the success of operations, the general after-treatment is, in a ma- jority of cases, still more essential. Usually, when there is no supervention of convulsions—and this is an accident which we have rarely observed, even after the most serious operations in children —or there are no special indications, we would do well to attend to the nourishment of the patient from the very day of the opera- tion. On the first day, children nursing should be given the breast in preference to the bottle, should this be possible, and as much or as little food of this kind should be given them as they may de- sire, but they should only be nursed every two hours. For other children, it is proper to commence by some fluid nourishment, on the first day giving them milk or broth, and after the succeeding day soup, wine, etc., gradually bringing them back to the diet to which they have been accustomed. To this may be sometimes added tonics, chocolate, coffee, and often cinchona in its various forms. This diet has seemed to us indispensable, except when there exist internal diseases which attack the patient consecutively, and which demand on the part of the surgeon a ready medical know- ledge, so that he may not overlook these affections, and may properly combat them. Without this there is but little success in surgery. We should not, then, lose sight of the fact that before an operation we must be physicians, surgeons in its performance and at last physicians again to cure the patient and bring to a suc- cessful result many of our surgical operations. Finally, all the means we have just extolled may fail, if we neglect the hygienic surroundings of our patient. All things CERVICAL ADENITIS. 23 being otherwise equal, children who are operated upon in the city, with parents in comfortable circumstances, and who occupy cham- bers well aired and well warmed, according to the indications, are in better condition for recovery than those on whom we operate m hospitals, where numerous patients are brought together in the same ward, the atmosphere of which is more or less vitiated, what- ever may be done to avert it. It is always possible in town, when the accommodations will admit of it, to make a change for the patient from one room to another. This will give an excellent opportunity to renew the air alternately in the room which he has just quitted, and which he will re-enter when thus purified and warmed, or not, according to the season. CHAPTER II. CERVICAL ADENITIS. Adenitis of the neck in children is met with so frequently in practice, and so often leaves frightful traces of its invasion, that I deem it expedient to speak of this affection, which is, unhappily, too often seen either neglected or badly treated. Enlargements of the lymphatic glands of the neck, whether in front, at the sides, or on the posterior portion, are sometimes symptomatic of wounds or blows on the scalp or on the face. They are very often the conse- quence of various affections of the skin of the head or of the face. Occasionally, we can only trace the cause to some disease of the mouth, lips, teeth, or throat. Finally, they may be symptomatic of a more or less lymphatic constitution. Whatever the causative condition may be, whether general or local, the indication always is at first to attack the cause. If it be a small wound of the head or of the face, we must attend to the wound; if an eczema of the scalp, we must subject it to the proper treat- ment; if a diseased tooth, and in such a case the glandular enlarge- ment will be seated in the neighbourhood of the upper or lower jaw, the tooth should be extracted. If the cause be a general one, such as a lymphatic constitution, the indication is to prescribe the ap- propriate remedies. In every case, we must at the same time act 24 CERVICAL ADENITIS. locally, either to obtain the resolution of the swelling, or to pro mote suppuration from it, or to modify the induration, which is a frequent termination of cases of adenitis. The local symptoms of this affection are sometimes acute, and progress rapidly; at other times, their course is slow or chronic. In all cases we may recognize three stages: 1. Swelling, redness, and increased sensibility over the seat of the ganglions, and, as constitutional symptoms, more or less pronounced fever and malaise. 2. Pain, more circumscribed, with augmentation of sensibility, diminution of volume, and often appreciable fluctuation, coming on with more or less rapidity; spontaneous openings, disintegra- tion, fistulas, irregular scars, slow in their formation; sometimes ulceration of long duration, and more or less disfiguring cicatri- zation. 3. Diminution of pain, without any notable amount of suppuration, induration, varying in degree, and terminating in a tumour, which gradually disappears by resolution. Finally, the swelling sometimes remains stationary, hard, and free from pain, and may even pass into an enchondromatous condition, but this is only met with in exceptional cases. 1. To obtain resolution, we no longer rely, as formerly, on re- peated applications of leeches, and if, under exceptional circum- stances, they seem to be indicated, we should only venture to have recourse to them in cases of adenitis arising from local causes such as a wound or contusion, and in a person who was not consti- tutionally lymphatic; otherwise, we should fear that we would obtain only a temporary relief for a few days, while we would re- tard suppuration, and in all cases weaken the patient. We depend rather on resolvents, such as the pure Neapolitan (mercurial) ointment, combined with extract of belladonna; or else to replace the mercurial ointment, we would advise the 'employ- ment of an ointment of calomel. The iodized ointments have not answered so well, but it is always necessary, in using these reme- dies, to associate them with glycerine, and to observe if they pro- duce redness of the delicate skin of children, when their further use must be suspended and only resumed at a favourable opportu- nity. Sometimes emollient poultices, made especially of marsh mallow flour, are of advantage ; but if any objection exists to their use, wadding, and even sheep's wool with the grease on, which contains the salts of soda, may be substituted for them. Layers of CERVICAL ADENITIS. 25 pure tincture of iodine applied with a pencil every other day may hasten the resolution of the swelling. This method is often to be preferred to poultices, which may become sour or grow cold. Such are the means to be adopted to prevent suppuration and induration from occurring. 2. To hasten suppuration.—When the process of suppuration is fairly established, we can no longer rely upon the use of resolvents. Sometimes, but rarely, blisters may succeed in aborting the abscess. We content ourselves then with emollients, usually in the form of general baths and greasy and ripening cataplasms. Finally, when fluctuation is evident, even before the skin becomes red, we, in common with many of our professional brethren, are favourable to opening the abscess, to prevent spontaneous openings, sometimes multiple, which lead to disintegration of the skin and to frightful scars. We do not absolutely reject the use of the knife, for there are some cases in which we have recourse to it, but we greatly prefer a procedure extolled by MM. Alquie" and Bonnafont, namely, the filiform seton, which leaves no traces of the operation. We take for this purpose three or four silk threads, which we pass through the abscess by means of a fine flat needle, in the proper direction, that indicated for the incision, in such a manner that one of the punctures shall be more sloping, and the threads shall be in the direction of the folds of the skin, or following the direction of the muscular fibres, those of the sterno-mastoid, for example. When the little seton, which is tied over as soon as it is passed through, is introduced at the time when fluctuation is evident, the pus will be seen escaping from the punctures, and its flow may be increased by means of pressure. The application of poul- tices must be continued, and care taken every day to move the thread. Under this treatment the abscess discharges itself in a few days. The seton should be withdrawn when there is no longer pus or swelling, for if any tumefaction still exists, its presence hastens the softening of the hard part of the abscess. There remain after this but two punctures, which, at a little later period, leave no traces. 3. To remove induration.—When, in certain cases, the adenitis terminates in induration, we resort to all the resolvents already suggested, iodized ointments, compound plaster of mercury, etc. 26 CERVICAL ADENITIS. But if these remedies fail, even when associated with the internal administration of the preparations of iodine, we may employ with advantage the seton applied in several places to bring on inflamma- tion and suppuration. We have obtained in this way, by four or five little setons, the suppurative discharge of these chronic cases of adenitis. When enchondroma results, extirpation is the only remedy. All that we have just said applies to cases of superficial adenitis; but we may add that we have seen quite a number of instances of the same affection deeply seated, even in children at the breast, and other surgeons have mentioned such cases to us. Dr. Fleming and MM. Velpeau and Bouvier have reported similar cases. We have treated several in which the deep ganglions, after being inflamed, commenced to suppurate and to form abscesses along the larynx, the trachea, and occasionally behind the oesophagus and the pharynx. True retro-pharyngeal abscesses may be recognized by a general tumefaction of the neck, which sometimes is more marked on one side than the other, and is occasionally seen on the side of the pharynx. The patient has fever, sometimes delirium, great suffering in moving the neck, difficulty in the use of the voice and in deglutition, and often the inconvenience is so great that asphyxia results. When the patient is old enough to speak, he has a snuffling voice similar to that met with in children with enlarged tonsils. Children have even been brought to me for the purpose of removing their tonsils, who were really suffering from retro-pharyngeal abscess, In exa- mining the little patient, depress the tongue, and, if the abscess is in the median line, a reddish, smooth, fluctuating tumour will be detected. At other times these abscesses, giving rise to a prominence over the lateral portions of the larynx, cause the sterno-mastoid to bulge more or less outwards. In such cases emollients in the form of general baths, and poultices around the neck should be applied at the beginning; but as soon as fluctuation is evident, incisions should be made at once, either along the sterno-mastoid, or in the back of the throat over the posterior wall of the pharynx. By such operations the lives of patients are sometimes saved who would otherwise die asphyxiated. Very often these abscesses being opened, empty themselves completely, and the sufferer is cured without a relapse. We must not confound these purulent collections which progress PHIMOSIS. 27 quite rapidly, with those that are symptomatic of caries of the cer- vical vertebrae. The latter are developed much more slowly, are always preceded with a different set of symptoms, especially con- nected with the bony tissues, and are much more serious in their character on account of the destruction of the articulations or of the vertebrae themselves, which are the source of these abscesses. We need make but brief mention of tuberculous deep-seated lymphatic ganglions, which are developed in the course of the larynx and the trachea. These tumours, scrofulous in their nature, of vary- ing consistence, and having a chronic course, are met with in the form of a string of beads on the lateral portions of the respiratory canal, along the great vessels of the neck. They are more or less voluminous and numerous, having the consistence of raw chestnuts or softened horse-chestnuts, and are often confounded with the bronchial glands, which they resemble. Surgery has sometimes endeavoured to remove these degenerated tumours, in order to relieve the patient from the asphyxia which may have resulted. Such operations, which should be rarely attempted, may in the course of their performance expose the sufferer to the greatest dangers, and are often left half finished. It is much better, then, almost always, in this class of cases, to refrain from the use of the bistoury, and to restrict ourselves to general anti-scrofulous remedies. CHAPTER III. PHIMOSIS. Contraction of the prepuce is the most frequent of all the vices of congenital conformation. In certain countries it brings with it so many inconveniences, that the lawmakers of the Jewish people did not hesitate to make circumcision a religious practice. Phi- mosis is not met with less often in our own country, and some sur- geons, reasoning upon the advantages derived by the Israelites from this operation, favour its introduction with us under pretence of its being a hygienic measure—a view of the subject we do not now propose to discuss. We are aware, however, that certain 23 PHIMOSIS. practitioners too persistently refuse to adopt the curative treatment of this infirmity. Phimosis presents itself under varied aspects, the prepuce being sometimes long and contracted, at others short, but invariably con- tracted. When the orifice is very narrow, the urine accumulates between the glans and the prepuce and dilates it, and the child will make considerable effort to facilitate the outlet of the fluid. In such a case, a small quantity of urine remains confined, and pro- vokes repeated inflammation of the mucous membrane, which may lead to the production of secretions or false membranes, resulting in the adhesion of the glans and the prepuce. Even when the opening of the prepuce leaves the meatus urinarius free, all danger has not passed, although micturition may be accomplished without any obstacle. The child is sometimes led to expose the glaus, and though ever so little of that organ is left uncovered, strangulation occurs and produces paraphimosis. If the narrow prepuce generally becomes gradually dilated in proportion to the development of the child, this is far from always being the case. When the prepuce is long and its opening very narrow, there is no chance of the orifice opening naturally, and of eventually allowing of the uncovering of the glans. The orifice may not be very seriously contracted, and yet the secretions may often produce and become the exciting cause of balanitis. Finally, we may add, that all glands habitually covered are more impressible and more susceptible to herpetic or venereal inflam- mations. With the probability of such accidents occurring, we should be to blame if we failed to act promptly. In our own practice, just as soon as we have recognized the existence of balanitis, we do not hesitate to operate for phimosis, even in cases in which the opening of the prepuce only allows the partial exposure of the glans, and renders the child liable to paraphimosis. Still another circumstance that induces us to operate is when we have reason to suspect the patient to be guilty of masturbation. The operation in such cases, has a great effect upon the morale of the little suf- ferer, at the same time that it renders it impossible for him to handle the organ for several successive days. If this practice has not always attained the object proposed, it has succeeded suffi- ciently often for us to recommend our professional brethren to fol- low our example. The operation for phimosis may be performed PHIMOSIS. 29 at all ages, although we rarely do so before the fourth or fifth year, because only at that period will it be possible to judge whether the opening of the prepuce is likely to enlarge sufficiently to uncover the glans. The surgeon may choose between two principal modes of opera- ting, circumcision and simple division of the contraction. When the prepuce is excessive, we should resort to the former; when it is not. too long, the latter method is preferable. For circumcision in adults, we may employ indiscriminately the plans of MM. Ricord and Vidal (de Cassis), or that of M. Chassaignac; in children we generally prefer the procedure of M. Bonnafont. This consists in introducing into the orifice of the prepuce a dilator, which allows of the opening and dilatation of the prepuce, and then with scissors making at a single sweep a section in front of the glans. By this mode of operating, surface is saved, the skin of the prepuce and the mucous membrane which borders upon it are cut off on the same line, and the glans freely exposed. We next place serres-fines in greater or less number, in order to reunite the skin with the border of the mucous membrane. In the course of twenty-four hours, we may frequently obtain union by the first intention, and be able to remove the serres-fines. If the first application of these requires any length of time, it will be well to chloroformize the patient, and to prolong the anaesthesia until they are properly adjusted. If any reason exists for not adminis- tering chloroform, the time spent in applying the serres-fines may be so protracted, that we may be satisfied with using the following dressing. By means of a fenestrated linen compress, cut in the shape of a Maltese cross, presenting in the centre a hole large enough to engage the glans in it without strangulation, we may push back the prepuce behind the base of the glans, next applying over it a circle of charpie, leaving the glans always exposed, and finally a new compress open in the centre, which allows all the dress- ing to be thrown still further back, the glans being exposed all the time without any risk of strangulation. A suspensory bandage completes the apparatus. With this dressing the patient can uri- nate without wetting the coverings, whether he be standing or kneel- ing. It is important that the dressing should not be disturbed until the lapse of forty-eight hours, when the child should be put in a bath, and the various pieces gently detached, while the patient is in the water, to prevent pain. We rarely obtain a rapid cure, 30 PHIMOSIS. and, until perfect union takes place, we should daily renew the dressing with great care, lest the prepuce should return upon the glans. In neglecting this precaution, we have reason to fear a recurrence, which may demand a second operation. The surgeon can always avoid this danger by personally attending to the dress- ings; as at best they are painful for children, the latte-r are apt to be awkwardly handled by those who are unaccustomed to surgical work and fear to make them cry. These are especially the.atten- tions subsequent to an operation, which have much more to do with its success than the precise method of operating to be adopted. When the prepuce is not too long, it is unnecessary to perform circumcision. Division of the contracted prepuce before or be- hind, along the fraenum, leaves deformities; it is better, there- fore, to multiply the incisions, or else make a triangular excision of a portion of the prepuce in the following manner: Pass one branch of an artery-forceps under the prepuce as far as the base of the glans, then make two incisions with the scissors in such a way as to circumscribe a triangle on the dorsal face of the prepuce, the summit of the triangle corresponding to the corona of the glans and its base to the edge of the prepuce. In this way we get a large incision, which gives an oval-shaped opening to the orifice of the prepuce; the dressing is then applied, either with serres-fines, or with the apparatus previously referred to. We have recommended these operative procedures as being those which have appeared to us to succeed best with children, without, however, rejecting those advised by MM. Ricord, Yidal (de Cassis), and Chassaignac, each of which has its value, but which we consider much better adapted for adults. We may add, to complete this subject, that there sometimes exists in children suffering from phimosis quite a common complication, even where the opening of the prepuce is considerable, in the shape of ad- hesions, which are developed between the glans and the internal face of the prepuce. They are usually very slight, and very easily broken up, and can be separated, with great facility, with the blunt extremity of the forceps or the closed scissors. It frequently happens in children, the orifice of whose prepuce is not completely contracted, that those who are guilty of mastur- bation sometimes retract the prepuce behind the base of the glans and cannot get it back again. This constitutes paraphimosis. We always commence our treatment by reducing this complication FRACTURES. 31 before resorting to an operation for phimosis. This reduction has nearly always been effected most easily by following the plan recommended by Dupuytren. This process consists in surrounding the whole penis, the glans and the collar-like swelling formed by the prepuce, with a compress smeared with cerate or oil, grasping with expanded fingers also the compress which already embraces the organ, and squeezing gradually, while restoring to itself the con- stricting ring of the prepuce, which passes over the glans; the latter being compressed takes a conical form which allows it to re-enter at its place of departure. Compresses steeped in cold water, and lotions of bran and water, may be used to cause the disappearance of swelling in the parts. This method is a painful one, but, on the one hand, it allows of complete reduction, and on the other the pain it gives rise to will always serve as a lesson by which the child may profit and be cured of a vicious habit; but at a later date it will often be necessary still to resort to an operation for phimosis. CHAPTER IV. FRACTURES. Fractures, or solutions of continuity of bones, are of nearly as frequent occurrence in childhood as in other periods of life. They are divided, as in adults and old people, into direct or indirect fractures, fractures of the body of the bone, of its extremities, and those involving joints. They may be transverse, oblique, longi- tudinal, simple, complicated, and comminuted. We have never yet seen a case of angular fracture, as described by M. Grosselin, and if it occurs in childhood, it must be less frequent than in adults. But the bones of children, not having reached a period of complete ossification, present us with another variety of fracture called the incomplete. We include under this name two conditions, which differ in their pathological anatomy; in one, the bone is curved and breaks like a stick of green wood, that is to say, it is fractured in only one-half of its cylinder; in the other it is entirely broken, and yet the fracture remains incomplete. This is due to the fact that the periosteum, being more or less completely pre- 32 FRACTURES. served, retains the fragments in their relative positions, which, so long as external violence or unskilful manipulation do not com- plete the fracture of the bone, or tear asunder that portion of the periosteum which supports the fragments, the too feeble muscular system of the child cannot alone overcome. We now understand the full importance of this fact. The frequency of incomplete fractures in children explains the comparative infrequency of over- riding of the bones, and of changes of relation between the frac- tured surfaces, a condition decidedly favorable to the rapidity and regularity of consolidation, to which we are accustomed in young subjects. A long experience has taught us that children suffer from fractures quite as frequently as old people. The comparative study of pre- disposing causes sufficiently accounts for this equality of frequency. Thus, if we look at the texture of the bones, we find an important analogy in the two extreme periods of life. In children, as in the aged, the medullary canal of the long bones is larger, and the walls of the shaft are more delicate; but whilst the osseous tissue is dry and fragile in the old, it is soft and flexible in children. The physical properties of the bones of the latter would seem to give them more power of resistance to fracturing causes: this is nothing, however, for experience shows that the bones of chil- dren, in spite of their suppleness, can only to a very limited extent be bent without breaking. Another predisposing cause, common to children and old people, is found in the feeble condition of mus- cular power in both classes. These are the two ages at which there exists the greatest liability to falls, and, for this very cause, to fractures; for they do not know how to support themselves, or else they yield to falls, or cannot resist external violence. In adults, on the contrary, the muscular mass may rather deaden the effects of direct causes; the muscles may contract to resist these, but their contraction, while preventing falls, may also produce fractures. So also falls lead to accidents more frequently in adults than in the young and the aged, who, like paralyzed people, may, in falling, avoid certain fractures. We may remark, too, that the majority of accidents occur to children and old people • this de- pends upon the rashness of the one class, who are not conscious of danger, and to the want of reflection of the other, who, forget- ting that years have diminished their strength, and slackened their pace, cross the street in the midst of passing vehicles. FRACTURES. 33 Among the special predisposing causes of fractures in childhood, we may particularly mention rickets, an affection of frequent occurrence in very young children, who, owing to their debility, are more liable to falls, and in whom the osseous tissue is more likely to become fractured. We have not referred to scrofula as a predisposing cause of fracture, and, in fact, the osseous tissue of scrofulous patients has the same density and solidity as that of healthy individuals, as long as it has not become the seat of the manifestation of that diathesis. As a general rule, every constitu- tional disease will predispose to fractures only when the morbid principle shall have attacked the osseous system. If we pass now to the exciting causes, we recognize the long list of violent agencies which standard writers have indicated in the fractures of adults. We must put falls in the front rank of causes, on account of the uncertain step of the youngest children, and of the sports, the races, and the wrestling of those more advanced in years. With regard to the special bones fractured, in seventy or eighty cases brought to our attention in a year at the hospital, we have established the fact that those of the thigh were much the most common, after which, in order of frequency, come those of the forearm, the elbow, and the humerus, the tibia alone, sometimes the fibula, and finally the clavicle, the ribs', and the jaw. Fractures of the patella are very rare, but three or four cases having come under our observation. In the arm, we meet with fractures of the body of the bone, but frequently the inferior part of the humerus is divided obliquely or longitudinally, in such a manner that the epitrochlea and epicondyle become detached. These fractures are often intra-articular. The middle portion of the bones of the limbs is usually the seat of the lesion, and we desire to draw more particular attention to a point connected with fractures of the forearm, which is fractured by preference at its middle or superior portion. Contrary to what takes place in the adult, we rarely meet with fracture of the inferior extremity of the radius. The cause of this inversion of frequency has appeared to us to depend on the entirely different manner in which children and adults resist external violence. In a fall, the latter throw out their hands instinctively to save themselves to the extent of their ability, and an indirect fracture of the radius at its lower extremity is thus produced. Little children, on the other hand, 3 34 FRACTURES. fall in such a manner that the upper extremity strikes directly on the ground, or on some hard substance; the fracture is thus often produced from a direct cause, and sometimes only affects the ulna. It is a fact worthy of mention that fractures of the neck of the femur are extremely rare, and we have only observed the epiphy- sary separation of the head of that bone, and this very rarely. As all varieties of fracture occur in children, they should present, and indeed do present, all the signs characteristic of fractures in the adult. Nevertheless in children they seem less prominent to the eye than in adults and old people, mainly by reason of the smaller dimensions of the limbs and the greater infrequency of deformity. This is especially true of incomplete fractures. Crepitation is sometimes absent, when the bone is completely broken, and the periosteum supports the fragments. If, however, this symptom is present, it is more obscure than in complete frac- tures ; but there is also pain, sometimes more or less swelling, and always suffering in the movements of the limb and abnormal mo- bility, for the portion of bone fractured and retained by the peri osteum may experience a greater or less amount of flexion. In complicated fractures we may have wounds, even the projec- tion of fragments, and yet have to deal with an incomplete frac- ture. In such a case the periosteum will have been torn in several places by the points of the broken bone, but it will still have suffi- cient power of resistance to support the fragments by several points. Be this as it may, in simple fractures, we must seek the place where pain is at its maximum; it is at this spot that we can recog- nize mobility and crepitation. But frequently children cry and become petulant the moment they are touched, and then it becomes impossible to estimate accurately the influence of pressure upon the pain. In such a case we cannot too forcibly recommend the surgeon to be delicate in his explorative manipulation; for inde- pendently of the fatigue occasioned to the young patient, we run the risk of breaking parts which have been incompletely divided • in other words, of transforming an incomplete into a complete fracture. It is much better to remain in doubt. We thus see how difficult it sometimes is to diagnosticate a fracture in a child for fre- quently there is no deformity, no crepitation, and consequently an impossibility to form a correct idea of the seat and intensity of the lesion, leading in many cases to a very laborious and often incom- plete investigation. Added to this, if the child is intractable, the FRACTURES. 35 firm and solid condition of the cellular tissue which covers the in- jured parts obstructs the exploration. Nevertheless, this is not always the case, and in many instances, the fracture may be recog- nized at a glance, if deformity exists—as it does in a sufficiently large number of cases—or is produced when the surgeon slightly bends the bone supposed to be broken. Fracture being recognized, what is the prognosis? We do not hesitate to say that when it is simple, it is an accident of but little importance; and as a general rule we should encourage the parents, letting them know that fractures at that age are not of equal gravity with similar injuries observed in adults and old people. At a middle period of childhood, consolidation is effected in eighteen or twenty days; but in the new-born it may take place in fifteen days. Simple fractures, when the patients are in good health, usually unite with perfect regularity, without apparent shortening, provided, however, that the treatment has been judicious. The case is modified by time, as is proved by the fact that when we re- ceive visits from conscripts at the period of re-examination, who seek from us certificates testifying that we have treated them at an earlier date for fractures of the thigh, we cannot decide, in many cases, that any fracture has ever existed, although the records prove that they were treated at the hospital. Nearly all of these young people are considered to be fit for military service. When there is shortening of the femur, at the removal of the dressing, for example, it soon ceases to be apparent, and can only be detected by the most accurate measurement If it be other- wise, the individuals affected are not lame for any length of time, for they soon accustom themselves to balance the body in walking by a corresponding deviation of the pelvis. In a little girl, four years of age, who was under treatment for twenty-five days in 1858 for a fracture of the thigh, it was impossible in 1860 to find the least trace of the lesion. When we have happened to see chil- dren mutilated by the wheels of machinery or crushed in the streets, we have established to our own satisfaction that, all things being otherwise equal, complications are attended with less danger at this than at any other period of life. When the fracture is complicated, whether it be with necrosis, or elimination of sequestra, the process of healing is much more rapid than in adults. If the complication is general, and attended 36 FRACTURES. with any acute affection, debility, diarrhoea, etc., then the work of consolidation is more tedious, and the prognosis often grave. A boy died of smallpox thirty days after the accident, by which his thigh had been fractured, and the autopsy did not reveal the slightest commencement of consolidation. If the fracture takes place in a scrofulous subject, who does not at the time exhibit con- stitutional symptoms, the prognosis will not be more unfavourable than in any other case. If, however, a contrary condition exists, especially if the osseous system is attacked, the prognosis will be more serious. In those affected with rickets, consolidation may occur very rapidly, and callus is found to be formed with them as promptly as in better constitutions. Sometimes, on the contrary, rickets really retards the union of the bones, and this difference seems to depend on the stage of that affection. If the fracture occurs during the last stages of rickets, the callus will form rapidly, as in healthy children, while consolidation may be postponed an indefinite time, if the disease is at its commencement, or in its first or second stages. Just as in adults, we sometimes in children meet with fractures which will not unite, without our being able to discover the cause. We had in our wards a little girl whose leg had been amputated for pseudarthrosis. We made, as might be supposed, numerous attempts to cure it before resorting to extreme measures, includ- ing the immovable apparatus, the cautery, in the form of needles heated to a white heat, introduced between the unconsolidated osseous extremities, setons, scraping of the ends of the bone, and perforation of the extremities by the method of Dr. Brainard, of Chicago. These serious operations were performed without accident, but also without any decided result. We compelled this child, so to speak, to walk with a mechanical apparatus for two or three years. At the end of that time, the parents, as well as the child, who was tired of the apparatus, requested the amputation of the leg. This was successfully accomplished, and she now walks very well with a wooden leg. (This is the patient presented by us to the Socie'te' de Chirurgie, and referred to by M. Bouchut in his work.) The treatment of fractures in childhood may be surgical hygienic and medical. The surgical treatment will present three phases, depending 0n FRACTURES. 37 the nature of the fracture, whether it be doubtful, simple, or com- plicated. We all know how easy it is not to recognize a fracture, when being incomplete there is absence of deformity and crepita- tion; when in the vicinity of an articulation, the abnormal mobility is not so striking; when in the leg or forearm, but one of the two bones is fractured, and the other acts as its support; or else, finally, when the surgeon, being summoned too late, a considerable amount of swelling has taken place. Our advice would be to act as if a fracture existed, to put on a retaining apparatus at first, and employ the proper means to cause the disappearance of the swelling, if there be any. It is not troublesome to apply the apparatus, and indeed, several days afterwards, the surgeon can examine the limb and make out his diagnosis with precision. If he finds a fracture, he continues the treatment he has commenced. If the case is a simple contusion, with tumefaction, the bandage which has already been applied will be found serviceable by its moderate compression, in causing the more rapid disappearance of the swelling. What- ever the condition may be, we should content ourselves with such symptoms as are indispensable to the diagnosis of fracture, and not seek to establish the presence of all; for, in addition to the dangers of which we have already spoken, irritation and suffering may be caused the little patient by unnecessarily moving the limb. The fracture being recognized, is reduced, as in adults, and often more easily. And it is here the proper place to inquire whether fractures in children can be treated by position alone, or demand the early application of apparatus. The want of docility in chil- dren but rarely allows us to dispense with the use of the latter. The employment of retaining apparatus appears to be indicated in almost all cases, for children generally pay but little attention to what is said to them, and move and are restless in spite of the pain which their movements cause them, and thus, among other accidents, run the risk of breaking up adhesions which might re- tain the fractured surfaces in contact with one another. Besides, it is by no means rare, as a sequel of fractures, to see convulsions occurring, and even in rare cases, tetanus, when they are accompanied with wounds. It will always be well in such cases to apply appa- ratus that will render the fragments perfectly immovable, and not to depend on position alone. The application of apparatus will also be invariably of service, even when employed as speedily as possible, if only for the purpose of preventing accidents, relieving 38 FRACTURES. the anxiety of parents, and giving a feeling of security to the surgeon. But should the apparatus be applied immediately after the occurrence of the fracture, or would it be better to delay? Dupuy- tren had recourse to it as soon as possible, to avoid the very accidents of which we have just spoken, and to give confidence at once to the patient, who having arrived at the age of reason, awaits not without apprehension the application of apparatus. At first he used only moderate compression, and he did not hesitate in the evening to take off an apparatus which had been put on in the morning, and which gave the patient annoyance. Every day he paid an evening visit to the hospital, frequently with the view of examining patients on whom such dressing had been applied in the morning. Lisfranc, on the contrary, removed the bandages only at the end of several days, and during that time employed externally refrigerants and emollients. We adopt the course recommended by Dupuytren, and unless special indications exist, we think it at least prudent to give immediate support in the fractures of young people, especially by the application of but moderately tight appa- ratus. The treatment of complicated fractures is the same as for adults. If there be only a slight amount of contusion, we should imme- diately apply apparatus, being careful not to make it too tight. If the swelling is considerable, we may modify the dressing by omit- ting one or two splints, carefully giving the limb a correct position, and covering it with compresses steeped in some resolvent liquid or cold water. When the fracture is complicated with a wound, we must first combat inflammation by the appropriate remedies, depending mainly on cold water, and apply the apparatus modi- fied in such a way as to leave the wound open, according to the plan of Scultetus or Seutin, making over the wound only a simple dressing, which may be taken off every day, and the linen soiled with pus removed. When the fracture is accompanied with serious mutilation of the soft parts, we prefer to every other method of treatment continuous irrigations, which we must check gradually for we have every reason to fear the effect of sudden suppression of refrigerants applied over the wounds of young patients. It may be remarked that the most extensive mutilations are more easily cured in children than in adults. There remains for discussion the very serious question to de- cide, when a fracture demands an amputation. We know that in FRACTURES. 39 adults it is necessary to resort to such an operation, when the arti- culation is largely opened ; when the limb is crushed and fractured in several places; when the wound is extensive and communicates with the seat of the fracture, and may thus give rise to a long sup- puration and consequently exhaust the patient; and when, even before inflammatory symptoms have had time to declare them- selves, gangrene comes on, involving a large extent of surface. In children, we follow the same indications, and in cases where there is reason to fear a fatal termination, we need have less hesitation to operate than in adults, for amputations succeed infinitely better with our little patients. We have frequently had cause to regret that we did not decide promptly in favour of amputation in certain cases in which the limb was almost pulverized. Dilatory amputa- tion has not succeeded in our hands; in a word, when the indi- cations are to operate, we prefer primary amputation after accidents rather than delay. Such was the opinion of Dupuytren. We make an exception to this rule in cases in which the fingers and toes are crushed, for in some instances we derive advantage from the employment of cold irrigations, prolonging their use until the complete separation of the parts, which may have been bruised almost to the point of mortification. We have thus been able to save portions of fingers, which have afterwards been of real service to their possessors. Let us now examine into the proper method of reducing fractures and of maintaining the fragments in apposition in children. We will not dwell here on the manner of proceeding to effect extension, coun- ter-extension and coaptation, which are similar to those employed in the adult. Fractures in children present this specialty, that but little force is required to overcome displacement. Even in those of thirteen or fourteen years of age, moderate traction is sufficient to reduce it. In addition to this, as we have already said, in young children the fragments have but little tendency to become dis- placed. The fracture being reduced, or not requiring it, we apply either the movable or immovable apparatus. We prefer the former in all those cases in which we desire to inspect the seat of the frac- ture, as we sometimes have to do, not only in complicated frac- tures, when the soft parts have been divided or there is reason to fear the reproduction of displacement, but also in simple fractures. There is still another motive for our preference for the movable 40 FRACTURES. apparatus in children, founded on the fact that when the fracture is seated in the inferior extremity, the apparatus is frequently soiled by excrement and by the urinary discharge. If in such cases a starch or plaster apparatus be used, it becomes soaked and irri- tating to the skin, and sometimes becomes softened and fails to fulfil the indications. When the dressing is removed, either to be changed, or to ascer- tain clearly the condition of the parts, much less difficulty is ex- perienced in children than in adults in maintaining the fragments in their proper relations to one another. The slight volume of their limbs is more favourable to freedom from movement while the dress- ing is being changed, than in larger persons. If the proper precau- tions be used, there is no danger in examining the injured parts, if they are again covered by the dressing; and we are enabled to see if any eruptions or excoriations exist, and, finally, to determine the state of the callus, which may be made more regular if necessary. This active inspection should not be neglected in young people, for with them especially the skin is easily wounded by the apparatus, and such wounds may be the exciting cause of grave accidents, such as erysipelas, and deep sloughs, the abundant suppuration from which may retard consolidation. In all cases, on the contrary, unaccompanied with wounds, when there is no reason to fear displacement or the contact of a liquid that may soften the apparatus or prevent it from becoming firm, we do not discard the immovable apparatus. We have recourse to this method of retention, when the inconveniences already men- tioned are no longer to be dreaded, and this fact sufficiently explains why in the same patient we sometimes commence the treatment with the one apparatus, and finish with the other. By way of recapit- ulation, we may say that we prefer in the great majority of cases the movable apparatus, which allows us, at least two or three times during the treatment, to take a view of the fracture, and, in case of necessity, to modify the formation of the callus, and more certainly prevent shortening. We will now pass rapidly in review the method of application in our wards of the various forms of apparatus adapted to the treat- ment of different kinds of fracture. We will not specially describe each form of fracture, for such descriptions may be found in all the treatises on surgery ; and the same is true of apparatus. We will FRACTURES. 41 refer only to those kinds of apparatus which we believe to be most useful in the treatment of fractures.1 Fractures of the skull, the jaw, the scapula, the ribs, the verte- brae, and the pelvis, in children, do not require any special con- sideration. This remark does not apply to fractures of the clavicle, which are far from being rare with them. These are generally incom- plete, the periosteum and even some of the bony fibres having resisted the force of the injury. As with adults, so with chil- dren, several kinds of dressing have been devised for fracture of the clavicle. Of all these bandages, the most simple is that of Desault, modified by Dupuytren, which we have seen constantly used at Hotel Dieu, and which we ourselVes employ both in adults and children. It consists in, first, a wedge-shaped woollen pad covered with a sufficiently thin and half-worn material; secondly, two bandages, the breadth of three fingers in width, and five or six yards in length, and of a piece of linen large enough to surround the chest, the arm being applied along the trunk, the forearm being flexed across the chest. To apply it, we must proceed to reduce the fracture, by placing the patient in an upright position, or, better still, seated on a stool, if possible; then extend the arm of the side affected, placing in the cavity of the axilla the base of the pad, which is supported by an assistant, by means of tapes stitched to the anterior and posterior part of this base. We very often omit this, without inconvenience, in children. An assistant then lowers the arm on the pad, carrying the patient's elbow inward and applied along the chest. The upper extremity of the humerus is thus carried upwards, and the lower extremity forwards, while flex- ing the forearm, and placing it, with the hand flat, over the chest. We must previously powder the axilla, the forearm and the hand with starch. The first bandage is designed to form turns which encircle the base of the chest while supporting the elbow, the forearm, and hand on that part. In the meanwhile, the assistant supports the elbow and carries it forward, pushing the humerus upward. The turns of the circular bandage should reach as far up as the insertion of the deltoid, so as not to press the upper extremity of the humerus inwards should the turns of the bandage be applied too high. The 1 On this subject a work entitled " Traite des Fractures chez les Enfants," by Dr. Coulon, a pupil of my colleague M. Marjolin, published in 1861, may be con- sulted with advantage. 42 FRACTURES. second bandage is applied in turns over and behind the chest, ob- liquely, passing from the elbow to the shoulder of the sound side, and strongly supporting the limb in this position, in such a manner, that after the application of this bandage, the shoulder of the side affected shall be powerfully elevated, and carried backward. In this way we fulfil the indications for reduction, and the shoulder draws upon the external fragment, which is the only movable one. In pushing the elbow forward, we cause the internal extremity of the external fragment to be carried forward, and we thus overcome its disposition to direct itself behind the internal fragment. Under many circumstances, especially in children a few months old, or in the new-born, we content ourselves solely with bandages, suitably applied to hold the arm and forearm half flexed against the chest, the turns of which are kept in place by stitches, to pre- vent the apparatus from slipping. The Mayor bandage answers also the same end sufficiently well, and may be employed some- times in place of the other forms of bandage. We have often used with success the sling of Delpech, and the apparatus of Desault, but when there is no overriding we omit the wedge-shaped pad, de- signed to furnish a point of support for the humerus, which acts as a lever on the scapula, and thus draws outward the external frag- ment of the clavicle. By not employing it, we avoid compression of the axillary vessels, as well as of the chest, which might be in- jured, especially in very little children. In fractures of the middle portion of the arm, we use the ordi- nary roller bandage with three splints applied over the first turns of the bandage, which are commenced on the arm, keeping always the forearm"flexed on the arm. We do not put splints on the internal aspect of the limb, for fear of compressing the vessels and nerves. The limbs of young children are rounded, without hollows or prominences, from which results the fact that graduated compresses are of no utility. We commence by surrounding the whole limb with circular turns, taking care to supply the bend of the elbow with a little wadding. Then, with the rest of the band- age we secure the splints by new circular turns. We may advan- tageously employ the immovable bandage, if there is neither in- flammation nor swelling. When the fracture has its seat in one of the humeral extremi- ties, we content ourselves with making the limb immovable by a roller bandage. When the neck of the bone is broken, a body FRACTURES. 43 bandage or circular turns supporting the arm on the thorax, as in fracture of the clavicle, fulfil very well the indications. In these last cases, splints would serve no useful purpose, for they would but imperfectly press upon the two fragments.—For fractures of the middle portion of the forearm, it is sufficient for us, as in the case of adults, to use compression in the direction of the interosseous space, with graduated compresses, and two splints, one on the an- terior, the other on the posterior aspect of the forearm, supported by turns of a bandage, or else with three little strips of gum- resin plaster, applied above, over the superior portion below the elbow; below, over the wrist; and in the middle, between the two others. With this last dressing, we may inspect the affected parts without the aid of assistants and without disturbing the apparatus. We may even loosen a strip without removing the whole bandage, and thus expose to view the bare forearm between the bandages which support the splints. If the inferior extremity of the radius is fractured, we should carefully incline the hand to the ulnar border of the forearm, either by the aid of the bandage or a strip properly applied, or by the elbowed splint of Dupuytren or that of Blandin. Fractures of the elbow are observed frequently in young people, and deserve the greatest attention on the part of the surgeon. They are always complicated, for they only take place by the application of a direct cause. The swelling is soon so considerable that it is difficult to make a certain diagnosis. But the fracture being once recognized, what is to be done? When the joint is very painful, and the tumefaction very decided, it is prudent to apply leeches, and to neglect nothing that will prevent or moderate the effects of traumatic arthritis, always a grave affection in children. Taking this course of action, I have never seen a serious inflammation after external violence. Inflammatory symptoms once appeased, our attention is called to the fracture. The indications now are different, according to the seat of the solution of continuity of the bone. When it is the olecranon which is separated from the ulna, we maintain the forearm in extension formed with a pad and a splint laid over the arm and forearm; the triceps brachialis thus becomes relaxed, and the fragments experience less separation than in any other position. It is not necessary to protract for too long a time this extension, and in removing the dressing it is better to 44 FRACTURES. accustom the joints to movements of flexion, and, as soon as con- solidation is effected, to put the forearm in a state of semi-flexion. In cases of forcible separation of the coronoid process we must, on the contrary, flex the forearm and support it by a sling, or, better still, by a series of figure-of-eight turns thrown from the arm to the forearm. When the fracture of the elbow is multiple or comminuted, if attended with very violent contusion, or there is reason to fear that inflammation may lead to loss of movement of the articulation, we must place it in a state of semi-flexion, for in this position anchy- losis is much less troublesome than if the limb is extended. The inflammatory symptoms having passed, we would do well to em- ploy immovable bandages, not forgetting that after twenty-five or thirty days at the most, we must take off the apparatus and use every precaution to prevent anchylosis. Fractures of the hand and of the fingers present the same points for consideration as in adults, and are treated in the same way; that is, by fixing the hand in a wooden scooped splint. In fractures of the thigh, we frequently apply in very young children only a simple roller bandage with three splints, one of which is on the outside of the thigh, extending from the great trochanter above to the external condyle; another from the inside of the fold of the groin, to the internal condyle; finally,- the third, from in front of the fold of the groin to the patella, These splints are placed over the first turns of the bandage applied around the thigh. The first turns cover the whole limb, on which the splints exert a moderate and regular compression; the second secure the splints. The application of the latter ought to be made with the greatest care, and we must particularly guard against their being placed over prominences of bones, for with young subjects pres- sure rapidly leads to gangrene of the integuments. The external splint should be long enough to reach beyond the iliac bone, to be included in the turns of the bandage or in a body bandage, and thus to serve as a support to the pelvis. By this method we avoid the applications of pads of bran which children so soon soil. After the apparatus has been adjusted it should be covered with a cerate cloth to protect it from the urine and from alvine evacuations If the child is already advanced in years, we give the preference to the apparatus of Scultetus, and we always employ the imme- diate splints of Dupuytren, applied over the first compresses which FRACTURES. 45 surround the thigh and which do not interfere with the use of pads and of the usual large splints. To these immediate splints we owe the regularity of the callus both in children and in adults. At the moment of applying the small splints we must use every effort to obtain reduction and perfect coaptation. To complete this apparatus we must never neglect the employment of a body bandage, which should previously surround the upper portion of the large external splint, and afterwards encircle the pelvis, at the same time fixing it firmly by a number of pins or by stitches on that portion of the bandage which surrounds the ex- ternal splint. In fractures of the leg, we also apply three splints with a roller bandage, being careful to avoid pressure by them over the crest of the tibia. When there are no complications, and there is nothing to make us fear a subsequent displacement, we unhesitatingly em- ploy from the commencement an immovable apparatus. Fractures of the patella are rare in young children. Only three or four of these have come under our notice during our practice at the Hopital de l'Enfant-Je'sus. We have no special remarks to make on the treatment. The limb must be kept extended. Fractures of the foot offer the same indications as in adults, in whom we attach the injured parts on wooden soles suitably stuffed. If the soft parts are divided, we have recourse to con- tinuous irrigation with great advantage. For all the forms of fracture, which we have just passed in review, we habitually wet all our bandages at the moment of their application, with a resolvent liquid, such as lead-water or camphor- ated brandy diluted with water, provided the fracture is not com- plicated with wounds. At what period should we finally remove the apparatus ? With the new-born, twelve days suffice for consolidation. For children of about two years, it is more prudent to keep the limb immovable for twenty days ; for those between twelve and fifteen years of age we should, as a general rule, retain the apparatus for twenty-five days. After this time we rarely meet with an un- consolidated fracture, though we sometimes observe this in fractures complicated either with local or general causes. Consolidation may be delayed for a greater or less length of time, and it is the duty of the surgeon to discover what may be the cause of it. If the fracture is complicated with a wound, it may happen that this 46 FRACTURES. wound may be kept up by the presence of a portion of necrosed bone, and then it becomes necessary to assure ourselves of this fact by examination of the wound, and to wait for the separation of the sequestrum. If the cause is a general one, we must combat it by the appropriate remedies. If a fracture is not consolidated and no sufficient cause can be detected to account for it, surgical assist- ance may be invoked. These cases of non-consolidation are rarely met with in children. Nevertheless we must employ successively protracted immobility in immovable apparatus. If these means do not answer, we may try acupuncture of the false joint with needles heated to a white heat, setons, scraping of the fragments, or resection of the osseous extremities. Dr. Brainard has suc- ceeded in inducing inflammation of the ends of the bone by perforating them in different directions. We may add that all these methods failed in our hands for a fracture of the leg in the little girl to whom we previously referred. As for vicious callus, we may, in certain fractures of the limbs, even at the end of three or four months, correct it more easily in children than in adults by applying the usual apparatus, more or less modified according to the circumstances of the case. Hygienic and medical treatment.—The apartment allotted to the little patient should be well aired and kept at a proper tempera- ture. Cleanliness is indispensable, and the linen of children should be changed whenever it is soiled; if this be neglected, we will speedily produce a focus of infection. Good nourishment is of the greatest importance when no phenomenon of general reaction exists, for children always do well with a tonic regimen. We should carefully wean those who are at the breast. We now understand that the indication always is, to attack the cause which appears to retard consolidation. Thus, when the pa- tient is affected with scrofula, syphilis, or rickets, we must prescribe a treatment appropriate to each of these diseases. It is for this reason that we often prescribe for patients suffering from fracture cod-liver oil, iodide of potassium, etc. W'hen complications arise we must, as a general rule, hasten to relieve them, even if we are obliged to neglect, for the time being, the treatment of the fracture. Of two evils, we must choose the least. TRACHEOTOMY IN CROUP. 47 CHAPTER V. TRACHEOTOMY IN CROUP. Tracheotomy, which consists in the opening of the trachea, performed with the view of giving respiration to a patient asphyx- iated by the presence of false membranes in the larynx, should always be considered an indispensable operation, since it brings back to life one who is suffocating, and is at the point of death. This operation, which, like all others, is only easy to those skilled in its performance, must nevertheless be resorted to by all practitioners, surgeons or physicians, for none is more urgent in a large number of cases. For this reason, we may be pardoned the length we shall give this article, as well as the details, in which we do not hesitate to enter to indicate the method of securing the successful interven- tion of art. The operator must be thoroughly familiar with the indications, the counter-indications, the method of operating, and the after- treatment. 1. Indications.—Asphyxia would seem to be the sole and only indication necessitating the operation of tracheotomy, which should only be practised when the asphyxia continues with or without more or less complete anaesthesia; but the condition of success which surpasses all others, as M. Millard has declared in his essay, is the predominance of the characteristics of asphyxia. This may seem so to the surgeon, who is purely and simply an operator, but not to him who is familiar with the terrible affection embraced under the name of croup. Unhappily, it is not a disease purely restricted to the larynx or the respiratory apparatus; but very often, though only characterized by the presence of a false membrane limited apparently to the larynx alone, it is caused by a general condition existing in the whole economy, and which, like a poison, infects it with more or less intensity. The first indication is that the suffocation and asphyxia from which the patient suffers, shall be permanent and without inter- 48 tracheotomy in croup. mission. The second indication is that the disease shall be local and not general. In the former state the patient is in the most favour- able condition; in the latter there is but little chance of success. In fact, if false membranes exist in the nose or behind the ears, or, as is frequently the case, there is ulceration even in the vulva; if there are many enlarged glands under the jaw, and if the urine is albuminous, it is necessary for the operator to know that he has very little or no chance of success. The third indication is, that the patient shall be at least two years old. The number of successful operations performed prior to that period has been very small, and the cases are only exceptional in which tracheotomy has succeeded in children of six months, a year, and eighteen months; and yet the successful result achieved by M. Scouttetten on a child of six months, and that of M. Maslieurat Lage'mar induce us not to always decline operating on children under a year old. There will be so many the more indications for the operation, according as the patient has not been debilitated by previous inju- dicious treatment, such as leeches, diet, emetics, blisters, &c, which are without effect in combating the disease, and put the patient in a very alarming condition, and thus render the operation abortive. When, on the contrary, we have but sparingly employed cauteri- zation, which acts merely on the visible disease, and not at all on that which poisons the whole system ; and when we have employed general modifying agents, such as chlorate of potash or perchloride of iron, combined with food and tonics, the patient will be in the most favourable condition, and this will be the best time to select for operation. 2. Contra-indications.—General diphtheria, false membranes in the nose, behind the ears, in the vulva or on an existing blister, large and numerous cervical ganglions, epistaxis, and gangrene of the pha- rynx as a complication of diphtheria, are the causes which make an operation unsuccessful, and which may induce us to decline operat- ing. Intermitting asphyxia will be a contra-indication under cer- tain circumstances, or will at least lead to a postponement of the operation. We have seen cases of croup with intermitting asphyxia cured without operation. False membranes which penetrate even as far as into the trachea and the bronchial tubes are not any contra- indication ; we have seen patients spontaneously expel false mem- branes which represented the cavity of the trachea and bronchi and yet recover without an operation, while others have only been tracheotomy in croup. 49 cured after tracheotomy. Even the gravest diseases, such as pneu- monia, cutaneous affections, typhoid fever, smallpox, scarlet fever, measles, &c, and even chronic diseases, such as phthisis pulmonalis, are unfavourable conditions for cure, but are not absolutely contra- indications ; for, in these cases, the alarming condition of the pa- tient is modified, momentarily at least, by the operation, and while at first restoring respiration, we may sometimes save his life. We should therefore, under these circumstances, attempt the operation; melius anceps quam nullum. 3. Method of Operation.—-We cannot dwell too minutely on all the steps of this operation, which is quite as difficult as any other, and demands so much the more care on account of the tender age of the patient. Like all operations, it requires practice, and there- fore should not only be performed first on the cadaver, but also on living animals, such as dogs, sheep, etc. It is one of those delicate operations that the surgeon will much more skilfully perform on the child after having had experience with it on living animals, in the midst of blood and cries, than after attempting it on the cadaver. For this purpose, it is important that the surgeons in attendance in hospitals for children should make the internes operate on ani- mals, such as rabbits and dogs—a view already expressed by M. Bouvier in a recent discussion at the Academy—for they will all of them undoubtedly be obliged to perform it on children. Though the surgeon should make use of the instruments best adapted to his purpose, it is especially important that an operator who is likely to meet with difficulties should more frequently employ those that are suited to his want of familiarity with the operation, rather than instruments that are in common use, that he does not yet know how to handle. Because an instrument is unskilfully managed by an unpractised hand, we must not modify or change it. Let us now consider in order the instruments, the position of the patient, the mode of placing the assistants, and the work of the surgeon. The instruments essential to the operation are: a straight bistoury, probe-pointed bistoury, grooved director, ligature forceps, tenacu- lum, dilating forceps, curved cranesbill forceps, double movable canula,1 a piece of isinglass plaster, a curved gum-elastic bougie of 1 Of the thirty-two children first operated upon, in which a simple canula was used, only two were saved. 4 50 tracheotomy in croup. a size to pass readily into the canula, to serve as a conductor, a small piece of whalebone furnished with a delicate sponge, a small fine feather to clean out the trachea, a gum-elastic tube with the end cut off,—with which to suck out the blood which may flow into the trachea,—sponges, also a syringe, if the surgeon hesitates to put his own mouth to the wound, and threads, in case they be wanted for ligatures. An indefinite number of modifications of canulas and dilators have been invented. We admit the advantages, in prin- ciple, of the canulas devised at first by Bretonneau, but M. Trous- seau has successfully modified them, as the operation has become more generally practised. Without referring to the numerous canulas contrived by differ- ent persons, we will simply express our preference for the double canula advocated, to the exclusion of all others, by M. Trousseau; it is terminated by a tracheal extremity cut somewhat obliquely, and with the edge rounded and not cutting, as suggested by M. Barthez, and furnished at the outer extremity with a flange with lateral wings to which to secure the tapes. The canula must be made in such a manner as to penetrate in a vertical direction to the middle of the trachea, without being too much curved, so as not to wound the ante- rior wall, and yet not to press by its extremity on the posterior wall. As M. Bouvier has remarked in an excellent treatise on canulas,1 the plate with which they are furnished must be arranged in such a manner that the tube is directed, as nearly as possible, in the direc- tion of the trachea. The canula must also be movable, according to the plan suggested by M. Roger, and constructed by M. Liier. With such precautions ulcerations of the trachea will become much less frequent. The diameter of the canulas should vary according to the age of the child. To insure accuracy in this respect, M. Morax, interne of M. Bouvier, has recently carefully measured the tracheas of children between the ages of two and fifteen. These measure- ments, ranging for this period between a quarter and a half inch, enable us to fix upon four different sizes, suitable to the various ages of children : 1. A canula of less than a quarter of an inch in diameter and two inches in length for children from one year to four years of age. 2. One of a third of an inch in diame- ter for those between four and eight. 3. One of two-fifths of an inch in diameter for those between eight and twelve • and 4. One of 1 Bulletin de Therapeutique, t. lxiii. pp. 299 346. tracheotomy in croup. 51 half an inch in diameter for those between twelve and fifteen; the last two being two inches and a half in length. A fifth number, having a diameter of three-fifths of an inch, would be better for adults, in whom the diameter of the trachea varies from five-eighths to two-thirds of an inch. Several dilators have been devised, and an infinite number of modifications made of these. Dr. Pouquet even proposed to do away with them entirely, and use only the finger as a conductor. We ourselves prefer, and even consider as indispensable, a dilator, which we invented about fifteen years since, now in daily use at the Hopital des Enfants. This is the dilator of M. Trousseau, much modified, longer, devoid of hooks at its extremity, and furnished with a spring which may be opened by pressure and not by sepa- rating the branches. Its extremity is curved at a right angle, while the two branches, being approximated again, form at the end a flattened beak, which is introduced with facility through the incision in the trachea. It may serve as a blunt tenaculum and also as a dilating forceps; in this manner it does not slip from the wound, as the first dilator devised by M. Trousseau did. Position of the Patient.—Whatever the position may be in which the patient is placed—the light not being allowed to come from above, unless he be in an apartment illuminated by a light sus- pended directly above him—the light will always be poor, for he must necessarily be on his back, and whatever may be done, it will be badly directed upon the neck. The child should rather be laid upon a convenient table covered with a mattress, and a supporting pillow placed in such a manner as to throw the head backward. Mode of placing Assistants.—One assistant will hold the head thrown back on the pillow, in such a way as to make the neck prominent. He will apply both hands on the side of the head and face, and will take great care not to be in the way of the operator by passing his hand under the chin. A second assistant may sup- port the legs of the patient by holding them on the bed with one hand, and grasp the hands with the other. A third assistant may be placed to the left of the patient to assist the surgeon, holding in one hand the sponge to cleanse the wound, and with the other a blunt hook with which to keep open the lip of the wound on his side. He should also be armed with some ligatures, in case they may be needed. A fourth assistant may be of use in handing 52 TRACHEOTOMY in croup. instruments, but he can be dispensed with if they are put within reach of the operator. The work of the Surgeon.—The patient being held immovable, the surgeon, placed to his right, should recall the anatomy of the superficial and deep portions of the anterior region of the neck, principally in the median line where the incision is to be made. Thus, in examining the anterior part of the neck from the hyoid bone to the sternum, we find at first the skin, beneath which is the superficial fascia, and next the first layer of aponeurosis cover- ing the anterior borders of the two sterno-mastoids. Between the edges of these two muscles a space exists, occupied by a layer of cellular tissue; in this from above downward run the two anterior jugular veins, uniting at the base of the neck to form one trunk, which passes beneath the two sterno-mastoids, and between the two external jugulars. We next meet with the second aponeurotic layer which covers the sterno-hyoid and sterno-thyroid muscles; and a little more deeply seated we find the deep aponeurosis. In the upper part of this region is the thyroid body, on a level with the upper rings of the trachea, very slightly developed in children; in the lower part, towards the episternal fossa, the left jugular vein, running obliquely across the brachio-cephalic trunk ; finally, in the median line, from before backwards and in the following order, the trachea, and, on each side, the veins and carotid arteries; behind the trachea the oesophagus a little to the left, and next the cervical vertebrae. We must not overlook the superior and inferior thy- roid arteries going to the thyroid body, and the venous plexus below the thyroid body; and in some rare cases the arterv of Neubauer, which ascends along the anterior part of the trachea, arising from the arch of the aorta. All this anatomical knowledge being present in the mind of the surgeon, he should at first be convinced that in this operation, he must perhaps rely more on his finger than on his eyes, and that, after the division of the skin and of the first aponeurotic layer, while using his eyes, he must not make an incision with- out employing his hand to separate the intermuscular spaces as far as the trachea. The surgeon makes a longitudinal incision in the median line, in the whole thickness of the skin, and from above downwards. This first incision should vary in length according to the size of the neck, being longer if the child is fat than if it is thin, for in the latter we more easily reach the deep parts. It should begin a little below the cricoid cartilage, and be continued to with- TRACHEOTOMY IN CROUP. 53 in a short distance of the top of the sternum. Having made this first incision, the aponeurotic layer should be divided with a bistoury, the operator using, at the same time, or not, the grooved director. The latter and left index finger may next serve to divide the sub- jacent cellular tissue, and to separate the superficial vessels, in a manner similar to that practised in seeking for a deep artery. The anterior part of the trachea may thus be reached and felt with the left index finger without risk of opening the veins. Before making an incision, the surgeon should bear in mind that he must not deviate to the right or left, lest the carotid arteries be wounded with the bistoury; nor should it be forgotten by him, in very small children, that in cutting too near the sternum he may come across the brachio- cephalic trunk, which crosses the lower part of the trachea. Finally, if hemorrhage follows from the opening of the veins, the wound must be washed out without waiting until the trachea comes into view, if the blood conceals it; the surgeon, carefully feeling for the elastic tube of the trachea, then makes a puncture, taking his finger, as the guide, with extreme care not to pass entirely through the trachea, and thus open its posterior wall and the oesophagus. Immediately after making the incision, whether it be large or small, he should continue to hold the index finger on the opening, by which blood might penetrate. The dilator should be carried directly under the finger, and be passed into the opening. In this manner, the surgeon takes with the right hand the dilator, which is in the shape of a blunt hook terminated by a lenticular extre- mity, slides the hook across the inferior angle of the wound of the trachea, retaining it in the same manner as he would a double tena- culum, and approximates the rings to close up the wound. The mucus and blood now flowing from the wound, the patient is placed in an upright position, andthus afforded the opportunity of coughing and of expelling the false membranes from the trachea. The child being thus placed in a strong light or before the window, the ope- rator can at that moment get a better view of the parts, for, as soon as the dilator is removed, the patient breathes, and the circulation being reestablished, the venous blood ceases to flow. The surgeon may also find out whether it is necessary to tie the vessels which would give rise to hemorrhage in spite of the reestablishment of respiration. If the wound is sufficiently large, he need not enter- tain the idea of making an additional incision ; if, on the contrary, 54 TRACHEOTOMY IN CROUP. it seems to be too small for the volume of the canula, it may be enlarged by the probe-pointed bistoury, either upwards or down- wards, as may seem most convenient to him. To make this inci- sion, it is not necessary to change the hand for using the dilator, which facilitates the performance of this operation, and is always held in the right hand; the left hand should always hold the probe- pointed bistoury. In regard to the introduction of the canula, which has been pre- viously furnished with a ring of isinglass plaster to intervene be- tween the skin and the flange, as well as with tapes to fasten it to the neck—this is a very difficult stage of the operation. The finger may be used with advantage as a conductor, but it is better to leave the dilator always held in place by the right hand, whether we employ the one used at the Hopital des Enfants, or that of M. Marjolin, a double tenaculum, or that devised by M. Gamier, which is a spring forceps with crossed branches, the extremities of which, curved at a right angle, rest only in contact by the spring of the branches, and separate by pressure applied above their point of crossing. This dilator takes up less room in the trachea than the other, and offers some real advantages. With the left hand, the canula should be introduced, which is furnished with a conductor passing beyond its extremity an inch or more. It may very readily enter between the separation of the branches of the dilator, the extremities of which are directed downwards. After this conductor has penetrated and been pushed a little further into the trachea, the dilator must be withdrawn. The canula is not interfered with by the dilator, and slides easily on the conductor, if the wound is of the proper size. When it is fairly in the trachea, its presence being recognized by the noise of air passing through it, the conductor is withdrawn. In this manner - much better success follows than without the conductor. Practice is of course necessary to insure the success of this operation as of every other, and the surgeon must, without precipitation, push the conductor sufficiently far, withdrawing the dilator before sliding the canula, for it would be an inconvenience if it was made to enter before removing it. The operator may, as previously remarked, without these agents, introduce the canula directly by conducting it with the finger or with the conductor, which we contrived, and Dr. Pouquet advised and which he considers as the most easy to apply. But ha vino- ner' TRACHEOTOMY IN CROUP. 55 formed tracheotomy more than three hundred times, we believe that the best procedure will be to employ the dilator and the gum- elastic guide to give more ready entrance to the canula. Only on the evening of the operation, or the next day after, when the wound is no longer inclined to bleed, may we remove the dila- tor and the conductor, because we can then get a good view of the opening in the trachea, when the patient is placed in an upright position. I will add also that the dilator with three branches de- vised by M. Laborde has appeared to me to take up more room in the trachea than the dilator with two branches, thus rendering the introduction of the conductor and the canula more difficult. We must not pass over in silence the accidents which may occur during the operation. The first is the opening of the superficial veins, which may be avoided by making the first incision slowly, by separating with the blunt hooks such veins as present them- selves, and especially by discontinuing the use of the bistoury, as soon as we have reached the point where they are met with. It will be found best to isolate them with a blunt grooved director. When we reach a deeper point, we must introduce the finger, which will thus enable us to separate the cellular tissue, in front of the trachea, in the same manner as when the surgeon wishes to reach a deep artery, so as to expose it to view; an assistant in the meanwhile being directed to apply his blunt hook. A second accident is, after puncturing the trachea, to have the incision escape the eye of the surgeon. This may be avoided by making the in- cision in this canal beneath the left index finger, which should secure the trachea, and should be applied immediately after this first in- cision. When, in spite of this precaution, the opening being too small escapes us, we must not lose time in hunting for so minute an orifice, but make a new one. On the forefinger as a guide, we may introduce the extremity of the dilator; the instrument being tightly closed, the lenticular end of the forceps, which may pass into an incision of an inch or more, enables us, when they are once introduced, to hold the trachea so that it cannot escape us. We may, if necessary, make an incision with the probe-pointed bistoury, always holding the dilator in the right hand, and the bistoury in the left; otherwise, in changing the hand, we may allow the dilator to slip from the trachea, and render an operation very long which should be performed, if not rapidly, at least in general without loss of time. An accident which some- 56 TRACHEOTOMY IN CROUP. times happens is making the incision on the side of the trachea; the index finger, held over the wound, enables us to properly direct the dilator, which itself may serve to restore to the median line the lateral wound. Sometimes it happens that the incision is made longer than was intended; it must not be forgotten, under these circum- stances, that if we have an ordinary canula, it may stretch and bend so as to escape from the wound, and it is only with a long canula that this accident can be remedied. When, after having opened the trachea, we cannot immediately find the aperture, the neighbouring cellular tissue becomes infiltrated with air in such a manner as to swell out the neck and the inferior part of the face. We have nothing else to do than to seek for the opening in the trachea with the left index finger, to introduce the dilator, and to separate the edges of the wound, to facilitate respiration through the latter. We are thus afforded time to keep the wound of the trachea separated, and to quietly introduce the canula over its con- ductor. Emphysema disappears in time, when respiration is well estab- lished, and the canula properly adjusted. As regards the danger of introducing the conductor of the canula into the cellular tissue surrounding the wound, this is only observed when the dilator is improperly applied. This does not take place when the surgeon re- members that this instrument serves as a double hook to retain the trachea, and that he must withdraw it after the conductor has been properly introduced. In tracheotomy a serious accident may compromise the life of the patient, when any length of time is allowed to pass before open- ing the trachea, and vessels have been opened, which give rise to hemorrhage. If these should be arterial vessels, from which the blood leaps in jets, they must be tied; if veins, this need not be done, but the surgeon should always speedily open the trachea, and the blood will then cease to flow. To avoid the introduction of blood into the trachea, the surgeon immediately places his finger on the incision made in it, for without this precaution the blood entering the air-passages may asphyxiate the patient. We must then introduce into the trachea the gum-elastic tube and suck out the blood through it, either with the mouth, or with a syringe attached to its extremity. 4. Surgical after-treatment.—-The after-treatment of tracheotomy is TRACHEOTOMY IN CROUP. 57 both medical and surgical; let us first examine the latter. Imme- diately after having introduced the canula, we must apply in front of its orifice a light neckcloth or scarf, performing the function of a 'breathing veil,' and having the advantage of preventing the direct entrance of air. Without this, we may witness the drying up of the mucus which passes into the canula, and consequent difficulty in respiration and irritation of the bronchial tubes. The operator must also frequently withdraw the inner canula, when it becomes choked with mucus, and clean it in warm water, passing into its interior a small swab. This little operation is very easily performed, when the manner in which the inner canula is fixed has been ascer- tained. Every time that it is withdrawn, it should be quickly cleaned, so that the outer canula may not be encumbered while the other one is being wiped, ready to be put back. If false membranes obstruct the trachea or the canula, they should be extracted with the cranesbill forceps, which, when intro- duced, follows the curve of the canula even into the respiratory tube. This is preferable to using a small whalebone furnished with a sponge, which has the disadvantage of pushing and not of ex- tracting. If the patient does not expectorate by the canula, we may sometimes, by introducing rapidly the extremity of a small feather, excite cough, and thus favour the expulsion of false membranes or mucus. Sometimes when expectoration is absent, and the trachea and the canula are dry, a few drops of tepid water introduced into the canula may cause the patient to ex- pectorate. Better still, however, would it be to make him breathe moist air; and for this purpose it is important that the air of the chamber should not be allowed to get dry, and consequently that it should not be warmed by a stove or a fireplace in which coke is burnt. It will frequently be advisable, if dryness exists in the respiratory tube, to put on each side of the patient's bed large vessels containing boiling infusions of emollient plants, the vapour from which will fill the air breathed by him. If the trachea is clogged up with thickened mucus or false mem- branes, which prevent the child from breathing, it is best to with- draw the canula and to boldly seize in the trachea, with the cranes- bill forceps, everything which obstructs the respiratory canal. For want of this care patients who are almost cured may die asphyx- iated. We thus see how extremely important it is that children operated on for tracheotomy should be watched, for a few days, by those capable of performing this operation of extraction. 58 TRACHEOTOMY IN CROUP. The first dressing consists in removing the entire canula to clean it, and to change the threads, and this should be made at the end of twenty-four or forty-eight hours, and the surgeon should make use of this moment to cauterize the wound with nitrate of silver. The following days he may, either daily or every other day, remove the canula to clean out the wound, and every time as- sure himself whether the air has commenced to pass into the larynx. To determine this, he should apply for a few moments a sponge over the wound, and if the child breathes without suffoca- ting—if he can, while the wound is closed, extinguish a light with his mouth—it is pretty evident that the larynx is free. Otherwise the canula should not be finally withdrawn until the end of three or four days at the very earliest, often eight or ten days, and some- times even longer. It is always advisable to withdraw the canula as early as pos- sible, for its curvature is such that it may produce by its ex- tremity ulceration, most frequently on the anterior wall of the trachea, sometimes on the posterior wall. With the view of avoiding this accident, our colleague, M. Roger, caused to be made by M. Liier movable canulas, which are carried easily in all directions, following the movements of the neck, and which pre- vent the extremity of the canula from constantly pressing on the same point. By means of this improvement, ulcerations pro- duced from this cause are very rare; nevertheless, we have seen even movable canulas produce ulceration. We think this accident may be best recognized by the expulsion of bloody expectorations through the canula, which cease when it is withdrawn; and when the patient is not yet able to breathe by the larynx, we must employ a canula curved at a right angle, the extremity of which is directed in the vertical direction of the trachea. In such cases the canulas usually employed do not have a proper curvature, and it will be better to have at the same time a canula made movable after the plan of M. Liier, and curved nearlv at a right angle after that of M. Charriere. With this kind of instru- ment, one canula cannot be placed in another of the same curva- ture. The inner tube, to be able to enter, must have a movable articulated extremity which will bend so as to enable it to pene- trate. There are circumstances in which the canula remains longer than the operator wishes, depending sometimes on the exist- TRACHEOTOMY IN CROUP. 59 ence of adherent false membranes on the vocal cords of the larynx. We may sometimes in such cases with advantage insti- tute a swabbing out of the larynx. This operation is very simple; to perform it it is necessary to have a small dossil of charpie tied with a double thread at its middle portion, arranged like the tam- pon used in closing up the posterior opening of a nostril in arrest- ing epistaxis. This tampon, of nearly the volume of a kidney bean, is furnished with a thread which is passed into the eye of a gum- elastic catheter; the latter being introduced from below upwards through the wound in the trachea, and passing easily into the mouth, is disengaged from the thread, and then withdrawn downwards, and the thread being in the mouth serves as a means of drawing from below upwards the little tampon, which passes between the vocal cords, and relieves them of any false membranes which may be present there. As a result of this procedure we have seen respi- ration restored immediately in patients who have been able at once to give up their canula and have no further occasion for its use. Unfortunately this method has not always succeeded, and we can recall patients who have worn their canula for several months, some of them for several years, always wearing it in dread of the loss of respiration. We may add that this difficulty in the final withdrawing of the canula may sometimes depend on paralysis of the larynx, analogous to paralysis of the velum palati, so well pointed out by M. Maingault. -Patients thus affected may in time do without the canula; but when the paralysis is persistent, a good result may be obtained from the effect of electricity on the larynx, an example of which has been cited by M. Debout. We may call special attention to a troublesome accident observed immediately after the operation—and sometimes, when we wish to finally withdraw the canula—consisting in difficulty in swallowing liquids, and even solids; the patient swallowing the wrong way, fluids and solid food pass through the larynx and through the wound. In such a case it is sometimes sufficient to wait with patience, to make the sufferer swallow carefully, without unnecessary haste; to give him thick food, such as pap, macaroni, and no fluids, and in a few days we will find things modified. But there are also cases in which deglutition continues to be poorly accomplished, and if the patient should waste for want of nourishment, we must employ the means already advised, even with those who, immediately after tracheotomy, refuse, as they sometimes do, to take any nourish- 60 TRACHEOTOMY IN CROUP. ment. Children should be nourished by means of a curved gum- elastic tube introduced through the nose, and pushed as far as into the oesophagus. We have seen children get accustomed to this operation performed three times a day, injecting each time with a glass-syringe either milk, or coffee and milk, broth or chocolate, who were restored to life when almost dead from deprivation of nourishment. This little operation for the introduction of the tube through the nose, passing through the pharynx and oesopha- gus, is much more easy than that by the mouth, in which we have reason to fear that the food may pass into the larynx. The im- portant point, in this introduction, is to follow closely the posterior wall of the pharynx, directing the extremity of the tube along the vertebral column. When finally we are able to permanently withdraw the canula and it is necessary to close up the wound, it is not worth while to apply adhesive strips. The opening of the trachea must be first closed, and the wound in the integuments afterwards. For this purpose, a simple dressing is sufficient, and sometimes the application of nitrate of silver, if the wound is slow in healing, or lotions of wine may hasten cicatrization. When we cannot finally withdraw the canula, there are cases in which we may leave the patient for an hour or two without a canula, and then replace it, or we may withdraw it during the day and return it at night. In this manner, chil- dren resume the habit of breathing which they had temporarily lost, after having been abruptly deprived of respiration by the mouth. The canulas devised by M. Laborde may also be employed, as they have been constructed by MM. Robert and Collin.1 5. Medical After-treatment—If the surgical treatment, to which we have already referred at some length, is of such extreme im- portance, the medical treatment may be considered as indispensable. The disease for which tracheotomy is performed being due to a general cause, cannot be cured by an operation which is, in reality only a method of allowing a patient to breathe, who would other- wise die of suffocation. Time and medical care are absolute es- sentials in the completion of the cure. Should the surgeon have confidence in the modifying treatment of diphtheritic inflammation. by chlorate of potash or perchloride of iron, or any other ao-ent he should continue its use, but it is also absolutely necessary°that he • These canulas are described and represented in the Bulletin General de Thera- peutique for Nov. 15, 1863, vol. lxv. p. 417. HYPERTROPHY OF THE TONSILS. 61 should support the strength of the patient, and give him good nourishment. Milk or light broth should be allowed him, and wine and solid food gradually administered. Cinchona, in its vari- ous forms, may also very often be prescribed with advantage. It is undoubtedly the fact that more cures are obtained in patients who are well nourished from the very day of the operation, than in those who are averse to taking food. We cannot too strongly recommend that the chest should be examined, in order that the complications that so often supervene may be checked. Even in convalescence we must combat every morbid condition that may arise, such as affections of the chest or of the stomach, or paralysis of the velum palati, and modify the diet according to circumstances. It is especially advisable in this operation that the patient should be at night in one room, and change in the daytime to another, taking care to air the apartment well which he has just quitted. This last precaution is of extreme importance, both for those operated on and those who have the care of them. In the interest of those last mentioned, it is highly ex- pedient that they should be relieved to take repose and fresh air, this being the only means by which they may escape contagion. CHAPTER VI. HYPERTROPHY OF THE TONSILS. Enlarged tonsils are met with in children of all ages, even in those of only a year old. Examined anatomically, they present considerable variation in increase of volume and in consistence. Sometimes they are without any definite shape, divided into sepa- rate lobes, very prominent and not in their normal position, either projecting inwards, or descending downwards into the pharynx. At other times, they are buried between the pillars of the velum palati, and become enlarged in such a manner that the anterior pil- lars cover them, and they mount upwards so as even to press upon the Eustachian tube. Their tissue is generally firm and consistent, sometimes softened, and even tearing easily. The vessels of the sub- stance of the tonsils are more largely developed in proportion to the duration of the hypertrophy. These organs are sometimes 62 HYPERTROPHY OF THE TONSILS. adherent, but I have never found them degenerated or cancerous, as in adults. This disease is much more frequent in children than in adults; more than a hundred cases come under treatment annually in the surgical service of the Hopital des Enfants. Not a year passes by without our operating on eighty to ninety children at the hospital, and fifteen to twenty-five in our private practice. Hypertrophy characterized by permanent, and not transient, en- largement of the tonsils, frequently has for its sole cause a lym- phatic constitution; nevertheless, it sometimes depends on frequent inflammations of the throat. The symptoms of this affection are generally easy to recognize. Usually children thus affected have the mouth wide open almost constantly, speech somewhat inarticulate and snuffling, writh some- times even a little deafness. During sleep they snore more or less, are somewhat disturbed, and lie with the mouth open, and consequently the tongue becomes dry. Some children have narrow chests, be- cause they insufficiently dilate their lungs. If we depress the tongue we perceive in some of our little patients that the tonsils meet in the median line. There are some cases in which this is not so marked, the tonsils being concealed by the pillars of the velum palati, which are likewise enlarged in front of them ; a con- dition to which the name of encysted tonsils has been given. They are, in fact, clustered together in the fossae for the tonsils, and they ascend more or less upwards. All children thus affected suffer from frequent pain in the throat, and are extremely distressed when attacked with inflammation. Left to themselves, these enlarge- ments of the tonsils, in some children, quite often diminish in time, especially if we attack their lymphatic constitutions, and, above all, when they reach the age of puberty, about twelve or fourteen years of age in young girls, and about sixteen or eighteen in boys. We frequently decline operating at this age. After the period of puberty, the tonsils may remain stationary or diminish in volume but before that they have a tendency to assume a certain bulk and to retain it. Diagnosis.—Unless special attention be paid by the surgeon he may occasionally confound abscess of the tonsils with hypertrophy The tonsils have sometimes been supposed to be increased in vol- ume, when the swelling was only due to a retropharyngeal abscess causing the posterior wall of the pharynx to project, impeding speech, pushing the tonsils forward, and giving the patient a snuf- HYPERTROPHY OF THE TONSILS. 63 fling voice. The greater or less rapid development of this last affection and careful investigation will prevent a mistake being made in the diagnosis. Prognosis.—Hypertrophy of the tonsils is more grave in propor- tion to the greater youth of the patient; in fact, the more narrow the pharynx and the more seriously the tonsils interfere with the free entry of air, so much the more do they narrow the passage, when acute inflammation increases their volume. For this reason, the younger the patients, the greater success in curing them. An operation is more difficult to perform with them, but I have several times performed it on children from eighteen months to two years old without difficulty. If, in very young subjects, in whom this portion of the pharynx is narrowed, enlargement of the tonsils is not usually of a nature to alarm by hemorrhage after the excision of these glands, the case is very different in individuals of eighteen to twenty years or more. We frequently have to fear hemorrhage in them, because, the hypertrophy being of longer duration, the vessels of the ton- sils have become more developed. I have operated on more than a thousand children, and I remember scarcely three of these who had sufficient loss of blood to make me uneasy. On the contrary, I have operated on twelve or fifteen adults, and I must acknow- ledge that at least four or five gave me anxiety, and that I was only able to arrest the hemorrhage in these cases by iron heated to a white heat, or the perchloride of iron. As the result of my own experience, I may therefore say that the operation is so much the more beneficial as the children are younger, and so much the more grave as they are more advanced in years. We may, and even should, operate on young children, but it must be done by surprise, a procedure which is not possible when the patient is older. Treatment.—If in many cases he should decide promptly in favour of surgical treatment—that is to say, excision—the surgeon should be perfectly well aware that his intervention is not always expedient, and that he may be content, in certain cases, to wait, counting on time, the efforts of nature, and sometimes on local means to pro- duce a beneficial effect. In fact, the modification of the lymphatic constitution by iodides, bitter tonics, and the preparations of iron may be sufficient. Certain local applications, such as astringents, alum, nitrate of silver, and tincture of iodine are employed with ad- vantage. Sulphurous douches have given good results in the hands of M. Lambron, at Luchon, but they invariably require patience 64 HYPERTROPHY OF THE TONSILS. and perseverance. Excision will always be the means preferred to relieve children promptly, and to spare them the repetition of local applications, which to them are really operations, irritating them, and laying the foundation for convulsions. I lost, by the latter accident, a child on whom, for several weeks before the operation, I had made repeated applications of powdered alum, and other as- tringents. Each application was to him more irritating than ex- cision itself. Excision of the Tonsils.—We dismiss from consideration the liga- ture and cauterization, to speak only at present of excision proper, performed with a sharp instrument, a bistoury or scissors, and a tonsillitome. The operation should be resorted to only when those affected are really inconvenienced by the presence of the tonsils, and when, besides this, they are in a healthy condition. It would be improper to operate in cases in which pseudo-membranous inflam- mation was commencing to develop itself on the tonsils, for after ex- cision of these organs, even when sound, a false membrane often be- comes developed after operation. It is better to prepare those who are subject to hemorrhage by the use of astringents, and even by the internal administration of perchloride of iron for several days, and the employment of gargles of water and lemon juice. Mus- tard foot-baths the evening before, and attention to diet on the morning of the operation, are also necessary. It may be beneficial to prepare children by depressing the tongue for a day or two be- fore, in order to accustom them to it. For the performance of the operation, we employ either the for- ceps of Museux, curved scissors, a probe-pointed bistoury, or, bet- ter still, the instrument of Fahnestock, in its simple or modified form. We may have recourse to any of these, dispensing entirely with tongue-depressors or plugs between the teeth, which interfere with the manipulation of the surgeon. In all cases we attach much importance to having the child held firmly while being operated on, without which precaution he may slip away from him, and the surgeon be unable to finish the operation he has commenced. The assistant should hold the child between his legs, retaining with his left hand the patient's head pressed firmly against his own chest and keeping his two hands grasped in his right hand. The assistant must appreciate how absolutely necessary the vigorous retention of the child is to the success of the operation, no matter how young the latter may be. He should never underrate the powers of the little EXCISION OF THE TONSILS. 65 patient, and he must always be prepared to meet with a certain amount of resistance. I need not dwell on the operation with the bistoury, which is everywhere described ; I will call special attention only to the mode of using the tonsillitome, either simple or modified, which seems to me indispensable for children. The operator, whatever the form of the instrument used, should have at command two, no matter which, whether it be that requiring two hands or only one, that of M. Charriere or of M. Mathieu. The important point, in our judgment, is to have recourse to the one with which the sur- geon has the greatest skill, with the mechanism of which he is most familiar, and, above all, the opening of which presents the greatest diameter in a vertical direction, for the tonsil is of greater extent from above downwards than from before backwards. It is also best to use an instrument proportioned to the age of the child, one of small size being sometimes more convenient than one that is too large. I have had an instrument constructed, the fenestra of which is a little smaller and more oval, so that we may draw the encysted tonsils behind the pillar of the velum palati, and more easily seize them. When we use two instruments, it is with the view of remov- ing the tonsils one after the other, without losing time in disengaging the first from the tonsil. We thus follow the method of my colleague, M. Chassaignac, which consists in placing at first an instrument on each tonsil, and only operating upon them one after the other. This plan, which requires another assistant, has the advantage of allow- ing the instruments to be perhaps better applied, because the hemor- rhage from the first tonsil renders the application of the instrument more difficult for the second. In any event, to use the tonsillitome, the operation may be divided into four stages: depression of the tongue; engaging the tonsil in the ring; puncturing the tonsil and drawing it inwards; and causing the cutting ring to act. It is well if the sur- geon be ambidextrous. The operator, standing in front of the patient, who has his face turned towards the light, places the instru- ment with his left hand on the right tonsil and with his right hand on the left tonsil. He at first depresses the tongue, carrying the ring flatwise over the base of that organ, then turning the ring, either to the right or to the left, depending on which tonsil is to be removed, engages the gland in the ring, and not until this is accom- plished must he push the little fork to puncture the tonsil and 5 6Q HYPERTROPHY OF THE TONSILS. draw it inwards, giving the fork at the same time somewhat of a see-saw motion. Finally, after this third stage, he should withdraw the cutting part of the ring to excise the tonsil. As soon as one tonsil is removed, he should take the other instrument which he has under his hand, and proceed to the excision of the second, with- out for a moment relaxing his hold upon the child. When the operator has but little skill in this operation, he may fail to seize the tonsil firmly and only clip it, an accident that may depend on his not sufficiently engaging it in the ring, or that he has not supported enough of it on the extremity of the fork, or that he has not given the latter sufficient see-saw motion. This clipping is sometimes sufficient, but nevertheless we must not trust too much to it; it is much better boldly to re-apply the instrument, and seize the remaining portion of the tonsil. We may sometimes bruise the pillar of the velum palati, and even slightly wound the velum itself, but this is an insignificant accident. Sometimes the excised tonsil may escape from the fork, and be swallowed by the patient, but this is not a serious matter. By attentively examining the mechanism of the instrument, the surgeon need not in the least dread cutting the velum palati or the tongue, or wounding the carotid, artery as it runs along the pharynx, on the side on which the tonsil rests. He should be aware that in the operation the ring, which is dull, presses outwards and pushes away in this direction the pharynx, thus removing the artery from reach, while the fork draws the tonsil inwards. It may thus be excised and enucleated without risk of touching the artery; and very often we do enucleate the tonsil. We should remark, however, that this method of ope- rating does not protect from hemorrhage any more than the old method by means of the forceps and bistoury. If with the tonsilli- tome we avoid wounding the carotid, we may still have hemorrhage from the wounding of the vessels which creep along in the tissue of the tonsil. This accident is very rare in children, being met with especially in adults, in whom the hypertrophy is of longer standing. Hemorrhage occurs at two periods, either at once after the ooera- tion or four or five days afterwards. In the former instance cool water acidulated with lemon-juice or vinegar usually answers the purpose. A camel's-hair pencil dipped in lemon-juice mixed with alum may be carried over the part from which the blood flows- but the most certain means is the use of a little medal-shaped cautery heated to a white heat. We may be content—and I at present AFTER-TREATMENT. 67 adopt no other plan—to apply over the tonsil a small tampon of agaric steeped in perchloride of iron mixed with a third part of water, and held for a moment over the surface of the wound. With this may be combined the use of a collar of vulcanized India- rubber, applied in theform of a chin-bandage, and containing pounded ice. This method of applying ice may be employed even before having recourse to the perchloride; having succeeded several times with it in my own practice, I believe that it is best to commence with its use and afterwards unite with it acidulated and iced drinks- In other cases, when there is secondary hemorrhage several days after the operation, ice, acid drinks, and perfect rest suffice. After-treatment.—In every case there is hemorrhage to a greater or less extent, which usually ceases after the patient has spit for several minutes, and rinsed and gargled his mouth. It must not be forgotten that very young children do not always spit up, and then they swallow the blood, and it often happens that a little while afterwards they vomit up the blood they have swallowed. Some- times this does not occur, the blood passes into the bowels, and the first evacuation contains clots. The parents should be forewarned that this may happen, so that they will not be alarmed unnecessa- rily. It is important that nothing warm should be applied around the neck. If the hemorrhage is very slight in children, it is only necessary that they should breathe the air, and not cry. Cool and acid drinks, lemonades, orangeades, cherry syrup and water, or even orange or lemon sherbet may be given, and it is also de- sirable that children should be able to gargle. For nourishment, the first day, the patient should take only cold milk or cold broth • and on the next and following days his diet should be increased gradually and include articles of diet that can be easily swallowed. Children should be allowed to talk very little the first days after the operation, and even for the first week. It must not be forgotten that false membranes have very fre- quently been met with on wounds produced by the operation, which have not the character of diphtheritic membranes. These occur only about the fourth or fifth day, producing a little hemor- rhage, which becomes of greater moment if the child, by his cries, his singing, or any other cause, detaches them too soon. These secondary hemorrhages are very readily arrested by acids and cold applications ; but quietness on the part of the patient, and the avoidance of talking, are especially important. These false 68 POLYPUS OF THE RECTUM. membranes should be carefully watched, and sometimes their de- cline may be facilitated by touching them with lemon-juice. We have had cases, but very rarely, in which diphtheritis and even croup have supervened, but this complication depends on whether the patients were predisposed to either of these affections or were operated on during the prevalence of an epidemic. Under such circumstances, we must at once treat the general diphtheritis, and even sometimes, if there be croup, resort to tracheotomy. The positive results of excision of the tonsils are often very re- markable. Deaf children sometimes hear after the operation, while those who speak indistinctly often pronounce much better. Those who sing gain also in clearness of the voice, although it is true that though some adult vocal artists have gained, others have lost. Finally, and this is one of the greatest advantages resulting from the operation, those who have narrow chests breathe more freely ; and the ribs, from being depressed as they were before, frequently return to their normal condition, and the chest assumes its proper breadth. This last result necessarily reacts on the whole economy. CHAPTER VII. POLYPUS OF THE RECTUM. Polypus of the rectum is far from being rare in children, and not a year passes in which we do not have occasion to treat at least six or eight cases, either in hospital or in private practice. Polypous tumours are usually found in the rectum, above the sphincter, and yet, in some autopsies, we have seen them higher up, and even in one case observed one of these growths in the caecum They are generally single, the largest of them having the volume of a small nut, although occasionally there are several of them. They are pediculated, and by examination are found to be composed of a mucous covering continuous with the internal membrane of the bowel and constituting the exterior of the little tumour. This is formed by a mucous follicle which has increased in volume and be- come hypertrophied. The mucous envelope constitutes the pedicle which unites the polypus to the intestine, and is quite large when the tumour has not been of long duration, and more delicate when POLYPUS OF THE RECTUM. 69 it has existed any time, on account of the mechanical distension to which it has been subjected at the time of the passage of fecal mat- ters. These tumours are generally soft and liable to bleed, at other times firm and resisting; and may be divided with a cutting instru- ment. Their tissue is vascular, presenting the appearance of follicles of the intestine augumented in volume. We may seek in vain for the cause of these tumours: the symptoms are less obscure. Children suffering from them will pass blood with their evacuations, especially towards the end of the passage. Sometimes they have tenesmus and frequent desire to go to stool, but without any result. If they pass hard substances, these are grooved in a manner to indicate the presence of a resisting body, which has stamped upon them a depression during their passage through the bowel. The tumour may exist for a long time without the general health being affected, if the quantity of blood lost is of but small quantity, but the hemorrhage is sometimes so con- siderable as to weaken the little patient, who becomes pale, colour- less, and of a chlorotic appearance. In the majority of cases, if children are examined after they have just finished an evacuation, a red tumour may be perceived at the entrance of the fundament, which re-enters after the evacuation. The parents believe the child is suffering from a prolapsed bowel or a haemorrhoidal tumour, which we have never met with in our little patients. If we inspect it care- fully, we become satisfied that it is not a haemorrhoid and still less a prolapse of the intestinal mucous membrane. In the latter case. a red cushion will be noticed filling the anal orifice, while if a poly- pus be present a tumour of a vivid red colour may be seen, of the volume of a small strawberry, and held by a pedicle. The diag- nosis is satisfactorily established, if, when the polypus is pushed upwards, the finger introduced into the rectum comes in contact with a body of greater or less size, attached at one point, very generally on the posterior wall of the bowel, which on being pressed slips under the finger like a cherry-stone. These polypous tumours are often unrecognized, it being some- times thought that the child has dysentery, for which he is accord- ingly treated. It sometimes happens also that they disappear with- out their existence being suspected; in fact, when the pedicle is but slender, it breaks under the pressure of the fecal matter, and the tumour being driven out with it, a spontaneous cure results. In the majority of cases, however, the polypus is more securely held 70 POLYPUS OF THE RECTUM. and remains firm, and we are not consulted in regard to it until it shows itself at the anus after each evacuation. While the prognosis is not grave and there is no cause for alarm, the surgeon should always relieve the little patient of tumours of this kind, the indication being still more urgent if there be much loss of blood. The operation is very simple. It consists at first in giving the patient an injection, when the little tumour will generally be seen to appear at the anus at the moment when the child has just finished voiding the injection. The tumour is then seized with a pair of forceps, and a silk ligature thrown around the pedicle. The poly- pus often falls off immediately; and at other times it is not detached until somewhat later, the tumour being allowed to pass up with its ligature and become separated the same evening or the next morning. We prefer the ligature to division with scissors, for we had in one case, when a cutting instrument was used, quite an abundant hemorrhage. It sometimes happens that we have to bring the poly- pus to the anus, introducing the finger into the rectum ; very often it slips under the finger like a fruit-stone and cannot be brought down. Under such circumstances, we must not withdraw the fin- ger, which serves as a conductor, but apply over it a small polypus forceps, which enables us to seize the tumour and draw it outwards, or better still, without seeking to bring it down, to twist off its pedicle. We have never observed any serious results; hemor- rhages are arrested by cold injections, but if they persist, injections of rhatany may also be employed. When the polypous tumours are situated in such a manner that they cannot be felt by the finder their presence may be suspected if the fecal matter is grooved, as we have previously stated. We may then have recourse to repeated injections, even those of a purgative character, which may act mechanically in breaking up the pedicle of the polypus, and thus enable it to be spontaneously expelled. A recurrence sometimes takes place, but in such cases the dis- ease runs less risk of passing unperceived. VASCULAR TUMOURS AND SPOTS—N^EVI MATERNI. 71 CHAPTER VIII. VASCULAR TUMOURS AND SPOTS—N^EVI MATERNI. Erectile tumours are characterized by an abnormal develop- ment of capillary bloodvessels, presented in the form of spots or tumours, which resemble one another in the predominance of the bloodvessels, their anatomical structure being the same, but their form different. Some of them are developed during intra-uterine life, others appear sooner or later after birth, as the sequel of a blow, of long compression, or else without appreciable cause. The spots (taches) are seated in the thickness of the skin, on all parts of the body indiscriminately, often on the face. They are not accompanied with any elevation, are flat, and do not stand out in relief, are in the majority of cases congenital, and are frequently seen in several members of the same family, as brothers, sisters, and children, whose progenitors had presented a similar affection. They vary in shape, number, and colour; but they are always of a more or less deep hue, either rose-coloured or red. They are in their nature venous, sometimes diffuse, but more generally circumscribed. They become obliterated under pressure of the finger, but return as soon as it is withdrawn. Some of them, those the least pro- nounced in colour and the most diffuse, disappear in time without any appreciable cause; others, becoming the seat of a slight furun- culous inflammation at their centre, suppurate, become modified, and leave scars which at last become sometimes scarcely visible. Finally, the great majority of these spots continue and remain stationary, but frequently they increase in extent, with a tendency to overrun more or less the surface of the skin. Erectile tumours are situated under the skin, and are different from the spots, as they occupy the subjacent cellular tissue; for they may extend to deeper regions, as the muscles and fibrous tissues, and indeed involve all the soft parts. A little patient, a cast of whose face was made and deposited in the Mus^e Dupuytren, suffered from enormous erectile tumours, not only on the face, but also in the lungs and the liver. All the tissues, even the bones, may be thus affected. 72 VASCULAR TUMOURS AND SPOTS—N.EVI MATERNI. As regards their structure, these tumours may be compared to the cavernous structure of the penis and to all erectile organs. They are composed of veins, arteries, and intermediate cellules, in which these vessels communicate, and a true spongy tissue fibrous and areolar. The arterial and venous capillaries be- come dilated, communicate with one another, and with the cellules which are filled with blood. Such is the anatomical composition of these tumours. In this we have adopted the same views as J. L. Petit and Dupuytren, and the injections performed by us have demonstrated that generally the venous predominate over the arte- rial vessels; and this applies to the spots as well as to the tumours properly so called. The spots are nevertheless more particularly composed of veins, while in the tumours there may be a predomi- nance of the arteries over the veins, or an equal development of the two systems. These tumours may present very great irregularities, being either sessile or pediculated, or, as in some cases observed by us, like a mushroom with several heads. Some of them are as large as a millet-seed, others the size of a nut and even larger. They rarely come singly on the same patient, and we can usually count from one to eight, ten, or even more. Vidal (de Cassis) has seen as many as nine on a single shoulder. The little girl cited above had her face covered with them. Their development and progress offer many points of difference; they may scarcely increase at all for years, and even remain sta- tionary, while at other times they may at some period or other com- pletely cover a region. They are generally, at the outset, small spots of a vermilion red or wine-dreg colour, sometimes quite limited in extent, and without appreciable elevation of the skin but the cellular tissue becoming gradually developed, a prominence results. This development is observed at once in the very first months after birth, or else only takes place at the commencement of puberty. Desault and Defrance have noticed in young girls a hemorrhage which took place periodically from the surface of these tumours, and became a kind of supplemental menstruation. Other surgeons have made similar observations. The nucleus of the tumour is generally formed beneath the cutaneous spot. This tumour, at first of small volume, circumscribed and movable ap- pears to be attached at its base and its circumference by means of prolongations, which are not always perceptible externally, although VASCULAR TUMOURS AND SPOTS—N^VI MATERNI. 73 spreading sometimes to a distance. The surface becomes irregular and uneven like a cock's comb, and the distended skin becomes thinner and assumes a bluish-brown tint. The tumour may remain subcutaneous, without the skin undergoing any very perceptible discoloration, or, as is sometimes the case, it may have its origin in the deep parts and at last reach the skin, which it elevates. These last are soft, smooth to the touch, yielding to pressure and sometimes becoming in a great measure reduced; the fluctuation being more obscure than that of an abscess, because the blood, to pass from one point to another, traverses the cellules which retard its movement. Venous tumours are accompanied neither with expansion, fluctua- tion, nor pulsation, but, though not ordinarily the case, we may hear in arterial tumours a peculiar sound, a sort of murmur, less pro- nounced than in arterio-venous aneurism, but still appreciable. We may also on applying the hand detect pulsation and movements of expansion, but only when the tumour is of large size or in the vicinity of an important artery. We have considered it as worthy of remark that tumours of the parotid region are most fre- quently arterial. Rest diminishes the discoloration and the volume of erectile tumours, but, on the contrary, cries, muscular exertions, exercise of all kinds, and even, in adults, moral emotions, will in- crease them. A crack by becoming distended, a blow, a wound, and every form of solution of continuity may give rise to hemorrhage or inflammation, which will sometimes produce a radical cure. In very young children, these tumours often become inflamed without any perceptible cause, though this may arise from friction of the clothes against the dressings. One of our little patients, to whom such an accident happened, was cured after cauterization with nitrate of silver applied for the purpose of arresting the hemorrhage that followed. These tumours may strictly be confounded with those of quite a different character, especially when they are deep; but those met with in children are generally easy to recognize. Nevertheless we presented in 1845 to the Societe* de Chirurgie a pathological speci- men which revealed an extraordinary error of diagnosis. A child having in the inner angle of the right orbit a small tumour present- ing all the characters of subcutaneous erectile tumours, several mem- bers of the society were in favor of passing seton threads through the tumour—a view which we shared. Shortly after this operation, 74 VASCULAR TUMOURS AND SPOTS—N.EVI MATERNI. the child was attacked with cerebral symptoms, from which it soon expired. An autopsy revealed that the tumour was an encephalo- cele, the sac of which, of the volume of a pea, after having passed through the fronto-ethmoidal suture, had just projected at the inner angle of the orbit, and was formed by a small portion of the cerebral substance surrounded by its membranes. Prof. Moreau reported a similar case. A practitioner who had written on the disease in question, mistook a parotid erectile tumour for a collec- tion of ganglions. It will thus be clearly seen that very serious diffi* culty may be experienced in the diagnosis of these lesions. The prognosis varies according to the predominance of elements belonging to either the arterial or venous systems, and accord- ing to the tissue invaded by the tumours or the region in which they are developed. Thus, the former are less grave than the latter, and erectile tumours of the orbit, the bones, etc., are natu- rally more dangerous than those seated in other regions. Many surgeons, Dupuytren at their head, scarcely admit the possibility of a cure without surgical interference. In this respect their views are extreme, for in three cases, Prof. Moreau was of the opinion that no operation was demanded on children, in whom Dupuytren had considered the intervention of art indispensable, and nature produced in them a radical cure. We have ourselves observed analogous cases, the most interesting that we may cite being that of a young girl who had several erectile tumours on the head and one on the face. The latter alone was cauterized, but those on the head afterwards became inflamed, without any known cause, and were spontaneously cured. Treatment.— When .the spots or the tumours do not undergo rapid development, as a spontaneous cure may be produced in the manner already mentioned, we should restrict ourselves to the exercise of a continuous surveillance, being fully prepared for active interference if the occasion should arise. Operative procedures may be reduced to three principal methods: 1. To prevent the blood from reaching the affected part; 2. To obliterate by inflammation the dilated vessels- 3. To effect by operation the destruction of the morbid tissue or remove it. Finally, we may refer to a fourth method, purely palliative, certain procedures which have for their objects a modification in the colour of the tissues. The first plan comprises four principal agents—topical astringents or refrigerants, compression, ligation of VASCULAR TUMOURS AND SPOTS—N^EVI MATERNI. 75 the arteries, and circular incision of the base of the tumour; while the second includes five—puncture with laceration, vaccination, the seton, pins (Lallemand's method), and incision. In the third, we have six—ligation, excision combined with the ligature and the suture, caustics, and extirpation. Finally, the fourth or palliative plan, for which we are indebted to M. Paul (de Landau), consists in the tattooing of the erectile spots. As all these methods may be found described in detail in standard authorities on the subject, we will now refer only to such procedures as have been attended with the most gratifying success at the H6pital des Enfants. If the majority of the methods just enumerated have been suc- cessful, we have also had to record many unfavourable results. We have, for example, by the employment of about fifty setons, effected a satisfactory cure of an enormous tumour of the parotid region in a young girl we saw with Vidal (de Cassis) and M. Vel- peau, and for whom we had almost considered ligation of the carotid indicated. But, on the other hand, a distinguished medical professor lost the grandson of one of the richest financiers in the world, after having introduced one or two threads in a small erectile tumour; erysipelas rapidly carrying off the little patient. We may like- wise report also a certain number of successful cases obtained by means of the ligature suggested by M. Rigal (de Gaillac),1 and yet we lost by this very method a little girl with a tumour in the anterior region of the neck. The most brilliant surgical operations sometimes meet with reverses, so that we should attempt to popularize those which are attended with the fewest accidents, even when they produce much less rapid cures. Faithful to this principle, we have employed, especially for the treatment of erectile tumours and naevi, the actual cautery and caustics, powerful remedies to which we resort in all surgical diseases in which they are applicable. We have also obtained excellent results from vac- cination, particularly in cases of naevi, and many other practitioners could furnish quite a number of observations going to confirm the efficacy of this procedure. Thus, taking up these methods in order, we put in the first rank in the treatment of spots, especially when they are limited in ex- tent and thickness, vaccination, which may be applied even to those that are slightly prominent and to tumours of very small volume. 1 Bulletin de ThSrapeutique, t. lxiv. pp. 16, 202. 76 VASCULAR TUMOURS AND SPOTS—N^EVI MATERNI. The punctures must be made as nearly as possible around the morbid tissue, which, if itself wounded, might give rise to hem- orrhage in sufficient quantity to carry off the vaccine virus. Next to this method, we have had recourse with success to blisters, the surface of which may be covered with perchloride of iron. MM. Guillot and Thierry have commended this plan of treatment, and deservedly so. We may also, by aid of the small syringe of Pravaz, inject into these tumours a solution of perchloride of iron. When the spots are somewhat deep, we employ Vienna caustic, of which we can only speak in terms of praise, spreading one layer of it, of a thickness and length proportionate to the dimen- sions of the part affected. It is not neccessary to cover the whole extent of the morbid surface; it will be sufficient for us to apply it within an eighth of an inch of the circumference, on account of the eliminating inflammation causing the rest of the erectile tissue to separate. If it be a spot or small tumour that is to be sub- jected to treatment, an application of the caustic for five or six minutes will be enough to produce its complete destruction. The in- stantaneous effect is the effusion of a small quantity of blood, which flows over the layer of caustic, but rarely in sufficient abundance to carry it off and destroy its effect. If it be otherwise, we must immediately remove the Vienna paste and arrest hemorrhage with the perchloride of iron and compression. A single application of caustic is in almost all cases sufficient; but if necessary a second may be made, a very delicate layer being applied. After each ap- plication the slough must be covered with a small shield of agaric, which adheres to it and falls off at last simultaneously with the part cauterized. A cicatrix then more or less rapidly results. Vienna caustic is followed by white regular scars, which are in no way repulsive to the eye. We may have recourse to it in cutane- ous and even subcutaneous tumours, if superficial; but some of these last are very deep and extensive, and in such cases the application of caustic would be difficult and dangerous. In a case of this kind that of the tumour of the parotid region to which we previously referred, we were obliged to employ quite a large number of seton s. If there be strong pulsations, and a pronounced vascular mur- mur, we should prefer to perform ligation of the corresponding arterial trunk, yet I have seen one case in which the facial artery was tied for a small vascular and arterial tumour of the cheek VASCULAR TUMOURS AND SPOTS—N.EYI MATERNI. 77 and the pulsation returned soon afterwards. If, on the contrary, the flexibility of the tumour, and the absence of movement and of the vascular murmur, lead us to suppose that this deep tumour belongs more particularly to the varicose variety, setons may be employed. The procedure attended most frequently with favourable results in our hands is the use of the actual cautery. Most authors never- theless consider the results of its application as much more grave than that of the bistoury, and advise its restriction to tumours of small extent, and those which are too much commingled with healthy tissues to admit of their extirpation, and to the destruction of the remains of the morbid tissue which may have escaped the bistoury. We are far from coinciding in this view. It is certain that too great destruction of tissue would be followed by a sup- puration, which might weaken and exhaust our little patients. We therefore take care to practise this method in such a manner as to render it as harmless as possible. Following the example of Carron du Villards and Aug. Berard, who have recommended it, our aim is to modify the erectile tissue rather than to destroy it. We use for this purpose a needle of steel or platina, from three quarters of an inch to an inch and a quarter in length, mounted on a metallic ball sufficiently large to allow us to make several punctures without any very considerable loss of heat. This needle is heated to a white heat, and plunged quickly into various points of the tumour or of the spot. (We may likewise resort to the electric cautery with the greatest benefit.) We generally puncture at first the base of the tumour or the periphery of the spot. If the needle is not sufficiently heated, blood will flow at each puncture, and the inflammation of the tissues will be insufficient; it is im- portant, therefore, not to apply it until it is properly heated. Com- presses of cold water are immediately applied over the tumour, and, when suppuration is established, if the inflammation threatens to be intense, we may have recourse to poultices. In all cases, we resort at last to simple dressings. The vascular tissue is rarely permanently modified by a single operation. We were compelled to practise as many as ten cauteri- zations in a little girl for the radical cure of an erectile tumour of the volume of a currant, seated in the angle of the eye, the affection having returned several times. We were obliged to riddle with punctures, at seven or eight successive visits, the nose of another child, which had been, so to speak, transformed into erectile tissue. In cases of this kind we always allow an 78 VASCULAR TUMOURS AND SPOTS—N^VI MATERNI. interval of eight days, fifteen days, and even more, between suc- cessive operations. In every case we cannot too strongly recom- mend watchful care for quite a long time over all our young patients, even those who appear to have most completely escaped all danger of relapse. If a red point shows itself afresh, a single puncture suffices to insure a definite cure. We have never seen erysipelas occur as the result of the employment of this method, and we have only lost one patient, who died of convulsions four or five days after the operation, so that we did not consider that this accident could be attributed to our mode of cauterization. We will conclude this list of remedies by mentioning the fact that in recent times a return has been made to the metallic ligature ; but it is open to the objection that it never completely removes the tumours and leaves behind some of the vascular tissue. We have also recently been satisfied of the superiority of the linear ecraseur in the extirpation of these tumours without hemorrhage, but in the employment of both of these methods, we have had a recurrence of the tumours and have found it necessary to return to the use of caustics. We have but little to say of true naevi or birth-marks. These pigmentary products, so variable and irregular in volume and form, are sometimes only simple little circular spots, known as mothers marks, more or less deeply coloured, smooth or giving origin to hairs. They may be destroyed with an application of Vienna caustic or even by means of a point of white heat. Others, which are larger and deeper, generally of a brown colour, may invade the whole of one side of the face, be covered with hairs, and resemble the skin of an animal. They are not susceptible of increase. Tattooing has been tried to make them disappear, but we have never recognized the necessity of employing it. A plan which succeeded in our hands in one case where the naevus was limited in extent, was the application of Vienna caustic. The paste may be applied over the whole surface of the tissue which we wish to destroy, if its dimensions are limited. If other- wise, we must use the caustic at several different times, success- ively at several points, taking the precaution, after each application, to cover the slough with a piece of agaric. The whole of this may be allowed to separate at the same time, and when the elimi- nation of the slough takes place, we find beneath a cicatrized surface. In every case, fresh application of caustic should only be made when the first has entirely produced its effect. CYSTS AND ENCYSTED TUMOURS. 79 CHAPTER IX. CYSTS AND ENCYSTED TUMOURS. It is not our intention to enter here into the history of cysts; we desire to refer only to those met with in the earlier periods of life, and to make known the methods of treatment which have been successfully employed by us. In children as in adults, we meet with cysts of various kinds and in different regions. 1. On the exterior of the body. We find in children wens or en- cysted tumours on the hairy scalp, on the face and neck, and on the trunk and limbs. These cysts, formed by a fibrous envelope, contain different fluid or solid substances; they may be congenital or developed after birth. In the new-born, we sometimes, but quite rarely, meet with cysts in various parts of the body, which contain the bones, teeth, hair, and different portions of a foetus. These curious and familiar facts may be explained by the unequal development of two germs, one of which is encroached upon by the other, and remains, so to speak, nestled in it. They are some- times for a very long time stationary, and in some cases terminate in inflammation. The form of cyst most frequently met with is the wen, seated on the hairy scalp, the face, and especially the eyelids, and varying in volume. Although this form of tumour, which is everywhere composed of an envelope containing a sebaceous substance, meli- cerous or otherwise, may become inflamed and thus be cured by elimination, or even become dissipated by means of resolvents, we believe that when they persist and increase in volume, or resist such resolvent methods as may be adopted, the indication is to extirpate them. We do not hesitate to say that as the bistoury sometimes induces erysipelas, we have relinquished the use of cutting instru- ments in extracting these cysts, and we apply to all, indiscrimi- nately, even of those of the eyelids, the Vienna caustic, unless they are seated on the inner surface of the lid, when the knife will be required to remove them. These cysts are laid bare by the slough 80 CYSTS AND ENCYSTED TUMOURS. produced by the caustic, and sometimes disappear without further interference, although in some cases it becomes necessary to enu- cleate them. The cicatrices following these operations are regular and not prominent, but they differ from those consequent on in- cisions, by being a little longer delayed in their formation. We have met with no bad results, especially when we allowed the cysts to become separated without assistance; in this way doing nothing to provoke traumatic irritation. Once or twice, being anxious to hasten their separation by pressure, we were the cause of the pro- duction of a small amount of erysipelas. The application of the caustic should be made by means of gum resin plaster, with which rather more than the mere surface of the tumour should be covered. Before doing this, however, an oval or linear opening should be made in the centre, of a shape and size corresponding to that we wish in the skin, for the discharge of the cysts. We then apply over the surface thus exposed the Vienna paste. At the end of eight or ten minutes the effect is produced, and a slough results, which may be dressed with poul- tices, or else with some digestive, to facilitate the separation of the cauterized portion. The separation of the slough may be delayed for eight or ten days, and as soon as it is detached and the cyst dis- charged, it may be simply dressed, and the cicatrization made more regular by nitrate of silver. We may even resort to this method to facilitate the separation of the cyst, and if it adheres and is slow in becoming detached, cauterize its interior. Following the plan of Dupuytren, I open small cysts on the eyelids, and after having emptied them cauterize the interior. Cysts of the neck are of frequent occurrence in children, and are of a different nature from those just referred to. They are often observed at birth, being sometimes unilocular, at other times munilocular, and distinct from one another. They contain fluids of varying character, limpid and albuminous, sometimes sero- sanguinolent. These cysts are sometimes accompanied with marked fluctuation, and are almost always indolent, without change of colour of the skin, and most frequently transparent like hydrocele from which resemblance the term "hydrocele of the neck" has been given them. When they are not preceded by this transparency, we may consider that we have a cold abscess to treat. These cy—M. Or the linimentum calcis (U.S.), or the following:— R.—Olei amygdal. dulc. f^iiss. Aquse calcis f§xx.—M. This must be painted on the burnt surface with a brush, several times in the day or night. A plan generally advised, and with which we have had success, is the use of wadding to protect it from the contact of the air; but in resorting to this dressing, which should only be removed at the end of several days, we must first, in applying it in its natural con- dition, cover the burn with a fenestrated cloth smeared with cerate or glycerine, and place the wadding over it. This enables us to readily remove the first dressing, a procedure which would be very painful without this precaution. 2. At the time of the elimination of the destroyed parts, we may excise the epidermis which is detached, and remove the sloughs which are separated, and the refrigerants may be replaced by a dressing of wad- ding, such as we have just described, or with charpie applied in the same manner, the linen being always covered with cerate, glycerine, or glycerole of starch, with the addition of the extract of lead or several drops of laudanum; or better still, we may moisten the charpie with a mixture of chlorinated water, which has the ad van- 122 BURNS. tage of dissipating the disagreeable odour which exists at this time. This kind of dressing is used for only a few days when the burn is superficial, being employed for a short time longer in cases in which the separated epidermis leaves beneath a slight suppuration; but when the burn involves the thickness of the skin, the muscles, etc., the suppuration does not cease so soon, and may last for a consider- able length of time. 3. At the period of suppuration, especially if persistent, it is im- portant that we should continue to apply chlorinated water. In my own experience, all the methods recently advised have no other advantages than water to which has been added solution of chlo- rinated soda, which exerts a good effect upon the wound, diminishes suppuration, and destroys the odour. In some cases, alcoholic lini- ments, with which the charpie is impregnated, may be employed. At this period, proceeding carefully, the dressing being properly applied, and being sprinkled from time to time with chlorinated water, we do not fatigue the children with the dressings, which we only apply every other day, in this manner avoiding their cries or the agitation that sometimes gives rise to convulsions. When we have to treat burns involving a large extent of surface, this method is indispensable. It is often very important to replace ordinary dressings with the use of powders, such as starch, rice flour, tannin, or cinchona, on the genital organs, the penis or scrotum, or the vulva, parts in which it is impossible to retain the dressings; giving them a daily ablution to take away the powder of the evening before, and to powder it afresh. In burns in the immediate vicinity of the anus, it is well to frequently introduce suppositories of cocoa butter, and even pieces of charpie, in cases in which we have reason to fear the contraction of this natural opening. For extensive burns of the trunk, we modify the dressing in order to diminish the period of prolonged suffering to our little patients. We have adopted the plan, with these large and almost general burns, of laying the chil- dren on some material powdered with starch, or rice flour, or potato flour, in such a manner that the burns are constantly covered with powder, which absorbs the suppuration. Crusts are thus formed, which become detached every time the child is moved to be pow dered. With this treatment, they suffer scarcely any pain, the dressing is quickly applied, and the burnt surface is exposed to the air for a shorter time than is required in the ordinary dressings. TREATMENT. 123 The crusts which are formed are alone detached, and the cicatrix underneath is produced more or less rapidly. Sometimes, to promote cicatrization, we apply a mixture of powdered tan and cinchona. When children suffer much, it is better not to lay them on an ordinary bed with a sheet, but on a long box of bran. They are then like chrysalides in bran, and pressure on them is nearly null. 4. At the moment of cicatrization, the dressings, which up to that time have been very light and without any compression, should be modified. The application of fenestrated linen covered with cerate should be continued, but the compresses and bandages should be applied in a sufficiently firm manner, and especially, with the view of avoiding contraction, should we prevent by dilating substances the natural openings from closing, keeping the eyelids separated, the nostrils clear, and the vulva and anus open by pledgets of charpie. We must give the patient different positions, according to the situation of the burn. If the anterior and posterior portions of the trunk are involved, the parts should be placed as much as- possible in a perfectly straight position. If the neck, it should be inclined forwards or backwards or to the side, according as we wish to prevent contrac- tion in any direction. If the limbs, we should keep them approxi- mated to or separated from the trunk by means of bandages, cush- ions, and splints, keeping the limbs in a state of flexion or exten- sion, according to the side on which we wish to have a large cica- trix. If the fingers, they should be separated from each other by splints, in order to avoid adhesions between them, and to prevent the fingers from being cicatrized in a flexed position on the hand. It is important, in all cases, to arrange the bandages so as to dimi- nish the sufferings of children, while at the same time making the applications in such a way as to fulfil the indications. It is proper to add that we should sometimes promote cicatrization by steeping the charpie in tonic solutions, which may advance the development of granulations, or sometimes repress them with nitrate of silver or else with astringent and tonic powders, such as cin- chona, tannin, and alum. In certain cases, we may accelerate cicatrization by making the dressings by occlusion, which should only be changed every three or even four days, as in the treatment of an ulcer. 5. At the time when there is a tendency to the formation of adhesions} our attention to the dressing must be redoubled, and we must 124 HARELIP. have courage to combat the tendency to contraction by resorting to the use of bandages adapted to stretch the adhesions—though this is painful for children—and even sometimes to tear them gently apart to prevent their formation. 6. Finally, when the adhesions are formed, it is necessary, at a period more or less remote, when the cicatrices are complete, to destroy them by transverse incisions, or else by incisions into them make flaps, so that we may slide them to produce extension or flexion, which these adhesions would interfere with. In cer- tain burns of the face, the nostrils, which have become obliterated, must be opened, and canulas worn in them for a long time. Then, these painful operations, varying according to the nature of the case, demand the employment of chloroform, and afterwards re- quire very painful dressings, with several kinds of bandages. Under these circumstances, where there is much suffering, the surgeon should have sufficient firmness not to allow himself to be disturbed by the cries of the child. Agents that oppose the return of the adhesions should be prolonged for a very long time, and be continued even after complete cicatrization, for. a recurrence is always to be dreaded. We have only spoken of the local treatment, but the constitu- tional treatment is very important. At the outset, general anti- phlogistic remedies may be of service; antispasmodics and narcotics are frequently indicated. Finally, in many cases, when suppura- tion has exhausted the patient, tonics are indispensable; and there are circumstances in which cinchona and wine ought to be pre- scribed. The general treatment varies according to the various periods of the burns, and according to the indications. In such a case, the surgeon should be a physician as well, in order to restore the patient to a complete cure. CHAPTER XV. HARELIP. Without discussing the causes of harelip, we will refer succes- sively to the different varieties of it met with in children, leaving out of consideration accidental harelip, to speak only of the con°- HARELIP. 125 genital form. This vice of conformation, sometimes hereditary, which children present at birth, is especially seen on the upper, and very rarely on the lower lip. Three kinds are met with: simple, double, and complicated harelip. Simple harelip (Fig. 1) consists in a division of the upper lip, on one of the lateral edges of the median line, this division corres- ponding to one of the nos- trils, and extending from the free border of the lip in the direction of the nostril, which it approaches more or less. Sometimes we observe a small adhesion, a slight bridge, pass- ing from one border to the other, near the nostril. We have seen the deformity con- sist in a kind of gap of very slight extent, or else prolonged into the interior of the nostril. We have also had occasion to meet with harelip half cicatrized when the children were born, the cicatrix being quite like that obtained by art. The free borders of this solution of continuity are rosy, like the borders of the lips, and are covered by the pro- longation of the labial mucous membrane. Sometimes there is a very slight separation, at other times it is very great. In some cases adhesions exist between the lips and the gums. The first question which presents itself for consideration in regard to treatment, is this: Should we always operate at birth, the next day, or the following, on cases of simple harelip; or would it be better to defer it to a later period? Bonfils, senior and junior, and Buth favoured an operation at the time of the birth of the child. In 1845, M. Paul Dubois and his pupils put this plan actively into practice. M. Danyau and other surgeons succeeded, and we have ourselves had favourable results at that time. Nevertheless, the experience we have acquired has taught us, as it has taught those who habitually perform this operation at birth, that when attempted at that time it was far from being always attended with success. It is because we have sometimes had failures at this period that we postpone operating on simple harelip until about a month after birth. By that time we can see if the child is in a healthy condition, 126 HARELIP. and is well nourished, a fact of which we are not certain during the first day or two of its life. The period of icterus of the new-born will then have passed, and we can have more confidence in the result of the operation. In case of the prevalence of epidemic smallpox, we have thus full time afforded us to vaccinate the child, and thus remove one cause of ill-success, especially in hospitals. In all cases, we are of the opinion that simple harelip should be operated on during the first months of life, for adhesion is then more easy, the child has no fear of the operation, it will cry a little afterwards, and the suture will not prevent it from sucking imme- diately after, without any apprehension existing that it will pro- duce a separation of the flaps. . The operation at this age does not compromise the health of the child, and if it fails there is no rea- son that it cannot be attempted afresh at the end of several months. Operation for Harelip.—A bistoury, or sufficiently strong straight scissors; straight harelip needles of silver or steel, with a movable point, or simple German pins; waxed silk Fig. 2. threads; silver threads, which do not cut any more than the others when moderately tightened; curved or straight needles, with sufficiently large eyes to allow a double silk thread to pass through; Thierry's screw needles (Fig. 2), which have given us good results:— such is the instrumental apparatus necessary, which will be completed by adding a tenaculum. The little patient should be given in the charge of an assistant, who is seated and presses its head against his chest, taking the precaution to hold the child's arms, leaving his own hand free. The surgeon, placed in front of the child, having at his side the instruments V already mentioned, and also a sponge slightly soaked in «s^ water, proceeds in the first place to pare the edges of the °U fissure. A second assistant holds himself in readiness to compress the lip with his fingers, the coronary artery being cut and giving rise to hemorrhage. The fingers of the left hand may be used to grasp the thickness of the lip, or else to pass through it a tenaculum, towards the inferior angle. Then, either with a bistoury or with scissors, which we prefer, the surgeon cuts at first the adhesions, which sometimes retain the flaps, removes the rosy part of the border of one of the flaps, and makes a vertical sec- tion on the other side in the same manner. Then, with the scissors, HARELIP. 127 he cuts from one side the lower angle, leaving a small flap at the infe- rior portion of the other side, in such a manner that in approxima- ting the two edges, the small flap becomes applied on the cut angle. We thus prevent the notch which we so often notice in making the two vertical sections. The edges of the wound being thus freshened and put into the proper condition for union, several forms of suture have been suggested. After having employed them all successively, we can- not decide in favour of always adopting the twisted suture, which many surgeons use, and which, to be efficient, should be made with great care. Sometimes when pressed with a little extra force, the pin cuts through from behind forwards. We prefer the needle of Thierry, made of iron with a movable lance, which, when once removed, enables us to slide on it a little screw, that may be tightened or loosened at will, by means of two small nuts, one of which is fixed, and forms the head of the needle, and the other, movable at will, is applied after the extraction of the lancet needle, and screws on the threads of the screw which are on the needle. By this contrivance, the edges of the wound may be approximated at will. (Fig. 3.) When we do not use these needles, we may resort Fig. 3. to the plan of M. Mirault of Angers, which we employ almost ex- clusively. It consists in making interrupted sutures by means of a curved needle, furnished with a double silk thread, or a silver thread. This has succeeded very often in the hands of other sur- geons, among whom I may mention M. Giraldes, my successor at the hospital. Having once applied the threads, two or three in number 128 HARELIP. according to the height of the lip, we no longer employ bandages, as formerly, which slip and do more harm than good. If the pins used are found to be too long, we must cut their extremities. The after-treatment necessary for the child is very important. If the patient be newly born, we need have no fear of letting it take the breast, but whenever it cries it is indispensable that the thumb should be placed on one of the cheeks, and the index and ring fingers of the right or left hand on the other, to prevent, by the pressure thus exerted, the separation of the commissures of the lips which draw upon the sutures. The pressure should only cease when the child falls asleep or stops crying. This precaution, which is much more practicable in private cases by nurses or mothers than at the hospital, enhances the prospects of success. We have endeavoured to remove the stitches on the third or fourth day, at first one, and then the other on the next day; but we have found it better to follow the plan recommended by MM. Mirault, of Angers, and Giraldes, to wait at least seven or eight days or even longer, for stitches do not exert any injurious effect unless they are improperly applied or too tightly pressed. What- ever may be the period at which we withdraw the stitches, we must not at once remove them all, but leave until the last the one which is situated on the point corresponding to the edge of the lip. The day on which the last stitch is removed, it is best, as a precaution- ary measure, to apply a long strip of good isinglass plaster to support the cicatrix. Double Harelip.—This consists in a division of each side of the median line of the lip, in such a manner that these two divisions, which are more or less regular, are separated by a median lobule which also varies in length and height, being at times very short and narrow. We may make the same remark here as in referring to single harelip, that the operation should be performed when the child is about a month old, and it should not be done on both sides at the same time. In our own practice we prefer an interval of three weeks or a month between the two operations, and we have met with much better success than in making the two sutures the same day. We also prefer the use of interrupted sutures with silk or silver threads. All the precautions already referred to for simple harelip apply as well to the double form. Sometimes, when the median lobule is too short or too narrow, it may be sacrificed, and a double harelip thus be transformed into a single COMPLICATED HARELIP. 129 one. At other times the lobule may be too short, but sufficiently large at its base to be freshened on one side or the other, and to form a triangle which may be preserved by adjusting it to the two lateral flaps, either by passing through its base a long needle, or by securing it on each side by means of common stitches. Complicated Harelip.—We meet with a great variety of compli- cations of harelip, such as a simple solution of continuity of the lip with a fissure of the alveolar border, or sometimes a cleft of the vault of the palate only, as far as the velum palati; in certain cases division of the velum without cleft of the vault, or in others division of both. These last may occur with double harelip. In all cases it is prudent at first to leave out of consideration the various com- plications, and in infancy only pay attention to the division of the lip, treating it in the manner pointed out in discussing simple and double harelip; then, at a later date, we may attend to the cleft of the palatine vault and the velum. In time these divided parts will have a tendency to become approximated a little, and then, at the age of twelve or fifteen, a time of life when the patient will be more tractable, we may entertain the question of an operation to approxi- mate the velum palati, a suture which succeeds when it alone is divided. Perhaps we may even attempt to fill up the fissure of the palate, yet for this bony part we prefer obturators, which are made at the present day very skilfully, and in our judgment are more useful than all the unions, more or less imperfect and difficult to procure, which several surgeons have attempted to bring about. It has appeared to us advisable, while waiting for the period when the obturator may be most usefully employed, or for the union by means of sutures, to apply for a very long time and almost continu- ously, at least during the night, a compressor, the object of which is the compression of the lateral portions of the superior maxillary bones. By this method we always accomplish a slight degree of approximation. A much graver complication, to which the name "wolf-mouth" has been given, consists in the following deformity: the lip is divided in the median line in a rather irregular manner, with a very variable amount of separation; and the two superior maxillary bones leave also a space of variable extent, in which frequently the vomer is suspended. It is prolonged forwards, and drives the incisive bone into the space between the lips; this extremity of bone then pushes forward the median lobule of the lip, which comes 9 130 HARELIP. to the end of the nose more or less elevated. The alae of the nose become, to some extent, separated and altered in shape. Generally the deformities just referred to present modifications of a varied character; but they are nevertheless for the most part essentially analogous. Not only do they render the countenance of the child repulsive, but they create the greatest difficulty in its taking the breast, for it cannot press the nipple, and can in many cases only be nourished with a bottle, or a spoon, and yet the greatest care must be exercised that fluids do not return by the nose. We are all familiar with the imperfect manner of speaking of children who suffer from such a deformity, and the difficulty they have in making themselves understood, as they grow older. We have, nevertheless, seen adults, and among others the father of a child having a similar deformity, who came at last to speak with considerable facility, and to make himself understood daily by a numerous service of workmen whom he directed. He had applied himself constantly with great attention to pronunciation. In view of such serious complications, we may appreciate how desirable it is to remedy these frightful deformities, and how anxious parents are for surgical intervention. But, while we are favourable to operating for simple harelip in the first month or six weeks of life, we think it better to postpone it for six, eight, and even ten months, if it is complicated. In fact, although in these operations we ought not to think of operating at birth for the closure of the space between the superior maxillary bones by means of the mucous membrane of the palate, or even to unite only the velum palati—for these unions fail at this period—it is nevertheless cer- tain that the operation, without regard to that required to remedy the separation of the jaw-bone, is injurious and more or less labo- rious, according to the multiplicity of the different stages; that the pain is protracted when we are obliged to prolong the operation; that the child loses so much the more blood from the same reason; that having lost blood, he is weakened, and is in bad condition for union of the wound; and finally, his nervous system being more fatigued, he is in a state that predisposes to convulsions. If we freely express these views, it is because they are the re- sult of observation, and because we can bear our testimony, not only from our hospital experience, but from our private practice, that in operating during the early months, we expose ourselves more to COMPLICATED HARELIP. 131 failure, on account of the pain, the loss of blood, which interferes with cicatrization, and the exhaustion of the nervous system, which disposes to convulsions, the consequence of which is the tearing apart of the sutures and even death. Let us now consider successively what it is necessary to do to meet these various complications. There are some cases in which the fissure produced by the harelip is of very considerable size, and is sometimes complicated with adhesions to the gums. It then be- comes necessary, to promote union, to dissect boldly and freely, sometimes very high up, on the superior maxillary bones, in order to obtain the approximation of the flaps, which are frequently only easily attacked, by making sufficiently large dissections. In cases of " wolf-mouth," an operation should always be per- formed, at the age of ten months or a year at the very earliest, and in two or three different stages, at an interval of fifteen days or three weeks between each. Thus, in cases in which the vomer causes a prominence in front, and pushes away the incisive bone, we should advise excision of the vomer by removing the intermaxillary bone. The first step of the operation consists then in division with the scis- sors or the bistoury, in such a manner as to allow the approximation of the two portions of the lip. Before making this division, the lobule should be broken off, which may be left hanging at the ex- tremity of the nose. We must endeavour to preserve as much of the thickness and length as possible, and then, when the excision is made of the parts we wish to remove, and the portions of the lip involved are pared, we must freshen the upper portion of the lobule, raise it up, and attach it to the upper part of the median sec- tion. This last is in other respects performed as we have already described it in simple harelip. If we do not wish to sacrifice the incisive bone, we must ope- rate twice, at first removing a triangular piece from the vomer. This division may be performed with a dissecting forceps or curved scissors. In the vomer a triangle should be cut, the summit of which is directed towards the upper part of the nasal fossae, its base corresponding to the lower part of the septum. To accomplish this stage of the operation, which is quite difficult with scissors, we had constructed by M. Charriere a cutting-punch in the form of a forceps, one side of which is engaged in one nostril, and the other side in the other nostril. We are thus enabled by a single cut to divide the triangle which we wish to remove. This first step of 132 HARELIP. the operation being accomplished, we should put on the child's head a small closely-fitting cotton cap; then, by means of a long strip of plaster applied over the occiput, the middle of which is placed over the nose, and the ends tied behind the head, com- pression is established which confines the two parts of the vomer. We may, in the same way, apply a narrow bandage rolled into two globes, the middle of which is applied on the nose, and its ends carried, crossing each other, behind the head; the incisive bone is thus pressed backward, and is engaged in the space ex- isting between the two superior maxillary bones, which are more or less separated, but at other times are very closely approximated; this last condition being a contraindication to the preservation of the incisive bone, which can never be restored to its normal position. By means of the long strip or the bandage with two globes, the middle of which is applied over the nose, and passed and re-passed around the head, and by carefully watching the dressing every day, we produce a depression of the incisive bone, and in about fifteen days the divided portions of the vomer will be found to be more or less solidly united. At the end of this time the second stage of the operation may be performed, and at this period there will be only a double harelip to operate upon. In harelip with serious complications, the nose is often greatly flattened, and the two soft parts forming the harelip are approximated with great difficulty, even after making free dis- section of the adhesions. We have found it best in these cases to have large, strong serres-fines (Fig. 4), the points of which are applied even with the furrows behind the alse of the nose. These press with sufficient force, and may bring too-ether the deep parts which have a tendency to separate. We have had placed on these serres-fines a trans- verse piece, with a female screw, which enables us, by means of a male screw, to tighten or sepa- rate them as we find necessary. The serre-fine is secured to the child's head by means of a tape; it should be the first point of union re- moved, and therefore should usually be taken off before the stitches. We need hardly add, that after both simple and complicated COXALGIA. 133 operations the surgeon should watch his little patient diligently, in order to detect and combat the medical complications which may arise in a number of cases. CHAPTER XVI. COXALGIA. Coxalgia is an inflammatory or sub-inflammatory affection of the coxo-femoral articulation, characterized at the outset by lame- ness and pain, which is sometimes only provoked by movements of rotation or by pressure of the head of the thigh-bone in the coty- loid cavity, or else by soreness rather than pain, without appreciable elevation of temperature over the point affected. This disease has often been called spontaneous luxation, pathological luxation, cox- arthrocace, etc. Whatever be the name given it, in our view it is certain that it has numerous points of similarity to the majority of articular diseases of a scrofulous character. The pathological al- terations are as variable as they are complicated. We are seldom afforded the opportunity of examining coxalgias anatomically at the outset. In the only case in which I was able to make such a study, in a patient who died of an intercurrent affection, I discovered a slight injection of the articular synovial membrane. Should I conclude from this that a moderate amount of inflammation of the synovial membrane always exists at the commencement of coxalgia? This single fact alone does not author- ize me to affirm it, and I am even induced to believe that, in certain cases, there might be, from the beginning, only a simple congestion of the fibrous parts around the joint. But in proportion as the affection of the joint progresses, the inflammation becomes more characteristic, and sometimes a purulent synovitis is established. The morbid conditions then extend progressively, the cavity of the joint becomes filled with pus, and the distended fibrous envelopes become softened, and cause the purulent collection to project, so as to open outwards. When the union of the various parts has yielded to the pressure from within outwards, by the process we have just referred to, the head of the femur, wasted and carious, tends to depart from the cotyloid cavity. Such is sometimes the origin of spontaneous luxations. 134 COXALGIA. In the progress of the disease, the two articular surfaces become successively altered, at times to a considerable extent. The coty- loid cavity especially is enlarged by the alteration of the cartilage, and the destruction of the substance of the bone itself. Frequently the borders of this cavity are pressed back, as if trodden outwards) and thus allow the surfaces of the bone to lose their relations, and to produce luxations, to which the term "spontaneous" has been applied. The round ligament becomes softened and elongated, and is destroyed. I have never seen any of these spontaneous luxa- tions produced around articular surfaces that were not altered, but always in a slow and gradual manner, consequent upon the destruc- tion of the surfaces of bone. These luxations are very generally in- complete, yet the complete form is sometimes met with, and in such cases the cotyloid cavity is effaced, either by morbid vegetations which fill up its depth, or by the disappearance of its edges, so that it becomes transformed into a surface almost devoid of excavation. On that part of the iliac bone on which the dislocated head of the femur rests, a new but imperfect cavity will be formed, which greatly interferes with the movements of the limb in this new position. Although we have seen coxalgias in little children six or eight months old, it is not less true that between four and fifteen years of age this disease most often takes its origin. Beyond fifteen years of age, we generally observe only relapses from coxalgias that have been temporarily improved. Patients who appear to be perfectly restored should also not forget that the injudicious choice of a profession, which compels them to keep much on their feet, and a defective hygienic condition, may provoke a recurrence. The con- stitution of the child most certainly exerts a very important influence on the manifestation of the coxalgia, for it is generally de- veloped in the lymphatic and scrofulous. To appreciate the etio- logical value of scrofula, we should be fully aware that a child may be lymphatic without presenting engorged ganglions or ophthalmia from an internal cause. While this affection may be constitutional, we sometimes recognize exciting causes; thus bad hygienic con- ditions, rheumatism, or neglected traumatic causes may bring on coxalgia in many individuals, who, but for these serious circum- stances, would have doubtless escaped its attack. There even exist traumatic coxalgias, properly so called, and these last have not by any means the same gravity_as spontaneous coxalgia. The symptoms of coxalgia vary according to the case. I need COXALGIA. 135 not dwell on details that may be found recorded in the authori- ties on the subject. Let it suffice to say that very generally this disease is slow and insidious in its inception. We may divide its morbid manifestations into three very different stages. The first, corresponding to the first stage of pathological alterations of a rheu- matic, traumatic, or scrofulous character, is characterized by slightly marked lameness, pain of but moderate intensity, a deceptive appearance of lengthening or shortening of the limb, produced by muscular contraction, which is itself an instinctive result of the pain, and distress in one or several movements of the coxo-femoral articulation. Generally there is a deviation of the pelvis, the side corresponding to the affected joint being depressed or elevated, and thus occasioning a lengthening or shortening of the limb. On the posterior side it presents a kind of saddle back, which may be con- sidered as characteristic. Those affected nevertheless continue to walk, and devote themselves to the ordinary occupations of their age. If the disease is not arrested by a natural modification of the general health of the patient under the influence of a proper medi- cal treatment, it passes soon to the second stage. The preceding symptoms then become aggravated, and the patient ceases to run, and then obstinately refuses to walk, so as to avoid the intolerable pain provoked by movement. In bed he takes a special position, and we find formed around the joint purulent collections which are very slow in being absorbed, or in opening externally. When these abscesses make their appearance on the exterior surface, they con- stitute inexhaustible fistulas, which commence the third stage of coxalgia. The articular surfaces destroyed by suppuration are the seat of the displacements already referred to. This suppuration, often very abundant, exhausts the little sufferers, who become marasmic, and often die after a variable length of time. We have sometimes detected in an autopsy perforation of the cavity of the joint, and the head of the femur projecting into the pelvis. Sometimes, instead of abscesses which at last open around the articulation, there are fungous growths which fill up the cotyloid cavity, drive out the head of the femur, and at last perforate the skin like a genuine abscess. We may find patients surviving the ravages of the third stage, but it is only after a long treatment of the fistulous canals that they escape a fatal termination. Still this 136 COXALGIA. cure is never thoroughly complete, for they remain infirm, and exposed to relapses. We have sometimes, but rarely, seen examples of cure of this third stage. Generally the progress of coxalgia is very slow, the disease lasting for years. Most frequently the cure is only effected about the age of sixteen or seventeen. We are sometimes surprised at the slight influence exerted by coxalgia on the general health of those who are its victims. During the first and second stages of the disease, the patient may retain all the appearance of perfect health. The termination of coxalgia depends on the cause which has produced it, and the stage which has been reached. The first stage may ter- minate without deformity, while the second always leaves a certain amount of stiffness in the articulation, or even anchylosis. Such patients, though lame, are nevertheless, after a considerable time, very strong on their limbs, and are able to devote themselves to quite rough work without fatigue. We can never produce a cure in the third stage without considerable deformity. Generally, a long suppuration leads to a fatal termination. So far as relates to the differential diagnosis, we may mention prominently rheumatic pains, which resemble those connected with the first stage of coxalgia; but their sudden appearance, occur- ring under the influence of cold or moisture, will enable us to recognize their nature. Abscess of the iliac fossa, and certain muscular contractions, may lead us into error, if we have not taken care to use every precaution for an accurate investigation. Con- genital luxation, with real shortening, closely resembles coxalgia, especially when complicated with rheumatic or neuralgic pains around the articulation. Under such circumstances, we must study the antecedent history of the case, and be assured that the patient has always been lame, under what conditions the pains are produced, etc. Nervous or hysterical coxalgia, described by M. Robert, may be confounded with it; it is met with in very excitable young girls, and will generally coincide with other nervous phenomena, and get rapidly well under the use of ferruginous and tonic preparations. The cause has much to do with the prognosis of coxalgia. We know that scrofula plays the principal rdle in the manifestation of non-traumatic coxalgia; but as that affection has only one stage in which it uses our little patients roughly, we must form our proo-uo- sis after the period of apparent evolution of the scrofulous diathesis. Sometimes, as our predecessor, M. Baffos, remarked, scrofula spends TREATMENT. 137 its full force on a single joint, the general health being excellent, and the patient, being otherwise well, may have only a coxalgia. In such a case, assisted by his age, we may effect a durable cure; I say a durable, not a complete cure, because those who, at the end of several years, recover the use of the affected limb, always have more or less deformity, and are always cured in a weakly condition. Nevertheless, they are satisfied even with this result, considering themselves lucky in regaining their health, after eight or ten years of suffering and continuous care. It need hardly be said that the prognosis of coxalgia assumes a fresh degree of gravity at each of the three stages in which it is presented to us. If the first and second stages leave us generally room for hope, the third is almost always discouraging; and yet we must not forget that even the gravest cases of coxalgia may be cured, especially if they are of a rheumatic character. Traumatic coxalgia is less serious than those that are spontaneous or connected with a constitutional cause. I could cite several cases consequent on external violence, the happy termination of which was secured after only seven or eight months of treatment. In the course of the year 1859, M. Roger sent us a young patient who had fallen from a tree upon her hip; an undoubted coxalgia followed, which was cured by rest in the space of eight months. Treatment.—Like the majority of chronic affections, coxalgia borrows its therapeutic resources from both local and general reme- dies, which act so much the more efficiently, as they are resorted to at the outset. Let us at first examine the local agents which are more especially within the province of surgery. The local treatment varies with each of the three stages of the disease. When the system of Broussais was in full force, leeches were often applied at the beginning; I have myself sometimes obtained by this means a momentary relief in cases of acute coxal- gia, with very sharp pains around the articulation. For several years we have almost entirely renounced the use of bloodletting, which weakens the patient without giving sufficiently durable re- sults. It is only, then, in these exceptional cases, when an intensely acute condition exists, that we have sometimes resorted to the use of the scarificator. The state of the patient must be our guide. After bloodletting, resolvents have been much extolled, such as inunction with the ointment of mercury and belladonna, iodine ointment, etc. We resort to them unhesitatingly, in conjunction 138 COXALGIA. with poultices and vapor douches around the joint, and are sure that we have often obtained good results from the combination. Revellents have also had their day. We may repeat, in regard to flying blisters, what we have already said of bloodletting; they produce a temporary improvement, but blisters become easily in- flamed, and sometimes produce sharp pain. On account of these annoyances, my father preferred flying cauteries successively ap- plied. From the results of his practice, I have persevered in the use of this form of revulsion, and have applied as many as forty around the same joint. These issues, of the size of a twenty centime piece, are retained for a variable length of time, with plaster and onguent de la mire} I have produced a soothing effect, of a more lasting character than with the remedies already referred to, and I may add that, in some cases, the cure has been permanent. We have, nevertheless, to acknowledge that with these cases of rare success, we may cite a fearful number in which we have completely failed. In spite of the uncertain results obtained by the cautery, I do not consider that I should yet renounce its use. I am con- vinced that in certain forms of coxalgia it may be of some ser- vice. This is not in accordance with the views of all surgeons— and of M. Bouvier in particular—who, after having used flying cauteries for a long time, have given them up, being persuaded that these continuous suppurations weaken the patient, and that, after all, the efficacy of these cauteries is too problematical to coun- terbalance their inconveniences. Bonnet, of Lyons, recommends perfect immobilization as a cura- tive means, without completely relinquishing the use of cauteries. We had long been familiar with the good effects of this treatment in articular affections; but to the surgeon of Lyons is due the honour of having made a methodical application for the treatment of coxalgia. Immobility is the surest plan to counteract muscular contraction, which is the cause of all the secondary disorders of this disease, and it should therefore be resorted to at the commence- ment, before even the slightest deviation of the pelvis manifests itself. With this object, M. Martin constructed an apparatus which held the limb in a state of semi-flexion, a position which has its advantages, and with which we have had some success; but it was also attended with the disadvantage that it kept the articulation • An ointment made of the following ingredients: olive oil, lard, butter, suet, yellow wax, litharge, and pitch. TREATMENT. 139 flexed, and the thigh, therefore, became more difficult to extend. Bonnet preferred to have the limb supported in the position of exten- sion ; to fulfil which indication, he at first employed a simple grooved splint, but he soon found that the pelvis must be kept abso- lutely at rest, as well as the lower limbs. He at first used a very complicated apparatus, very difficult to adjust, and dextrined or starched, requiring a large number of bandages, a considerable time to dry, much care in the application, and great difficulty in changing. This is not the form of apparatus we recommend. Bonnet constructed a double-grooved splint, with which every one is familiar; I need not, therefore, enter into a detailed descrip- tion of it. It should, however, be mentioned that for its proper application the patient should be kept constantly under the influ- ence of anaesthetics, that he may be placed in a proper position, by extending the contracted muscles. It must be also understood that the anaesthesia should be prolonged until the surgeon is able to extend ,the limb to its normal condition; to accomplish which object he evokes gentle and gradual movements of flexion and extension, to obtain a proper position of the joint and of the lum- bar region. The limb should then be firmly fixed in the grooved splint, and the healthy limb be also cared for. The results ob- tained by this improved apparatus of Bonnet are admirable. By applying it at the beginning of the disease, we may often prevent the alarming conditions already indicated; and, if our patients are not always cured without lameness, they can walk quite well, and rest their foot on the ground without a crutch, and even with- out a cane. We have but a single objection to make to it, and this is that its price is too high for the generality of those who have occasion for its use. Having, in the majority of cases, to treat coxalgia in persons of moderate circumstances, we have made every effort to devise a system of perfect immobility within reach of their pecuniary resources, to replace the apparatus of Bonnet. The apparatus decided upon after a number of experiments, which has appeared to us to fulfil the double purpose proposed, seems to us preferable to that of Bonnet for keeping children clean. It is composed of two oak splints, about one-fifth of an inch thick, an inch and a half to two inches in breadth, and rather longer than a crutch of a size adapted to the patient. These should be applied on the outside of each of the lower extremities, to reach as high up as the axilla, without however interfering with the movements of the arms, 140 COXALGIA. and should pass downwards below the feet from four to six inches (Fig. 5.) These two splints are symmetrical, presenting three mor- tises thus arranged; the first corresponds with the pelvis, and in extent to the height of the pelvis, and serves to secure the body bandage. It may be replaced by two: Fig- 5. one on a level with the upper border of the iliac bones, the other on a level with the great trochanter, in such a manner as to prevent the bands from becoming dis- placed. The other two mortises corre- spond with the knee and above the mal- leoli, and are designed to receive scarfs to secure the limb. Beneath the lower mor- tise are placed two notches for the pur- pose of securing the lower bands of the pad to prevent it from ascending along the splint. The upper extremity of the splint is rounded, and when applied is capped with a gusset secured to the pad. (Fig. 6.) The lower end, passing beyond the Fig. 7. TREATMENT. 141 feet, as already described, terminates in a cleft with a hole for a peg, arranged in such a manner as to secure it firmly in the mortise of the cross-piece. The cross-piece consists in a small board transversely elliptical, and on this cross-piece, in a vertical direction, are six rectangular mortises (Fig. 7.) Two of these are larger, and closer to the poste- rior curve, and are designed to receive the fork of the splints, and the space between them is equal to that of the feet when in a ver- tical position. The four others, which are smaller and arranged in pairs, and are placed a little higher up and to the inside, serve to secure the extending bands. By this arrangement, the cross-piece secures the splints, and at the same time gives firmness to the appa- ratus, protects the toes from the weight of the coverings, and pre- vents the heel from suffering from severe pressure from its own weight. Another important advantage is that it enables the sur- geon easily to move the patient on his side, when it is necessary to examine him posteriorly. So much for the mechanism of the ap- paratus; let us now consider the mode of putting it together. The other parts are more especially within the province of the needle. We require—1. Two symmetrical fracture-pads, placed on the inside of the splints, beyond which they pass upwards and down- wards for about two inches. Each pad is composed of a linen bag, two or three times wider and a little longer than the splints, and filled with bran. The upper extremity of each is furnished with a gusset, which receives the corresponding extremity of the splint. On the rest of its extent are arranged three tapes, to secure it to the splint. 2. Two modes of securing it; a body bandage formed of two pieces, one in front, the other behind, and two small square wadded mattresses, which may be placed under each piece of the body band- age. This last is cut; in other words, the half designed to attach the splints behind, although like it, is independent of the half de- signed to secure them in front. Each half of this bandage is com- posed of a rectangular piece of strong linen, or better still, of some sufficiently firm elastic substance, having three pairs of thread tapes sewed on the sides. These bands are attached two and two, in such a manner as to produce free compression, when they are tied on the edge of the mortise, in which they should readily glide. The small wadded mattresses are a little wider than the pieces of the body bandage, and have for their object relief from too great pres- sure of the material. The scarfs require no special mention, being 142 COXALGIA. simple handkerchiefs folded like a scarf, two for each side, one for the knee, and one for the lower part of the leg. Sometimes, to support the foot in a proper position, we may make use of an- other scarf arranged like a stirrup, as in the apparatus for fractures. This stirrup may be attached to the lower mortise, and be useful in making extension. When patients present a very decided saddle-shape, and the body bandage is not sufficient to keep the pelvis in proper position, we add to our apparatus an ordinary body bandage, which we place around the nates, lower than the preceding. The middle of the full part of this bandage is placed behind; and the ends are brought to the front, between the pads and the hips, then reversed again at the rear, on the splints, which make a return pulley. In this manner the pelvis is firmly pressed forward between the pieces of the appa- ratus, while the rest of the trunk is supported by the anterior piece of the cut bandage. These two forces acting in a contrary direction are sufficient to overcome the saddle-shape, and to give to our apparatus still another advantage. If the bony surfaces are already worn, and there is a tendency to displacement, we attach two extending strings around the leg with a roller bandage, or else by means of a silk handkerchief folded like a cravat, arranged in a slip-knot beneath the malleoli, and we then secure the extremities of the handkerchief, more or less tightened, on the mortises of which we have already spoken. As very slight extension is sufficient, the weight of the body effects sufficient counter-extension. Nevertheless, if very strong traction is neces- sary, it would be easy to support the trunk with a large scarf attached to the bed or the under part of the thighs, which may be moved alternately to the right or the left, so as not to injure by continuous pressure. Thus prepared, our apparatus is of extreme simplicity; its selling price is moderate; it requires only a carpenter and a seamstress to make it; and provincial practitioners will always have it in their power to procure it, this being, in our view, an important advantage it offers over the grooved splint of Bonnet. When ready for use, it is applied as follows: if there is any deformity of the hip or of the pelvis, and the straightening of it produces ever so little pain or provokes muscular contractions, we anaesthetize our patient, and can thus more conveniently give to the limbs and to the pelvis a proper position, while at the same time we profit by the state of TREATMENT. 143 sleep resulting from the chloroform to determine the exact condition of the affected joint. When the patient is in the attitude desired, the limb being well extended, the child lying on its back, we cause the apparatus to be slipped into place, well carried from below up- wards, and then pass under the lumbar region the small mattress, and the posterior half-bandage. We carefully tie the bands in a double knot to the right and left, in order that the splints may be equally pressed on both sides. We must necessarily tighten it at first behind, for the various parts of the apparatus have a strong tendency to become displaced in front, and to let the great tro- chanter project behind the splint, a result which must be carefully avoided. The anterior half-bandage and the small mattress are secured last of all, and the scarfs which surround the splints and the limbs from below upwards are successively tied, the surgeon being careful not to produce too firm compression, so as not to interfere with the circulation. The apparatus being once properly adjusted, we must half raise the patient, and this may be easily done without causing him pain. Starch or rice powder may be laid on the bed, in the place corresponding to the nates. Every day the patient should be inclined to the right or the left, to keep him clean and to pow- der him. Every time that the necessity arise he should be raised up, and a flat bed-pan passed beneath him. He may also be placed on a sofa or another bed, while his own is being made. It will always be well also to arrange the patient's bed in an inclined plane, so that the trunk may be more elevated than the feet. From time to time the scarfs on both sides may be loosened, in order to allow of movements which may prevent the articulation from be- coming stiff. The time during which this immobility should be maintained is very variable. Since having recourse to our mode of treatment three months were sufficient to produce in one of our patients such an improvement, that we considered ourselves justified in taking off the apparatus. This result is as satisfactory as possible, but we can very rarely remove it so soon, and are generally obliged'to let it remain a very long time. With the view of relieving con- valescent patients from the fatigue induced by a prolonged stay in bed, we advise the withdrawal from time to time of the apparatus, reapplying it only at night. But to avoid weakening the patient by keeping him constantly in his room, we give him exercise in 144 COXALGIA. the fresh air in a small carriage, in which he is placed with the apparatus on. As a general conclusion, we may say that up to this time our apparatus has appeared to unite the advantages of much more expensive apparatus. Our patients may, as with Bonnet's grooved splint, be transported from one place to another without experi- encing any painful shocks. They are kept sufficiently immovable not to suffer any more, and to become anchylosed, if necessary, in a proper position. Besides, there is a better circulation of air in our apparatus, and a greater opportunity to attend to cleanliness. Nevertheless, when it becomes a question of intrusting the patient to a railroad, for example, for a long journey, the double-grooved splint of Bonnet will be preferable, for it protects more closely the affected parts. As this apparatus requires perhaps less watching and is less liable to get disarranged, we give it the preference over our apparatus in all cases in which the patient is in a pecuniary condition that enables him to incur the expense. In hospital practice, however, and among the poorer classes, we may substitute our own for it without losing any of the advantages of immobility. Whatever may be the apparatus used, whether that of Bonnet of Lyons, or our own, it must be applied as soon as possible after the commencement of the disease, and be watched for a very long time, the patient not being allowed to walk until after several months of treatment, a year, or even longer. From time to time we may attempt to let the patient remain a day or two without the appa- ratus, which must be reapplied the next day. Before completing the subject of local treatment, let us say a word in regard to abscesses. When the abscess becomes decidedly prominent, is it our duty to open it? As a general rule, we post- pone this as late as possible, to avoid the exhaustion consequent on a long suppurative discharge. When we decide to open it, we some- times have recourse to puncture with a long flat trocar devised by M. Gue*rin, and to suction by means of a syringe, which may be screwed to the canula; sometimes to simple puncture, or the application of a drainage-tube, according to the method of M. Chas- saignac. Sometimes the purulent collections emptied by the trocar do not fill up afresh. Most frequently the abscess is reproduced as before, or else the puncture becomes the seat of a fistulous tract. We have in such cases derived advantage from iodine injections (one part of tincture of iodine to two parts of water) according to IRRIGATION OF THE PHARYNX. 145 the suggestion of our colleague, M. Boinet. The drainage tube has the advantage over ordinary setons of allowing of detergent injec- tions into the purulent collection, by adapting to it the canula with a syringe. Finally, if the pathological luxation is an accomplished fact and recent, we must endeavour to reduce it and to support it with appa- ratus. In cases in which the luxation is likely to be of long-stand- ing, or anchylosis to result, we must give proper attention to the lesion, and abstain from all such attempts, fearing to provoke a re- newed occurrence of the symptoms which are in course of extinc- tion. It must not be forgotten that, in certain cases of coxalgia, the head of the femur becoming dislocated, and not having been kept in place by apparatus, is carried near to the skin, which it tends to perforate. This necrosed portion of bone acts like a foreign body, and may be removed with advantage. My prede- cessor, M. Baffos, performed this operation successfully, and I was desirous of undertaking it myself, but the parents of the child objected to it. MM. Follin, Dolbeau, and others before them, have also had good results. It is an operation which, under certain cir- cumstances, should not be rejected. In regard to the general treatment, we have nothing to add to what has been already said of white swelling in general. CHAPTER XVII. IRRIGATION OF THE PHARYNX. There are a great many cases in which the indication is to prescribe gargles for children, but the majority of the latter, the oldest as well as the youngest, do not know how to employ them. There are even adults who are not skilled in their use. In gar- gling one's own throat, it may be remarked that most generally the fluid does not reach the tonsils, and that it does not act as well as we may desire. We must also observe, that in cases of very intense inflammation of the pharynx, th'e patients have much trouble in opening their mouths, and that they can scarcely separate the teeth. For these cases, and especially for children, in simple or violent inflammation of the tonsils, in abscess of those organs, in pseudo- 10 146 IRRIGATION OF THE PHARYNX. membranous stomatitis, in diphtheritic pharyngitis, or gangrenous inflammations, or even in chronic granular or other forms of angina, we have derived advantage from injections, or, better still, irriga- tions of the throat. As we must always use a syringe, or an irrigator, which we can have at home or within easy reach, it would i only be a question of having a suitable canula, to depress the tongue and make the fluid spirt into the different parts of the throat. The ordinary gum canulas do not depress the tongue, and may be bitten and broken by children. We have had constructed an instrument which we call the canula tongue-depressor (Fig. 8). Having experimented with several Fig. 8. metals, on the suggestion of M. Charriere, we decided on making them of bronzed aluminium, that metal having the advantage of not being altered by sulphurous water, which may be used under certain circumstances, in chronic amygdalitis for example. It has the shape of the extremity of a spoon-handle, is slightly curved, from five to six inches in length, and one-fifth of an inch thick, and hollow in its whole extent. Its extremity, which is designed to depress the tongue, has on its circumference and on its convexity a certain number of small holes like those of a watering-pot. At the other end is a true canula extremity, which may be adjusted to the caoutchouc tube of an irrigator or even of a syringe. Once arranged, and the apparatus filled with the fluid we wish to inject, a basin is placed under the chin to receive the fluid as it reflows from the mouth. The patient's head should be gently inclined backward, and the tongue being depressed, as if to examine the pharynx, the fluid is made to pass out very gently, so that it at first falls gently into the mouth, then gradually with more force, that it may produce a real irrigation. In this manner, the liquid thrown into the mouth strikes upon the affected parts, and may wash away mucus, concre- tions, false membranes, and even'sloughs upon the mucous mem- brane of the tonsils, the velum palati, and other regions of the mouth. These irrigations may be repeated several times a day. Older persons easily accustom themselves to its use, and even VULVITIS OF YOUNG CHILDREN. 147 children at last consider it an amusement. In certain forms of chronic amygdalitis, and in granular inflammation, I have obtained good results from irrigation, by the use of sulphurous waters, as practised by Dr. Lambron at Luchon. CHAPTER XVIII. VULVITIS OF YOUNG CHILDREN. Vulvitis—inflammation of the vulva — is met with in the youngest as well as the oldest children, and under several different forms, which may be separately described, as follows: Simple, diph- theritic, ulcerative, gangrenous, and syphilitic vulvitis. Simple Vulvitis commences by a very slight erythema of the mucous membrane of the whole vulva, with or without itching It occurs in the youngest children, sometimes a few weeks after birth, and is characterized by redness and pruritus with mucous oozing. Want of cleanliness is its main cause, and gives rise to discharge and leucorrhoea, so common among little girls. As soon as its existence is discovered, it may be checked by lotions of cool or slightly astringent water. If these are neglected, it very often happens that the lips of the vulva become glued together, giving rise to adhesion of the labia, which is sometimes congenital, in other words, formed before birth, but we have not had any very positive cases of this kind. We have been very often consulted by parents, and even by our professional brethren, who believed they had an obliteration of the vagina to treat, which consists, in such cases, in adhesions of the greater labia formed by very small transparent false membranes, analogous to those met with between the prepuce and the glans in several little boys who had had balanitis, and in whom the glans was not uncovered. This false membrane keeps the greater labia pressed together, but does not cover the meatus urinarius, so that the children thus affected are not inconvenienced in urinating; and it becomes detached and tears off very easily by means of a blunt stylet, or when a slight effort is made to separate the labia. In performing this little operation, we destroy an adhesion that might 148 VULVITIS OF YOUNG CHILDREN. at some future time become more solid, and occasion much annoy- ance at the period of the appearance of the menses, when a more painful operation would become necessary. When the greater labia are separated, it will be well to apply pieces of charpie so as to pre- vent new adhesions. Lotions of water and extract of lead, applied two or three times daily, are of advantage, and may prevent a recur- rence, which quite often occurs. We have sometimes seen cases of vulvitis produced by oxyures vermiculares in the rectum, which, passing from the anus to the vulva, provoke inflammation of the mucous membrane there. In such cases little girls have very annoying itching, which may lead them to masturbation. It is important, therefore, to subdue these symptoms rapidly. Mercurial inunction, calomel suppositories, lotions of infusion of absinthe, and sulphurous baths are the best means to employ to destroy these worms, and to cause the disappear- ance of the inflammatory irritation they have caused. Diphtheritic Vulvitis is characterized by false membranes, and is met with either at the outset in children who present no other mor- bid manifestations, or more frequently in little girls attacked or menaced with diphtheritis in other parts, such as the pharynx, the larynx, or the tonsils. The inner surface of the greater labia is fringed with white false membranes, more or less solid, analogous to those met with on the tonsils in the true pseudo-membranous affection. When these false membranes are detached, the subja- cent cellular tissue is raw; they have a tendency to become repro- duced ; the ganglions of the groin are often swollen, and in addition to this, the general health of the patient is more or less feeble, and there is often fever. This affection often indicates that the child is the victim of a general diphtheritic condition, which most generally resists local remedies, and rarely yields even to constitutional treatment. Though the prognosis may be serious, we must nevertheless not neglect to attack the disease both by topical and general remedies. The local treatment consists in the application of nitrate of silver, either in crystal or in solution. Lemon-juice may also be employed with success, as well as insufflations of alum and tannin. These agents especially succeed when there is no general diphtheritis, for if it exists, general treatment alone is capable of modifyino- the disease. We must not confound this false membrane with that GANGRENOUS VULVITIS. 149 met with in syphilitic children, the latter generally presenting other concomitant symptoms, such as chancre, mucous patches, etc. Ulcerated Vulvitis.—It is not uncommon to meet with ulcerations or excoriations on the internal surface of the greater labia in little girls. They may be consequent upon neglected cases of simple vulvitis, and are also the result of improper treatment, especially when the children are affected with leucorrhoea; or they may be caused by repeated masturbation. They have no syphilitic characters, and yet they are sometimes accompanied with mucous patches. Some of them yield to local medication, as general and local baths, as- tringent lotions, lead-water, the application of lemon-juice, chlori- nated water, nitrate of silver, and especially attention to cleanliness, followed by a dressing, which consists in keeping the labia separated by charpie. Gangrenous Vulvitis.—This affection is often the termination of the forms of vulvitis already referred to. It nevertheless only declares itself when the children are in a miserable condition of general health. It occurs also as the result of severe fevers, of adynamic diseases, and of certain grave forms of scarlatina. It is characterized by a transformation of the mucous membrane bordering the greater labia and the entire vulva into a blackish tissue constituting a genuine, soft and moist slough, which tends to become developed, and to gain ground, as long as the disease is abandoned to the efforts of nature. The treatment may be local or general, the principal indication being to combat the disease, which debilitates the patient. Thus the various kinds of tonics, as cinchona, bitter tonics, broth, wine, coffee, etc., may be placed in the first rank. The local treatment is not less indispensable. Applications of lemon-juice, powders of cinchona and camphor, vinous lotions, etc., may answer the purpose, but these means often fail. The best means of limiting the gan- grene is the use of iron heated to a white heat. Cauterization should go beyond the boundary of the slough, which may still often be crossed by the disease the next day. When this powerful local agent succeeds, there remains a large ulcer, a real burn of variable depth, which requires the same dressing as burns of this region. It is important that we should apply slightly camphorated powders of cinchona and charcoal; and lotions including aromatic wine or chlorinated water may be found of service. Finally, all possible precautions for the prevention of adhesions of the labia are of the 150 VULVITIS OF YOUNG CHILDREN. highest importance. The dressings should be carefully made and frequently renewed. Syphilitic Vulvitis.—This is characterized by chancres or mucous pustules: but the mucous patches which are seen between the greater labia and are also observed at the anus, are not always of a syphilitic character, and are frequently developed as a result of improper treatment, and of want of cleanliness. They then yield to washes of lead-water, to applications of nitrate of silver, and to general baths, without a constitutional treatment being necessary. When, on the contrary, these mucous patches resist such remedies, and they are accompanied with true chancres, or pemphigus of a syphilitic nature, we must, independently of attention to cleanliness, add to the treatment cauterization, and a general treatment either by corrosive sublimate baths, or by the liqueur de Van Swieten internally or the protiodide of mercury. This affection, in very young children, is hereditary, and often makes its appearance fifteen or twenty days after birth. In older children, those of eight to ten years of age, for example, it is acquired and produced by contact with individuals affected with syphilis. In the new-born, we have used the following treatment with advantage. Every day a bath should be given it in a wooden tub, to which half a drachm to a drachm of corrosive sublimate has been added, and eight to ten drops of Van Swieten's solution in a small spoonful of syrup of gum Arabic should be administered internally. If the mother nurses her child, we must subject it to a general treatment. If the child cannot be suckled by its mother, the indication is not to give it to a nurse, and while following the treatment prescribed, to nurse it with the bottle. We think in some cases it would be better to nourish the child with the milk of a goat that had been submitted to mercurial frictions. It will be especially important that the animal should be well cared for, being as much as possible in the open air, that its milk may be of the best quality. Again, we may nourish syphilitic children with the milk advised by Dr. Labourdette, which is daily brought into Paris, and is produced from cows fed in the pasturages of Normandy. These animals every day swallow a bolus of iodide of potassium expressly prepared, and faithfully administered to them before their departure for the pasturage and after their return. We are familiar with the good results of the use of this milk, which we prescribe in cases of syphilis and scrofula in the new-born. FOREIGN BODIES IN THE EAR. 151 CHAPTER XIX. FOREIGN BODIES IN THE EAR. If we except ceruminous concretions, which are principally met with in old people, and rarely in children, we may state that in the latter, more than at any other period of life, foreign bodies are found in the external auditory canal. For our own part, we have seen a considerable number of such cases in hospital and in private practice. The foreign bodies which we have found, are of very different character, comprising hardened cerumen, pebbles, cut stones extracted from rings or ear-rings, pearls, peas, fruit-stones, beans, fragments of glass tubes, paper pellets, fruit-seeds, etc., etc. Insects have also been found there, but never in our own expe- rience. Itard, the learned surgeon of the deaf-mute institution, has reported several cases, in which they were found in the ear. All foreign bodies, when they remain in the auditory canal, may lead to complications, principally of a class attended with tumefac- tion, such as inflammation, suppuration, buzzing, cerebral pheno- mena, or meningitis. The indication is, of course, to relieve children as speedily as possible, who have a pea in the ear or a seed, which may become developed under the influence of moisture. The surgeon should first be thoroughly satisfied of the presence of the foreign body, for very injurious explorations have sometimes been made, when no such body existed there. If, after having placed the patient in a proper position, with the light introduced in the direction of the canal, we detect the foreign body, we should adopt a different treatment to suit the circum- stances of the case. 1. If the body is fluid, as water from swimming or oil, a single succussion of the head will be sufficient to expel the fluid. 2. If hardened wax accumulates in the ear, a simple ear- pick, previously dipped in oil, will enable us to get rid of this concretion. We may be compelled to precede its use by softening this foreign body with several injections of tepid water, oil or glyce- 152 FOREIGN BODIES IN THE EAR. rine. 3. Peas, beans, seed, and paper pellets swell and soften, and may be grasped or torn sometimes quite easily, either with a small pair of forceps, or with a small short hook, which penetrates the foreign body. 4. Hard bodies, such as pebbles, fruit-stones, or different kinds of resisting seed, may be removed in several ways, and especially, as was advised a very long time since, and prac- tised by Meniere, physician of the deaf-mutes, by injections. We have very often followed this plan, and for all forms of foreign bodies, but they must be applied in a certain way, and steadily persevered in. We ought, therefore, to explain to parents how these injections should be given, for we have often to repeat them for several days in succession, before crowning the treatment with success. To administer these injections, it is well to procure an Eguisier irrigator (No. 2 or 3), armed with a straight canula, and filled with cold water, or, better still, warm water. The child should be held by some one, who takes the precaution to surround it with a cloth folded several times, the arms being thus kept wrapped up, and this cloth should surround the child's neck to avoid wet- ting it. Besides, an assistant should place the patient in such a manner that the head may be slightly inclined, and a basin be arranged under the ear so as to catch the water as it flows out. The surgeon introduces the canula of the irrigator into the audi- tory canal, discharging the fluid from it at first very slowly, that the water may pass between the foreign body and the walls of the canal, strike on the membrana tympani, and by the return shock expel the foreign body, which falls into the basin, sometimes after the first injection. It is important that the surgeon, while making irrigation with the right hand, should draw the pavilion of the ear alternately upward, downward, forward, and backward, so as to modify the direction of the current, but it is not necessary to adhere to this rule under all circumstances. We may urge a repe- tition several days in succession, if no results have been obtained at the first injection. Having taught parents how to use these injections, I have met with with some of them who, after eight or ten days, succeeded in extracting the foreign body. It is essential, therefore, to success, that the operator should not lose patience. Nevertheless, when this method is not attended with success, the operations which have appeared to us to succeed best, are those performed with simple small forceps, especially useful in cases in CATARACT. 153 which soft substances, such as paper, charpie, etc., are present in the ear, or else those with the ordinary curette, or the articulated curette devised by M. Leroy d'Etiolles for small calculi entangled in the urethra, which is generally easy to use and successful. In many cases, it is important to introduce it mainly along the lower wall of the canal, which is wider. The introduction of the curette being more painful than the former method, and children being always disposed to move, if this plan be followed, we should unhesitatingly resort to the use of chloroform, in order to operate with more certainty on unma- nageable and excitable children. When children are, on the contrary, docile, besides the inclined position of the head, M. Debout has recommended the opening of the patient's mouth. The extremity of the little finger should be introduced into his external auditory canal, and his jaw moved, so that the surgeon may be made aware of the enlargement which the canal undergoes each time the condyle of the jaw leaves its articular surfaces. This posture facilitates the putting into practice of all the various ope- rative procedures, but that which it mainly aids is the very unob> jectionable method of injections. CHAPTER XX. CATARACT. Cataract, in children, consists, as in adults, in opacity of the crystalline lens. It may be of two kinds, congenital and accidental. Congenital cataract is met with at birth, and is sometimes here- ditary, but most frequently has no appreciable cause. Sometimes it is very complete, when the child comes into the world; yet it sometimes happens that it has its commencement during the earliest periods of life, and it only becomes well-marked at the end of several months and even years. .We have seen in the new-born well-formed cataracts; are they caused by an arrest of development, or are they the result of an intra-uterine inflammation ? This form of cataract may be membranous or capsular, clear or milky. Whichever of these varieties it may be, it offers to view the following character- istics : in the centre of the pupil a white portion of a bluish tint 154 CATARACT. like that of starch when prepared in a paste for the purpose of stif- fening linen, all the crystalline lens having the same tint; the iris, which is very movable, preserving its normal condition, and the anterior chamber having its full capacity, the uvea which circum- scribes the pupil being distinctly traceable on the bluish opacity. From such children as come into the world with an incomplete congenital cataract and reach the age of reason, we find that vision is greatly enfeebled, especially in the evening, but never completely extinguished, and that they are able to distinguish the day from the night. We also meet with cataracts in the new-born that are attended with opacity of only the centre of the crystalline, and in these cases especially we detect nystagmus and strabismus; in this condition they see a little, not through the centre of the lens, but through the circumference. The new-born who have cataract, if left to themselves, are still able to see at seven or eight years of age, but they reach that period without having any idea of objects. Fre- quently the eye may have lost its volume and its visual power, and it tends to become atrophied, so that we should not postpone too long an operation in congenital cases, for the greater the delay the more we have to dread the diminution of power in the retina, and the more we have to fear not only that the education of the vision may take place slowly and imperfectly, but also that the child's intellectual development, which is associated so intimately with the faculty of seeing and appreciating objects, may be greatly retarded. All children, who are operated on very late, take not only a considerable time to learn the use of their organs of vision, but also see more imperfectly than those who have received early surgical attention. We are therefore partial to the performance of the operation a short time after birth. Prognosis.—The child affected with congenital cataract will be in a favourable condition, if its eye makes movements to find the light, the prognosis under other circumstances being serious. In any case there is nothing to be gained by waiting, especially if, during the first month after birth, the opacity continues. At this age, when the child is one month, six weeks, or two months old, we derive advantage from operating on cataracts of this kind. At this time, the child has passed the period of the small com- plaints of the earliest stages of existence. The child may be vac cinated, and in this way it is in proper condition to be subjected OPERATION. 155 to the operation, without there being so much apprehension of alarming complications. Operation.—Having dilated the pupil by a drop of a collyrium containing atropia, and having emptied the intestinal canal, either by enemas or a light purgative, such as syrup of succory, or calo- mel, we may proceed to operate in the following manner: The child should be laid on a pillow firmly fastened to a board of the same length as the little patient, secured by means of two napkins arranged like scarfs, one passing under the arms and the chest, the other pressing on the pelvis and thighs. We may then keep the child lying down, as Dupuytren did, or in an erect position before the light. Then, the head being secured by the hand of an assistant, he supports the upper lid with the other hand with the pulpy part of the middle or index finger, or else with an elevator. The ope- rator, placed in front of the patient if the latter be raised up, or to one side if the patient be in bed, may resort to the operation of extraction or depression. This last method seems to us preferable, for generally the cataracts are soft, or milky, or else capsular, and under these circumstances, depression is favourable and absorption easy, and, besides, the operation is more simple. If the child is of the age of a year or more, we may administer chloroform, but we should abstain from its use, if the patient is only a few weeks old. The operator, provided with a flat needle, very slightly curved, keeping the lower lid depressed with the pulp of the middle finger of the right or left hand, according to the eye to be operated upon, follows for the operation the different stages indicated for the method by depression. After having carefully attempted the couching and depression of the crystalline lens, it frequently happens that the cataract being soft, the latter flows towards the lower part of the eye, without the surgeon being obliged to depress it; or else the cataract being soft, and the membrane of the crystalline opaque, we must move the instrument from above downwards with great care to divide the capsule; or if the cataract has a resistance which does not allow us to depress it, we must divide it, and after thus operating, lacerate it. We have not found it advisable to let the fragments of the crystalline pass into the anterior chamber; these portions are readily absorbed, and after having sometimes filled the whole chamber, they are found to dissolve more or less rapidly, especially if the fragments are small. After the operation, we apply, over the eye, a compress steeped 156 CATARACT. in cool water, which we support lightly and renew frequently with- out opening the eye. We lay the child in a curtained bed or else in a room in which the light is shut out by blinds or heavy curtains. We continue the application of cold water for two or three days in succession. If there be pain or sleeplessness, we give a spoonful of coffee with syrup of codeia. We also employ a strong infusion of lettuce leaves, or the application of compresses steeped in a col- lyrium composed as follows:— R. Zinci sulph., Morphia? sulph., aa gr. ij. Aquae destillat. f§ij. M. If inflammation of the eye exists, with much pain, we should not hesitate to apply a leech behind the ear corresponding to the eye operated upon, and we may spread around the eye an ointment containing mercurial ointment and extract of belladonna. We give calomel as a purgative, and keep both legs constantly sur- rounded by a layer of wadding and covered with adhesive plaster. When the case does well, we gradually diminish the application of compresses steeped in cold water, and also lessen the darkness, but allow the light to penetrate into the chamber only when there is freedom from pain and from acute sensibility. The education of the eye is thus accomplished in a very slow manner, and requires that this organ shall not be exercised in too bright a light. Consequently children that are operated upon should wear a shade for some time, or else a veil or spectacles with glasses coloured with lampblack, if they are old enough to wear them. When, after a month or six weeks, absorption of the crystalline is not complete, we may, advantageously, introduce the needle afresh, with proper precaution, and endeavour to complete the operation at a second effort. We may take a similar course, if, after a first operation, a secondary cataract should form. In all cases, we must only operate a second time when there no longer exist traces of ocular inflammation. Accidental Cataract.—This affection is developed most frequently without any appreciable cause, yet it is sometimes met with in children who have gazed at the sun or remained in sandy regions where the light of the sun is intense. The same symptoms and the same treatment apply to them as to adults. We have seen this form of cataract occurring in children debilitated by long ABDOMINAL HERNIA. 157 chronic diseases, under which circumstances the operation will be unsuccessful. Traumatic Cataract.—This variety of the disease is quite fre- quently observed in children, as the result of contusions of the eye or of wounds of the eyeball. It is only developed after an inflam- mation of greater or less intensity, which must be combated with perseverance, and an operation should not be decided on for a long time. The mercurial ointment, belladonna, purgatives, and flying blisters behind the ear corresponding to the eye affected, are reme- dies that must not be neglected, and we have had satisfactory results in cases in which we were called to operate; yet we need not persevere too long with these remedies, if after five or six months they produce no good effects, but decide to operate. It is not uncommon to find these cases complicated with amaurosis, when an operation will be contra-indicated. The collyrium with atropia may then make the diagnosis clearer. If there is opacity of the lens, and the pupil is movable, we may, in cases of traumatic cata- ract, follow the operative procedure already pointed out. The necessity will often arise to destroy the adhesions of the capsule to the iris, and this must be done with extreme care, so that the iris will not be wounded. The after-treatment will be the same as that previously referred to. CHAPTER XXI. ABDOMINAL HERNIA. Abdominal hernia, which is characterized by the escape of the abdominal viscera through natural openings, is met with nearly as often in childhood as at other ages, especially in the earliest months of life, and more frequently, in our experience, in little boys than in little girls. Several facts authorize us to declare that this affection may be hereditary, but without dwelling at present on this point, there are certain peculiar conditions to remark in children, which may ex- plain the development of a considerable number of hernias. These causes are due, on the one hand, to the arrangement of the openings, which are less tense and less tightly closed than in the adult, and 158 ABDOMINAL hernia. on the other hand, to the freedom which children use in the efforts they make. In fact, the child that is new-born or but a few months old, checks its cries as little as it does its desire to evacuate, and it expels with all its strength, often intensifying this as much as possible. In our view, these are the chief causes of hernias in children; not that we should exclude in them causes that prevail among adults, but these act much less frequently in childhood, and at the same time they are much less appreciable. The constituent parts of a hernia are not always the same. We have seen it formed by the epiploon, the small intestine, the large intestine, and the ileo-caecal appendix; and in three young girls there was a hernia of the ovary through the inguinal ring, that organ descending to the greater labia. The other abdominal or- gans may also present themselves. Generally, all these hernias are enveloped in a sac formed by the peritoneum, except in cases of congenital inguinal hernia in which the displaced organs descend directly into the tunica vaginalis. The openings through which hernias are produced in children are at first, in the youngest of them, at birth the umbilical opening, and the space of the linea alba; at a later period, and yet sometimes at birth, the inguinal ring. The symptoms are generally as nearly as possible the same as those of adults. Let us examine in regular order umbilical hernia, that of the linea alba, and of the inguinal ring. Umbilical hernia is seen at birth or a very few days afterwards; it may have for its cause at first the cries of the child, and some- times the want of proper attention in supporting the belly with the body bandage, and sometimes also the want of plumpness and feebleness of the child. It is easily recognized in examining the umbilicus; we detect either through the opening or a little to its outside, below or above, a tumour without change of colour of the skin, having the volume of half a hazel-nut, or of a walnut, easily reduced and giving the sensation under the finger which presses it of a marked gurgling. It may be made to disappear by pres- sure, and it shows itself afresh as soon as the finger is removed; sometimes the child has colic, but what is especially to be remarked is that the tumour is increased by the cries of the child. When the hernia is of small volume, it will be sufficient to sup- port the belly, when the umbilical opening will be found to be con- tracted, and the tumour will diminish promptly, especially if the ABDOMINAL HERNIA. 159 child increases in strength and gains flesh. Frequently, however, it tends to augment in size, and the indication is to confine it by means of a bandage, several forms of which have been devised, but most generally these bandages slip, do not support the hernia, and are totally insufficient. We believe as the result of our own expe- rience, that it is better to reject entirely the elastic bandages whether they be of the most simple or the most complicated kind; belts with cushions fastened in their centre do not render any better service. We consider it better to employ adhesive strips, and we also prefer to all bandages the application of a simple hemisphere in yellow wax or in vulcanized rubber to form the cushion, attached with a long strip of gum resin plaster applied in the form of a belt. This passes around the body one and a half times, and has a width of about an inch and a half; it adheres to the skin and easily supports the hernia. This* simple bandage, which seems to us superior to all others, and which is always at hand, should be carefully pre- pared. We make a hemisphere with yellow wax, by softening the latter by heat, and forming with it a kind of ball, which is cut in two. This half-ball may be of variable size, according to the di- mensions of the opening of the ring, on which it has to be adjusted in such a manner as to exert compression; but it is necessary that it shall be larger than the opening, into which it should not enter, for it would then do more harm than good. This cushion, wrapped in fine linen, should be placed in such a way that its convexity may be in relation with the ring, and its flat part with the strip of plaster, over which we make several circular turns of a bandage around the abdomen. Before applying this bandage, it will be well to powder with starch or rice powder the umbilicus and the portion of the trunk and loins which may be in contact with the plaster, and thus prevent the occurrence of ery- thema, caused by the action of the plaster upon the skin. This kind of bandage should be left in place three or four days in succession, and when it is to be removed, it is better to prepare in advance a new cushion and adhesive strip. In removing the bandage, we must at once place the finger over the umbilicus, in order to pre- vent the hernia from escaping before we can apply the fresh cushion; and thus, if the umbilicus is already contracted, we do not lose, by the escape of the intestine, all that we have gained. With children, whose skin is irritable and becomes reddened by the use of plaster, we must use only a bandage tightly applied 160 ABDOMINAL HERNIA. around the abdomen, but this form of bandage has the disadvantage of slipping, and becoming displaced, and does not support as well as the plaster. Umbilical hernia is cured most frequently in six weeks, two months, and sometimes longer, by carefully applying this form of bandage. We have never thought of resorting to the method of radical cure by the ligature after the reduction of the portion con- tained in the sac, for whether the ligature be simple or multiple, and with or without torsion, it does not inspire in us a sense of perfect security, for it is attended with danger. I have never met with strangulated umbilical hernia in children ; I have seen them slightly choked up, but they were reducible, after the application of poultices. Hernia of the linea alba is sometimes produced by quite a con- siderable separation, either above or below the umbilicus. It pre- sents a tumour of oval form more or less elongated, is fluctuating, and re-enters under pressure. In such cases, the ventral belts pro- perly applied are of advantage. Inguinal hernia, in children, and in small boys especially, is quite common. It may be simple or double. In children as in adults, the symptoms may be both local and general. The latter consist of colicky pains varying in degree, sometimes of repeated vomiting. The local symptoms are the same as those met with in adults. In the region of the groin we detect a tumour of greater or less volume, sometimes very small, as large as a hazel-nut, at other times much larger, always devoid of change of colour of the skin, fluctuating and easily reducible, with gurgling, generally by a moderate amount of pressure, which causes the intestine to return through the inguinal ring. These symptoms are frequently met with on the right and left side at the same time, for it is not un- common to have two inguinal hernias occurring simultaneously. The parts contained are generally small or large intestine, with or without epiploon. We once found, while operating for strangulated hernia, the ileo-caecal appendix in a child of seven or eight years of age, who had died of peritonitis. In three little girls, we have seen a hernia of the ovary through the inguinal opening. Inguinal hernia in children may be confounded with°hydrocele, cyst of the cord, a descending testicle, a tumour of malignant cha- racter of the testicle, and in little girls with a descent of the ovary. The first case of this kind we saw was misunderstood. We had under treatment in the Hopital des Enfants, in 1851, a girl of INGUINAL HERNIA. 161 eleven years of age, wrho, below, and on the internal surface of the left greater labium, had a small tumour, which was mistaken for a cyst by myself, by M. Broca, and others of my professional brethren, and from which the child had suffered since she was a year old. Believing that we had a small encysted tumour to deal with, and as it had become very painful and interfered with her walking, we removed it. After having uncovered it by an inci- sion, finding that it was suspended by a prolongation, a ligature was placed on the pedicle, which was then cut. It proved to be an ovary, and the child died two days afterwards of peritonitis, which took its origin on the broad ligament that formed the pedicle. We avoided making a similar error in two other little girls, whose cases came under our attention at a later day. We then discovered that these hernias presented a small tumour placed on the inside of the greater labium, which rolled like a cyst, and on being pressed slipped between the fingers. It appeared to be retained when an attempt was made to draw it downwards, and it reascended when it was relaxed, as a cyst of the cord ascends when we eudeavour to bring it down. In both cases, we could not cause the tumour to return. We must not confound hernia with simple or encysted hydrocele. At first, in simple hydrocele, there is an appreciable fluctuation of fluid and not of gas. There is often reduction, but this only occurs in hydrocele communicating with the abdomen, and finally its transparency may be detected. Encysted hydrocele is a small trans- parent tumour, circumscribed over the tract of the cord, which ascends or descends as we lower or raise the testicle. It is very important to distinguish a testicle descending through the ring from a hernia. This descent usually happens towards the seventh month of conception, but it frequently takes place at the time of birth, or occasionally some time afterwards. When the testicle descends, we learn at first from the parents, or by the examination we ourselves make, that there is nothing in the scrotum on the corresponding side, and we detect at the inguinal ring a rounded, moderately firm tumour, which may be made to pass back by pressure, without gurgling. We may also, by taking the tumour between the fingers and drawing it downwards, discover that it is held by a pedicle, which is the cord; and that it will re-enter com- pletely to appear again, if the child be made to cough or even to walk. This tumour is no longer painful after it has passed up, 11 162 ABDOMINAL HERNIA. while the compression exercised by the ring, when it reappears through it, sometimes produces pain. We must also make a distinction in the child between congenital hernia and the accidental form of the affection. In the former, the hernia is formed in the tunica vaginalis, a condition which is often met with in children, whose tunica vaginalis is not closed; in the latter, there is a sac independent of the tunica vaginalis. Inguinal hernia is generally formed by the epiploon or the intestine. Left to itself, it tends to increase in volume and may become enormous. Children may suffer from this form of hernia without any grave symptoms accompanying it, yet they generally have colic, especially when the hernia has not been returned, or is incompletely supported. It may become inflamed by pressure of the bandages, when there will be pain, and under these circum- stances a few baths, poultices, and temporary suspension of the bandage, if the child is wearing one, are sufficient to cause a ces- sation of these symptoms. The hernia may also, as in the adult, become choked up or even strangulated. This choking up of the intestine (engouement) is characterized by the presence of fecal matters in the bowel. This accident, which is especially met with in feeble old people who do not support their hernias, is seen also in weak or delicate little children. Several surgeons, and among them M. Goyrand, have seen such cases. It is characterized by augmentation of volume and of weight, and its soft and doughy consistence ; and by borborygmi and eructations. The skin covering the tumour has a normal colour, and the abdomen is swollen, without being painful. Sometimes there is nausea and even vomiting. By the use of emollients applied over the hernia, and of several enemas, we may frequently remove the obstruction, which is effected through the evacuations. The taxis and a gentle purgative are indicated. Strangulation occurs less frequently in children than in adults and old people, but we have met with it several times, even in children but a few weeks old. We have found, in these cases of strangulation, all the symptoms met with in adults, such as hard- ness and tension of the tumour; a hard and painful condition of the abdomen; eructation and vomiting, the patient at first emptying the contents of the stomach, fecal matters from the intestines being afterwards voided by the mouth, and little or nothing at all by the anus. In a word, the symptoms are identical with those INGUINAL HERNIA. 163 observed in adults and old people. The tumour may become inflamed and perforated, and an artificial anus be then established with greater or less rapidity, while at the same time the countenance undergoes a change, the pulse, which was frequent at first, becomes weaker, and death may follow. These grave symptoms are however less frequently seen than in adults, and often the hernia may enter spontaneously, or at least be reduced more easily. In fact, in instances in which we have been called to see cases of strangulated hernia in children, we have generally been able to employ the taxis with success, and we have only met with failure in very rare cases. When we wish to resort to the taxis, especially in the youngest children, we place them on an inclined plane, in such a manner as to keep the head and trunk lower and the pelvis elevated, and follow the rules laid down for the taxis in adults. We press the tumour near the ring, so as to cause the upper portion to be re- duced first, and the rest of it afterwards, and this we attempt for a very short time only without administering chloroform. As soon as we have discovered its inutility—and this often happens, because children in their struggles make a resistance to reduction—we advise the application of a poultice over the tumour. We then give the child a bath, and afterwards have recourse to an anaesthetic, so that we may be able to employ the taxis without having to dread the effect of the cries and movements of our little patient. We have nearly always in this way effected the reduction. When this is impossible, we must resort to an operation, and success is much more certain if the taxis has not been kept up for too long a time, and if the operation is performed as early as pos- sible after the commencement of strangulation. At the end of eight or ten hours, reckoning from the beginning of the symptoms, we should employ the bath and the taxis, with chloroform, and not stop short of an operation, if the hernia is unreduced. In fact, Pott lost in two days a child suffering from strangulated hernia ; Gooch one six weeks old; Dupuytren operated on a child twenty days old; M. Goyrand on one four months of age, which he cured; and Prof. Roux on one two years old. We have met with several cases of strangulated hernia which we usually had the good fortune to reduce by the taxis assisted by chloroform, even in children but six weeks or two months old. Rarely have we had occasion to perform an operation, and in the only three cases in which we 164 ABDOMINAL HERNIA. operated we had unfortunate results. The precautions to be adopted in the operation should be the same as for adults. The after-treatment is likewise very important and more minute on account of their tender age. We have to combat peritonitis. The accidents just pointed out are very rare in children, and generally if we are consulted early there is the greater probability of having them promptly cured of their hernia, by constantly and care- fully applying properly-fitting bandages, especially if the children from being lean become fleshy. Those who are treated in the early months of life may be cured by the regular application of a bandage in four or five months, and those a year and more of age may often be cured by wearing the bandage for a year. But when they are older, they must not be allowed to give up the use of the bandage for several years, and then, when they wish to relinquish it, they must not finally do so all at once. We should, in the majority of cases, at the commencement make them wear the bandage night and day, and when we consider it necessary to withdraw it, it is advisable to suspend its use at first only at night, and resume it the next day. Generally, we find it advantageous to apply bandages as soon as we are consulted. At first we use light bandages of fine caoutchouc with air-cushions, for the new-born; but for children from six months to a year old, we prefer elastic bandages, of very fine material, covered with fustian, and then a cover of gummed silk. It is absolutely indispensable, for very young children, always to have at least two bandages, because they are so often soiled, and require to be changed every day. We may conclude this subject by remarking that whenever the testicle has cleared the external orifice of the inguinal canal, and is very near the ring, the indication clearly is not to let it re-enter and to leave it outside. Sometimes in time it descends further, unless the cord be too short, as we have seen it; but it also happens that the testicle compressed in the canal causes frequent pains, which are repeated at close intervals. If, in such cases, we cannot support the testicle outside the ring by means of a hernial pad expressly arranged for the purpose, which can support the returned intestine and the testicle outside, without compressing it too much it is much better, in our view, to follow the advice of Mariolin, who said that if there existed a hernia of the testicle and a hernia of the intestine, if the latter could not be supported without compressing LEUCORRHffiA. 165 the testicle, it was better to return the hernia and the testicle^ and support the whole of it reduced, rather than expose the child all at once to the accidents of compression of the testicle and of strangulation of the intestine. CHAPTER XXII. LEUCORRHCEA. Leucorrhoea, an affection characterized by a white or yellowish- green discharge from the vagina, is frequently met with in young girls from the first months of life to the age of puberty. Among the causes producing it, the first and principal one is the lymphatic constitution. It is quite often hereditary, as proved by numerous examples. It may become developed only under the influence of the scrofulous diathesis, or as the result of an acute disease, or succeeding the suppression of an eczema of the vulva. Local causes may also give rise to it, such as oxyures passing from the rectum to the vulva, occasioning vulvitis, and, as a consequence, inflammation of the mucous membrane of the va- gina with leucorrhoeal discharge. Finally, it may be the result of the introduction of foreign bodies into the vagina or of masturbation. Symptoms.—Sometimes there is heat, pruritus of the vulva, and at other times neither pain nor itching. The discharge is often colourless and mucous, or else it is thick, yellowish and even green- ish. Sometimes, in examining the vulva, we find it bathed with sero-purulent fluid and even fetid pus, as in true uterine and vaginal catarrh. By carrying the finger into the rectum, and pressing from behind forward the posterior part of the vagina, the fluid is made to escape by the vulvar orifice. Sometimes these local phenomena exist alone without affecting the general health, but we quite often see little girls pallid, with circles around their eyes, complaining of loss of appetite and feeble digestive powers, easily fatigued, and shrinking from walks o»f any length. It sometimes hap- pens that the leucorrhoea ceases of itself without treatment, but it may continue to increase, and then it occasions exhaustion and loss of flesh. In cases in which the discharge is considerable, vul- vitis of varying intensity may declare itself, and cause so much 166 LEUCORRHCEA. pain that the child refuses to walk. We can readily imagine that this affection, though in itself attended with but little danger, may debilitate the child when its duration is prolonged. The pathological alterations are difficult to determine; we cannot employ the speculum, and it is only by chance that we have the opportunity of examining the vaginas of little leucorrhoeal patients, who die of intercurrent affections. Two or three times only have we had such an opportunity. Twice we saw the mucous membrane of the vagina, as well as the internal surface of the uterus, inflamed, and were able by pressure to make the thick mucus ooze through the neck of the latter, and this has led us to think that there is often at the same time utero-vaginal catarrh. The prognosis of this disease is not serious; the latter may last for a long time, and sometimes be alleviated to return with greater in- tensity. The establishment of the menses is sometimes sufficient to cause its disappearance. The surgeon should therefore be very circumspect, and not give an opinion on the duration of this annoy- ing form of indisposition, for it may also happen that after men- struation has been well established the leucorrhoea may still remain. When the cause is a local one, there is better prospect of a speedy cessation of the discharge, than when it is produced from constitu- tional causes. Treatment.—Leucorrhoea should be attacked by both local and general remedies, as lotions of different kinds or emollients early applied, if there is much heat, such as marsh-mallow water, bran water, or flaxseed water. But these emollients should only be em- ployed for a short time, and if the local cause depends on oxyures of the rectum, we must destroy these worms by the use of suppositories of calomel introduced into the anus morning and evening. When the leucorrhoea is not caused in this way, we may especially resort to the use of astringents in the form of lotions or even of injections into the vagina. Water and extract of lead, infusion of walnut leaves, or infusion of Provence roses may be employed as a frequent wash to the vulva; but when the discharge comes from the vagina we prefer to inject these fluids in the morning and evening care- fully into that canal, using a syringe furnished with a deligate gum- elastic canula well fastened and capable of being introduced through the opening of the hymen. These injections may be made by intel- ligent mothers, by placing the child on the edge of the bed and keeping the labia separated. The surgeon should show the mother TREATMENT. 167 at least once how these washes are to be used. They have ap- peared to give me good results, especially when freely adminis- tered with an irrigator, which enables us to introduce at least a pint of fluid to sprinkle the neck of the uterus and the walls of the vagina. We have used injections of water and nitrate of silver, in the pro- portion of six grains of the crystallized salt to four ounces of dis- tilled water. When this kind of injection is employed, we should use it once each day with a small glass syringe, for only three or four days in succession, and endeavour to make the child retain the fluid in the vagina for several minutes, by applying at once between the greater labia a tampon of cotton and approximating the thighs. We only return at long intervals to this kind of injection, if we obtain good results from them, once or twice a week, for example. All local medication is successful only when combined with general remedies that act on the whole economy, such as tonics given by the stomach or general baths. Sometimes gentle purgatives, such as half an ounce of castor oil, administered once a week, produce a diminution of the discharge; or enemas, made of about three drachms of the pods of senna in infusion, or an ounce and a half of honey of mercury. Of all pur- gatives, an enema of colocynth is the most active and even quite violent, and according to Dr. Claude, should be prepared as follows: Bitter apple, if small, one-third of it, if large, one-fourth, which should be macerated for twenty-four hours in a covered vessel filled with about four ounces of warm water. This very active purge is followed by several evacuations, which may even be bloody. We then give the child mucilaginous drinks and light soups. This purgative treatment may be repeated, five or six days afterwards, a second and even a third time. It has caused also the disappearance of the leucorrhoea for a considerable period. As general remedies acting on the whole economy, full gelatinous and saline baths, sulphurous baths, sea-bathing, and sprinkling and lotions of the whole body with cold water, are powerful means whose very frequent use should not be neglected. The prepara- tions of iodine, and especially those of iron, pills of phosphate of iron, protiodide of iron, natural chalybeate waters, and, for a change, wine of cinchona, and cod-liver oil when combined with a tonic course of diet, constitute a plan of treatment which should be perse veringly employed. We may be assured that all the methods 168 TORTICOLLIS. we advise are useful, and should not neglect them; but some time is necessary before the constitution will become modified, and the disease be thoroughly checked. CHAPTER XXIII. TORTICOLLIS. This affection is a curvature of the neck, with involuntary in- clination towards one shoulder. This symptom most generally presents differences according to the nature of the case, and usually requires different treatment according to the diseases which are its cause. It may depend on both acute and chronic affections. In the new-born, torticollis or wry-neck is due to the feeble muscular power of one side of the neck, the equilibrium being only re-established by strengthening the side opposite the inclina- tion, and a few days will very often effect this. Erysipelas, a phlegmon, engorgement, a recent burn on one side of the neck, or rheumatism may produce it, and we should treat the affection which is the cause of the torticollis, the latter being more or less severe according to the nature of the disease. Chronic affections, such as paralysis, cervical arthritis, caries of the vertebrae, rachitis of the cervical region, and vicious cicatrices after burns, all of which may produce a deviation of the neck, require appropriate treat- ment. Torticollis induced by muscular contraction, which will chiefly occupy our attention in the present article, consists in a lateral inclination of the neck, occasioned by the shortening of a single portion, or of two portions, of the sterno-cleido-mastoid mus- cle, as may be clearly shown by attentive examination of a case of this kind, and on this point the views of Albinus and Mickel harmonized. In causing an individual to breathe, it will be seen, as M. GueVin has already remarked, that the sterno-mastoid is a motor muscle of the head, and the cleido-mastoid an inspiratory muscle. This is not the general view of their functions. The causes of this deformity are obscure. It may depend upon an arrest of development, or convulsions leading to muscular con- traction. In carefully studying the symptoms of this contraction, TORTICOLLIS. 169 we perceive the inclination of the head either to the right or the left, a diminution in the length of the cleido-mastoid or of the sterno- mastoid, and, in addition, inclination of the cervico-dorsal region opposed to the inclination of the head. The contraction is seated most frequently in the sternal mass of the muscle; sometimes, how- ever, the clavicular mass is contracted conjointly with the former. The contracted muscle is shorter, and of smaller size, and this is so much the more marked if the patient is older. The mus- cles of the face on the contracted side are all less developed, and atrophied, and the movements of the head are made all at the same time with the shoulders, and without pain. When the head is carried to the side opposite the flexion, we notice the muscle becoming stretched under the skin and preventing the inclination of the head on the opposite side. We very often notice, also, a tension of the trapezius, which is more or less contracted. This deformity, if left to itself, may become aggravated. The body of the vertebras settles down on the side of the curvature. Generally only an operation, combined with mechanical appliances, can overcome it. Bandages, which were formerly employed at the commencement of the deviation, nearly always failed to produce any result. We may employ them to prepare the patient to wear mechanical apparatus, but without relying on them alone. We must, in addition, perform an operation which has been in vogue for a long time; Tulpin and Cheselden practised it, and at a later day, Dupuytren, Roux, Magendie, and Dieffenbach performed the section of the muscle, but in a faulty manner. Since the time of J. Gue'rin and Bouvier the operation in general favour to-day has been regularly performed,-and almost with certainty. We refer to the subcutaneous method of operating. Laying aside bandages, which were formerly employed to coun- teract the deviation, all surgeons have come to use a mechanical collar which surgical-instrument makers can easily make, and which should be preferred to all others, unless it is impossible to procure it. This collar consists of two solid portions made with metallic plates properly padded and stuffed, one of which is applied under the base of the skull and under the lower jaw, the other over the upper part of the thorax, the shoulders, and the clavicle. They are both kept separated from one another by means of metallic stems, which ascend on the lateral portions of the neck, and which may be elon- gated on one side or both in such a manner as to separate the head 170 TORTICOLLIS. from the base of the neck and be reversed in one direction or the other. One of these mechanical collars being appropriated to the patient on whom we are about to operate, and arranged in such a manner as to fulfil satisfactorily the indications, we accustom the child to wear this apparatus for several days, after which we may decide to perform the operation. Operation.—Surgeons have completely abandoned the old methods, in which the skin was first divided, and afterwards the muscles, a source of great difficulty during and after the operation. We now employ the subcutaneous method, which is very simple and very easy. It is sometimes necessary to cut the sternal portion, the clavicular portion, and even the edge of the trapezius, which we have found contracted. We must then, before operating, endeavour to decide in advance, by careful examination, if we have to divide a single muscle or several of those referred to. We should not, however, be ignorant of the fact, that if we do not obtain complete straightening after the first division of the sterno-mastoid muscle, we must generally operate on the other portions which cause the promi- nence, and which interfere with the complete success of the operation. In this manner we avoid repeating the division several days after- wards, either of the cleido-mastoid or of the edge of the trapezius. In all cases we must lay the patient on the side opposite to that on which we are about to operate. If the child is restless and unmanageable, it is better to chloroform him. The surgeon should study on the patient the distribution of the superficial veins, which creep along under the skin, in the inferior cervical region near the sternum and clavicle. The arrangement of these veins is variable; they may sometimes embarrass by their size, and it is well to avoid them as much as possible. The child should be held in such a manner as to make the contracted muscular mass bulge out. For this purpose the head should be carried in a direction the reverse of the inclination, so that not only will the muscle be made to project, but also be separated from the subjacent parts. This enables us to avoid injuring it. The operator then making a fold in the skin in the direction of the fibres of the tendon, should use a straight sharp-pointed tenotome, with which he pierces the base of the fold between the skin and the muscle about half an inch above the insertion of the latter, introducing it transversely, with the blade flat-wise and without pushing it, so as not to pierce the skin on the other side. This first stage being accomplished, we use OPERATION. 171 a probe-pointed tenotome, concave on the edge or convex, which having been introduced flatwise through the passage thus made is directed in such a manner as to place the edge in front of the fibres of the tendon, and is pressed from before backwards to divide the tendon in that direction, pressing it rather than sawing so as to avoid accomplishing the complete division too abruptly. We prefer this plan; we may, however, introduce the tenotome behind the tendon, and then direct the edge forward, to make the section from behind forwardsVithout dividing the skin, thus rendering the operation more delicate. When, after the division of this principal portion, we still find, on inclining the head, the cleido-mastoid muscle prominent, we should treat it in the same way and also the trapezius, the projecting edge, of which it will be sufficient to divide. In the majority of cases, we may confine ourselves to division of the sterno-mastoid; twice, however, in my own experience, I have been obliged to divide the cleido-mastoid. After these divisions, we must not hope to have at once a complete cure of the torticollis, for there is still some passive contraction, as M. GueVin calls it, in the deep muscles of the neck, which only yields gradually to apparatus. The operation once performed, we should place over the puncture a strip of isin- glass plaster, applying several turns of the bandage, and waiting three or four days for the wound of the skin to cicatrize. We must not be alarmed at a slight effusion of blood which sometimes occurs under the skin, depending on the wounding of several sub- cutaneous veins. At the end of three or four days the wound in the skin is closed, and the effused blood absorbed, and we may then resort to mechanical treatment. We may, indeed, be assured that the section of the muscles being effected, the placing of the head in a straight position becomes easy, but it is still far from complete, for the deep muscles, by their passive contraction, resist the inclina- tion and rotation of the head; and on the other hand, the divided muscles have a tendency to become approximated, and a cure can only be effected by keeping the ends of these separated. It is still never perfectly complete, on account of the contraction of the deep muscles that were beyond our reach, and the subsidence of the bodies of the vertebras, which cannot be made to disappear completely. In any event, three or four days after the operation on the mus- cles, we must come to the mechanical treatment, without which the 172 TORTICOLLIS. result would be incomplete. This is frequently designed to over- come the cervico-dorsal inclination and the contraction of the deep muscles. Bandages applied so as to incline the head might be em- ployed, but not with any good results. There is nothing so really useful and appropriate as the mechanical apparatus known under the name of the casque, applied to an orthopaedic bed, or even a helmet; or, what is still more simple, the mechanical collar already described. This may be found at many instrument-makers, with modifications and additions, some of them rather ingenious, designed to facilitate the inclination of the neck and of the head in all positions, to overcome the principal inclination and the secondary inclinations caused by the action of the muscles and by the curvature of the cervical region. This collar should be applied very carefully to prevent excoriation, and should be taken off under various circumstances, but only for a few moments. At the com- mencement, it should be worn for a very long time, and so much the longer in proportion to the age of the patient; so that it is better to commence the treatment of torticollis of long standing as soon as possible. We consider it proper to operate on children when they are about two or three years old. As a general rule we should prefer to operate at a time of year when there are fewer acute diseases prevailing among children, so that we may prevent the early days of treatment from becoming complicated with some febrile or other affection. When the neck appears to be restored to its normal straightness, it is indispensable that the collar should not be completely abandoned. We must continue to apply it every day, at least for a few hours, and when not wearing it the patient must put on a cravat surrounded by a firm and resisting stiffener, which will still carry the head on the side opposite to the pathological inclination. To conclude this subject, permanent success can only be assured by acting as in cases of club-foot, resisting for a long time any return of the de- formity. MALFORMATIONS OF THE FINGERS AND TOES. 173 CHAPTER XXIV. MALFORMATIONS OF THE FINGERS AND TOES. Malformations of the fingers and toes arise from excess or deficiency, or from adhesions. We have met with them in children the issue of marriages of consanguinity, and of others where no such relationship existed. We have seen them come into the world with fingers deficient; in acephalous foetuses, either mere appen- dages of fingers or the hand composed of only two fingers ; and in one case a phalanx was wanting, but we have more frequently found the fingers in excess. We have discovered in these cases that the malformation was often hereditary, and we have seen two double great toes in a grandmother, mother, and child. We have found it to occur in fingers and toes, or the parts in excess are insignificant, very small, and very slightly developed. On the contrary, we have met with a double left hand, composed of eight fingers well formed, the two thumbs being wanting. It is not uncommon to find a thumb or a little finger in excess, composed of one or two phalanges, sometimes having tendons, which pass from it and may produce movement, while at other times they even communicate with the principal joint of the finger or the next toe. They may be opposite the joint of the thumb, at other times that of the little finger or the great toe. Some of them are quite well developed and in juxtaposition; in other words, we find two thumbs or two little fingers, or else the same arrangement as in the toes, united by a cutaneous membrane and the bony parts free, and sometimes also fingers held together. Thus we have seen a double thumb and a double great toe. Under such circumstances, the two thumbs are sometimes united by skin only, and have each phalanges and separate joints. Others have the phalanges in juxtaposition, closely consolidated together, while at times the first is single and the others are separated. We have seen a thumb with a single first phalanx and the ungual phalanx double, each part separated, articulated in a detached manner on 174 MALFORMATIONS OF THE FINGERS AND TOES. the first phalanx and thus resembling a fork, each extremity of which represents the end of a tolerably well-formed thumb. Some- times this fork is formed by the bifurcation of the last phalanx. Some thumbs are well separated, but both of them articulate with the first metacarpal bone, and this is seen not only in the hand, but also in the foot. Two great toes may be found to articulate at the same point, one of them having a deviation inwards and standing off from the other. Malformations of the fingers from adhesion are very often seen in the ring and middle fingers. Sometimes four fingers are united by a cutaneous membrane which holds them together in their whole length, constituting a genuine case of web-foot, generally involving only half their extent. We have seen the ring and middle fingers united by a cutaneous membrane as far as the ungual phalanx; and this last may be laterally consolidated with the other, so that the bony portions are not distinct and only make one large deformed phalanx, having both nails united. We have seen fingers when united forming a shapeless stump, in which we could distinguish nothing, either finger or joint. This kind of ad- hesion is especially met with in children whose hands have been burned, and especially in the new-born, as a malformation. Let us now examine into the operations to be performed for these various malformations. ■ When the fingers are in excess, we must distinguish those that are useless or annoying and insignificant appendages. In such cases the indication is positive, we must sooner or later remove them, and the sooner the better, unless some concurrent affection may lead us to defer the operation. But it sometimes happens that they are in regular position near each other without being separated, and then there will be nothing better to do than to leave them alone, for they act simultaneously with the others and do not inter- fere with their movements. If there are supernumerary fingers which stand off from the rest, and form an angle with the thumb or with the little finger, on the hand as on the foot, these should often be removed; but some of them stand off a little, having an appear- ance like a fork, are articulated on the same metacarpal bone as the principal finger, or on the first phalanx, embarrass the movements, and are perhaps applied to the side of the principal finger. Here an operation is indicated, which consists in causing the adhesion either of both fingers or of both phalanges. The plan of cauterization MALFORMATIONS OF THE FINGERS AND TOES. 175 suggested by M. Cloquet, producing the adhesion of the two por- tions, presents sometimes more advantages than the removal of the supernumerary finger. This method has succeeded in one case in which both great toes formed a kind of fork. As for fingers that adhere together (syndactilie), they are some- times extended and without flexion, or very much flexed and con- tracted. If there be two fingers or several, the indication is to operate. This is not a matter of much difficulty, but if it is easy to divide the cutaneous membrane that unites the fingers, it is very difficult to keep them separated. We have made a simple incision, prolonging it as much as possible on the dorsal side, to obtain an oblique cicatrix which will restore the normal commissure. Follow- ing the advice of Dupuytren, we have exerted compression on the angle of union of the fingers by means of a long narrow strip of plaster or linen, applying the middle part of this over the inter- digital angle, and bringing the extremities in front of and behind the forearm. We have employed the method of Rudtorffer, piercing the base of the interdigital fold by means of a needle, with a leaden thread, which should be left in the wound until the edges of the opening are cicatrized. The interdigital fold then presents an opening analogous to that made on the lobe of the ear, and is then divided. All these means may fail, but such are the autoplastic methods that have given us the best results. Zeller's mode of operating has been successful in our hands; it consists in making on the dorsal surface of the interdigital membrane a V-shaped incision, the pointed end of which comes opposite to the middle of the first phalanx, and the base of which looks towards the metacarpo-phalangeal articulation. We dissect up this flap, giving it as much thickness as possible, and incise the whole extent of the adhesion, reversing the flap in the interdigital space, to apply it over the palmar surface of the hand, and securing it with a strip of plaster. The fingers should be dressed separately, keeping them apart. M. Morel-Lavall^e advises that two flaps be made; Dr. Deces, that the fingers should be kept separated as much as possible, and the interdigital fold seized in one forceps, an incision being then made to the right and left in a direction parallel to the united fingers, the fingers separated, and an interdigital tongue of skin left in the interval; the fingers are kept apart by means of a suitable scooped splint, and straightened, and thus, if they were flexed before the operation, they become straight 176 MALFORMATIONS OF THE FINGERS AND TOES. and draw the arch formed by the tongue against the normal com- missure. The wounds of the fingers are, however, dressed sepa- rately, keeping them always apart. Another very ingenious method of Dr. Didot, of Lie'ge, which we have also employed, is thus performed. Supposing the ring and middle fingers to be united, we make an incision along the dorsal surface of the former, from the free extremity of the interdigi- tal fold to the middle of the first phalanx. From each extremity of this incision, we direct two others transversely, the superior one being prolonged to a point opposite the centre of the middle finger, the inferior as far as the free border of the interdigital membrane; and we then dissect this square flap from the ring-finger as far as the middle finger. This flap is formed of the posterior part of the skin of the ring-finger, of the interdigital palm and the middle finger. A similar flap, but cut in an inverse direction, is made on the palmar surface of the middle finger; it is formed of the skin of the anterior portion of the latter, of the interdigital palm and ring-finger. This dissection being made, we divide the few cellular adhesions which retain the fingers, and one of the flaps serves to cover the denuded part of the ring-finger, and the other the denuded part of the middle finger; the cutaneous fold of the base of the two fingers is formed through the medium of a suture. This mode of operating, which is difficult and tedious to execute, de- mands, like the other methods referred to, the use of continuous sprinkling with cool water. It is quite frequently complicated with inflammation, whatever may be done, and often with gangrene of the flaps. Besides, there is a liability almost always to a. recurrence, whatever may be the operation resorted to. I hold to the view of Chelius, with whom I had a conversation on this subject, that prudence demands that we should not perform this kind of operation before the complete development of the fingers; otherwise we will find new adhesions appearing, either because the skin cannot become developed as rapidly as the fingers on account of the cicatrix, or because the adhesion progresses from the base of the fingers towards their extremity in proportion to their growth in length. We should therefore prefer to postpone an operation until the fingers have ceased to grow. Whatever the plan adopted, or the age of the patient, it is very important to keep the fingers extended on a splint, the fingers of which are separated, and it is indispensable to make continuous irrigation -pf - the ope- CARIES OF THE VERTEBRAE. 177 ration, and not to discontinue it abruptly, but in a slow and gradual manner. Especially is it of the highest importance, that when the cicatrix is completed, the fingers shall still be kept extended on a wooden splint, and that the patient, after having worn it for several weeks, day and night, should continue to wear it for several months at night, and exercise the fingers during the day. Adhesions of the toes are far from requiring the same considera- tion as those of the fingers. We must remember that malformations of the toes are mainly deviations, forced extensions, or flexions. Under these circumstances we must be cautious about operating, and especially of amputation; mechanical appliances and tenotomy are often the only remedies we have to use. Operative interference is confined to the removal of toes in a rudimentary condition, where they are the cause of inconvenience in walking by becoming -. caught in the stockings. We need hardly refer to the importance of resorting to these operations only in cases of absolute urgency, and of taking the greatest precautions by appropriate after-treat- ment to guard against subsequent angeioleucitis. CHAPTER XXV. CARIES OF THE VERTEBRAE (POTT'S DISEASE). Caries of the vertebrae is an affection which may be said to be peculiar to childhood, in spite of the few cases occasionally met with in adults, and is one of the diseases most frequently met with in hospitals for children at all ages. It is characterized by osteitis of one or several of the vertebrae, and, anatomically, presents three stages: the commencement, the increase, and the termination. First Stage.—There is at first osteitis with bony swelling, some- times slightly sensitive; somewhat later, in the course of one or two vertebrae, a more or less marked gibbosity,—that is to say, a projection formed by a spinous process of one or two vertebra?, This prominence, which makes its appearance in an angular shape, is always accompanied and produced by an alteration of the osseous tissue of the body of the vertebra. On post-mortem examination, we find this tissue more or less red and infiltrated with blood and 12 178 CARIES OF THE VERTEBRAE. pus, and the cellules of bone distended. The presence of tubercles of varying consistence has also been sometimes, but quite rarely, detected. In all cases, the body of the vertebra or vertebrae affected is always less resisting than in the normal condition. The gib- bosity, which at the beginning is not very marked, offers an angle of greater or less prominence, according to the extent to which the vertebrae are affected, and their want of resistance. The cervical, dorsal, and lumbar regions of the vertebral column are attacked by this disease, which most frequently, perhaps, involves the inferior portion of the dorsal region. Second Stage.—The gibbosity may be more or less prominent, on account of the advanced condition of softening of the bodies of the vertebrae, which are in various stages of deformity. When the caries occupies the anterior portion of the body, the sinking of the latter takes place forward, and the gibbosity is then more prominent, if the softening takes place in the whole thickness. There is greater heaping up of the vertebrae in the direction of the thickness of the bone, and then the vertebral column is diminished in height, while sometimes the lesion is more marked on the sides. The trunk then has a lateral inclination either to the right or the left. It is also in this second stage that we have detected purulent collections, which are only seen on an autopsy, because they are not of sufficient amount to be recognized during life. The pus will be seen spreading in the form of a net under the anterior vertebral ligament, either in the pharyngeal region or the dorsal or lumbar region. The organs in front of these collections are found to be but slightly compressed, when these are only of trifling amount, but are much more so when the abscesses are developed to a point that entirely obstructs and even arrests the functions of the pharynx, oesophagus, bronchial tubes, lungs, stomach, or in- testines, according to the region in which we meet with them. These collections are sometimes so greatly developed that we find them effused into the chest, the stomach, or the small Delvis, and in such cases death frequently comes suddenly. At other times they have become diffused into the iliac fossa, and find an outlet from the pelvis by the inguinal ring, by the sciatic notch, and turn around the articulation of the thigh. They are met with in the sheath of the psoas and iliacus muscles. We have seen these purulent collections perforating the intestine, the rectum for example, and this explains the relief experienced, CAUSES. 179 or the cures resulting, from the discharge of pus by the anus. We have quite often seen, as have many others also, purulent collections which were situated behind the vertebral column, but the consequences are much less serious. These may be emptied by the efforts of nature or by the hand of the surgeon. Sometimes the pus is absorbed more or less slowly, or discharges through openings made spontaneously or by art, and if the patient has resisted all this, which may last for years, he then arrives at the third stage. Third Stage.—This is either a period of aggravation ending in death, or of cure. In the former case, the vertebrae are more and more destroyed, the portions of the bone swim in purulent col- lections of varying extent, and the pus is more or less diffused. We sometimes find purulent absorption complicated with tuber- cular meningitis or pulmonary phthisis, which puts an end to the life of these unfortunate patients. When the disease has a tendency towards cure, nature makes prodigious efforts to support the verte- bral column, which tends to become more and more flexed. The abscesses diminish in extent and finally disappear either without being opened or are emptied outwards. Fistulas become gradually dried up and close, and the canals are obliterated or reduced to the state of fibro-cellular cords. The vertebrae which were affected sink down, and become consolidated, passing beyond the neighbouring vertebrae, several adhering among themselves, and anchylosis re- sulting. We see portions of vertebrae remaining in a healthy condi- tion surrounded by true bony stalactites, which serve as a support to the destroyed parts, and finally the vertebral column, which may have considerable deformity, regains, by this wonderful effort of nature, sufficient solidity to support the trunk perfectly, but always with curvature and often compressing the spinal marrow. Causes.—We recognize two sets of causes of this terrible disease, the predisposing and the exciting. Under the former we place a lymphatic constitution, a scrofulous diathesis—an affection peculiar to childhood; among the latter we class falls, blows on the vertebral column, and also masturbation, which may at the same time be both cause and effect, for it may happen that those unfortunate children, who are for the most part obliged to keep in bed, are led to indulge in it only from this cause, and that this vice weakens them and aggra- vates the vertebral disease. To produce this affection there must be a special predisposition, which is its true cause. A traumatic 180 CARIES OF THE VERTEBRAE. cause sometimes, but rarely, produces vertebral caries. This at least is the result of a large number of observations that we have had occasion to study. We recognize in the symptoms of this disease three stages, as we have already found three in the ana- tomical lesions. First Stage.—This includes sometimes pain at a fixed point in the vertebral column; arching more or less marked in the course of one or more of the vertebrae, a prominence to which the name gibbosity, has been applied, pressure at this point increasing the pain; diffi- culty in walking; sometimes the trunk curved forward or backward; lassitude, pricking in the legs, desire to sit down, and not to remain in the erect position; and when the disease is seated in the cervical region, the necessity of supporting the head by resting the chin on the hand, or on the back of a chair, or some other support. In dorsal or lumbar caries, the limbs become weak or paralyzed, the patients are soon brought to a condition in which they cannot move much, and even remain voluntarily extended on their back complaining if they are touched or assisted involuntarily. Second Stage.—All the symptoms become increased in intensity ; and sensibility is greater over the gibbosity, which becomes more prominent on account of the softening. Sympathetic abscesses become developed and make themselves prominent in the pha- ryngeal, inguinal, gluteal, or femoral regions, or in any region whatsoever of the posterior part of the trunk. We have, for instance, treated a patient with an enormous collection of pus in the lumbar region, which could be returned into the abdomen like a hernia through the interval above the iliac crest, limited by the edges of the great oblique muscle of the abdomen, and the great dorsal muscle. The sheaths of the nerves emanating from the spinal marrow serve as conductors for the pus, which may be seen diffus- ing itself in the aponeurotic sheaths of the various muscles of the trunk. The various functions may be interfered with or abolished. Abscesses of the cervical region affect the speech and deglutition, and paraplegia and paralysis of movement and sensation, or both, are produced as the result of compression of the spinal cord or of the nervous cords emanating from it. The simultaneous loss of both these functions is especially observed when the pus makes its way into the spinal canal. Third Stage.—It is at this time that the opening of internal DIAGNOSIS. 181 abscesses takes place into the cavities of the thorax and abdomen, terrible accidents in both cases. If they open into the thorax, sometimes death occurs rapidly from asphyxia caused by compres- sion of the organs of the chest. When the abscess pours into the pelvis, it sometimes produces a swelling in the groin, and may open spontaneously by passing under the peritoneum. It .is likewise in this third stage that hectic fever, diarrhoea, marasmus, and finally death occur. At this period of the disease, however, caries does not attack the vertebrae only, but also the various pieces of the skeleton, and all parts of the economy appear to yield to the destructive effort; or, what may be properly called an ulcerous diathesis. Nevertheless the termination of the disease is not always a fatal one, for we are sometimes fortunate enough to find the caries arrested, having been checked by skilful hygienic treatment or rational medication, or even when abandoned to the efforts of nature. Fistulous canals are established as a sequence of openings made spontaneously, or by the hand of the surgeon. It may happen that these become dried up or obstructed, and a cure takes place, but always with more or less deformity, and very slowly. There are pain and stiffness in movement, and a gibbosity of greater or less magnitude, which in time becomes solid. Considered in regard to its duration, vertebral caries is an affec- tion which requires eighteen patients out of twenty to be confined to their beds for years at a time. Sometimes we are more fortu- nate when the disease is treated with intelligence from the com- mencement, or is less intense. We then may find the constitutional manifestations disappear in a few months, but this is uncommon, and more, frequently the cure is delayed". Under all circumstances, we must, to obtain a cure, perseveringly insist on the methods of treatment we adopt. When a fatal termination is about to take place, fever, diarrhoea, infiltration of the limbs, and serous effusions occur; in a word, the symptoms of a complete cachexy, and the patient dies from exhaustion and marasmus. Diagnosis.—-It is important not to confound vertebral caries with other affections having some of its characters. At the commence- ment of the disease there is some impediment in the walk, with stiffness and even pain in the movements, which are likewise met with in lumbago; but, in this latter affection, the pain is violent and acute, often accompanied by fever, which is of short duration. This rarely occurs in vertebral caries, which is attended with very 182 CARIES OF THE VERTEBRJ3. little fever at first. Besides, if any prominence exists at any point of the vertebral column, painful on pressure, the question is settled. We must not confound vertebral caries with rickets, in which the curvatures of the bones are produced slowly without giving rise to sharp angles or severe pain ; in fact, we have here no subsi- dence or bearing down of the bodies of the vertebras, but rather softening of all the spinal column, accompanied with incurvation and not shortening. Most frequently the projection met with in those suffering from rickets is rounded, but we must not depend absolutely on this as the characteristic, for it is not constant, and may likewise be met with in caries of the vertebrae. We have ourselves seen several illustrations of this. The diagnosis of rickets is mainly established from a general view of the temperament and constitution of the patient. The keel-shaped thorax, swollen ab- domen, the nodes on the wrists and ankles, the shape of the head, and the pathognomonic curvature of the bones will be symptoms more than sufficient to prevent all error in the diagnosis. Rickets usually precludes scrofula, which is the most frequent cause of Pott's disease, yet one disease may be complicated with the other. Another differential symptom is found in the fact, that in caries there is increase of the volume of the bones and more or less acute pain on pressure, a condition not met with in rachitis. If with all the symptoms of caries should be combined sympathetic abscess, there is no further room for doubt. Certain affections of the pelvis, such as sacro-iliac arthritis, may be mistaken for caries, but careful investigation will prevent all error, whether we exert pressure on the painful part or move the pelvis on the sacro-iliac articulation. The pain here would be more lateral, and less in the middle line, than in caries of the vertebrae. Complications.—This disease may be complicated with all the symptoms of scrofula, of pulmonary and cerebral tuberculosis, and of nearly all the acute affections. Congestive abscesses, becoming diffused to a distance, produce considerable separations of parts. These abscesses may open spontaneously, and the patient be some- times cured, and we have seen cures result even in rebellious cases. Another terrible complication is the purulent infection which occurs after the opening of the abscess; whether the latter be spontaneous or produced by artificial means, in either case it is mortal. Prognosis.—Everything in this disease conspires against the un- TREATMENT. 183 fortunate patient and the medical attendant. The structure of the vertebrae singularly favours the origin and development of caries, and its deep situation causes the disease to pass a long time unde- tected, and there is no possibility of attacking it directly. The prog- nosis then is always serious. Everything else being otherwise equal, the prognosis will be more favourable, if the disease is accidental and traumatic, and if the treatment is commenced at the beginning. In every instance, a greater or less amount of deformity will remain, which will occur very slowly in the majority of the cases cured. A considerable amount of gibbosity will often result, which does not yield.to any treatment; we have rather to treat it as a bony consolidation which the healing powers of nature have pro- duced and which we have to let alone. When fistulas are estab- lished, much time is usually required to close them up. Treatment.—The treatment of Pott's disease presents three prin- cipal indications: 1. To modify the general constitutional disposition in virtue of which the caries is developed; 2, to combat the inflam- matory action of the bones and neighbouring parts; and 3, to prevent the disorders which may result from the movements which are made in the vicinity of the affected part of the spine. We come then to the therapeutics of abscess. 1. To fulfil the first indication, we must have recourse chiefly to a strengthening regimen. The patient must be placed in the most favourable hygienic condition. Bitter pharmaceutical preparations, such as gentian, hops, juglans regia, chalybeates, and certain medi- cines whose antiscrofulous properties are generally recognized, such as iodine, iodide of potassium, cod-liver oil, and the preparations of phosphate of iron, may be administered in different forms. As may be readily perceived, the internal treatment will be the same as that for scrofula. 2. With the view of combating inflammation, especially if the caries results from external violence, we may employ wet cups or leeches, but with great prudence, for generally those in whom the disease declares itself, even under the influence of external causes, are of a lymphatic or scrofulous temperament. We prefer to blood- letting the mercurial frictions of Dr. Serres, of Uzes, irritating frictions, flying blisters, moxas, and chiefly the actual or potential cautery, under the form of points. Experience on this subject has taught us that burns from the actual cautery cicatrize much more promptly than cauterization produced by caustics; but as we con- 184 CARIES OF THE VERTEBRA. sider the indication to fulfil is to exert as frequently as possible a revulsion on the skin, cauterization by the iron is to be preferred. As we experience less repugnance on the part of patients and their parents to the application of caustics than to that of the hot iron, we frequently use the Vienna paste, and we hasten the separa- tion of the sloughs by dressings with the onguent de la mere, or some digestive ointment. We carefully introduce issue peas in the wound which results from it, as advised by certain physicians, so that we have a prompt cicatrization, and only flying cauteries, which we can renew a very large number of times. We may add that these applications of caustics have never produced, in our hands, any accidents or erysipelas. The disease often progresses in spite of these applications. Our colleague, M. Bouvier, rejects them in all cases, and contents him- self with dry cupping and applications of tincture of iodine, but we consider these agents as very weak for a disease of so grave a character. We only omit cauterization when the paralysis has ceased or diminished, or when pressure, exerted quite forcibly over the prominent spinous processes, does not develop pain. We may still, as a matter of prudence, only omit them gradually. We thus adopt the views of Pott, since we do not reject the cautery in all cases. Nevertheless, in many cases of slight intensity, we abstain from its use. 3. We must, as much as possible, prevent movements in the affected part, and support the vertebral column, not straighten it. After what we have said of the formation of the gibbosity, it is evident that we must treat it with great moderation. We must endeavour to give regularity to the spine, or sustain it by apparatus that has no other effect than rendering immovable the two seg- ments of the column. These segments, on account of the destruc- tion of the ligaments that unite them, have a tendency to exert dangerous friction on each other. These in fact produce pain and induce in the deep parts an inflammatory condition, the least incon- venience of which would be to interpose an obstacle to consoli- dation. Besides, they may compress the spinal cord, which is frequently already compressed by the suppuration which has been diffused into the vertebral canal. Let us here inquire into the value of the mechanical means employed, which may be reduced to three: mechanical beds, cor- sets, and crutches. TREATMENT. 185 We at once dismiss from consideration the use of the bed referred to, for it is in fact, not a question of straightening, but of support- ing. If then we make the patient lie down, let it be on an ordinary bed, taking care always that the mattress, made of hair, fern, or sea- weed, presents a certain amount of resistance. A soft bed would be objectionable and injurious. We will be able to see, from the' region affected, what are the parts to be supported in a straight position. If in the cervical region, the head must be supported either on a hair pillow, or, better still, by means of mechanical col- lars, which rest on the shoulders and support the head by ascending over the lateral portions of the base of the skull and the lower jaw. This method is followed, when we wish to make the patient get up. If the caries exists in the dorsal region, we should cause the patient to lie on his back or on his abdomen, but not in a curved position, for soon the straightening would present great inconveniences, or would be impossible. A cure might be effected, perhaps even would occur more rapidly, but one of the most frightful deformities would remain. Rickets may be sometimes straightened by the mechanical beds, which are generally prescribed in caries. Mechanical corsets succeed at a certain stage of the affection. They have this certain advantage, that they support, by means of uprights, which pass under each of the axillas, the upper part of the unaffected body, which would otherwise weigh upon the lower, crushing it, and would augment the disorders already produced by the caries. They may arrest the gibbosity in its formation, and are useful at the commencement. These corsets, in order to be properly made, should fit the hips perfectly by a resisting belt, from each side of which proceed two guards movable by means of a screw, in such a manner as to follow the patient's growth in his successive evolutions. These two guards have the same effect as crutches in supporting the shoulders. The corset has some real advantages both as a medium of protection and support, and the patient should wear it for a long time, and even after a cure, which may be more apparent than real, and be followed by a relapse, if the support of the vertebral column be neglected. Bonnet, of Lyons, devised two forms of apparatus, which satis- factorily fulfil the indications desired. One of these is designed for patients who are confined to bed, the other to those who are on their feet and walking about. The first consists of a kind of breast-piece in metallic wire, modelled upon the gibbosity, and 186 CARIES OF THE VERTEBRA. padded on its concave face to prevent all painful contact. The second is composed of two springs united in front of the pelvis and terminated by crutches which rest on the external and upper por- tions of the chest, while a belt placed above the pelvis serves to support the lower part of these crutches. This apparatus is par- ticularly useful when the patients commence to go about. After what has just been said, we may easily conceive how use- ful crutches are. If there be complete or incomplete paralysis, the weight of the pelvis and lower extremities will exert a salutary traction, when the shoulders will be supported by the upper por- tion of the crutches. An immense advantage for the patient, in a hygienic point of view, is the power to walk by means of these forms of apparatus just as soon as there is a probability of cure. But especially must we never lose sight of the fact that no mechanical method can be followed by completely satisfactory results independent of internal treatment aided by a healthy atmos- phere and good food. We therefore combine with these mechanical appliances permission to our patients to lie back in a small, gentle carriage, and be drawn through a garden, and over an even soil, which causes no shock to the child. As for sympathetic abscesses dependent on caries of the vertebrae, they deserve a special mention, on account of the regions they occupy and the difficulty often experienced in reaching them. Sometimes they are even inaccessible to cutting instruments, and they can only be subjected to general treatment; an example of which may be found in abscesses of the anterior dorsal region. Collections of pus in the cervical and lumbar regions are more easily reached. Abscesses of the cervical region, by the obstruction they occasion to the functions of deglutition and phonation, are promptly recog- nized, and their fluctuation may be detected, by the finger carried into the pharynx; and the pus may be evacuated by the bistoury or the pharyngotome, an instrument which we have for some time found exceedingly useful. It may be objected to this method that it allows the air to enter into the purulent focus, causing putrefac- tions of the pus, and sometimes purulent absorption; but we have never yet met with accidents from evacuation of the pus, which is driven out by the energetic and simultaneous contraction of the muscles of the pharyngeal region. In the lumbar and gluteal regions, the pus produces a prominence over the iliac crest, or else TREATMENT. 187 it empties through the sciatic notches as far as possible in the deep or superficial regions of the thigh, or in the sheath of the psoas and iliacus muscles. Under all circumstances, the pus often remains stationary, and then if the abscesses only give rise to a small amount of inconve- nience, we must leave them untouched and confide mainly in gene- ral treatment and repose. But when they have acquired a large volume or become red and painful, we must decide to open them, and this will only be accomplished by successive subcutaneous punctures by means of the flat trocar and syringe of M. Guerin. A piece of adhesive plaster is then applied on the puncture, and methodical compression exerted on the sac with bandages and com- presses. In spite of these precautions, the pus re-forms with con- siderable rapidity, and at the end of a few days or weeks we are obliged to recommence the operation, taking care, all this time, to continue the general treatment. When the pus collects afresh, we have derived benefit from using injections of tincture of iodine diluted with water one-third or a half, following the example of Dr. Bonnet. These injections are reapplied several times, at an interval of eight days, allowing the fluid to remain only a few minutes. Fistulous tracts are sometimes established in place of the open- ings, and the pus flows from them little by little, in a continuous or intermittent manner. It is thus that nature often proceeds to accomplish a cure. When the fistulas remain, they may still be successfully injected with tincture of iodine diluted with water. Flaubert, of Rouen, and after him, Lisfranc, advised that over the abscess incisions should be made, an inch or more in length, not fearing the contact of air, the introduction of which, according to these surgeons, facilitates the adhesion of the walls by producing a slight inflammation. We have tried this method, but not with suc- cessful results. We had to deplore the death of a patient from purulent infection, the result of violent inflammation of the sac of the abscess. There is still another method of opening the abscess. We refer to caustics; but when the slough falls off', the air may penetrate the sac and produce serious accidents. We have considered it our duty, therefore, to abandon this class of remedies, and have given our preference to the trocar, even making several successive punc- tures, and, if necessary, resorting to iodine injections. It is certain that, by means of all the local methods we have 188 IMPERFORATION OF THE ANUS AND INTESTINES. referred to, we have cured some of our patients, but we have also frequently seen the disease progress and death result. Under the in- fluence of general medication only, patients have recovered; so that we must not neglect a continuance for a very long time of iodides, chalybeates, cinchona, and all the bitter tonics; and even at the termination of the disease, when it advances towards a cure, it is often beneficial to prescribe sea-bathing and sulphurous baths, even several years in succession, at suitable periods. In all cases, these cures are effected only after a great length of time, and nearly always, also, with more or less marked deformity. CHAPTER XXVI. CONGENITAL IMPERFORATION OF THE *^NUS AND INTESTINES. We sometimes meet with new-born children that come into the world with a malformation, in the shape of an imperforate anus. It sometimes exists alone, but is often accompanied with an imper- forate condition of the intestines. Without entering fully into all the details of this important subject, we shall speak only of what •we have observed and done for it, as well as what our experience induces us to do at present. 1. Anal Imperforation; Complete Atresia.—Children born with an imperforate anus or anal atresia are in such a condition that they can- not relieve themselves of the meconium. They are like those who are attacked with strangulated hernia, having the abdomen distended with gas, vomiting at first everything they drink, the meconium next ascending into the stomach and being voided by the mouth, and death occurring in two, three, or four days, unless they are speedily relieved. There are several varieties of this form of im- perforation. Sometimes we have found no vestige of an anus; at other times the anus has been well-formed externally, and in the midst of its radiating folds a diaphragm exists contiguous to the intestine, which terminates in a cul-de-sac, so that the rectal pouch is formed even with the sphincter ani; in other instances, we have found a properly shaped anus which would admit the end of the little finger, but presenting a cul-de-sac, in which it cannot ANAL IMPERFORATION. 189 penetrate further than a half or three-quarters of an inch, and there terminates the rectal pouch, which is separated by a partition of the cul-de-sac already referred to. In these cases of simple anal imperforation, it is sufficient, after having emptied the bladder, to make a puncture directing it on the side of the sacrum, to avoid wounding the vagina or the bladder, and we thus sometimes very readily reach the bowel. To perform this operation with safety, it is better not to operate im- mediately after birth, but wait until the meconium descends and dilates the lower part of the intestine. For this purpose we have de- vised a small, curved, grooved trocar, and making the puncture in the normal direction of the rectum, we withdraw the stylet. If nothing escapes through the canula, we should confine ourselves to this explorative puncture, but if the meconium presents itself, as it does in simple cases, it is proper that the canula should be replaced by a gum-elastic tube. The canula is not made with a flange, but in its place is the interior thread of a screw, which enables us to adapt to it a metallic stem, which gives it additional length and readily retains it without allowing it to escape. We may then conduct on the groove of the tube a bistoury, and divide the contraction to the right and left. It is easy to introduce a gum-elastic tube on the stem, and to push this tube into the bowel. If we desire to bring down the bowel with a blunt hook, or with grasping forceps, or with the dilator devised by M. Bonnafont for the pre- puce, we may dissect the periphery of the extremity of the intes- tine, and secure the freshened edges of the bowel on a level with the anus, by means of several stitches. In cases in which we do not bring down the lower end of the bowel, nor attach it as just described, it will be very important to retain in the anus either a gum-elastic canula, or a piece of charpie, to keep the opening dilated, for it tends in the majority of cases always to become contracted. I have seen children in whom this form of anus performed its functions well without any tendency to become contracted, provided a dilating substance was used for several months, either a canula or the charpie. If, at the end of several days, we do not wish the canula to remain in the rectum, we must at least introduce it every day and let it remain a quarter or half an hour, and do this for several months. As the result of this operation, the sphincter ani sometimes regains its strength, little by little, and the children retain their feces. Sometimes, however, 190 IMPERFORATION OF THE ANUS AND INTESTINES. they are obliged to wear a tampon constantly for this purpose; and yet this infirmity, which frequently persists, is less disagreeable than that resulting from artificial anus established in other regions. 2. Incomplete Imperforation; Fistulous Atresia in an Abnormal Situation.—When the anus does not exist in the normal region, it may happen that the rectum will open at other points, which will be seen on examining the child. Authors have cited many anoma- lies of this kind, and in our own experience we have seen quite a large number. For example, we have observed several cases in which the rectum opened through the perineum, the scrotum, or the vulva, by a very narrow passage, the urethra, the bladder, or the vagina; and in the latter case the child may live, though we must always endeavour to re-establish the anus in the perineum. 3. Imperforation with Loss of Substance of the Rectum.—The rectum has been found to be to a greater or less extent wanting. The lower extremity of this bowel is then seen to be replaced by a fibrous ligament, which ascends to a varying height, and descends to the point at which the anus should be. The rectal pouch is sometimes in the pelvis towards the neighbouring part of the lower end of the sacrum, at other times ascending as far as the base of the sacrum, and even getting into the left iliac fossa. It finally may happen that the rectum is wholly absent, and that the intestinal canal terminates in the sigmoid flexure of the colon. The large intestine has also been found to be deficient. In one case we saw a new-born child that was unable to evacuate its bowels, though the anus was properly formed, and the finger could be introduced into it; the large intestine existed, but was so narrow that in its whole extent it would scarcely allow, from the anus to the caecum, a catheter as large as a goose-quill to be admitted. It presented, in the place of junction of the caecum and colon, a dia- phragm, which retained the feces in this portion of the intestine, the rest of the canal being in a normal condition, the ileo-caecal valve and the whole of the small intestine having undergone no change. Among other curious cases, we saw a foetus with an intestinal tube extremely narrow in its whole extent, from the anus to the jejunum; it was reduced to the size of a crow-quill, and presented at very close distances, say about an inch and a half to two inches, diaphragms, which retained the meconium. This little patient vomited continually, and lived about three days. In these last cases, surgery is totally powerless, but when the large intestine stops IMPERFORATION OF THE RECTUM. 191 in the left iliac fossa, which we generally hope to find, and when attempts have been made to establish an anus in the perineal region, the surgeon in his efforts to preserve the life of his patient has two kinds of operation to resort to, especially if the parents demand direct operative interference. But they must be told in advance that these operations are very uncertain, and are very often followed by inflammations which carry oft" the little sufferers; and that if they succeed, the poor children may remain with an infirmity which is frequently the torment of their lives. It is then very important to arrive at a correct diagnosis of these various forms of malformation of the intestine. Unfortunately it is very difficult at the outset to recognize the particular kind we have to treat. In nearly all cases, percussion of the abdomen gives a sonorous sound, and if there should be dulness, announcing the presence of fecal matters in the intestine, this fact gives us very little assistance in making a diagnosis. We may nevertheless dis- cover that the lower extremity of the rectum is near the imperfect anus, and if we feel fluctuation in the perineum, either before or after making an incision, we may easily detect the communication with the bladder and the vagina; but, in other cases, the diagnosis is impossible. It will therefore be necessary to use. prudence in endeavouring to establish the anus in its normal situation, by the procedure above referred to; or, better still, by at first slowly making a transverse incision, carrying it towards the coccyx to avoid the bladder, vagina, etc. It will be well, so as to guide himself in this dissec- tion, if the operator previously makes the puncture with the trocar we devised, introducing through the opening made in the intestine a blunt hook, putting a metallic curved bougie in the bladder in small boys, in the vagina in little girls, to remove them from reach of the bistoury, and then carefully dissect around the portion of intestine that may present itself. This should be opened and secured, as we have already described, to the wound. In any event, if we do not reach the rectum, we must resort to one of two opera- tions, which have for their object the going in search of the colon, bringing it to the external surface of the abdomen, and establishing an artificial anus, either in one of the iliac fossae, or in the lumbar region. The first is known under the name of Littre's operation, the other as Callisen's. The latter was actively resorted to by Amussat. 192 IMPERFORATION OF THE ANUS AND INTESTINES. The operation of Littre consists in making an incision of six or eight inches, above the left or right inguinal ring. Though the colon is sometimes found on the right side, it is most generally so on the left. The incision being made into the skin, fascia, and muscles of the abdomen, we come to the peritoneum, which should be divided on the grooved director. Generally at this situation we find the sigmoid flexure of the colon, which is divided longitudinally to the extent of an inch to an inch and a half, and we then secure, by means of stitches, the edges of the wound in the intestine to the fresh edges of the wound in the skin. The meconium escapes, the abdomen, which was tense, sinks, and the patient is relieved, a catheter is secured in the wound, and if inflammatory symptoms do not arise, the child may be cured. Such results have followed, but in the dozen or more operations we have performed, our patients died of peritonitis two or three days afterwards, with or without the discharge of fecal matters. The operation of Callisen, perfected by Amussat, is performed in the left lumbar region, without dividing the peritoneum. A trans- verse incision is made in the soft parts, in the middle of the space which separates the last false rib from the iliac crest of the left side, so that the middle portion is outside of the sacro-lumbalis and dor- salis longus mass. In this direction we meet the descending colon, which we incise at its back part, where it is not covered by peri- toneum, and we secure the edges of the wound in the bowel to the incision in the skin by four stitches, as we have previously stated. We must not forget that in the new-born the kidney, which should be our guide in the operation, passes considerably beyond the ex- ternal border of the quadratus lumborum muscle, and even descends into the iliac fossa. We next come to the posterior surface and external border of the kidney, covered by the colon, which lies alongside of it, or passes in front of it. In the adult, we only meet with the inferior extremity of this organ, which we find surrounded with its covering of fat. From what has now been said of the operations of Callisen and Littre, we may discover that the execution of the former is more difficult than that of the latter, but there is greater probability of peritonitis in Littre's operation, for the serous membrane is twice divided, and in that of Callisen this is avoided entirely. Neverthe- less, several successful cases have been published by Littre's method, and Robert, in his report to the Academy, gave an extract with IMPERFORATION OF THE RECTUM. 193 favorable results from them. M. Rochard, of La Rochelle, showed us a preparation from a patient operated on by himself according to Littre's plan, who lived five years, and died of diphtheritic in- flammation of the throat. The ends of the divided intestine, which was the sigmoid flexure of the colon, were perfectly adherent to the parietes of the divided abdomen. M. Goyrand, of Aix, who ad- vocated this operation, has also reported favourable results with it, while Amussat has, on.the other hand, credited success to that of Callisen. If we consult the small number of patients who have been cured by either of these operations, they nearly always express regret that they ever survived it, for nothing is as annoying as the dis- gusting infirmity of which they are the victims. And yet some have been cured, and the authorities on this subject have cited ex- amples of those who have lived fourteen, twenty-two, forty, and even forty-three years. (See article by M. Giraldes, Malformation de VAnus, in the Nouveau Dictionnaire.) After these two operations, even immediately, or some time afterwards, if the patient does well, we should be disposed to attempt to re-establish the anus in its normal situation, adopting the method of M. Demarquay. A silver conductor of the size of a female catheter may be introduced into the lower end of the intestine as far as the point corresponding to the anus; and by means of this conductor a needle armed with a thread may be pushed through the partition of the cul-de-sac of the intestine, which should be pierced at the natural situation of the anus. This thread should carry with it a small metallic ball, which, by exert- ing pressure on the point corresponding to the anus, will cause the adhesion of the intestine. At the end of some time it will serve as a guide to make an incision which would thus penetrate the rectum. This opening should then be subsequently dilated, and the anus in the iliac region afterwards closed, as soon as we are perfectly satisfied of the passage of fecal .matters through the peri- neal anus. 13 194 TRAUMATIC LUXATION OF THE FEMUR. CHAPTER XXVII. TRAUMATIC LUXATION OF THE FEMUR. Many practitioners are almost ignorant of the fact that trau- matic luxation of the femur occurs in children. This lesion is so uncommon, that those who have had occasion to observe it may be considered specially favoured. This is not because no one has written upon the subject: the majority of standard authorities are, it is true, silent upon it, but Hippocrates has much more care- fully discussed it thau any of his successors. He distinguishes in children three kinds of luxations of the femur, those which are congenital, the result of accident, and of disease, and he gives, in regard to the last, a summary description, in which we at once recognize coxalgia. {Trad, de Littre, tome iv. p. 243.) Hippocrates appears to have observed in children four varieties in the seat of luxations of the femur, and as in his day the means of reduction were as yet but little known, he compares in these four varieties the consequences of unreduced luxation in children and adults, and considers that generally they are more serious in the former than in the latter. We find in his work the cause of this difference in the prognosis in the old and the young; it is because the thigh-bone does not follow the progress of growth, and remains shorter than that of the sound side (op. cit., p. 235). Not only does the luxated femur not attain its length, but the inferior extremity is affected throughout, becoming atrophied and emaciated much more thau in other dislocations, on account of the absolute want of exercise. (Op. cit., p. 253.) On this subject, the divine old man made this admirable reflection: "In a word, all parts of the body which were made for active use, if moderately used and exercised at the labour to which each has been habituated, become healthy, increase in bulk, and bear their age well; but when not used, and when left without exercise, they become diseased, their growth is arrested, and they become old before their time." After having thus laid the rational foundation of gymnastics, he could not fail to make it useful; so he urges several times the good TRAUMATIC LUXATION OF THE FEMUR. 195 effects from it, which particularly attend children suffering from unreduced luxations of the thigh. After Hippocrates, no author appears to have treated of the subject now occupying our attention. Here and there we find a very few scattered facts, and to gather fresh details, we must trans- port ourselves from the most ancient work to one of the most modern, from that which was at the foundation of the science to that which has given the best resume of it. Thanks to the progress of sur- gical practice, M. Malgaigne has scarcely been able to study the results of unreduced luxation. Hippocrates, however, left him nothing in this connection to discover; but the erudition of the learned professor would lead him to recognize some cases, and the use that he knows how to make of statistics would reveal to him the relative frequency of the lesion in adults and children. In his Traite des Luxations, these predictions are confirmed, for we find mentioned in it the fact of the reduction of a traumatic luxa- tion of the femur by Lisfranc, in a little girl of eighteen months; also cited in it the case of a little patient twelve years of age, of Saint-Andre', in whom a simple fall produced a sciatic luxation; the history of another of the same age observed by Paletta, re- ferred to here as a luxation of the femur with rotation of the limb outwards, but the seat of the luxated head of the bone was not sought for; and finally, a boy of fourteen years, the subject of an in- complete luxation above the cotyloid cavity, and another, of sixteen years, with a luxation below that cavity. Nevertheless, the statis- tical labours of M. Malgaigne prove that traumatic dislocation of the femur is extremely uncommon in children, since, in a summary of fifty-one cases made by this professor, in only a single case was the patient under fifteen years of age. In our own experience, wre had met with but a single example of this lesion, when, by one of those coincidences with which patho- logy is not sparing, two children who were suffering with it came under my treatment at the hospital at only a week's interval. On account of their exceptional character, so far as the question of age was concerned, these two cases deserve to be reported. It may be interesting also to compare them with one another, and to see how the descriptions agree with those given for the same affection in the adult. Case I.—Alphonse D., thirteen years old, entered the Hopital des Enfants, Nov. 1st, 1860, for a traumatic lesion of the left thigh. 196 TRAUMATIC LUXATION OF THE FEMUR. He stated that at night, at the time of leaving the theatre, having laid himself down on a bench, he was picked up by the police and conveyed to prison. While seated there, he perceived that the beds, which in these premises are placed one above the other like bookshelves, were about to fall over. He immediately put the left knee on the ground, and curved his back to protect his head. He received the shock on his back, and as the left femur sustained the weight of his body, the luxation was apparently produced by a forced movement of flexion of the trunk on the thigh. Examined on the 15th, at the morning visit, he was lying on his back, the left thigh slightly flexed on the pelvis, the leg semi-flexed on the thigh, the entire limb adducted and rotated inwards, the thigh and the leg resting on their inner surface, the foot on the corresponding border. The hip was very large, and the hand at once felt the superficial projection formed by the head of the femur, while, on the contrary, there was difficulty in finding the depression of the fold of the groin. The limb appeared to be slightly dimin- ished in length. All spontaneous movement was impossible. That of flexion was produced without pain, but it was impossible to abduct and rotate it outwards. The patient being put under the influence of chloroform, the method of Despre'z rapidly produced reduction with the character- istic sound. The following day, the child moved his leg in the bed. On the 22d, seven days after the reduction, he got up, and made the tour of his bed supported, but could go no farther. On lying down, he still experienced pain, when his limb was subjected to movements of abduction and rotation outwards. On the 25th, he took a few steps unsupported; the next day he walked rapidly, but was still a little lame; on the 3d of December, he walked very well, and only experienced a slight soreness in stooping to tie his shoes; on the 7th, he left the hospital. Case II—On the evening of November 22d, was brought to the Hopital des Enfants. young Victor Marie B., twelve years of age, strong and of good constitution. It was stated that an hour before, this child, employed in a tobacco manufactory, was drawn by the end of his scarf towards a wheel, which was turning horizontally, when a workman, to save him, caught him by the leg and drew him in an opposite direction. He succeeded, but also produced a dislocation of the right femur. The movement thus impressed on the limb seemed to be one of abduction and rotation inwards. TRAUMATIC LUXATION OF THE FEMUR. 197 The next day, the child was lying on his back, the right lower extremity slightly flexed and abducted, resting in its whole ex- tent on its inner surface, with a slight curvature of the pelvis, as in coxalgia. The gluteal region was prominent, and, at its external part, the head of the femur was very readily felt rolling under the fingers, when the limb was subjected to movement. The great tro- chanter appeared to have preserved its normal height; an interval of about four inches separated it from the anterior and superior iliac spine, while on the side unaffected the corresponding interval was nearly five inches. From the iliac spine to the extremity of the external malleolus, the distance was about twenty-eight inches and a half on the affected side, and fifteen inches and a half on the sound side. The measurement repeated several times gave like- wise very slight variations. The violent pain prevented us from determining what movements were provoked, which persisted. In addition to this, the child having been very nearly strangled by his scarf, still presented, the next day after the accident, a greatly in- jected face and ecchymosis of the conjunctiva. Chloroform was administered, and the reduction attempted; ex- tension was made by two assistants, who drew upon a slip-knot made with a napkin, and placed above the malleoli; counter-exten- sion was made by means of a large cloth passed under the right side of the perineum, and secured to a bedpost. Another cloth, directed transversely, supported the pelvis. After the first trac- tion, reduction was obtained. The next day, the child performed, in his bed, all the movements of the thigh, except those of adduc- tion and flexion, on account of the pain they produced. He could, however, sit down. On the 28th, all the movements of the thigh were possible, in his bed; on the 3d of December, he was allowed to get up a mo- ment, and walked without limping; on the 5th, he arose and walked without difficulty; and, on the 9th, he left the hospital completely cured. In a comparison of the two cases, we find a striking resemblance. The lesion was produced in two patients of the same age, both healthy and with good constitutions, who had reached that period of childhood which borders on adolescence. The mechanism differed, it is true; in one, the cause was a forced flexion of the trunk on the thigh; in the other, probably a violent movement of adduction and rotation inwards; but the symptoms were identical, even to the 198 TRAUMATIC LUXATION OF THE FEMUR. position of the limb, the deformity in the gluteal region, the pro- minence of the head of the femur, and the impossibility of the movements of abduction and rotation outwards. Reduction was equally prompt and easy, although obtained by different methods. The results were also happy, and the cure so rapid that in less than fifteen days both little patients could walk without difficulty in the ward. Considering especially the identity of the symptoms, these two luxations evidently belong to the same variety. But what is this variety? The problem is easy, if we content ourselves with the standard opinion of the day. This luxation, MM. Malgaigne and Vidal denominate the iliac, and M. Nelaton the ilio ischiaiic, but the name given by Hippocrates, luxation out- wards, is better, and is thus described:— "When the head of the femur is dislocated outwards, the limb in these cases, when compared with the other, appears shortened. Inwardly, the thigh about the perineum appears more hollow and flabby, but externally the buttock is more rounded, because the head of the thigh has slipped outwards, but the nates appear to be raised up, owing to the flesh there having yielded to the head of the thigh-bone. The extremity of the thigh-bone at the knee ap- pears to be turned inwards, and the leg and foot in like manner." But, in the iliac variety, Sir Astley Cooper recognized two sub- varieties, the iliac, properly so called, and the sciatic, distinguished from each other by the symptoms they presented, and by a very decided difference in the reduction, easy for the former, often very difficult for the latter. This distinction has not been recognized by the majority of modern surgeons. Nevertheless, in a recent work, Dr. Chapplain, of Marseilles, has, with some ability, come to the defence of the sciatic luxation of Sir Astley Cooper, and if our two cases are compared with the one he has published, we will be led to admit two sub-varieties—one superficial or iliac, the other deep or sciatic. In fact, in both our patients, the foot of the side affected rested on its inner border, and followed the movements of rotation of the limb. In that of Dr. Chapplain, the foot rested on the heel, and did not follow the thigh in its movement of rotation. In the one case, the great trochanter did not appear to be sensibly depressed; in the other, it visibly descended. In one it was a little closer to the an- terior and superior iliac spine, in the other it was more remote. The head of the femur, the position of which was wholly superficial, and its movements perfectly appreciable in our two patients, was TRAUMATIC LUXATION OF THE FEMUR. 199 much deeper and could not be clearly distinguished by the Mar- seilles surgeon. A difference of much greater importance was the following: the ordinary procedure of traction and counter-extension, and that of M. Despre's, gave an immediate result in our two cases, but Dr. Chap- plain employed them without success, though he attempted the former according to all the rules laid down by Sir Astley Cooper, and the latter at two different times. It was by a method founded on the study of the cadaver that he accomplished reduction. Having decided that he had to overcome two obstacles—on the one hand the position of the head behind the posterior border of the cotyloid cavity, on the other hand the resistance of the pyra- midalis and obturator intern us muscles—he overcame the first by carrying the limb into a state of forced adduction, and the second by forcing the movement of rotation of the neck by means of the leg flexed and used as a lever, so as to approximate it to the bony surface of the external iliac fossa, thus depressing the head of the femur beneath the two tendons. It is not, moreover, the first time that we have found reduction of luxations of the head of the femur in this region embarrassed by muscular obstacles; an illustration of which was presented to the Societe Anatomique by M. Parmentier, in which the head of the femur, situated directly opposite the sciatic notch, was caught in a button-hole formed by the pyramidalis and obturator internus. M. Malgaigne, it is true, attributes to incomplete luxation the symptoms that Dr4Chapplain refers to sciatic luxation, and espe- cially the position of the foot and the depth of the head of the femur. But, without taking any account of the almost paternal affection of M. Malgaigne for incomplete luxations, and without opposing the authority of Hippocrates, who strictly denied them for spherical surfaces like those of the head of the humerus and femur, has not the former written that incomplete luxations of the femur naturally present less difficulty in reduction than the others? This is certainly not the fact in the case observed by Dr. Chapplain. We conclude with the remark that it is important to distinguish in iliac luxations two varieties, except that in place of founding this distinction on their relations with the bones, which may pre- sent very slight differences in the two cases, and only produce of themselves trifling consequences, it would perhaps be more natural, looking at the symptoms, prognosis, and treatment, to establish one 200 FOREIGN BODIES IN THE AIR-PASSAGES. variety of superficial, and another of deep luxations. In the for- mer, the head of the bone, always superficial and easily felt under the fingers, and not in relation with any muscle which can re- tain it, is always reduced without difficulty, as Hippocrates has remarked in regard to his luxation outwards, which corresponds perfectly with this (op. cit., p. 305). In the second variety, the head of the femur, deeply situated and not easily felt with the finger, is in relation with the tendinous and muscular portions, which holding it by au adhesion, or imprisoning it in a button- hole, may interfere with its reduction. The two cases we have described in our own practice would then be examples of super- ficial iliac luxation. CHAPTER XXVIII. FOREIGN BODIES IN THE AIR-PASSAGES. Foreign bodies in the air-passages may come from the exterior or the interior of the body, and are met with in the larynx, trachea, and bronchial tubes. They are observed especially in children, and are very different and of many various kinds, as Louis has described in the Memoires de VAcademie de Chirurgie. Foreign bodies arising from the interior of the body may be worms, which, ascending through the oesophagus, pass into the larynx and sometimes cause sudden death; at other times, pus proceeding from an abscess of the neck, or a tubercular produc- tion developed primarily in a ganglion, or in the lung, and pene- trating the larynx. There are also foreign bodies passing from the interior, which in the first instance had an external origin, such as arise from wounds of the chest sometimes making a channel into the pulmonary tissue for pieces of the dressing, as charpie, or bits of lint, which thence get into the respiratory passages. Even por- tions of necrosed bone may penetrate the lung-tissue, to be expelled by the bronchial tubes and trachea. A ball may follow the same course, as the result of a wound of the chest. All these foreign bodies often present themselves without any phenomena indicating their existence; and yet, for abscesses of the neck which find an FOREIGN bodies in the air-passages. 201 outlet into the trachea, for retro-pharyngeal abscesses which threaten to empty into the larynx, and for foreign bodies coming from a penetrating wound of the chest, there are symptoms which put us in the way of a true diagnosis. Nevertheless, we must say that these cases frequently terminate without having been suspected, and several cases of this kind are reported by writers. This does not apply, however, to foreign bodies from without, which are numerous, and introduced directly by the mouth, whether they be fluid, soluble, soft, or solid. The fluids may be water, wine, spirits, all forms of drink; the soluble bodies may be sugar, pieces of gum, sugar-plums, bits of bonbons of all kinds, pills, &c; the soft substances, food more or less masticated; and the solid bodies, raw beans, nuts, beads, teeth, plates of several teeth, bones, fish- bones, pieces of money, button moulds, &c. Symptoms.—The foreign body is either in the larynx or the trachea, and the symptoms are more serious in proportion to the tender age of the child, as both these channels are then much nar- rower. If the foreign body is fluid, the phenomena it provokes are a lively irritation, a convulsive and suffocating cough, a kind of stoppage of the breath and a rale, which disappear quite rapidly when the fluid is expelled. If the foreign body .be soluble or soft, it causes almost the same symptoms. Immediately after the accident, there is so much suffo- cation that the patient may die on the spot; but generally there is a violent, rough, convulsive cough, with threatened suffocation, appreciated both by the patient and the physician, the voice is raucous or extinct, there is anxiety, a feeling of fright on the part of the patient, and pain in the respiratory tract, the locality of which is easily indicated by him, while at other times it is more vague. If the foreign body is solid, these symptoms persist, and even in- crease in intensity, but they vary according to the consistence of the body introduced into the air-passage, those substances that are solu- ble sometimes only producing these symptoms for a short time, for, becoming dissolved, they diminish in size, and are promptly expelled by the efforts of coughing. A piece of sugar, for example, of small volume, is soon expelled, and a piece of gum or barley-sugar, or a bonbon or pill, when dissolved, becomes smaller, and is dis- charged by the efforts of the child, either whole or in fragments. 202 foreign bodies in the air-passages. The same thing may occur, but more slowly, with pieces of chewed meat, and soft bodies in general. We once saw a child who for several days in succession brought up pieces of chewed meat, and thus was relieved of it in violent fits of coughing, and the same thing occurred in another who had eaten a sugar-plum with the kernel, the pieces of which had entered the larynx and trachea. The case is quite different with bodies that are really solid, for the symptoms already referred to not only persist, but produce other symptoms. A pin or a fish-bone may settle itself in some part of the larynx and produce very severe inflammation; and bodies of this kind may remain fixed at one point. Round and solid bodies have a tendency to change their position, and they may pass from the larynx into the trachea, or else remain in the ventricles of the larynx when they are small, or even descend into the bronchial tubes. In cases of this kind we may find the foreign bodies moving and becoming displaced, and giving rise to inter- missions that induce the persons surrounding the patient to believe that there is no foreign body present, because a perfect calm suc- ceeds most alarming symptoms of cough and suffocation. When these foreign bodies are in the larynx, the symptoms vary less, because there is no displacement, but when they are in the trachea they may ascend and descend, and on placing the hand in front of the neck there is a sensation of a body rising and falling in the trachea. Sometimes these bodies descend into the bronchial tubes, and do not budge. We had occasion to diagnosticate the presence of a bean in the left bronchial tube of a child, in whom respiration was only heard in the right lung, the respiratory mur- mur being entirely absent in the left. We may therefore throw light on the case by careful observation of the respiration. When these foreign bodies are left to themselves, either in the larynx or the trachea, if fluid and soft they are naturally expelled, but not so if they are hard, remaining constantly of the same vol- ume, or increasing in bulk, as is the case with beans, for instance. Under such circumstances the symptoms increase in intensity, and the threatened suffocation is renewed; sometimes the patient is agi- tated by convulsive movements, the face becomes violet, the eyes are suffused with tears, the veins of the neck dilated, and there is a pro- minence in the air-tube. The child makes very energetic efforts at expulsion, and in this way produces an accumulation of air in the lungs, which distends their parenchyma; a rupture ensues, the air PROGNOSIS. 203 penetrating the cellular tissue above the clavicles and through the chest, producing pneumothorax, and death gradually results, but, all things being otherwise equal, more quickly in children than in adults, on account of the smaller dimensions of their organs. The diagnosis, made through the means already indicated, is quite often easy; yet we cannot lay too much stress on all the symp- toms detailed. We must also attach the greatest importance to the information furnished by the persons surrounding the child at the moment of the accident, who were witnesses of the first symp- toms observed, which are sometimes followed by the expulsion of the foreign body, for then the symptoms that persist may require only a temporizing treatment. It is very important that we should not confound the introduction of a foreign body into the pharynx with the presence of one in the larynx. Usually in the latter the pharynx and oesophagus admit the passage of drinks, which is not possible when the substance is in the pharynx. Nevertheless, a foreign body of large size, such as a portion of an alimentary bolus, may enter the trachea, and compress the oesophagus, and thus obstruct the passage through this canal, so that the patient cannot swallow with- out regurgitating; in such a case, the trachea being distended by the foreign body, we must ascertain with certainty whether the oeso- phagus is free, and this can be detected by introducing a catheter which will pass into the alimentary canal. If sometimes we find the alimentary mass in the oesophagus, we should push it into the stomach, when the difficulty will be overcome, and the diagnosis certain. If the contrary occurs, we will find in the oesophagus an obstacle beyond which it is difficult to pass, and which cannot be pushed forward. We then know that there is a distended trachea compressing the alimentary canal, and we discover the cause to be in the air-passage. Prognosis.—The gravity of these cases varies according to the age of the child, his general condition, the consistence of the foreign body, its volume, and the length of time it has remained in the air- passage. Very small children, a year old, for example, may expe- rience much more serious symptoms, on account of the narrowness of the larynx and the trachea. It is additionally serious if the child's health is impaired. Fluids only produce momentary symp- toms; soluble substances are less dangerous than those that are soft, and hard bodies which produce permanent symptoms all pre- sent greater or less- gravity. Those with smooth surfaces are not 204 FOREIGN BODIES IN THE AIR-PASSAGES. accompanied with the same danger as if they had points or rough- nesses. Foreign bodies may, by their bulk, intercept more or less rapidly the passage of air, and lead us to dread an abrupt asphyxia. If foreign bodies remain for any length of time, we have reason to fear that they may produce by their presence inflammatory or other complications, which may be prevented by very early removal of these substances; and yet we are aware that they have remained for months or years in the respiratory passages, and have been ex- pelled by the efforts of nature. Treatment.—When called to a child having a foreign body in the larynx, if we examine him with the laryngoscope or the speculum of Dr. Labordette, and the body is at the entrance of the larynx, or even between the vocal cords, we may, by the assistance of this last instrument, positively see the foreign body and seize it with a pair of polypus forceps; and this is the best plan to follow. If this method cannot be adopted—and it seems to us of indispensable ser- vice in such cases—we should at once turn the child head down- ward, striking it on the back, and causing it to cough and cry. We have seen bodies expelled in this way, such as beans, pieces of money, &c. If this fails, we may, but without any great hope of success, em- ploy emetics, sternutatories, and at last, most frequently without delay, resort to laryngotomy, if we think the body is in the larynx, or else to tracheotomy, if in the trachea or the bronchial tubes. For the performance of these operations, we must follow the pre- cepts laid down in the article on "Tracheotomy in Croup" (p. 47) and not forget to use the small cranesbill forceps in seeking for the foreign body, which may be lodged in a bronchial tube. In a case of this kind we were fortunate enough to use this instrument with success, for these bodies do not escape from the bronchial tubes as easily as they do from the trachea. We must decide so much the more promptly in favour of tracheotomy, as we do not have to fear the want of success that attends it in cases of croup, in which wTe rarely succeed; for, in fact, in tracheotomy performed for the removal of a foreign body, death is the exception, a cure the rule- We have had occasion to perform tracheotomy five times for the extraction of beans from the trachea; four of these recovered, but one, who was operated on eighteen days after the accident, died of pneumonia. We have always applied a simple dressing to the wound on the PURULENT OPHTHALMIA OF THE NEW-BORN. 205 first day, and we have only gradually effected a union. We may endeavour to produce union at once, when the foreign body has escaped, but not when it still remains and we hope that it will be got rid of at a somewhat later period. The edges of the wound may then be kept apart by a canula. After an operation of this kind the surgeon should apprehend an attack of bronchitis or pneumonia in his patient, and be always on his guard, examining every day the chest, and at once treating the earliest symptoms. CHAPTER XXIX. PURULENT OPHTHALMIA OF THE NEW-BORN. This disease receives its name from a specific inflammation of the oculo-palpebral conjunctiva, met with in children at birth, or some days afterwards. It solely attacks children, and sometimes several at the same time. It may attack one eye or both, and may be epidemic. The causes are often obscure, and there may be several of these. The child may contract this form of ophthalmia at birth, in its passage through the vagina, which may be bathed by a leuco - rhoeal discharge, or it may have caught cold soon afterwards What is certain is that this ophthalmia sometimes declares itself under the influence of special conditions of the atmosphere, and is essentially contagious, the child giving the disease to its mother, to its nurse, and to other children. On this subject all authors are agreed. Symptoms.—The commencement of this disease may be recognized by the following symptoms: In the first stage, the third day after birth, the eyelids are found to be adherent by several slight crusts, the upper one being somewhat smaller, and presenting a transverse linear redness. There is tumefaction of the border of the lid, es- pecially on the inner side, with pain and sometimes fever. This tumefaction goes on increasing, the redness extends, and the inner surface has a villous appearance, with an injected condition of the ocular and palpebral conjunctiva. We have difficulty in reversing 206 PURULENT OPHTHALMIA OF THE NEW-BORN. the lids, which the patient keeps closed, for the eye is sensitive to light. In the second stage, there forms under the lids a mucous viscous fluid, which clings to them, and soon becomes white and thick, and separates from them when we raise them. The edge of the upper lid tends to pass over that of the lower, the injected condi- tion spreads from the lids over the globe of the eye, and advances towards the eornea, and a swelling of the conjunctiva results, by which the cellular tissue becomes infiltrated and forms a chemosis. The secretion becomes more and more abundant, then ceases to be thick, becomes serous, and trickles over the cheek. The cornea remains transparent, examination of the eye becomes very painful the orbicularis palpebrarum muscle contracts, and we have to raise the levatores palpebrarum to see the globe of the eye. We should not hesitate to chloroformize our patient under such circumstances, to determine the exact condition of the eye, and we will then find either pus, or granulations, or false membranes, from which we may describe three varieties of this affection, the purulent, granular, and pseudo-membranous or diphtheritic. An ectropion sometimes forms at the moment of examining the eye, which may persist, and then decided granulations are seen on the palpebral conjunctiva, and the matter of the discharge becomes sanious, being mixed with blood. If the disease does not continue to develop, it may termi- nate without leaving any traces, the granulations cease to be formed, the pus dry up, and the false membrane become detached. Third Stage.—If the ophthalmia is not arrested, we now find the discharge becoming completely purulent, and there often exists, at this time, a false membrane, but not constantly so in all cases. Usually, the cornea, which had remained transparent, becomes muddy, softened, and infiltrated with pus, followed by abscesses, which open and leave perforating ulcerations of the cornea, which is sometimes destroyed, mortified, and as if strangulated. At other times, before the loss of the cornea, there may be seen, within a twenty-fourth to a twelfth of an inch of the circumference, an annular effusion, more or less complete, followed by a slight cloud spread uniformly over the surface of the membrane. This some- times extends with great rapidity, and then a general opacity fol- lows, which is due to purulent infiltration. The cornea, softened in its whole extent, soon presents a conical projection; ulcers form upon it, that open and give an outlet to the humours of the eye, LOCAL TREATMENT. 207 which escape with the crystalline; sometimes there is a hernia of the iris through these ulcerations; at other times, at the moment we endeavour to examine the eye, it ruptures, producing a peculiar sound, and becomes atrophied. We may anticipate this serious ter- mination when we see the annular effusion, already referred to, spread over the whole cornea, and taking a general yellow tint. It is in these cases that the disease is checked; the ring gradually diminishes in width, and circumscribes at the centre of the cornea an opaque spot of varying extent. When it has reached this con- dition, the disease may remain stationary, or else is subject to re- lapses, which we should be on the lookout for. Prognosis.—This is generally grave, unless the symptoms are checked at the outset. At that time the disease may terminate by resolution, but slowly. Under these circumstances, the palpebral swelling diminishes, the discharge ceases, and the photophobia is less marked, and this resolution enables us to separate the lids and bring the eye back to its healthy condition. But if the disease pro- gresses without being checked, it may bring in its train specks, which may remain for a long time, and yet may in time diminish. We have also to fear the occurrence of capsular cataracts, hernia of the iris, staphyloma, leucoma, and the total loss of the eye, which may take place in two or three days. Treatment.—We may divide this into the local or surgical treat- ment, and the hygienic and medical, which is especially efficacious at the commencement. The remedy par excellence is the nitrate of silver; the treatment by leeches and emollients generally fails, and is even injurious. 1. Local treatment.—At the very outset of the disease, we should at once drop into the eye three or four times in the twenty-four hours a weak collyrium of nitrate of silver—a grain and a half of this salt to half an ounce of water. If the disease has already reached its second or third stage, we may act more energetically and pass between the lids a small brush steeped in a somewhat stronger solution of the same salt. We have often derived advan. tage from passing the solid stick of nitrate of silver rapidly over the inner surface of the lids, and then causing to trickle into the eye either water acidulated with several drops of chlorohydric acid or salt-water. We thus change at once the excess of the nitrate into the insoluble chloride, which becomes detached from the mucous membrane. In this little operation we have to act rapidly, 203 PURULENT OPHTHALMIA OF THE NEW-BORN. and especially take every precaution not to touch the cornea, which is already slightly altered. We sometimes recommend the application of one or two leeches in the neighbourhood of the eye, at the same time that these cauterizations are made, though we have rarely resorted to them. We have derived benefit from employing irrigation of cool water over the eye, as recommended by M. Chassaignac, by means of a large funnel, filled with a quart of simple water, terminated by a capillary tube, which enables us to let fall into the eye a continuous threadlike stream of water. To practise this irrigation, we uncover the head of the child, which had previously been laid across its nurse's knees, and hold the lids apart, the head being inclined backwards, so that the water falls off on each side, and runs into a basin placed behind the head. By v means of a sufficiently large piece of isinglass plaster applied around the child's neck, we may establish a gutter, which directs the water into the basin, and thus prevents it from running down the neck and over the shoulders. After these irrigations, we immediately dry the head, which we cover up lightly, and make continuous applications of compresses steeped in cool water and often renewed over the eye or eyes affected. We have had very good results from these irrigations, repeating them four or six times in the twenty-four hours. When we do not wish to follow this course of treatment, or hesitate to wet the child's head, we obtain benefit from the inunction around the eye, two or three times daily, over the forehead and the temple, and beneath the lower lid, of an ointment composed of corrosive sublimate, glycerine, and extract of belladonna, in proper propor- tions. We must combine with this, gentle purgatives, syrup of succory for the new-born, and for those that are older a very simple and very efficient prescription. Every hour, or every two hours, we give the child a powder, containing about one-twelfth of a grain of calomel to a grain and a half of powdered sugar. Besides this, we must continue for a greater or less time the collyrium of nitrate of silver, the composition of which must be varied according to the intensity and persistence of the disease. We may also return to cauterization of the lids with nitrate of silver, according to circum- stances, being very careful in regard to it, when there is perforation of the cornea. Nevertheless, we need not hesitate to touch with the pencil of nitrate of silver, very lightly, certain ulcerations of the cornea and slight hernias of the iris. HYGIENIC AND MEDICAL TREATMENT. 209 As a result of these cases of ophthalmia, we sometimes find the cloudy cornea covered with vessels, which pass over it from the con- junctiva. Following the example of Prof. Sanson, we have made circular cauterization around the cornea, and have in such cases seen the cornea become again transparent. To perform this operation, we have always chloroformized our patient, and employed either the ring porte-caustique of Sanson, or a pointed pencil carried rapidly over the circumference of the cornea. Independently of chloroform, we must employ elevators for the lids, and have one or two assistants to hold the child properly. 2. Hygienic and Medical Treatment.—The hygienic treatment consists in modifying the diet according to the age of the little patient and the condition of the intestinal canal. If there are any febrile symptoms, we must diminish the nourishment; but if there is no frequency of pulse, we must give it the ,milk of the nurse, if it is still at the breast, and, if accustomed to another kind of nourish- ment, it is desirable that this should be continued. We must still take the precaution, in moist and cold seasons, to keep the child in an apartment properly warmed, according to the season, and not to take him into the cold air, if it is at all unpleasant. It is better that we should not keep the patient in a room made too bright by the light of the sun or by artificial light. The child should not, on the other hand, be kept in complete darkness, but in a medium light. It is, above all, improper to cover the eyes with thick and tight bandages, a light piece of linen being sufficient, if there is photophobia. In fine weather it will be of service to the child to give it the fresh air, taking the precaution to choose a time when the pain from the disease is least, and carefully covering its head with a light veil. There frequently remain on the cornea one or two spots, which in time may be diminished, and even when they are of considerable size they sometimes entirely disappear. We have found that by means of insufflation of calomel and sugar-candy into the affected eye, employed after the disappearance of inflammation, once only in the morning, with the dropping of a single drop of laudanum in the evening, we may hasten the resolution of these specks. 14 210 INCONTINENCE OF URINE. CHAPTER XXX. INCONTINENCE OF URINE. Incontinence of urine is of frequent occurrence in children, both in girls and boys, being met with in the former quite as often as in the latter. It most generally dates from birth, and sometimes continues until the child is fifteen years or more old. In the ear- liest period of life the quantity of urine excreted, compared with the fluid drunk, is very considerable; the bladder contracts very often, the urine is very slightly coloured, and there is no difference between that of the day and of the night. In children there is no, or very little, absorption through the bladder, the urine is abundant, and when the child is very young, defecation and urination are accom- plished day and night almost without any desire for them. The resistance offered by the neck of the bladder and the sphincter ani is so slight that a single contraction of the bladder and the rectum suffices for the expulsion of the urine and the fecal matters. At a later period, about the end of ten or twelve months, children have a sensation, which then first leads them to retain the fecal mat- ters. The faculty of retaining the urine is developed somewhat later, after first dentition has been accomplished. It is then that the child, that does not retain its urine, is affected with considerable incontinence, if it also possesses its intellectual faculties. Other- wise, if it is idiotic or attacked with paralysis of the rectum or bladder, there would be symptomatic incontinence of urine, which would demand a treatment of the principal disease. Causes.—Incontinence of urine in children is sometimes diurnal, at other times nocturnal, and this is the most frequent form. Which- ever it may be, the cause may not always be the same, and if, as is often the case, there be weakness, this may be the real cause. In fact, we quite often see strong children, in good health, with noc- turnal incontinence of urine. We may at first discover in them no general weakness, and the condition may depend on too fre- quent and sudden contractions of the bladder, as Desault thought. PROGNOSIS. 211 In others we find a lymphatic, scrofulous, or rachitic constitu- tion, and the incontinence is then referable to this general cause. In the former, the cause is nervous irritability, and here, with MM. Bretonneau and Trousseau, we recognize a neurosis of the neck of the bladder. According to Dr. Mondiere, who has written on this subject, many young boys, apparently of excellent constitutions, are subjects of this affection. We cannot, then, always refer in- continence to the same causes. Nevertheless, we believe that if the lymphatic constitution is often met with in children who urinate in bed, the incontinence would really arise from weakness, while in others, who are strong and robust, we would be induced to believe that profound sleep is a cause that may be invoked; or else the too frequent contraction of the bladder. This disease, which is easy to recognize, especially presents itself in the impossibility of retaining the urine at night, and is charac- terized by the discharge of urine several times or only once or twice during the night; and this condition persists, no matter what may be done to prevent it. Even if we make children urinate when they go to bed, or wake them several times in the night for the same purpose, it very often happens that they still pass their watei in the bed in spite of all our precautions. In these cases we believe there is want of tone of the bladder, whatever may be the general constitution. This may be combated by the will while the child is awake, but sleep puts the whole muscular apparatus in a state of muscular relaxation. Reviewing these causes, we consider that incontinence may be due to feebleness of the patient or a bad constitution, nervous irri- tability of the bladder, and, in some cases, profound sleep. Prognosis.—This is a very annoying disease, but it is not dan- gerous ; it is only tenacious. Generally it yields, at the latest, at about eight or nine years of age, and yet it is sometimes in excep- tional cases met with at the age of puberty. After the employ- ment of different treatments without success, it ceases with time. When it does cease, we must not believe that we have cured it; fever, an eruptive disease, a day of much fatigue or in which the child has perspired a good deal, may momentarily cause the patient to pass a night or two without having involuntary passages of urine, but two or three days afterwards the incontinence reappears. Thus, then, we must believe that there are some circumstances that 212 INCONTINENCE OF URINE. may cause intermission of greater or less length. In all cases, if we can make a favourable prognosis in respect to its non-gravity, we can only be sure that the disease will not be tenacious. Very often it demands time for its cure. Treatment—We will not speak of the popular remedies, which are numerous, and to which we attach no importance. The treat- ment may be external or internal. The complaint being very rebellious, of long duration, sometimes only yielding with time, and not to remedies that are advised, it is right that we should employ successively different modes of treatment, and have recourse to both internal and external medication. 1. External Treatment—If we can learn at once the cause pro- ducing the incontinence, we may employ one remedy rather than another; but as we cannot easily decide this, we employ succes- sively the following external remedies. We may advise river or sea bathing in warm seasons, applications of cold water over the hypogastrium or to the perineum, cold lotions over the whole body morning and evening, shower-baths, douches of cold water on the loins and the posterior part of the pelvis, and cold immer- sion baths. In cold seasons, we would give the preference to tepid sulphur, saline, and gelatinous baths, and vinous or aromatic baths. These different remedies have given good results, espe- cially if perseveringly used. The introduction of a catheter for a quarter of an hour, morning and evening, into the canal of the urethra, has been suggested; and cauterization of the neck of the bladder with nitrate of silver two or three times, several days apart, has also been practised. It has been advised that injections of cold water should be thrown into the bladder, and that this be repeated several days in succession. In some cases we may derive advantage from electricity. Compressors of the urethra have also been applied during the night, and by this method, proposed by J. L. Petit, the bladder has been forced to retain the urine. M. Jacquemin has employed them with success in young patients. 2. Internal Treatment.—We have used internally for incontinence, as others have done for a long time, tonics, cinchona, iron under different forms, antiscorbutics, preparations of iodine and iron, cubebs, ergotine, and strychnia. To complete this internal treat- ment, we must add a proper regimen, which should be tonic, principally good roast meats; the patient should drink but little water, but good wine; avoid soup in the evening, at dinner; and INTERNAL TREATMENT. 213 eat but few beans and but little fruit that has a tendency to the urine. After having resorted to all the external and internal means advised for incontinence of urine in children, we may say that the agents that have succeeded most frequently are cold baths, sea- bathing, sulphurous and shower baths, douches of sulphurous water, or of cold water, combining with it a tonic treatment, cod- liver oil and ferruginous preparations when the children thus affected are delicate, lymphatic, or scrofulous. But when they are not of such a temperament, but rather nervous, sea-bathing, sul- phurous baths, and douches, often excite them without any good result following. We must subject such cases to the use of other remedies, either the preparations of belladonna or the employment of strychnia. The belladonna may be given in pills, containing the simple extract combined with the powdered root, in appropriate doses, morning and evening, gradually increased. The strychnia may also be given in pill form in combination with the,black oxide of iron, evening and morning. Whatever the treatment may be, we must persevere in it a long time—two, three, or six months. M. Trousseau, who has great con- fidence in the extract of belladonna, as prescribed by Bretonneau of Tours, and advised by Thomas of the same city, and Dr. Blache, recommends that it be given perseveringly, commencing with a moderate dose, and gradually increasing it, for several months in succession. We must not cease the use of belladonna just as soon as we have procured a decided amelioration, but continue it with- out increasing the dose, and only stop it little by little by diminish- ing: the dose, until we reach that with which we had commenced. This treatment should be modified according to the effects pro- duced in different patients, either suspending it or abandoning it entirely. 214 CANCER OF THE EYE. CHAPTER XXXI. CANCER OF THE EYE. Cancer of the eye is met with more frequently in children than in adults, and is presented under two principal forms, encephaloid and scirrhus. Melanosis is very uncommon in children ; fungus hsematodes sometimes occurs. Pathological Anatomy.—Encephaloid is frequently found to com- mence by a point on the retina, and then to invade successively all the elements of the eye. It does not differ from that met with in other regions, and is a soft tissue of a consistence and colour analogous to softened cerebral tissue. Scirrhus is hard, resisting) and whitish, and when cut resembles fibrous tissue. It begins in the globe of the eye, without our being able to ascertain satisfactorily its point of departure. The melanotic tissue presents itself in the form of a soft bluish-black tumour, and may commence in the interior of the globe, and sometimes in the external parts. These various tissues are met with in the eye, and sometimes spread into the cellular tissue of the orbit, invading the eyelids, and even penetrating through the foramen of the optic nerve into the base of the brain, the structure of which they attack and modify. Even the bony walls of the orbital cavity are sometimes altered to a greater or less extent. Causes.—These are obscure, as in all cancerous affections; never- theless, it is established that sometimes this disease follows a con- tusion, but usually there is at the same time a disposition to a cancerous affection. We must admit two different forms or varie- ties; one commences through the retina and constitutes encepha- loid, the other by attacking the whole globe, constituting scirrhus of the eye. In the first stage of encephaloid the eye looks healthy, the sclerotic is white, there is no redness, and the iris has its normal colour and mobility. Children that are not very young complain that they see badly or not at all, but not of any pain at the corn- CAUSES. 215 mencement. Gradually, if the disease progresses, the pupil becomes irregular, and if the light is made to penetrate obliquely into the eye, we notice at the bottom something brilliant, and in the con- cavity of the globe we discover a spot of a copperish colour on the dark base of the eye. This is of the size of a small bean, then gradually increases, and invades the whole breadth of the retina, and is radiated with red vessels. If the pupil has been previously dilated with atropia, all the symptoms are more easily detected. The tumour compresses the vitreous body, which becomes lique- fied, and now enables us to see the encephaloid matter. In the second stage, the inflammatory condition, which did not exist at first, now commences. The tumour becomes prominent in front, and pushes the crystalline against the iris, the eye increases in volume, the sclerotic becomes injected, and there is redness and lachrymation. The iris, pushed forward, becomes joined to the cornea, the irregular pupil becomes immovable, dilated, and dis- coloured, the diameters of the globe of the eye are augmented in all directions, the conjunctiva becomes infiltrated, and forms a ring around the cornea, and the lids, also infiltrated, are pushed for- ward by the prominence of the eye. At the same time there are very acute lancinating pains, chiefly at night. Children complain incessantly, and are then attacked with intense and continuous fever, sometimes delirium. Third Stage.—Up to this time the outer coat has resisted, but soon it breaks, and sometimes the cornea, at other times the sclerotic, becomes torn. The very acute pains caused by the strangulation then partly cease, and this cessation reveals, to us that rupture is effected. If the sclerotic is opened, we may not see at once the encephaloid tissue appear, but if the rent extends to the cornea, a reddish sanguinolent fluid makes its appearance, the crystalline escapes, the tumour becomes prominent, diffuses a fetid odour, and is sometimes the seat of hemorrhage. General'debility throws the child into a state of coma, and death soon follows. In scirrhus of the eye, the disease invades the entire globe. At its commencement, we recognize all the symptoms of internal ophthalmia, such as lachrymation, photophobia, redness of the eye- ball, and injection of the eye, the sight becoming gradually weakened and completely lost. The pain, which becomes more and more acute on the corresponding side of the head, soon becomes continuous, with loss of sleep, diminution of appetite, and at the same time 216 CANCER OF THE EYE. swelling of the submaxillary and auricular ganglions; the globe of the eye increases in volume, loses its shape, and becomes irre- gular. The cornea remains for a long time healthy, the iris becomes displaced and is inclined forwards, and the anterior chamber becomes filled with blood. All this progresses slowly, while in encephaloid the development is more rapid; gradually chemosis occurs, the cornea becomes altered in its shape, and the vessels become varicose. The eye projects between the lids, becomes ulcerated at several points, the cellular tissue of the orbit passes into a cancerous condition, as well as the lids, which can no longer be moved, the eyeball likewise remains fixed, and then the disease progresses more rapidly, the child becomes ex- hausted with continuous fever, and death soon occurs with or without convulsions. Encephaloid progresses rapidly, scirrhus is developed slowly. In either case, the disease is grave, and unhap- pily always followed by a recurrence after operation. The only treatment consists in the extirpation of the globe of the eye. There are two kinds of operation to perform, whether the eye and the lids are affected, or the lids are healthy and only the globe is involved. When the eye alone is affected, we may operate in the following manner. Having laid the patient down, with his head supported and resting on a pillow, and then chloroformizing him, we enlarge with a bistoury the external angle of the lids, and seize the eye with the Museux forceps, or a tenaculum, or introduce a curved needle conducting a thread. The operator, holding the forceps, the tenaculum, or the thread in the left hand, or having it held by an assistant, draws the eyeball slightly towards himself while another assistant keeps the lids separated with two elevators. He then introduces a straight bistoury, after the manner of Louis, into the external angle of the orbit and along the bony wall, incising all the soft parts surrounding the globe. He spares the mucous membrane which borders the eyelids, unless these latter should themselves be affected and must be sacrificed. He then divides at a single cut, with curved scissors, the optic nerve and the recti muscles, which retain the eyeball at the bottom of the orbit. No inconvenience results from removing the lachrymal gland, even when it is not affected. Several surgeons, Demours, Sanson, and Lisfranc, recommend this ablation of the gland. We should, in conclusion, make a careful exploration of the fatty tissues CLUB-FOOT. 217 of the orbital cavity, and remove them with the forceps and curved scissors if they are ever so little affected. It is very difficult to make a complete extraction of the affected tissues, for very often they penetrate through the fissures of the base of the skull, and creep into the cavity of the bone; sometimes even the bones are attacked, and the indication is to scrape them. The dressing should be very simple, such as charpie steeped in cold water, and very gently placed in the orbit. Slight compression might be used if there be hemorrhage; otherwise we must avoid all compression, which may produce symptoms of encephalitis, and these should be very attentively watched. The orbital cavity is filled with granulations, and a transverse cicatrix gradually results. We must acknowledge, however, that too often cancer grows out again, and that granulations of a malignant character appear. The indication is to repress them immediately, but we rarely accom- plish their destruction. During twenty years at the Hopital des Enfants, in more than thirty or forty patients operated on for this terrible disease, we only obtained cures of very slight duration, even by removing the eye at the commencement, when there as yet existed on the retina but a simple yellowish tumour. We have most frequently met with. relapses before the formation of the cicatrix, or at the latest a year or eighteen months afterwards, and these then progress with extreme rapidity. Pain, generally of very great violence, forces from the child continual groans and cries; fetid pus runs over the face; the patient becomes exhausted, and sometimes hemorrhages occur, repeated with greater or less frequency, and finally the pa- tient falls into a state of marasmus. CHAPTER XXXII. CLUB-FOOT. We meet with a deformity in the new-born, to which we apply the term club-foot, characterized by a permanent vicious deviation of the foot. For a long time two varieties of this disease have been distinguished, the congenital and the accidental. The former is of course observed at birth, the latter subsequently, and is only 218 CLUB-FOOT. the consequence of diseases which declare themselves more or less tardily and the cause of which we can appreciate. By the faulty direction of the foot in various directions, we distinguish four principal kinds, talipes equinus, talipes varus, talipes valgus, and talipes talus. In talipes equinus, the point of the foot is inclined downwards, and the patient walks upon the toes, the sole of the foot and the heel not touching the ground. In varus, the sole of the foot is turned inwards, and the outer edge of the foot bears upon the ground. In valgus, the contrary is the case. In talus, the patient walks on the heel, the sole of the foot looks forwards, and the toes are directed upwards. The causes which produce congenital club-foot have their action in the mother's womb, and cannot be very positive, being rather presumable or conjectured. It is thus that club-foot becomes hereditary, and we meet with children the issue of club-footed parents. Independent of this inherited cause, we must suppose that a child comes into the world with a club-foot either as the result of a primary anomaly, the cause of which exists in the germ, or of an affection seated in the nervous system, convulsions or other diseases of the cerebro-spinal apparatus, which we must admit may become developed in the foetus as in the new-born child, or by a bad position taken by the child. The mother being questioned and watched, we may sometimes learn by her answers that she herself is very impressible and very nervous, having had convul- sions at various times, either before or during her pregnancy, and that thus the child may take from its mother, and have intra- uterine convulsions. Whatever the cause, we are reduced to mere conjecture, but in all cases we find permanent muscular contrac- tions. Symptoms.—Careful investigation presents us with different symp- toms, and we will therefore describe these and the indications for treatment in the four kinds of club-foot. In talipes equinus, which is quite rare, I refer to that which is simple and uncomplicated, the child walks on the point of the foot or the toes; there is forced extension of the tibio-astragaloid joint, the foot is inclined forwards, the heel raised backwards, and the sole of the foot looks backwards. There is another variety, in which there is very considerable extension, the foot is turned in a direction from above downwards, the sole of the foot looks upwards, SYMPTOMS. 219 and the dorsal surface rests on the ground. The French term "Enroulemeni" has been given to this variety. In simple talipes equinus, there is, so to speak, only a decided contraction of the tendo Achillis, and consequently the muscles of the calf, the flexor muscles of the foot and of the toes then act like the tendo Achillis, and contribute to this vicious position of more or less decided forced extension of the tibio-astragaloid articulation. In enroulement, there is sometimes very powerful contraction of the flexor muscles of the toes, the muscles of the plantar surface, and the aponeurosis. In varus, the foot is strongly adducted, the outer border of the foot rounded and depressed, the inner elevated and concave, and the point and the sole of the foot look inwards, as well as the heel. The child walks on the outer border of the foot, the internal mal- leolus is effaced, and the external is very prominent. The tibialis anticus and tibialis posticus muscles are shortened and tense, the peroneus brevis is elongated and weakened, and the peroneus longus and extensor digitorum pedis are also elongated. The weight of the body rests on the foot, and distends the ligaments which are already elongated by the vicious position; the skin covering the fifth metatarsal bone, which rests on the ground, is painfully compressed at the point corresponding to the projection of that bone, and be- comes covered with corns in patients who walk for any length of time with this deformity. The varus we have just described is usually complicated with symptoms of talipes equinus; the heel is carried at once inwards and upwards, the astragalus is depressed in front, its pulley be- comes exposed under the skin of the dorsal surface of the foot, and we then have a variety, to which the name varus equinus has been given. Varus equinus presents still some subvarieties in which there are more or less marked subluxations of the bones of the foot, with displacements of the bones, which M. Rouvier has very care- fully described in his lectures at the Hopital des Enfants. There are also numerous deformities of the bones, also described, involving the astragalus, the scaphoid, the calcaneum, and the cuboid, and more or less marked by reason of the exaggeration of the deformity. In valgus, the foot is contracted outwards, the patient has a ten- dency to walk on the inner border of the foot, through the action of the peronei muscles and chiefly through the peroneus longus 220 CLUB-FOOT. muscle, which, by its contraction, elevates the outer border of the foot. Valgus is always accompanied with more or less equinus. Talipes talus is the most uncommon form of club-foot, and is generally congenital. It is characterized by direct flexion of the foot upon the leg. We have had occasion to meet with it in two new-born children, the feet being at an acute angle with the leg. This angle varies according to the case, and may be more decided in some cases than in others, the point of the foot cannot be brought down, extension is limited, and flexion carried beyond the normal state. The tendo Achillis is relaxed and appears prominent, and the tendons of the flexors of the foot contract when we forcibly bring down the foot. It is very rarely that talus is unaccompanied with valgus; in other words, the outer border of the foot is always more or less raised. Talipes talus may be either hollow or straight; in one the sole of the foot is hollow, in the other it is flat. In the former, the triceps cruris is paralyzed or weakened, the muscles of the sole of the foot and the plantar aponeurosis are shortened and contracted, while in the latter, there is no such paralysis, as M. Duchenne of Boulogne has satisfactorily shown by electricity. Differential Diagnosis.—The various forms of club-foot are, as already said, congenital and accidental. An examination of the foot and the antecedent history of the case given by the parents enable us to distinguish these two varieties from one another, but it is often difficult to recognize a club-foot at all, when it is not well defined, and the deviation is at its commencement. Sometimes there is great difficulty in distinguishing contraction of the muscles which produce an exaggerated position, but without permanent con- traction, and which yields as the result of convulsions, or eclampsia. In these cases we may have difficulty in forming a diagnosis, and we must examine these with scrupulous attention, and resort to electricity. There are also difficulties in the diagnosis, when several varieties of club-foot are complicated together. Prognosis and Treatment.—This may vary, according as the club- foot is congenital or accidental. If the former, the prognosis may be not at all grave, if the deviation is not considerable. Simple means may easily produce straightening, if the child is very young, for if of long standing there is more resistance to overcome, and after twelve or fifteen years of age there is but slight prospect of success. If the club-foot is accidental, the muscles are frequently PROGNOSIS AND TREATMENT. 221 paralyzed, and the case is still more serious. We have several times seen the talus variety at birth easily straightened by applying bandages in a certain way to bring the feet straight, and to keep them in forced extension. In a few months we have brought them to their normal condition. It is not the same thing, however, in regard to the equinus, varus, and valgus. These three varieties, simple or complicated, present greater resistance and they interfere more with walking. The indication is to endeavour to restore the deformity to the normal state, after having employed simple apparatus, retaining methods by means of bandages, or even mechanical means, or they demand at once both tenotomy and apparatus. We do not hesitate to operate in the first year after birth, if the child is in good health, and the club-foot resists manipulation and apparatus. 1. Talipes equinus. In this form of club-foot, in which the point of the foot is depressed and the heel raised, we have the tendo Achillis to contend with. The muscles of the calf are contracted in a permanent manner, and in endeavouring to bring the foot to a right angle, we observe the resistance of the tendo Achillis. Here, as in all the forms of this affection, it was a very long time ago remarked that mechanical means fail to overcome the action of contracted muscles, and that it is necessary, without abandoning such apparatus, to aid them by division of the tendons, this divi- sion being made in those days in rather an irregular manner. Delpech, in 1816, performed the first tenotomy, and about twenty- five or thirty years later, in Germany, Stromeyer and Dieffenbach practised it; and afterwards, in France, MM. Bouvier, Duval, and GueYin advocated and regularly performed division of the tendons of contracted muscles in the different forms of club-foot, and from that time the following methods and procedures have been used in our own practice. To speak here only of the equinus, we will say, in the first place, that in this form of club-foot, as in the others, it is best to give careful attention at once to the deformity at birth. Several means may be adopted, including the use of the hand, simple bandages, mechanical appliances, and tenotomy. With the hand we may, from a few days after birth, act upon the tendo Achillis, gradually bringing the foot towards a right angle, morning and evening, holding with one hand the lower extremity of the leg near the malleoli, and with the other grasping 222 CLUB-FOOT. the foot. The hand holding the leg should keep it firm; the other should impress on the foot movements of flexion. By means of a simple bandage applied to a new-born child, carrying the foot as much as possible to a right angle, and by daily renewing these manipulations, we may obtain successful results in this form of club-foot; but when the child has become a year old, and no good has been done by these manual efforts to straighten the foot, the in- dication is to employ more powerful methods, bandages, for instance, made with splints or wooden boards, padded, and of the length of the leg, on which the latter is to rest, and at the extremity of which is a wooden sole with a hinge-joint, which enables us to move the foot in various directions, and chiefly at a right angle, for the equinus. We have found this apparatus, which is particularly easy to make, of good service. We have also successfully employed starched or gutta-percha and even plaster apparatus, moulding these bandages on the feet, which are placed by the hands in a normal position; but we derive more benefit from mechanical boots, contri- vances which are made of a more or less improved character at the present day by surgical instrument makers. They are generally designed to replace in a permanent manner the action of the hand employed to straighten the foot. In early childhood, we may pro- duce cures with them. For the equinus, a mechanical boot, composed of a splint secured to the leg by a strap at the upper part and to the lower extremity by a sole, which enables the foot to be gradually brought to a right angle, being arranged expressly to fit the patient, may sometimes answer the purpose perfectly; but after the child has worn this apparatus for several weeks without any result, we should decide to perform tenotomy, and this operation may be practised even when the child is a year old. In such a case, as in several other forms of club-foot, we will have only the tendo Achillis to divide. For this operation, it is not necessary to chloroformize the patient; we must lay him on his stomach, and have his leg held by an assistant, who with one hand supports it at the lower part above the malleoli, and with the other causes the tendo Achillis to project, by flexing the foot as much as possible. The operator, supporting also the leg with the left hand, performs subcutaneous tenotomy, as advocated by MM. Duval, Bouvier, and J. Gue'rin, using for the division a straight, very narrow and sharp tenotome. He plunges the point of the instrument flatwise, passing it along the posterior part of the TREATMENT. 223 tendon opposite the malleoli, in the direction of a line from left to right, or from right to left, depending on which side is operated on, but without piercing the skin on the other side. The instrument being then withdrawn, is replaced by a probe-pointed tenotome, introduced at first flatwise; its edge is turned against the tendon, its back portion being behind the skin, and the edge is conducted like a violin bow so as to divide the tendo Achillis from behind for- wards very slowly, in such a way as not to cut abruptly the tendon, which lies close to the vessels and nerves on the side of the inter- nal malleolus. After this division, there is a want of resistance; we detect the space between the ends of the tendon, and we feel its cellular sheath, a portion of which remains at the place of division. This is the point where repair occurs, cicatrization commencing bj^ an inflammatory condition, followed by union. The division being made, the instrument is withdrawn. The little puncture is united with a piece of isinglass plaster, retained with a stirrup bandage, and we apply the apparatus anew two days afterwards, when the wound is united. If suppuration occurs, we retard it. It appears to us important to establish satisfactorily union of the wound before applying apparatus. For want of this precaution, we have detected erysipelatous inflammation around the puncture, and there may even be abscess, but this rarely occurs. The apparatus once in position, we must straighten the foot gradually each day. The use of this boot should be watched every day, to avoid too strong pres- sure of the apparatus, for this may often cause excoriations or bruises of the skin, which can only be prevented by dint of great care and by not too roughly tightening it. In such cases it is very important to listen to the complaints of patients, which some- times are without cause, but often also well founded, of the pressure of the apparatus. This may be remedied by taking off the boot, powdering with potato-starch the bruised parts, and especially by loosening the apparatus. Finally, we make the patient wear this mechanical arrangement for several weeks, the action of which is carried even to exaggera- tion of the straightening we wish to obtain, and only after some time do we allow him to walk with the apparatus. When we wish to remove it, we must not do so without having previously had boots arranged to permanently overcome the deformity. These may be 224 CLUB-FOOT. worn in the daytime, and taken off at night and replaced at that time by the apparatus previously used. It is only by persevering for several years in these applications that we may successfully overcome abnormal deviations of the foot. A long time after this operation, we have found the cicatrix of the divided tendon firm, gradually extended, and giving greater or less length to the contracted muscle. With all our care, the tendon may remain too short, and the cicatrix may not have been formed with sufficient space, and we are then obliged to perform a new operation. 2. Varus is the most common form of club-foot. In this variety the foot is carried inwards, the point as well as the sole of the foot; it is, besides, in extension, consequently more or less equine, and hence the condition is called equinus varus. In walking, the foot rests on the outer edge, the toes are pressed back, sometimes luxated, and there is frequently a tendency to displacement be- tween the two rows of the tarsal bones, but this is not always the case. There are varieties of this form of club-foot that incline towards equinus and valgus. It is rarely that we meet with a totally uncomplicated varus. The older it is, the more likely it is to be complicated with deviation and deformity of the bones of the foot. 3. Valgus, which is more uncommon than varus, is still not a simple valgus; the foot is turned outwards, but there is a union of extension, as in equinus, and of abduction, and hence the term equinus valgus or valgus equinus has been given to it. There are varieties of this affection of a more or less decided character, often even accompanied with deformity of the bones, increasing with the age of the patient. Let us examine successively the varus and valgus forms of club- foot, and the treatment appropriate to each. In varus, we always find that the tendo Achillis is more or less con- tracted, and then we must commence by flexing the foot, which is extended, and by simple or mechanical apparatus act at first on the tendo Achillis. But the foot is in a state of adduction from the contraction of the tibialis posticus and the flexors of the toes, which thus produce it; we must overcome these deviations by the arrangement of apparatus and appliances properly made to fulfil the indications opposed to adduction of the foot, and then after- wards by tenotomy, when this becomes necessary. It should be performed on the tendo Achillis, on the tendon of the tibialis pos- CLUE-FOOT. 225 ticus, near its inferior insertion below and on the inside of the sca- phoid, and on the tibialis anticus, on its insertion at the posterior extremity of the first metatarsal bone. Tenotomy is performed on the tendo Achillis, as already mentioned for equinus; but it is not always sufficient. If other tendons, after division of the tendo Achillis and the tendon of the tibialis, appear to interpose resistance to the straightening, we must, in making them prominent by ex- tending the foot, divide them also. At the end of two days, when the small wounds of the skin are cicatrized, we should apply me- chanical apparatus, using for varus that which we have already referred to for equinus. For valgus, the apparatus should carry the foot inwards, and should combat the action of the peronei muscles; and when, after being worn for a certain time, it does not remedy the deformity, we must resort to tenotomy, which, in this case, should be performed successively, but the same day if possible, on the tendo Achillis and the tendons of the peroneus longus and peroneus brevis, where they appear to be stretched under the skin when the foot is forcibly adducted. As for talus, generally the action of the tendo Achillis is null, and the flexors of the foot or extensors of the toes, act alone. This kind of club-foot, which is often complicated with valgus, yields in time to the use of apparatus well and perseveringly applied. From congenital club-foot we now pass to the accidental form. The majority have for their cause, convulsions, which have produced at the most tender age, or still later, more or less complete paralysis, which affects the lower extremities. Often by medical treatment or in the course of time these paralytic attacks progress towards a cure, but with the re-establishment of movement in certain muscles and not in others. From this, contractions of some of the muscles result, which produce various kinds of club-foot. These second- ary club-feet ought not to be treated surgically immediately after their appearance, for by treating the cause of the paralysis with perseverance, or by the assistance of nature, it sometimes happens that we have equilibrium re-established in the muscles, and the de- formity more or less abated. But if the paralyzed muscles do not regain their power, we must treat these accidental club-feet like the other forms; we must put on apparatus, and even, in certain cases, practise tenotomy, but it often happens that the muscles remain 15 226 CLUB-FOOT. paralyzed, and that we are obliged to make the child wear me- chanical boots. To sum up, congenital club-foot may be treated with success sometimes by simple apparatus or mechanical boots, by applying these during the first year of life or later. At the commencement we should apply very light apparatus, and increase the power in proportion to the age and the muscular resistance. When in a few months we do not obtain straightening, we should resort to tenotomy, often of the tendo Achillis alone, and sometimes of other tendons. It is better to leave the patient for two days after the operation with a simple dressing, and only to apply the apparatus at the end of about forty-eight hours. We must, in the first stages after the operation, aid every day or two the straightening by a series of manipulations, which overcome the deviations, by different movements directed for about a quarter of an hour in whatever direction the nature of the deformity may demand. The subse- quent application of apparatus should be watched with the greatest care, to avoid very injurious pressure on the limb. We must prolong for an extended time, sometimes for years, the employment of mechanical means, and often modify them accord- ing to circumstances. All things being otherwise equal, we shall have greater chance of success in treating club-foot too soon rather than too late. Very simple and very light apparatus should be used at the commencement of the treatment, and we should employ mechanical means only if other plans fail. Finally, we may operate with benefit about the second year after birth, but greater care and precaution are needed if the child is very young. Up to the age of twelve or fifteen we may hope for success, but after that period, if success follows, it is exceptional. The remarks here made on congenital club-foot may also apply to the accidental form, except that, in these last cases, before resorting to tenotomy, we must have exhausted such remedies as can attack the cause of the paralysis of the muscles. In these acci- dental club-feet there is often less chance of success, because the paralysis may resist all the means advised; but as thev may some- times succeed, we should never neglect them, such as gymnastics, shampooing, sulphurous baths, electricity, friction, etc. Unfortu- nately, all means usually fail, and the children are obliged always to wear apparatus to assist them in walking. CANCER OF THE TESTICLE, 227 CHAPTER XXXIII. CANCER OF THE TESTICLE. Cancer of the testicle is not extremely uncommon in children; many authorities cite examples of it, and we have, for our own part, seen at least ten cases in very young children, even at birth, a year of age, etc. Pathological Anatomy.—The tumour formed by the degenerated testicle represents, as in the adult, a scirrhous and often encephaloid structure. Sometimes we have met with colloid or fibro-plastic tissue. The examination of a testicle that was removed by us exhibited an organ of more than three times the natural size. It was smooth, soft, and revealed to the eye a firm tissue, white and resisting in certain points, having a lardaceous appearance, while in others it was of a soft encephaloid substance, rosy, nearly diffluent, studded with small bloodvessels, and easily crushed under the fingers. The albugineous covering or tunic appeared to us healthy under the microscope. We discovered the existence of fibro-plastic nuclei, more or less infiltrated, and only here and there, in the midst of the tissue, irregular cellules of a granular form. We noticed some red points formed by extra vasated blood, but we did not detect seminiferous vessels. We have not had occasion to see tumours of this kind which had produced ulceration of the scrotum, but others have met with examples of it; neither have we seen chimney-sweeper's cancer, which is more common in England than with us. At the autopsy of children who have died as the result of a recurrence of the disease, we have found lymphatic ganglion's, which have passed into a cancerous state, and sometimes also can- cerous lesions in other organs, as the mesenteric ganglions and the liver. Causes.—In children the causes are perhaps still more obscure than in adults. We have seen cancerous testicles in children whose parents had not had cancer, consequently we cannot say that 228 CANCER OF THE TESTICLE. this disease recognizes hereditary transmission for its cause in all cases. Sometimes bruising of the organ may give rise to degene- ration ; therefore, if the testicle of a child becomes cancerous after a contusion, we may admit that this circumstance operates to excite it in an organ already predisposed by an organic cause. Symptoms.—The commencement of these cancers passes unper- ceived. Children are frequently brought to us when there is first discovered in the scrotum a development which has already ex- isted for a long time, and we can therefore say, as children do not at the outset suffer, that the disease is at first indolent, and appears under the form of a tumour, which occupies either the right or the left side of the scrotum. Thus, when we examine a child who is suffering from a cancer of the testicle, we discover a tumour of more than double the ordinary size of that organ, with a certain weight and elastic consistence, most frequently without change of colour of the skin, the venous circulation of which appears slightly modified, the scrotum generally sliding over the non-adhe- rent testicle, often without pain. We easily detect the tumour as distinct from the cord; it rests more or less heavily upon it, is well separated from the inguinal ring, and usually presents a rounded shape, sometimes tuberculated. Generally we have not met with this last appearance, but others have done so. When the disease is recent, the glands of the groin are not found to be swollen, and the cord is healthy; and there is usually no fluctuation, unless the affection is complicated with hydrocele. Nevertheless, when the testicle is in an encephaloid condition, there is a softness, which might be con- founded with the fluctuation of a fluid, but there is no transparency. The diagnosis is sometimes difficult. If, as an explorative means, we'make a puncture, there is little or no fluid, and the instrument is not movable as it is in a bag of fluid. The tumour is distinguished from tubercular tumours, which are met with in children pre- senting other symptoms of tubercles; in such cases the skin of the scrotum is adherent at the point corresponding to a softened tubercle, and there is a more or less decided prominence, in which we find a real fluctuation formed by pus. We may confound these degenerated testicles with tumours produced by a false conception, sometimes seen in this region; but these tumours are rare. By the touch we detect, in such cases, hard or bony parts, as we have had occasion twice to find. Before removing them, we may be TREATMENT. 229 uncertain from the touch alone, but anatomical examination leaves no doubt. Inflammatory engorgements of the testicle become developed and progress rapidly, with pain, and this does not occur in cancer, which is indolent for a greater or less length of time. If there be hasmatocele, we may often mistake the disease, and it is only by an operation, when we expose the tumour, that we recognize the lesion. We must then leave the gland untouched, and only remove the haematocele, if that be possible. The prognosis of this disease is quite as grave in the child as in the adult, and of six cases operated on by us, one, a patient of eigh- teen months, was carried off by convulsions, three days after the operation; one we lost sight of, and in the four others we saw or learned of recurrences, either in the glands of the groin or even in the deep abdominal ganglions. Treatment.—At the commencement, and especially in the doubt as to the diagnosis, we may try the effect of preparations of iodine internally and externally; but in cases in which this treatment succeeds, it is probable that an error has been made as to the diag- nosis, and that we have to deal with an engorgement of a scrofulous or tubercular nature. We must always, in these cases of cancer, resort to castration. In fact, if the anti-scrofulous treatment has failed, we must not rely on mercurials as often as in adults, where there are more positive fears of syphilis. For the performance of this operation, as in adults, it is best to make an incision in the back part of the scrotum, prolonging it as far as its lower part, unless the gland, being adherent to the skin, which may or may not be ulcerated, requires the removal of the covering of the scrotum at any special point, for then we are obliged to remove a portion of oval shape from the coverings of the affected organ. The tissue once exposed, we isolate the cord, which we may cut, and tie the artery separately, or else tie the whole mass of the cord. We must then introduce a double silk thread, and bind together very firmly all the constituent parts of the cord, so as to completely include the nervous filaments. If some of the arteries besides the principal artery are divided, we must tie them and bring out all the threads together through the inferior portion of the wound. They serve to conduct the pus to the most depending portion. We should next apply three or four stitches, surround the scrotum with a fenestrated piece of linen 230 ENCEPHALOCELE. smeared with cerate, and covered with charpie, and support the whole with a suspensory bandage. To prevent inflammatory symp- toms, we must sprinkle the dressing with cool water, taking care not to cease its use abruptly, to avoid reaction, which may induce erysipelas. We find it advantageous to renew the dressing on the next day and the following days, merely leaving the stitches, which should only be withdrawn, one after the other, according to the pro- gress of cicatrization. In those on whom we operated, this result occurred rapidly, and suppuration was of moderate quantity, with no primary accidents; but we always met with a recurrence, ex- cept in one case which we lost sight of. CHAPTER XXXIV. ENCEPHALOCELE, OR HERNIA CEREBRI. The name encephalocele is given to hernia of the cerebrum or cerebellum through the separation of the bones of the skull. Generally this affection is congenital, and is observed at birth. The encephalocele may nevertheless be accidental, as the result of a wound of the cranium with loss of substance. We have observed these two varieties in children, but we chiefly meet with the con- genital form. Congenital encephalocele exists especially in connec- tion with the sutures of the cranial bones. We have met with hernia of the cerebellum through the occipital foramen. We believe that all the sutures, even the smallest, may be the seat of it. We have ourselves seen and others have observed encephaloceles making their appearance through the fronto-ethmoidal suture in the inner angle of the orbit. One such case occurred in our own experience, and Moreau, the accoucheur, has also seen one. Accidental encepha- locele may occur in all the bones of the cranium. Causes.—Frequently an arrest of development of the bones takes place in the foetus and leads to congenital encephalocele; but acci- dental encephalocele is always produced by a wound or necrosis of the bone. Symptoms.—The size of encephaloceles is very variable; some of them are no larger than a pea, others are as large as the head of a new-born child. In examining the tumour in the living sub- TREATMENT. 231 ject, we find that it is round, smooth, uniform, more or less circum- scribed, sometimes pediculated, and without change of colour of the skin; presenting pulsation, isochronous with the beat of the pulse, and increasing by expiration, coughs, and cries. If we press the tumour we may reduce it partially or entirely, and we may also by such pressure produce cerebral phenomena, as drowsiness or momentary paralysis of some parts of the face. Sometimes the encephalocele is not covered by the integuments, and the tumour appears with the membranes only. These tumours may be confounded with cephalaematoma, but the regular pulsations, which are very perceptible and very ap- preciable, and the border of bone which surrounds the tumour, are very distinctive characteristics of encephalocele. The diagnosis, therefore, can only be difficult where the tumours are very small, or where they appear through very narrow sutures of bones, the fronto- ethmoidal, for example. A tumour of the size of a pea, situated in this region, was mistaken by us and by several members of the Socie'te' de Chirurgie, for an erectile tumour, and a ligature was thrown around it, from which a rapid meningitis resulted, carrying off the patient the third day after the application of the thread which strangulated the tumour. Fungus of the dura mater might be confounded with encephalocele, for undoubted instances of such an affection have been observed in children, but in such cases the tumour is not for any length of time covered by the skin, it wears away and destroys the bony wall, is sensitive, the surface is bloody, and the pulsa- tions are not always perceptible—for the fungus comes sometimes from the bony tissue, and is not adherent to the dura mater. In any event, it has often the appearance of an encephaloid cancerous tumour. The prognosis of encephalocele is always grave; all we can hope for is, that the tumour may remain stationary. If it be of small volume, the child may live for a considerable time; but when it has become quite large, the intellectual faculties are more or less impaired, and sometimes the subjects of it are idiotic. Treatment—When encephalocele is complicated with effusion, the indication is to puncture it. Cures have been reported, not of the encephalocele, but of the effusion. Otherwise we should confine the treatment to gentle compression with covered leather plates, rather to protect the tumour from external shock than to compress it, for compression would be dangerous in the majority of cases. 232 CEPHALHEMATOMA. These plates may prevent the violent shocks which have often pro- duced immediate death, as has been found in some rare cases in which an attempt has been made to remove them. CHAPTER XXXV. CEPHALHEMATOMA. Some children come into the world with blood tumours, which have been justly distinguished from erectile tumours seated in the thickness of the hairy scalp and the subcutaneous cellular tissue, and from sero-sanguinolent ecchymoses also seated in the subcuta- neous cellular tissue of the hairy scalp ; but there is a kind of tumour, known under the name of cephalaematoma—blood tumour of the head—which depends on effusion of blood between the peri- cranium and the cranium itself. The effusion has sometimes, but rarely, occurred between the dura mater and the cranial bones; hence a division has been made into external and internal cephalae- matoma. The external variety, the only one we have ourselves seen, is a disease which is not very common, for obstetricians of the largest practice only meet with it at rare intervals. Michaelis and Schmaltz say that they are very uncommon, and Dubois reports that he had seen six cases. Three or four have presented them- selves in our own experience, at the hospital, or in private practice- These tumours are met with on different parts of the skull; some authors state that they are chiefly seen on the two parietal bones, and quite frequently on but one of them. The cause of this disease is obscure; it may be produced by a material cause, such as pressure on the head at the time of birth, and it may also depend on an anomaly of organization. Naegele, who gave this disease its name, claims that it exists previous to birth. Whatever may be the cause, it is very important that the characters of these tumours should be pointed out. Anatomical Symptoms.—We meet with these tumours between the bones and the pericranium. The blood which constitutes them is half fluid, half solid. Sometimes the surface of the bone is slightly eroded. Generally the cephalaematoma occurs in the form of a DIAGNOSIS. 233 colourless, painless, circumscribed, fluctuating or resisting tumour, and is especially apparent from the first to the fourth or fifth day after birth; sometimes it exists at the time of birth. These tumours are seated upon the parietal bones, especially on the right one, on the occiput, or the temporal region. Naegele saw one of these tumours on each parietal bone of the same patient. At the commencement, this tumour is soft to the touch; we may depress the top of it with the finger, and touch the bone on which it rests. A hard circle or a kind of ring sometimes exists at the circumference of the tumour, which may lead us to believe that the external plate of the bone is destroyed. Sometimes, but rarely, a movement of pulsation may be detected, but in the greater number of cases it is wanting. Diagnosis.—We must avoid confounding cephalaematoma with other tumours. It is developed in the bones, while encephalocele is met with in the sutures, and is formed by the substance of the cerebrum or cerebellum. The tumour has pulsations analogous to those of the brain, and may be reduced. The pulsation, which is very rare and scarcely appreciable in cephalaematoma, is quite dif- ferent from the regular and always perceptible movement of ence- phalocele. We cannot confound cephalaematoma with pneumatocele of the cranium, described recently by Dr. Thomas, of Tours, which is a gaseous elastic tumour. Erectile tumours might be confounded with cephalaematoma, but they change colour on pressure, and there are movements of expansion, and vessels more or less marked on their surface. Wens are distinguished by their colour and mobility in all directions, and an oedematous tumour produced by a sero- sanguinolent infiltration is very easily diagnosticated from cepha- laematoma. Left to itself, this affection is not of a serious character; it gene- rally terminates by resolution, but is a longer time in disappearing than a simple superficial infiltration under the hairy scalp. When patients die of other diseases, "and we have the opportunity to dissect these tumours, we find the same alterations as in blood swellings, but they are usually seated under the aponeurosis or on the pericranium; and then sometimes the surface of bone is found to be rugose. A projecting edge of bone is noticed around the affected point, and it is this edge which is perceptible under the fingers during life. These tumours are doughy to the touch and formed of coagulated blood. 234 HYPOSPADIAS AND EPISPADIAS. The treatment consists at first of simple revellents, lead-water, camphorated brandy, and water. Generally, at the end of several days, the tumour disappears; but if such is not the case, we derive very good results from puncture with a lancet. Sometimes there is hemorrhage, and the tumour may give way and not return. If it reappears, as sometimes happens, we repeat the puncture once or even twice, and there is always more or less discharge of blood. Slight compression usually suffices, after the puncture, to bring this affection to an end. CHAPTER XXXVI. HYPOSPADIAS AND EPISPADIAS. Hypospadias is a malformation of the canal of the urethra ob- served in some new-born children of the masculine sex. There are several varieties of this affection. 1. Hypospadias of the Base of the Glans.—This is the most com- mon form, and the orifice of the canal of the urethra, in place of being at the summit of the glans, is found at its base, at the place where the fraenum is attached. In such cases, which are generally considered as obstacles to generation, we have in several in- stances established the fact that men affected with this form of hy- pospadias could have children. We have even seen two little brothers, suffering from hypospadias, who were the children of a father like themselves hypospadiac. There is sometimes a very small orifice at the top of the glans, but the principal opening of the canal is found at the spot referred to, and this is what is quite commonly observed. In such a case, the stream of urine branches off, and is discharged chiefly through the orifice at the base of the glans. In the majority of cases there is only one opening, that just mentioned. In this last case there is a very narrow orifice, analogous to the openings of the puncta lacrymalia; at other times it is much larger, and enables us to introduce a child's catheter. In this malformation, after having attempted, as others have done, to restore the meatus urinarius to the top of the glans to HYPOSPADIAS. 235 its usual location, either by making a puncture by means of a trocar, or by an incision from the base of the glans, where the meatus urinarius exists, to the summit of the glans, we have never suc- ceeded, because the portion of the canal which we wished to estab- lish artificially would have a tendency always to become obliterated, and because the orifice which we have freshened, and endeavoured to close up, would always be kept open and only be closed momen- tarily, to open afresh, in spite of the continued use of catheters. We have also, after several attempts, renounced an operation for the restoration of the canal, in which we have very often failed. When the meatus urinarius is situated at the base of the glans, we content ourselves with making an incision and enlarging it towards the upper part of the glans. For this little operation, which is attended with difficulties, when the orifice is capillary, and only allows of the introduction of an Anel's stylet, we derive ad- vantage from the use of a small narrow bistoury, slightly curved, and terminated by a small Anel's stylet sufficiently delicate to pene- trate the meatus urinarius. In this manner we divide the contrac- tion, but always directing the edge as much as possible towards the summit of the glans, so as to carry the incision towards the normal position of the meatus urinarius. This operation would be useless unless the patient afterwards wears, and for quite a period, the end of a catheter, introduced only to the depth of an inch and a quarter to an inch and a half into the canal, to main- tain for a long time the dilatation of the orifice, which has just been enlarged. This end of a catheter or bougie should be furnished at its outer extremity with a wax button, which prevents it from penetrating further than we wish. We may accustom the child's parents to introduce this dilating body a quarter of an hour each day, and it is only on condition that we do so for at least one or two months in succession, that we prevent contraction of the urin- ary meatus from resulting. 2. Hypospadias of the Base of the Penis and the Perineum.—These two forms differ from the preceding; in the former the lesion is opposite the anterior part of the scrotum, in the latter behind it, in more or less proximity to the anus. We find among authors several methods and operative procedures for these two forms of hypospa- dias, which have not generally been attended with success. Some of these we have attempted, and must acknowledge that we have 236 EPISPADIAS. failed in them; so that, in such cases, we generally refrain from operating. Epispadias.—This deformity is, like hypospadias, most generally a malformation consisting in an opening, of greater or less extent, of the canal of the urethra, but at its upper part. Sometimes there exists, at the upper portion of the penis, a solution of continuity surrounding the canal of the urethra. This is often the result of a wound, but the form especially met with, more rarely, however, than hypospadias, is a cleft of the canal of the urethra, of greater or less extent, on the dorsal surface of the penis, a malformation which sometimes exists without extroversion of the bladder, but is often accompanied with this last-mentioned anomaly. In such cases surgery has most generally failed, and if we attempt to pare the edges of the cleft,afterwards uniting the divided portions of the canal over a catheter placed in the urethra, it is still one of those operations which may be attempted without any great hope of success. It has not succeeded in our hands, and we should not again venture to un- dertake these operations except upon the solicitation of the parents. When the epispadias, which usually stops at the pubis and con- sequently at the neck of the bladder, is complicated with extro- version or exstrophy of the bladder, the malformation is still more serious. This anomaly is characterized by a tumour situated over the pubes, with or without separation of those bones. It presents a mucous surface formed by the exposed posterior portion of the bladder. At the bottom of this tumour we distinguish the openings of the ureters, and sometimes at the bottom of the central groove in man the fossa navicularis and verumontanum, and on each side the orifices of the ejaculatory ducts. In the circumference of the whole tumour, the mucous membrane of the bladder is confounded with the skin of the abdomen. The genital organs in man exist; in woman we have often discovered the absence of sexual organs, or else they present anomalies. Such a malformation produces, as we may readily understand, very painful functional troubles. Until these later days, surgeons restricted themselves to advis- ing the use of bandages, and of apparatus to guide the flow of the urine, to avoid irritating the skin of the neighboring parts. More recently Gerdy at first proposed to pare the edges of the skin, and afterwards unite them by sutures. Roux of Toulon, Nelaton, and Richard had the idea of performing an autoplastic operation, by taking the flaps of the skin from the anterior portion of the abdo- RANULA. 237 men, to form the anterior wall of the bladder, and to make also walls for the canal of the urethra, divided with the skin, and a scro- tum. These experimental operations, very painful in the execution and very difficult, have rarely been performed, and have sometimes been followed by death or incomplete results. They do not appear to us worthy of our advocacy, and we can only say that they are not dictated by sound surgery. CHAPTER XXXVII. RANULA. Ranula, in children as well as in adults, is characterized by a tumour of varying volume, fluctuating, and transparent, seated under the tongue or else in its vicinity. It is found, on anatomical exami- nation, to be formed by a delicate transparent covering, opaque at several points, sometimes presenting several small cysts united to- gether, some of them more developed than others—true mucous cysts. In tne interior we find a viscous fluid, which is sometimes purulent. The tumour is over the course of Wharton's duct, usually com- municating with it. At other times there is a cyst on the outside of the canal. Breschet found these cysts in the new-born, and we have seen them in children of a year or two of age or older. The causes of ranula or grenouillette are the distension of the ducts of the sublingual salivary glands. The saliva distends the ducts, becomes diffused under the surrounding cellular tissue, and a cyst is formed. The symptoms sire, a tumour of greater or less volume situated beneath the tongue, sometimes on one side only, at other times on both sides. There is then a double ranula, having the appearance of the abdomen of a frog, from which it derives its name. Ranula is superficial, beneath the buccal mucous membrane, and in contact with the sublingual gland. There is fluctuation, some- times transparency, the tongue is elevated, and speech is more or less impeded. Left to itself, it sometimes increases very slowly in size, and may then attain the dimensions of a small nut, and sali- vation will be quite abundant. The tumour causes a prominence, 238 RANULA. and has a tendency to escape from the mouth, when the tongue is raised. At other times, instead of occupying the sublingual gland, it exists in the submaxillary gland, and has its seat in the canal of Wharton. It then lies in the submaxillary region, in such a man- ner that it is not seen so much under the tongue, but more deeply situated beneath the aponeurosis. Under such circumstances, the ranula is not at all of a superficial character. This latter form is met with in adults rather than in children. Ranula is an affection of but little gravity, which may become inflamed and be spontaneously cured, but in most cases it may remain stationary. Superficial ranula is less serious than that attacking the submaxillary gland; we have observed the former most frequently in children. Treatment.—We usually have recourse to an operation for the cure of this disease, either incision, dilatation, excision, or the seton. The latter was proposed by Physick, and has been advocated for many years by Prof. Longier. Having employed incision and the peculiar button advised by Dupuytren to maintain a fistulous opening without success, we have decided, in adults and children, to use the seton, made of three or four silk threads, which are passed from before backwards through the largest diameter of the tumour. We secure it by means of two knots, and we leave it in the mouth for at least a month. Generally, this method has been of service in children, and if we have sometimes had a recurrence, we have in- troduced a fresh seton, which we have left for a long time. We may quite easily perform excision and cauterization with nitrate of silver. As for iodine injections, we have not employed them; and we may- say the same in regard to the removal of a flap of the mucous membrane, as suggested by M. Jobert, who, after having exposed the cyst, removes it and unites the flap by means of stitches. The complications of this difficult and especially long operation in children induce us to prefer the seton or excision with cauteriza- tion, two procedures which have given us good results. INFLAMMATION OF THE BREASTS. 239 CHAPTER XXXVIII. INFLAMMATION OF THE BREASTS. Inflammation of the breasts, in children, exhibits itself in both sexes and at different ages. 1. In the New-born.—The breast of very young children some- times presents an engorgement to which the name milky has been applied, and which often coincides with the appearance of the milk in the mother. The symptoms are very evident; swelling of the mammary gland, sensibility to the touch, sometimes redness of the skin, and the oozing of a true milky fluid through the nipple when the gland is pressed upon. M. Donne" and all those who have taken up milk as a study, have discovered, on examination by means of chemical reagents, all the elements of milk. Some- times, but very rarely, these engorgements have been found to ter- minate in abscess; pus may be formed, and the necessity arise for the surgeon to open it. In robust and healthy children, the abscess once opened, the cure is rapid; while in those that are weakly the abscess may ulcerate and continue to suppurate for some time. Generally, on the contrary, these engorgements terminate by reso- lution. Emollients, resolvents, belladonna ointment, poultices of potato starch, and lead-water are the remedies to be employed. 2. In Children at the Age of Puberty.—Towards the age of twelve or fifteen years in little girls, and from fifteen to sixteen in boys, we sometimes notice a mammary engorgement. This is a prelude to puberty in the boy as it is in the girl. The swelling is either acute or chronic. In the former inflammatory symptoms accom- pany it, such as heat, pain, sensibility, and sometimes abscess; baths and local emollients are indicated. In the latter there are no symp- toms of inflammation, the tumour is more or less hard, and without pain on pressure. We may apply either wadding or wool, and also, as means of cure, dissolvents—ioduretted ointment especially. If an abscess forms, we must open it; but in the majority of cases 240 OSTEITIS. in little girls these engorgements promptly cease to be painful, and we soon discover that they are connected with the normal de- velopment of the mammary gland, which gradually increases until it attains its normal condition. CHAPTER XXXIX. OSTEITIS. Inflammation of a bone, to which the name osteitis is applied, is often met with in children, and may attack all the bones of the skeleton. Anatomical Characters.—An inflamed bone, like one that is frac- tured, or through which amputation has been performed, when examined in an autopsy at the end of fifteen days from the accident, presents the following alterations. The periosteum of the portion of injured bone is easily detached, and the latter is found to have preserved its polish and its consistence, but we notice little red spots, varying in prominence and in number, and the surface has a rosy tint. If we cut the layers of bone longitudinally, penetrating it more or less deeply, we see notches in which are vessels more developed than in the normal condition. If we saw the bone trans- versely, we discover a number of rounded orifices, which are the openings of vascular canals more or less gorged with blood and serum. According to Gerdy, when we observe the enlargement of the vascular orifices, and at the same time the affected portion of bone has lost its weight and has become more friable, we have what is. called by the French osteite rarefiante. We have often noticed in children this form of alteration. When we meet with dilatation of the vessels, but with a compact and hard condition, we have osteite condensanie; and this is the variety of the disease we have espe- cially found in old people, when we were connected with the surgical service of Bicetre. In cases of osteite ulcerante, the bony tissue is soft- ened, and very easily cut with the scalpel; it appears to be spongy, and small particles of bone, in the form of little splinters, are bathed by the pus and are crushed or become readily detached. TREATMENT. 241 These alterations are much more easily recognized on the spongy extremities of the bones; they are very perceptible in the bones of children, for, as a general rule, the osseous tissue is much more vascular in them than in adults. We have observed in the former a variety of osteitis, pointed out by Gerdy, of the shape of a bulb or a radish, seen on the fingers of scrofulous subjects. We have also found this form of osteitis to terminate in the discharge of a true sequestrum. Causes.—Osteitis is generally developed under the influence of local causes, as contusions, wounds, or division of a bone in ampu- tation; but we also see it occurring in scrofulous children, who frequently suffer from an inflammatory swelling of the bones or of their periosteum only. Hence we say that a scrofulous constitution may be the cause of osteitis, as syphilis and gout may be of a spe- cific osteitis. Whatever its cause may be, the disease generally offers in children a certain train of symptoms. Symptoms.—We find in the tract of a bone pain, increased on pressure, increase of volume, and heat over a more or less circum- scribed region. These symptoms may exist with simple periosteitis, or with osteomyelitis, or inflammation of the marrow and its cover- ing. The diagnosis can only be well made out as the disease be- comes more developed. Osteitis may terminate by resolution, and then the pain will gradually disappear, and the swelling also dimin- ish, but it may often persist for a long time, as in the case of scrofu- lous children. Osteitis terminates in suppuration in such cases, in which we meet with extra-osseous or even intra-osseous abscesses. Abscesses in the direct vicinity of a bone may be recognized by the fluctuation, but this is not true of abscesses of the interior of the bones, in the medullary canal or in the tissue. In such cases, there is very sharp pain, with increase of the volume of the bone. The abscesses may show themselves at the affected point, and often at a distance from it?, and are then congestive or symptomatic abscesses. Osteitis may pass into a chronic state, presenting no other symptoms than increase of volume, usually without giving rise to pain; or, if at all, only at long intervals. This termination is met with in scrofula and syphilis. Finally, osteitis may end either in caries or necrosis. Treatment.—At the commencement, in the acute state of osteitis, we may employ emollients, cataplasms, baths, and sometimes, but 16 242 CARIES. rarely, apply leeches. In scrofulous children, inunction with oint- ment of mercury and belladonna has succeeded in our hands. Sometimes the application of elastic collodion is sufficient to allay it. In scrofulous children, these local agents answer our purpose. As a palliative, we must also employ an anti-scrofulous treatment, provided the osteitis is not due wholly to a traumatic cause. CHAPTER XL. CARIES. Caries is an alteration of the osseous tissue characterized by a greater or less amount of vascularization, with friability and soft- ening of the tissue, presenting fungosities and granulations de- veloped and bathed in a sanious and purulent humour. Causes.—In children, external violence and scrofula are the causes. We have seen hereditary syphilis also give rise in them to caries of the bones of the face, and of the bones of the nose and the vault of the palate. We have not, in such cases, detected tubercles as a complication of this form of caries. We cannot say that masturbation is positively a cause of this affection, as we have no positive facts to support such an opinion, and we have not absolutely seen children who were very much addicted to this prac- tice attacked with caries of the vertebrae, but we have met with cases of vertebral caries, requiring the patient to remain in bed, which have led to masturbation. Physiological Alterations.—These anatomical lesions are observed in the spongy portions of the bones; the substance of this tissue has its cellules enlarged and dilated, and is more vascular, rarefied, light, softened, friable under pressure of the finger, reddish, violet, and impregnated with sanious blood or fetid pus having a specific odour. Symptoms.—In children, the beginning of the disease often remains unperceived; there is at first an indolent swelling, and for a while the little patients do not complain of pain, though after some time it gradually becomes more acute and continuous. If the caries is developed in a bone that is subcutaneous, we recognize it by the swelling being sometimes not well circumscribed, hard TREATMENT. 243 and painful on pressure. The neighbouring soft parts gradually become inflamed, and abscesses are developed in the affected part; or further off, at variable distances, cold abscesses form, which, in course of time, open. These openings become enlarged, and sani- ous pus is discharged; sometimes small pieces of bone brought away by the pus appear in the midst of the suppuration; fistulas are established, and, by introducing through the openings a resist- ing metallic stylet, we may feel a hard, rugose, irregular, sharp surface. If we push the stylet, we discover that it penetrates a tissue that is diseased, soft and yet rugose, and at the same time a variable quantity of blood is discharged and sometimes small portions of bone. It is evident that, when caries attacks the vicinity of a joint, symptoms of arthritis will become developed. If it occurs in the neighbourhood of the great thoracic or abdominal cavities, symp- toms are noticed, which are developed in the viscera contained in them. If caries is seated in the bones of the cranium, it produces cerebral symptoms. Finally, it may be the cause of paralysis of the upper or lower extremities, if it attacks different points in the vertebral column. The progress of this disease is sometimes very slow. If it occupies a circumscribed situation, it may terminate by the elimi- nation of small particles or minute fragments, and the detached portion be covered with granulations and a cicatrix. If it involves a considerable extent of bone, it may induce grave symptoms, the loss of a portion of the foot, the hand, etc. Sometimes it may give rise to an abundant fetid suppuration, slow fever, marasmus, and death. Diagnosis.—If this is sometimes difficult at the commencement, we cannot make any mistake in the advanced stages of caries, es- pecially when the abscesses are opened, and we are enabled to make an exploration with a metallic stylet. Caries is always more or less grave, according to the extent involved. It is less serious if superficial, but it is always dangerous if developed very deeply in the vertebral column, in the bones of the pelvis, or those of the foot or the hand, as we very often meet with it in scrofulous children. Treatment.—This serious disease requires a general treatment, when the cause which gives rise to it depends on a constitutional affection. Thus, scrofula and syphilis should be treated, when they 244 NECROSIS. are the cause of the caries. We must also employ a local treatment especially if the disease has a traumatic cause. Pain, for instance, may be sometimes, but rarely, overcome, by the application of leeches, emollients, fomentations, poultices, and inunction with dis- solvent ointments, as mercurial or iodine ointment; but these reme- dies are only palliative. For caries in children, we have returned to the use of the cautery, heated needles, and transcurrent cauteriza- tion, to arrest the progress of the disease; but these methods have not given us good results. When abscesses are developed, we must open them, even if they are of the congestive form. When the abscesses remain open, we derive benefit from the application of tonic solutions, such as infusion of walnut leaves, aromatic wine, or solution of iodine, and even from injection of one part of tincture of iodine to two parts of simple water. These injections may be successfully practised in congestive abscesses at a distance from the affected bone, and in abscesses symptomatic of caries of the vertebras, or of coxalgia. When the carious spot is superficial, we may some- times carry the red-hot iron over the diseased bone, and thus pro- duce a sequestrum, which may become detached. The caries may be sometimes so extensive and so deep, occupying several bones, as in the hand or the foot, that we are often obliged to perform either extraction or resection, and sometimes amputation, when the local disease produces general symptoms, which so greatly debilitate the patient, that we cannot wait for the separation of the diseased part and its elimination by the efforts of nature alone. CHAPTER XLI. NECROSIS. Necrosis—partial or entire mortification of a bone—is often seen in children, and may result from either traumatic or internal causes. Wounds, injuries, and especially scrofula, sometimes syphilis, are the causes of this disease during childhood. The vas- cular arrangement of the periosteum and the medullary membrane, which is very remarkable in young people, much more than in adults, will explain how necrosis occurs from lesions of each of ELIMINATION. 245 these structures, and of the bone itself. The latter, deprived of its periosteum or its medullary membrane from any cause, only living by the vascularity of these membranes, must become morti- fied, and, being deprived of the circulation, comes to form a dead portion, called a sequestrum, which tends to become detached, as a slough is separated from the soft parts. The sequestrum presents considerable differences: sometimes it is very small and very cir- cumscribed, and at other times occupies a large portion or the whole extent of a bone; it is recognized in childhood, as in adults. and old people, by its tarnished or dull white colour; and percussion gives a clearer sound, as if cracked. The sequestrum is variable in appearance, sometimes in the form of delicate irregular plates, at other times in angular fragments representing a portion of bone involving a greater or less extent, and when this sequestrum is of long standing it loses in time the dimensions it formerly had. If a sequestrum is treated by chemical agents, we find that it has lost its organic tissue; left to itself, the elimination is effected in chil- dren as in adults, perhaps more promptly in the former than at other periods of life. In young subjects we recognize three stages: exfoliation, elimi- nation, and absorption. 1. Exfoliation, or the expulsion of small, more or less circum- scribed bony plates, is developed either spontaneously as the result of an abscess from a general cause, or after a wound or contusion, or an erosion of the skin over a bone that is more or less subcu- taneous, as on the skull, the face, the jaw, the tibia, etc. There is at first inflammation of varying duration, sometimes very acute, at other times slow; and an abscess is formed and opens spontane- ously, or is opened by the hand of the surgeon. The mortified portion of bone is uncovered, and generally becomes detached in mass in the form of a plate or small fragment, sometimes of the most minute kind. At other times, if of small extent, it may be absorbed or escape the eye of the observer. The periosteum which covered this bony portion has been destroyed, but the perioste- um which exists around it on the sound portion of bone remains intact, and soon extends and fills up the denuded part. 2. Elimination.—It is not always an extensive lamella that is detached, but a portion of necrosed bone of variable size; it is the true sequestrum, which cannot be discharged by exfoliation, but by total or partial elimination. This bone, the vitality of which 246 NECROSIS. is lost, remains more or less enveloped in its periosteum; the other, which is inflamed, is developed slowly, and moulded on the diseased portion with very little definite shape, and constitutes the new bone. The sequestrum is enveloped in mass by the bone which offers, at certain points, openings of different shapes, narrow, circu- lar, and oval, through which the necrosed portion may be felt and seen. This constitutes an invaginated sequestrum which floats in pus, and is sometimes more or less in contact with the tubercular substance which we have at times met with in the extremities of bones or chiefly in the short bones. Left to itself, this portion sur- rounded with pus tends to become gradually detached from the healthy portions, and it may be separated by the efforts of nature alone, after long suppurations which discharge through fistulas made in the bone and in the skin, in the course of the disease. Time and nature, constantly aiding the escape of this portion of diseased struc- ture, sometimes suffice to produce its expulsion. 3. Absorption is a slow termination by the dissolution of the sequestrum; it is rarely met with, but we have seen the latter waste away and be destroyed gradually in an insensible manner, becoming reduced to the most simple expression. The causes of all these disorders in children are-, as we have saidi traumatic lesions, and, in the majority of cases, scrofula. The symp- toms are at first tumefaction, swelling without great pain in the situation of the necrosis, and, in some cases, sensibility and ery- sipelatous redness, but usually inflammation of slow progress- When we have extensive necrosis to deal with, as in the jaw or the limbs, there may be acute, very intense inflammation, with rapid tumefaction, fever, and the formation of deep abscesses, which are sometimes sub-periosteal. In such cases there may be general disturbance, delirium, in fact all the phenomena of phlegmonous inflammation. When the necrosis is of small extent, circumscribed and superficial, there is only a local trouble without general re- action; an abscess occurs with a spontaneous opening, and a fistula. In extensive necrosis, however, the general symptoms are grave, and the suppuration abundant and deeply situated. If the child does not sink under these symptoms, considerable time elapses before the pus makes its appearance on the surface, and often not until after becoming diffused, as in cases of congestive abscess of the vertebral column and of the pelvis. Frequently the abscess does SITUATION. 247 not open till after some months, and forms inexhaustible fistulas up to the time of the elimination of the necrosed portions of bone. Prognosis.—As a general rule, all things being otherwise equal, the prognosis is more or less serious, and the disease usually of long duration. If it is not of marked intensity, and but a small extent of bone is involved, the disease may terminate in fistula, and the escape of sequestra of small size; but, if it implicates a large portion or the whole of a bone, it will most likely prove fatal. In any event we must be very cautious in our prognosis, and always bear in mind that the smallest portions of necrosed bone often take months to work their way out, and suppuration ceases and the fistulas become closed only when these mortified parts are removed. Children are generally cured of circumscribed necrosis, and, even when this is of considerable extent, it quite fre- quently happens that they are finally cured if they pass the period of suppuration without being too much exhausted. Its progress, as may be seen from a glance at the symptoms, is most frequently slow, but is perhaps a little more rapid if the case is one of necrosis from traumatic causes. When we have to treat necrosis due to a scrofulous cause,—and these unhappily are the cases most often met with,—this is not the case. We have seen them persist five or six years or more. Situation.—Necrosis, which is of very common occurrence in young people, is observed in all the bones, long, short, and flat, inde- pendently of the form of the disease developed on the alveolar border. In children who are met with in places where they manufacture sul- phur, we find the upper or lower jaws necrosed. Under the influence of a scrofulous constitution, it sometimes involves only a very small surface, the border of an alveolus, for example. At other times, and generally after inflammation of the gums, and more or less decided stomatitis, often of a gangrenous nature, we find the necrosis affect- ing the alveolar border in one portion, and sometimes nearly the whole of the upper or lower jaw. The enormous sequestra which follow these necroses, for a very long time retained, and surrounded with abundant suppuration, give an intensely fetid character to the mouth, and produce fever and all the symptoms of absorption. They are expelled by the efforts of nature or are extracted by the surgeon. We have had occasion to remove sequestra several times, representing the upper or lower jaw almost in its entire extent. Children are cured rapidly, and as if by enchantment, after the 248 NECROSIS. extraction of these diseased portions. New jaws, formed by the development of the periosteum, most generally without teeth, may replace the old ones. We see in children a number of partial necroses, usually of the bones of the face, the borders of the orbits to a greater or less extent, the proper bones of the nose, etc. and of the vault of the palate, as in syphilis. All these forms of necrosis terminate generally by exfoliation; after having been attended at first with swelling, some- times with abscess, afterwards with fistulas, which persist, and require time, and the use of general rather than local remedies. They usually terminate by a cicatrix of the soft parts'adherent to the portion of diseased bone. Frequently, these adhesions cease with time, and the skin becomes movable. Necroses of the ribs or of the sternum are rare; those of the vertebras are unfortunately very common, and, so to speak, a dis- ease peculiar to childhood, and are sometimes tuberculous. We have but rarely discovered the true tubercular substance in the vertebras. Necrosis very frequently occurs in the limbs and in the long bones, as the humerus, radius, ulna, femur, tibia, and fibula. We find in these different cases in children more or less circumscribed engorgements at a point on one of the bones, which progress with extreme slowness, and are only accompanied with dull pain. At other times, there are all the symptoms of a profound phlegmonous inflam- mation, with fever and even delirium. We have met with this several times in periostitis of the femur, which begins with fever and de- lirium, and often runs its course very rapidly, speedily terminating in deep abscesses. These throw the children into a grave condition, that can never be checked by the most active antiphlogistic treat- ment, which is more injurious than useful. In such cases, applica- tions of the mercurial ointment around the affected limb, and, in- ternally, the administration of the preparations of cinchona, are the remedies to be employed. Finally, when the pus is formed, even before there is very decided fluctuation, it will be advisable to make free incisions, which give relief even if there should be no such collections of pus present. If the indication is to subject the child to active surgical treatment, the object will be to quiet acute pain, and the general symptoms that complicate the local affection; but after such active treatment, we have only to employ expectant surgery, such as emollients, TREATMENT. 249 baths, poultices, sometimes drainage, emollient and detersive injec- tions, and then simple dressings. Fistulas become established, and through them may be felt, sooner or later, the sequestrum, which at first is not at all movable, and only becomes so in time. We always find that the more extensive the sequestrum the greater length of time it requires to become movable. In a child ten or eleven years of age, we found a sequestrum occupying the whole of the body of the femur, only movable seven years after the com- mencement of the disease, and we successfully extracted it. Necrosis of the short bones is also met with in children, chiefly of the phalanges of the fingers, and then the latter have a peculiar shape, and the swelling is fusiform, sometimes in the form of a radish. In this kind of necrosis, the children may lose one or several phalanges. The bones of the foot may also be attacked, as the astragalus or os calcis, the sequestra from which are only movable several months and even several years afterwards. Treatment.—In children, as in the majority of cases in which ne- crosis is developed under the influence of a scrofulous or lymphatic constitution, the antiscrofulous treatment should be resorted to from the commencement to the end of the disease. It should not be modified or suspended except when accompanied with violent inflammations and fevers, which must be combated by local and general means. Otherwise, and when the necrosis remains stationary, we must employ locally tonic lotions and general tonic baths; in certain cases, emollients alone, and waiting for the efforts of nature, which tend either sometimes to the absorption of the sequestrum, or, most frequently, to its expulsion and to the formation of a new portion of bone to replace the old. The duty of the surgeon is limited to waiting for the mobility of the sequestrum. During this time, he may, nevertheless, keep a watch over the patient, and, especially when a long bone of the limbs is involved, endeavour by position or bandages to prevent the newly-formed bone, which for a long time is of a soft consistence, from being curved, as sometimes occurs either in the upper or lower limbs. Immobility of the limb is absolutely necessary in all cases in which the sequestrum is of small extent, for movement may cause inflammation or erysipelas. We must watch these inter- current affections, which will demand different treatment, according to the nature of the case. Usually we must be satisfied, for a long time, to exercise a good deal of caution in regard to the moving of 250 OCULO-PALPEBRAL CONJUNCTIVITIS. the sequestra, when situated in such a way as to be capable of extrac- tion. There are some cases in which we must abstain from touching them, as in necrosis of the vertebras, for example. But, when after more or less time he can be assured, by sounding the fistulous spots, that the sequestrum is movable in different directions, the surgeon should interfere, and either seize the portions which can be extracted with the forceps, or divide the fistulous parts. Under certain circumstances, as in sequestra of the scapula, the humerus, the femur, etc., we must not only divide the soft parts, but also enlarge the openings of the new bone to extract the sequestra. We do not hesitate in these cases, in our little patients, to trepan them, using a gouge and mallet to facilitate such extractions. This we have done in several instances. When we have to detach the sequestrum, we may be compelled to divide it before extracting it. After these operations, which are often very laborious and very long, we may apply very light dressings, and gently tampon if there be hemorrhage, afterwards sprinkling carefully with cold water. It is also beneficial, after these operations, to support afresh the limb operated on in its normal position. We must care- fully watch the cicatrization, and make it as regular as possible. We must not forget that, in the limbs, the bones of the new for- mation are not at first solid, and that it is prudent not to allow of movements, walking especially, for some time after the extraction of the sequestrum; otherwise we may have the limbs remaining curved, and not properly shaped. CHAPTER XLII. OCULO-PALPEBRAL CONJUNCTIVITIS. Inflammation of the oculo-palpebral conjunctiva is as frequent in children as in adults. This disease is often met with at birth, and is then known under the name of ophthalmia of the new-born. Of this disease we have already spoken. It is also observed in children at all ages. Sometimes the ocular conjunctiva is alone affected; at other times the disease extends to the eyelids, and may invade the other parts of the eye, and constitute as many symptoms. 251 special diseases,—keratitis, iritis, etc.,—which are complications of the conjunctivitis. Causes.—In children, as in adults, the causes may be either ex- ternal or internal. The external causes are draughts of air, wounds, punctures, burns, turning in of the lashes, the presence of foreign bodies of all kinds, prolonged fatigue of the eye, especially a bright light, etc. The chief internal cause is often in childhood the scrofu- lous taint, giving rise to scrofulous ophthalmia. This cause is often the only one that can be discovered in certain children; nevertheless, in some of them, the causes are connected with other individual con- ditions, as rheumatism, intestinal obstruction, abrupt suppression of transpiration by cold, or certain eruptions. Sometimes the con- junctivitis appears under the influence of measles or variola, and is even a prodromic symptom of those diseases. The symptoms are either anatomical or physiological. Anatomical Symptoms.—We notice redness over the whole of the conjunctiva, or over a circumscribed spot, which is more or less decided according to the intensity of the inflammation, and is char- acterized by injected vessels, which creep in a tortuous way through the sub-mucous cellular tissue. These are, at first, visible on the inner aspect of the lids, and gradually spread to the globe of the eye, and sometimes extend even over the transparent cornea. The swelling of the mucous membrane is at first seen in a slight aug- mentation of thickness different from the infiltration of the sub- mucous tissue, which is met with somewhat later. If in this patho- logical condition we interrogate the children, we find that they ex- perience annoyance as if from the presence of a foreign body in the eye. At the beginning there is not yet photophobia, which occurs only when the cornea is invaded, or inflammation of the deep mem- branes commences. It is then no longer simple conjunctivitis, which generally lasts only ten or twelve days when it is limited, but some other disease of the eye, the duration of which is very variable. In children suffering from affections of the skin, measles or small- pox, it is transient; but, when connected with a scrofulous taint, it may remain simple but tenacious. In this condition, however, we must fear, as in ophthalmia of the new-born, the complication of conjunctivitis with pustules, granulations, chemosis, keratitis, iritis, internal ophthalmia, purulent dissolution of the eye, and atrophy of the eyeball. All these diseases should be studied separately; 252 OCULO-PALPEBRAL CONJUNCTIVITIS. and, in this article, after having examined simple conjunctivitis, we will confine ourselves to the description of the most common com- plications. Physiological Symptoms.—Simple conjunctivitis does not usu- ally present very grave general symptoms: there is only sensi- bility to a bright light, and rather soreness than great pain; but, as soon as complications arise, the local disease may be accom- panied with fever, loss of appetite, constipation, and very acute pain. The progress of the disease is variable according to its nature. It may terminate in ten or twelve days if a simple uncom- plicated case, but if otherwise it may be retarded. We should then be very reserved in our prognosis, for conjunctivitis may assume a chronic form, with spots upon the cornea, ulcerations, etc. Treatment.—This may be local or general, and vary according to the complications. To institute a local treatment, we must first examine into the condition of the eye, sometimes a difficult task with children. For this purpose, we must reverse the lids or raise them with elevators. It is important sometimes to make the ex- amination during sleep, as this will prevent the child from strug- gling. When simple conjunctivitis is occasioned by a draught of air, washing with cool water may generally be the sole treatment required; and this is true also of that form of the disease which is produced by the introduction of a foreign body into the eye, some- times after its extraction if it can be removed. Thus, grains of dust or metal filings should be first of all sought for carefully by reversing the lids, using the magnifying glass, the ophthalmoscope, etc. These foreign bodies, which we have several times found in the eyes of children, may be extracted, when they are movable, by the aid of a simple brush or a curette. Others, which are in- crusted, can only be extracted by means of the point of a cataract needle, in cases in which a steel or other filing is fixed upon the cornea, for example, or the sclerotic coat. In these various cases, it may suffice, the extraction being made, to use lotions, to apply cool water, and to keep patients away from too bright a light. In conjunctivitis produced by irritating liquids, we have derived benefit from irrigations of simple water, made every three hours, either by means of a funnel or an irrigator. For such applications we must employ, with either apparatus, a very small canula, that the jet of water may be made quite delicate. But if the conjunc- tivitis from a traumatic cause is accompanied with intense in- TREATMENT. 253 flammation, with very great injection and violent pain, as in some cases where it has been impossible to extract the foreign body (for often surgical prudence demands that it shall be left alone, as when a shot is buried in the eye), we have always found it best to adopt an energetic antiphlogistic treatment, associating with it resolvent and calmative remedies. We must say in advance, however, that these means are especially attended with successful results, when the conjunctivitis is not accompanied with the presence of foreign bodies which we have been unable to extract. The treatment con- sists in local depletion by leeches behind the ear or to the temple, sometimes by cups; we rarely resort to general bloodletting, at least in children. We must often give purgatives, then apply re- solvent and calmative ointments around the eye, the mercurial oint- ment, belladonna, or atropia in solution dropped on the eyeball. When the conjunctivitis is produced by internal causes, and chiefly by the scrofulous taint in children—and this is a very frequent cause—we must have recourse to antiscrofulous remedies, which should always constitute the internal treatment, but be suspended during the progress of very intense conjunctivitis. We must, in young lymphatic children, be cautious of the use of bloodletting, and we have most frequently obtained good results from more or less astringent collyria, as those made with sulphate of zinc or ni- trate of silver:— R. Zinoi sulphat. gr. iij. Aquae destillat. f §iiss. M. Or, R. Argent, nitrat. gr. v-x. Aquae destillat. f §iiss. M. Revellents to the lower extremity, in the* shape of foot-baths of salt water or mustard foot-baths, often give good results. We have not used the concentrated solution of nitrate of silver, applied in light layers on the external surface of the lids, after the manner of M. Serres d' Elz&s, who borrowed it from the German oculists; but it has the advantage of not being painful for children, as col- lyria in the eyes are. We should also employ belladonna in the manner already indicated in traumatic conjunctivitis. Purgatives are of the greatest necessity in many cases; castor oil, solution of citrate of magnesia, and small doses of calomel for the youngest children, have generally rendered us good service. By means of 254 OCULO-PALPEBRAL CONJUNCTIVITIS. these different remedies, we often see the disease terminating by resolution more or less rapidly. Certain very common complications induce us to adopt other modes of treatment. Thus, in chemosis—in other words, infiltra- tion of the sub-mucous cellular tissue in the form of a circular ring, soft and slightly paiuful around the cornea—which may extend over the whole eyeball, giving the cornea a sunken appearance, an energetic treatment must be resorted to, consisting in deep scarifica- tions over the ring, either with a lancet, or, better still, with scissors and forceps. After incising it, we apply lotions of warm water, and after six or eight such applications the chemosis will be found to disappear. A few purgatives may be needed to put an end to this complication, which very often involves the cornea, but this treatment is not always sufficient. We must carry the pencil of nitrate of silver over the mucous ring, and then bathe the affected eye with cold water to which hydrochloric acid has been added, in the proportion of twenty drops to half a pint of water; this mixture being used as a wash for the eye every two or three hours during the first twenty-four. Blisters behind the ears, which were for- merly advised, have not succeeded in our hands; they appeared to excite unnecessary irritation. When the conjunctivitis is complicated with pustules, the patient complains of having a foreign body in the eye. If we examine it carefully, we discover, in lymphatic children more frequently than in others, a certain number of vessels forming on the eyeball a tri- angular group, the base of which comes from the oculo-palpebral cul-de-sac. These.vessels, when united, form the summit of the tri- angle, which passes as far as the border of the cornea, where there is a pustule, generally'of the volume of a millet seed or a little larger. Sometimes this pustule is flattened, and bright yellow; at other times it is purulent, and more or less prominent. It some- times exists alone, or there may be two, three, or four others, always around the cornea, having their triangles of vessels arranged in the same manner. As long as they are confined to the conjunctiva of the ball, the case is not of much gravity; but if they invade the cornea, ulceration may occur at the points corresponding to them. Such cases are frequently accompanied with photophobia. When these pustules do not involve the cornea, they may be absorbed or leave a slight ulceration, which terminates by resolution conjointly with the vascular injection. TREATMENT. 255 This complication may be treated with lotions of cold water, or applications of compresses steeped in water, and these often answer the purpose. I have found advantage result from touching the pustules very gently and very rapidly at the commencement, with the point of a pencil of nitrate of silver or the lapis divinus, and especially by carrying it over the vessels which form the point of the triangle. But we may generally derive benefit from, and should chiefly content ourselves with, simple water or the borax collyrium of M. Desmarres:— R. Sodae borat. gr. iij. Aquae lauro-cerasi destillat. f 3vj. Aquse f§iv. M. The child should be kept in an apartment dimly lighted. If there be photophobia, advantage will be derived from dropping into the eye, two or three times daily, a drop of a mixture containing a grain and a half of the neutral sulphate of atropia to half an ounce of distilled water. We must also persevere in the use of purgatives, and, for the time, suspend the use of tonic or antiscrofulous reme- dies. Conjunctivitis may be complicated with granulations, with the secretion of a puriform fluid, and the development on the inner surface of the lids of a multitude of small projections like the pa- pillae of the tongue. Sometimes the inflammation interferes with the movement of the eyelids, and there is itching on the inflamed surfaces and chiefly towards the large angle of the eye. Gradually the redness becomes more intense, the sub-mucous cellular tissue becomes infiltrated, and the granulations increase in volume. There is an exacerbation of the symptoms in the evening and morning, and the edges of the lids are gummed together by the secretion of desiccated mucus. These granulations may terminate by resolu- tion, but they may also be complicated with serous chemosis. They may occur in an epidemic form, and we have seen several children of the same family attacked with this affection together or succes- sively. This has been seen in our surgical wards at the hospital, and has also been noticed in children who are taken to asylums in the different arrondissements of Paris. Whatever the cause of the development of these granulations may be, cold, contagion, etc., we must chiefly rely upon light appli- cations of the pencil of nitrate of silver, or, better still, the lapis 256 TRAUMATIC LESIONS OF THE CORNEA. divinus, on the inner surface of the lids, which should be reversed, and the pencil passed gently and rapidly over them. Combined with this, may be used the slightly astringent collyrium of M. Desmarres:— R. Acid, tannic, pur. gr. xv. Aquae lauro-cerasi destillat. f^j. Aquae destillat. f §iv. M. This should be dropped several times in the day between the eyelids. If the granular affection passes into a chronic state, we must employ a slightly stimulating ointment between the lids, such as crystallized nitrate of silver combined with fresh washed butter, or red precipitate combined with washed butter, in proper propor- tions. Conjunctivitis may be complicated with ulcerations of the cornea, which are often attended with photophobia, and require the use of solution of atropia. Collyria of sulphate of zinc or nitrate of silver may be sufficient to overcome them. We have sometimes treated them successfully by touching the ulcerations very gently with the point of a pencil of nitrate of silver. We often find on the cornea, in cases of conjunctivitis, spots, which are nothing more than the consequence of superficial kera- titis, followed by effusion between the layers of the cornea, or of ulcerations that are cicatrizing. Many of these spots may be ab- sorbed, and are consequently only a transient obstacle to vision. We have seen some of these of very large size in very young chil- dren disappear as they advanced in age. They must, however, be subjected to treatment, but of this we shall have more to say under the head of Keratitis (Chap. LIL). CHAPTER XLIII. TRAUMATIC LESIONS OF THE CORNEA. Wounds of the cornea may be produced from a number of cir- cumstances, more frequently in children than in adults. Contusions, punctures, cuts, foreign bodies, burns and perforations, are so many traumatic lesions which may be observed on the cornea. All these PUNCTURES AND CUTS OF THE CORNEA. 257 wounds may be very slight and easily cured, or be very serious and involve the loss of the eye. Contusions of the cornea are met with quite frequently in children, because they receive a cuff or a lash either in playing, as when they mount behind vehicles, or a foreign body is thrown against the eye. Under such circumstances, the cornea may be bruised or even torn; and, as a result of the contusion, the pupil maybe dilated, its shape altered, vision momentarily disturbed and afterwards re- established. The cornea may be lacerated with the discharge of the fluid of the anterior chamber, which may last for several days; and there is redness of the conjunctiva covering the cornea, some- times sanguineous suffusion of the anterior chamber. If the lesion is not very considerable, the contusion and even the laceration ter- minate in a favourable manner. The treatment consists in applications of cool water; often by the single precaution of keeping the eye closed by applying over the lid compresses steeped in simple water, or lead-water with laudanum in it, the wound will become cicatrized. In some cases in which the pain and inflammation are marked, an application of leeches to the temple appears to be indicated, but we must only apply two or three of these, according to the age of the child, and only let them flow for an hour after they are detached. Punctures and cuts of the cornea are quite frequent, but if they do not penetrate deeply into the eye and only involve the thick- ness of the cornea, they are of but little gravity, and tend to cica- trize under the influence of applications of cold water, and especi- ally with the precaution of keeping the upper lid depressed with- out compressing it with a tight band, for the pressure does more harm than good. When the punctures or the cuts give issue to almost the whole of the humours of the eye, the case is then very serious; we must not hesitate to deplete. We must, when the wound has allowed of the discharge of the fluids, keep the child in bed on his back, and not let him turn his head either to the right or the left, for this position greatly facilitates cicatrization. If union does not take place by the first intention, there is then suppuration, which greatly compromises the safety of the eye, unless we treat the little patient energetically. We must act as we would in the gravest forms of ophthalmia, returning to bloodletting, the applications of ointment, as mercurial ointment and belladonna, 17 258 TRAUMATIC LESIONS OF THE CORNEA. around the eye, and also employing drops of a solution of atropia, and continue the use of repeated purgatives. Foreign bodies, which produce lesions of the cornea, give rise to different symptoms, according to the depth to which they penetrate. Generally, the indication is to extract them. Left in the wound, they produce all the gravest symptoms. For the extraction, if that be possible, we must place the child before a window, after having seated him in such a manner that an assistant holds his head firmly and raises the upper lid; then, by means of a brush or a stylet, or very fine forceps, we may relieve the child. In other cases, when the foreign bodies are encrusted in the cornea, we must use a cata- ract needle or a lancet; sometimes we must even incise the cornea if the foreign bodies are in the anterior chamber. The foreign body once removed, we must continue the applications of cool water, and a more or less active antiphlogistic treatment, which may be discontinued if the symptoms should justify it. Burns of the cornea are all more or less serious, the slightest of these sometimes producing a very circumscribed and superficial wound. Others destroy the whole of the cornea, and hence we have in each case a very different prognosis. As for the treatment, what- ever be the nature of the burn, washes of cold water, and applica- tions of compresses steeped in soothing solutions may be employed- There may remain, as a result of the treatment, ulcers or fistulas of "the cornea, and we may fear the occurrence of softening and gangrene; but to prevent all accidents, we must, at the commence- ment, resort to an energetic antiphlogistic treatment. Perforation of the Cornea.—This accident succeeds traumatic lesions of the cornea or the various forms of ophthalmia, and especially those developed in scrofulous subjects. They are even observed at the commencement of scrofula. Perforations are noticed at the centre or the circumference of the cornea, at first in the shape of very minute depressions, like the very small head of a pin ; they are sometimes developed with very great rapidity, and the perfora- tion may make its appearance the next day, the iris sometimes making a hernia. It is of the highest importance to resist this rapid progress. We must, while using the collyrium of nitrate of silver conjointly with antiphlogistics, also employ belladonna; but, as in these cases the vitality of the iris is considerably increased, it is important to combine with it the use of ice. We therefore suggest the following treatment: keep the patient lying on his back, CHILBLAIN. 259 with his head immovable-and thrown slightly backwards; then apply over the eye, the upper lid being closed, compresses steeped in an infusion of belladonna leaves, an ounce and a half of the leaves infused in a quart of water passed through, filtered, and kept in ice. The compresses should be frequently changed; and three or four times in the day, and three or four times in the night, there should be dropped between the lids a drop of a solution of atropia, containing a grain and a half of the salt of atropia to three ounces of distilled water. We may, by this means, prevent a perforation of the cornea; if it takes place, the fluid of the anterior chamber flows out. The iris is not always carried forward producing a hernia; but if the iris is involved, we may reduce it by pressure of the lid on the eye, keeping it closed by a headband. If the iris has been involved but a short time, we will succeed, but when the hernia exists for some days, we may fear that we shall have a failure, and then we must have recourse to cauterization with ni trate of silver once or several times at a day's interval. CHAPTER XLIV. CHILBLAIN. This affection consists in a swelling or engorgement of the subcu- taneous cellular tissue, often indolent, sometimes burning and pain- ful, having a light purplish tint. As a general rule, we meet with chilblain in children, and sometimes in old people, in the fingers, toes, nose, and ears. There are usually several of them at a time, and they are most frequently met with in weak lymphatic children. Causes.—The lymphatic diathesis is the usual predisposing cause; cold, moisture, and bad shoes which keep the feet wet, are its ex- citing causes. Symptoms.—This disease, which manifests itself towards the end of autumn or in winter, is characterized by swelling on one of the regions already referred to,—the fingers, toes, nose, or ears. There is a light purplish redness,—quite circumscribed, and disappearing on pressure of the finger, like erysipelas,—and itching,—especially when the affected part is exposed to heat,—pain on pressure, and in the movements. The violaceous tint becomes bluish, sometimes 260 CHILBLAIN. with ulceration, the skin becomes gangrenous, and we have seen tendons, bones, and joints denuded, and even toes become detached. Sometimes this disease is complicated with erysipelas, which may invade the whole of a limb. It often happens that the chilblains, whether ulcerated or not, are complicated with angeioleucitis, either in the ham or in the groin. Diagnosis.—Chilblain should not be confounded with erysipelas; the latter does not invade a circumscribed part, such as a phalanx. Chilblain tends to remain on the situation affected by it; erysipelas usually, on the contrary, has a tendency to travel to a greater or less distance. Prognosis.—In the majority of cases it is favourable, for chilblain) as a general rule, has a tendency to terminate by resolution, with- out following the serious course we have previously pointed out; but it habitually appears in children on the return of winter. Termination.—Chilblain nearly always diminishes in intensity, and terminates by resolution, when the mild season arrives and the cold weather is at an end; but it frequently disappears not to return until the age of puberty. This fact, which is quite general, is far from being always constant, for we still see adults attacked with chilblains. Besides, old people, who have had chilblains in their younger days, sometimes have it, which present in them the same characters as in childhood. Treatment—It is important that the treatment should be distin- guished into prophylactic and curative. We may sometimes save children from chilblains, at first by giving tone to the constitu- tion if it is lymphatic; all the general internal antiscrofulous reme- dies may modify this predisposition to chilblains, and without at all neglecting these various remedies, the treatment by tonic baths appears to us to be very beneficial, such as cold baths, sea- bathing, and sulphurous baths. Independently of these baths, which act at one and the same time on the general and local con- dition, we have derived good results from tonic foot-baths, such as those made with slightly warm coarse wine, or infusion of walnut leaves, or baths of soap and water, or water with the addition of camphorated brandy, lavender brandy or water, with a small quan- tity of Labarraque's solution of chlorinated soda. These local baths should be taken nearly cool; they will act injuriously if they are too warm. The curative treatment consists of either lotions or baths,— which may still be employed with success, when the chilblains are TRAUMATIC DISLOCATIONS. 261 severe, as when they are accompanied with heat, redness, and pain,— to be combined with the agents last mentioned as preservative re- medies. Frequently, however, emollients are useful, as baths of marshmallow water or gelatinous water, and sometimes applications of emollient poultices; but if the pain is very acute, the indication is to employ them at a cool rather than a warm temperature. When phlyctenas are formed, and when ulcers appear, we must apply simple dressings with fenestrated linen smeared with cerate, and covered with charpie. After several days of this simple dress- ing, we must at once apply tonic dressings, by steeping the char- pie in heavy aromatic wine or water, slightly chlorinated. If the ulcers have a grayish look, we must employ a simple digestive of a more or less stimulant character; if granulations spring up, we must repress them with nitrate of silver. Sulphurous waters at this period are often indicated, but we may sometimes modify them with simple water or bran water. We should be cautious in the use of warm water, which might soften the flesh, and do more harm than good. If there be fetor, powdered cinchona or dressings with permanganate of potash may be of service, in the proportion of two drachms and a half of that salt to four ounces of water; two spoonfuls of this solution in a glass of water in which the charpie used in the dressings may be steeped. In a word, at all periods of the disease, chilblain requires, as prophylactic or as curative treat- ment, the use of tonics in all forms, unless the inflammation be very intense. The ointment advised by Dr. Carreau appears to be of service at all periods of this affection:— R. Potassii iodid. 3J. Tincturae iodinii Tt\,xx. Adipis §j. M. CHAPTER XLV. TRAUMATIC DISLOCATIONS. Traumatic dislocations, or permanent displacements abruptly produced by external violence in the articulations, are more un- common in children than in adults, and yet we have met with all the traumatic luxations in young subjects. The most frequent are 262 TRAUMATIC DISLOCATIONS. those of the elbow and ulnaat its upper portion, those of the radius at its upper part, and, separately, that of the clavicle from the humerus. We have also met with luxation of the inferior extremity of the ulna, of the first metacarpal bone, and the phalanges of the fingers- We have seen luxations of the coxo-femoral articulation, of the patella, of the toes, and of the inferior maxillary, and even of the cervical vertebras. All these dislocations are produced by the same causes, which are usually falls or blows. They are attended with the same symp- toms and require the same treatment as in adults. After reduction, we must watch children for a longer time, on account of their lymphatic constitution, which predisposes them to chronic arthritis and white swellings. We therefore, after reduction, which is more easy on account of the less powerful muscular action, and is effected with or without chloroform, believe it to be necessary to employ resolvents, and especially to prolong the immobility of the articulation by simple position, or by the application of an appa- ratus during fifteen or twenty five days, as if we had a fracture to deal with. If we wished to speak of all the dislocations met with in children, we would only have to repeat, in all respects, the descriptions of the same lesions in adults given by standard authorities (Boyer, Malgaigne, Richerand, Vidal, etc.). We will only add, that while they may be reduced much more easily, even when they are of two or even three months' standing, the surgeon should be cautious in his efforts to reduce certain old dislocations, by the fear of break- ing the epiphyses, Which are not yet solid. We have found also that dislocations in children are often complicated with fractures of the articular extremities without displacement; at other times, sepa- rations of the epiphyses, which are not always very easy to recog- nize, because they may likewise exist without displacement, and for this reason it is always much better, even where there is a doubt, to keep for quite a long time the dislocated articulations in apparatus, even when the conformation tells us that there is no deformity, and that the articular surfaces are in proper relation to each other. There are some dislocations which cannot be reduced, or if re- duced cannot be kept so without difficulty; dislocations of the elbow for instance, which are more frequent in children than in adults, always result either as a consequence of a direct fall on the SYMPTOMS. 263 elbow or the hand, or by jerking the forearm. We very often, in practice, meet with children suffering from traumatic lesions of the elbow; frequently there is simple contusion, sometimes articular twitching, complete or incomplete dislocation and fracture. Ob- served at the very moment of the accident, the injured elbow may be free from tumefaction, and in such cases the deformity or non- deformity of the articulation is sometimes very readily recognized, enabling us to detect certain simple or complicated dislocations, and often, if complicated with fracture, crepitation is present, and assists in the diagnosis. But without tumefaction, and especially with it, there is sometimes great difficulty in making a positive diagnosis. Crepitation certainly enables us to decide generally that there is a fracture, but fractures often occur in which we are unable to produce movement in the part in order to discover it, and hence difficulty arises in saying, whether there is or is not fracture, and especially what is its direction. Uncertainty must exist also when the fracture is unattended with displacement and appreciable crepitation. There are some dislocations in which the articular prominences are so easily detected, and certain movements so impossible, that they cannot fail to be recognized; but, although the surgeon may be thoroughly versed in the study of these dislocations, so well de- scribed by modern writers, such as Malgaigne, Vidal, Bonnet, Ne'- laton, and especially in the excellent memoir of M. Denuce', it is very often next to impossible to detect several of these varieties of dislocations, for, being attended with slight displacement, they es- cape observation in the same way that certain fractures do. Thus, in a large number of children that we have seen, we have perfectly recognized, and always easily detected, complete dislocations of the elbow backwards, forwards, inwards, and outwards, and of the ra- dius by rotation forwards and inwards; but we have often failed to recognize incomplete dislocations, such as subluxations with or without swelling of the soft parts. Besides, these incomplete dis- locations, so well described by M. Denuce', are frequently impercep- tible in the living subject, so slightly marked are they, especially in the child when there is swelling. All the easily detected dislocations we have found in children are produced by the causes usually described for adults, and the principal symptoms pointed out for dislocations of the elbow in the latter are always observed in children, and the methods of reduc- 264 TRAUMATIC DISLOCATIONS. tion advised have always succeeded when the dislocations were recent. But there are some dislocations, the symptoms of which are but slightly marked, or, being incomplete, often escape notice, and are reduced by simple flexion of the forearm at a right angle. As for late reductions, we have succeeded in children, after the lapse of a month or six weeks, in reducing dislocations of the elbow backwards, but we have frequently failed in the three forms of dislocation forwards, backwards, and outwards of the upper ex- tremity of the radius, even when these were not at all old. If we have sometimes brought the articular surfaces in relation, we have not been able to properly maintain them so. In these luxa- tions of the upper extremity of the radius, and even in all those of the elbow, whether unreduced or reduced incompletely, time has done much to re-establish the movements, and, by gentle and con- tinuous pressure, we have been able to restore the head of the radius gradually to its proper place, and the deformity has, in time, become much less considerable, and the movements have been preserved. We have very often seen dislocations of the elbow backwards, chiefly the ulna alone, rarely both bones. We found one case of dislocation of the humerus forwards easily reduced, and we have generally seen dislocation of the upper extremity of the radius very often incomplete, and then we have been able to reduce it and keep it reduced, and this does not usually occur in complete dislocations. In regard to the after-treatment of all reductions of the elbow, we have always put the forearm in a state of flexion on the arm, keeping the forearm either in supination or pronation, according to the nature of the dislocation, whether it be backwards or forwards. We have several times been in doubt as to whether certain dislocations were simple or complicated with fracture, and in all cases, even in the doubt, we have kept the limb flexed; and we believe that this is advisable except in cases of dislocation with fracture of the olecranon, when semi-flexion rather than complete extension will be indicated. We always remove our apparatus at first at the end of twelve or fifteen days, in order to institute a slight movement in the articulation, and we re-apply a new ban- dage for a longer or shorter period, according to the necessities of the case. If there are any complications of fracture, we do not hesitate to apply an immovable dextrine apparatus, or else we place the limb in a grooved elbow splint, every twelve or fifteen days taking the precaution to institute movements in the elbow, to avoid anchylosis. ERYSIPELAS. 265 A mode of treatment which we have adopted for a long time when there is much tumefaction about the joint is, before or after the reduction of the dislocation the application of leeches and cata- plasms around the elbow, with the view of preventing subsequent arthritis; but we now only employ cataplasms, and an application consisting of mercurial ointment and belladonna for several days, for we have noticed that arthritis consequent on external violence in children is much more uncommon than is generally supposed; and besides, the use of immovable bandages, the articulation being surrounded with wadding or not, with the precaution to watch the bandage, is the true prophylactic method in arthritis, particularly in scrofulous children. We still sometimes apply leeches in chil- dren of strong constitutions, and chiefly when the dislocation is complicated with fracture or serious contusion. In children as in adults, if we have often easily reduced dislocations of the fingers and of the phalanges, we have sometimes been obliged to make subcutaneous section of the ligament, to reduce in both cases dislo- cations of the phalanx, and have sometimes easily reduced disloca- tion of the first metacarpal bone, but once in a child of twelve years old we failed, as did our master, M. Velpeau. The child finally in time made good use of its thumb. In concluding this notice of dislocations of the elbow in children, we may observe that the special indication in these cases is to em- ploy methods of graduated extension with mechanical apparatus, in cases of incomplete anchylosis of the elbow, resulting from too long-continued immobility of the articulation from various causes, fractures, or dislocations. The use of these forms of apparatus requires at first the preparation of the articulation by baths, deli- cate handling, etc., and we must then proceed slowly, keeping a constant and attentive watch over it if we wish to avoid accidents. CHAPTER XLVI. ERYSIPELAS. Erysipelas, a superficial inflammation of the skin essentially spreading, is often met with in children and the new-born. Causes.—These are either general or local, as the result of opera- 266 ERYSIPELAS. tions, of external injuries, wounds, hurts, vaccinations, simple ex- coriations, blisters, inflammation of the umbilicus, eczema of the hairy scalp, erosions of the genital organs, nates, etc. In the new- born, want of care is the principal cause of erysipelas, a serious affection at that age. Symptoms.—A redness of the skin of greater or less intensity, often circumscribed, will be noticed, which disappears on pressure, and returns afterwards. This redness is more or less painful, and some- times indolent. Very often these local symptoms are accompanied with swelling of the neighbouring ganglions, and of the lymphatic vessels of the affected region, in the form of reddish lines starting from the erysipelas, and directed toward the ganglions. Erysipelas is sometimes limited, and this is more appreciable to the touch than sight,and there is a very feeble ring forming the circumscribing boun- dary. When the erysipelas is seated in the eyelids, in the scrotum, or in the vulva, it is accompanied with infiltration of the subcuta- neous cellular tissue. All these symptoms are preceded by chills, fever, and general disturbance; in some children fchere is even pre- cursory delirium with vomiting. The symptoms of this disease gradually increase in intensity: there is heat of skin, fever, and great thirst, and besides, the skin being distended, the epidermis is modified, becoming elevated with the formation of vesicles full of serum; generally the erysipelas terminates by resolution, rarely by suppuration or gangrene. This affection is sometimes epidemic, and even contagious, ac- cording to the opinion of the English surgeons, Arnott, Gibson, Lauveau, and of the French physicians, Alibert, Rayer, Chomel, and Costallat. We have not had occasion to establish its conta- gious character at the Hopital des Enfants; nor have we had any more reason to believe in its positively epidemic character in our surgical wards at this hospital. This partly explains the more common success of operations in childhood. Diagnosis.—This is easy, and to any one who has seen measles, scarlet fever, or urticaria in children, no confusion can exist in the diagnosis between these diseases and erysipelas. Erythema might be confounded with it, but this affection is free from tumefaction and pain, and is, so to speak, fugacious, and usually unaccompanied with general symptoms. Prognosis.—As a general rule, this is as grave in children as in adults. Nevertheless, if we refer to our own experience, we will LOCAL TREATMENT. 267 say that this disease frequently follows a course more or less gradual, lasting ten or twelve days, and being cured without treatment by resolution. The redness, heat, and swelling diminish, and desquama- tion occurs; but this favorable prognosis is not exempt from ex- ceptions, and should be especially modified for erysipelas in the new-born, which we will separately describe. Erysipelas should be considered as of a very grave character when it is not purely local, and is complicated with purulent absorption, characterized by pro- longation of the general symptoms; chills, fever, vomiting, with rapid transition of the redness from one point to another, or when the disease is ambulant, as it is called. It is also, grave when complicated with phlegmon, or inflammation of the subcutaneous and deep cellular tissue.' The treatment may be divided into general and local. Local Treatment.— We do not agree with some authors, that local treatment is useless. If, in many cases in which the erysipelas arises from some general influence, we should abstain from local remedies, it is not the same thing in regard to the form of the dis- ease arising from traumatic causes. When the erysipelas is due to a general cause, the treatment may be confined either to lotions more or less often repeated, with infusion of elder leaves or bran- water, inunction with lard, or, better still (for we are not at all partial to washes, especially those that are emollient and warm) powdering the affected part with potato starch or rice flour. In erysipelas occurring as the result of a wound, a slight hurt or an operation, if there is intense fever, very great heat, and a tendency to the extension of the disease, it has appeared to us that in some cases the inunction with mercurial ointment has succeeded, and the ointment of the sulphate of iron has given us some good results. Following the example of Dupuytren in certain ambulant cases attended with fever, delirium, etc., a blister placed in the centre of the part affected has put an end to all the symptoms, even in very young children. Having often employed these local remedies, I am satisfied that leeches over the lymphatic ganglions above the seat of mischief are sometimes very useful, but the application of collodion especially, according to the formula of Robert Latour, has given us in children the best results in traumatic cases. As for leeches, if there be heat and fever, we follow the example of Blandin in traumatic erysipelas, and apply them over the ganglions of the axilla for an erysipelas of the arm or forearm, if the gan- 268 ERYSIPELAS. glions are tumefied and painful; and over the region of the groin for erysipelas of the lower extremity. General Treatment—The indication always is, in erysipelas from general causes, to prescribe purgatives, emetics, diluent and laxative drinks, whey, lemonade, and herb broths, which are useful, ac- cording to the nature of the case. But, after operations when we fear the occurrence of purulent absorption, the alcoholic tincture of aconite, in appropriate doses in a julep, should be prescribed for our young patients, and repeated each day. Cinchona in coffee, given in the dose of fifteen to thirty grains of the soft extract of cinchona in black coffee, once daily, has appeared to us to be very useful in cases of purulent absorption, even in very young children. Erysipelas of the New-born requires separate mention. It is ob- served within a few days after birth, and may be fixed or wandering, like that met with at all other periods of life; but its characteristic feature is, that it becomes developed in the earliest infancy, and has its seat most frequently around the umbilicus or about the genital organs, on the cirumference of the anus or the nates. Causes.—The smallest excoriation may be the principal cause of it. Cracks of the thighs or the scrotum, and frequently the inflam- mation that accompanies the descent of the umbilical cord, may produce the disease, and vaccine pustules may be its point of de- parture. Sometimes there is an epidemic cause, as is seen from time to time in lying-in hospitals when there exist epidemics of puerperal fever. The cause may also be found in the bad condi- tions under which children of the labouring classes live. Symptoms.—As a general rule, there are few prodromic symp- toms, although sometimes the infant has fever, vomiting, convulsions, and jaundice. The coloration of the skin now declares itself, and at one of the points indicated there is heat, with restlessness, insomnia and continuous frequency of the pulse; the redness, at first of slight extent, progresses, becomes painful and more or less diffused, sometimes taking the character of erysipelas, and overrunning all parts of the body. There is always more or less tumefaction, with infiltration of the subcutaneous cellular tissue. If the disease terminates by resolution, the symptoms referred to gradually di- minish ; but, on the contrary, and unfortunately, the child very often becomes enfeebled, and refuses to take the breast, diarrhoea and vomiting take place, and the affected part becomes of a more in- TREATMENT. 269 tense red, and even the skin becomes gaagrenous. When the sloughs become detached, the wounds resulting should be dressed with powder rather than with cerate, and the suppuration may only cease very slowly. We frequently notice also symptoms of peritonitis, and at the autopsy we discover pus in the spaces of the cellular tissue of the walls of the abdomen, and also false mem- branes on the intestines, and pus in the abdominal cavity. Prognosis.—This disease is very grave, often mortal. The chances of saving children are so much greater in proportion to their age; but nearly all those only a few days old are carried off, no matter what may be done for them. Treatment—Internally we may prescribe laxatives, or calomel in fractional doses, and enemas if there should be constipation. We should not stop completely the milk of the nurse, if it is of the proper quality. We have not adopted the suggestion of Eng- lish writers, and given two drops of the tincture of the chloride of iron every two hours in sugared water. Externally we may employ a few body baths of bran-water of short duration, and, as a general rule, few or no cataplasms; but what has succeeded best in our hands, is powder of potato or rice starch, but especially the appli- cation of elastic collodion repeated several days in succession, graduated in quantities according to the extent of surface involved; and we must, so to speak, pursue the disease with the collodion, changing very frequently the linen of our little patient, so that it may not become too moist. Every time that it is changed we should reapply the collodion. When the skin becomes gangrenous, applications of digestives may be sometimes useful to facilitate the separation of the sloughs; and this being effected, we must use simple dressings, still preferring starch mixed with tonic powders, renewed frequently and carefully. By such means we avoid fresh attacks of erysipelas, which are too often provoked by the fat sub- stances, preparations of lard, of glycerine, etc., suggested in these cases. We have had some success, but very rarely, in the use of dressings with the powders only. 270 SPRAINS. CHAPTER XLVII. SPRAINS. In children as in adults, a sprain is an abrupt articular distension, with or without laceration of the ligaments and the soft parts sur- rounding the articulation. This is generally met with in the tibio- tarsal articulation, but also in all the articulations, and chiefly in children in those of the forearm and wrist. It may be said in ad- vance, that all the disorders which are produced in children who are lifted by the arms are sprains, in all cases in which this traction produces neither dislocation nor fracture. Causes.—The suppleness of the articulations in children appears to us to be a cause which predisposes them to sprains less frequently than adults. The usual causes are falls, contusions, and strong trac- tions which exaggerate the movements beyond the normal state, and give rise to distension and laceration of the articular ligaments. Pathological Alterations.—It is only by experiments on the cada- ver that we are able to estimate properly, as Bonnet of Lyons did, the lesions produced by sprains; for we very rarely have the op- portunity of observing at an autopsy a recent sprain. In the few rare cases that we may meet with in those who have died after sprains, and especially experiments on the cadaver, we discover in very slight sprains scarcely any distension of the ligaments, with slight sanguineous exudation; at other times when distension is observed in the articulations which have experienced violent and forced movements, the subcutaneous and intermuscular cellular tissue, and that around the joint, is lacerated to a greater or less ex- tent, and the small bloodvessels are torn, producing ecchymoses; the aponeurotic fibres, the muscular fibres, and the tendinous sheaths are also sometimes lacerated, resulting in serous infiltration around the articulation. Physiological Symptoms.—These are infinitely variable, accord- ing to the intensity; they may be transient and momentary, or protracted to a greater length of time. A distension of the TREATMENT. 271 joint may cause a rapid and transient pain; there is suffering if the ligaments have been injured, and in an individual who has made a misstep by turning his foot abruptly in one direc- tion or another, sometimes five or six minutes elapse before he can again rest his foot on the ground. Sometimes, however, it may produce pain of longer duration, and may then present the following symptoms: around the affected joint the patient may suffer more or less acute pain which impedes the movements, and when the sprain is seated in the foot, may prevent him from walk- ing. This pain, caused by the distension of the nervous filaments, of the synovial membrane and of the soft parts surrounding the articulation, may last for a longer or shorter time, or cease almost immediately. Generally very soon after the accident, or some little time afterwards, the soft parts become swollen, ecchymoses appear, the pain increases, and the patient feels that it is necessary that he should not move his limb. In the simplest cases, the inflammation is of short duration, and the effusions of blood or other fluid be- come absorbed, and there remains a slight stiffness, which disappears in a few days. If the case is one of greater intensity, and the lacerations more extensive; if the constitution of the child is lym- phatic, or if we do not at once make the articulation immovable, an acute inflammation occurs, which becomes chronic and may de- generate into white swelling. The diagnosis is quite easy. In children a dislocation can hardly be confounded with a sprain, the deformity of the joint being very different. In the articulation of the foot, by instituting lateral movements of the foot in such a manner as to press alternately on the two malleoli, it is difficult not to recognize fracture of the fibula; and yet we may remain in doubt if the swelling is con- siderable, and only at the end of a few days can the diagnosis be made out with certainty. We cannot always at once appreciate the extent of the mischief, and in such a case it is better to abstain from making too long and painful an exploration. The prognosis cannot then be made in all cases, especially if there is acute pain and considerable swelling, for the degree of the sprain may be infinitely variable, and we cannot affirm that the cure will be prompt, especially in lymphatic children. Treatment—This may consist, for cases of little gravity, either in the application of wadding around the articulation, secured with a retaining bandage, or else in massage, practised at once or in the 272 ERYSIPELAS. earliest hours after the accident, but only when there is tumefaction or infiltration of the soft parts, such cases being the only ones in which we can obtain a good result from this mode of treatment, employed at the commencement, and even'later, taking the pre- caution to follow it with a retaining bandage, wet with a resolvent and soothing liquid, water, camphorated brandy, and a few drops of extract of lead. Massage or shampooing may be especially practised on the foot, or the knee, or the wrist, and in the following manner: we must grease the hands with a fat substance, lard, for example, and exert gentle pressure very slowly and prolonged from below upwards) in order to cause the fluids effused around the articulation to ascend* We must carefully institute movements, as advised by Bonnet, of Lyons, and repeat them at different times and more or less frequently) according to the intensity of the sprain. We know that sometimes, after one or two such operations, the patient can walk. This has been observed several times by Dr. Lebatard, and has also occurred in our hands, in cases of slight sprains. We must continue the massage for several days when the sprain is not of much gravity. Another treatment, employed for a long time, and still used by surgeons, and by us especially, particularly for grave cases, consists in the application of leeches, when there is considerable swelling and extreme pain. We may be satisfied merely to apply com- presses wet with cold water, and to sprinkle the dressing either with cold water, or with a mixture of lead-water. I have derived benefit from continuous irrigations on the affected part. At the end of several days, we apply a gently retaining bandage, and place the affected part on a pillow arranged in the form of an inclined plane, in such a manner that the foot may be more elevated than the knee. When there is no longer swelling, we apply an immovable bandage, which may be left on for some time, fifteen days, a month, Or longer. When we remove this apparatus, there remains in the joint, nothing more than a stiffness, which disappears gradually when the joint is subjected to movements. If the sprain passes into a chronic arthritis the case is grave, for then we have to deal with a white swelling. Sprains of the Forearm deserve a special mention. These acci- dents, produced in children who are roughly lifted by the arm, are, in our experience, with the exception of fractures and dislocations SPRAINS OF THE FOREARM. 273 which may arise in this manner, the most frequent of true slight sprains. These sprains take place in the various joints of the fore- arm, according to the nature of the movement impressed on the limb. In such cases—and we have seen a large number of them —the children have been lifted roughly by the arm, either to make them dance, or to jump over a gutter, or to prevent them from stumbling. Some of them had fallen, but nearly all had been taken by the hand, some by the wrist, others by the forearm; and in all cases the limb had been turned more or less abruptly, either in supination or pronation. Under these various circumstances, it is evident by observation, reasoning, and physiological examination) that the distension or pulling may involve several articulations- Thus, when the child is roughly lifted by the wrist or forearm, the movement of pronation or supination may take place either in the articulation of the superior extremity of the radius, or in the wrist. Either the lower extremity of the radius or that of the ulna may then be carried forward or backward, and the distension takes place in the ulno-radial or the radio-carpal articulation. When these children are brought to the surgeon—and we have seen quite a large number—very few present fractures of the ulna or the radius, or dislocations either of the upper extremity of the radius or the lower extremity of the ulna; the majority, on the con- trary, are not attended with any of these grave symptoms, though they nevertheless present features which especially alarm the parents, and sometimes even the physicians, on account of the cries and complaints of the children. In any event we find in children symptoms which are nearly always the same; thus, they cry and complain a good deal when the limb is moved, either extended or flexed, or movements of rotation or supination are impressed on it, and we do not observe any appreciable deformity. We sometimes hear, during the movements that are executed, a sound, without no- ticing the point from which it is produced, and we are induced to ascribe it to a gliding of the articular surfaces over one another. All at once, when these movements are once produced, a child ceases to complain, and without our being able to say that we have done much to cure it, we see him move the limb as he did before the accident. At other times this is not the case, and the pain persists; sometimes there exists sensibility over the superior arti- culation of the radius, sometimes the inferior articulation, and in- ferior ulnar articulation. 18 274 OZ^NA. In our own experience we are generally far from being able to make out a precise diagnosis in all cases. We believe when we detect neither fracture nor dislocation of the upper extremity of the radius, nor displacement of the carpal extremity of the ulna, that there has occurred a sprain, generally of a slight character; that is to say, slipping of the articular surfaces and distension of the ligaments, or at least a tendency to a dislocation which has not been effected. We do not believe that these accidents are produced always at the elbow or wrist joint, but, on the contrary, at several situations in the articulation of the forearm. Sometimes this lesion, when not of much gravity, passes into the wrist-joint, as our con- frere M. Goyrand observed it in several cases, but we do not pre- tend, like him, that it is always at this point. We think we have heard, as he did, the peculiar noise over this articulation, but we have often detected it in the superior articulation of the radius. In all cases, the prognosis being only grave if there are several recurrences, we content ourselves with putting the forearm in a state of flexion at a right angle, by placing the hand in supination or pronation, according as the patient prefers one position or the other, and in nearly all cases this position is excellent for the patients, who no longer complain, and as a general rule are cured in three or four days. If the pain persists at the end of that time, our advice would be to put on an immovable bandage for eight or ten days, placing the limb in the position indicated. CHAPTER XLVIII. OZ^ENA. The name ozasna is given to a symptom produced by deep ulcer- ations of the nose, from which exhales so strong an odour that we cannot speak to children who are affected with it, without at once finding that the air they expire is charged with a peculiar fetor. It exists in the interior of the nasal fossae and the frontal and maxillary sinuses. In these deep situations, which cannot be seen on the living subject, we notice, as may also be detected on parts less deeply seated, at the entrance of the nasal fossae, ulceration of TREATMENT. 275 the mucous membrane at one or several points, but sometimes no- thing can be seen. Causes.—In adults, syphilis is frequently the cause of this affec- tion. In the child, it is due to scrofula and often caries of some portion of the bones of the nasal fossae. Sometimes very robust and healthy children, without any appreciable constitutional affec- tion, are attacked with this disease. We have met with it in those who had narrow flat noses. Pathological Lesions.—These are often true ulcerations at different points in the nasal mucous membrane, sometimes modification in the thickness of that membrane; at other times, ulcerations at the entrance of the nasal fossae, but most frequently very deep in the anfractuosities of the turbinated bones and of the ethmoid. Symptoms.—These are, abundant secretions in the nasal fossae, of a purulent and sanguinolent character, forming crusts in the nose and chiefly exhaling a fetid odour, a cadaveric odour peculiar to caries, which has been compared to that of bed-bugs, and hence the term punais (punaise, a bug) has been applied to those thus affected. Ozasna is developed without anything announcing its approach; sometimes it commences in an obstinate stoppage of the nose, with local sensibility; at other times, headache, the expulsion of purulent mucus, and even of crusts. Very often there is loss or diminution of the sense of smell. Prognosis.—As a general rule, ozasna is a tenacious affection; it is, nevertheless, of a less serious nature in children than in adults, for it often depends on a scrofulous vice, which may become modified as the child gVows older; and the disease, therefore, yields sometimes in children at the period of puberty. It is modified also by the appro- priate treatment. The general health is not usually influenced by this disease, which is often incurable, but which does not interfere with the healthy appearance of its victim. Treatment.—In children we place in the first rank the varied anti- scrofulous general treatment, and at the same time deem it very important to combine with it good diet, the use of general tonic, saline, gelatinous, sulphurous baths, artificial baths during the winter, taken especially at the sulphur springs themselves, or sea- bathing, at the proper seasons. Benefit will also be derived from letting the child walk in the open air. Although we do not place the same value on local remedies, regarding it as of the first importance, before everything else, to 276 LACHRYMAL FISTULA. modify the constitution, we nevertheless prescribe in succession powders to be snuffed up and injections. The powders we have used are those composed of tannin and alum, of one part of white precipitate to fifteen of powdered marshmallow root, or two parts of calomel and fifteen parts of tannin or cinchona. All these powders are snuffed up, or insufflated, several times daily. As injections, we have employed successively infusions of walnut leaves repeated morning and evening, sulphurous injections, Enghien water mixed with barley-water, the mineral waters of Bonnes, solution of bichlo- ride of mercury (Van Swieten's solution) two spoonfuls in a glass of milk, injected morning and evening, the injection of chlorinated water, etc. A form of injection which has succeeded best with us consists of two spoonfuls of the following solution in a glass of water:— R. Potassae permanganat. 3ijss. Aquae f^iv. M. It must be acknowledged that many of these remedies are em- ployed without success for a long time, and as the child's constitu- tion changes a cure may follow in some cases. In an excellent treatise on this subject, produced by M. Cazenave of Bordeaux, he states that he has used nitrate of silver with good results, applying it by means of a portecaustique contrived by himself. We must not confound with ozasna the fetid emanations exhaled from the nasal fossae as the result of caries or necrosis of the bones, as the vomer or the turbinated bones. When the ozasna depends on these causes, it will always yield more or less promptly after the expulsion of the diseased portions of bone, as we* have our- selves observed in several children. CHAPTER XLIX. LACHRYMAL FISTULA. Lachrymal fistula presents itself at the inner angle of the eye in the form of a small ulceration, which gives passage to the tears. We will confine our remarks to what we have observed in children. This affection is quite frequent, and is attributable to a lesion of the lachrymal canals causing swelling of the mucous membrane of LACHRYMAL FISTULA. 277 the lachrymal apparatus. The cause is often the lymphatic or scrofulous vice, and then it is a general cause; but it is sometimes local, a foreign body coming from without, or a concretion formed in the lachrymal canals, or else compression over the nasal canal by tumours of different nature in the neighbourhood of the lachry- mal apparatus. We have seen, in very young children, very minute openings over the inner angle of the lids, beneath the tendon of the orbicu- laris palpebrarum, scarcely allowing the introduction of an Anel's stylet, and giving an outlet at long intervals to a few drops of transparent fluid, especially when the inner angle of the eye is compressed ; and yet we cannot really assert that the lachrymal sac was distended and formed a tumour. In some cases these little fistulas were congenital, while others occurred, without any known cause, after birth. We have seen several "of these little fistulas, in young children, cured under the influence of astringent lotions, or by injections with infusion of walnut leaves; and we have seen them persist, no matter what was done for them. But the form we have generally observed has been true engorgement in the inner angle of the eye beneath the tendon of the orbicularis palpebrarum. There are two forms of this affection. One of these, a true ab- scess, opens and results in suppuration, followed by ulcerations which cicatrize more or less slowly under the influence of general antiscrofulous remedies, or even of very simple local means, and have no communication with the lachrymal passages. The other form is a lachrymal tumour, presented in the shape of a small swelling, quite hard, and at first without change of colour of the skin. It is accompanied with epiphora, the eye is suffused, and on touching the tumour it becomes depressed. Tears may be made to flow, and may even be purulent, through the lachrymal puncta or through the inferior orifice of the canal through the nose. This kind of engorgement may remain for a long time stationary, and may sometimes be cured by injections made through the lach- rymal puncta or the lower part of the canal. Generally the engorge- ment becomes inflamed, and ulceration is established; and we de- tect a fistulous point which communicates with the lachrymal passages, and gives an outlet to the tears. In scrofulous children, the fistula may be cured under the in- fluence of a general antiscrofulous treatment, prolonged for a con- siderable time, combined with the local treatment by means of 278 LACHRYMAL FISTULA. lotions of decoctions of walnut leaves, repeated for years, morning and evening, with perseverance. But there are cases in which the remedies we have suggested are not followed with any result, and in which, after being well assured that there is no necrosis of the bones, no foreign body or polypus, we have operated with success with the canula of Dupuytren; but we have been obliged to aban- don it on account of accidents which require the more or less prompt extraction of this canula. We have seen it worn for several years, and afterwards those operated on blew out their canula and were cured. Recently we have decided upon the employment of butter of antimony for the cauterization of the nasal canal. After having met with numerous accidents, the slowness of the other methods adopted, and especially numerous recurrences, after such remedies as dilatation, setons, canulas, etc., we now resort to oblite- ration of the canal. Dr. Magne has lately published several observations, and we have ourselves had several cases, which militate in favour of this procedure. Besides, nature has pointed out this method of treat- ment, since lachrymal fistulas are sometimes cured by the oblitera- tion of the canal without an operation. After such, obliteration, there is, at first, lachrymation, which gradually diminishes, and finally disappears. Hannoni opened the sac under the tendon of the orbicularis palpebrarum, filled it with charpie, and on the next day, after the pain had ceased, he cauterized the sac with a mixture of alum and precipitate. Dr. Magne cauterizes the sac with butter of antimony. We ourselves operate as follows: we first open the sac beneath the tendon of the orbicularis, and, after washing out the cavity, separate the lips of the wound with a small bivalve dilator introduced into the orifice of the canal, carrying to the bottom of the sac a small sponge, firmly secured on a stylet, im- pregnated with butter of antimony, and sufficiently small to pene- trate easily. In these cases we have also employed general anaes- thesia. Swelling may occur, the cauterized part may suppurate, the canal become obliterated, for several days there may be lachrymation, and the wound slowly cicatrize. We are sometimes obliged to practise a second cauterization, but, as a general rule, it may be sufficient, after cauterization with butter of antimony, to touch the wound with nitrate of silver, and cicatrization thus terminates. ANAESTHESIA. 279 We have seen patients cured after a single application of butter of antimony, who, several years after the operation, had no recurrence of the disease. CHAPTER L. ANAESTHESIA. General and local anaesthesia may be, and should be, resorted to in certain cases, in children as in adults. We have employed it in those of only a few months of age, and have never had any accidents. We believe that even in childhood we may, by the prevention of acute pain, obviate the occurrence of convulsions, which certain very painful operations might otherwise induce. It may, indeed, serve to facilitate the performance of several delicate operations. General anaesthesia is indicated in children in all operations which require any length of time, such as lithotomy, lithotrity, amputation, operations for hernia, and even simple reduction of strangulated hernia, extirpation of a tumour of greater or less volume, the re- duction of certain old dislocations, ligation of a principal artery, as the brachial, the femoral, the carotid, etc. Local anassthesia is reserved for operations which are rapidly executed, as the opening of abscesses, phimosis, extraction of a nail, extirpation of a small tumour, or cauterization of erectile tumours with red-hot iron. General Anaesthesia.—In all cases in which we employ it, we use either pure chloroform, or, better still, equal parts of chloroform and ether. We administer it to the patient fasting, or at least three hours after eating, the child being in a recumbent, not in a sitting, position. We use a conical sponge, shaped like a mushroom, having an opening at the top and bottom of it, placing the sponge in a horn made with a compress or a handkerchief, the point of the horn being permeable to air. We pour the liquid upon it in such a way as to soak the sponge moderately, and we place the base of this apparatus in front of the mouth and the nose, keeping it at a certain distance without touching the lips of the patient. We cause him to breathe as freely as possible, carefully watching the pulse and the respiration. When the former becomes more feeble and less frequent, we suspend the inhalation, resuming it if 280 AN^E sthesia. necessary. When the skin is insensible to a pinch, when the pupil is dilated, and the patient is not excited, the time has arrived to operate. If the respiration and circulation diminish, we must not keep up the inhalation, but carefully put the child in a sitting posture, keeping him lying on his back, with the head slightly inclined down- wards. If the respiration continues to diminish, or takes place in an incomplete manner, we must depress the tongue rapidly, in order to force the child to take a full inspiration, and throw cool water over the face, and at the same time excite movements in the chest to increase the activity of respiration. We must place both hands on the lateral portions of the child's chest, and thus embrace the thoracic cavity, making with both hands movements from above downwards, to successively elevate and depress the ribs, and thus produce artificial respiration. This method has always been of service in our little patients, and we have never met with any diffi- culty in making the respiration persis . Local Anaesthesia.—When we cannot employ general anaesthesia, we must resort to methods for rendering insensible the part on which we have to operate. This we have often done with success. To fulfil this indication, we make an application either of ice or of the vapour of ether. We pulverize the ice and mix it, as Arnott suggested, with a third part of gray salt, and place this mixture either in a little gauze bag, or in gold beater's skin, and apply this bag over the part we wish to render insensible, a result which follows at the end of three or four minutes. To apply the vapour of ether, we have used Richardson's apparatus, constructed by M. Galante, on the suggestions of M. Salles-Girons, the object of which is to project pulverized ether on the point where the bistoury is to be used, so great a coldness being produced that we can make an incision without the patient experiencing any acute pain. The sensation of very painful cold, which impresses them, makes some children cry. In any event, this agent may be resorted to with advantage, as may ice also, and either of these can be employed with children, to obtain local anaesthesia, when general anaesthesia cannot be used; but we have found that patients bear ice better than ether. We must repeat that this local anassthesia can only be employed when we have to operate in a circumscribed situation. Otherwise we should prefer general anassthesia. PHLEGMON. 2S1 CHAPTER LI. PHLEGMON. In children, as in adults, phlegmon, which consists in inflam- mation of the cellular tissue, is met with in the new-born as well as in children more advanced in years. We find it either circum- scribed or spread, superficial or deep. Causes.—Frequently the causes are traumatic, and sometimes spontaneous in children, chiefly as the result of certain diseases, as measles, scarlet fever, smallpox, etc.; and we see phlegmons that are, so to speak, critical. The traumatic causes are numerous; contusions, wounds, excoriations, the presence of foreign bodies, splinters, needles, shot, etc., may give origin to phlegmon, and these are its most frequent causes. Different operations are also very often followed by erysipelas, which is complicated with serious phlegmons of greater or less extent, superficial or deep. Affec- tions of the bones and of the periosteum may be causes of phleg- mon. Local Symptoms.—The affected part is tumefied, with redness that does not disappear on pressure, more or less hardness and resistance, acute pain with pricking or pulsation, and heat. There is swelling which is not circumscribed, and extends more or less deeply under the aponeuroses through the tendinous sheaths. The movements are painful, and the disease may progress very rapidly or very slowly, either towards resolution, or towards suppuration or gangrene. Sometimes resolution may occur in a few days, and the heat, pain, and tumefaction will diminish rapidly, and the affec- tion be cured. If suppuration declares itself, it may be developed in two or three days; if the phlegmon is superficial, the skin be- comes elevated, attenuated and soft, and fluctuating at one point, proving that the abscess is about to open, destroying the skin. But if the phlegmon is deep, the pus, instead of endeavouring to find an outlet through the skin, becomes more deeply diffused, detaches the muscles, passes alongside the tendinous sheaths, sepa- 282 PHLEGMON. rates the periosteum, and reaches even the bones which it denudes, and then spontaneous openings slowly appear on the skin, and the pus makes its appearance externally through the fistulous orifices. If the inflammation terminates in mortification, the skin is seen to become gangrenous, and the aponeuroses, muscles, and tendons are exposed and bathed in pus. The gangrene may act on the deep parts in the small pelvis, in those surrounding the rectum, etc., for example, or on the excretory ducts in the vicinity of the purulent collection. General Symptoms.—When the phlegmon is not very deep, the general symptoms are sometimes almost null, but there is, never- theless, always more or less acute pain; but if the inflammation is more deeply seated, there may exist at first a precursory chill, even before any local phenomena are observed. In children, we have met with chill, fever, delirium, convulsions, and even vomiting; we have seen the most circumscribed phlegmon produce convulsive movements, which presented themselves before the appearance of the inflammation, and which ceased as soon as it was well marked, like that which takes place in certain diseases of the skin. As a general rule, at the commencement of the local symptoms, the fever is very intense, but it frequently diminishes, without dis- appearing, at the time of the development of suppuration, to persist sometimes for a considerable time. When the pus makes its appear- ance externally, in circumscribed phlegmon, the fever ceases com- pletely; but in cases in which it occupies a vast extent, when it is diffused and the suppuration abundant and occurring in a well-sup- plied part of the cellular tissue, the fever then continues, and becomes augmented, and the patient may become marasmic and sometimes die with symptoms of purulent absorption. On a post-mortem exami- nation, we often find the evidence of very serious mischief; the muscles, tendons, vessels, and nerves are as if dissected and deprived of their cellular tissue; the denuded bones are bathed in pus, and very often, in scrofulous children, the bones are necrosed, and be- come the point of departure of the phlegmon. Diagnosis.—This is easy for superficial subcutaneous phlegmon, but difficult for deep phlegmons, of the thigh, for example, and neighbouring parts of the pelvis. We must call both sight and touch into requisition to establish the diagnosis, and we must, by the assistance of the fingers, discover the engorgement of the soft parts and distinguish the pus by the appreciation of the fluctuation, TREATMENT. 283 which is detected by placing the fingers on one side of the swelling, and pressing with the fingers of the other hand on the opposite side. W'e thus feel the wave by the movement given to the pus, which does not take place in engorgement occurring at any other time than in this purulent condition. Prognosis.—This varies with the location and extent of the phleg- mon: when the latter is circumscribed, it may be favourable: when diffused and occupying a large surface, it may be very grave, es- pecially in cases of deep phlegmon. Treatment.—As a general rule, we should administer internally soothing drinks, restricted diet, or at least a light course of food of milk, broth, mild soups, and cooked fruits. Externally in the local treatment at the commencement, if the cause is the presence of a foreign body, we must extract it, if possible. If it be due to any other cause, we must, in children as in adults, commence with emollients in the form of baths or cataplasms, being cautious in regard to the use of bloodletting. If, nevertheless, the disease is observed in a strong and vigorous child, with much fever, we may in phlegmons involving a large surface and of a very intense character, arising from a traumatic cause over the whole of a limb, for example, obtain resolution rather by general bloodletting than from the ap- plication of leeches. It has, in fact, the advantage over leeching, that we can extract the quantity of blood the child is to lose, while by leeching we may not be certain of this quantity. This treatment, however, which we regard as very useful in phlegmon arising from a local cause, appears to us to be injurious, if the cause is a general one, which is often not appreciable. We, therefore, in the greatest number of cases, rather than debilitate the child by loss of blood, prefer at first to prescribe a gentle purgative, with a proper position of the limb, which should be elevated and placed on an inclined plane, with applications of cataplasms. Frequently, compression well exerted over the whole limb, fol- lowing the plan of Bretonneau, has succeeded. In these cases, the application of blisters has not been attended with favourable results, and we greatly prefer, at first, to employ the treatment of Serres d'Uzes, which consists in making large inunctions, repeated three times in the twenty-four hours, with pure mercurial ointment, com- bined with extract of belladonna, if there be acute pain. The elastic collodion of M. Robert Latour has not succeeded as it has 284 CERATITIS. in erysipelas; and yet it is of service in some phlegmons, and we do not, therefore, ignore it in all cases. These remedies, employed from the commencement, and one after the other, have been of positive advantage in obtaining resolution; but if, in twenty-four or thirty-six hours, the phlegmon does not show any signs of diminution, we at once, in children as in adults, make early incisions, more or less numerous and deep, according to circumstances, and even before the establishment of fluctuation. This method of treatment is also beneficial in extensive phleg- mons, as it is for whitlow, which is really only a phlegmon of the finger, and requires prompt division. Even by a single incision only, we prevent very grave symptoms, and it is especially by means of two, three, or more, which we may often prolong under the aponeuroses, that we obviate purulent collections and gangrene. Following the example of our colleague, M. Chassaignac, we have sometimes derived great benefit, in very extensive abscesses, from establishing drainage with caoutchouc tubes riddled with holes, which might serve as a means of introducing emollient or detersive injections, according to circumstances. Injections without the drainage are also useful. As in certain cases of absorption, so also in these cases of deep suppuration, we may administer internally alcoholic tincture of aconite and cinchona. The patient should be strengthened, and simple and often tonic and modifying dressings be carefully applied. We have very rarely had phlegmons to treat that were so severe as to demand amputation, which is only indicated in these cases, when the child's general health allows of it, and when all other methods of treatment are inapplicable. CHAPTER LII. CERATITIS. Ceratitis, or inflammation of the cornea, is often met with in scrofulous children. This disease, which was observed many years ago, but especially studied by Wardrop, Travers, and later still by M. Velpeau and all the oculists, may bd divided into several varie- SYMPTOMS. 2S5 ties, the superficial, interstitial, and deep. The first attacks the most external layer, the second the tissue of the cornea, and the third the membrane bordering the concave surface, the membrane of Descemet. Causes.—These are the same as those enumerated for ophthalmia or oculo-palpebral conjunctivitis, and in addition to these the scro- fulous diathesis is often the special cause. Symptoms.—Superficial ceratitis, which is observed on the ex- ternal surface of the transparent cornea, is most frequently an ex- tension from the conjunctiva. The external layer loses its brilliancy, becomes dull, and even as if deprived.of its polish through a greater or less extent, and the conjunctiva in these cases becomes of a violet red; the vessels are spread over the cornea, or isolated and forming very fine threads, or else arranged in a semilunar or trian- gular patch. Sometimes there is a little pustule at the apex of the triangle, which is directed from the circumference to the centre. Often the conjunctiva forms a ring around the cornea, not as pro- minent as chemosis. If the ceratitis travels further and is not checked in its course, the outer membrane may be raised and form a kind of phlyctena. Interstitial ceratitis is thus developed. In such a case, the sight, which was at first merely obscured, is now effected only through a very thick mist; the colour of the cornea is notably changed, and it is cloudy. There is, in the interstices of the cornea, either lymph or pus, and if the morbid products are spread over the whole cornea, vision is lost. As long as there is no solution of continuity in the anterior membrane, the patient bears the light, but the smallest ulceration of the cornea produces photophobia. We sometimes find pus formed between the layers escape externally or become very slowly absorbed. Inflammation of the cornea, when it reaches the internal mem- brane, constitutes deep ceratitis, and the name keratite ponctuee has also been given it by the French. It very often happens then that there is cloudiness in the anterior chamber, situated in front of the iris; this is plastic lymph mixed with the aqueous humour. The three varieties of ceratitis are not always met with separately; that which is seated in the anterior membrane is the most easily distinguished, and most frequently the different varieties succeed each other in the same eye. When the ceratitis is in the acute state, it may be resolved, or terminate in specks formed of plastic lymph, or may give rise to pus, ulceration, or even become softened. 286 CERATITIS. These various forms of ceratitis may terminate in the chronic state, invading the cornea totally or partially; in such cases the membrane, which in the normal state is transparent, at first becomes pale, and loses its transparency; there is a slight cloudiness, then small points followed by spots that are sometimes very minute; there is neither photophobia nor lachrymation, the cornea has lost its polish, gradu- ally assuming a milky, opaline appearance, and if the chronic cera- titis commences at the circumference, we notice there a peculiar vascularization, and sometimes vessels starting from the circum- ference and going towards the centre. This chronic state is very often the cause of loss of sight, yet, in children, time, aided by anti- scrofulous remedies, sometimes brings back the transparency. Treatment.—This may be both local and general; in children, it is usually that advised for scrofula. Under some rare circumstances, if there exist much pain and very active inflammation, we may have recourse to the application of leeches to the temple or behind the ear, but we must be cautious in their use. Advantage will also be derived from the use of the various purgatives. The local treatment directed to the cornea should be composed chiefly of preparations containing the nitrate of silver. If there be superficial ulceration, and the cornea has lost its polish, collyria of nitrate of silver are of great service, but they should be employed with prudence. As ceratitis is always accompanied with iritis, the preparations of atropia are indispensable in the form of collyrium or ointment. Mercurial ointment often appears to us to be indi- cated, either over the temples, or on the cutaneous surface of the lids. A light layer of tincture of iodine, spread by means of a brush over the external surface of the lids every two days only, has been of advantage in our hands. When the ceratitis is characterized by a vascular condition, in which the bloodvessels spread from the circumference to the centre, cauterization around the circumference of the cornea is beneficial. The circumscribed ulcerations often improve under a light cau- terization with a pencil of nitrate of silver, according to Sanson's method. When the ceratitis is deep, and invades all three layers of the cornea, topical applications are almost valueless, and so also is even scarification of the conjunctival swelling, though sometimes it is practised with useful results. Blisters over the eyelids, advised by M. Velpeau, have often appeared to be attended with success, except in certain cases of ceratitis with chemosis. When the three STRABISMUS. 287 membranes are opaque, topical means are then useless, and we must resort slowly to abrasion of the cornea, and yet this operation, which is very delicate and very serious, may only offer a hope of success if the internal membrane is intact, a condition which is difficult to distinguish. We have never performed it, and the indications for this operation do not seem to us sufficiently positive for us to ad- vise it. All the various spots which are seen upon the cornea as the result of ceratitis are difficult to distinguish in their shades, to decide with certainty on the various operations proposed for their destruction. A superficial spot, depending on plastic effusion under the external layer of the cornea, may be touched with nitrate of silver, and in this case we substitute an acute for a chronic inflammation, which may sometimes be followed by successful results. CHAPTER LIII. STRABISMUS. This name is given to permanent deviation of the eye, which is, as a general rule, observed in young people. It may affect one eye or both. In the former case, there is want of harmony or a peculiar convergence between the two visual axes; and if the sound eye be closed, the other becomes straight and directs itself towards the object presented to it. When the deviation exists in both eyes, there is divergence or convergence. Strabismus may be transient or permanent; thus, during a convulsion, the eyes may deviate, and not continue so afterwards. There are four principal varieties of the direction of the strabismus; it may be internal or convergent, external or divergent, and upwards or downwards, ascending or descending. Strabismus may be fixed and remain as it is, or pass from one eye to the other, and then it is the alternative form. We may find in these deviations more or less intensity; thus, sometimes there is a first stage, in which the axes of the eyes are well directed when viewed from a distance, while they look inwards when viewed more closely. This is called the false line of vision. There is a second stage, in which there is 288 STRABISMUS. an open deviation of the eye, and the cornea is half concealed under the lid; and a third stage, in which there is so much deviation, that nothing more than the white of the cornea is visible. The causes of strabismus are either alterations of vision arising in different manners, or mechanical obstacles, as an orbital tumour, paralysis or retraction of the muscle. One of the chief causes, espe- cially in tender infancy, is the bad habit of using only one eye, as the position given to a new-born child in relation to the light causes it to direct only one of its eyes towards it, and hence produces strabismus. Several cases of this kind are cited in works upon this subject, and in such cases the children have been cured by changing the position and exercising the affected eye. There are certain occupations in which only one eye is used, in using a mag- nifying glass, for example, and this practice may cause strabismus, even in individuals already advanced in years. Certain injuries of the retina, and opacity of the crystalline, existing on only one side, are also the cause of strabismus. The central spots, resulting from ceratitis in children, are also the cause of the deviation of the af- fected eye. There are cases of transient strabismus, such as those occurring during convulsions, and sometimes these may become permanent. We must also remember that if moral emotions, as chagrin, anger, etc., are not causes of strabismus, they may mo- mentarily increase its intensity. Certain lesions of the cerebral substance, whether acute or chronic, may gradually or suddenly produce strabismus. Symptoms.—In referring to the varieties of this affection, we have made known the principal symptoms, and as a general rule it is easy to recognize them. There is always want of harmony between the axes of the eyes, but the sound eye is frequently the only one which preserves the faculty of vision, and yet the contrary may be the case. Nevertheless, the affected eye is always the weakest, and may as a result even become amaurotic. We notice that usually the affected eye has a normal direction, if we close the sound one. In some children, we have found the strabismus to be only appreciable when they looked at distant objects, and no longer existed when they examined those nearer at hand. The affected eye does not present, in its different membranes, any alteration, unless the stra- bismus succeeds an amaurosis, a cataract, etc. Frequently strabismus is produced by a paralysis of the sixth or the third pair of nerves. In the former case, the deviation is in- OPERATION. 289 wards, and there is nothing special about the pupil; in the latter, the eye is drawn outwards. We often find dilatation of the pupil, and besides but little action in the upper lid. Treatment.—To overcome the strabismus, we must employ varied means, according to the causes. Thus cerebral affections and pa- ralysis should be combated, if they cause the strabismus. When specks or amaurosis or cataract are the causes, these are the affec- tions we have to treat; and so also lesions of the retina, which may be detected by the ophthalmoscope, must be treated according to the nature of the case. We should commence to treat the strabismus by means of certain exercises, with the view of restoring the devious eyes, consisting in directing the sight in different directions,—inwards, outwards, and upwards. We may, with much patience, by means of bandages, glasses, goggles, or lateral reading, as advised by Rognetta, obtain some good results. These different means may be usefully em- ployed in strabismus of a single eye, even when complicated with myopia, spots on the cornea, and weakness of the muscles, and even in cases attended with contraction of the latter. But, as all these means just mentioned usually fail, the indication is to resort to division of one or several muscles of the eye. Stromeyer advised ocular tenotomy, and a year afterwards Dieffenbach put it into operation. It was soon practised widely by numerous surgeons, perhaps too much so, by Amussat, Baudens, Bouvier, GueVin, etc. In 1841, we performed this operation about sixty times, chiefly in adults, in young subjects fourteen or fifteen years of age, and in some under seven or eight years, but more rarely. The division should be made on the contracted muscle; thus, in divergent strabismus, we should practise myotomy of the external rectus; in the convergent form, the internal rectus; in ascending strabismus, the elevator muscle; and in the descending form, the inferior rectus. The division of one muscle is generally sufficient, and yet, in certain cases, we must divide the oblique muscles. In any event, let us point out the plan of operating. We have, as a general rule, performed Dieffenbach's operation. We have generally operated without chloroformizing our patient, but we do not hesitate to administer by inhalation a mixture of equal parts of chloroform and ether. We keep the child in a re- cumbent position, with the head elevated on a pillow, an assistant holding the head thus supported, or we may operate with the child 19 290 STRABISMUS. in a sitting posture. The instruments necessary for the operation are an elevator for the upper lid, a depressor for the lower, two small sharp-pointed hooks for fixing the eye, a blunt hook, a pair of scissors with curved blade and pointed. Three assistants are absolutely sufficient, yet, when operating on a child, it is well to have a fourth to support the limbs. If we do not administer chloroform, we may keep the child seated, with the head resting on the back of a chair, or else on the breast of an assistant, who holds the child on his knees. The first assistant is charged with the duty of holding the head, and he places himself over the head of the bed or behind the chair. The operator, having placed the bed before a window, places himself to the left or the right of the patient, according to the eye to be operated upon. It is the duty of a second assistant to keep the upper eyelid raised with the elevator, which the operator has himself previously placed in position. A third assistant keeps the lower lid depressed. The surgeon, having applied a bandage over the eye on which he does not operate, should proceed in the following manner. If the patient is seated, the operator likewise takes a seat in front of him. If chloroform is to be administered, we must hold the child on the bed, and then the surgeon will require the two assist- ants holding the lids to preserve perfect immobility in them. The operator is armed with the two small sharp pointed hooks in one hand, the left,ifhe operates on the right eye in convergent strabismus. Having told the patient to look outwards, he introduces a small simple sharp hook in the conjunctiva, at the distance of two-fifths of an inch from the caruncula lacrymalis. After having properly in- troduced it as far as the sclerotic, he may then draw the eyeball outwards and keep it in that position. With the right hand he introduces a second hook at a distance of a fourth to a fifth of an inch to the inner side of the first one, nearer the caruncle. He raises the conjunctiva by forming a fold transverse to the eyeball, and, causing the assistant who supports the lower lid to hold this last hook, he retains the former in his left hand. Then, having the right hand free, the surgeon takes the scissors, divides in the middle of the fold the whole thickness of the conjunctiva perpendicularly to the direction of the muscle, exposes the subconjunctival fibrous layer, incises it, and lays bare the muscle which it covers. Then, while the assistant holds the other hook, he takes with his left hand the blunt hook, and passes it under the muscle, which he OPERATION. 291 raises, and carefully divides the aponeurotic sheath, but not too freely as otherwise the eye would no longer be satisfactorily held in place, and exophthalmia would occur as the result of the operation. When the muscle is plainly visible, it may be divided at a single cut with the scissors, or else the surgeon may follow, as we have done, the plan of Dr. Philips, which consists in making an excision of the attachment of the muscle. In operating thus, the contracted muscle is grafted farther back on the ball; we then remove some very minute portions of the muscle by means of a second cut of the scissors on the side of its attachment to the sclerotica. If any mus- cular fibres escape, we must repeat the division, and, if after this the eye is carried upwards or downwards, the indication is to carry the blunt hook either upwards or downwards, to divide the con- tractions which might interfere with the straightening of the eye. We must, in such tjase, act with deliberation, and not divide too much, and yet enough. In cases of divergent strabismus, and likewise in the ascending and descending forms, we also make a division of the muscle which, by its contraction, causes the deformity. In ocular myotomy, re- quiring two'assistants, the operator must, before commencing, secure by means of a piece of thread, a small sponge, held by the ring and little finger. This does not prevent him from holding the scissors, and enables him to wash out the wound during the progress of the operation. As a general rule, there is but little hemorrhage, and sometimes there is no necessity to use the sponge. The operation over, the eye must be washed with cool water, and kept closed, and for twenty-four or forty-eight hours lotions of water applied. A compress of soft linen should be left on the eye, and it is prudent to let the patient remain for two or three days with the room moderately lighted. There are even many cases in which these precautions are not taken, and in which acute inflam- mation does not occur, nor any bad symptom, even when the child continues to go out. In fact, in more than seventy cases of strabis- mus on which we have operated, only one has been, as the result of imprudence, attacked with violent inflammation, the others having all been followed by good results. Some of them have had the eye made perfectly straight, others have only had a slight improvement, while three or four remained after the operation as they were before it. In many of our cases, we have had to cut out a granulation, which 292 CYNANCHE PAROTIDAEA. was developed on the wound; sometimes we have seen it disappear without any interference on our part or by touching it with nitrate of silver; generally we have been obliged to practise excision, but not until eight or ten days after the operation. After performing a large number of operations, we have come to know that we must quite frequently resort to strabotomy, and that this operation ap- pears to us to be indicated in almost all cases in which, before we close the good eye, we find the affected one become straight, and in cases of double strabismus, when one of the eyes returns to its normal condition of straightness when the other is closed. We may absolutely practise this operation at all ages, but too tender infancy is a contraindication, for we may obtain modification of the strabismus with time and the means previously suggested. We would consider it more reasonable to wait until about the age of twelve or fifteen for the performance of this operation. In re- establishing the straight position of the eyes, there' is sometimes advantage in giving strength to an eye which has not been used, and to enable a useless eye to be employed. Accidents being rare, a surgeon is not rash to attempt the operation, except in certain cases of strabismus resulting from an injury, in which we have seen it performed without success, and in which we have once failed, and in cases of paralysis, the result of acute or chronic cerebral lesions. CHAPTER LIV. CYNANCHE PAROTIDE A. This disease is characterized by a swelling situated in the parotid region, on the outside of the parotid gland, and is observed in child- ren and in youth. We have certainly seen this affection in young children, most frequently in those in the second stage of childhood, but we are far from having been able to detect many things that are referred to in the authorities on the subject of these engorge- ments, which have been confounded with inflammation of the parotid gland, a disease of a much more serious character, that we have sometimes met with in scrofulous cases. The parotid glands are not involved in cynanche parotidasa, which attacks the cellular tissue external to these salivary glands. TREATMENT. 293 Causes.—As stated in all the standard authorities, we have found moist and cold weather, draughts of air, and abrupt changes of temperature acting as causes of this affection, while sometimes we have been unable to ascribe it to any very evident causes. We have found the disease epidemic in variable seasons. Symptoms.—It has appeared to us to commence always with a general condition of fever preceded with chills, followed with sore- ness and pain in the parotid region, with swelling, rather of an ©edematous than of an inflammatory character, which may extend over the lateral portions of the neck and the face, so as to singu- larly enlarge their transverse diameter. There is pain, but little change of colour of the skin, sometimes heat, and the skin becomes tense, rosy, and smooth; and these phenomena are accom- panied with trouble in deglutition, the patient opens his mouth with difficulty, the submaxillary ganglia are engorged, and there is salivation. Frequently the two sides are developed at the same time, and yet one may be of larger size than the other. As a general rule, we have obtained a termination of the affection by resolution, the general and local symptoms gradually diminishing; the fever, of which there is more or less, rapidly subsiding, as well as the tumefaction of the engorgements. We have, however, seen, but rarely, suppuration occurring, and have then detected subcuta- neous abscesses. We have also seen these engorgements diminish in volume and disappear quite rapidly, and engorgement of the testicle appear as a result, by metastasis. Prof. Grisolle cites an atrophy of the testicle resulting from the rapid termination of this disease by resolution. We have not met with such a case at the Hopital des Enfants. This kind of engorgement has not been of a very grave nature in the cases we have seen, and has not been followed by serious results. It is quite otherwise with parotitis, which must not be confounded with the disease in question, for true inflammation of the parotid gland is usually accompanied with very grave general symptoms, terminates in a deep suppuration, and is often fatal. Cynanche parotidasa, as presented to us in children, is of a benign intensity, has a duration of eight or ten days, and sometimes a little longer. Treatment.—Most frequently, we have employed only a simple method of treatment; no general ©r local bloodletting, a few mild purgatives, the application of resolvents and emollients over the 294 SPINA BIFIDA. engorgements, and, better still, no moist applications, but by preference wool or wadding; in case of suppuration, a few poultices, and when a collection of pus is formed, instead of an incision, the introduction of a seton thread which may be left in for several days, and which, by puncture with needles, allows the pus to discharge without leaving afterwards visible scars on the face. CHAPTER LV. SPINA BIFIDA. Spina bifida is quite a rare malformation. It consists in an arrest of development of the spine and especially of the laminae, involving one or several vertebras, which allows the membranes of the cord to produce a hernia. Causes.—As in the majority of malformations, the cause is far from being positively known. Symptoms.—These are a fluctuating tumour on the posterior portion of the vertebral column, more common in the lumbar region, more rare in the sacral region, and still more so in the cervical. The tumour is often without change of colour of the skin, some- times reddish, because it threatens to break through. Children may come into the world with a gangrenous or even a fistulous point. As a general rule, we see only a tumour, with or without hydrocephalus; sometimes several exist on the same subject. The tumour is hard and resisting when the patient is placed in an upright position. If we keep the child lying on its stomach, the tumour is of less size, more or less soft, especially if the head is held back and lower than the trunk. Inspiration and expiration produce movements of subsidence or of distension in the tumour. It may be wholly reduced by pressure or only partially so. When there is hydrocephalus, by pressing on the head we may cause the liquid to reflow into the vertebral tumour, or vice versa. By the compression of this tumour we may produce cerebral symptoms, sometimes coma; we provoke cries in the child, and even paraplegia may occur. We very often find other malforma- tions in those affected with spina bifida. Prognosis.—This vice of conformation is essentially grave, when TREATMENT. 295 the tumour is of large size; nature is in the great majority of cases impotent, and surgery of but little service. Spontaneous rupture before or after birth leaves little hope of cure, though it often occurs. Nevertheless, when the tumour is small and exists alone, it is not always completely incurable. In the majority of cases, the serious influence of this tumour is felt upon the general health, especially if it opens and produces a fistula. Very often it occasions wasting, and the nearer the tumour is to the cervical region the more rapidly is the child debilitated. Those who live usually present symptoms connected with the nervous centres; they become paraplegic, if they are not so at birth ; always, or at least very often, there is a general condition of languor, emaciation, incontinence of urine and of fecal matters, sometimes convulsions. Some children live for a very short time, dying of cerebrospinal meningitis, but at times, however, their existence is prolonged for several years, twenty to twenty-five years or more. Pathological Alterations.—One vertebra alone may be divided, at other times several. Usually there is a separation of the vertebral arches, or else the lateral arches are destroyed. An opening is consequently seen, of variable length and width, like a button hole, in the vertebral column. In examining the liquid which bathes the spinal marrow, we find it to be the cerebral fluid; it is more or less abundant, according to the size of the tumour, which is variable. This fluid is limpid, insipid or saline; sometimes containing flakes, in which is pus or blood, especially after the operations, which are considered beneficial in these cases. In carefully dissecting the marrow, we have several times seen the two lateral halves of the spinal cord separate and distinct, the cord then appearing flat and enlarged. The spinal marrow may also be longer; it may be atro- phied and softened, or it may be deficient sometimes opposite the vertebral hiatus. The spinal nerves are lost in the thickness of the walls of the tumour, or these nerves float in the cavity of the sac. Treatment—It has seemed to us wholly impossible to cure the spina bifida in a radical manner; in fact, whatever wimay do, we can never fill up the portion of bone, which is deficient in the spinal canal. We may, however, hope for a palliative cure, which will put children that are born with this malformation in a better con- dition. The means to be employed should produce adhesion of the walls of the sac, that it may no longer be distended with the spinal fluid. 296 SPINA BIFIDA. Compression.—The first and most simple method consists in compression, either by means of cushions or bandages, a procedure which Sir Astley Cooper practised with success, employing com- pression alone or combined with punctures. We have performed it successfully two or three times; those operated on have lived, but we lost them from sight, as they came to us from the provinces, being brought to us for consultation. One case died of another disease; we had it under observation for two years, but we did not succeed in getting an autopsy. As a general rule, we have made a capillary puncture, and afterwards compression with disks of agaric and a circular flannel bandage. At the end of eight or ten days, the tumour filling up again, we made a fresh puncture. Two patients treated in this manner died of spinal meningitis. Suture of the Sac.—We owe this method to Dr. Dubourg, who published two successful cases. An elliptical incision was made over the tumour, and the finger at once placed over the opening to prevent the entrance of air, and the wound united by the twisted suture. We have had occasion to perform this operation three times in the lumbar region, using the quilled suture, and three times our patients died of spinal meningitis, with pus and flakes in the vertebral canal. We adopted a plan which consisted in pinching the sac in a vertical direction by means of two pieces of catheter placed laterally and strongly tightened at their extremities, but the result was inflammation and death, on the next day, from spinal meningitis. Following the example of M. Dubois, we passed two pins into the base of the tumour; and beneath their extremity we passed the ends of catheters firmly secured together. Two days afterwards, ulceration of the tumour occurred, with inflammation of the sac, cerebral symptoms and death. The injections proposed by Dr. Brainard of the United States were at first made with distilled water, four ounces; iodine one- fiftieth of a grain; and iodide of potassium, one-fifteenth of a grain. The strength of the solution was gradually increased. He reported several successful cases from this plan of treatment. Each time he took the precaution of only injecting into the sac, and used sufficient compression to prevent the fluid from entering the vertebral cavity. MM. Velpeau and Chassaignac have em- ployed these injections with tincture of iodine diluted with water, as if for hydrocele; and the latter exhibited to us one successful case. We have not employed this method. We have been partial TONGUE-TIE. 297 to the use of punctures and compression, as advised by Abernethy and Sir Astley Cooper, making very small punctures with a needle, and only in cases in which the tumours are not of large size, are not painful, inflamed or fistulous, and especially if they are small and pediculated. In these cases, and when the fluid is easily reduced by pressure, there are some very rare chances of success, and by continuing compression for a long time, we find the tumour subside and re- main in the condition of an empty sac. Sometimes the tumour becomes buried, and presents a kind of umbilical depression. By this means we have seen several patients live to twenty and twenty- five years of age. CHAPTER LVI. TONGUE-TIE. The term filet or frasnum of the tongue is given to the mucous fold, which extends from the inferior surface of the tongue over the genian process. This fold is vertical, and more delicate above than below and behind; it is triangular, and its anterior border becomes prominent when the tip of the tongue is carried to the palate, and its inferior border is fastened on the floor of the mouth. When the frasnum is of the normal dimensions, it serves to retain the tongue, but in such a manner as to allow it to be moved and to apply itself on the arch of the palate, and to escape from the mouth sufficiently to be able to project the tip of that organ in front of the lips, and to carry itself to the right and left in the cavity of the mouth, and to move itself on the inner surface of the cheeks in- side and outside the dental arches with facility. When all these movements are practicable, the frasnum is in its normal condition, but when the child comes into the world with a frasnum which does not allow of these different movements, there is a malformation, which is sometimes met with, but much more rarely than is generally supposed. Usually, we find the tongue carried with difficulty to the palate, so that the child cannot em- brace the nipple with it, and sucking is difficult of accomplish- ment. We may assure ourselves of this difficulty by placing 298 TONGUE-TIE. the little finger on the dorsal surface of the tongue; then, if the latter can advance, it embraces the finger, and will make efforts at suction, which show that the child can take the breast. Otherwise we may fear that the frasnum is not properly formed, and then, by endeavouring to pass the finger under the tongue we discover that it is retained by this contracted band. If we raise the tip of the tongue, we discover that it is fixed over the floor of the mouth, because the frasnum is scarcely prominent, and it retains the tongue below, and is confounded with the floor of the mouth. In such a case, the mucous membrane is not formed in such a way as to make this sublingual fold, and prevents or impedes the move- ments of the tongue. Hence arises the necessity of making a divi- sion of the fraenum, especially if in addition the nurse is in good health, and her nipple well developed. The operation for division of the frasnum, which is very simple, should then be performed. We notice, in raising the tongue, a fold formed by the arrangement of the two layers of mucous membrane of the floor of the mouth, which advance towards the inferior sur- face of the tongue to form a delicate transparent fold, but this is not carried sufficiently close to the tip of the tongue to allow of the different movements of that organ. Under these circumstances, we employ two fingers to hold the tongue up, and we make a division of the frasnum engaged between the two fingers which, by pressing upwards, separate it from the vessels of the floor of the mouth, or else we engage the frasnum in the fenestrated plate of the grooved director, so as to stretch the frasnum while isolating the vessels. A single cut of blunt-pointed scissors, directed backwards and on this mucous band, will divide it. We must also protect the veins and arteries, visible likewise under the mucous mem- brane of this region. There is another case in which the frasnum is not at all visible, and it appears that the tongue is not detached from the floor of the mouth. In such a case, we must, while having the child's head held by an assistant, introduce the plate of the grooved director under the tip of the tongue, in such a manner as slightly to engage the mucous membrane corresponding to the inferior surface of the tongue. Then, in place of a single cut of the scissors, we must make a small incision and others in succession, gradually raising and slowly dissecting the inferior surface of the tongue, especially endeavouring OPERATION. 299 to see the vessels, which may be exposed as we prolong backwards the cuts of the scissors. This operation of the division of the frasnum of the tongue, which should not be made in the normal state, should be most often performed at birth to facilitate suckling. We have operated on children at the age of two years who spoke imperfectly, without however stammering, and who have been benefited by the operation. I do not confound these two operations with those which I have practised, unfortunately without success, in children who were really stammerers; in them I even cut the genio-glossi muscles without any result, several surgeons hoping, by this procedure, to cure the stammering. But we abandoned this kind of operation, when we found after practising it for eight or ten times, that it did not give the result hoped for, and that, besides, we once or twice had serious hemorrhage, which we have reported in the journals. As a general rule, the division of the frasnum is performed with- out any accidents, and with scarcely any hemorrhage. Neverthe- less, we have sometimes met with recurrences, retraction of the tongue, and hemorrhage. 1. Recurrence.—To prevent this accident, we suggest, and we never fail to have recourse to it, the passing morning and evening, for two or three days after the operation, of the little finger be- neath the tongue to prevent adhesions after the division. This is sufficient in ordinary cases, but if the frasnum is thick, and cicatri- zation tends to approximate the lips of .the wound, it will be well the next day, or the day after, to touch the angle of the wound with a pencil of nitrate of silver, as suggested by M. Hervez de Chegoin. 2. Retraction of the tongue.—J. L. Petit cites cases of suffoca- tion produced by the tongue being carried abruptly over the pha- rynx after division of the frasnum ; but we have not seen any such cases. Petit refers to several in which the tongue was brought into place with the finger, it having been pulled backwards, making a valve over the orifice of the larnyx. He retained it by means of a bandage after having restored the tongue to its position. When this was removed, the accident again occurred, and the child died as if it had been strangled. In a like case, it would be of the greatest importance to retain the tongue in place by a thread passed through the thickness of that organ, and this must be secured 300 TONGUE-TIE. outside of the buccal cavity by means of a thread secured to the child's cap. Petit cites the case of a child in which without division of the frasnum, the tongue tended to be carried backwards; it fell several times in an hour attacked with suffocation. In such a case, which is perhaps but seldom met with, it will be advisable to secure the tongue rather with a thread than with a bandage, as advised by J. L. Petit. The use of the thread, prolonged for twenty-four or forty- eight hours, would give more security. 3. Hemorrhage.—This accident is rare, and yet it has been known for a very long time, and many methods have been devised for arresting it. Although generally of a serious character, and yet but little feared by surgeons, and indeed but little to be feared, it has nevertheless been the cause of death. There are examples of it in the older authors, and on this subject a treatise on division of the frasnum by M.Ferdinand Teissier,offered at Paris in June, 1866, may be consulted with advantage. A recent death from this operation in a hospital only confirms the fact that the accident may occur even to men of skill. To prevent these hemorrhages, which are doubtless met with in children predisposed to them, it would be very desirable if we could distinguish at birth .those children who are naturally dis- posed to hemorrhage. We have observed several such cases, but at a more advanced age. In the new-born, when we fear the occur- rence of hemorrhage, we must postpone the division of the frasnum. In any event, to prevent this accident, we must, in the division of the frasnum, redouble our precaution and not look upon this ope- ration as one of trifling importance. We cannot, therefore, repeat too often, that we must hold the child securely, the head especially; with the left hand hold the grooved director, elevating the tongue, engaging the frasnum completely in the opening designed for this purpose; it should, when pressed from below upwards under the inferior surface of the tongue, cause the frasnum to pro- ject, and protect the vessels which are distributed under it. It is very important to cut the frasnum, as we have already said, by directing the point of the scissors downwards. If the hemorrhage is slight, it ceases, as do the child's cries, when it is given the breast, but if it continues, we may pinch the point from which the blood comes by means of a small spring forceps, which may be kept for some time in place, or else, as practised by M. Verneuil, use a PROLAPSUS OF THE URETHRA. 801 strong serrefine retained by a thread passed through the ring. But we prefer placing under the tongue, and keeping it compressed with the finger for several minutes, a piece of agaric steeped in lemon juice, or better still perchloride of iron diluted with water. If these remedies do not succeed, we must, without using styptics, powders, or nitrate of silver, so difficult to apply properly and with which we lose so much time, raise the tongue as at the moment of operating with the plate of the grooved director, have the head held very immovable, endeavour to distinguish the point from which the blood flows, and boldly apply a stylet heated to a white heat, with the extreme and indispensable precaution of keeping the lower lip depressed with a soft linen compress or a spatula. CHAPTER LVI I. PROLAPSUS OF THE URETHRA. Surgical works, even those which treat specially of the urinary passages, have little or nothing at all to say of prolapsus of the urethra, and yet it is not a very uncommon affection in little girls. I have seen at least a dozen or fifteen cases of it, from the age of two to twelve, in twenty years of hospital and private practice. Causes.—The causes we have been able to discover are repeated efforts, either of coughing, as in the violent paroxysms of hooping- cough, or chronic bronchitis with frequent cough, or constipation necessitating violent and repeated efforts of defecation, or general debility. We have also found instances of this procidentia of the mucous membrane of the urethra in small girls debilitated from various causes, principally in cases of very long convalescence, as the result of acute diseases, and often in chronic affections. Symptoms.—Children, as a general rule, do not complain much of this affection; nevertheless, they have frequent desire to make water, and they experience a sensation of heat during the dis- charge of urine. As this disease does not always cause pain, and the children do not complain, a long time may elapse before we examine the vulva, and only by inspection of this part can an accu- rate diagnosis be established. Then, if we separate the labia, we 302 PROLAPSUS OF THE URETHRA. generally find the vulva with more colour than usual. If we examine the meatus urinarius, we observe a small, rosy, mucous tumour, which appears to escape from the interior of the canal, and is not at first very considerable. It presents in its centre an opening, in which a catheter may be introduced; but we find that we enter the centre of a ring of variable size, formed by the mucous membrane of the canal of the urethra. If we push the catheter further, we soon penetrate the bladder and the urine escapes. This condition may last a long time stationary without becom- ing aggravated; but at other times the tumour is developed slowly, with an exudation of blood, and soon afterwards purulent serum. It increases in size and is irritated on its surface, which be- comes gangrenous superficially, inflaming the neighbouring parts, and producing vulvitis. The discharge may increase without causing great pain, but there is heat and smarting when the patient urinates. We have not seen any of these tumours that had been left to themselves for a very long time; but we think they might gradually become either wholly or partially gangrenous, and keep up a sero-purulent discharge. We may confound these tumours, formed by the prolapsus of urethral mucous membrane, with polypus of the urethra, but by carefully examining it, we find that the polypus appears under the form of a small tumour, with more or less pedicle, the latter pene- trating into the canal, whilst prolapsus is presented in the aspect of a very small ring surrounding the urinary meatus, and re- sembling, on a small scale, prolapsus of the mucous membrane of the rectum. This affection, which is not serious, may occasion inflammation of the vulva; and may lead children to handle the parts frequently on account of the itching. Treatment.—It is advisable to relieve little girls of this affection, and by excision restore them speedily to their normal condition. Other means, such as ligation or cauterization, only enable us very slowly to destroy the prolapsus. To perform this excision, there is no necessity to chloroformize the patient; nevertheless, as little girls are often timid and quite hard to hold, we derive benefit from giving chloroform. We place the child on the edge of a bed, keeping its thighs flexed and separated; the greater labia being then held in such a way as to let us clearly see the tumour, we PEMPHIGUS. 303 seize it with a portion of thread, which allows us to draw it out gently, and curved scissors carried behind it enable us to remove it at a single cut. We may also with the left hand, armed with a tenaculum, draw it forwards, without employing the thread, and then cut it from behind. There will be a little hemorrhage, which the application of cool water may check, and which may be arrested with the perchloride of iron diluted with water, or else by a small tampon of agaric steeped in this mixture, and applied for several minutes on the wound resulting from this excision. Washes of cool water, and a few applications of a pencil of nitrate of silver suffice to procure cicatrization of the wound. The little patients suffer for a few days in urinating, but this does not last. In one of our cases, a hemorrhage occurred which we could not arrest with the perchlo- ride, and we had, therefore, for twenty-four hours to keep a bladder, filled with ice, over the hypogastric region, and in front of the vulva. This last method succeeded perfectly. In this little girl, ten years of age, the tumour dated from about the age of four, and was raw before the operation. CHAPTER LVIII. PEMPHIGUS. This is a cutaneous affection, characterized by one or several rounded bullae, about a third of an inch in diameter, more or less distended by a fluid, which is at first transparent, but gradually becomes cloudy. It occurs in children as well as in adults, being seen quite often in the new-born, and exists, either in the acute or the chronic state. Causes.—It may be developed in children of imperfect nourish- ment, kept in an unclean condition, but more frequently in those under the influence of hereditary syphilis. This is the opinion of M. P. Dubois and some others, and it is shared by MM. Ricord and CazenaVe. Symptoms.—This affection is generally situated in the palms of the hand or the soles of the feet in children, and is presented in the 304 PEMPHIGUS. form of bullas or pustules, which vary in number, are surrounded with a violet aureola of very variable diameter, and contain a sero- purulent fluid ; there is pain and sensibility to the touch, the epi- dermis becomes raised and the derma may be ulcerated and some- times covered with a plastic membranous deposit, and suppura- tion may also occur. The edges are sometimes rounded and in relief. If the pemphigus is simple, the bullas are distended with a clear or opaline serous fluid, and are followed with desquamation, the epidermis dries off'in delicate lamellae, the pain ceases, and in a few days the disease terminates. We do not meet with ulcerations, and there is no other phenomenon on the skin; but in syphilitic pem- phigus, the bullas are filled with a well-formed yellowish pus, and ulcerations follow. The child also presents other syphilitic symptoms, as spots, specific roseola, a general condition of emacia- tion and decay, and alteration of the countenance, which becomes.pale and thin, with the appearance of old age, and remarkable wasting. The prognosis is of very little gravity in the simple form of pem- phigus, but, on the contrary, serious in the syphilitic variety, for this localized phenomenon on the skin may sometimes be compli- cated with syphilitic lesions of internal organs. When the disease is simple, it may last for several days or for several months, and sometimes there are prodromic symptoms, as in certain acute dis- eases, measles, scarlet fever, etc. It may indeed pass into a chronic condition and terminate in a serious manner, while sometimes it is of no gravity. In syphilitic pemphigus, however, this disease, which is often congenital, is met with in children born of syphilitic pa- rents. In addition to this, there are several known cases of preg- nant syphilitic women who had pemphigus, and were placed on an antisyphilitic treatment after a first delivery, and afterwards gave birth to children who were free from pemphigus, thus proving satisfactorily the syphilitic nature with which the mother was affected at the first delivery, and was cured at the second. Treatment.—If the pemphigus is not of the syphilitic form, a very simple local treatment answers the purpose. Thus, for simple pemphigus, it is often sufficient to content ourselves with attention to cleanliness, bran baths, or application of powder of starch or rice flour over the bullas, good nourishment, and placing fn a pure air those in whom the affection has been developed through want of care. In such cases the bullas are only a local disease. THORACENTESIS. 305 If, on the contrary, the affection is of a syphilitic nature, or the bullae are only a local symptom of a constitutional disease, it is a very grave medical affection, the true treatment of which lies in the employment of general antisyphilitic remedies. If the mother herself nurses the child, we must put her on antisyphilitic treatment, using either the liquor of Van Swieten or the bichloride of mercury ; if the child derives its sustenance from a nurse, she should be fore- warned of the chances which threaten her, and she should be put under treatment. When it does not get its milk from the breast, we should put the child itself under treatment, administering five, six, or eight drops in the day, in divided doses, of Van Swieten's solution, in a small spoonful of milk, and, in addition to this, baths medicated with this solution, a drachm or more of it being added to the bath of a new-born child. The child may also take for nour- ishment iodized milk, either from a cow or from a goat treated ac- cording to the plan of our confrere M. Labourdette, especially if we believe there are syphilitic lesions of internal organs. CHAPTER LIX. THORACENTESIS. We have not had traumatic cases requiring in children thoracen- tesis, an operation which consists in opening the chest to give out- let to fluid effused in the pleural cavity. We have almost always found effusions consequent on contusions of the chest or fractures of the ribs easily absorbed. Nevertheless, in young subjects, as in adults, effusions consequent on pleurisy may require puncture of the chest, in acute as in chronic cases. As a general rule, this operation is indicated in children, when medical means have not been sufficiently powerful to obtain reso- lution of the effusion, or even when, from the commencement, there is a threatening of asphyxia. Two cases then present themselves: either the fluid is circumscribed at one point, which rarely occurs, or else the space between the pleura costalis and pleura pulmonalis is completely filled up. If the effusion is circumscribed,, it is the situation in which we detect dulness and the absence of respiration 20 306 THORACENTESIS. which will be chosen for the operation ; but when the effusion is general through the right or left cavity, we must then operate at the point of election. Operation.—As this is not very painful, we do not entertain the question of employing chloroform, but content ourselves with having the child well held. We are far from rejecting certain well known trocars, those with a spout, the trocars of M. GueVin or M. Barth. They have undoubted advantages, but as a gene- ral rule we use either an ordinary trocar or a small curved one, having the form of a tracheotomy canula, except that it has a dia- meter of an eighth of an inch, and a length of an inch and a half; this enables us to penetrate as far as the fluid, without any risk of touching the lung. It should be furnished with a little goldbea- ter's skin sac, securely fastened behind the pavilion of the canula, and capable of falling over the outer orifice. We must also, after the example of M. Barth, who has suggested them, have tubes of vul- canized India-rubber, which can fit into the canula. We should also have at our disposal a syringe capable of being well adjusted either to the canula or to the caoutchouc tube, if we think proper to make injections. The child being laid on its back, and held securely in this position, the surgeon takes the trocar with his right hand, present- ing its convexity upwards and its concavity downwards; grasps the skin with the finger of the left hand, in order to prevent the cutaneous wound from being parallel with the deep opening, and plunges at a single cut above the upper border of the left third rib, and the fifth on the right side, counting the ribs from below upwards. The gold-beater's skin previously moistened surrounding the handle, he will choose, as the point of election, the union of the posterior third with the two anterior thirds of the intercostal space, taking care to approximate the upper border of the lower rib, so as to separate the point of the trocar from the lower border of the rib above, where the artery is situated. By means of our curved trocar, he easily turns around the lower rib and directs the point downwards; in this way, if there is but slight space between the bony frame and the lung, he does not risk wounding that organ. The puncture once made, the surgeon should conduct himself differently according to circumstances. If the effusion is serous, a simple puncture is sufficient to give exit to the fluid, without allowing the air to enter the canula,—thanks to the gold-beater's OPERATION. 307 skin. As the cavity which contains the fluid contains nothing else, we withdraw the canula, and close up the little wound, which unites by the first intention. In chronic cases, when the effusion is no longer serous, but purulent, we must, after a first puncture, make several others in succession, at several days' interval; and it appears to be well, as M. Barth points out, to wash the surface bathed with pus, to obtain adhesion more easily. Besides, if the pus is fetid, there may be an indication to inject modifying fluids, as tincture of iodine diluted with water or chlorine; and often a single injection does not suffice, and several are required. In such cases, a permanent opening is necessary. The canula with which the puncture was made may therefore be left in place, and for this reason we had our small curved canula made with little flanges like the one used in tracheotomy; and it may, by means of tapes, be fastened around the body, as the tracheotomy canula is secured around the neck. We prefer to substitute, as rapidly as possible, a vulcanized rubber tube for the metallic canula, for its pliability removes all danger of irritating the pleura, and the tube does not enlarge the wound as the metallic canula does. It may also be subjected to all positions in the thoracic cavity and around the chest; it may be very readily passed into the canula, but before using it we should take the precaution to supply ourselves with tubes of such a diameter that they can pass into the canula of the trocar. We introduce the tube alone, or furnished with a whalebone punch into the canula, which may be withdrawn as we bury the tube more and more deeply. We must fasten, at the outer extremity of the tube, a gold-beater's skin sac, tied at its opening, so that the fluid which escapes through the tube may discharge into the cul-de-sac formed by this skin; it may, otherwise, be enveloped in a linen pouch suspended at the patient's neck. When he wishes to make an injection, the surgeon pinches the tube at a short distance from its outer extremity; an assistant removes the gold-beater's skin pouch, and he then introduces the beak of the syringe into the end of the tube and gently throws in the injection. When the quantity of fluid introduced appears to be sufficient, he pinches the tube anew, and then, to discharge the injection, he takes the precaution to put the extremity of the tube in a vessel of water, so that the air cannot penetrate; when he has finished, he withdraws the extremity of the tube from the water, 308 THORACENTESIS. compressing it again, and fastens it in the gold-beater's skin pouch. When the collection of pus is diminished, this pouch or reservoir may be omitted, and the surgeon content himself with a small plug to close up the tube. This should be secured firmly over the walls of the chest by means of several strips of isinglass plaster or ad- hesive plaster, the chest being then surrounded with a light body bandage, or a bandage to secure the tube around the chest, so as to prevent its escaping from the thoracic cavity or from entering too far. When the tube is in the chest, the interior portion must not be too long; it would irritate and might prevent the gradual approxi- mation of the surfaces, and thus retard the cure. It should not be too short, for it would not then penetrate deeply enough to give exit to the fluid. In order to know how much of it is in the chest, we should, as advised by M. Barth, measure the tube before intro- ducing it, and remember its length, so that we may know exactly how much of the tube is inside or outside of the chest. At first, two or three inches of it may be left in the chest, but as the morbid cavity diminishes in extent—a condition which is recognized by the smaller quantity of pus discharged at each dressing, and the amount of fluid which may be injected without effort—we should diminish the length of the- tube by withdrawing some of it from the chest each day. When everything goes on favorably, the fluid becomes more and more clear, and diminishes in quantity, and at last a time comes in which only a few drops of pus escape, when we can remove the tube. By this mode of operating, we have had much success, which follows as a general rule, when the pulmonary tissue is sound or but little diseased. If any tubercular affection exists, the cure is an exception or at least very uncommon. ECTROPION. 809 CHAPTER LX. ECTROPION. Ectropion, or turning of the eyelids outwards, occurs on both lids with many children. Several causes may produce it, some of which are seated in the conjunctiva, as acute or chronic conjuncti- vitis, others in the skin, or in the nervous system, such as paralysis, or spasm of the orbicularis muscle. In children we have several times found an ectropion the result of tumours of the orbit, and at other times of necrosis of the orbital border at a more or less cir- cumscribed spot. Exophthalmia may also give rise to ectropion. Very often it is caused by a burn cicatrizing with contraction of the lid. Whatever the cause, it presents general characters which cannot be misunderstood. Symptoms.—These are more or less marked, according to the stage of this affection. At first there is seen a slight separation of the lower lid. Usually the border of the lid is carried forward, and tears escape over the cheek, the lid not being able to retain them. It is often only the commencement of blepharitis. But soon the lid becomes further depressed, tears course the cheeks, the conjunc- tiva, already reversed and at first healthy, soon becomes inflamed, thickened, and tumefied; the secretion of the tears diminishes, and the cornea becomes more vascular, sharing the inflammation and sometimes becoming gradually ulcerated. This corneal inflamma- tion is due to exposure to the air and the diminution of the tears. Finally, the mucous membrane of the lid, becoming more and more reversed, is covered with granulations. When this disease depends on a burn, the lid is attached to the cheek by the contraction of the cicatrix. The diagnosis is easy, after the symptoms just mentioned, but we should not at once form any prognosis, which must be variable, until we become thoroughly acquainted with the cause. Some- times it is the commencement of a blepharitis or even of an in- tense conjunctivitis, and is often a phenomenon of purulent ophthal- 310 CHRONIC ECTROPION. mia. The prognosis will, in the latter case, be of considerable gravity, while if we have only to deal with a slight conjunctivitis, the ectropion will yield with the disease which is its cause. Treatment—This should be varied according to the cause pro- ducing the ectropion. In cases of simple blepharitis or ophthalmia, we must combat them, as we will also have to do with paralysis or tumours of the orbit, which last may require removal. Two forms of ectropion require a special, and surgical treat- ment. Acute Ectropion, with Swelling of the Palpebral Conjunctiva.—-This affection, as often met with in childhood, is a condition following upon intense ophthalmia or rather very acute blepharitis. In such cases we must, if the disease does not yield to the treatment ad- vised in blepharitis, make repeated scarifications over the mucous swelling, either with the lancet or with the scissors, while endeav- ouring to raise the lid, and thus reduce the swelling and the ectro- pion. We must then keep the lid raised with a bandage. Chronic Ectropion.—In certain cases the mucous membrane which ' is constantly puffed up, is an excrescence, a real foreign body which pushes the lid back and keeps it reversed. It becomes hypertro- phied out of all proportion, and can only be reduced by a surreal operation. After having employed different remedies, as mTrate of silver, sulphate of zinc, and calomel, frequently without success, we must adopt the following treatment:— 1. Cauterization with nitrate of silver applied directly to the mucous swelling, protecting the eyeball by placing within the swell- mg a smal cylinder of wadding. We may also, after each cauteriza- ion let fell into the conjunctival notch, water very slightly acidu- lated with hydrochloric acid; and then at the end of an hour remoVe the small roll of wadding, and apply oil over the part whitened by the nitrate. We next let the lid be raised, and apply repeated lotions of cool water over the eye. At the end of one or two days after the separation of the slough, cicatrization of the submucous tissue commences, and the contraction of the mucous membrane gradually corrects the position of the lid We mav sometimes make a second application, but we must make a proper IZ ''t , g S°' " t0 What WG haVe Sained> for - BhoSld hesitat to produce too rapidly a new cicatrization which would straighten the eyelid too much. If, by means of these cauteriza- tions, which may be several times repeated, the desired result is TREATMENT. 311 not obtained, we must resort to excision, and this we have per- formed on several children. 2. Excision of the Mucous Swelling.—When this remains of con- siderable size, and becomes covered with granulations, cauterization fails, and excision of this mucous fold may be performed with advan- tage. There are several methods we may adopt, but, in children, we have confined ourselves to the removal of the exuberant portion of the conjunctiva, having previously administered chloroform. We seize the swelling with a tenaculum or with grasping forceps, and by means of curved scissors remove a portion of it. More or less hemorrhage occurs, and we close the eye in its normal condi- tion, and apply compresses steeped in cool water and held in place by a bandage lightly applied to keep the eye closed. There is a form of ectropion occasioned by caries of the border of the orbit, which we have often met'with in scrofulous children as the result of abscess symptomatic of partial caries of the orbital edge, and the inferior part of the lid is drawn into the diseased part, and becomes fixed there by adhesion, and thus involves the lid, often turning it outwards. In these cases we have performed an operation described in the work of M. Desmarres, and which this oculist regards as being the method of Amnion. It consists in detaching the adherent part by a semicircular incision, follow- ing the curve of the orbit, and dissecting the skin in such a man- ner that it will be movable on the bone; the lower lip of the wound must be brought up towards the upper, and be kept in place by strips, which serve then to retain the skin and to prevent it from sliding towards the point where it is adherent. There are some cases in which we ought to practise blepharo- plasty. When, after a burn, there is adhesion of the lid with or without ectropion, but either the upper or lower lid is incapable of being closed, the eyeball is exposed, and, as may be conceived, this infirmity is repulsive, and exposes the eye to a number of causes of inflammation. We must then perform an operation which has been known for a long time, practised at first by Graefe and still later by many foreign and French surgeons. Following the example of Velpeau, Blandin, and Desmarres, we have had occasion to perform this operation in several children. If we have had two or three successful results, we have also performed it without deriving any such advantage. We have operated either on the lower or on the upper lid, and we have adopted three 312 ENTROPION. methods of operation, according as one or another appeared most applicable to the case, either by extension of the flap, or by in- clination or torsion. In two cases of burns with vicious cicatrices of the upper lid, we performed autoplasty, taking a flap over the temple, twisting the pedicle, and bringing it back over the upper lid, after having made a dissection, which removed the narrow cicatrix that kept the lid elevated and reversed upwards as far as the lash. We twisted the pedicle of our flap, which was near the outer angle of the eye, and made several stitches to fasten this flap on the eyelid, which was still provided with subcutaneous cellular tissue and a part of the orbicularis palpebrarum. We found the flap healing up, and were able to divide the twisted pedicle at the end of eight days, and the stitches on the following days. The first operation, which we performed on a girl of nine or ten years, did not succeed; there was no erysipelas, which we especially feared, but the flap became gangrenous and the patient remained as before. A second, opera- ted on in the same manner by torsion, succeeded in our hands, and the eye, which was always inflamed before the operation, on ac- count of the impossibility of covering it, soon returned to its normal condition. We have only had unsuccessful operations in cases of ectropion after burns; but though the operations failed, there were no serious after-symptoms. After our various operations, we always used cold water during at least seven or eight days in succession, and we checked a few cases of erysipelas at the commencement by the use of elastic collodion. CHAPTER LXI. ENTROPION. When the edges of the lids are turned inwards, with the ciliary border in relation with the eyeball, we have a case of entropion. This affection, which is not repulsive like ectropion, is of a nature greatly to irritate the eyeball, and to produce almost continual ophthalmia. TREATMENT. 313 The causes of entropion are numerous; they may be reduced to relaxation of the skin of the lid, contraction of the mucous membrane, a faulty arrangement of the tarsal cartilages, a spas- modic state of the orbicularis, atrophy of the eyeball, and also certain tumours developed in the eyelids or their vicinity. The symptoms are noticed either on a part of the free border of the lid, or on its whole extent, or even on both lids, but most frequently on the lower one only, and chiefly on its outer side. The lashes are turned inwards with incurvation of the tarsus, and the lid is rolled on itself. The vertical diameter between the lids is often enlarged, the conjunctiva of the eyeball red and to a variable extent often thickened. This inflammation extends to the cornea. The patient complains of severe pain in the eye, and ex- periences inconvenience in looking at objects. If the entropion is partial or of slight extent, it may remain stationary, but if it is very marked through the whole extent of the lid, it may give rise to inflammatory symptoms of a grave and profound character. Treatment.—This should vary according to the exciting causes. In children we have especially found intense ophthalmia, a spas- modic condition of the orbicularis muscle, relaxation of the skin, and sometimes the presence of certain tumours of the eyelids. We must treat the ophthalmia, and especially the photophobia which is its true cause; and in such cases, we cannot obtain in children that which M. Desmarres advises for adults, the constant straightening of the lid every moment with the finger, by looking into a mirror. Antispasmodics are indispensable, and are the only means to be used in childhood, mild purgatives being afterwards ad- ministered, to be repeated if necessary; and if there be inflamma- tion, we should at once prescribe, for the straightening of the eyelids, either the use of mercurial ointment, combined with extract of belladonna, equal parts of each, by friction, repeated two or three times a day around the orbit; or else the dropping into the eye, two or three times a day, of a drop of solution of atropia, in the proportion of a grain and a half of neutral salt of atropia to three ounces of distilled water. We have derived no benefit from com: pression or adhesive strips, at least in children. We have not thought it worth while to employ fly blisters around the orbit. In permanent contraction of the orbicularis, we have not performed subcutaneous division of the muscle as 314 ENTROPION. suggested by MM. Cunier, Philips and P&requin. We have not followed the plan of Janson, which consists in transverse excision of the muscle, nor the vertical section likewise proposed by Janson. In relaxation of the skin of the lid, the treatment should be purely surgical, and, as a general rule in children, we have been satisfied with cauterization or excision. We have employed for cauterization, after chloroformizing the patieut to prevent move- ment, either the actual cautery or Vienna caustic, applied by means of a piece of fenestrated plaster at the spot where the caustic paste should be spread. We have, in these cases, endeavoured to produce a transverse slough at the distance of an inch and a quarter to an inch and a half from the free border of the lid, in the form of an elongated melon-seed, more or less narrow at the centre, according to the extent of the reversal of the lid. We allow the slough to become detached naturally, and the cicatrix, being formed beneath, corrects the position of the edge of the lid generally in a satisfactory manner. By excision, according to the plan of Celsus, as a general rule, after having put the child under the influence of chloroform, and having previously estimated the amount of skin of the lid to be removed, we seize a fold of skin of the shape referred to in the application of the caustic. This fold, of the shape of an elongated melon-seed, which we may seize with a convex spring forceps, or else raise up, either with forceps or with a double tenaculum, is excised by a single cut with the curved scissors. We have had afterwards the same result as with caustic, and we can, immediately after excision, apply two stitches, and union will take place very rapidly. We will do well, if we take excessive care, in this little operation, before operating, to trace with ink the ex- tent and shape of the portion of skin we wish to remove, to guide the action of the scissors. We have also followed the method of M. Velpeau; we raise with the fingers or the forceps a transverse fold, piercing the base of this fold with three needles, at about two- fifths of an inch distant, each furnished with a long thread, and ex- cise with the scissors the fold, a short distance in front of the threads, taking care not to cut them. In this manner, after the excision, we have to concern ourselves with three stitches. Imme- diately after the operation, we must apply compresses steeped in cool water and frequently renew them. We have had success in TRICHIASIS. 315 this mode of operating, and we have often had benefit derived after excision, from the closing of the eye, applying a soft compress re- tained by a bandage in such a way as to keep the lips of the wound united without using stitches, which may sometimes produce ery- sipelas of the face. We have also derived benefit from the use of three serres-fines instead of three stitches, applied for the purpose of approximating the lips of the wound of the lid. CHAPTER LXII. TRICHIASIS. This disease, characterized by reversal of the eyelashes, is some- times observed in children. The lashes are brought into contact with the conjunctiva and even the cornea; the tarsal cartilage is not turned around, and yet the trichiasis, like the entropion, is often met with in the lower lid, and may produce ophthalmia. Some- times this turning in is only observed in a few lashes, at other times in all the lashes of the affected lid. The causes are glandular blepharitis, inflammation of the glands of Meibomius, burns, and relaxation of the skin, and in children ophthalmia very often repeated, complicated with photophobia. We sometimes also find a second row of lashes acting as an ex- citing cause, but this is seen in adults rather than in children. The symptoms are nearly always those of entropion; trichiasis may produce inflammation of the mucous membrane of the eye, keratitis, even ulceration of the cornea, opacity, or pannus, caused by the development of vessels extending in the form of a pencil over the cornea. Children suff'ering from trichiasis have a vicious position of the head, which is curved forward on the neck, and this is produced by the habit they have of inclining the head while looking at objects. The diagnosis is easy; the prognosis quite grave, for trichiasis produces, as we have already said, serious affections of the eyeball. Treatment.—The treatment includes the reduction of the lashes; and of all the agents proposed, we prefer the use of serres-fiues 316 NASO-PHARYNGEAL POLYPUS. with or without sharp points, which only pinch up a transverse fold of the lid, in such a way as to reverse the border of the latter, at first for twenty-four hours, and then a longer period, if neces- sary, but allowing the child to repose for a greater or less time, and recurring to them several times at intervals. Plucking out of the lashes has been advised, but this is troublesome and painful to accomplish. It may be done with blunt non-cutting forceps, which enable us to seize the lids without breaking or cutting them. This method, however, only relieves the deviation for the time being, and should be frequently repeated. Without referring to several plans which we have not followed, such as extirpation of the free border of the lid, or a portion of its extent, or cauterization of the bulbs of the lashes, we may reduce the operations for the cure of these devious lashes to the following: plucking them out, when two or three of the lashes are reversed; excision of the partial fold, or of the whole fold of the anterior portion of the skin of the eyelid, as in entropion; or extirpation of the bulbs of the devious lashes, according to the method of Vacca. We may make a fold of the skin of the lid involved with the devious lashes, and excise this fold as far as the orbicularis muscle, afterwards dissecting the bulbs with a pair of forceps. In such cases, we must support the lid by means of fenes- trated forceps, held firmly by an assistant. With children we must use chloroform. After these operations, a dressing by means of compresses steeped in cool water should be frequently renewed, until the cicatrization of the little wounds occurs. CHAPTER LXIII. NASO-PHARYNGEAL POLYPUS. In attending the surgical service in a children's hospital, we are struck with the fact that we never, or scarcely ever, meet with mucous polypus in the nasal fossae. They present, however, the same symptoms, and require the same treatment as in adults. In children, we sometimes see fibrous polypus, but usually only in TREATMENT. 317 those of ten or twelve years of age, the smallest children being, as a general rule, exempt from it. These polypi, of a more or less considerable consistence, firm, sometimes bleeding, present varying prolongations, and rarely have a pedicle. They generally take their origin at the base of the cranium, over the basilar process to the inner side of the pterygoid processes. The causes are obscure, as they always are in abnormal produc- tions. Symptoms.—These polypous growths exist in a latent state at the commencement, which may last for some time, and they become developed slowly. Gradually they acquire sometimes considerable dimensions, and invade the nasal fossae, becoming developed from behind forwards. They produce irritation of the nasal mucous membrane, and affect the smell and the voice, as well as the secretion of the tears, audition, respiration, deglutition, and even mastication. Some of them become developed from above, and raise up the floor of the orbit in such a way as to push the eye forwards. Sometimes when this is observed on both sides, the eyes project like those of the batrachia. A polypus has been found to elevate the upper wall of the orbit, compressing the brain and producing cerebral symptoms. When they acquire a develop- ment backwards, they depress the velum palati, and may descend into the pharynx, and compress the Eustachian tube. If they spread outwards, they penetrate the maxillary sinus, pressing down the arch of the palate. The bone then becomes thinner; the portions of bone involved are destroyed, the cavities are dilated, and give way before the development of the polypus. When these tumours grow over the larynx, there are attacks of cough and suf- focation. The diagnosis, at first difficult when the affection is at its com- mencement, admits of no doubt as to its character as it grows, and the disease is not difficult to recognize, especially when, in- dependently of the symptoms referred to, it reaches the opening of the nasal fossae or the pharynx. By the sight and touch we can then easily recognize it. Treatment.—This affection may, in certain cases, produce serious symptoms, and the indication is to relieve the child of it, as we would the adult. We have resorted in them to evulsion and to ligation and excision, sometimes without preliminary operation, at 318 NASO-PHARYNGEAL POLYPUS. other times preceding the excision with preliminary operations, and sometimes cauterization to make the operation complete. Evulsion has always seemed to us to be indicated in very rare cases of fibrous polypi appearing in the nasal fossas, springing from the base of the cranium, and not having any prolongations to retain them too strongly. We have been able to remove them, and every time they thus present themselves, we believe we should content ourselves with plucking them out by means of various forms of straight or curved forceps. If the polypous growths have a pedicle, and we can circumscribe it, the indication appears to be to ligate it by the aid of different serre-noeuds, and chiefly those of a chaplet shape. We should, whenever we can, through the open- ing of the nasal fossas or the mouth, direct scissors with blunt points over the pedicle of the polypus, prefer excision to ligature, which latter has the inconvenience of only slowly relieving the patient of the tumour, leaving him for perhaps a long time with a strangulated polypus, that may become fetid and give rise to other symptoms. But frequently we must resort to several preliminary operations to facilitate the execution of measures for the removal by a cutting instrument, and the destruction by cauterization, of the point of insertion of the polypus. We should sometimes be contented with dividing the nostril; we may even divide the nose, separating the proper bones of that organ, and whenever we can, while thus operating, should resort to these methods, which may be effected more easily in children than in adults. At other times, we may practise section of the velum palati only, and by this in- cision, we may, as M. Guerin advises, by introducing one finger, and even two, in the mouth, carry the instrument over the point of insertion of the polypus. Then, with a straight rasp, intro- duced through the nasal fossa as far as the insertion of the polypus, and guided by the finger introduced through the mouth, we may scrape the portion of bone in which the polypus is inserted. In admitting that this method may be employed in the adult, we doubt its applicability to a child. In concluding our remarks on these grave operations, we may speak of those disfiguring operations on the face, which have been advised, and which we have practised, for the extraction of these naso-pharyngeal polypi. As all surgeons have been able to con- vince themselves, the principal insertion of these tumours is at TREATMENT. 319 the base of the brain; the other points of insertion are really only secondary, and not at all firm and resisting like that from which the tumour takes its rise. Let us now examine rapidly the previous operations which should be performed for the purpose of exposing the base of the tumour, so that we can properly attack it. We may, and should, in certain cases, confine ourselves to dividing, more or less boldly, the velum palati, by which incision we may sometimes introduce curved forceps, seize the polypus, and tear it out, twisting the pedicle, and with the finger carried deeply through the nostril aiding the re- moval of the polypus from the interior of the nasal fossas. In other cases, we may cut the velum palati, and make a resec- tion of the bony portion of the arch of the palate, as suggested by M. Nelaton, which may be done by at first perforating the arch of the palate right and left with a punch, and cutting the intermediate portion of bone with a Liston forceps. We thus remove the mid- dle part of the bony arch, and a part of the septum. In this way we may see the base of the skull, and feel the insertion of the polypus without disfiguring the face. For this operation, we must take the precaution to have the hot cautery, either to arrest hemor- rhage, or to cauterize the point of insertion of the polypus after having excised it. Resection of the lower jaw may be performed when the polypus is of large size, and it has several branches in the pharynx, the nasal fossas, and the maxillary sinus. It has been sug- gested (Flaubert, Jr., Dupuytren, Robert, Maisonneuve, Lisfranc) to remove, as a preliminary operation, the superior maxillary bone. This operation has been systematized, and it is described in all the treatises on surgery. We had occasion to perform this on a child twelve years of age, and we had a favourable result at the time, but there was a rapid relapse after several cauterizations, either with the red-hot iron, or with the caustique Filhos. At the end of two years, he was operated on again by one of our professional brethren. Any operation that may be adopted, that requires the gouge, mallet, shears, and chain saw, is tedious and laborious, and jars the patient's head very much. Whichever plan be adopted, either that of Gensoul or of Velpeau, or others modified subsequently, we must, after this preliminary operation, always act on the point of insertion of the polypus, either with iron heated to a white heat, or with the variety of Vienna caustic, known as caustique Filhos, 320 ONYCHIA. even after having excised and scraped the point where the polypus has taken root. The operation of M. Nclaton, which consists sim- ply in the resection of the arch of the palate, enables us to expose sufficiently well the point of insertion. It should often be pre- ferred as being a less frightful operation. Finally, if we wish to obtain definite results in these operations, we must not delay cau- terizing for any length of time the point of insertion. Otherwise a recurrence is infallible. CHAPTER LXIV. ONYCHIA. Onychia is an inflammation of the matrix of the nail. It is met with, in children as in adults, in the great toe; it is seldom seen in the other toes and quite rarely in the fingers. Causes.—These are sometimes scarcely appreciable; and we may regard this affection as produced by the lymphatic constitution. Usually, however, there is a puncture or pressure at one point of the matrix of the nail, chiefly on the internal border of the great toe, and this happens from cutting the nail in such a manner that a point of the nail punctures the ungueal matrix, or when the under part of the nail is punctured either with the points of the scissors or with a corn-cutter, or even with a pin. We have seen, in children, punctures with a pin under the nail produce inflam- mation of the matrix, or at least an inflammation under the nail followed by vegetations analogous to those of onychia. Most fre- quently very tight shoes, which press upon the great toe, cause this affection. Symptoms.—At the commencement, there is slight pain in walk- ing, and gradually redness over the inner angle of the nail, with ulceration of the skin which is pressed upon by the edge of the nail. A fungous vegetation is developed, which is very sensi- tive; then the pain is such, that the patient walks with difficulty when he puts the heel on the ground. He may cut the corner of the nail which is buried in the proud flesh, and in this manner experience momentary relief, but the pain soon reappears, the OPERATION. 321 granulations cover in the form of a swelling the internal edge of the nail, and produce angeioleucitis on the inside of the leg and the thigh, and frequently adenitis in the region of the groin. The disease gradually extends, and the nail becomes movable; there is an oozing of sanious matter, which becomes more and more abun- dant and fetid, and then the pain increases in intensity. We have seen analogous vegetations become developed more rarely in the fingers, but producing symptoms like those met with so often in the great toe. The presence of the nail being the cause which, by its pressure on the ulceration, keeps up the mischief, we must operate on the nail, either by correcting its position, or destroying it by caustics, or extracting it. Nevertheless, when the disease is at its com- mencement, before resorting to operations, we derive benefit from preventing the children from walking. Emollients must be ap- plied at first, if there be pain, but we must also employ, as speedily as possible, tonic foot-baths; at the same time urging the im- portance of the patient wearing properly-fitting shoes, which do not press on the toes. When the disease is more advanced, and ulceration occurs, we must adopt some mode of modifying the position of the nail,—caustics, and even extraction. Modifying the Position of the Nail.—This method, which prevents the edge of the nail from compressing the granulations, which sprout from the ulceration, consists in raising the ungual border with the extremity of a spatula or the point of a scissors, or with some other firm substance; but we must then either push charpie under the nail, repeating this every morning, or introduce a small me- tallic malleable plate of tin or pewter (Desault's method) and secure it with a bandage. Besides these modes of treatment, which are very painful, and should be employed'for a longtime and daily, we must also excise the fungous growths or repress them with nitrate of silver. This last method is an excellent palliative, and sometimes produces a cure. Cauterization of the Granulations.—We prefer this plan, which has quite often succeeded in our hands, to the one just mentioned. It is painful, but we may anaesthetize the toe on which we operate, by surrounding it with a little sacket of pounded ice; the pain is then less acute, and we may, almost without producing any, excise the o-ranulation, or cauterize it with the nitrate of silver or pow- dered alum. To obtain a good result from these cauterizations, which 21 322 ONYCHIA. should be repeated several times, at three or four days' interval, we must carry the pointed extremity of the pencil even under the nail, always using ice to prevent the pain, which is very acute. With this mode of treatment, we have noticed that emollient baths and applications were more injurious than useful. We there- fore prefer slightly warm foot-baths in tonic liquids, as infusion of walnut leaves, wine and water, water slightly alcoholized at first, and afterwards still more so; and we may conclude the treat- ment with sulphurous baths diluted with simple water. We have thus perfected several cures, by especially advising, after this treat- ment, the use of broad shoes, keeping the toes well separated from each other. We have also practised cauterization, as already suggested, with Vienna caustic on the swelling formed by the fungous growths and on the portion of the nail which enters into the flesh. In this manner the slough invades the portion of ingrown nail and the fungous growth. When the cauterized portions become detached, there remains a wound which cicatrizes* slowly, and which may be di- rected in such a way that the portion of nail which grows out passes above the cicatrix which is formed. Extraction of the Nail.—This method, by Dupuytren, is the most certain, and has often succeeded in our hands. It is very painful if we do not employ general or local anassthesia, but it gives a very expeditious and often very effective result. We prefer it to other methods, and have often used it in children, either administering chloroform or applying ice over the affected toe. In this manner we produce but little pain, and if we then carefully apply simple dressings, we find a nail of new formation covering well, but slowly, the ungual surface. This gives time to the ulcerated part, dressed with tonic fluids, to cicatrize firmly, and besides, as a general rule, does not allow the nail to grow in anew. We consider this method preferable for children ; it causes, it is true, acute pain, which may be avoided by anassthesia, but we thus especially avoid subjecting them to those painful dressings required by the other methods previously detailed. As a general rule, we follow in this operation the plan of Du- puytren. We pass under the middle portion of the free border of the nail the point of a branch of straight scissors, which we in- troduce rapidly flatwise as far as the root of the nail, turning the edge upwards, and with a single cut dividing the nail into two ABNORMAL CICATRICES. 323 parts. We seize the ingrown part with strong dissecting forceps, and forcibly extract it, rolling it on itself from within outwards. We often remove the other portion of the nail in the same manner. We may, without thus extracting the nail, as Raymond of Tou- lon has advised, cauterize deeply with red-hot iron the whole of the skin sorrounding the base of the nail, and thus have the nail detached with the slough produced by this method. The nail is less likely to grow out again, for we destroy the matrix, which does not occur in the operation for extraction. After these different operations, it is important to dress the wound with cold water, and to wait until the cicatrization of the ungual surface is firm and it no longer suppurates, to enable the subject of our operation to walk. Time is always needed for the new nail to be complete; or, if the nail does not return, the exposed part offers a perfect and solid cicatrization. CHAPTER LXV. ABNORMAL CICATRICES. Without speaking of malformations, congenital imperforations of natural openings, as of the nostrils, the labia, the anus, etc., or adhesions of the fingers and toes, we find in children many vicious cicatrices, characterized by the existence of a fibrous tissue, called by Delpech the modular tissue. They may be prominent, adherent, depressed, or obliterating. The causes are, as a general rule, wounds, scrofulous ulcerations, and burns, so frequent in children. Abnormal Cicatrization after Wounds.—In children, as in adults, wounds may be followed by cicatrices of a more or less vicious character, and this often depends on the nature of the wounds, some- times on the manner in which they are attended to from the begin- ning, and the circumstances which may complicate the treatment. Vicious cicatrices may be especially met with in wounds attended with loss of substance, in which nature always tends to approximate the edo-es. Thus, in a wound where a portion of the skin or of the subjacent soft parts is carried away, the cicatrix, left to itself, will 324 ABNORMAL CICATRICES. be more or less contracted, and will bind down the part on which it is seated,in such a manner as to impede the movements, either in ex- tension or flexion. Thus, in connection with the ginglymoid articu- lations of the knee, of the elbow and the phalanges, we may observe wounds of this kind. We have seen children with a wound on the anterior part of the knee, incapable, especially if there be loss of substance, of exerting movements of flexion without constantly tearing the cicatrix; and when the wound was on the opposite side, of executing extension. The method of preventing vicious cicatrices, which we must prac- tice in advance, consists in the mode of treatment of the wounds themselves. By keeping the limbs as a general rule in continuous extension, or in a state of flexion, we may avoid abnormal contrac- tions, or difficult or almost impossible movement. When these cicatrices, the results of wounds, are firm, we may hope that they will stretch in time, and that there will be no necessity to perform operations to re-establish the movements in the normal condition. In such cases the movements of extension or flexion made gradually may slowly overcome these vicious cicatrices. Finally, at the end of quite a long time, we may under some circumstances be compelled, for a flexed limb, which cannot be extended, to perform operations, as in the case of contractions from burns connected with the ginglymoid joints. Small wounds of the face are often met with, which have recovered with a vicious cicatrix, consisting only of a black tint through the whole extent or a portion of the cicatrix, as in powder wounds from cannon. We must not forget that the colour of these cicatrices often results from having dressed the wounds with court plaster of a black colour, and that the preventive means consist in only using colourless plaster to promote union of wounds of the face. Abnormal Cicatrices following Scrofulous Ulceration or Abscess.— We often meet with this kind of cicatrix in children. In them scrofulous ulcers of greater or less extent may destroy a large por- tion of the skin, on the face or on the neck, and produce loss of substance. These ulcerations are then like burns, and when they cicatrize, if their progress is not attentively watched, contractions occur, which reverse the lids, draw the lip down on the chin, some- times the chin on the neck, the neck on the chest, etc. To prevent these abnormal scars, we should do everything to obtain broad cicatrices by combating the contractility of the cicatricial tissue, by extending the affected parts in dressings, and by opposing the ABNORMAL CICATRICES. 325 efforts of nature, which endeavours always to supply by the cicatrix the loss of substance. When we have been unable to prevent these contractions, they become similar to the contractions after burns, and often require operations analogous to those resorted to in such cases. We also find in children cicatrices consequent upon spontaneous opening of abscesses, in the form of a swelling of greater or less length and prominence which rises above the level of the skin. These occur especially in the neck, and may be successfully treated by several methods, such as compression with leaden plates or pieces of agaric, excision with scissors and bistoury, and by caustics. Vienna caustic has been especially efficacious, applied carefully over these prominent cicatrices, and in swellings rising above the level of the surface of the skin. Whatever plan may be employed in these cases, we produce wounds which must be watched with great care to prevent a recur- rence. We must compress the new wound so that it may not become prominent, powdering it with alum, calomel, etc., frequently touching the granulations with nitrate of silver. We must do everything to prevent a recurrence, and one of the conditions of success is especially, as suggested by Dupuytren, not to be in haste to operate, the more so as in time these cicatrices occasionally disappear. Abnormal Cicatrices after Burns.—We find that burns most frequently produce this inodular tissue, which is contractile and has been ably studied by Delpech and Dupuytren. Cicatrices from burns may be observed in all regions. We may counteract these contrac- tions, which are of such frequent occurrence and chiefly in children, by dressings properly applied, by position, by the assistance of band- ages and apparatus suitably adjusted, or by opposing the contrac- tion of the wounds; but, in spite of the greatest care, we meet with a laro-e number of burns which terminate with various contractions. Thus we often see inversion of the lids, obliterations of the auditory canal or the nostrils, adhesions or inversions of the lips, inclinations of the neck in different directions, approximation of the arm to the trunk, flexion of the forearm on the arm, turning in of the hand, adhesions of the fingers, adhesions keeping the abdomen closely applied to the chest, the thighs flexed on the abdomen, the penis adherent to the pubis or the scrotum, the greater labia more or less approximated, and abnormal cicatrices in the lower limbs simi- lar to those in the upper. All these cicatrices are prominent, adherent, depressed, or oblite- 326 ABNORMAL CICATRICES. rating. As all of them give rise to difficulty in the movements and vicious positions, and prevent, in children, the development of the parts or movements, the indication is to operate, to prevent atrophy of the limbs in children, and especially to re-establish the functions, remedy obliterations, etc. We repeat, however, that Dupuytren advised that we should not operate too soon, and that we should wait until the cicatrices were firm. We must often resort to operations which are unavoidable, and which we have had occasion to perform in children. These include transverse incisions and graduated extension or dilatation kept up for a long time, even after perfect cicatrization; the removal of the cicatrix; sliding of the flap, and autoplasty. Whenever the cicatrices keep the fingers flexed, the hand flexed or extended on the forearm, the forearm flexed on the arm, the internal surface of the arm applied to the body, or the head flexed backwards or forwards on the chest, benefit may be derived from making over these prominent cicatrices, according to the method of Dupuytren, incisions through the contractions, either transversely or obliquely or V-shaped, then stretching the cicatrices thus cut in order to widen the incisions, but making the incision very slowly, more or less deeply, at the same time carefully avoiding the tendons, nerves, and great vessels. We must, as a dressing, employ appa- ratus and bandages to keep the wound separated during the whole duration of the new cicatrization. This demands a good deal of time and care, and often requires incision of fresh contractions which may be formed. The method of Delpech, which consists in removing the cicatricial tissue as far as the healthy tissue, is sometimes and even frequently preferable, when we are able to thoroughly circumscribe the whole of the vicious cicatrix, and to approximate the edges of the healthy skin in the opposite direction to the contraction formed by the vicious cicatrix. We have often employed this method when this has been possible, but we have abandoned it in all cases in which we could hardly cover completely the loss of substance, which is to be filled up by following this plan. When we can approximate them we should do so, either by separated stitches, serres-fines or adhesive strips. Whichever method we adopt, that of Dupuytren or Delpech, we have always derived a great deal of benefit from keeping the wounds covered with fenestrated linen and charpie, and finally from constantly subjecting them to continuous irrigation, ABNORMAL CICATRICES. 327 only refraining from the use of cold water gradually, and not abruptly. When, in certain forms of vicious cicatrices, we can make a flap with the cicatrix, and by sliding this we can obtain the proper extension, this method has sometimes succeeded in our hands, by combining with it several transverse incisions through the parts which we could not raise with the flaps. In vicious cicatrices which obliterate a natural opening, we have always employed multiple incisions; or, by means of the neigh- bouring skin, we have sometimes made a hem with the skin united to the mucous membrane—the commissure of the lips, for in- stance. As for iucisions, we have made them in the contracted orifices of the auditory canal, the nostrils, meatus urinarius vulva, and anus, always taking the precaution to employ tents, catheters, and canulas, the use of which may be prolonged for a considerable time. As for autoplasty for the treatment of vicious cicatrices, it should be especially reserved for those of the face and for cases of contractions of the lids. We have had occasion, in some cases, to treat cicatrices that were depressed and adherent over a bone, in partial osteitis of the frontal and the cheek bone,—in a word, subcutaneous bones. We have then operated with a tenotome introduced under the skin as far as the adhesion, which we divided transversely. By drawing on the skin, we destroyed the parallelism of the adhesion to the bone. In this manner the skin cicatrizes more thoroughly, and no longer presents its former appearance, that is to say, the depression. There is another form of abnormal cicatrix which is observed quite as frequently in children, a cicatricial contraction of the jaws, usually consequent on burns, gangrene of the mouth, etc. Formerly all the methods consisting in the division of the contractions causing the adhesion of the cheeks to the lower jaw, combined with the introduction of foreign bodies of various kinds into the mouth to pre- vent a recurrence, failed with us as with our predecessors. All other sur»-eons, as well as ourselves, have had very incomplete results from excision of cicatrices in the mouth, as proposed by Delpech, incisions as practised by Serres, of Montpellier, or wooden wedges between the jaws, suggested by Gensoul after excision of the con- tractions. The plan of Essmarck, which laid down the principle of the resection of the anterior portion of the jaw, and which I have not practised, appears to me of very little advantage, if I may judge 328 DISEASES OF THE UMBILICUS. of it, not by the results of several foreign surgeons who claim to have been successful with it, but by the attempts made by some of my colleagues of the Societe de Chirurgie, who have had nothing but failure or partial success not of a kind to encourage them to repeat them. Nevertheless, if called to a patient who had his jaws so tightly pressed together that he could only take fluids, if he was wasting away on account of his nourishment being restricted to liquid or feculent substances, and desired an operation to enable him to pass between his jaws solid substances, meat, etc., I would decide to resect a part of the middle portion of the lower jaw, according to the plan of Essmarck. I believe it, however, to be prudent, before this resection, to attempt to divide the contrac- tions, to introduce wedges between the jaws for a long time and frequently repeated, and, after excision of the bands, plates between the internal surface of the cheek and jaw, worn as long as possible. CHAPTER LXVI. DISEASES OF THE UMBILICUS. Independently of umbilical hernia, of which we have spoken, we may refer to several pathological lesions which are met with in children in the umbilical region. Hemorrhage.—Usually, the umbilical cord shrinks up from the first to the third day after birth, and on the fourth or fifth day the cord dries up, then separates with more or less suppuration, leav- ing beneath it a cicatrix, which is the umbilicus. In children who die at birth, this drying up of the cord is not observed; the child must live two or three days before this vital phenomenon takes place. Sometimes this work of nature is interfered with by hemorrhage. In the progress of labour, violent tractions on the cord, or the descent of the child suspended by the placenta, drag it or tear it from the cord at its point of insertion to the umbilicus. This dragging has been found to take place, but rarely, as a conse- quence of the parturient efforts, when the cord was extremely short. The child has also, in such malformations, died as the result of hemorrhage seen at birth, which is most frequently, UMBILICAL VEGETATION. 329 however, met with at the period of the separation of the cord, six, seven, or even more days after birth. The blood then flows in an intermittent dribbling manner, and not by jets. The hemorrhage sometimes takes place because the ligature is not tight enough; it is sufficient then to apply a fresh ligature more tightly above the other one. This hemorrhage may be observed in children suffering from purpura hasmorrhagica. If we find petechias on the body, the diagnosis is not in doubt. At other times, we cannot discover the cause. The hemorrhage may be considerable and the cause of death, if not immediately relieved. If it is only slight, it may be easily arrested, but in many cases we must act energetically. The remedies suggested have been alum, colophony, ice, nitrate of silver, aud even the red hot iron; but we should prefer to all of these either a suitable application of perchloride of iron or ligation in mass. In using the former, we have derived benefit, under two or three circumstances, from at first making compression of the entire umbilicus between the index finger and the thumb of the left hand; and, after having clearly seen the point from which the blood comes, having stopped the compression for a moment, to renew it after- wards still more effectively, we apply on the spot from which the blood flows a small ball of hard charpie, held between the dress- ing-forceps and previously impregnated with the perchloride, and kept there by compressing it for four or five minutes, and continu- ing it by means of disks of agaric applied over the charpie, the whole of it being secured by a body bandage. A still more certain means consists in the ligation of the whole umbilical mass. To make this ligation, we must pass a pin through the base of the umbilical tubercle, and pass beneath the pin a thread, turning it several times to make it very tight. This method has appeared to us, as well as to other surgeons, the most efficacious. If, however, we discover a general cause, such as purpura hasmorrhagica, we must prescribe astringents internally, and chiefly with two drops of perchloride of iron given diluted with coffee-water, followed by a spoonful of milk, and repeated according to the result. Umbilical Vegetation.—W"e have often, in new-born children, met with a vegetation in the depression of the umbilicus. In the first weeks after birth, sometimes even at the end of three or four months, it resembles a small red polypus of the size of a grain of wheat or a pea. It is pediculated, allows a small amount of bloody 330 DISEASES OF THE UMBILICUS. serum to discharge, and sometimes produces inflammation. Fre- quently, in time, it is detached, but it irritates the umbilicus. It is easy to produce separation with a thread placed around the pedicle. It is nothing more than a granulation, taking on the appearance of a small polypus. Phlegmon of the Umbilicus.—It sometimes happens that the sepa- ration of the umbilical cord is accompanied with a circumscribed inflammation, which occupies the umbilicus and sometimes the vein and artery. This grave disease presents, at the autopsy, con- secutive pathological alterations, as detected several times by Dr. Maynet, who has written on this subject. The alterations, which we have twice seen, are, as a general rule, rapid putrefaction, the epi- dermis of the abdomen being elevated, macerated, with a black discoloration around the umbilicus, depressed abdomen, the cellu- lar tissue around the umbilicus infiltrated with purulent serum, but not a collection of pus, usually a circumscribed redness in the peri- toneum around the umbilicus, sometimes general peritonitis, or inflammation of the umbilical vein alone, at other times inflam- mation of the vein and artery. These grave pathological lesions, recognized many years ago and still more lately by MM. Baron, Trousseau, and others, have the following causes and symptoms. Causes.—These are sometimes traumatic, ligation of the cord badly accomplished, irritating ointments applied over the umbilicus, or want of cleanliness; at other times general, as improper diet or poor nourishment to the new-born, or, as established by Maynet and Bouchut, the influence of puerperal peritonitis in the mother. Symptoms.—These are at first constitutional, and may interfere with our at once recognizing the disease, which often occurs in the earliest days after birth, on the eighth after delivery. The child is constantly fretting and crying, there is frequency of pulse, with weakness, diarrhoea or constipation, sometimes with aphthae, and the child refuses the breast. We discover around the umbilicus an inflammation which accompanies the separation of the cord, and soon an ulceration which retards this separation, added to which is an erysipelatous redness, more and more pronounced around the umbilicus, and tumefaction in the form of a ring. The ulceration becomes still deeper, the edges inverted, the surface covered with a grayish membrane, and the pus fetid. The erysipe- latous circle, more and more swollen, is covered with phlyctenas EPIPHYSEAL SEPARATIONS. 331 filled with serum, and the tumefaction invades the whole surface of the abdomen, the wound soon taking the characters of hospital putrefaction. This disease, the progress of which is quite rapid, sometimes lasts two or three days, is, as a general rule, grave, and terminates in death. If, in some very rare cases, a cure results, it is but very slow; the ulceration does not then extend, the false membrane becomes detached, granulations are developed, the pus is arrested, becomes of a better character, and the general symptoms diminish; the child again takes the breast and drinks what is offered it. Treatment—Internally, we must combat the constipation, which is of very frequent occurrence, giving calomel in fractional doses. Externally, emollients should be used at first, but as speedily as practicable, and this plan has succeeded in two of our cases; in the first, applications of mercurial ointment with belladonna, then, as soon as possible, elastic collodion. In case of ulceration, powdered tannin and cinchona should be employed, the abdomen being covered with wadding. We have not used cauterization externally, according to the advice of M. Maynet, with a paste of chloride of zinc, nor perchloride of iron, according to Dr. Valette of Lyons, who has employed it both internally and externally. CHAPTER LXVII. EPIPHYSEAL SEPARATIONS. The epiphyses are only consolidated at a certain period of life. Up to that time, they are separated from the bones by a cartila- ginous portion. Traumatic separation of the epiphyses, which was described a great many years ago, can only take place before complete solidification, and is consequently met with in children between four and sixteen years of age. Nevertheless, there are cases in which the union is delayed, from which results traumatic rupture in those between eighteen and twenty years and more. Epiphysary separations are not very common. During twenty years of practice at the Hopital des Enfants, it has often, perhaps, 332 CUTANEOUS TUMOURS. happened that I failed to recognize them, for I have seen very few cases of this affection. Sometimes I have had occasion to detect it in the extremities of the humerus, then in the inferior extremity of the radius. Causes.—We may admit, as predisposing causes, rickets, consti- tutional syphilis and scrofula, which put children in proper con- dition for epiphysary separation, without referring to the deep affections of the articulations, which may also make us fear the prolongation of arthritis to the connection of the epiphyses, in this way producing the separation; but the traumatic causes are those especially which may produce the separation of the epiphyses from the shaft. Thus falls and blows, striking in the vicinity of articulations, may disunite one or several epiphyses. Epiphysary separations may occur in certain stages of the process of labour. The symptoms of these lesions are those of fractures in the neighbourhood of the joints; mobility between the separated parts, and sometimes crepitation, so that we have often remained in doubt whether the case was one of epiphysary separation or fracture. The age of the patient has sometimes led us to say that there was epi- physary separation rather than fracture. Crepitation, less marked than in fractures, may again induce us to think that the case is one of forcible rupture of the epiphysis. The prognosis is not more grave than that of simple fracture. As a general rule, the treatment is that of fractures in the vicinity of the joints. We must especially resort to immobility of the neighbouring articulation. CHAPTER LXVIII. CUTANEOUS TUMOURS. The follicles, the derma, and epidermis may form superficial tumours on the skin. They are often met with in children, and require the same care as in adults. Acne is an affection characterized by small tumours formed by hypertrophied sebaceous follicles, containing an accumulation of a varying amount of fatty substance. They are chiefly seen on FOLLICULAR CYSTS. 333 the nose, the cheeks, sometimes near the nipple, on the sternum, etc. When pressed between the fingers, these little tumours may be squeezed out, and there will be discharged, through the orifice of the follicle, a whitish substance of vermicular form; and this constitutes the whole treatment. Follicular Cysts.—These are encysted tumours which take their origin in a cutaneous follicle. The envelope is cellulo-fibrous in the thickness of the skin, which distinguishes them from wens, properly called, which are in the subcutaneous cellular tissue. The membrane of these follicular cysts is smooth, even, soft, and often filled with villous prolongations on its internal surface. It is not susceptible of degeneration, as the other cysts are. We find, in the interior, either a sebaceous matter, or an unctuous and ropy substance; this is atheroma, or else a substance having the con- sistence of honey, and hence called meliceris. These cysts are met with in the hairy scalp in the thickness of the skin, are developed and may acquire a certain volume without causing pain. They are not sensitive to the touch, are of varia- ble size, increase slowly, and do not terminate by resolution, but remain for a long time stationary. They sometimes become in- flamed, and may open externally; the cyst is thrown out ex- ternally with suppuration, but it may remain and be filled up afresh. In some cases, we find that, the cyst being opened and emptied, there remains a fistulous spot, and fungous vegetations spring from its interior. These follicular cysts, which may sometimes be taken for cold abscesses or lipoma, are, as a general rule, of little gravity. Never- theless, if they acquire a certain volume and inconvenience the patient, the indication is to relieve him of them. The treatment, in children as in adults, demands removal, not with the bistoury, but with caustic. We for a long time knew that by the use of the bistoury we could very promptly relieve our patients, and that very often we could produce a rapid cure, but for a long time also we had the opportunity of knowing that most frequently, as the result of this removal, very severe erysipelas resulted. We are in favour of employing Vienna caustic, as we do, as a general rule, for all subcutaneous cysts. This method is much longer than when a cutting instrument is used; it may leave a more decided cjcatrix, but it obviates mortal symptoms, and we should, as a matter of good surgery, give it the preference. We have already, 334 CUTANEOUS TUMOURS. in Chapter IX. (page 79) referred to the method of applying the Vienna caustic. Spots of different colours, circumscribed, brown, yellow, promi- nent or not, developed on the skin, known under the name of lentilles, or commonly naevi, of variable size, may remain stationary during the whole of life, but they may increase in time both in width and thickness, and at a certain period they give origin to hairs. Under such circumstances, these spots, which, when of small dimensions, may be looked on as beauty spots, have a disagreeable appearance. It appears to us that the indication, when they are too large, is to remove them in young people, and we know no better method than the application of a slight layer of Vienna caustic covering the surface of the spot. Warts, whitish-yellow rugous excrescences, are developed on the hands, chiefly on the dorsal surface. They are usually multiple, rarely solitary, are elevated above the cutaneous surface, and are of various shapes, rounded, granular, angry-looking, more or less con- sistent, sometimes pediculated. They are formed by the epidermis, having a tissue of variable density, traversed by little vessels, especially appreciable at their base when they are cut transversely. The true treatment consists in excision. writh a bistoury or scissors, and in caustics, either nitrate of silver applied immediately after excision has been made of the wart as far as the point where the blood appears by the little vessels cut at the base, or a drop of nitric acid applied over the cut. Usually, this little operation may be performed two or three times, two or three days apart, on certain warts. In timid persons, we may, before resorting to this method, try to surround the affected fingers several times daily, and several days in succession, with compresses of linen steeped in acetic acid. This method has succeeded with us, in timid little girls, who dreaded the use of the scissors or the bistoury. Corns are hard, callous, flat protuberances formed by the epider- mis, and are met with on the toes, in children as well as adults, although they are much more uncommon in the former. We have, nevertheless, seen them in young children four or five years of age- Anatomically, the corn is composed of two portions; one superfi- cial, dry, shaped like the head of a nail, formed of several layers of epidermis, sometimes quite easy to separate, and having no ap- pearance of organization; the other, deeper, of a horny character,, semi-transparent, springing from the centre of the former, and CRUSHED FINGERS. 335 penetrating through the derma as far as the tendons, the ligaments, and even the bones. This portion is painful on pressure, and when cut into several vessels are seen, even by the naked eye. In the centre of the corn we find a depression or cavity of a gray colour, surrounded with a ring of cartilaginous appearance. We must distinguish callosities from corns; the former are only formed by the thickening of the epidermis, are seen in the heel, over the head of the first metatarsal bone, and do not present that portion of a conical shape situated in the middle of the corn, which is buried over the deep parts. The use of proper shoes is the prophylactic means; they should not be too tight, but they should not be too large. Treatment.—We may, by rest, emollients, and cataplasms, palli- ate the pain produced by corns; and baths, especially sulphurous baths, employed when the inflammation is not too acute, are excel- lent palliatives. The remedy par excellence, however, is to cut the corns, confining ourselves to the removal of the callous portions as far as the sensitive parts, refraining from going further. Finally, the curative method is extirpation by the bistoury, a delicate opera- tion performed with fine forceps and a bistoury, with which we slowly and carefully accomplish the removal of the corn as far as the root. This little operation is very difficult, and, for prudence sake, we cannot completely extirpate it. As for caustics, they are very difficult to handle. We see too many accidents conse- quent on their use, to advise them in all cases indiscriminately, and we should prefer the palliative methods to which we are often compelled to resort, but without danger. We may meet with bony growths in children as in adults. We have had occasion to observe them on the toes, and chiefly under the nail of the great toe. They require excision with a strong bistoury. CHAPTER LXIX. CRUSHED FINGERS. We have had occasion, both in hospital and private practice, to observe many cases of crushed fingers in children. The worst of 336 CRUSHED FINGERS. these were under treatment in the hospital, for, in private practice, though we may sometimes meet with severe injuries of the fingers and even of the hand, the cases are, as a general rule, less serious and limited to one or several fingers, and usually to one or two phalanges, especially the ungual phalanx. Causes.—In printing offices or workshops in which machinery worked by steam is used, young workmen or apprentices get their fingers caught in the gearing, and these are the most fatal causes met with, producing very serious wounds, which sometimes involve all the fingers or the entire hand, sometimes the arm, and even the patient's life. There is hardly a month in which we do not have cases of this kind to treat in the Hopital in the Rue de Sevres, and still more frequently in the Hopital Sainte Eugenie, on account of its proximity to the manufactories in the quartier Saint Antoine, where many children are employed as apprentices. Other less serious causes occur, especially in civil practice, from windows, doors, drawers, etc. in which one or two fingers become pinched and sometimes badly crushed. Symptoms.—We meet with cases of but little gravity, and some- times of the most serious injuries, in children who have had the extremity of one or several fingers pinched in a door or in such tables as have a part movable and raised at will. We then notice simple pressure with wounds or contusions of the soft parts, without fracture of the phalanges. At other times there is frac- ture with flattening of the phalanx; and in certain cases, nothing like fracture appreciable. Sometimes, especially when the hand has been caught in a machine, the lesions are of much greater extent; portions of fingers are carried away, sometimes one or several; there is laceration of the soft parts of the tendons, the wounds extend as far as the dorsal surface of the hand, and the metacarpal bones are fractured or denuded. All these fractures are comminuted. These several lesions, which are very different from each other, the most circumscribed as well as the most extensive, present nu- merous varieties, and may all give rise to nervous symptoms, phlegmon, erysipelas, or purulent infiltration, or require amputa- tion. On account of these serious complications, amputation of the phalanges of the fingers has been performed for a long time, and even of whole hands which appeared to be so thoroughly crushed, that it was hoped that, by substituting a simple wound for a very SYMPTOMS. 337 complicated one, all the consequences just detailed might be ob- viated. In the early days of our practice at the Hopital des En- fants, we made quite a large number of amputations of greater or less importance, from the phalanges to the forearm. For a certain number of years, however, encouraged by the proper use of cold water, we have almost entirely abandoned all these operations, ex- cept in cases attended with very considerable mutilation ; for exam- ple, in complete comminution of the soft parts and of the bones. Otherwise, when the phalanges, the fingers, and even the hands are fractured with contusions and lacerated wounds, we may and should attempt to preserve the part, even in very serious lesions, or in cer- tain almost total separations of a finger. We employ continuous irrigation with cold water in warm seasons, and water moderately warm in cold seasons, taking care not to cease its use abruptly, but at the end of three days di- minishing gradually. As for the dressings that we make in such cases, we confine ourselves to surrounding the affected parts with fenestrated linen spread with cerate and covered with charpie, the whole lightly supported with a bandage, and we place the hand under continuous irrigation, or else we place it on a mat surrounded with a piece of isinglass plaster, and we advise that the affected part shall be frequently wet without removing the dressing, if this be not oftener done than every two or three days. We take good care in all cases not to employ such agents as may press the fingers together, such as strips of plaster, which we look upon as injurious in the greater number of cases. We prefer to support lightly the parts which appear to be separated or even almost entirely detached. Immobility of the wounded parts is indispensable, and the hand and the fingers should be placed on a wooden splint covered with linen, retained by bandages lightly applied. Continuous irrigation prevents accidents which might occur. At the end of three or four days we should commence to support more firmly the parts which have a tendency to be separated. We thus avoid the pain and tumefaction of the injured parts. We must only gradually employ retentive methods. We often find, in this mode of treatment, that the most mutilated portions tend to become detached naturally. In cases of crushing of the extremity of a fin- ger with fracture of the phalanx, the nail becomes lost. Sometimes portions of soft parts and even of bone become detached, but we also see parts that are very severely contused that do not become gan- 22 338 LANCING OF THE GUMS. grenous but regain all their vitality. We have seen flaps of the skin, which could scarcely be retained with fenestrated linen and charpie, becoming approximated, and articulations of the phalanges which were opened, not becoming inflamed, and even closed. Thus we see the fingers or portions of fingers preserved, which have been on the point of being sacrificed. As the inflammation becomes extinguished, and the gangrenous parts are naturally detached, and the hand of the surgeon has pro- moted the separation of the slough, we must make the dressings more retentive, so as to maintain as much as possible the normal shape of the parts. There is nothing then to oppose our applying strips made moderately and gradually tighter at each dressing. Tonic liquids, such as alcohol, or spirits of camphor more or less diluted with water or glycerine, or aromatic wine, are employed with benefit. When, in crushing of the fingers, the wounds are closed, we derive advantage from placing the ends of the fingers in a kind of thimble of bone covered with wadding, which should come up on the fingers to a distance corresponding to the extent of fracture, whether one or several phalanges be broken. This serves also as a protector as long as the extremities of the fingers are not sensitive. These thimbles should be held with a finger-stall of skin or cloth, secured at the wrist by tapes. It is the completion of a treatment of the most useful kind for children, which is espe- cially indicated in cases in which the nail is lost and requires a good deal of time to grow again. Sometimes granulations occur, which should be repressed with alum, especially in the place which will be covered by the nail. CHAPTER LXX. LANCING OF THE GUMS. In former times, and also at the present day, many diseases of childhood have been attributed to dentition. It is especially the want of familiarity with diseases of children, which is the cause of this opinion, too generally diffused, even among physicians. The child is subject, from its birth, to various diseases observed at all LANCING OF THE GUMS. 339 ages. It may be attacked with a number of these during first den- tition, and we should be able to recognize them. The irregularity of the process of dentition may nevertheless interfere with the development; they may be cut either too rapidly or too slowly. By the eruption of the first teeth, which do not appear for several months after birth, we at first notice ptyalism a long time before the tooth makes its exit from the alveolus. This flow of saliva is a salutary phenomenon; it prepares and renders supple the tissue of the gums. The salivary glands become engorged, and there is a peculiar sensation which leads the child and the young animal to bite the substance which it seizes. This pressure of the gum is useful, and consequently favourable for promoting the separation which occurs between the two layers of bone to gradually open the alveolus. At this period corals are useful, but somewhat later, when the gums become sensitive and the point of the tooth commences to press on the swollen tissue, it is much better to give children, instead of hard substances, marshmallow or liquorice roots—in a word, bodies easy to soften with the saliva. Children frequently accomplish their first dentition without having any bad symptoms, but sometimes the tissue of the gum becomes tense and swollen; there is even thirst, fever, and redness of the cheeks. This is the fever of dentition. At this period we must pay care- ful attention to the child, and learn if these symptoms positively depend on swelling of the gums alone or on any other disease, such as aphthae, diphtheritic affections, or convulsions, which may mani- fest themselves under the influence of dentition, as a result of the congestion, which this process may develop in that region of the head. We should at first employ in these cases only emollients, fomentations over the gums with the finger impregnated with a soothing solution, borax, honey of roses, etc.; slight derivatives acting through the intestinal canal; pediluvia, the use of wadding boots covered with isinglass plaster, secured by tapes to the legs, to prolong a heat which produces transpiration in the lower extremi- ties. When these simple means, which most frequently succeed, fail, we may sometimes resort to incision of the gum, which appears red' and distended by pressure of the tooth. This little operation is especially indicated if convulsions are produced by the pain. To perform this operation,, it is necessary that an assistant shall hold the child's head firmly; the operator then separates its cheek 340 ABSCESS OF THE NASAL SEPTUM. with a finger of his left hand, holding in his right a bistoury, the blade of which is wrapped in linen in two-thirds of its extent, in such a way that the point is only uncovered for rather less than half an inch. At first one incision should be made transversely, then another, which will produce a crucial incision. It is still better to remove at a single cut a flap of the gum, without making any previous incision. The swelling is more easily reduced in this way, with the advantage of not having the wound closing up on the very next day. We should introduce the extremity of the finger into the wound, to assure ourselves if we can detect the tooth, and if the alveolus is not too tightly pressed, and does not require an incision, which can be readily done with scissors. We must not too frequently perform this operation, which, however, is a harm- less one; we must particularly reserve it for the molar teeth, the tubercles of which oppose more resistance to the tissue of the gums. We must also urge the importance of relaxant and calming agents, before deciding to operate. We have obtained successful results, but we have observed that by making the incision too soon, we may have sometimes retarded the escape of the tooth, because we may open the dental capsule before the tooth has reached its degree of perfect ossification; it then makes its appearance very slowly. It is often then more prudent to refrain from it. CHAPTER LXXI. ABSCESS OF THE NASAL SEPTUM. Children have very often been sent to us who were supposed to be suffering from nasal polypus, and we have discovered, as a general rule, these supposed polypous tumours to be purulent col- lections seated under the mucous membrane covering the vomer. Causes.—These abscesses seated in the nasal septum are most frequently developed under the influence of falls or blows on the nose; sometimes they are occasioned by a disease of the vomer, as caries or necrosis, often from a scrofulous cause. It has been among lymphatic children that we have met with this affection. Symptoms.—When these abscesses are developed as the result of a fall on the nose, or a blow on this region, there are pain, swelling SYMPTOMS. 341 and sensibility to the touch, and the patient experiences difficulty in respiration through the nose. In examining the interior of the nostrils, it appears sometimes that the nasal septum is inclined to one side or the other, or presents on both sides tumefaction, with sensitiveness to the touch, and fluctuation easily recognized by in- troducing the little finger, feeling the projecting part with the pulp of the finger, and compressing the nose on the other side. These abscesses have not at all the appearance of the mucous polypous tumours which we have scarcely had the opportunity of observing in children, and which, besides, are movable and pediculated; such is not the case in these abscesses. Left to themselves, the latter may open naturally, but this takes place slowly; the patient some- times suffers for a long time, and is always more or less embar- rassed in respiration. In acute cases, it is necessary to give issue to the pus just as soon as it is appreciable. In chronic cases, which are developed more slowly without great pain, there is less soreness, and we may postpone it. In any event, emollient injections and fumigations may be employed, but the true curative method consists in punc- ture performed with the point of a bistoury, which must be guarded with a strip of linen to within about half an inch of its extremity. In this way, when we introduce it into the nose, we avoid wounding the border, if the patient should happen to move. It is also essential, in this little operation, that the patient should be held firmly, Avith his head supported on the chest of an assistant, with his face turned t to the light. When the incision has been made, pus flows out freely, and its discharge may be encouraged by pressing the nose, and causing the patient to blow. The next day, if the wound has a tendency to close, we may introduce into it the end of a catheter to separate the edges of the wound, and by pressure may cause the freshly formed pus to be discharged. We may also use injections, which will vary according to the case, being emollient at first, and afterwards detersive, if such is the indication. As a general rule, such children are easily cured, and we have always had success in many cases in which physicians have misunderstood these abscesses, and have even employed several remedies uselessly. It may be, that, if these abscesses are occasioned by a disease of the vomer, the indication will be to subject the child to a general anti-scrofulous treatment, for in these cases there may exist more or 342 CONGENITAL LUXATIONS. less extensive necrosis of the nasal septum, which is only cured after the separation of a portion of necrosed boiie, and this some- times requires a long time. CHAPTER LXXII. CONGENITAL LUXATIONS. Articular displacements existing in children at birth have received the name of congenital luxations. Since the last investi- gations of M. GueVin on this subject, they have been very numerous, some of which are quite rare. Having only had occasion to meet with a small number of these luxations, if we except club-foot, con- genital luxations of the thigh, a few cases of luxation of the clavicle, and luxation of the head of the radius, we cannot speak in a practical manner on this subject, and we shall have but little to say on the cases which we have seen. Several of these luxations, however, were pointed out a very long time since, but lately a greater number have been described. The list of congenital luxations observed on the living subject and on the cadaver by M. J. Gudrin, is as follows: 1. Occipito-atloid luxations; 2. Luxations in various parts of the vertebral column; 3. Complete luxation of the jaw in the zygomatic fossa; 4. Luxations of the clavicle on the sternum in- ward, forward, and backward; 5. Luxations of the scapular extrem- ity of the clavicle upward and outward; 6. Scapulo-humeral luxa- tions downward, inward, upward, and outward; 7. Ulno-humeral luxation backward: 8. Luxation of the head of the radius upward and forward; 9. Luxation of the wrist forward, backward and upward, and backward and outward; 10. Sacro-iliac luxation up- ward and backward, diastasis of the pubes; 11. Coxo-femoral luxations, upward and outward, directly upward, forward and upward, backward and upward; 12. Incomplete luxation of the knee forward, incomplete backward, incomplete inward and back- ward, and backward and outward; 13. Luxations of the foot, incomplete tibio-astragaloid, incomplete calcaneo-astragaloid, astra- galo-scaphoid, calcaneo-cuboid, and metatarso-phalangeal. Several of these congenital luxations have been met with in anencephalous monstrosities, others in children at birth, or in children of four, eight, ten, and fifteen years of age, and even older. Speaking in a CONGENITAL LUXATIONS. 343 general way, congenital luxations are quite rare, are often multiple, and sometimes seen on two congenerous limbs, and are observed with other anomalies, which are frequently the causes of non- viability. Post-mortem examination of these luxations presents variations, according to the period of life at which it is made; and great differences are observed in the foetus, the child, and the adult. Dissection of the foetus gives us ligaments, articular ligaments, relaxed, not lacerated, as M. Guerin remarked; there is not complete luxation, but we can separate very easily thcarticular surfaces, as cannot be done in the normal articulation. As the patient be- comes older, two years or four years or more, we may detect much more readily the precise nature of these different deformities. Thus we find extremities of bones without definite shape, articular cavities becoming filled up and disappearing, new ones formed in their vicinity, new ligaments developed, all the alterations, indeed, that are met with in unreduced traumatic luxations. The limb may become diminished and shorter, the muscles retracted, and, in addition to this, atrophied on account of the small amount of move ment it undergoes, this being always more limited than in cases in which the limb is in its normal condition. The causes of these congenital luxations are very obscure, for as in club-foot we are unable to make direct observations, we must supply the deficiency with theories. According to the views of some, congenital luxations are original; others claim that they are hereditary, and cases have been cited to prove it. Diseases of the nervous system may be the cause of these luxations; convulsions, for instance, according to M. Gudrin ; so also arrest of development, perhaps also malformations of surfaces. Articular diseases may also be developed in the womb of the mother, and then these luxations have for their cause an arthritis occurring at different periods of pregnancy, hydrarthrosis, etc., according to the opinion of Malgaigne of Paris. Mechanical injuries operating on the uterus during pregnancy have also been supposed to produce these luxations. It may also happen that in a natural labour the child may produce a luxation, and with much more reason in a tedious labour requiring manipulation and the use of instruments. Which ever cause of all those mentioned may be the real one, we find these luxations at birth, or some time afterwards, with symptoms analogous to traumatic luxation. 344 CONGENITAL LUXATIONS. To refer only to congenital luxations which we have had occasion to observe, we may remark that, 1. In luxation of the clavicle, we have found the symptoms of this dislocation of the sternal extremity forwards; at birth, as at a later period, the bandages which must be applied to support this luxation, which is quite easily reduced, irritate the child's breast, and cannot be continued. Besides, no bandage gives proper support to the luxation, and none can prevent the reduction from being very incomplete. 2. Of luxation of the head of the radius forwards, which we have seen two or three times, the same may be said as in luxation of the clavicle, it not being very decided at birth, but becoming in time more appreciable. Reduction was quite easy, but could not be maintained. 3. Cases of congenital luxation of the coxo-femoral articulation, which we have more often seen, we have found to be more frequent in girls than in boys, and, as a general rule, we have noticed the following symptoms. Usually we have met with the luxation upwards and outwards, often on both sides symmetrically; sometimes, however, we have seen both femurs differently luxated on the right and left sides. As the attention of parents is not generally awakened until the child commences to walk, it is only at the age of a year at the earliest, that we have had occasion to see these cases. We have not had the opportunity to observe them at birth, as M. Verneuil had, who had the advantage of examining a dead foetus which had scarcely breathed. This little subject presented a luxation of the left side, which was incomplete, the hip of that side being more elevated, the thigh being flexed one-fourth on the pelvis. In decided adduc- tion combined with a movement of rotation inwards, the upper portion of the femur formed a considerable prominence backwards, outwards, and upwards, the articular movements were impeded, flexion and rotation outwards were restricted, extension was but slightly practicable, and abduction was impossible. Only when the child has attained the age of one or two years have we observed these phenomena, which constitute luxation on the living subject. When the luxation is only on one side, there is a remarkable dif- ference in the length of the two limbs, and the amount of their shortening varies according to the degree to which the head of the femur ascends in bilateral luxation. They are out of all propor- tion to the trunk; the thighs appear short relatively to the legs; the great trochanter is more or less approximated to the iliac crest, and CONGENITAL LUXATIONS. 345 is projected outwards and thrown backwards; there is separation of the great trochanter from the median axis of the body; the nates present a rounded prominence formed by the head of the femur more or less appreciable when the head is buried in a new cavity of reception, or it may be made more apparent by rotating the limb inwards and flexing it. As remarked by M. Bouvier, we should seek the head of the femur forwards, near the iliac spine, by insti- tuting in the extended limb movements of rotation inwards and then outwards. The femur is oblique inwards; and in double luxation, the pa- tient being in a standing position, the two knees are seen to touch. The thigh is of large size above, and small below; there is a de- pression in the groin, and when movements of rotation are instituted by placing the fingers in this depression, we cannot feel the head of the femur turn. This is, however, what is often remarked in many cases in which there is no luxation. On the luxated side the nates are flattened, and enlarged transversely, and the fold of the nates is more elevated. In double luxation, if the patient is in an upright position, the pelvis is thrown forwards, and the anterior iliac spines are brought nearer to the axilla. There results a very decided concavity in the lumbar region, the patient looking as if he was saddle-backed. In unilateral luxations, the pelvis is inclined laterally, and the lumbar region and the spine describe an entire curve, with the convexity turned on the side of the luxated limb. In luxation of one side progression is made by the trunk being at first flexed on the luxated limb, the hip of that side being alternately depressed and elevated in such a way that there is a balancing of the whole body. In double luxation, the patient is raised on tiptoe and can only with an effort raise his feet successively from the ground to put one before the other, so that he walks with his body bent, and oscillating right and left. Pathological Anatomy of Congenital Luxations of the Coxo-femoral Articulation.—The few autopsies we have made in these cases have exhibited to us cotyloid cavities of greater or less extent on the part on which the head of the femur glided. In one case we observed that the cotyloid cavity was higher than in the normal state; in another, we found it of very small depth and narrower than usual; we also found the head of the femur luxated upward, resting on the worn cotyloid edge, which looked as if it was trodden 346 FOREIGN BODIES IN THE OESOPHAGUS. down. The capsule was elongated and distended. We also had occasion to find the head of the femur atrophied, worn away, and deprived of cartilage. Treatment—We have abstained from treatment, riot having been persuaded of the utility of extension, which,, according to their accounts, gave cures to Drs. Humbert, and Jacquier, Pravaz, Bonnet of Lyons, and M. Gue>in. Like M. Bouvier, we are in doubt in regard to these successes which have been pointed out as cases of cure. We have not employed apparatus for extension, and have been content with making the patient wear a belt sur- rounding the pelvis, and compressing the two trochanters, as advised by Dupuytren. We believe that we can displace the head of the luxated femur, but we cannot maintain it in position, and it con- stantly slips on the point in which it rested, before attempts were perseveringly made, and prolonged for a considerable time, what- ever may be the apparatus employed. CHAPTER LXXIII. FOREIGN BODIES IN THE OESOPHAGUS. We most frequently meet with foreign bodies in the oesophagus in children and old people. In the latter, it is due especially to the want of teeth, which does not allow of complete mastication, and besides, in some of them, to feebleness of the muscles which act in deglutition, and are attacked with more or less marked paralysis. In children it is often the want of teeth in the youngest of them, but is rather inattention and gluttony, or the desire to speak while holding a foreign body in the mouth, which cause these accidents. Most commonly, these substances are fishbones, pins, small fragments of wood, fruit stones, sugar-plums, sugar, sometimes portions of bone, and even small entire bones, patellas, vertebras of winged animals, phalanges, morsels of bread or mea- not well masticated, fruit swallowed whole, olives, pennies, chest- nuts, sometimes pieces of money, buttons, etc. All these foreign bodies act differently, according to their shape- they may dissolve, as sugar-plums and bonbons, and thus diminish SYMPTOMS. 317 in size and pass onwards without stopping long. But insoluble substances may reach the thoracic portion of the oesophagus, more or less rapidly when they are not rough or of too large size; or else they are arrested by being of too considerable a volume, and at other times retained by the roughnesses on their surface, such as a piece of bone, or because they are pointed, as needles, pins, fish- bones, etc. They may become implanted lengthwise or obliquely: or crosswise in the mucous membrane of the pharynx, the pillars of the velum palati or the oesophagus. If the foreign body is of a certain volume, as a piece of money, a fruit stone, etc., it is arrested at the inferior orifice of the pharynx, and is then compressed by the contractions of the canal of the oesophagus. The muscular fibres, when they act, prevent it from either descending or ascending, and by its presence it produces convulsive movements of deglutition or vomiting, which wedge it in more tightly. Frequently, if it descends lower, it penetrates the pectoral portion of the oesophagus more easily, and is less obstructed after having passed a spot corresponding to the upper portion of the sternum and the trachea. At last it arrives towards the lower portion of the oesophagus which enters into the diaphragmatic orifice. If the foreign body is of a certain size, there is difficulty in its passing through the cardia, and this causes great distress and a painful sensation all the time that it takes to pass into the stomach. Once passed, relief is experienced and the trouble is over. Symptoms.—These are, continual or remittent pain in the region of the neck, violent and convulsive efforts of vomiting, with more or less difficult deglutition of solids; and the respiration may be embarrassed, if there is a body of any size pressing on the opening of the larynx before it arrives in the pharynx. If the substance reaches the pharynx or the oesophagus, it may still interfere with respiration by lateral compression of the trachea. If the foreign substance is arrested and remains, inflammatory symptoms arise, even when it is very small; a fishbone or a pin, may, even when it has passed through the stomach or been expelled by the mouth, leave a sensation of pain, which causes the patient often to believe that he has not been relieved, although he may have been so. If the foreign body is expelled, the slight local irritation ceases of itself; but, if the body remains, suppuration may be developed around it where it is attached to the mucous membrane. Sometimes it may be expelled by coughing, preceded by vomiting of blood mixed 318 FOREIGN BODIES IN THE OESOPHAGUS. more or less rapidly with pus, or pass into the stomach, carrying with it the foreign body. More serious symptoms may be developed, as tumefaction of the face, obstruction of the respiration, and in the course of the neck sometimes a tumour appreciable to the sight and touch, which announces the presence of the foreign body, and frequently an abscess. In these cases, we must perform catheterization, holding the child seated on an assistant, who will support it with its chest on his own, securing its arms, while another assistant supports the head carried backwards. Then, armed with a properly proportioned oesophageal sound, the surgeon directs the instrument through the nasal fossas, which is more easy in children who are unwilling to open the mouth, and who likewise bite the sound. We must con- duct the instrument through one nostril, as far as the posterior wall of the pharynx, which we must closely follow, to avoid passing into the larynx. Then, if there is neither anxiety nor raucous cough, we may continue to push the sound and recognize the presence of the foreign body, which is met with at one point or another. Treatment—When such a child presents himself, and this fre- quently occurs,he complains of having swallowed a foreign body. If he experiences pain in the throat or the pharynx, examination with a tongue-depressor may often detect a fishbone, a pin, or a small por- tion of bone implanted at a point within sight, and then the foreign body may be extracted with a pair of forceps. In these easy cases we should not think of employing oesophageal catheterization, but when we can see nothing, and we presume that the foreign body is further on, we must not forget, before making an examination, that foreign bodies conduct themselves differently according to their nature. They may be expelled by efforts of coughing or vomiting; they may be swallowed and pass into the stomach, some- times a short time after their introduction, by the efforts of deg- lutition, or a little later, after a suppuration is formed around the foreign body imbedded in the mucous membrane. In these cases nature has taken the trouble and surgery has nothing to do. Arrived in the stomach, the foreign body may be expelled through the intestinal canal. Thus, in children, we have seen pebbles, buttons, pieces of money, fruit stones, and even pointed substances, such as a needle, after passing through the entire intestine, discharged more or less promptly by the anus. Never- theless, we must not always count on so favourable a termination. TREATMENT. 349 It has been found that the foreign body may open a passage and make an outlet for itself by ulceration; or it will tend to escape through the cervical region of the oesophagus, producing, as we have said, an abscess; or it may descend through the digestive passages and become engaged in another canal, as the biliary canals,or the appendix casci; or it may ulcerate the trachea, and pass into the great vessels, etc., and cause subsequent mortal symptoms. In good practical surgery, being familiar with the formidable acci- dents that may happen, and without forgetting the successful results often observed, or being too rash, we must act according to the indications. 1. There are cases in which we can operate through the mouth and make extraction by means of forceps of different shapes and of various dimensions, as polypus forceps or cranesbill forceps. As a general rule, we have found these means very useful, either to extract bones engaged in the pharynx or in the upper part of the oesophagus, or to seize a penny that a small girl had swallowed, and which was arrested in the passage of the pharynx and the oesophagus. Generally, after having explored at first with the eyes, then with the finger or with the oesophageal sound, the indica- tion is to perform certain extractions with the oesophageal forceps. When the foreign body is appreciable to the touch in the cervical region, we should hold the portion of the neck in which the sub- stance is felt with the fingers of the left hand, which support it and prevent it thus from being pushed forwards with the forceps, which is directed with the right hand. This precaution is in- dispensable for the ready seizing of the body we wish to extract. 2. Sometimes we must, before removing the.foreign body, un- hook it; otherwise, we may thrust it further in. When, for example, a hook has been swallowed, which has occurred many times, the extraction should be made in the following manner: a steel ball is pierced at its centre, through which the thread is passed which holds the hook, and the ball is made to slide over the thread; then, using a reed, the knots of which are perforated, this last is con- ducted by means of the thread as far as the ball. We draw gently on the reed, and thus we may detach the hook, and in drawing on the thread cause the ball, the hook, and the reed to come up. Another method that has been suggested is as follows: we endeavour to have a hook like that which has been swallowed, and we procure a leaden ball of a diameter double that of the hook 350 FOREIGN BODIES IN THE OESOPHAGUS. swallowed. This is pierced with a hole in which we engage the thread holding the hook; the weight of the ball which slides on the thread as far as the hook may unfasten it, and the whole may be withdrawn together. Both of these plans, which resemble each other, have been resorted to successfully. Hooks have also been used; the double ring-hook of Graefe being the most effective. It represents a kind of small metallic bivalve hoop, in the centre of which is fixed a piece of whalebone, in such a manner that the two valves may be movable, and may be carried by the slightest pressure either to one side or the other. This instrument, of a volume which enables it to pass through the pharynx and into the oesophagus, is intro- duced deeply, going beyond the foreign body; then, in withdraw- ing it, the movable valves, on one side or the other, catch the foreign body, which may thus be extracted. It has done good service to Dupuytren, Blondin, Berard, and others, chiefly for the removal of pieces of money. We may also use a sponge fastened on a whalebone, which may be introduced without being moistened, between the walls of the oesophagus and the foreign body. The sponge is left several minutes beneath the foreign body we wish to extract; it thus increases in volume, and when withdrawn the foreign body is brought away with it. 3. When we cannot succeed by these various means of extraction) or the indication is not to employ them, we must resort to methods of pushing the foreign body into the stomach. In fact we may often, without great inconvenience, do this with a badly masticated morsel of meat, a fruit stone of greater or less size, etc. To push down these foreign bodies, we may successfully employ a large quantity of fluid, or of maccaroni, of marmalades, or of pea soup, which may carry along the foreign body downwards. We had occasion, in a patient who had swallowed a needle while eating vermicelli, after having failed with emetics, which may sometimes be employed, to advise that he should drink every night gum-water, and take enemas; he had several alvine evacuations, in one of which, the next day, they found the needle. To carry the foreign body onward, we may make the patient eat prunes and panada, or else use leeks, as suggested by Pare. Finally, it is often of advantage to push forward the foreign body with a sponge fastened on a whalebone, etc. TREATMENT. 851 4. If all these methods fail, and the foreign body is not dislodged, we must act in two ways: cutting into the oesophagus, either in the cervical portion, using as a guide the foreign body, which may be felt at some point or other; or else, if we cannot be guided by this foreign body, and it is lower down, we must, in recalling thoroughly the anatomical relation of the cervical region on the left side, perform oesophagotomy as described in the works on surgery. We may sometimes, if the foreign body is at a point corresponding to the larynx and the patient is suffocating, be obliged before every- thing else to perform tracheotomy, if we cannot at once extract it. We thus prevent death by asphyxia, and may then make up our mind afterwards as regards the removal of the foreign body. INDEX. ACNE, 332 Adenitis, cervical, 23 Air-passages, foreign bodies in, 200 Anassthesia, 279 Anus, imperforation of, 188 Arthritis, chronic, 100 Atresia of rectum, 188 B REASTS, inflammation of, 239 Burns, 119 pALCULUS, vesical, 83 \J Callisen, operation of, 192 Cancer of eye, 214 of testicle, 227 Caries, 242 of the vertebrse, 177 Cataract, 153 Catheterization of children, 85 Cephalhematoma, 232 Ceratitis, 284 Chilblain, 259 Cicatrices, abnormal, 323 Circumcision, 29 Club-foot, 217 Conjunctivitis, 250 Cornea, inflammation of, 284 traumatic lesions of, 256 Corns, 334 Coxalgia, 133 Croup, tracheotomy in, 47 Cynanche parotidaea, 292 Cysts, 79 follicular, 333 j\ISLOCATIONS. See Luxations. }?AR, foreign bodies in, 151 li Ectropion, 309 Encephalocele, 230 Entropion, 312 Epiphyseal separations, 331 Epispadia 'Mo 25 Erysipelas, 265 Eye, cancer of, 214 I^EMUR, traumatic luxation of, 194 Fingers, crushed, 335 malformations of, 173 Fistula, lachrymal, 276 after lithotomy, 96 Forearm, sprains of, 272 Foreign bodies in the air-passages, 200 in the ear, 151 in the oesophagus, 346 Fractures, 31 GRENOUILLETTE, 237 Gums, lancing of, 338 HARELIP, 124 He ernia, abdominal, 157 cerebri, 230 Hydrocele, 98 congenital, 101 encysted, 102 Hypospadias, 235 TNCONTINENCE of urine, 210 1 Intestines, imperforation of, 188 Irrigation of pharynx, 145 T ANCING of gums, 338 Ij Leucorrhoea, 165 Lithotomy, 83, 91 fistula after, 96 Lithotrity, 83, 87 Littre", operation of, 192 Luxations, congenital, 342 of the femur, traumatic, 194 MALFORMATIONS of fingers, 173 of toes. 173 Mammitis, 239 354 INDEX. VTiEVI, 334 i\ materni, 71 Nail, extraction of, 322 Nasal septum, abscess of, 340 Necrosis, 244 fC'SOPHAGUS, foreign bodies in, 346 Ull Onychia, 320 Ophthalmia, purulent, of new-born, 205 Osteitis, 240 Ozaena, 274 PEMPHIGUS, 303 Pharynx, irrigation of, 145 Phimosis, 27 Phlegmon, 281 Polypus, naso-pharyngeal, 316 of rectum, 68 Pott's disease, 177 Prolapsus ani, 103 of urethra, 301 RANULA, 237 Rectum, imperforation of, 1! polypus of, 68 OPINA bifida, 294 U Spots, vascular, 71 Sprains, 270 of the forearm, 272 Strabismus, 287 Surgical operations, 17 TACHES, 71 Talipes, 217 Testicle, cancer of, 227 Thoracentesis, 305 Toes, malformations of, 173 Tongue-tie, 297 Tonsils, excision of, 64 hypertrophy of, 61 Torticollis, 168 Tracheotomy in croup, 47 Trichiasis, 315 Tumours, cutaneous, 332 encysted, 79 erectile, 71 vascular, 71 TTMBILICUS, diseases of, 328 U Urethra, prolapsus of, 301 Urine, incontinence of, 210 V ERTEBR^], caries of, 177 Vulvitis, 147 w ARTS, 334 White swelling, 106 SMITH ON CHILDREN—Enlarged Edition—Now Ready. A TREATISE OX~THE DISEASES OF INFANCY AND CHILDHOOD. By J. LEWIS SMITH, M.D., Curator to the Nursery and Child's Hospital, New York; Physician to the Infants' Hospital, Ward's Island, &c. SECOND EDITION, THOROUGHLY REVISED AND GREATLY ENLARGED. In one large and handsome octavo volume of 741 pages ; extra cloth, $5 ; leather, $6. From Preface to the Second Edition. In presenting to the profession the second edition of his work, the author gratefully acknowl- edges the favorable reception accorded to the first. He has endeavored to merit a continuance of this approbation by rendering the volume much more complete than before. Nearly twenty additional diseases have been treated of, among which may be named Diseases Incidental to Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, and the various forms of Paralysis. Many new formulas, which experience has shown to be useful, have been introduced, portions of the text of a less practical nature have been condensed, and other portions, especially those relating to pathological histology, have been rewritten to correspond with recent discoveries. Every effort has been made, however, to avoid an undue enlargement of the volume; but, notwithstanding this, and an increase in the size of the page, the number of pages has been enlarged by more than one hundred. 227 West 49th Street, New York, April, 1872. The work will be found to contain nearly one-third more matter than the previous edition, and it is confidently presented as in every respect worthy to be received as the standard American text-book on the subject. It is gratifying in looking over the second edition of this excellent work to find that the author has consci- entiously gone well over the ground of his former la- bors, and modified and improved wherever there was an opportunity, in accordance with the most recent and most reliable authority for so doing. The diseases incidental to childhood form a considerable part of the physician's practice. There is no work that we can recommend with more thorough satisfaction than the volume before us.— Am. Journal of Syphilography, Oct. 1872. One is often asked, What is the best work on the diseases of children ? and the reply may be safely made, that the volume here noticed is, perhaps, the best single guide that can be obtained in this country. —Richmond and Louisville Med. and Surg. Journ., July, 1872. The high favor with which the first edition was re- ceived renders unnecessary any formal introduction of this treatise to our readers. The present edition has been enlarged by something over a hundred pages, nearly twenty additional diseases being treated of, and many new formulae included. As it is now presented, the book is one we can sincerely recommend as both creditable to the author, and more than usually pro- fitable to the studious practitioner.—Chicago Med. Journal, May, 1S72. We know of no book on this subject that we can more cordially recommend to the medical student and the practitioner.—Cincinnati Clinic, June 29, 1872. The same careful inquiry seems to pervade the whole work, which makes it not only interesting, but also exceedingly valuable as a textbook on this important subject.—Canada Lancet, July, 1872. The work is for this reason an eminently practical one, and satisfactory to the physician for reference. or as a textbook for the student of medicine.— Wes- tern Lancet, Aug. 1872. One of the very best now in the hands of the pro- fession, both for the student and busy practitioner.— Michigan University Med. Journal, Oct. 1872 The short time which has elapsed since our notice of the first edition of this book, and the favorable character of that notice, make it unnecessary for us to do more than express our pleasure at seeing a se- cond edition with additions which make the work much more nearly complete than it was at first. One of the great excellences of the work is the rich clin- ical and pathological illustration of disease. The style of the author is clear and practical, and alto- gether the book is one which practitioners will find very valuable. We must again refer with satisfaction to the treatment of the subject of diarrhoea and other intestinal diseases in children.—Lond. Lancet, Sept. 7, 1872. We confess to increased enthusiasm in recommend- ing this second edition.—St. Louis Med. and Surg. Journ., Aug. 1872. The additions and corrections which have been made in the second edition leave nothing to be de- sired to make a text-book which as authority in this class of disease is second to none.—Buffalo Med. and Surg. Journal, July, 1872. The work before us bears evidence of being written by an indefatigable and competent student, and of incorporating within its pages a vast number of care- fully recorded facts. An enthusiastic pathologist, Dr. Smith presents the latest views on all pathologi- cal questions discussed. Skilled in the knowledge of remedies as applied to children, he gives in detail his mode of using them. The present volume contains a discussion of nearly twenty more diseases than the last. Taken all in all, we regard it as superior to any other single work on the diseases of infancy and child- hood—IHtroit Review of Med. and Pharmacy, Aug. 1S72. Will rank with the best works on the interesting subject on which it treats.—The Boston Med. and Surg. Journal, Nov. 1872. BAENES ON DISEASES OF WOMEN-Preparing. A CLINICAL EXPOSITION OF THE MEDICAL AND SURGICAL DISEASES OF WOMEN. With numerous illustrations. By Robert Barnes, M.D , Obstetric Physician to St. Tho- mas's Hospital; Examiner on Obstetrics to the University of London, Ac. In one handsome octavo volume. THOMAS ON DISEASES OF WOMEN—Just Issued. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN By T. GAILLARD THOMAS, M.D., Professor of Obstetrics and Diseases of Women and Children in the College of Physicians and Surgeons, New York; Obstetric Physician to the Strangers' and the Roosevelt Hos- pitals ; Consulting Physician to the N. Y. State Women's Hospital, &c. With about Two Hundred and Fifty Illustrations. THIRD EDITION, ENLARGED AND THOROUGHLY REVISED. In one large and handsome octavo volume of 784 pages. Leather, $6; cloth, $5. If we have ventured to criticize certain passages in Dr. Thomas's book, it is only to make more emphatic the assertion that, regarded as a whole, there is no book on the diseases of women in which the student will find the subject presented in so practical and use- ful a form.—Philadelphia Med. Times, Aug. 1S72. It is to such practitioners we conceive the work of Dr. Thomas is especially directed ; certainly it is their needs that it in a remarkable manner meets. In the universality of its scope, in its clear, system- atic method, and in its practical teachings, it has long seemed to us to offer to the doctor, who has no time to wade through the immense literature of the spe- cialty, the most useful and reliable guide in the lan- guage. The present edition is a decided improvement on the book as it first appeared, being more full and exhaustive, and taking more cognizance of the works of European co-laborers.—New Remedies, July, 1872. Space does not allow us to make extracts or to enter into any critical comparison of the views of the au- thor, nor is it necessary in a work which has been as often reviewed, and the text of which is so familiar to the profession. The past evidence of its high ap- preciation by students and practitioners is sufficient proof of its superior merits, and, thus enlarged and enriched by recent improvements in gynaecological practice, it cannot fail to maintain its great and in- creasing popularity.—Michigan University Medical Journal, Oct. 7, 1872. We look on it as being one of the most practical, and therefore one of the most valuable of the works on obstetric medicine and surgery with which we are acquainted. While all parts of the work under con- sideration are well worthy of careful perusal, the portions devoted to treatment are specially so. We commend the volume to all who desire to study the important class of diseases of which it treats, and we look on it as a most valuable addition to the works already in existence on obstetric medicine and sur- gery.—Dublin Medical Press and Circular, July 10, 1S72. We rise from a perusal of this much improved edi- tion with a disposition to iudulge in remarks that we fear would be considered extravagantly laudatory.— Leavenworth Med. Herald, Oct. 1872. No physician who desires to he fully up to the times should be without it.—Nashville Med: and Surgical Journ., June, 1872. The work is improved in every respect, and is still more worthy of the confidence of the profesMon as a guide in the treatment of diseases peculiar to women. —Canada Lancet, Jnne, 1872. It is as a- whole by far the best American work on the subject, as it most certainly is superior to any foreign treatise which has been reproduced in this country. It is most cordially commended to our readers—Chicago Med. Journal, Feb. 1872. To the practitioner, too busy to read all the medi- cal journals, and so keep pace with the rapid advance of gynaecology, this new edition will be invaluable, and even should he have both previous editions he will want this. To the American student there is no one work of equal value, in enabling him to grasp the principles that underlie the successful diagnosis and treatment of uterine affections.—Detroit Rev. of Med. and Pharmacy, April, 1S72. For clearness of style and therapeutics it has no parallel.— Va. Clinical Record, April, 1872. It better represents the present condition of gynae- cology than any work in the English language of which we know.—Am. Practitioner, April, 1872. The most thoroughly practical work of its kind known.—Kansas City Med. Journ., April, 1S72. The work of Dr. Thomas has become indispensable to American practitioners.—Pacific Med. and Surg. Journ., May, 1872. As a text-book for students and as a guide for prac- titioners we believe it is unequalled.—Amer. Journ. of Medical Sciences, April, 1S72. It has firmly established itself as the American text- book of gynaecology.—Am.. Journ. of Syphilography, April, 1S72. It is undoubtedly the best work in the English lan- guage on the specialty of which it treats. For apposite and lucid language and perspicuity in the manner of presenting the different subjects to the consideration of the reader it has few equals, while it is admirable for its thoroughness and accuracy of detail, fairness in discussing mooted points, and candor in the state- ment of the views of other authorities from whom the writer differs jn opinion. The book is the outcome of the man, and his cautious, patient, philosophical mode of treating disease, and thorough honesty in his professional relations, well reflected in its pages, fur- nish the secret of his deservedly high reputation as a successful gynaecologist and the esteem in which he is personally held by a wide circle of brother phy- sicians.— Western Lancet, June, 1872. Thomas on Diseases of Women, as offered to the profession in this, its third edition, is the latest and best work in the English language (or we believe any other language) upon this subject. We have taken great interest in carefully perusing its pages, and find that he has given his opinions without apparent bias by what has been previously said either by himsel. or anybody else. If he wishes to condemn, he does so in a positive and manly way, and when he expresses opinions he carries conviction that he is correct. The comprehensive character of the work commends it to the profession, since nothing within its scope will be found wanting; it may truly be said to be complete in discussing every topic legitimately inf nearly 900 pages, with 465 large and elaborate engravings on wood. Price in extra cloth, $6 00; leather, raised bands, $7 00. (Just Issued.) , The author has endeavored in this work to cover a more extended range of subjects than is ous- tomary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Notwithstanding the enlargement of this edition, it has been kept at its former very moderate price, rendering it one of the cheapest works now before the profession. The illustrations are beautifully executed, and ren- der this work an indispensable adjunct to the library of the surgeon. This remark applies with great force to those surgeons practising at a distance from our large cities, as the opportunity of refreshing their memory by actual dissection is not always attain- able.— Canada Med. Journal, Aug. 1870. The work is too well known and appreciated by the profession to need any comment. No medical man can afford to be without it, if its only merit were to serve as a reminder of that which so soon becomes forgotten, when not called into frequent use, viz., the relations and names of the complex organism of the human body. The present edition is much improved. —California Med. Gazette, July, 1870. Gray's Anatomy has been so long the standard of perfection with every student of anatomy, that we need do no more than call attention to the improve- ment in the present edition.—Detroit Review of Med. and Pharm., Aug. 1870. From time to time, as successive editions have ap- peared, we have had much pleasure in expressing the general judgment of the wonderful excellence of Gray's Anatomy.—Cincinnati Lancet, July, 1870. Altogether, it is unquestionably the most complete and serviceable text-book in anatomy that has ever been presented to the student, and forms a striking contrast to the dry and perplexing volumes on the same subject through which their predecessors strug- gled in days gone by.—N. Y. Med. Record, June 15, 1870. To commend Gray's Anatomy to the medical pro- fession is almost as much a work of supererogation as it would be to give a favorable notice of the Bible in the religious press. To say that it is the most complete and conveniently arranged text book of its kind, is to repeat what each generation of students has learned as a tradition of the elders, and verified by personal experience.—N. Y. M10.Gazette, Deo. 17,1870. VMITH {HENR Y H.), M.D., and TJORNER { WILLIAM E.),M.D., Prof, of Surgery in the Univ. of Penna., &c. Late Prof, of Anatomy in the Univ. of Penna. ,&e. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $4 50. The plan of this Atlas, which renders it so pecu-1 the kind that has yet appeared; and we must add, liarly convenient for the student, and its superb ar-1 the very beautiful manner in which it is "got up " tistical execution, have been already pointed out. We is so creditable to the country as to be flattering to must congratulate the student upon the completion our national pride.—-American Medical Journal. of this Atlas, as it is the most convenient work of I gHARPEY (WILLIAM), M.D., and Q UAIN {JONES §• RICHARD). HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidt, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00. The very low price of this standard work, and its completeness in all departments of the subject should command for it a place in the library of all anatomical students. ' TTODGES, {RICHARD M.), M.D., ■LJ- Late Demonstrator of Anatomy in the Medical Department of Harvard University PRACTICAL DISSECTIONS. Second Edition, thoroughly revised In one neat royal 12mo. volume, half-bound, $2 00. The object of this work is to present to the anatomical student a clear and concise description of that which he is expected to observe in an ordinary coui&e of dissections. The author has endeavored to omit unnecessary details, and to present the subject in the form which many years' experience has shown him to be the most convenient and intelligible to the student In the revision of the present edition, he has sedulously labored to render the volume more worthy of the favor with which it has heretofore been received. ' Henry C. Lea's Publications—(Anatomy). 1 ffi'ILSON (ERASM US), F. R. S. A SYSTEM OF HUMAN ANATOMY, General and Special. Edited by W. H. Gobrecht, M. D., Professor of Generaland Surgical Anatomy in the Medical Col- lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, of over 600 large pages; extra cloth, $4 00; lea- ther, $5 00. 6^6. The publisher trusts that the well-earned reputation of this long-established favorite will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to in- troducing everything which increased experience in its use has suggested as desirable to render it a complete text-bopk for those seeking to obtain or to renew an acquaintance with Human Ana- tomy. The amount of additions which it has thus received may be estimated from the fact that tho present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appropriate manner, and to render the whole as clear and intelligible as possible. The editoi has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest oi importance. IJEATH {CHRISTOPHER), F. R. C. S., ■*-*- Teacher of Operative Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From the Second revised and improved London edition. Edited, with additions, by W. W. Keen, • M.D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. In one handsome royal 12mo. volume of 578 pages, with 2-17 illustrations. Extra cloth, $3 50; leather, $4 00. {Just Issued.) Dr. Keen, the American editor of this work, in his preface, says: "In presenting this American edition of 'Heath's Practical Anatomy,' I feel that I have been instrumental in supplying a want long felt for a real dissector's manual," and this assertion of its eflitor we deem is fully justified, after an examina- tion of its contents, for it is really au excellent work. Indeed, we do not hesitate to say, the best of its class with which we are acquainted ; resembling Wilson In terse and clear description, excelling most of the so-called practical anatomical dissectors in the scope of the subject and practical selected matter. . . . la reading this work, one is forcibly impressed with tlie great pains the author takes to impress the sub- ject upon the mind of the student. He is full of rare and pleasing little devices to aid memory in main- taining its hold upon the slippery slopes of anatomy. —St. Louis Med. and Surg. Journal, Mar. 10, 1871. It appears to us certain that, as a guide in dissec- tion, and as a work containing facts of anatomy in brief and easily understood form, this manual is complete This work contains, also, very perfect Illustrations of parts which can thus be more easily understood and studied ; in this respect it compares fav-orably with works of much greater pretension. Such manuals of anatomy are always favorite works with medical students. We would earnestly recom- mend this one to their attention; it has excellences which make it valuable as a guide in dissecting, as well as in studying anatomy.—Buffalo Medical and Surgical Journal, Jan. 1871. The first English edition was issued about six years ago, and was favorably received not only on account of the great reputation of its author, bat also from its great value and excellence as a guide-book to the practical anatomist. The American edition has un- dergone some alterations and additions which will no doubt enhance its value materially. The conve- nience of the student has been carefully consulted in the arrangement of the text, and the directions given for the prosecution of certain dissections will be duly appreciated.—Canada Lancet, Feb. 1871. This is an excellent Dissector's Manual; one which is not merely a descriptive manual of anatomy, but a guide to the student at the dissecting table, enabling him, though a beginner, to prosecute his work intel- ligently, and without assistance. The American edi- tor has made many valuable alterations and addi- tions to the original work.—Am. Journ. of Obstetrics, Feb. 1871. MACLISE {JOSEPH). SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best style and beautifully colored, containing 190 figures, many of them the size of life; together with copious explanatory letter-press. Strongly and handsomely bound in extin 'cloth. Price $14 00. As no complete work of the kind has heretofore been published in the English language, the present volume will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascer- tain the exact relative positions of the various portions of the human frame towards each other and to the surface, as well as their abnormal deviations. Notwithstanding the large size, beauty and finish of the very numerous illustrations, it will be observed that the price is so low as to place it within the reach of all members of the profession. We know of no work on surgical anatomy which refreshed by those clear and distinct dissections, can compete with it.—Lancet. The work of Maclise on surgical anatomy is of the highest value. In some respects it is the best publi- cation of its kind we have seen, and is worthy of a place in the libiary of any medical man, while the student could scarcely make a better investment than tllj8__yfo. Western Journal of Medicine and Surgery. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given. While the operator is shown every vessel and nerve where an operation is contemplated, the exact anatomist is which every one must appreciate who has a panicle of enthusiasm. The English medical press has quite exhausted the words of praise, in recommending this admirable treatise. Those who have any curiosity to gratify, in reference to the perfectibility of the lithographic art in delineating the complex mechan- ism of the human body, are invited to examine our specimen copy. If anything will induce surgeons and students to patronize a book of such rare value and everyday importance to them, it will be a survey of the artistical skill exhibited in these fac-similee ol nature.—Boston Med. and Surg. Journal. HORNER'S SPECIAL ANATOMY AND HISTOLOGY. I In 2 vols. 8vo., of over 1000 pages, with more than Eighth edition, extensively revised and modified. | 300wood-cuts; extra cloth, *S 00. 8 Henry C. Lea's Publications—(Physiology). M~ARSHALL {JOHN), F. R. S., U.U. Professor of Surgery in University College, London, Ac. OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. With Additions by Francis Gurnet Smith, M. D., Professor of the Institutes of Medi- cine in the University of Pennsylvania, Ac. With numerous illustrations. In one large and handsome octavo volume, of 1026 pages, extra cloth, $6 50; leather, raised bands. $7 50. em physiological science, both human and compara- tive, with which we are acquainted. To speak of this work in the terms ordinarily used on such occa- In fact, in every respect, Mr. Marshall has present- ed us with a most complete, reliable, and scientific work, and we feel that it is worthy our warmest commendation.—St. Louis Med. Reporter, Jan. 1869. This is an elaborate and carefully prepared digest of human and comparative physiology, designed for the use of general readers, but more especially ser- viceable to the student of medicine. Its style is con- cise, clear, and scholarly; its order perspicuous and exaet, and its range of topics extended. The author and his American editor have been careful to bring to the illustration of the subject the important disco- veries of modern science in the various cognate de- partments of investigation. This is especially visible in the variety of interesting information derived from the departments of chemistry and physics. The great amount and variety of matter contained in the work is strikingly illustrated by turning over the copious index, covering twenty-four closely printed pages in double columns.—Sillimun's Journal, Jan. 1869. We doubt if there is in the English language any compend of physiology more useful to the student than this work.—St. Louis Med. and Surg. Journal, Jan. 1869. It quite fulfils, in our opinion, the author's design of making it truly educational in its character—which is, perhaps, the highest commendation that can be asked.—Am. Journ. Med. Sciences, Jan. 1869. sions would not be agreeable to ourselves, and would fail to do j ustice to its author. To write such a book requires a varied and wide range of knowledge, con- siderable power of analysis, correct judgment, skill in arrangement, and conscientious spirit. It must have entailed great labor, but now that the task has been fulfilled, the book will prove not only invaluable to the student of medicine*and surgery, but service- able to all candidates in natural science examinations, to teachers in schools, and to the lover of nature gene- rally. In conclusion, we can only express the con- viction that the merits of the work will command for it that success which the ability and vast labor dis- played in its production so well deserve.—London Lancet, Feb. 22, 1868. If the possession of knowledge, and peculiar apti- tude and skill in expounding it, qualify a man to write an educational work, Mr. Marshall's treatise might be reviewed favorably without even opening the covers. There are few, if any, more accomplished anatomists and physiologists than the distinguished professor of surgery at University College ; and he has long enjoyed the highest reputation as a teacher of physiology, possessing remarkable powers of clear exposition and graphic illustration. We.have rarely the pleasure of being able to recommend a text-book We may now congratulate him on having com- so unreservedly as this.—British Med. Journal, Jan, pleted the latest as well as the best summary of mod-1 2d, 1868. /CARPENTER {WILLIAM B.), M.D., F.R.S., v^ Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new American from the last and revised London edition. With nearly three hundred illustrations. Edited, with additions, by Francis Gurnet Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, &c. In one very large and beautiful octavo volume, of about 900 large pages, handsomely printed; extra cloth, $5 50; leather, raised bands, $6 50. With Dr. Smith, we confidently believe "that the present will more than sustain the enviable reputa- tion already attained by former editions, of being one of the fullest and most complete treatises on the subject in the English language." We know of none from the pages of which a satisfactory knowledge of the physiology of the human organism can be as well obtained, none better adapted for the use of such as take up the study of physiology in its reference tof the institutes and practice of medicine.—Am. Jour. Med. Sciences. We doubt not it is destined to retain a strong hold on public favor, and remain the favorite text-book in our colleges.— Virginia Medical Journal. The above is the title of what is emphatically the great work on physiology; and we are conscious that it would be a useless effort to attempt to add any- thing to the reputation of this invaluable work, and can only say to all with whom our opinion has any influence, that it is our authority.—Atlanta Med. Journal. JDY THE SAME AUTHOR. PRINCIPLES OF COMPARATIYE PHYSIOLOGY. New Ameri- can, from the Fourth and Revised London Edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations. Pp.752. Extra cloth $5 00. As a complete and condensed treatise on its extended and important subject, this work becomes a necessity to students of natural science, while the very low price at which it is offered places it within the reach of all. t J^IRKES {WILLIAM SENHOUSE), M.D. A MANUAL OF PHYSIOLOGY. A new American from the third and improved London edition. With two hundred illustrations. In one large and hand- some royal 12mo. volume. Pp. 586. Extra cloth, $2 25; leather, $2 75. It is at once convenient in size, comprehensive in design, and concise in statement, and altogether well adapted for the purpose designed.—St. Louis Med. and Surg. Journal. The physiological reader will And it a most excel- lent guide in the study of physiology in its most ad- vanced and perfect form. The author has shown himself capable of giving details sufficiently ample in a condensed and concentrated shape, on a science in which it is necessary at once to be correct and not lengthened.—Edinburgh Med. and Surg. Journal Henry C. Lea's Publications—(Physiology). 9 J)ALTON {J. C.), M.D., Professor of Physiology in the College of Physicians and Surgeons, New York. &c. A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use of Students and Practitioners of Medicine. Fifth edition, revised, with nearly three hun- dred illustrations on wood. In one very beautiful octavo volume, of over 700 pages, extra cloth, $5 25 ; leather, $6 25. (Just Issued.) Preface to the Fifth Edition. In preparing the present edition of this work, the general plan and arrangement of the previous editions have been retained, so far as they have been found useful and adapted to the purposes of a text-book for students of medicine. The incessant advance of all the natural and physical sciences, never more active than within the last five years, has furnished many valuable aids to the special investigations of the physiologist; and the progress of physiological research, during the same period, has required a careful revision of the entire work, and the modification or re- arrangement of many of its parts. At this day, nothing is regarded as of any value in natural science which is not based upon direct and intelligible observation or experiment; and, accord- ingly, the discussion of doubtful or theoretical questions has been avoided, as a general rule, in the present volume, while new facts, from whatever source, if fully established, have been added and incorporated with the results of previous investigation. A number of new illustrations have been introduced, and a few of the older ones, which seemed to be no longer useful, have been omitted. In all the changes and additions thus made, it has been the aim of the writer to make the book, in its present form, a faithful exponent of the actual conditions of physiological science. New York, October, 1871. In this, the standard text-book on Physiology, all that is needed to maintain the favor with which it is regarded by the profession, is the author's assurance that it has been thoroughly revised and brought up to a level with the advanced science of the day. To accomplish this has required some enlargement of the work, but no advance has been made in the price. The fifth edition of this truly valuable work on Human Physiology comes to us with many valuable improvements and additions. As a text-book of physiology the work of Prof. Dalton has long been well known as one of the best which could be placed in the hands of student or practitioner. Prof. Dalton has, in the several editions of his work heretofore published, labored to keep step with the advancement in science, and the last edition shows by its improve- ments on former ones that he is determined to main- tain the high standard of his work. We predict for the present edition increased favor, though this work has long been the favorite standard.—Buffalo Med. and Surg. Journal, April, 1S72. An extended notice of a work so generally and fa- vorably known as this is unnecessary. It is justly regarded as one of the most valuable text-books on the subject in the English language.—St. Louis Med. Archives, May, 1872. We know no treatise in physiology so clear, com- plete, well assimilated, and perfectly digested, as Dalton's. He never writes cloudily or dubiously, or in mere quotation. He assimilates all his material, and from it constructs a homogeneous transparent argument, which is always honest and wellinformp«l, and hides neither truth, ignorance, nor doubt, so far as either belongs to the subject in hand —Brit. Med. Journal, March 23, 1872. Dr. Dalton's treatise is well known, and by many highly esteemed in this country. It is, indeed, a good elementary treatise on the subject it professes to teach, and may safely be put into the hands of Eng- lish students. It has one great merit—it is clear, and, on the whole, admirably illustrated. The part we have always esteemed most highly is that relating to Embryology. The diagrams given of the various stages of development give a clearer view of the sub- ject than do those in general use in this country; and the text may be said to be, upon the whole, equally clear.—London Med. Times and Gazette, March 23, 872. Dalton's Physiology is already, and deservedly, the favorite text-book of the majority of American medical students. Treating a most interesting de- partment of science in his own peculiarly lively and fascinating style, Dr. Dalton carries his reader along without effort, and at the same time impresses upon his mind the truths taught much more successfully than if they were buried beneath a multitude of words.—Kansas City Med. Journal, April, 1872. Professor Dalton is regarded justly as the authority in this country on physiological subjects, and the fifth edition of his valuable work fully justifies the exalted opinion the medical world has of his labors. This last edition is greatly enlarged.—Virginia Clin- ical Record, April, 1872. D UNGLISON {ROBLEY). M. D. Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY". Eighth edition. Thoroughly revised and extensively modified and enlarged, with five.hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes of about 1500 pages, extra cloth. $7 00. TEHMANN {C. G.). PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- tion by George E. Dat, M. D., F. R. S., Ac, edited by R. E. Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two hundred illustrations, extra cloth. $6 00. nf THE SAME AUTHOR. MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German with Notes and Additions, by J. Cheston Morris, M.D., with an Introductory Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- vania. With illustrations on wood. In one very handsome octavo volume of 336 pages. extra cloth. $2 25. 10 Henry C. Lea's Publications—(Chemistry). ATTFIELD {JOHN), Ph.D., Professor of Practical Chemistry to the Pharmacei'tim 1 Society of Great Britain, but little has remained to be done by the American editor. Such additions as seemed advisable have however been made, and especial eare has been taken to secure, by the closest scrutiny, the accfuracy so essential in a work of this nature. Thus fully brought up to a level with the latest advances of science, and presented at a price within the reach of all, it is hoped that the work will maintain its position as the favorite text- book of the medical student. i This work is so well known that it seems almost superfluous for us to speak about it. It has been a favorite text-book with medical students for years, and its popularity has in no respect diminished. Whenever we have been consulted by medical stu- dents, as has frequently occurred, what treatise on ehemistry they should procure, we have always re- commended Fownes', for we regarded it as the best. There is no work that combines so many excellen- ces. It is of convenient size, not prolix, of plain perspicuous diction, contains all the most recent discoveries, and is of moderate price.—Cincinnati Med. Repertory, Aug. 1869. Large additions have been made, especially in the department of organic chemistry, and we know of no other work that has greater claims on the physician, pharmaceutist, or student, than this. We cheerfully recommend it as the best text-book on elementary chemistry, and bespeak for it the careful attention of students of pharmacy.—Chicago Pharmacist, Aug. 1869. The. American reprint of the tenth revised and cor- rected English edition is now issued, and represents the present condition of the science. No comments are necessary to insure it a favorable reception at the hands of practitioners and students. — Boston Med. and Surg. Journal, Aug. 12,1869. It will continue, as heretofore, to hold the first rank as a text-book for students of medicine.—Chicago Med. Examiner, Aug. 1869. This work, long the recognized Manual of Chemistry, appears as a tenth edition, under the able editorship of Bence Jones and Henry Watts. The chapter on the General Principles of Chemical Philosophy, and the greater part of the organic chemistry, have been rewritten, and the whole work revised in accordance with the recent advances in chemical knowledge. It remains the standard text-book of chemistry.—Dub- lin Quarterly Journal, Feb. 1869. There is probably not a student of chemistry in thi s country to whom the admirable manual of the late Professor Fownes is unknown. It has achieved a success which we believe is entirely without a paral- lel among scientific text-books in our language. This success has arisen from the fact, that there is no En- glish work on chemistry which combines so many excellences. Of convenient size, of attractive form, clear and concise in diction, well illustrated, and of moderate price, it would seem that every requisite for a student's hand-book has been attained. The ninth edition was published under the joint editor- ship of Dr. Bence Jones and Dr. Hofmanu; the new one has been superintended through the press by Dr. Bence Jones and Mr. Henry Watts. It is not too much to say that it could not possibly have been in better hands. There is no one in England who can compare with Mr. Watts in experience as a compiler in chemical literature, and we have much pleasure in recording the fact that his reputation is well sus- tained by this, his last undertaking.—The Chemical News, Feb. 1869. Here is a new edition which has been long watched for by eager teachers of chemistry. In its new garb, and under the editorship of Mr. Watts, it has resumed its old place as the most successful of text-books.— Indian Medical Gazette, Jan. 1,1S69. T>0 WMAN {JOHN E.), M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fifth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. $2 25. (Just Issued.) The fourth edition of this invaluable text-book of Medical Chemistry was published in England in Octo- ber of the last year. The Editor has brought down the Handbook to that date, introducing, as far as was compatible with the necessary conciseness of such a work, all the valuable discoveries in the science which have come to light since the previous edition was printed. The work is indispensable to every, student of medicine or enlightened practitioner. It is printed in clear type, and the illustrations are numerous and intelligible.—Boston Med. and Surg. Journal. DY THE SAME AUTHOR. ---- INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Fifth American, from the fifth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., extra cloth. $2 25. (Just Issued.) It is by far the best adapted for the Chemical student of any that has yet fallen in our way.—British and Foreign Medico-Chirurgical Review. One of the most complete manuals that has for a long time been given to the medical student.— Athenaeum. We regard it as realizing almost everything to be desired in an introduction to Practical Chemistry. The best introductory work on the subject with which we are acquainted.—Edinburgh Monthly Jour. jyRANDE { WM. T.), D. C.L., and J>AYLOR {ALFRED S.), M.D., F.R.S. X> CHEMISTRY. Second American edition, thoroughly revised by Dr. Taylob. In one handsome Svo. volume of 764 pages, extra cloth, $5 00; leather, $6 00. 12 Henry C. Lea's Publications—(Mat. Med. and Therapeutics). pARRlSH {ED WARD), Professor of Materia Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 pages, with several hundred illustrations, extra cloth. $5 00; leather, $6 00. The immense amount of practical information condensed in this volume may be estimated from the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- ences; under Emplastrum, 36; Extracts, 159; Lozenges, 25; Mixtures, 55; Pills, 56; Syrups, 131; Tinctures, 138; Unguentum, 57, Ac. We have examined this large volume with a good deal of care, and find that the author has completely exhausted the subject upon which he treats ; a more .complete work, we think, it would be impossible to find. To the student of pharmacy the work is indis- pensable; indeed, so far as we know, it is the only one of its kind in existence, and even to the physician or medical student who can spare five dollars to pur- chase it, we feel sure .the practical information he will obtain will more than compensate him for the outlay.—Canada Med. Journal, Nov. 1864. The medical student and the practising physician will find the volume of inestimable worth for study and reference.—San Francisco Med. Press, July, 1864. When we say that this book is in some respects the best which has been published on the subject in the English language for a great many years, we do I not wish it to be understood ae very extra vajjnnt praise. In truth, it is not so much the best as the only book.—The London'Chemical News. An attempt to furnish anything like an analysis of Parrish's very valuable and elaborate Treatise on Practical Pliarmacy would require more space than sve have at our disposal. This, however, is not so ui^ch a matter of regret, inasmuch as it would be Jitficult, to think of any point, however minute and apparently trivial, connected with the manipulation >f pharmaceutic substances or appliances which has not been clearly and carefully discussed in this vol- ume. Want of space prevents our enlarging further on this valuable work, and we must conclude by a simple expression of our hearty appreciation of iti merits.—Dublin Quarterly Jour, of Medical Science, August, 1864. CfTILLE {ALFRED), M.D., *J Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Third edition, revised and enlarged. In two large and handsome octavo volumes of about 1700 pages, extra cloth, $10; leather, $12. Dr. Stille's splendid work on therapeutics and ma- teria medica.—London Med. Times, April 8, 1866. Dr. Stille stands to-day one of the best and most honored representatives at home and abroad, of Ame- rican medicine; and these volumes, a library in them- selves, a treasure-house for every studious physician assure his fame even had he done nothing more.—The Western Journal of Medicine, Dec. 1868. We regard this work as the best one on Materia Medica in the English language, and as such it de- serves the favor it has received.—Am. Journ. Medi- cal Sciences, July 1868. We need not dwell on the merits of the third edition of this magnificently conceived work. It is the work on Materia Medica, in which Therapeutics are prima- rily considered—the mere natural history of drugs being briefly disposed of. To medical practitioners this is a very valuable conception. It is wonderful how much of the riches of the literature of Materia Medica has been condensed into this book. The refer- ences alone would make it worth possessing. But it is not a mere compilation. The writer exercises a good judgment of his own on the great doctrines and poiiits of Therapeutics. For purposes of practice Stille's book is almost unique as a repertory of in- formation, empirical and scientific, on the actions and uses of medicines.—London Lancet, Oct. 31, 1868. Through the former editions, the professional world Js well acquainted with this work. At home and abroad its reputation as a standard treatise on Materia Medica is securely established. It is second to no work on the subject in the English tongue, and, in- deed, is decidedly superior, in some respects, to any other.—Pacific Mud. and Surg Journal, July, 1808. Stille's Therapeutic* is incomparably the best work on the subject.— N. Y. Med. Gazette, Sept. 26, 1868. Dr. Still6's work is becoming the best known of any of our treatises on Materia Medica. . . . One of the most valuable works in the language on the subjects of which it treats.— N. Y. Med. Journal, Oct. 1868. The rapid exhaustion of two editions of Prof. Stille's scholarly work, and the consequent necessity for a third edition, is sufficient evidence of the high esti- mate placed upon it by the profession. It is no exag- geration to say that there is no superior work upon the subject in the English language. The present edition is fully up to the most recent advance in the science and art of therapeutics.—Leavenworth Medi- cal Herald, Aug. 1868. The work of Prof. Stille" has rapidly taken a high place in professional esteem, and to say that a third edition is demanded and now appears before us, suffi- ciently attests the firm position this treatise has made for itself. As a work of great research, and scholar- ship, it is safe to say we have nothing superior. It is exceedingly full, and the busy practitioner will find ample suggestions upon almost every important point of therapeutics.—Cincinnati Lancet, Aug. 1868. G RIFFITH {ROBERT E.), M.D. A UNIYERSAL FORMULARY, Containing the Methods of Pre- paring and Administering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceutists. Second edition, thoroughly revised, with numerous additions by Robert P. Thomas, M.D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume of 650 pages, double-columns. Extra cloth, $4 00; leather, $5 00. Three complete and extended Indexes render the work especially adapted for immediate consul- tation. One, of Diseases and their Remedies, presents under the head of each disease the remedial agents which have been usefully exhibited in it, with reference to the formula containins them—while another of Pharmaceutical and Botanical Names, and a very thorough General Index afford the means of obtaining at once any information desired. The Formulary itself is arranged alphabetically, under the heads of the leading constituents of the prescriptions? We know of none in our language, or any other, so comprehensive in its details.—London Lancet One of the most complete works of the kind in any language.—Edinburgh Med. Journal We are not cognizant of the existence of a parallel work.—London My. Gatette. JLenry C. Lea's Publications—{Mat. Med. and Therapeutics). 13 pEREIRA {JONA THAN), M. D., F. R.S. and L.S. MATERIA MEDICA AND THERAPEUTICS; being an Abridg- ment of the_jate Dr. Pereira's Elements of Materia Medica, arranged in conformity with tne British Pharmacopoeia, and adapted to the use of Me lical Practitioners, Chemists and ^ruggists, Wlioal and Pharmaceutical Students, Ac. By F. J. Fabre, M.D., Senior hysician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia; assisted by Robert Bentley, M.R.C.S., Professor of Materia Medica and Botany to the i-narmaceutical Society of Great Britain; and by Robert Warington, F.R.S., Chemical uperator to the Society of Apothecaries. With numerous additions and references to the united States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the University of Pennsylvania. In one large and handsome octavo volume of 1040 closely printed pages, with 236 illustrations, extra cloth, $7 00; leather, raised bands, $8 00. The task of the American editor has evidently been no sinecure, for not only has he given to us all that is contained in the abridgment useful for our pur- poses, but by a careful and judicious embodiment of over a hundred new remedies has increased the size of the former work fully one-third, besides adding many new illustrations, some of which are original. We unhesitatingly say that by so doing he has pro- portionately increased the value, not only of the con- densed edition, but has extended the applicability of the great original, and has placed his medical coun- trymen under lasting obligations to him. The Ame- rican physician now has all that is needed in the ghape of a complete treatise on materia medica, and the medical student has a text-book which, for prac- tical utility and intrinsic worth, stands unparalleled. Although of considerable size, it is none too large for the purposes for which it has been intended, and every medical man should, in justice to himself, spare a place for it upon his book-shelf, resting assured that the more he consults it the better he will be satisfied of its excellence.—N Y. Med,. Record, Nov. 15, 1866. It will fill a place which no other work can occupy lu the library of the physician, student, and apothe- eary.—Boston Med. and Surg. Journal, Nov. 8, 1866. Of the many works on Materia Medica which have appeared since the issuing of the British Pharmaco- poaia, none will be more acceptable to the student and practitioner than the present. Pereira's Materia Medica had long ago asserted for itself the position of beiug the most complete work on the subject in the English language. But its very completeness stood in the way of its success. Except in the way of refer- ence, or to those who made a special study of Materia Medica, Dr. Pereira's work was too full, and its pe- rusal required an amount of time Which few had at their disposal. Dr. Farrehas.very judiciously availed himself of the opportunity of the publication of the new Pharmacopoeia, by bringing out an abridged edi- tion of the great work. This edition of Pereira is by no means a mere abridged re-issue, but contains ma- ny improvements, both in the descriptive and thera- peutical departments. We can recommend it as a very excellent and reliable text-book.—Edinburgh Med. Journal, February, 1866. The reader cannot fail to be impressed, at a glance, with the exceeding value of this work as a compend of nearly all useful knowledge on the materia medica. We are greatly indebted to Professor Wood for his adaptation of it to our meridian. Without his emen- dations and additions it would lose much of its value to the American student. With them it is an Ameri- can book. — Pacific Medical and Surgical Journal, December, 1866. JjJLLIS {BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions derived from the writings and practice of mnny of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- tion, carefully revised and much improved by Albert H. Smith, M.D. In one volume 8vo. of 376 pages, extra cloth, $3 00. (Lately Published.) This work has remained for some time out of print, owing to the anxious care with which the Editor has sought to render the present edition worthy a continuance of the very remarkable favor which has carried the volume to the unusual honor of a Twelfth Edition. He has sedu- lously endeavored to introduce in it all new preparations and combinations deserving of confidence, besides adding two new classes, Antemetics and Disinfectants, with brief references to the inhalation of atomized fluids, the nasal douche of Thudichum, suggestions upon the method of hypodermic injection, the administration of anaesthetics, Ac. Ac. To accommodate these numerous additions, he has omitted much which the advance of science has rendered obsolete or of minor importance, notwithstanding which the volume has been increased by more than thirty pages. A new feature will be found in a copious Index of Diseases and their remedies, which cannot but increase the value of the work as a suggestive book of reference for the working practitioner. Every precaution has been taken to secure the typographical accuracy so necessary in a work of this nature, and it is hoped that the new edition will fully maintain the position which " Ellis' Formulary" has long occupied. /1ARSON {JOSEPH), M.D., v/ Professor of Materia Medica and Pharmacy in the Vniversity of Pennsylvania, Ac. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. With three Lectures on the Modus Operandi of Medicines. Fourth and revised edition, extra cloth, $3 00. CUNGLKON'S NEW REMEDIES, WITH FORMULAE F<>K THEIR PREPARATION AND ADMINISTRA- TION seventh edition, with extensive additions. One vol. Svo., pp. 770; extra cloth. $1 00. ROYLE'S MATERIA MEDICA AND THERAPEU- TICS. Edited by Joseph Carson, M. D. With ninety-eight illustrations. 1 vol. 8vo., pp. 700, ex- tra cloth. *M 00. CHRISTISON'S DISPENSATORY. With copious ad- ditions, and 213 large wood-engravings. By R Eglesfeld Griffith, M.D. One vol. 8vo., pp. 1000; extra cloth. $4 00. CARPENTER'S PRIZE ESSAY. ON THE USE OF Alcoholic Liquors in Health and Disease. New edition, with a Preface by D. F. Condie. MD., and explanations of scientific words. In one neat 12mo. volume, pp. 178, extra cloth. 60 cents. De JONGH ON THE THREE KINDS OF COD-LIVEB Oil, with their Chemical and Therapeutic Pro- perties 1 vol. 12mo., cloth. 75 cents. 14 Henry C. Lea's Publications—(Pathology, v any means trifles ; but the contents of the book are astonishing. Not only is it wonderful tbut any one man cau hi ve grasped in his mind the whole scope of medicine with that vigor which Dr. Flint shows, but the condensed yet clear way in which this is done is a perfect literary triumph Dr. Flint is pre-eminently one of the strong men, whose right to do this kind of thing is well admitted ; and we say no more than the truth when we affirm that he is very nearly the only living man that could do it with such results as the volume before us.—The London Practitioner, March, 1869. This is in some respects the best text-book of medi- cine in our language, and it is highly appreciated on the other side of the Atlantic, inasmuch as the first edition was exhausted in a few months. The second edition was little more than a reprint, but the present has, as the author says, been thoroughly revised. Much valuable matter has been added, and by mak- ing the type smaller, the bulk of the volume is not much increased. The weak point in many American works is pathology, hut Dr. Flint has taken peculiar pains on this point, greatly to the value of the book. —London Med. Times and Gazette, Feb. 6, 1S69. Published in 1866, this valuable book of Dr. Flint's has in two years exhausted two editions, and now we gladly announce a third. We say we gladly an- nounce it, because we are proud of it as a natioual representative work of not only American, but of cosmopolitan medicine. In it the practiceof medicine is young and philosophical, based on reason and com- mon sense, and as such, we hope it will be at the right hand of every practitioner of this vast continent. —California Medical Gazette, March, 1869. Considering the large number of valuable works in the practice of medicine, already before the profes- sion, the marked favor with which this has been re- ceived, necessitating a third edition in the short space of two years, indicates unmistakably that it is a work of more than ordinary excellence, and must be accept- ed as evidence that it has largely fulfilled the object for which the author intended it. A marked feature in the work, and one which particularly adapts it for the use of students as a text-book, and certainly ren- ders it none the less valuable to the busy practitioner as a work of reference, is brevity and simplicity. .The present edition has been thoroughly revised, aud much new matter incorporated, derived, as the author informs us, both from his own clinical studies, and from the latest contributions to medical literature, thus bringing it fully up with the most recent ad- vances of the science, and greatly enhancing its prac- tical utility; while, by a slight modification of its typographical arrangement, the additions have been accommodated without materially increasing its bulk.—St. Louis Med. Archives, Feb. 1869. If there be among our readers any who are not fa- miliar with the treatise before us, we shall do them a service in persuading them to repair their omission forthwith. Combining to a rare degree the highest scientific attainments with the most practical com- mon sense, and the closest habits of observation, the author has given us a volume which not only sets forth the results of the latest investigations of other laborers, but contains more original views than any other single work upon this well-worn theme within our knowledge.— N. Y. Med. Gazette, Feb. 27, 1869. BARLOW'S MANUAL OF THE PRACTICE OF I TODD'S CLINICAL LECTURES ON CERTAIN ACUTE MEDICINE. With Additions by D. F. Condie, Diseases. In one neat octavo volume, of 320 pages, M. D. 1 vol. 8vo., pp. 600, cloth. $2 50. I extra cloth. $2 60. PA VY (F. W.), M. D., F. R. S., Senior Asst. Physician to and Lecturer on Physiology, at Guy's Hospital, &c. A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- ders and their Treatment. From the second London edition. In one handsome volume, small octavo, extra cloth, $2 00. (Lately Published.) The work before us is one which deserves a wide treatise, and sufficiently exhaustive for all practical circulation. We know of no better guide to the study of digestion and its disorders.—St. Louis Med. and Surg. Journal, July 10, 1869. A thoroughly good book, being a careful systematic purposes.—Leavenworth Med. Herald, July, 1889, A very valuable work on the subject of which it treats. Small, yet it is full of valuable information. —Cincinnati Med. Repertory, June, 1869. TyRINTON {WILLIAM). M.D., F.R.S. "^LECTURES ON THE DISEASES OF THE STOMACH; with an Introduction on its Anatomy and Physiology. From the second and enlarged London edi- tion. With illustrations on wood. In one handsome octavo volume of about 300 pages, extra cloth. $3 25. 16 Henry C. Lea's Publications—\tractxce oj mean-me). fJARTSHORXE {HENRY). M.D., ■*- *- Professor of Hygiene in the University of Pennsylvania. ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book for Students and Practitioners. Third edition, revised and im- proved. In one handsome royal 12mo. volume of 487 pages, clearly printed on small type, cloth, $2 38; half bound, $263. (Now Ready.) The very remarkable favor which has been bestowed upon this work, ns manifested in the ex- haustion of two large editions within four years, shows that it has successfully supplied a want felt by both student and practitioner of a volume which at a moderate price and in a convenient size should afford a clear and compact view of the most modern teachings in medical practice. In preparing the work for a third edition, the author has sought to maintain its character by very numerous additions, bringing it fully up to the science of the day, but so concisely framed that the size of the volume is increased only by thirty or forty pages. The extent of the new informa- tion thus introduced may be estimated by the fact that there have been two hundred and sixty separate additions made to the text, containing references to one hundred and eighty new authors. This little epitome of medical knowledge has al-I mulasare appended, intended as examples merely, ready been noticed by us. It is a vade mecum of not as guides, for unthinking practitioners. A corn- value, including in a short space most of what is es- plfte index facilitates the use of this little volume, in poutial in the science and practice of medicine. The which all important remedies lately introduced, such third edition is well up to the present day in the [ as chloral hydrate and carbolic acid, have received modern methods of treatment, and in the usp- ot'newly discovered drugs.—Boston Med. and Surg. Journal, Oct. 19, 1871. Certainly very few volumes contain so much pre- cise information within so small a compass.—N. Y. Med. Journal, Nov. 1871. The diseases are conveniently classified; symptoms, causation, diagnosis, prognosis, and treatment are carefully considered, the whole being marked by briefness, but clearness of expression. Over 2o0 for- their full share of attention.—Am. Journ. of Pharm., Nov. 1871. It is an epitome of the whole science and practice of medicine, and will be found most valuable to the practitioner for easy reference, and especially to the student in attendance upon lectures, whose time is too much occupied with many studies, to consult the larger works. Such a work must always be in great demand.—Cincinnati Med. Repertory, Nov. 1871. TUA TSON {THOMAS), M. D., frc. f LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Edited, with additions, and several hundred illus- trations, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- sylvania. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. (Justready.) Witli the assistance of Professor George Johnson, his successor in the chair of Practice of Medi- cine in King's College, the author has thoroughly revised this work, and has sought to bring it on a level with the most advanced condition of the >ubject. As he himself remarks : "Consider- ing the rapid advance of medical science during the last fourteen years, the present edition would be worthless, if it did not differ much from the last"—but in the extensive alterations and addi- tions that have been introduced, the effort of the author has been to retain the lucid and collo- quial style of the lecture-room, which has made the work so deservedly popular with all classes of the profession. Notwithstanding these changes, there are some subjects on which the American reader might reasonably expect more detailed information than has been thought requisite in England, and these deficiencies the editor has endeavored to supply. The large size to which the work has grown seems to render it necessary to print it in two vol- umes, in place of one, as in the last American edition. It is therefore presented in that shape, handsomely printed, at a very reasonable price, and it is hoped that it will fully maintain the position everywhere hitherto accorded to it, of the standard and classical representative of Eng- lish practical medicine. At length, after many months of expectation, we have the satisfaction of finding ourselves this week in possession of a revised and enlarged edition of Sir Thomas Watson's celebrated Lectures It is a sub- ject for congratulation and for thankfulness that Sir Thomas Watson, during a period of comparative lei- sure, after a long, laborious, and most honorable pro- fessional career, while retaining full possession of his high mental faculties, should have employed the op- portunity to submit his Lectures to a more thorough revision than was possible during the earlier and busier period of his life. Carefully passing in review some of the most intricate and important pathological and practical questions, the results of his clear insight and his calm judgment are now recorded for the bene- fit of mankind, in language which, for precision, vigor, and classical elegance, has rarely been equalled, and never surpassed The revision has evidently been most carefully done, and the results appear in almost every page.—Brit. Med. Journ., Oct. 14, 1871. flHAMBERS {T. K.), M. D., yj Consulting Physician to St. Mary's Hospital, London, &c. THE INDIGESTIONS; or, Diseases of the Digestive Organs Functionally Treated. Third and revised Edition. In one handsome octavo volume of 333 pages, extra cloth. $3 00. (Lately Published.) So very large a proportion of the patients applying to every general practitioner suffer from some form of indigestion, that whatever aids him in their man- agement directly "puts money in his purse," and in- directly does more than anything else to advance his reputation with the public. From this purely mate- rial point of view, setting aside its higher claims to merit, we know of no more desirable acquivition to a physician's library than the book before us. He who should commit its contents to his memory would find its price an investment of capital that returned him a most usurious rate of interest.—if. Y. Vvlieal Gazette, Jan. 28, 1871. T>Y THE SAME AUTHOR. (Just Issued.) RESTORATIYE MEDICINE. An Harveian Annual Oration, deliv- ered at the Royal College of Physicians, London, on June 24, 1871. With Two Sequels In one very handsome volume, small 12mo., extra cloth, $1 00. Henry C. Lea's Publications—(Diseases of Lungs and Heart). It pLINT {A USTIN), M. D., -*- Professor of the Principles and Practice of Medicine in Bell ewe Hoopital Mf.d. College, N. Y. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF "DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, extra cloth, $4. (Just Issued.) The author has sedulously improved the opportunity afforded him of revising this work. Portions of it have been rewritten, and the whole brought up to a level with the most advanced condition of science. It must therefore continue to maintain its position as the standard treatise on the subject Dr. Flint chose a difficult subject for his researches, and has shown remarkable powers of observation and reflection, as well as great industry, in his treat- ment of it. His book must be considered the fullest and clearest practical treatise on those subjects, and should be in the hands of all practitioners and stu- dents. It is a credit to American medical literature. —Amer. Journ. of the Med. Sciences, July, I860. We question the fact of any recent American author In our profession being more extensively known, or more deservedly esteemed in this country than Dr. Flint. We willingly acknowledge his success, more particularly in the volume on diseases of the heart, In making an extended personal clinical study avail- B he able for purposes of illustration, in connection with cases which have been reported by other trustworthy observers.— Brit, and For. Med.-Chirv.rg. Review. In regard to the merits of the work, we have no citation in pronouncing it full, accurate, and judi- cious. Considering the present state of science, such a work was much needed. It should be in the hands of every practitioner.—Chicago Med. Journ. With more than pleasure do we hail the advent of this work, for it fills a wide gap on the list of text- books for our schools, and is, tor the practitioner, the most valuable practical work of its kind.—N. 0. Med. News. Y THE SAME AUTHOR. PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, extra cloth, $4 50. which pervades his whole work lend an additional force to its thoroughly practical character, which cannot fail to obtain for it a place as a standard work on diseases of the respiratory system.—London Lancet, Jan. 19, 1S67. This is an admirable book. Excellent in detail and execution, nothing better could be desired by the practitioner. Dr. Flint enriches his subject with much solid and not a little original observation.— Ranking's Abstract, Jan. 1867. Dr. Flint's treatise is one of the most trustworthy guides which he can consult. The style is clear and distinct, and is also concise, being free from that tend- ency to over-refinement and unnecessary minuteness which characterizes iuauv works on the same sub- ject.— Ihiblin Medical Press, Feb. 6, 1867. The chapter on Phthisis is replete with interest; and his remarks on the diagnosis, especially in the early stages, are remarkable for their acumen and great practical value. Dr. Flint's style is clear and elegant, and the tone of freshness and originality FULLER {HENRY WILLIAM), M. D., ■L Physician to St. George's Hospital, London. ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised English edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. Dr. Fuller'6 work on diseases of the chest was so favorably received, that to many who did not know the extent of his engagements, it was a matter of won- der that it should be allowed to remain three years out of print. Determined, however, to improve it, Dr Fuller would not consent to a mere reprint, and accordingly we have what might be with perfect jus- tice styled an entirely new work from his pen, the portion of the work treating of the heart and great vessels being excluded. Nevertheless, this volume is of almost equal size with the first.—London Medical Times and Gazette, July 2C, 1867. TXTILLIAMS {C. J. B.), M.D., ' Senior Consulting Physician to the Hospital for Consumption, Brompton, and w 7LLIAMS {CHARLES T.), M.D., Physician to the Hospital for Consumption. PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- ment. With an Analysis of One Thousand cases to exemplify its duration. In one neat octavo volume of about 350 pages, extra cloth. (Just Issued.) $2 50. He can still speak from a more enormous experi- ence and a closer study of the morbid processes in- volved in tuberculosis, than most living men. He owed it to himself, and to the importance ot the sub- jeer to embody his views in a separate work, and re are glad that he has accomplished this duty. .fter all, the grand teaching which Dr Williams has forlhrprofession"rs'to be found in his therapeutical ch ten even forty years apters, and in the history of individual cases ex- uded by dint of care, over ten, twenty, thirty, and en forty years.—London Lancet, Oct. 21, 1871. His results are more favorable than those of any » previous author; but probably there is no malady, the treatment of which has been so much improved withiu the last twenty years as pulmonary consump- tion. To ourselves, Dr. Williams's chapters on Treat- ment are amongst the most valuable and attractive in the book, and would alone render it a standard work of reference. In conclusion, we would record our opinion that Dr. Williams's great reputation is fully maintained by this book. It is undoubtedly one of the most valuable works in the language upon any special disease.—Lond. Med. Times and Gaz., Nov. LA ROCHE ON PNEUMONIA. 1 vol. Svo., extra cloth, of 500 pages Price $3 00 Bl'OKLER ON F1BRO-BRONCHITIS AND RHEU- MATIC PNEUMONIA. 1 vol. Svo. $125. FiSKE FUND PRIiSE ESSAYS ON CONSUMPTION. 1 vol 8vo,, extra cloth, $1 00. SMITH ON CONSUMPTION; ITS EARLY ANDRE- MEDIABLE STAGES. 1 vol. 8vo., pp. 254. $2 25. SALTER ON ASTHMA. 1 vol. Svo. $2 50. WALSHE ON THE DISEASES OF THE HEART AND GREAT VESSELS Third American edition. In 1 vol. 8vo., 420 pp., cloth. $3 00. , 18 Henry C. Lea's Publications—(Practice of Medicine). ROBERTS ( WILLIAM), M. D.. •*■*' Lecturer on Medicine in the Manchester School of Medicine, Ac. 'A PRACTICAL TREATISE ON URINARY AND RENAL DTS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- ond Edition, Revised. In one very handsome octavo volume. (Preparing.) T>ASHA M { W. R.), M. D., •*-* Senior Physician to the Westminster Hospital, Ac. RENAL DISEASES: a Clinical Guide to their Diagnosis and Treat- ment. With illustrations. In one neat royal 12mo. volume of 304 pages. $2 00. (Just '•> ment render the book pleasingand convenient.—Am. Journ. Med. Sciences, July, 1870. A book that we believe will be found a valuable assistant to the practitioner and guide to the student. —Baltimore Med. Journal, July, 1870. The treatise of Dr. Basham differs from the rest in its special adaptation to clinical study, and its con- densed and almost aphorismal style, which makes it easily read and easily understood BesHes, the author expresses some new vijws, which are well worthy of consideration. The volume is a valuable addition to this department of knowledge.—Pacific The easy descriptions and compact modes of state- I Med. and Surg. Journal, July, 1870. Issue The chapters on diagnosis and treatment are very good, and the student and young practitioner will find them full of valuable practical hints. The third part, on the urine, is excellent, and we cordially recommend its perusal. The author has arranged his matter in a somewhat novel, and, we think, use- ful form. Here everything can be easily found, and, what is more important, easily read, for all the dry details of larger books here acquire a new interest from the author's arrangement. This part of the book is full of good work.—Brit, and For. Medico- Chirurgical Review, July, 1S70. MORLAND ON RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. 1 vol. 8vo., extra cloth. 75 cents. TONES [C. HAND FIELD), M. D., " Physician to St. Mary's Hospital, Ac. CLINICAL OBSERVATIONS DISORDERS. Second American Edition. extra cloth, $3 25. Taken as a whole, the work before us furnishes a short but reliable account of the pathology and treat- ment of a class of very common but certainly highly obscure disorders. The advanced student will find it a rich mine of valuable facts, while the medical prac- titioner will derive from it many a suggestive hint to aid him in the diagnosis of "nervous cases," and in determining the true indications for their ameliora- tion or cure.—Amer. Journ. Med. Sci., Jan. 1867. ON FUNCTIONAL NERVOUS In one handsome octavo volume of 348 pages, We must cordially recommend it to the profession of this country as supplying, in a great measure, a deficiency which exists in the medical literature of the English language.—New York Med. Journ., April, 1867. The volume is a most admirable one—full of hints and practical suggestions. — Canada Med. Journal, April, 1867. pSSAYS ON NERVOUS D7SEASES. {Now Ready.) ON DISEASES OF THE SPINAL COLUMN AND OF THE NERVES. By C B. Radcliff, M. D., John Netten Radclifp, J. Warburton BeUMSTEAD {FREEMAN J), ^ Surgeon to the Hdpital du Midi. J-* Professor of Venereal Diseases in the College of Physicians and Surgeons, N. Y. AN ATLAS OF VENEREAL DISEASES. Translated and Edited by Free tan J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life; strongly bound in extra cloth, $17 00; also, in five parts, stout wrappers for mailing, at S3 per part. (Lately Published.) Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, thus placing it within the reach of all who are interested in this department of prac- tice. Gentlemen desiring early impressions of the plates would do we'l to order it without delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. We wish for once that our province was not restrict- ed to methods of treatment, that we might say some- thing of the exquisite colored plates in this volume. —London Practitioner, May, 1869. As a whole, it teaches all that can be taught by means of plates and print.—London Lancet, March 13, 1869. Superior to anything of the kind ever before issued on this continent.—Canada Med. Journal, March, '69. The practitioner who desires to understand this branch of medicine thoroughly should obtain this, the most complete and best work ever published.— Dominion Med. Journal, May, 1869. This is a work of master hands on both sides. M. Cnllerier is scarcely second to, we think we may truly Bay is a peer of the illustrious and venerable Ricord, while in fcbis country we do not hesitate to say that Dr. Bumstead, as an authority, is without a rival Assuring-our readers that these illustrations tell the whole history of venereal disease, from its inception to its end, we do not know a single medical work, which for its kind is more necessary for them to have. —Calif jrnia Med. Gazette, March, 1S69. The most splendidly illustrated work in the lan- guage, and in our opinion far more useful than the French original.—Am. Journ. Med. Sciences, Jan.'69. The fifth and concluding number of this magnificent work has reached us, and we have no hesitation in saying that its illustrations surpass those of previous numbers.—Boston Med. and Surg. Journal, Jan. 14, 1869. Other writers besides M. Cullerier have given us a good account of the diseases of which he treats, but no one has furnished us with such a complete series of illustrations of the venereal diseases. There is, however, an additional interest and value possessed by the volume before us ; for it is an American reprint and translation of M. Cullerier's work, with inci- dental remarks by one of the most eminent American syphilographers, Mr. Bumstead. The letter-press is chiefly M. Cullerier's, but every here and there a few lines or sentences are introduced by Mr. Bumstead ; and, as M. Cullerier is a unicist, while Mr. Bumstead is a dualist, this method of treating the subject adds very much to its interest. By this means a liveliness is imparted to the volume which many other treatises sorely lack. It is like reading the report of a conver- sation or debate; for Mr. Bumstead often finds occa- sion to question M.Cullerier's statements or inferences, and this he does in a short and forcible way which helps to keep up the attention, and to make the book a very readable one.—Brit, and For. Medico-Chir. Review, July, 1869. TTILL {BERKELEY), ■*■-*■ Surgeon to the Lock Hospital, London. In ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. one handsome octavo volume ; extra cloth, $3 25. (Lately Published.) to whom we would most earnestly recommend its study; while it is no less useful to the practitioner.— St. Louis Med. and Surg. Journal, May, 1869. Bringing, as it does, the entire literature of the dis- ease down to the present day, and giving with great ibility the results of modern research, it is in every respect a most desirable ^vork, and one which should find a place in the library of every surgeon.—Cali- fornia Med. Gazette, June, 1869. Considering the scope of the book and the careful attention to the manifold aspects and details of its subject, it is wonderfully concise All these qualities render it an especially valuable book to the beginner, The most convenient and ready book of reference we have met with.—N. Y. Med. Record, May 1,1869. Most admirably arranged for both student and prac- titioner, no other work on the subject equals it; it is more simple, more easily studied.—Buffalo Med. and Surg. Journal, March, 1869. LALLEMANO AND WILSON ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMA- TORRHEA. cloth, £2 76. In one vol. 8vo., of about 400 pp., 20 Henry C. Lea's Publications—(Disease* of the Srtn). VSTILSON {ERASMUS), F.R.S. ON DISEASES OF THE SKIN. Willi Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $5. (Lately Published.) A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. The industry and care with which the author has revised the present edition are shown by the fact that the volume has been enlarged by more than a hundred pages. In its present improved form it will therefore doubtless retain the position which it has acquired as a standard and classical authority, while at the same time it has additional claims on the attention of the profession as the latest and most complete work on the subject in the English language. We can safely recommend it to the profession as the best work on the subject now in existence in the English language.—Medical Times and Gazette. Such a work as the one before us is a most capital and acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his book on diseases of the skin has long been re- garded as one ot the best text-books extant on the subject. The present edition is carefully prepared, and brought up in its revision to the present time In this edition we have also included the beautiful series of plates illustrative of the text, and in the last edi- tion published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great fidelity the various groups of diseases treated of in the body of the work.—Cin- cinnati Lancet, June, 1863. No one treating skin diseases should be without a copy of this standard work.— Canada Lancet. August, 1868. T>Y THE SAME AUTHOR. ---- THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- eases op the skin. In one very handsome royal 12mo. volume. $3 50. (Lately Issued.) Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases; it includes almost every fact or opinion of importance connected with the anatomy and pathology of the skin.—British and Foreign Medical Review. These plates are very accurate, and are executed with an elegance and taste which are highly credits) Me to the artistic skill of the American artist whoexecuted them.—St. Louis Med. Journal. The drawings are very perfect, and the finish and coloring artistic and correct; the volume is an indis- pensable companion to the book it illustrates and completes.—Charleston Medical Journal. jyELIGAN {J. 310 ORE), M.D.,M.R.I.A. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M. D. In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. Fully equal to all the requirements of students and young practitioners. It is a work that h,as stood its ground, that was worthy the reputation of the au- thor, and the liigh position of which has been main tained by its learned editor.—Dublin Med. Press and Circular, Nov. 17, 1869. Of the reminder of the work we have nothing be- yond unqualified commendation to offer. It is so far the most complete one of its size that has appeared, and for the student there can be none which can com- pare with it in practical value. All the late disco- veries in Dermatology have been duly noticed, and their value justly estimated; in a word, the work is J^Y THE SAME AUTHOR. fully up to the times, and is thoroughly stocked with most valuable information.—New York Med. Record, Jan. 15, 1867. This instructive little volume appears once more. Since the death of its distinguished author, the study of skin diseases has been considerably advanced. af»r. Keli- gan. This, however, has not so far increased i rs bulk as to destroy its reputation as the most convenient manual of diseases of the skin that can be procured by the student.—Chicago Med. Journal, Dec. 1866. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of Extra cloth, $5 50. inclined to consider it a very superior work, com- bining accurate verbal descriptionwith sound views of the pathology and treatment of eruptive diseases. —Glasgow Med. Journal. A compend which will very much aid the practi- tioner in this difficult branch of diagnosis Taken with the beautiful plates of the Atlas, which are re- markable for their accuracy and beauty of coloring, it constitutes a very valuable addition to the library of a practical man.—Buffalo Med. Journal. disease. The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheless, Dr. Nrfligan has certainly, "as far as possible," given a faithful and accurate representation of this class of di-i-f. es, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to examine also the "Practical Treatise," and we are TJILLIER {THOMAS), M.D., ■*--*- Physician to the Skin Department of University College Hospital, Ac. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations Extra cloth, $2 25. We can conscientiously recommend it to the stu- dent; the style is clear and pleasant to read, the matter is good, and the descriptions of disease, with the modes of treatment recommended, are frequently Illustrated with well-recorded cases.—London Med. Times and Gazette, April 1, 1865. It is a concise, plain, practical treatise on the vari- ous diseases of the skin ; just such a work, ind< -1, as was much needed, both by medical students ciai practitioners. — Chicago Medical Examiner, M^ v 18b5 » ■•/. Henry C. Lea's Publications—(Diseases of Children). 31 gMITH{J. LEWIS), M. D., *^ Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. Y. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Second Edition, revised and greatly enlarged. In one handsome octavo volume of 742 pages, extra cloth, $5; leather, $6. (Now Ready.) work is an illustration, and pervading every chapter of it is a spirit of sound judgment and common sense, without which any work on any department of the practice of medicine is, to use the mildest word, de- fective. We are sorry that we csinnot give further illustrations of the excellence of this book.—London Lancet, Sept. 4, 1869. We have no work upon the Diseases of Infancy and Childhood which can compare with it.—Buffalo Med. and Surg. Journal, March, 1869. The description of the pathology, symptoms, and treatment of the different diseases is excellent.—Am. Med. Journal, April, 1869. An original and valuable work. — Glasgow Med. Journal, Feb. 1871. The excellence of this book is one explanation of our not having reviewed it sooner. Taking it up from time to time, we have been freshly interested in its various chapters, and so been led to defer writing our opinion of it. It is one of those works with which we are happily becoming familiar, as coming tons from time to time from across the Atlantic, which contain all that is good in European works of the same kind, together with much that is original, both In reflection and observation. It is astonishing how well the American writers succeed in gleaning, and yet giving a fresh character to their books. This rtONDIE {D. FRANCIS), M. D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, extra cloth, $5 25 ; leather, $6 25. (Lately Issued.) in this department of medicine. His work has been so long a standard for practitioners and medical stu- dents that we do no more now than refer to the fact that it has reached its sixth edition. We are glad once more to refresh the impressions of our earlier days bywandering through its pages, and at thesame time to be able to recommend it to the youngest mem- bers of the profession, as well as to those who have the older editions on their shelves.—St. Louis Med. Reporter, Feb. 15, 1868. The present edition, which is the sixth, is fully up to the tiuiesin the discussion of all those pointsin the pathol.'.:;y and treatment of infantile diseases which have bci-u brought forward by the Germau and French teachers. As a whole, however, the work is the best American one that we have, and in its special adapta- tion to American practitioners it certainly has no equal.—New York Med. Record, March 2, 1868. No other treatise on this subject is better adapted to the America.' physician. Dr. Condie has long stood before his countrymen as one peculiarly pre-eminent WEST {CHARLES), M.D., ' ' Phijsician to the Hospital for Sick Children, Ac. LECTURES ON THE DISEASES OF INFANCY AND CHILD- HOOD. Fourth American from the fifth revised and enlarged English edition. In one large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $4 50; leather, $5 50. Of all the English writers on the diseases of chil-1 living authorities in the difficult department of medi- dren, there is no one so entirely satisfactory to us as | cal science in which he is. most widely known.— Dr. West. For years we have held his opinion as | Boston Med. and Surg. Journal, April 26, 1866. Judicial, and have regarded him as one of the highest | DF THE SAME AUTHOR. (Just Ready.) ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- HOOD; being the Lumlefan Lectures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small 12mo., extra cloth, $1 00. 03IITH{EUSTACE), M. D., ^ Physician to the Northwest London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTING DISEASES OF INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged English edition. In one handsome octavo volume, extra cloth, $2 50. (Now Ready.) scribed as a practical handbook of the common dis- eases of children, so numerous are the affections con- sidered either collaterally or directly. We are acquainted with no safer guide to the treatment of children's diseases, and few works give the insight into the physiological and other peculiarities of chil- dren that Dr. Smith's book does.—Brit. Med. Journ., April 8, 1871. This is in every way an admirable book. The modest title which the author has chosen for it scarce- ly conveys an adequate idea of the many subjects upon which it treats. Wasting is so constant an at- tendant upon the maladies of childhood, that a trea- tise upon the wasting diseases of children must neces garily embrace the consideration of many affections of which it is a symptom ; and this is excellently well done by Dr. Smith. The book might fairly be de- flUERSANT {P.), M. D., **" Honorary Surgeon to the Hospital for Sick Children, Paris. SURGICAL DISEASES OF INFANTS AND CHILDREN. Trans- lated by R. J. Dunglison, M. D. (Publishing in the Medical News and Library.) Ab this work embodies the experience of twenty years' service in the great Children's Hospital f P«ri« it can hardlv fail to maintain the reputation of the valuable practical series of volumes which have been laid before the subscribers of the " American Journal of the Medical Sci- bnceb." For terms, see p. 3. DEWEES ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN 8to. of 548 pages. $2 80. Eleventh edition. 1 vol. 22 Henry C. Lea's Publications—(Diseases of Women). rPHOMAS {T.GAILLARD),M.D., ■*■ Professor of Obstetrics, Ac. in the College of Physicians and Surgeons, N. Y., Ac. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Third edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 764 pages, with 246 illustrations. Cloth, $5 00; leather, $6 00. (Now Ready.) The author has taken advantage of the opportunity afforded by the call for another edition of this work to render it worthy a continuance of the very remarkable favor with which it has been received. Every portion has been subjected to a conscientious revision, several new chapters have been added, and no labor spared to make it a complete treatise on the most advanced con- dition of its important subject. The present edition therefore contains about one-third more matter than the previous one, notwithstanding which the price has been maintained at the former very moderate rate, rendering this one of the cheapest volumes accessible to the profession. As compared with the first edition, five new chap- instruction as Dr. Thomas.—Cincinnati Lancet and ters on dysmenorrhcea, peri-uterine fluid tumors, composite tumors of the ovary, solid tumors of the ovary, and chlorosis, have been added. Twenty- seven additional wood-cuts have been introduced, many subjects have been subdivided, and all have received important interstitial increase. In fact, the book has been practically rewritten, and greatly in- creased in value. Briefly, we may say that we know of no book which so completely and concisely repre- sents the present state of gynecology ; none so full of well-digested and reliable teaching; none which bespeaks an author more apt in research and abun- dant in resources.—N. Y. Med. Record, May 1, 1872. We should not be doing our duty to the profession did we not tell those who are unacquainted with the book, how much it is valued by gynaecologists, and how it is in many respects one of the best text-books on the subject we possess in our language. We have no hesitation in recommending Dr. Thomas's work as one of the most complete of its kind ever published. It should he in the possession of every practitioner for reference and for study.—London Lancet, April 27, 1872. The extended notice of this highly meritorious work by this journal, on the issue of the first edition in 186S, as well as the second edition which soon fol- lowed, renders it quite superfluous for us to do more at present than to call the attention of our readers to the fact of the issue of the third edition in the short period of three years, although the former editions were large. This fact indicates more certainly the favorable estimate by the profession at large than any other testimony possible to adduce. Our author is not one of those whose views "never change." On the contrary, they have been modified in many par- ticulars to accord with the progress made in this department of medical science: heuce it has the fresh- ness of an entirely new work. No general practi- tioner can afford to be without it.—St. Louis Med. and Surg Journal, May, 1872. We are free to say that we regard Dr. Thomas the best American authority on diseases of women. Seve- ral others have written, and written well, hut none have so clearly and carefully arranged their text and Observer, May, 1S72. If the excellence of a work is to be judged by its rapid sale, this one must take precedence of all others upon the same, or kindred subjects, as evidenced in the short time from its first appearance, in which a new edition is called for, resulting, as we are i nformed, from the exhaustion of the previous large edition. We deem it scarcely necessery to recommend this work to physicians as it is now widely known, and most of them already possess it, or will certainly do so. To students we unhesitatingly recommend it as the best text-book on diseases of females extant.—St.Louis Med. Reporter, June, 1869. Of all the army of books that have appeared of late years, on the diseases of the uterus and its appendages, we know of none that is so clear, comprehensive, aud practical as this of Dr. Thomas', or one that we should more emphatically recommend to the young practi- tioner, as his guide.—California Med. Gazette, June, 1869. If not the best work extant on the subject of which it treats, it is certainly second to none other. So short a time has elapsed since the medical press teemed with commendatory notices of the first edition, that it would be superfluous to give an extended re- view of what is now firmly established as the American text-book of Gynaecology.—N. Y. Med. Gazette, July 17, 1869. This is a new and revised edition of a work which we recently noticed at some length, and earnestly commended to the favorable attention of our readers. The fact that, in the short space of one year, this second edition makes its appearance, shows that the general judgment of the profession has largely con- firmed the opinion we gave at that time.—Cincinnati Lancet, Aug. 1869. It is so short a time since we gave a full review of the first edition of this book, that we deem it only necessary now to call attention to the second appear- ance of the work. Its success has been remarkable, and we can onie congratulate the author on the brilliant reception his book has received.—N. Y. Med. Journal, April, 1869. QHURCHILL {FLEETWOOD), M. D., M. R. I. A. ESSAYS ON THE PUERPERAL FEYER, AND OTHER DIS- EASES PECULIAR TO WOMEN. Selected from the writings of British Authors previ- ous to the close of the Eighteenth Century. In one neat octavo volume of about 450 pages, extra cloth. $2 50. A SHWELL {SAMUEL), M. D., Late Obstetric Physician and Lecturer at Guy's Hospital. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third Ame- rican, from the Third and revised London "edition. In one octavo volume, extra cloth, of 528 pages. $3 50. DEWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's last improvements and correc- tions. In one octavo volume of 536 pages, with plates, extra cloth, $3 00. J>ARXES {ROBERT), M. D., F.R. C.P., J-* Obstetric Physician to St. Thomas' Hospital, Ac. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. In one handsome octavo volume with illustrations. (Preparing.) Henry C. Lea's Publications—(Diseases of Women). 23 ffODGE {HUGH L.), M.D., Emeritus Professor of Obstetrics, Ac, in the. University of Pennsylvania. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. Second edition, revised and enlarged. In one beautifully printed octavo volume of 531 pages, extra cloth. $4 50. (Lately Issued.) In the preparation of this edition the author has spared no pains to improve it with the results of his observation and study during the interval which has elapsed since the first appearance of the work. Considerable additions have thus been made to it, which have been partially accom- modated by an enlargement in the size of the page, to avoid increasing unduly the bulk of the From Prof. W. H. Byford, of the Rush Medical College, Chicago. The book bears the impress of a master hand, and must, as its predecessor, prove acceptable to the pro- fession. In diseases of women Dr. Hodge has estab- lished a school of treatment that has become world- wide in fame. Professor Hodge's work is truly an original one from beginniag to end, consequently no one can pe- ruse its pages without learning something new. The book, which is by no means a large one, is divided into two grand sections, so to speak: first, that treating of the nervous sympathies of the uterus, and, secondly, that which speaks of the mechanical treatment of dis- placements of that organ. He is disposed, as a non- believer in the frequency of inflammations of the uterus, to take strong ground against many of the highest authorities in this branch of medicine, and the arguments which he offers in support of his posi- tion are, to say the least, well put. Numerous wood- cuts adorn this portion of the work, and add incalcu- lably to the proper appreciation of the variously shaped instruments referred to by our author. As a contribution to the study of women's diseases, it is of great value, and is abundantly able to stand on its own merits—N. Y. Medical Record, Sept. 15, 1868. In this point of view, the treatise of Professor Hodge will be indispensable to every student in its department. The large, fair type and general perfec- tion of workmanship will render it doubly welcome. —Pacific Med. and Surg. Journal, Oct. 1868. WEST {CHARLES), M.D. LECTURES ON THE DISEASES OF WOMEN. Third American, from the Third London edition. In one neat octavo volume of about 550 pages, extra cloth, $3 75 ; leather, $4 75. The reputation which this volume has acquired as a standard book of reference in its depart- ment, renders it only necessary to say that the present edition has received a careful revision at the hands of the author, resulting in a considerable increase of size. A few notices of previous editions are subjoined. The manner of the author is excellent, his descrip- tions graphic and perspicuous, and his treatment up to the level of the time—clear, precise, definite, and marked by strong common sense. — Chicago Med. Journal, Dec. 1861. We cannot too highly recommend this, the second edition of Dr. West's excellent lectures on the dis- eases of females. We know of no other book on this subject from which we have derived as much pleasure and instruction. Every page gives evidence of the honest, earnest, and diligent searcher after truth. He is not the mere compiler of other men's ideas, but his lectures are the result often years' patient investiga- tion in one of the widest fields for women's diseases— St. Bartholomew's Hospital. As a teacher, Dr. West Is simple and earnest in his language, clear and com- prehensive in his perceptions, and logical in his de- ductions.—Cincinnati Lancet, Jan. 1862. We return the author our grateful thanks for the vast amount of instruction he has afforded us. His valuable treatise needs no eulogy on our part. His graphic diction and truthful pictures of disease all speak for themselves.—Medico-Chirurg. Review. Most justly esteemed a standard work.....It bears evidence of having been carefully revised, and Is well worthy of the fame it has already obtained. —Dub. Med. Quar. Jour. As a writer, Dr. West stands, in our opinion, se- cond only to Watson, the "Macaulay of Medicine;" he possesses that happy faculty of clothing instruc- tion in easy garments; combining pleasure with profit, he leads his pupils, in spite of the ancient pro- verb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a candid, safe, and valuable guide.—N. A. Med.-Chirurg Review. We must now conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical physician is apparent on every page.—N. Y. Journal of Medicine. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language, and that it stamps Dr. West as the facile princeps of British obstetric authors.—Edinburgh Med. Journal. We gladly recommend his lectures as in the highest degree instructive to all who are interested in ob- stetric practice.—London. Lancet. We know of no treatise of the kind so complete, and yet so compact.—Chicago Med. Journal. >Y THE SAME AUTHOR. ---- AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCERATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. TLfEIGS {CHARLES D.), M. D., JXL Late Professor of Obstetrics, Ac. in Jefferson Medical College, Philadelphia. WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lectures to his Class. Fourth and Improved edition. In one large and beautifully printed octavo volume of over 700 pages, extra cloth, $5 00; leather, $6 00. * TOY THE SAME AUTHOR. ---- ON THE NATURE, SIGNS, AND TREATMENT OF CHILDRED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume of 365 pages, extra cloth. $2 00. 24 Henry C. Lea's Publications—(Midwifery). HODGE {HUGH L.), M.D., Emeritus Professor of Midwifery, Ac. in the University of Pennsylvania, Ac. THE PRINCIPLES AND PRACTICE OF OBSTKTRICS. Illus- trated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. The work of Dr. Hodge is something more than a simple presentation of his particular views in the de- partment of Obstetrics; it is something more than an ordinary treatise on midwifery; it is, in fact, a cyclo- paedia of midwifery. He has aimed to embody in a single volume the whole science and art of Obstetrics. An elaborate text is combined with accurate and va- ried pictorial illustrations, so that no fact or priuc iple Is left unstated or unexplained.—Am. Med. Times, Sept. 3, 1864. We should like to analyze the remainder of this excellent work, but already has this review extended beyond our limited space. We cannot conclude this notice without referring to the excellent finish of the work. In typography it is not to be excelled ; the paper is superior to what is usually afforded by our American cousins, quite equal to the best of English books. The engravings and lithographs are most beautifully executed. The work recommends itself for- its originality, and is in every way a most valu- able addition to those on the subject of obstetrics.— Canada Med. Journal, Oct. 1864. It is very large, profusely and elegantly illustrated, and is fitted to take its place near the works of great obstetricians. Of the American works on the subject It is decidedly the best.—Edinb. Med. Jour., Dec. '64 #** Specimens of the plates and letter-press will be forwarded to any address, free by mail, en receipt of six cents in postage stamps. We have examined Professor Hodge's work with great satisfaction; every topic is elaborated most fully. The views of the author ;ire comprehensive, and concisely stated. The rules of practice are judi- cious, and will enable the practitioner to meet every emergeucy of obstetric complication with confidence. —Chicago Med. Journal, Aug. 1864. More time than we have had at our disposal since we received the great work of Dr. Hodge is necessary to do it justice. It is undoubtedly by far the most original, complete, and carefully composed trpatise on the principles and practice of Obstetrics which has ever been issued from the American press.—Pacific Med. and Surg. Journal, July, 1864. We have read Dr. Hodge's book with great plea- sure, and have much satisfaction in expressing our commendation of it as a whole. It is certainly highly instructive, and in the main, we believe, correct. The great attention which the author has devoted to the mechanism of parturition, taken along with the con- clusions at which he has arrived, point, we think, conclusively to the fact that, in Britain at least, the doctrines of Naegele have been too blindly received. —Glasgow Med. Journal, Oct. 1864. ITANNER {THOMAS H.), M.D. ON THE SIGNS AND DISEASES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates and illustrations on wood. In one handsome octavo volume of about 500 pages, extra cloth, $4 25. • The very thorough revision the work has undergone has added greatly to its practical value, and increased materially its efficiency as a guide to the student and to the young practitioner.—Am. Journ. Med. Sci., April, 1868. With the immense variety of subjects treated of and the ground which they are made to cover, the im- possibility of giving an extended review of this truly remarkable work must be apparent. We have not a single fault to find with it, and most heartily com- mend it to the careful study of every physician who would not only always be sure of his diagnosis of pregnancy, but always ready to treat all the nume- rous ailments that are, unfortunately for the civilized women of to-day, so commonly associated with the function.— N. Y. Med. Record, March 16, 1868. We have much pleasure in calling the attention of our readers to the volume produced by Dr. Tanner, the second edition of a work that was, in its original state even, acceptable to the .profession. We recom- mend obstetrical students, young and old, to have this volume in their collections. It contains not only a fair statement of the signs, symptoms, and diseases of pregnancy, but comprises in addition much inter- esting relative matter that is not to be found in any other work that we can name.—Edinburgh Med. Journal, Jan. 1868. In its treatment of the signs and diseases of preg- nancy it is the most complete book we know of, abounding on every page with matter valuable to the general practitioner.—Cincinnati Med. Repertory, March, 1868. This is a most excellent work, and should be on the table or in the library of every practitioner.—Hum- boldt Med. Archives, Feb. IStiS. A valuable compendium, enriched by his own la- bors, of all that is known on the signs and diseases of pregnancy.—St. Louis Med. Reporter, Feb. 15, 1868. s WAYNE {JOSEPH GRIFFITHS). M. />., Physician-Accoucheur to the British General lL:t->ito.l, Ac. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- MENCING MIDWIFERY PRACTICE. From the Fourth and Revised London Edition, with Additions by E. R. Hdtchins, M.D. With Illustrations. In one neat 12mo. vol- ume. Extra cloth, $1 25. (Lately Published.) It is really a capital little compendium of the sub- ject, and we recommend young practitioners to buy it and carry it with them when called to attend cases of labor. They can while away the otherwise tedious hours of waiting, and thoroughly fix in their memo- ries the most important practical suggestions it con- tains. The American editor has materially added by his notes and the concluding chapters to the com- pleteness and general value of the book.—Chicago Med. Journal, Feb. 1870. The manual before us contains in exceedingly small compass—small enough to carry in the pocket,—about all there is of obstetrics, condensed into a- nutshell of Aphorisms. The illustrations are well selected, and serve as excellent reminders of the conduct of labor— regular and difficult.—Cincinnati Lancet, April, '70. This is a most admirable little work, and completely aDswers the purpose. It is not only valuable for young beginners, but no one who is not a proficient in the art of obstetrics should be without it, because it condenses all that is necessary to know for ordi- nary midwifery practice. We commend the book most favorably.—St. Louis Med. and Surg. Journal, Sept. 10, 1870. A studied perusal of this little book has satisfied us of its eminently practical value. The object of tbe work, the author says, in his preface, is to give the student a few brief and practical directions respect- ing the management of ordinary cases of labor; and also to point out to him in extraordinary cases wh«a and how he may act upon his own responsibility, and when he ought to send for assistance.—N. Y. Medical Journal, May, 1870. Henry C. Lea's Publications—(Midwifery). 25 MEIGS {CHARLES D.), M.D., Lately Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Fifth edition, revised. With one hundred and thirty illustrations. In one beautifully printed octavo volume of 760 large pages. Extra cloth, $5 50; leather, $6 50. It is to the student that our author has more par- ticularly addressed himself; but to the practitioner we believe it would be equally serviceable as a book of reference. No work that we have met with so thoroughly details everything that falls to the lot of the accoucheur to perform. Every detail, no matter how minute or how trivial, has found a place.— Canada Medical Journal, July, 1867. The original edition is already so extensively and favorably known to the profession that no recom- mendation is necessary; it is sufficient to say, the present edition is very much extended, improved, and perfected. Whilst the great practical talents and unlimited experience of the author render it a most valuable acquisition to the practitioner, it is so con- densed as to constitute a most eligible and excellent text-book for the student.—Southern Med. and Surg. Journal, July, 1867. PAMSBOTHA3I {FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- • CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised bands; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in ail nearly 200 large and beautiful figures. $7 00. To the physician's library it is indispensable, while to the student, as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med. and Surg. Journal. When we call to mind the toil we underwent in acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which this work will afford him.—Am. Jour, of the Med. Sciences. We will only add that the student will learn from It all he need to know, and the practitioner will find It, as a book of reference, surpassed by none other.— Stethoscope. The character and merits of Dr. Ramsbotham's work are so well known and thoroughly established, that comment is unnecessary and praise superfluous. The illustrations, which are numerous and accurate, are executed in the highest style of art. We cannot too highly recommend the work to our readers.—St. Louis Med. and Surg. Journal. fJHURCHILL {FLEETWOOD), M.D., M.R.I.A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additions by D. Francis Condib, M. D., author of a "Practical Treatise on the Diseases of Chil- dren,'' &c. With'one hundred and ninety-four illustrations. In one very handsome octavo volume of nearly 700 large pages. Extra cloth, $4 00 ; leather, $5 00. In adapting this standard favorite to the wants of the profession in the United States, the editor has endeavored to insert everything that his experience has shown him would be desirable for the American student, including a large number of illustrations. With the sanction of the author, he has added, in the form of an appendix, some chapters from a little '' Manual for Midwives and Nurses," recently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of advantage to the junior practitioner. The result of all these additions is that the work now contains fully one-half more matter than the last American edition, with nearly one- half more illustrations; so that, notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. These additions render the work still more com- plete and acceptable than ever; and with the excel- lent style in which the publishers have presented this edition of Churchill, we can commend it to the profession with great cordiality and pleasure.—Cin- cinnati Lancet. Few works on this branch of medical science are equal to it, certainly none excel it, whether in regard to theory or practice, and in one respect it is superior to all others, viz., in its statistical information, and therefore, on these grounds a most valuable work for the physician, student, or lecturer, all of whom will find in it the information which they are seeking.— Brit. Am. Journal. The present treatise is very much enlarged and amplified beyond the previous editions but nothing has been added which could be well dispensed with. An examination of the table of contents shows how thoroughly the author has gone over the ground, and the care he has taken in the text to present the sub- jects in all their bearings, will render this new edition even more necessary to the obstetric student than were either of the former editions at the date of their appearance. No treatise on obstetrics with which we are acquainted can compare favorably with this, in respect to the amount of material which has been gathered from every source.—Boston Med. and Surg. Journal. There is no better text-book for students, or work of reference and study for the practising physician than this. It should adorn and enrich every medical library.—Chicago Med. Journal. lU~ONTGOMERY {W. F.), M.D., "^ Professor of Midwifery in the King's and Queen's College of Physicians in Ireland. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREG- NANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. In one very handsome octavo volume of nearly 600 pages, extra cloth. $3 75. KIGBY'S SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American edition. One volume octavo, extra cloth, 422 pages. (2 60. •DEWEES'S COMPREHENSIYE SYSTEM OF MID- WIFERY. Twelfth edition, with the author's last improvements and corrections. In one octavo vol- ume, extra cloth, of 600 pages. $3 50. 26 Henry C. Lea\s Publications—(Surgery). /1ROSS {SAMUEL D.), M.D., ^-" Professor of Surgery in the Jefferson Medical College of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Filth edition, carefully revised, and improved. In two large and beautifully printed imperial octavo vol- umes of about 2300 pages, strongly bound in leather, with raised bauds, $15. (Just Ready.) The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. In the present revision no pains have been spared by the author to bring it in every respect fully up to the day. To effect this a large part of the work has been rewritten, and the whole enlarged by nearly one-fourth, notwithstanding which the price has been kept at its former very moderate rate. By the use of a close, though very legible type, an unusually large amount oi mutter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. It must long remain the most comprehensive work ou this important part of medicine.—Boston Medical and Surgical Journal, March 23, 1865. We have compared it with most of our standard works, such as those of Erichsen, Miller, Fergussou, Syme, and others, and we must, in justice to our author, award it the pre-eminence. As a work, com- plete in almost every detail, no matter how minute or trifling, and embracing every subject known in the principles and practice of surgery, we believe it stands without a rival. Dr. Gross, in his preface, re- marks "my aim has been to embrace the whole do- main of surgery, and to allot to every subject its legitimate claim to notice;" and, we assure our readers, he has kept his word. It is a work which we can most confidently recommend to our brethren, for its utility is becoming the more evident the longer it is upon the shelves of our library.—Canada Med. Journal, September, 1865. The first two editions of Professor Gross' System of Surgery are so well known to the profession, and so highly prized, that it would be idle for us to speak in praise of this work.— Chicago Medical Journal, September, 1865. We gladly indorse the favorable recommendation of the work, both as regards matter and style, which we made.when noticing its first appearance.—British and Foreign Medicv-Chirurgical Review, Oct. 1865. The most complete work that has yet issued from the press on the science and practice of surgery.— London Lancet. This system of surgery is, we predict, destined to take a commanding position in our surgical litera- ture, and be the crowning glory of the author's well earned fame. As an authority on general surgical subjects, this work is long to occupy a pre-eminent place, not only at home, but abroad. We have no hesitation in pronouncing it without a rival in our language, and equal to the best systems of surgery in any language.—N. Y. Med. Journal. Not only by far the best text-book on the subject, as a whole, within the reach of American students, but one which will be much more than ever likely to be resorted to and regarded as a high authority abroad.—Am. Journal Med. Sciences, Jan. 1865. The work contains everything, minor and major, operative and diagnostic, including mensuration and examination, venereal diseases, and uterine manipu- lations and operations. It is a complete Thesaurus of modern surgery, where the student and practi- tioner »nall not seek in vain for what they desire.— San Francisco Med. Press, Jan. 1865. Open it where we may, we find sound practical in- formation conveyed in plain language. This book ia no mere provincial or even national system of sur- gery, but a work which, while very largely indebted to the past, has a strong claim on the gratitude of the future of surgical science.—Edinburgh 3IeU. journal, Jan. 1865. A glance at the work is sufficient to show that the author and publisher have spared no labor in making it the most complete "System of Surgery" ever pub- lished in any country.—St. Louis Med. and Surg. Journal, April, 1865. A system of surgery which we think unrivalled in our language, and which will indelibly associate his name with surgical science. And what, in our opin- ion, enhances the value of the work is that, while the practising surgeon will find all that he requires in it, it is at the same time one of the most valuable trea- tises which can be put into the hands of the student seeking to know the principles and practice of this branch of the profession which he designs subse- quently to follow.—The Brit. Am. Journ., Montreal. OY THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In 1 vol. Svo. cloth, with illustrations, pp. 468. $2 75. BKEY'S OPERATIVE SURGERY. In 1 vol. 8vo. GIBSON'S INSTITUTES AND PRACTICE OF SUR- cloth, of over 650 pages; with about 100 wood-cats. oery. Eighth edition, improved and altered. With $3 25 thirty-four plates. In two handsome octavo vel- COOPER'S LECTURES ON THE PRINCIPLES AND umes, about 1000 pp.,leather,raised bands. $6 50. Practice op Surgery. In 1 vol. Svo. cloth, 750 p. $2. MILLER {JAMES), +■!-*- Late Professor of Surgery in the University of Edinburgh, Ac. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with two hundred and forty illustrations on wood, extra cloth. $3 75. T>Y THE SAME AUTHOR. , ---- THE PRACTICE OF SURGERY. Fourth American, from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume of nearly 700 pages extra cloth. $3 75. jZARGENT {F. W.), M.D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SUR- GERY . New edition, with an additional chapter on Military Surgery. One handsome royal 12mo. volume, of nearly 400 pages, with 184 wood-cuts. Extra cloth, $1 75. Henry C. Lea's Publications—(Surgery). 21 j^SHHURST {JOHN, Jr.), M.D., Surgeon to the Episcopal Hsopital, Philadelphia. THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, evra Cl°th' *6 5°' leather> raised bands, $7 50. (Just Issued.) The object of the author has been to present, within as condensed a compass as possible, a complete treatise on Surgery in all its branches, suitable both as a text-book for the student and a work of reference for the practitioner. So much has of late years been done for the advance- ment of Surgical Art and Science, that there seemed to be a want of a work which should present the latest aspects of every subject, and which, by its American character, should render accessible to the profession at large the experience of the practitioners of both hemispheres. This has been the aim of the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- torily. The plan and general outline of the work will be seen by the annexed CONDENSED SUMMARY OF CONTENTS. Chaptt-r I. Inflammation. II. Treatment of Inflammation. III. Operations in general: Anaesthetics. IV. Minor Surgery. V. Amputations. VI. Special Amputations. VII. Effects of Injuries in General : Wounds. VIII. Gunshot Wounds. IX. Injuries of Bloodvessels. X. Injuries of Nerves, Muscles and Tendons, Lymphatics, Bursaa, Bones, and Joints. XI. Fractures. XII. Special Fractures. XIII. Dislocations. XIV. Effects of Heat and Cold. XV. Injuries of the Head. XVI. Injuries of the Back. XVII. Injuries of the Face and Neck. XVIII. Injuries of tne Chest. XIX. Injuries of the Abdomen and Pelvis. XX. Diseases resulting from Inflammation. XXI. Erysipelas. XXII. Pypemia. XXIII. Diathetic Diseases : Struma (in- cluding Tubercle and Scrofula); Rickets. XXIV. Venereal Diseases ; Gonorrhoea and Chancroid. XXV. Venereal Diseases continued : Syphilis. XXVI. Tumors. XXVII. Surgical Diseases of Skin, Areolar Tissue, Lymphatics, Muscles, Tendons, and Bursas. XXVIII. Surgical Disease of Nervous System (including Tetanus). XXIX. Surgical Diseases of Vascular System (includ- ing Aneurism). XXX. Diseases of Bone. XXXI. Diseases of Joints. XXXII. Excisions. XXXIII. Orthopaedic Surgery. XXXIV. Diseases of Head and Spine. XXXV. Diseases of the Eye. XXXVI. Diseases of the Ear. XXXVII. Diseases of the Face and Neck. XXXVIII. Diseases of the Mouth, Jaws, and Throat. XXXIX. Diseases of the Breast. XL. Hernia. XLI. Special Hernias. XLII. Diseases of Intestinal Canal. XLIII. Diseases of Abdominal Organs, and various operations on the Abdomen. XLIV. Urinary Calculus. LXV. Diseases of Bladder and Prostate. XLVI. Diseases of Urethra. XLVII. Diseases of Generative Organs. Index. Its author has evidently tested the writings and experiences of the past and present in the crucible of a careful, analytic, and honorable mind, and faith- fully endeavored to bring his work up to the level of the highest standard of practical surgery He is frank and definite, and gives us opinions, and gene- rally sound ones, instead of a mere resume of the opinions of others. He is conservative, but not hide- bound by authority. His style is clear, elegant, and scholarly. The work is an admirable text book, and a useful book of reference It is a credit to American professional literature, and one of the first ripe fruits of the soil fertilized by the blood of our late unhappy war.—N. Y. Med. Record, Feb. 1, 1872. Indeed, the work as a whole must be regarded as an excellent and concise exponent of modern sur- gery, and as such it will be found a valuable text- book for the student, and a useful book of reference for the general practitioner.—N. Y. Med. Journal, Feb. 1872. It gives us great pleasure to call the attention of the profession to this excellent work. Our knowledge of its talented and accomplished author led ns to expect from him a very valuable treatise upon subjects to which he has repeatedly given evidence of having pro- fitably devoted much time and labor, and we are in no way disappointed.—Phila. Mtd. Times, Feb. 1,1872. PRICHSEN {JOHN), ■*-' Senior Surgeon to University College Hospital. THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- gical Injuries, Diseases, and Operations. From the Fifth enlarged and carefully revised London Edition. With Additions by John Ashhurst, Jr., M. D., Surgeon to the Episcopal Hospital, Ac. Illustrated by over six hundred Engravings on wood. In one very large and beautifully printed imperial octavo volume, containing over twelve hundred closeiy printed pages : cloth, $7 50 ; leather, raised bands, $8 50. (Lately Published.) Erichsen's Surgery needs no review at the present! last London edition of '• Erichsen's Surgery" the day. Long ago it took and has since maintained a leading position in surgical literature, and this posi- tion is so firmly held, that no efforts on the part of a reviewer would serve to weaken the estimate which has been placed upon the book—nor, indeed, could they materially strengthen it. The duty, then, de- volving upon us is simply to note the appearance of this new edition, and to point out the improvements therein made.—N. Y. Med. Journal, Jan. 1870. In the recent republication in this country of the practitioner and student are supplied with a guide and text-book which apparently leaves nothing to be desired. Full and complete in every essential par- ticular, and inculcating the most advanced and cor- rect modes of practice, it is certain to come into very general use. The additions of Dr. Ashhurst, though not extensive, are to the point; they relate chiefly to items of American practice.—The Journal of Psy- chological Medicine, Jan. 1870. T>Y THE SAME AUTHOR. (Just Issued.) ON RAILWAY, AND OTHER INJURIES OF THE NERYOUS SYSTEM. In small octavo volume. Extra cloth, $100. TDIRRIE {WILLIAM), F. R. S. E., jy Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, Ac. In one very handsome octavo volume of 780 pages, with 316 illustrations, extra cloth. $3 75. 28 Henry C. Lea's Publications—(Surgery). T)RUITT {ROBERT), M.R.C.S., Sfc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition. Illun- trated with four hundred and thirty-two wood-engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages. Extra cloth, $-1 00; leather, $5 00. All that the surgical student or practitioner could theoretical surgical opinions, no work that we_are M desire.—Dublin Quarterly Journal It is a most admirable book. We do not know when we have examined one with more pleasure.— Boston Med. and Surg. Journal. [n Mr. Druitt's book, though containing only some seven hundred pages, both the principles and the present acquainted with can at all compare with it. It is a compendium of surgical theory (if we may use the word) and practice in itself, and well deserves the estimate placed upon it.—Brit. Am. Journal. Thus enlarged and improved, it will continue to rank among our best text-books on elementary sur- p^racUce" "of~su7ge'r7 are treated, and so'clearly and j gery.-Columbus Rev. of Med. and Surg. perspicuously, as to elucidate every important topic, j We must close this brief notice of an admirable The fact that twelve editions have already been called work by recommending it to the truest attention of for, in these days of active competition, would of 'every medical student.—Chdrlestvu Medical Journal Itself show it to possess marked superiority. We and Review. hare examined the book most thoroughly, and can ; A text-book which the general voice of the profes- 8*y that this success is well merited. His book, j „jon in ^th Eugland and America has commended as moreover, possesses the inestimable advantages of, one 0f the most admirable "manuals," or, "vade having the subjects perfectly well arranged and clas- < mecum» as its English title runs, which can be sided, and of being written in a style at once clear piace(j jn the hands of the student. The merits of and succinct.—Am. Journal of Med. Sciences. \ Druitt's Surgery are too well known to every one to Whether we view Druitt's Surgery as a guide to ' need any further eulogium from us.—Nashville Med. operative procedures, or as representing the latest Journal. 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