AN EPITOME BRAITHWAITE'S RETROSPECT PRACTICAL MEDICINE AND SURGERY; CONTAINING CONDENSED SUMMARY OF THE MOST IMPORTANT CASES J THEIR TREATMENT, AND AM ~ T^MEDIES AND OTHER USEFUL MATTERS EMBRACED IN THE FORTY YOLUMES-.-T11E HEING ALPHABETICALLY CLASSIFIED, AND SUPPLIED WITH AN ADDENDA, PRISING A TABLE OF FRENCH WEIGHTS AND MEASURES, REDUCED TO ENGLISH STANDARD—A LIST OF INOOMPATIBLES—EXPLANATION OF THE PRINCIPAL ABBREVIATIONS OCCURRING IN PHARMACEUTICAL FORMUL.fi--A VOCA- BULARY OF LATIN WORDS MOST FREQUENTLY USED IN PRESCRIP- TIONS, AND A COPIOUS INDEX. k % tar Mums. BY WALTEK S. WELLS, M.D. VOL. I. NEW YORK: DICK . BLADDER. BLENORRHAGIA. BLOODLETTING. BOILS. BONES. BRAIN. BREAD. BREAST. BROMINE. BRONCHITIS. BUNION. BURNS AND SCALDS, BURSAL AFFECTIONS. CACHEXIA. CAESARIAN SECTION. CALCULI. CAMPHOR. CANCEROUS AFFECTIONS. CARBUNCLE. xu SUBJECTS EMBKACED I>T THE EPITOME. CARIES. CARTILAGE. CASTRATION. CATARRH. CATALEPSY. CATHETERISM. CATHETERS. CAUSTICS. CHAPS AND FISSURES. CHARCOAK CHILBLAINS. CHLOROFORM CHLOROSIS. CHOLERA. . CHOLERA INFANTUM. CHOKING. CHORDEE. CHOREA. CICATRICES. CINCHONA. CLUB FOOT. CLYSTERS. COLCHICUM. COLD. COLIC. COLLAPSE. COLLODION. COMA. CONDYLOMATA. CONGESTION. CONIUM. CONSTIPATION. CONVULSIVE AFFECTI COPAIBA. CORNS. CORYZA. COUGH. COUP DE SOLEIL. COUNTER-IRRITANTS. CRAMP. CREASOTE. CROUP.. CUPPING. CYNANCIIE. CYSTS. DEAFNESS. DEFORMITIES. TELIRIUM. DELIRIUM TREMENS. DENTITION. DIABETES. DIAPHRAGM. DIARRHOEA. DIGITALIS. DIPHTIIERITIS. DISINFECTANTS. DISLOCATIONS. DIURETICS. DROPSY. DROWNING. DYSENTERY. DYSMENORRHEA. DYSPEPSIA. EAR. ECRASEUR. ELECTRICITY. EMMENAG0GUE5. EMPHYSEMA. EMPYEMA. ENURESIS. ENTERITIS. EPILEPSY. EPISTAXIS. ERGOT. ERYSTPELA8. ETHER. EYE. FEET. FEVERS FINGER. FIRE. STTBJECTS EMBKACED IN THE EPITOME. xiii FIRING. FISTULA. FLATULENCE. FOOD. FRACTURES. FROZEN PERSONS. GALACTAGOGUES. GALLIC ACID. GANGLIONS. GANGRENE. GASTRALGIA. GASTRODYNIA. GLANDERS. GLANDULAR AFFECTIONS. GLEET. GLYCERINE. GONORRHEA. GOUT. 5RAVEL. GUARANA. GUMS. GUM RESINS. GUTTA PERCHA. HAIR. HAND. HANGING. HARE-LIP. HAY ASTHMA. HEADACHE. HEART AFFECTIONS. HEMATEMESIS. HEMATURIA. HEMATOCELE. HEMICRANIA. HEMIPLEGIA. HEMORRHAGIC DIATHESIS. HEMOPTYSIS. HEMORRHAGE. HEMORRHOIDS. HEPATIC AFFECTIONS. HERNIA. HICCOUGH. HOARSENESS. HOOPING COUGH. HYDATIDS. HYDROCELE. HYDROCEPHALUS. HYDROPHOBIA. HYPOCHONDRIASIS. HYSTERIA. INDIAN HEMP. INFANTS. INFLAMMATION. INFLUENZA. INSANITY. INTESTINAL AFFECTIONS. INTESTINAL OBSTRUCTIONS. INTESTINES. INTOXICATION. IODIC PREPARATIONS. IPECACUAN. IRON. IRRIGATION. ISSUES. JAUNDICE. JOINTS. KIDNEY AFFECTIONS. LABIUM. LABOR. LACTATION LARYNGEAL AFFECTIONS. LARYNX. LEAD. LEECHES. LEECH BITES. LEUCORRHEA. LIGATURES. LIGAMENTS. xiv 8TJBJECT3 EMBRACED IN THE EPITOME. LINIMENT. LINT. LIP. LITHECTASY. LITHOLIBY. LITHOTOMY. . LITHOTRITY. LOBELIA INFLATA. LOCKJAW. LOINS. LUMBAGO. MALARIA. MANGANESE. MANIA. MARASMUS. MATICO. MEASLES. MEDICINES. MELANCHOLIA. MELANOSIS. MELENA. MENINGITIS. MENORRHAGIA. MENSTRUATION. MERCURY. MILK. MOLES. MORBUS COXARIUS. MORTIFICATION. MOUTH MOXA. MUSCLES. KMYh NECR^EMIA. NECROSIS. NEEDLES. NERVOUS DISORDERS NEURALGIA. NIPPLE. NITRIC ACID. NOSE. NYMPHOMANIA. EDEMA. ESOPHAGUS. OIL. OMENTUM. ONYCHIA. OOPHORITIS. OPERATIONS. OPIUM. ORCHITIS. OVARIAN AFFECTIONS. OX GALL. PALATE. PANCREAS. PARACENTESIS. PARAPHYMOSIS. PARALYSIS. PARAPLEGIA. PARASITES. PARONYCHIA. • PEDICULI. PENIS. PERICARDITIS. PERINEUM. PERIOSTEAL AFFECTIONS. PERITONITIS. PERSPIRATION. PESSARIES. PHLEBITIS. PHLEGMASIA DOLEN8. PHTHISIS PULMONALI3, PHYMOSIS. PILLS. PLACENTA. PLASTERS. PLEURISY. PNEUMONIA. POISONING. POLYPI. SUBJECTS EMBRACED PREGNANCY. PROLAPSIONS. PROSTATIC AFFECTIONS. PUERPERAL AFFECTIONS. PULSE. PURGATIVES, PYROSIS. QUININE. RECTUM. RESPIRATION. RHEUMATISM. RICKETS SALIVATION. SARSAPARILLA. SCALP. SCARLATINA. SCIATICA. SCORBUTIC AFFECTIONS. SCROFULA. SEA SICKNESS. SENSATION. SILVER. SINUSES SKIN. SKIN DISEASES. SLEEPLESSNESS. SMALL POX. SNAKE BITES. SOAPS. SORES. SPASMODIC AFFECTIONS. SPERMATOCELE. SPERMATORRHEA. SPINA BIFIDA. SPINE. SPLEEN. SPONGE TENTS. SPRAINS. SQUILL. THE EPITOME. TV STAMMERING. STERILITY. STOMACH. STRANGURY. STRICTURES. STYPTIC. SUPPOSITORIES. SUTURES. SYNOVITIS. SYPHILIS. TABES MESENTERICA. TANNIN. TEETH. TENDONS. TESTES. TETANUS. THROAT. THYROIDEAL AFFECTIONS. TIBIA. TOBACCO. TOE NAIL. TONGUE. TONSILS. TOOTHACHE. TOURNIQUET. TRACHEA. TRACHEOTOMY. TRANSFUSION. TUBERCLES. TUMORS. TURPENTINE. ULCERS. UMBILICAL CORD. UMBILICUS. UTERUS. UTERINE HEMORRHAGE. URETHRA. URINE. IN xvi SUBJECTS EMBRACED IN THE KPnWni. VACCINATION. VAGINA. VAGITUS UTERINUS. VARICOCELE. VARICOSE VEINS. VEINS. VENTILATION. VERMIFUGES. VOMITING. ADDENDA. FRENCH WEIGHTS, ETC. INCOMPATIBLE**. LATIN VOCABULARY. TABLE OF THE MUSCLES. VULVA. WARTS. WATER, WHEY. WHITLOW. WORMS. WOUNDS. AN EPITOME OF BRAITHWAITE'S RETROSPECT. -wv ABDOMEN. Chloroform for painful affections of—Vide Art. "Chlorofcrm" (post, —). Case 0/ Wound of—This accident occurred to a boy between nine and ten years old, while bathing, by his falling upon a broken wash-hand basin. A wound thereby was inflicted, three inches in length, commencing a little below the umbilicus, nearly to the pubes, through which the greater part of the small intestines, transverse arch of the colon, and the omentum, immediately protruded. Mr. Blacklock states : When I first saw him he had been lying upon the bank of the river up- ward of an hour, and the protruded parts, which were chiefly hanging over his left thigh, had evidently been in contact with the ground, for a considerable quantity of sand, withered grass, and other extraneous mat- ters, adhered to them; and, from long exposure to the atmosphere, and fruitless attempts on his own part to force them back into the abdomen, they had become of a deep red color. Twenty minutes more had elapsed before a supply of warm water and a sponge could be procured, and the washing of the intestines and mesentery, which was chiefly done by allow- ing the water to flow over them from the sponge, also occupied a consider- able time before they could be replaced. The reduction was by no means 60 simple and easy a process as some mignt suppose; for it frequently hap- pened that patches of sand, etc., which had not previously been observed, were brought into view, as convolution after convolution of intestines was about to be replaced, and of course had to be washed off before the oper- ation could be proceeded with. I may therefore safely say, that it was fully an nour and a half from the time that the intestines were immersed in the cold river until they were fairly returned into the abdominal cavity. The whole, however, being replaced, and the omentum spread out, so as to come as much as possible between the intestines and the external wound, the lips of the latter were immediately approximated, and secured in contact by three interrupted sutures, which were afterward supported by strips of adhesive plaster. The unfortunate boy was now conveyed to his father's house, about a mile from the place where the accident occurred; and three hours after, when reaction had fairly commenced (for, in the first instance, or at 18 ABDOMINAL AFFECTIONS. least, from the time of my arrival, he was pale and almost pulseless although little or no hemorrhage had taken place), twelve leeches were applied, and a grain and a half of calomel, combined with one-twelfth of a gram ot opium directed to be given every two hours. In about two weeks this patient was perfectly cured. Strict antiphlogistic measures, together with the foresroins: remedies, pro re nata, comprising the treatment. 00 'F Part xx\i., p. 194. Pendulous—Mechanical Support in Cases of.—Very often from flatu- lence and intestinal torpidity. Its true pathological nature we once heard pointedly indicated by a Borough obstetrician in three words—" fat, faeces, flatus." The abdominal bandage tightly applied will soon dispel all suspicions, cither of pregnancy or of ovarian disease, which might previously have been entertained. The use of tonics and mild purgatives (e. g. aloes) at the same time is of course advisable. Dr. West often employs frictions with the tincture of aloes over the abdomen, with the object of restoring tone to the muscles of the abdominal wall and the intestines. We believe, however, that he considers mechanical support as the most important part of the plan. Part xxxii., p. 241 ABDOMINAL AFFECTIONS. Hints on the Diagnosis and Treatment of—In the treatment of acute inflammation of the bowels by purgatives, there is a danger of the irrita- tion being propagated from the mucous to the serous surfaces ; conse- quently, their use as derivatives cannot be taken advantage of, as in affec- tions of the head and chest. Of the use of opium in peritoneal enteritis, Dr. Griffin entertains the highest opinion, and relates several cases in which very large and frequent doses were given with the happiest results. In one case, first two grains and then one-grain doses were given every two hours, until thirty-two grains had been taken, two or three-grain doses having been resorted to on the occurrence of a relapse. In the case of a girl ten years of age, whose condition had been previously much aggravated by the use of pur- gatives, and who appeared to be sinking, twenty drops of laudanum were given, and in half an hour a grain of opium. Sound sleep ensued, and the patient, who had seemed almost moribund, was saved, the opiate being continued for some time at longer intervals. To a boy, set. five, in whom peritonitis occurred during the last stage of typhus fever, probably from perforation, grain doses were given with a successful result. Dr. 'Griffin does not propose opium as a substitute for general or local bleeding where these can be borne, but as a most useful remedy where this is *not the case; or where the disease continues in spite of their institution. The state of the bladder should be carefully watched, as retention of urine is not of unlikely occurrence during the use of full opiates. Dr. Griffin does not entirely condemn the use of purgatives, even in the early stages of enteritis, but the greatest advantage is to be derived from them when the force of the disease is broken, and we wish to empty the bowels of their contents. This he effects by mild purgatives, combined ABDOMINAL AFFECTIONS. 19 With henbane, but he would feel disposed to defer doing this till a later period, if there was no injurious distension present. He concludes, and general experience confirms the conclusion, that in the early stages of enteritis, purgatives do not act until the inflammation has been subdued by depletion, or the disease has otherwise subsided; while, as soon as thii has been accomplished, the bowels act spontaneously, or by the use of mild purgatives: that if purgatives are exhibited early, and act freely, death may nevertheless ensue, unless the disease is arrested by other remedies: that purgatives may, per se, occasion inflammation or cause its recurrence ; and that inflammation of the bowels may be subdued withoui any evacuation at all, and the bowels may continue confined for three or four days without any injurious distension. In determining the diagnosis of abdominal inflammation, where both pain and tenderness on pressure exist, we should always endeavor to ascer- tain—1. Whether there be any pain or tenderness on pressure in the cor- responding portion of the spinal column; because, if there be, although it may not absolutely decide whether inflammation be present or not, it is quite sufficient to account for both the pain and tenderness, without assum- ing the existence of any inflammation. 2. Whether, if there be no spinal tenderness or pain, the soreness of the abdomen be superficial or deep- seated, which may be ascertained with tolerable certainty in all cases, by an examination directed to that end. And whether, if both superficial and deep-seated, as it usually is in peritoneal inflammation, gentle, steady press- ure with the flat of the hand can be easier borne than with the points of the fingers. In pain and soreness from affection of the spinal nerves it commonly can be so borne, while in peritonitis every kind of pressure, and even the weight of the bed-clothes, is very distressing. And yet, one oi the best means of distinguishing hysterical tenderness will often be found to be the observation of how the slightest degree of pressure gives rise to the expression of intense suffering, although the countenance does not always corroborate this. The tenderness in these cases is quite cutaneous. 3.. Whether the boundaries of the pain or soreness extend beyond what the suspected inflammation could produce. Thus, if inflammation of the liver be suspected, and we find the soreness extending to the ileum or groin, or to the opposite side of the abdomen, it is obvious the soreness cannot be attributable to mere disease of that organ. Again, if the whole abdomen be tender to the touch in a case otherwise closely resembling peritonitis, and we find the tenderness is not confined to the abdomen, but extends over the hips and lower extremities, it is obvious we can attach no importance to the abdominal soreness as a sign of inflammation. Of the antiphlogistic powers of opium, Dr. Griffin expresses his high opinion ; and states that for many years he has almost entirely relied upon it for the subdual of enteritis and peritonitis. He bleeds first, however, in subjects who will bear depletion, employing calomel also when the dis- ease is very intense and resists opium powerfully—suspending this as soon as the symptoms give way, and giving the opium alone, whereby trouble- some salivation is usually prevented. In rheumatic inflammation it is as useful. In acute inflammation of the. mucous membranes opium was formerly supposed to be contra-indicated ; but the cases published by Dr. Stokes and others, of cure of inflammation of the mucous membrane of the bowels with exhausting diarrhoea, show the propriety of the practice. Dr, Griffin attributes the evil effects which have followed the use of opium in 20 ABORTION. these inflammatory affections to its having been given in too small doses, which, hi cases of mucous phlegmasioe, suppress the diarrhoea without subduing the inflammation to which this had even acted as a relief But in these, as well as in serous inflammations, bleeding must be premised where the strength will admit of it, applying at the same time warm poul- tices to the abdomen. In other cases, in which bleeding is out of the question, and opium seems powerless, as in bad dysentery, a combination of ipecacuan and opium acts sometimes surprisingly. Dr. Griffin alludes to two cases in which he gave three grains of opium with from three to five of ipecacuan every two hours with the best effect. Although opium is contra-indicated in inflammatory affections of the cerebro-spinal system, from its tendency to produce congestion, yet when combined with sufficient doses of tartar-emetic, it allays nervous irritation, quietens the action of the capillaries, and procures sleep. Its effects are Wonderful in many cases of puerperal mania, delirium tremens, and the advanced stages of fever. It is to Dr. Graves we are indebted for point- ing out the value of this combination. Dr. Graves directs four gr. of emet. tart, and two drachms of laudanum to be mixed with half-a-pint of camphor mixture, two table-spoonfuls of which are to be given for the first dose, and one every half hour after- ward, until the delirium abates, or some signs of drowsiness appear. Dr. Griffin believes that the restorative power of opium in exhaustion from haemorrhage, depends principally upon its property of producing congestion of the brain, and thus restoring tension to the cerebral vessels. Part xiii., p. 94. —•-•-•--- ABORTION .—(Vide " Labor.») Abortion—Ulceration of the Cervix Uteri—A cause of—Dr. Bennet observes that though ulcerative inflammation of the cervix, occurring in pregnant females, may generally be entirely subdued by judicious treat- ment without disturbance of the course of pregnancy, some cases occur where abortion cannot be prevented. This may be produced, in the early months, by disease of the ovum occasioned by the uterine inflammation*; and, in a more advanced stage, by contraction of the uterus excited by reflex action. He relates such a case, met with in the sixth month of pregnancy. The patient had miscarried four times previously. The first was at three months, the others at about six months; they were preceded by slight pains and flooding, and the case now referred to had a yellow dis- charge ever since the second miscarriage. Dr. B. says : On examining with the hand, I found the abdomen developed, the uterus rising above the umbilicus, as in the beginning of the seventh month of pregnancy. The vagina Avas moistened by an abundant secretion. The cervix, in its usual position, more voluminous and softer than it is normally at this period of pregnancy, constituted a quaggy mass • its surface, of a fungus softness, presented, more especially round the os. which was very open, numerous small indurations, about the size of small peas. On withdrawing my finger, it was covered with thick whitish pus. Thij pulpy, fungous state of the cervix, along with the partial indurations the purulent discharge, the general symptoms, and the previous history of the ABORTION. 21 case—all indicating the existence of extensive ulcerative inflammation of the cervix, I mentioned the necessity of an instrumental examination. The vulva was congested and swollen ; the vagina red, tender, and bathed with pus. On getting the cervix between the extended blades of the bivalve speculum, I found that it presented a large, soft, florid, fungous mass, covered with pus, and bleeding easily on being touched. The entire cervix was covered with these fungous granulations, and presented a very different appearance to what ulceration of that organ offers in the unim- pregnated state. It was a fungous ulcerated surface softened and broken up. From the regularity of its surface, however, the absence of uneven, deep-seated induration, and the frankly purulent nature of the secretion from its surface, it was evidently an inflammatory ulceration that I had to deal with. I therefore touched the entire ulcerated surface with the nitrate of silver, and ordered astringent vaginal injections with the sul- phate of zinc night and morning; mild aperients, and a tonic ant&ud mix- ture (compound infusion of gentian, and carbonate of magnesia) ; light diet; complete rest. The application of the nitrate of silver was followed by a slight oozing of blood for three days, but by no increase in the local pains. The latter are still severe in the lower segment of the developed abdomen, and in the loins. The yellow discharge is very abundant. She has the same bearing- down pains which preceded her other miscarriages. The pains continued, and she bore a seven months' child. In a few weeks the treatment was resumed, the ulcerated surface being cauterized once a week, with nitrate of silver, or the acid nitrate of mercury. In the beginning of June the catamenia appeared, attended with much pain. At the end of two months, the ulceration was healed, and all the symptoms ameliorated. Dr. Bennet makes the following remarks: When this disease exists in the pregnant state, its symptoms are the same as in the non-pregnant condition, but obscured, and more or less modified by the pregnancy. It is a frequent cause of disordered health during pregnancy, or of " laborious pregnancy." It is also one of the most frequent causes of abortion, both in the early and in the later months of pregnancy. It may occasion abortion; either directly, by reflex action, or indirectly, by giving rise to disease of the ovum or placenta, or to uterine haemorrhage. The instrumental examination of females laboring under inflammatory ulceration of the cervix during pregnancy is unattended with any risk, either to the mother, or to the foetus; and it is absolutely necessary, in order not only fully to recognize the disease, but also to treat it. The treatment of these forms of uterine inflammation must be governed by nearly the same rules in the pregnant as in the non-pregnant state. A properly conducted treatment is nearly always successful in preserving the life of the child, and the integrity of the pregnancy, as well as in curing the inflammatory and ulcerative disease. It is also the only means we possess of warding off the imminent danger of abortion to which the pa- tient is exposed. This form of uterine inflammation being, generally speaking, the cause^ of those repeated and successive miscarriages which prevent females giving birth to a living child ; it is only by curing it that we can hope to make them bear the product of conception to its full period. The serious inflammatory and haemorrhagic symptoms which sometimes Lilow abortions are generally occasioned by unrecognized inflammatory C2 ABORTION. ulcerations of the uterine neck. On investigation it often becomes evident that this disease existed previous to the abortion, and occasioned it. The rame remark may apply to some cases in which the above-mentioned symptoms precede and follow labor at the full time, as ulcerative inflam- mation of the cervix in the pregnant state is by no means necessarily fol- lowed by abortion. Although inflammatory ulceration of the cervix seems generally to be a cause of sterility, yet, as will appear from the above essay, there are frequent exceptions to the rule. In some females, the tendency to become impregnated is so great, that no amount of uterine dis- ease appears to prevent conception taking place. Part xv.p. 292. Puncturing the Membranes to produce Abortion.—To produce abortion during the early months of pregnancy, use a gum male catheter sufficiently firm to preserve its straight form against moderate resistance, and having a perforation at its extreme point large enough to admit the passage of a common wire stilet. The patient being placed on her left side, guide the instrurhent by the finger into the os uteri and through the cervix; pass it on until it meets the membranes, then introduce the stilet, and press it through the opening at the apex of the catheter so as to perforate the membranes; then push the catheter itsolf forward, and evacuate the liquor amnii. Part xvi., p. 244. New mode of bringing on Premature Delivery.—To excite prematuro labor, inject about an ounce and a half or two ounces of tar water slowly and gently through a canula introduced about two inches between the membranes and the anterior wall of the uterus. Repeat the operation in six hours, if labor does not seem to be approaching. Part xvi., p. 245. Prevention of Habitual Miscarriage.—Dr. Griffin, physician to the iounty of Limerick Infirmary, recommends to the notice of the profession (he use of tonics and antispasmodics when there is a habitual tendency to vbortion or miscarriage. In three cases, which he treated successfully, he employed the following remedies—two grains and a half of oxide'of zinc, with two grains of extract of hops, three times a-day; and, after each pill, two tablespoonfuls of a mixture of valerian, aromatic spirits of ammonia, and infusion of snake-root. He recommends also a box of pills to be kept by the patient, containing a grain of opium in each, to be taken when pain comes on, and to repeat the dose every hour till relief is obtained. Part xvi.,^>. 276. Note on Abortion.—If, after a careful examination, we find the cervix preserves its normal length, figure and thickness, we must try to prevent the abortion; but if the cervix is found shortened or distended, and the organ is assuming the ovi-form shape, we must assist, by all safe means, the expulsive action. In making this examination, do not introduce the finder into the os. part ^\\., p. 215. Abortion: Flooding in cases of threatened.—When there is severe flooding during threatened abortion, evacuate the liquor amnii, pass a coni- cal plug into the os uteri, fill up the vagina behind it, and give one or more doses of ergot. Part xvii., p. 234. Abortion: Prevention of.—We must endeavor to ascertain n.e cause sC the abortion, and attempt its removal. If the cause be ovarian irrita- ABORTION. 23 tion, we should give warm hip baths, not exceeding blood heat, and enemata of the same temperature; apply a plaster of opium to the sacrum, and enjoin the avoidance of coitus; these precautions must be especially attended to at the catamenial or periodic dates of pregnancy, for ascer- taining which a little table recently published, termed a periodoscope, will be found useful. Vaginal irritation being not an uncommon cause of abortion, the most rigid continence must be observed during the whole of pregnancy, by women who have previously aborted ; and if we use the plug in threatened abortion, we must take care that it is not too large, and that it is introduced into the upper and roomy part of the passage. Uterine irritation, dependent on ulceration of the os and cervix, or re- troversion, must be treated by the means calculated to relieve those diseases. Mammary, dental, vesical and rectal irritation, if existing, must Uso be removed by appropriate treatment. Morbid conditions of the placenta often cause abortion by preventing the due oxygenation of the foetal blood. We must treat these cases by great attention to the depura- tion of the blood of the mother, by means of carefully regulated diet, the respiration of pure air, attention to the secretions, etc. The exhibition of chlorate of potash has been found useful by Professor Simpson, by arterial- izing the maternal blood. To eradicate the abortive diathesis, prolonged ♦ continence is especially necessary. Besides this, any source of irritation and any disease of the utero-vaginal passage must be relieved ; and such tonics as iron, the cold douche, and cold bathing must be employed. In very obstinate cases, it is recommended to try the effect of a long-continued galvanic current through the spine and sexual organs, or to prescribe small and continued doses of ergotine or strychnine. Part xviii.,^). 251. Mode of inducing Abortion.—A safe and efficient mode of inducing remature labor, is by the warm douche applied to the uterus twice a ay, by means of a canula properly introduced into the vagina. The ^ater should have a temperature of 108° F., and should be projected with a force equal to a fall of eight feet. Part xix., p. 235. Abortion.—In cases of inevitable abortion, where the uterine con- tractions are feeble and inefficient, and there is considerable hemorrhage, let the patient swallow pounded ice freely, with a view to promote the action of the uterus. Part, xix., p. 233. Abortion; Threatened.—An an early period of the attack, when the hemorrhage is slight, and the pains few and wreak, give tincture of Indian hemp (Donovan's tincture of the resin), in doses of five drops thrice a day. Part xix., p. 329. Induction of Abortion by puncturing the Ovum.—The plan for open- ing the ovum by puncturing the membranes, is by employing an instru- ment which consists of a cylindrical silver canula, slightly curved at its further end, with a single opening, and two wire loops projecting from the sides of the other extremity, through wdiich two fingers may be passed to hold and fix it. A movable stilette, tipped with a sharp point like a trocar, and so cut that the point does not.touch the sides of the cylinder when the stilette is run through it, can be made at option to pass beyond the end of the ranula. The way to use it is this : Place the patient, if you like, on the left side, run up the index finger of the left hand to the u ABORTION. os uteri, and if possible within it; then guide the instrument with the poin, of the stilette concealed in the canula, on the finger, within the uterus, anc* carry it forward until you feel that there is some resistance ; then prese the point of the stilette against the membranes and press the canula a little further on. Then withdraw the stilette and let the liquor amnn flow through the canula. The time which elapses between the puncture of the ovum and the supervention of labor varies very much in different cases. Five or nearly six days is a long interval. Part xx., p. 200. Abortion produced by Metastasis in Cynanche Parotideea.—[Mr. Sal- ter's patient was a lady about twenty-five years of age, who was attacked with cynanche parotideea when advanced just beyond the third month of her third pregnancy. (She had gone to the full time in her previous pregnancies.) The usual treatment was adopted. After a clay or two of vaginal discharge, uterine pains and hemorrhage came on suddenly in the night, and a foetus was discharged. The hemorrhage continuing, Mr. Salter gave ergot of rye, and adopted other proper treatment, and in fifteen hours after the birth of the foetus, he was enabled to remove the placenta. Mr. S. says:] We have abundant experience to show, through the influence of the disease, the relation subsisting between the parotid glands, whilst affected with this specific inflammation, and the testicles in the male ; and also between the same organs and the breasts in the female ; and from the known sympathetic association of the mammary glands with the ovaria and uterus, it may readily be supposed that in cynanche parotideea, an irritation may be communicated to the uterine system leading to results incompatible with the continuance of the process of utero-gestation. And, on the other hand it is possible, in this chain of causation, in cases where the female breasts are affected in cynanche parotideea, that the influence on them may be secondary to some primary disturbance of the ovaries, though this may not be disclosed by any palpable symptoms referred to the latter organs themselves. The analogy between the testes and the ovaries, and the sympathy of the breasts with the ovaries, are in favor of this hypothesis. Part xx., p. 201. Uses of Opium in.—[Speaking first of the uses of opium in threatened abortion, Dr. Lever says:] In the management of cases of threatened abortion, it is my rule, if pos- sible, to get a thorough knowledge of the immediate or exciting cause of the hemorrhage or pain, or both ; secondly, before using opium, to ascer- tain the state of the os uteri, and especially whether the anterior part of the neck has lost its plumpness and firmness, and has become soft and baggy. If with the discharge we have a patent state of the os uteri, and if the neck be soft and loose, the exhibition of opium will do harm b) retarding the emptying of the uterus, which must sooner or later take place. But while I do not advocate the use of this drug under the cir- cumstances related, I can speak loudly in its praise after the abortion has occurred, especially if such have been attended with a large loss of blood- it will allay excitement, tranquillize the circulation, and procure sleep These remarks, however, do not altogether apply to those cases which menace from accident, or from mental causes, or those which may be said to be due to habit. In these, with the application of cold perfect ABORTION. 25 quietude, and unstimulating diet, I have known the exhibition of opium by mouth—or, what I prefer, a cold starch injection, with opium thrown into the bowel, and repeated every night or more often, according to exist- ing circumstances—followed by the best results. Part xxi., p. 305. Prophylactic Treatment of Habitual Disposition to Abortion.—When there is no local or general plethora, but the disposition to abort depends upon weakness of the uterine system, give savine, an infusion being made of from two to four drachms to six ounces of boiling water; give a table- spoonful morning and afternoon, in the intervals between the menstrual periods; rest of the uterine and general system, and regulation of the diet, being also enjoined. If, in addition to the uterine weakness, there is augmented irritability and contractility, give ergot of rye in con- junction writh the savine. In cases of habitual abortion, occurring in women of weak and irritable fibre, aad without vascular congestion, the administration of assafoetida as soon as pregnancy occurred, has been very beneficial. Part xxi., p. 308. Auxiliary Treatment of—In a case of abortion at the sixth week, the administration of chloroform has been successful, in causing dilatation of the os uteri. ******** In abortion during the early months, the ovum can always be got away by giving a stimulating enema, such as turpentine. Part xxi., p. 363. Premature Labor—Induction of by Galvanism.—In a case where it was necessary to induce premature labor, for half an hour, on the 23d of Jan., the poles of the galvanic battery were applied on either side of the uterus. The womb became contracted. On the 24th and 26th the appli- cation was continued one hour, and on the evening of the 27th slight pains came on. On the morning of the 28th they had increased, and at 9 a.m., the child was born. Galvanism is more valuable than ergot in these cases, because if any unforeseen obstacle occur to the birth of the child, rupture of the uterus might be induced. Besides, if the case were prolonged, there is some danger, from the number of doses required, of producing ergotism in the mother. Part xxix., p. 263. Premature Labor Artificially Induced by Ergot of Pye.—In a large number of cases the following prescription proved successful in inducing premature labor. R. Secale cornut. pulv. 3iij.; aquas ferventis §vj.; infunde per semihoram in vasa leviter clauso, et cola. #. Infusi supra prescripti § vss.; acid, sulph. dil. 3ss.; syrupi 5ij.; tinct. card. co. 3ij.; Misce, sumat partem quartam 4tis horis. The doses required varied from three to thirty. part xxix>j p 274> Syphilis—a Cause of Abortion and premature Labor.—Dr. Johns maintains that there is but one method of preventing abortions and pre- mature labors in females tainted with syphilis, and that is the use of mer- cury for both parents—to the female when not pregnant—the patients being kept under its influence for six weeks or two months. Dr. Johna draws the following deductions : I. That secondary syphilis is not curable in the pregnant female. 26 ABORTION. 2. That mercury is the only certain means of preventing the abortions and premature labors depending on syphilis. 3. That both parents must be" submitted to this treatment. 4. That as the disease in such cases exists in the secondary form, the system must be kept under the influence of the metal for at least six Weeks, and in some cases even longer. 5. That syphilis is communicable to the female through the semen of the male, without the presence of any ulcer or purulent discharge. 6. That secondary ulcers on the female genitals do not infect the male by whom she was contaminated, so long as he is poisoned by the infection which gave it to her. 7. That as syphilis is communicable from a child to its nurse, and vice versa, great care ought to be taken that an infected child be not given to a sound nurse, nor a pocky nurse be hired for a sound child. 8. That syphilis in infants is only curable by mercury, which is best given directly to the child, as also to its nurse. 9. That there is no disease of the uterus, save the Hunterian chancre, which is pathognomonic of syphilis. 10. That the order of abortions and premature labors is a very good test of their cause. 11. That ulceration may exist to a great amount on the os and cervix uteri, and not be discoverable by the toucher. 12. That the patulous state of the os uteri, induced by inflammation, may be present during pregnancy. 13. That children dying in the uterus from syphilis, like those dying from other causes, are thrown off within a fortnight or so after the cessa- tion of vitality. 14. There is a class of abortions and premature confinements preventible by iodide of potassium and similar medicines. Part xxx , p. 200. Treatment of Abortion.—When nervous excitement prevails, with inter- mitting uterine pain, a full opiate is of great service. Dr. Fleetwood Churchill has given the cannabis Indica with good effect. As astringents, the acetate of lead or gallic acid with opium are the best. The patient must be kept cool, and in the horizontal position, for standing greatly adds to the probabilities of abortion. Keep the bowels open with conf. senna, ?r potass, bitart.; castor oil irritates the uterus and ought not to be given. When abortion has threatened at a catamenial period, great care ouo-ht to be taken as the next monthly period comes round, to avoid every cause of irritation, and keep perfectly quiet. In severe cases, where all the more powerful astringents have been tried in vain, the vagina must be plugged firmly with lint or sponge ; if this do not arrest the hemorrhage, the membrane should be ruptured to excite expulsive action of the uterus. If the bag of the early ovum can be felt with the finger in the cervix uteri, it can generally be separated by care- ful manipulation. Dr. Simpson recommends the introduction of a sponge pessary, to dilate the os and cervix, but if you do use thespono-e you must not allow it to remain long enough to become foetid. Galvanism has been suggested by Dr. Robert Barnes. A drastic cathartic will often complete the expulsion of an ovum in a very satisfactory manner. Part xxxiii., p. 255. Abortion, with Flooding—New Plug.—The common vulcanized india- ABSCESS. 27 rubber air ball, about the size of a large orange, makes an admirable and easily-adapted plug. If fastened to one end of a metallic tube, furnished with a stop-cock at the other end, when the air is pressed out and the tap turned, it may be very readily introduced into the upper part of the vagina ; air may then be admitted by turning the tap, or, if necessary, cold water maybe injected into it. Part xxxiv.,p. 235. ---•-•-•— ABSCESS. Abscesses about the Anus and Perineum.—Abscesses about the anus or in the perineum are frequently met with in phthisical patients, and it is often dangerous under such circumstances to operate, as the thoracic* symptoms are very apt to increase, when the local disease is meddled with. Part in., p. 116. Abscess in the Lumbar and Sacral Regions.—Caries of the crest of the os ilii is a not unfrequent cause of symptomatic abscess in the lumbar and sacral regions. Part iii., p. 116. Abscess in the Calf of the Leg.—In certain individuals, after lithotomy or other great operations, an abscess is apt to be formed in the calf of the leg. Part iii., p. 116. Mammary Abscess.—Complete compression of the breast, by means of strips of plaster, broad and sufficiently long to go several times round the body recommended. To compression thus employed the authors attribute many advantages. In the first place, it immediately relieves the pain ; it combats and diminishes the inflammatory engorgement, at whatever period :t is applied. When employed after opening the abscess, it decidedly favors die evacuation. And although when employed too long, at a period when he process of suppuration is active, it might have the disadvantage of making the pus extend over a larger surface, yet this may be avoided by removing the bandages at a time when it is probable that matter has fairly formed. If this be done, and the abscess opened, the bandages may be again applied, after two or three days' poulticing, with good effect. Part i\.,p. 104. Chronic Abscesses—Sub-Cutaneous Method of Opening.—This opera- tion is in order to prevent the admission of air into the cavities of psoas and other abscesses of the like kind. M. Guerin uses a flat trocar, long, but of small diameter, and inclosed tightly in a canula. The canula is furnished with a cock near its larger end, which, when opened, permits the trocar to pass, but when shut, exactly closes the canula. The outer end of the canula fits on the nozzle of an ordinary syringe, and all those parts are so adapted that no air may pass where they fit one to the other. A fold of skin being made at some little distance from the abscess, the trocar and canula are introduced at its base, and carried under the integuments till the point of the former has entered the sac; then the trocar is slowly withdrawn, and at the instant that its point passes the cock, that is turned, and the pus prevented from flowing out. The syringe is now adapted, the cock turned back, and the pus sucked out at once, or with one or more emptyings and refillings of the syringe, if its quantity be very large. When this is finished, 28 ABSCESS. the canula is slowly withdrawn, care being taken to keep the walls of the track through which it passes close together. A pad and bandage are then put on the sac, and the track leading to it, and the orifice of the latter is closed with sticking-plaster. Part v., p. 141. Chronic Abscess and Disease of the Heart and Joints.—In this case there was a chronic abscess of considerable size, the hand's breadth above the right knee, the joint was much swollen, and there was a large indolent ulcer on the leg on the same side: her pulse was quick, and she was considerably emaciated. The following mixture was ordered : P Decoct. Guaiaci §viij. Potass. Iodid. gr. xxiv.; Tine. Cardam. co. gss. • Tinct. Hyosciam. 3i. M. Dose.—One ounce, three times a day. An ointment consisting of equal parts of mercurial and iodine ointments was applied over the abscess. The ulcer on the leg was dressed with lint, moistened with black wash, and covered with oiled silk. The patient recovered. Part vi., p. 64. Urinary Abscess—Complications of.—Sometimes the abscess in the perineum is accompanied by typhoid symptoms. If it is opened, the matter that issues is putrid and urinous ; if the opening is deferred, the patient may die. Sir B. Brodie remarks that it is often more complicated. It is not always confined to the perineum; sometimes it makes its way forward through the upper part of the scrotum, and presents itself on the lower part of the penis, between the scrotum and the glans. At other times it burrows in the opposite direction, forming a large collection of matter in the nates, or it may burst in the groin, or in the scrotum. In one case, in which I had the opportunity of examining the body after death, I found a large abscess in front of the pubes, extending half way toward the navel; another among the adductor muscles of the left thigh : and a third among the muscles at the upper part of the right thigh, as far outward as the foramen ovale of the ischium ; the periosteum having been destroyed, and the bone itself rendered carious to a considerable extent; and all these abscesses could be traced into an abscess in the perineum, communicating with the urethra behind a stricture by a small orifice. In another case there was a fistula inperinceo, communicating with a large abscess of the pelvis on one side of the bladder. ( Vide, Art. " Stricture of Urethra.") Part vi.,/>. 93. Milk Abscess.—In cases of inflammation of the mamma?, threatening milk abscess, the application of cataplasms, formed by adding to any quan- tity of the acetous tincture of the unripe fruit of the persimmon, when hot, the requisite proportions of any kind of farinaceous material, recom- mended. Part\i\.,p. 30. Mode of forcing out Collections of Pus from Pony Cavities by Atmos- pheric Pressure.—In a case of collection of pus in the antrum of High- more, for the evacuation of which a tooth had previously been extracted which communicated with the cavity, but through which the matter would not descend, owing to well known physical principles, a blow-pipe was procured, having the necessary degree of curvature at its smaller end and a bladder attached to the other end, which was inflated by the patient The nozzle of the blow-pipe was then introduced into the orifice in the bottom of the maxillary cavity, when, on compressing the bladder the air ABSCESS. 29 ascended to the top of the antrum, and forced the matter downward into the mouth. By this- means about one ounce and a half of foetid matter was discharged ; two ounces were collected, but probably at least half an ounce was saliva. The same operation was repeated morning and evening, and a small quantity of matter obtained for some time after. Part ix., p. 191. Mammary Abscess—Treatment of by the Breast-pump and Syringe.— This very annoying affection most commonly occurs during lactation, and is then more unmanageable than when the breast is in its natural state. It is preceded by inflammation which is either acute or chronic, and as Sir Astley Cooper has succinctly expressed it—" is adhesive in the first stage, suppurative in the second, and ulcerative in the third." Notwithstanding the most prompt and judicious treatment of the first stage, suppuration will occasionally take place. As the inflammation by which these abscesses are preceded is either acute or chronic, so is the abscess itself. When chronic, they are apt to give rise to deep-seated sinuses, filled with a soft fungus. Previous to the time of Mr. Hey, the practice often was to extirpate the breast for this affection: he, howrever, suggested, as preferable, dividing the sinuses throughout. Sir A. Cooper, instead, recommended that they should be syringed with a solution of two or three drops of strong sulphuric acid to an ounce of rose-water, and that the same should be applied as a lotion to the breast. It is very evident that, however treated, this is a very formidable affection, and it is of great importance to prevent the formation of the sinuses. For this purpose, Sir Astley Cooper recommends early and free opening of these abscesses, particularly if there be much fever and symptoms of hectic, unless the abscess be deeply seated, in which case the aperture closes, and ulceration will still continue. In obedience to the precepts of Sir Astley Cooper, as soon as the indistinct fluctuation, or rather the boggy feeling, by which the formation of matter in these abscesses can be detected, is distinctly ascertained, let a small bistoury or abscess lancet (the common lancet will sometimes not penetrate deep enough) be carried down until the matter begins to escape. After all that can be squeezed out by the pressure is removed, let the breast-pump be applied over the orifice, and the rest of the matter be drawn out. The sinus is then to be injected with some astringent solution, by means of a small syringe. The syringe employed is the small glass one for the urethra, sold by most apothecaries. The lotion Dr. Wood has used is the one recommended by Mr. Hey, though it may be doubtful if it possesses any peculiar advantages. #. Aquae purae, §xv.; spt. rosmarin., §j.; spt. lavandul. comp. 3j.; zinci sulphat. gr. xxx. M. fiat lotio. The sulphuric acid lotion of Sir A. Cooper will probably answer as well. A pledget of lint dipped in the lotion is then to be applied outside, and covered with oiled silk; over this a compress may be placed, and firm pressure maintained on it by means of adhesive plaster. In some cases the walls of the abscess will unite at once, and all that remains to be done is to trust to time for the removal of the surrounding induration, or to attempt to discuss it by friotl°™**¥^&™^^ mercurial or iodine ointment, or the application of the emplast. ammomaci cum hy- ^Where the surfaces do not thus unite, the falling in of the breast, pro- 30 ABSCESS. duced by the exhaustion of the glass, will be found to have ^ppoared j the cavity in such cases has only to be injected two or thiee ^^^ which will serve at once to keep the opening free foi the dis < ™ *e °i matter, and will also tend to arrest the further exteusion ^ the ukxiatove process. The treatment of acute -f ™>;^ ducted on the same general principles. I he eai iy e> ac , t ter saves the patient much suffering, and alsyna™e* ^ breast to be resumed at a much earlier period. The cic.it *-is also much smaller than in cases where the matter is allowed to discluige P™ta"e ouslv; indeed, if the incision be made in the direction of the natui a fold, of tne breast,'that is, radiating toward the nipple, the cicatrix .will ma short time be imperceptible. -™l M-> P' 1Dy' Abscess of the Tibia.—After alluding to organization of bone, and its liability, the same as other tissues, to diseased action, and remarking upon the peculiarity of the symptoms in consequence of the presence of phos- phate of lime, Sir B. Brodie asks, what symptoms lead us to suspect the existence of abscess in the tibia, and what can be done for its relief t lie replies thus: . in , When the tibia is enlarged from a deposit of bone externally—when there is excessive pain, such as may be supposed to depend on extreme tension, the pain being aggravated at intervals, and these symptoms con- tinue and become aggravated, not yielding to medicines or other treat- ment that may be had recourse to—then you may reasonably suspect the existence of abscess in the centre of the bone. You are not to suppose that there is no abscess because the pain is not constant; on the contrary, it very often comes on only at intervals, and in one of the cases which I have related, there was, as I then mentioned, an actual intermission of seven or eight months. After the disease has existed a certain number of years, indeed, the pain never entirely subsides, but still it varies, and there are periods of abate- ment and of exacerbation. The combination of circumstances which I have described will fully justify you in making an opening into the bone with a trephine. But how will it be if you are mistaken ? This will not often occur, but if it should, really the taking out a circle of bone can be of no consequence; no injury follows the operation ; it is unattended with danger. The operation is a very simple one. You expose the surface of the bone, and make a circular opening with a trephine at that part where there seems to be some tenderness and some pain on pressure. One prin- cipal thing to be attended to is that you have a proper trephine. One of very small diameter is quite sufficient. The operation may be more easily performed with a trephine having no shoulder; which will at once pene- trate to the abscess, however deep it may be, and render the chisel unne- cessary. The after-treatment is as simple as possible. There may be some pain for a day or two, and especially, as in the case I last mentioned, if the patient be a hysterical female, there may be hysterical pain after- ward ; but all that is required is to maintain the general health, and lay on some simple dressing; the bone soon granulates, the space is tilled up by a sort of fibrous substance, and the wound cicatrizes. Part xiii., p. 180. Abscess in the Perineum.—The following is an abbreviated lecture on this subject, by Sir B. Brodie : ABSCESS. 31 Abscesses may occur in the perineum attended with disease of the urinary organs, in the cellular membrane, or in any other part. Abscesses in the perineum are generally connected with the prostate gland, and occasionally with the bladder. The most common circumstances under which these abscesses form are when the patient labors under gonorrhoea. Thus, a patient has a profuse gonorrhoeal discharge, which at first di- minishes little by little, till it disappears entirely; this may happen in consequence of his using strong injections, but it often occurs in that stage when surgeons do not recommend injections, as in the inflammatory stage. The discharge suddenly ceases, then the patient complains of pain in the urethra, and experiences difficulty in making water, and particularly when in the commencement, from the pressure at the neck of the bladder, and the water comes away in a diminished stream. There is also pain felt in the back, groin, pubes, and sense of weight in the perineum. The stream is very small, and. sometimes there is complete retention. The patient at last feels fullness in the perineum, which increases very much, and which depends on the presence of matter which forms deep in the perineum. If this is left to itself it breaks, perhaps, in the perineum or in the neck of the bladder, or sometimes, instead of coming down to the perineum, it makes its Avay back to the rectum and bursts in front of the anus. Now, you will observe that in this case all the painful symptoms indicate inflam- mation of the neck of the bladder; I believe there is a translation of the inflammation from the urethra to the prostate gland or cellular mem- brane covering it. It may be that this inflammation is not only in the prostate itself, but in the cellular membrane covering it, in the same manner as you sometimes find suppuration about lymphatic glands. There is only one circumstance that would lead us to suspect that abscesses of the perineum have their origin in another way than what I have stated ; it is that when the abscess bursts, upon the patient making water, a small quantity of urine comes away from the perineal opening. When you are called to a patient under these circumstances of abscess after stoppage of the gonorrhoeal discharge, and there is inflammation of the neck of the bladder, it is very important that you should stop the progress of this inflammation of the bladder, to prevent its going on to suppuration. The patient should lose blood by the application of leeches to the perineum, or by cupping; hut employ none who is not a dexterous cupper, for it is not every cupper who can do it in this part successfully, though in London there are plenty who can do it very well. The patient may lose from gv. to §xiv. of blood, according to the intensity of the symptoms and the strength of his constitution. Give calomel and opium, so as to place the patient under the influence of mercury, as in the treat- ment of inflammation in general—as, for instance, of the iris; two or three grains of calomel and half a grain of opium, or more ; endeavor to get the gums affected as soon as possible, until there is time for the cup- ping to have effect. You may relieve the patient by means of an opiate clyster; I sometimes inject 5j. of tinct. of opium and fiij. of starch. The opium tends to allay the inflammation as well as the pain. A person sometimes cannot empty the bladder, and a straining is kept up from the morbid sensibility of the bladder, and this straining aggravates the in flamniation. Now, by administering opium you allay the pain which causes him to strain, and the consequence of the straining ceases. Another thing is necessary in some instances. The patient's urine must 32 ABSCESS. be drawn off with a catheter. Use, then, a small elastic catheter, and even when there is not absolute retention of urine, as when the patient is con- stantly straining to make water, because he cannot entirely empty the bladder, but at every time leaves some behind. This residuary quantity of urine keeps up a constant irritation, which the use of the small gum catheter will prevent; it may be used for this purpose two or three times in the day. But this catheter you must employ with alight hand, and as gently as pos- sible, as the inflamed parts are very much in danger of injury where the greatest care is not taken. Supposing the disease is in an advanced stage, and you have hardness and fullness of the perineum, and you examine the perineum, and can feel no matter there, but there is in one spot a more fluctu- ating feeling than elsewhere, and in some cases a rigor, or perhaps more than one. But the mere circumstance of hardness and increase in size of the parts is sufficient to show that there is a deep-seated abscess; and the matter is situated behind the triangular ligament, which prevents its coming to the surface, and hinders you from feeling the fluctuation of matter. If you wait till the fluctuation becomes distinct, you may wait till the abscess has produced serious injury, by dissecting its way among the neighboring textures. When you have hardness in the perineum in such a case, you must introduce the lancet in that part in which the hardness is most dis- tinct ; but the lancet will be required to enter very deep, even up to the shoulder, if the lancet is a common one, before you can reach the seat of the matter ; this is especially the case when your patient is fat, so that the lancet will barely reach it. However, you may introduce the lancet with the greatest confidence, there being nothing to injure ; if you introduce it to an insufficient depth, you do no good; and if you introduce it to a proper depth, the matter comes^way, and your end is gained. When no matter has been felt externally, I have sometimes let out §ij. or §iij. of pus, by this use of the lancet, from under the deep fascia?. In some cases you find that the abscess becomes fistulous ; a little urine drips out through the opening in the perineum, only a few drops perhaps at first; the flowing of these few drops will prevent the abscess from heal- ing, and make it a fistulous abscess; but the urethra contracts in the membranous part, and all you have to do is to introduce a bougie or sound every now and then into the bladder; the contraction is not a permanent one, and there is no difficulty in doing this; you may introduce a full- sized sound almost in the first instance ; should this, however, distress your patient, you ma use a small one at first, and increase the size by degrees —using it once in two or three days. By this means the urine will be brought out at its proper canal, instead of the unnatural opening, which soon heals. Abscesses of the perineum are often old strictures of the urethra. The patient's stricture prevents his making water in a full stream, and the urine is pressed against the back part of the urethra ; this constantly oc- curring, at last the part ulcerates. At first the hole is not much bigger than a pin, through which a: little drop of urine will escape into the cellu- lar membrane, whilst the great part will go along the natural passage and half a drop is sufficient to cause inflammation of this membrane ' You are called to a patient with an old stricture of the urethra and you find symptoms of matter forming in the perineum, hardness and swelling' but, besides these symptoms, there is very great constitutional disturb ABSCESS. 33 ance. You find a small, quick pulse, dry black tongue, hot skin, sordes of the teeth, and the patient looks like one dying of putrid fever. These symptoms are caused by the generation of carbureted hydrogen and sul- phureted hydrogen from the putrid matter resulting from the mixture of urine with pus; and patients have frequently died of the poisonous gases thus absorbed into the system. This is a very distressing ease, but you may generally relieve it. In cases of stricture of the urethra, the treatment of abscess is different in one respect from those in which the abscess arises from gonorrhoea: in these last you may prevent the formation of matter, but in the other case you cannot prevent it, indeed you should not, and by applying leeches and exhibiting mercury you only do harm; you may retard this forma- tion of matter and thus prolong the case, but you cannot prevent it. Rather let the patient foment the parts, let him use the warm bath, and do all you can to promote suppuration ; let him set over a bidet, and sponge the parts three or four times a day. Then, as soon as the abscess is well advanced, let out the matter with a lancet, especially if there are symptoms of presence of putrid matter, without a moment's delay : this has been done over and over again. Patients have been brought into this hospital at death's door, with hardness in the perineum, from presence of an old abscess, and all the symptoms of dying from putrid fever; I have run in a scalpel and found matter—I never failed ; the moment the matter has been let out, all thete symptoms have subsided. These cases of abscess in the perineum, with typhoid symptoms or re- tention of urine, or both combined, require immediate attention; their urgency will not allow you to go home and think about the case, or to con- sult with another upon it; Avhile you are so doing the patient might die ; it is, therefore, of the greatest importance that you should bear in mind what I have just said, in order that you may have a fund of knowledge available at any moment. The treatment of these abscesses, then, in the first in- stance, is as simple as possible, namely, abscesses in the perineum, con- nected with old strictures, require to be. opened, and, if not urgent, you may let it come near the skin before you make an opening, hut if it is urgent, however deep, you must make it directly. But I told you there was a communication between the urethra and abscess: sometimes the opening is small, and only a drop of urine can get into the abscess ; and Bometimes the opening is large, and the patient will make as much or more water through the orifice in the perineum, as through the natural passage. It was at one time thought that these fistulas should be laid open like fistula in ano. You cannot here perform that operation for obvious anatomical reasons. It was formerly supposed that all fistulas required to be laid open, but, except those in the rectum, there is no fistula requiring to be laid open unless there is a lodgment of matter. The first thing required for the healing is, that matter should come out as fast as it is generated, whether in one part of the body or another. Part xv., p. 229. Best means of Ope?iing certain Abscesses.—Dr. Hargrave criticises the ordinary practice of opening abscesses in the groin by an incision parallel to Poupart's ligament. He states that in this case the lips of the wound are never at rest, being continually displaced by the movements of the abdomen and by the motions of the thigh, which movements cannot ba 3 34 ABSCIISS. entirely prevented bv the best adjusted bandages. These unpleasant results can, he observes, be always obviated by opening the abscess by an incision at right angles to Poupart's ligament. By this practice, the abscess is fully evacuated, the lips of the wound assume an oval figure, they remain in repose, not being affected by the abdominal movements, and when the incision heals, the mark is scarcely apparent. ..... There are certain deep-seated abscesses, occasionally met with in locali- ties rendered dangerous bv the proximity of large vessels, such as the calf of the leg, the sole of the foot, and the neck. Dr. Ilargrave asks when the abscess is in the calf of the leg, at a considerable distance from the surface, between the thick superficial, and deep layer of muscles, and in the vicinity of the popliteal space, are we to cut boldly down to the matter, as is advised by some surgeons? Dr. Ilargrave thinks not, but recommends instead, that a careful examination be made along the external and internal part of the leg ; and if the abscess points externally, to make the incision parallel and posterior to the fibula, which will allow of the separation of the muscles, and puncture of the abscess without risk. In opening abscess in the sole of the foot, in which the matter has a ten- dency to pass through the metatarsal spaces, and to point on the dorsum of the foot, he advises that the pus be evacuated, not by a direct puncture through the sole of the foot, but by incision along the outer edges of the foot, near the fifth metatarsal bone, when, by dividing the subjacent tissues, the very centre of the sole of the foot may be reached without danger of wounding any important part. Part xvi., p. 321. Treatment of the Abscesses which precede Fistida in Ano.—Mr. Vincent says : I have many opportunities of treating those previous abscesses from which fistulas in ano are formed. In that mass of adipose substance filling up the ischio-coccygeal space, the patient's notice is perhaps drawn to a deep tumor, just differing in substance enough to be clearly distinguishable from the surrounding structure, of a doughy consistence, little sensible, and not at all rising to the level of the surface. This is, I apprehend, {he first abscess in its earliest state, which, if allowed to go on, will end in the genuine fistula in ano. I have had such cases in the hospital, and have no doubt that this is the fact, as I have compared these sort of swellings with other presentations in a more advanced stage in the formation of fistulas. The practice to be adopted is unhesitatingly pointed out: this lumpy mass is to be transfixed ; and this I have done the very first moment the case has been presented to me. I plunge a knife down to the very centre of the mass, and then I have found a small quantity of pus come out; and upon passing my finger down (and the opening should always be large enough to admit this part), I have found in the centre of the mass a small cavity of the peculiar pulpy feel that is familiar to sum-eons as the interior of an abscess. This prompt measure stops all further3 pro- gress of the abscess, which otherwise would lead its way either to the rectum or to the surface, and terminate in fistula. The course of these abscesses, when opened, is to close, and finally heal; but the surgeon must not expect that they will heal with the readiness of ordinary active abscesses. Part xxVl^ m Treatment of Mammary Abscess.—The following is a case of no very unusual occurrence: A mother loses her infant, and broken-hearted at the event, she neglects to pay that attention to herself which iier case ABSCESS. 35 requires. No attempts being made to relieve the distended breast of its secretion, the gland becomes hard and painful, and at length abscesses form in different situations. If the treatment is confined to the evacuation of matter by puncture, and to the application of fomentations and poultices, but little good is done. The former abscesses continue to discharge; fresh ones are constantly forming, and the woman at length sinks in a state of hectic. Means should be used to stop the secretion of milk, which has been going on all this time, and perpetuating the mischief. We have no better means of effecting this than by the administration of a hydra- gogue purgative. I am usually in the habit of prescribing the sulphate of magnesia in the compound infusion of roses, to which, when there is much hectic and debility, I add some quinine, and dilute sulphuric acid. The effuct of this treatment is sometimes almost magical. I have known a woman, who for months had been suffering from a succession of mammary abscesses, begin to get well from the moment that the salt produced its liquid evacuations from the bowrels(; the secretion of milk ceased, and the purulent discharge diminished, a more adhesive inflammation being established in the place of these two actions. Part xvii., p. 293. Abscess in the Perineum.—Mr. B. Cooped gives the following case:— I was sent for to see a patient who was suffering from retention of urine, of which the symptoms were so urgent that I immediately attempted to pass a catheter; not succeeding, however, in relieving the patient, I pro- ceeded to examine the perineum, where I discovered a tumor of con- siderable size; in this I made an incision, and a quantity of pus and urine was immediately evacuated. As the patient stated that he had been the subject of stricture for many years, I considered it better to open at once the membranous part of the urethra; I therefore passed a female catheter into the bladder, and, drawing off the urine, relieved the patient from the symptoms arising from the retention; I next passed a male catheter along the natural passage of the urethra, as a preliminary to the division of the stricture ; to my great surprise, the instrument passed readily on, and when the female catheter was withdrawn, at once entered the bladder: this circumstance showed that if I had attempted to pass the male catheter before I divided the membranous portion of the urethra, I should have found the more formidable part of the operation to be altogether unneces- sary. The experience I derived from this case has since often prevented me from cutting into the membranous part of the urethra, after opening an abscess in perineo, without first attempting to pass the male catheter along the natural course of the urethra; such a precaution is, indeed, ren- dered doubly necessary by the fact that abscesses in the perineum may result from external injury, without any other implication of the urethra or the canal than that arising from the mere pressure of accumulated matter, the evacuation of which immediately relieves the symptoms. Part xix., p. 181. Substitute for Tents in dressing Abscesses.—In place of introducing tents, which are not only painful, but give rise to other inconvenience^ M. Nonat passes a crayon of nitrate of silver into the opening, to the depth of from ^ to 1 centimetre, withdrawing it immediately. The pain caused by this is trifling and evanescent, and the eschar produced pre^nts the union of the walls of the trunk of the abscess. It is in abscess of the breast that this procedure has been found especially useful; the deepest 36 ABSCESS. abscesses being thus brought to heal in seven or eight days. The cau*en zation has to be repeated every two or three days. 1 art xx.,p. 180. Pelvic Abscess.—-The abscess must be opened where it points. If in the vagina, an incision may be made there ; but if in the hypogastric region; adhesion of the two surfaces of the peritoneum must be obtained before opening the abscess. In order to effect this adhesion,.apply a por- tion of potassa fusa cum calce, made into a paste with alcohol, to that part of the abdominal parietes where it is wished to make the opening. When, by the action of the caustic, after one or more applications, tho seat of the fluctuation is nearly reached, an adhesion is shown to havs taken place by the impossibility of moving the abdominal parietes ovc the tumor; then make an incision in the centre of the sore. Or, instead of using the caustic, make an incision through only a portion of the thickness of the abdominal parietes, and then apply linseed poultices; the pus will frequently find an exit through the sore. After the abscess is opened, use injections of tepid water, to remove foetid secretions, and to prevent the admission of air, by keeping the cavity full of liquid. Part xx., p. 230. Abscesses.—In opening abscesses, if the attenuated skin is of a circular form, so that when divided by the knife in any direction, it must leave broad thin flaps, apply caustic round the edge where the healthy and thin skin meet; and the whole of the latter being, as it were, included in a ring of eschar, will perish This plan answers well in large buboes, especially in scrofulous subjects. If the abscess has opened spontaneously, and there is much unhealthy skin, and also unhealthy granular and cellular tissue below it, use the caustic at once, as all this has to be got rid of before a cure can be accomplished. Part xxii., p. 343. Pelvic Abscess.—Among the most important of the cases in which puru- lent collections form within the abdomen are those known aspelvic abscesses, in which inflammation of the cellular tissue of one or other part of the pelvis ends in suppuration. In all probability the disease is generally located in the cellular tissue only, and may originate in any part of the pelvis. The prognosis of pelvic abscess following parturition is probably for tho most part favorable. The patients often sink into hectic under the profuse discharge which follows, but as there is no persistent cause of irritation (as in psoas abscess, or those depending on foreign bodies), they generally rally as the abscess diminishes in size. The treatment-should of course consist of the^ most liberal diet, combined with such tonics as may appear necessary. The abscess should be opened as soon as a tendency to point in any direction is perceived. The most favorable class are those, perhaps, in which the opening is into the vagina, as a free and depending channel of exit is then procured, while no risk from the contraction of the cicatrix afterward is encountered, as might be the case were the rectum the part selected. Part xxx., p. 158 Deep-Seated Abscesses.—The injection of deep-seated abscesses with tincture of iodine is coming into more favor in hospital practice. In two cases during the present month, in the analogous sacs of ovarian cysts one by Dr. West, at St. Bartholomew's, and another at University College Hospital, iodine was used. In a third case of immense abscess of the loma ACIDS AND ALKALIES—ACONITE. 37 not lumbar abscess), Mr. Paget found the iodine injection very valuable, The rapidity with which the iodine is absorbed and spread over the sys- tem, and then eliminated by the kidneys, seems to prevent excessive local stimulation. In hydrocele, iodine is almost always used, also, as the danger of too much local inflammation by the old port wine injection is thus avoided. Part xxxn.,p. 196. Abscesses in the Perineum.— Vide Art. "Perineum." —•-•-•— ACIDS AND ALKALIES. Proportions for the saturation of.—In the application of this table it should be observed, that the articles adduced are those of the London Pharmacopoeia of 1836, in their pure state. Supposing the articles kept by chemists and druggists to be in a perfect state of purity, this table will be found intrinsically correct, and available for all ordinary purposes in compounding prescriptions wherein " quantum sufficit ad saturationem" is ordered. ONE SCRUPLE. LEMON JUICE. CITRIC ACID. TARTARIC ACID. Potassse Bicarbonas............. Drachms. 3 to 4 6—6 2—3 SJ —4* Grains. 13-68 16-76 23-74 9-72 16-86 Grains. 1485 17-95 25 44 1041 18-07 " Carbonas.............. Part v., p. 82, —••• ACONITE. Action and External Use of.—Dr. Eades laments that the distinction oetween sedatives and narcotics is not more clearly defined, and remarks that, from the terms sedative, anodyne, soporific, and narcotic, being indis- criminately used by authors, the object of their treatment, or the treatment rtself, is frequently rendered obscure, if not doubtful. He then says: " To prevent any misunderstanding of the action of this substance, so "ar as our knowledge goes, I am anxious to have it classified among the ■jerebro-spinants, or, 'those agents,' to use the words of Pereira, 'whose primary and specific effect is a disorder of one or more of the functions of the cerebro-spinal system. To this class, therefore, are referred all those substances which occasion sleep, insensibility, erroneous perceptions, judg- ments, and volitions, or delirium, stupor, or coma, paralysis, convul- sions," etc. The cerebro-spinants are subdivided according to the nerves, motor or sen- tient, which they more particularly affect, or the systems upon which they more decidedly display their action. Thus Pereira places aconitum amongst those cercbro-spi'xants which cause paralysis of the nerves of sensation. 38 ACONITE. [With a view to test the correctness of this classification, Dr. E. made some experiments with aconitine upon animals, the results of which were " sufficient to show that aconitine acts as a paralyzer of the nerves of sensation, and does not cause stupor or convulsions; when the latter occur they take place a short time previous to death, and appear to be caused by a want of the circulation of the brain." The first case in which Dr. E. tried this remedy externally, was a "Mrs. II., of nervous tem- perament, married 6 years, had several miscarriages, caused by a morbid irritability of the sacral nerves." The form used was the tincture of the root as an embrocation with tincture belladonna—3ij. of each in |iv. of rose water.] To have a couple of teaspoonfuls rubbed upon the sacrum, inguinal regions, and inside the thighs. In the course of a few minutes there was a complete suspension of pain. For five months she had every fourth ■week these attacks, and frequently in the interval sudden and severe excite- ment. It was such attacks as these which caused her former miscarriages, and after the sixth week of gestation, they always excited uterine pains with more or less of a "bearing down" sensation. I found that the belladonna, when used alone, whether in the form of embrocation or a plaster, to the sacrum, gave no relief. At the expiration of the fifth month these pains returned no more ; she arrived to her full time and became the mother of a strong and healthy child. The second was a case of neuralgic attacks in the gums, jaws, and cheeks. As the patient was disposed to dyspepsia, these were supposed to be merely secondary, and the ordinary treatment was tried without effect. The tinct. aconite lotion, 3j. to §j., was then ordered as a gargle; and also to be applied externally to the cheeks ; after a few applications, this treatment succeeded perfectly, the pains not having returned for eight months. Dr. Eades has received accounts of cases where it has been tried, and one is mentioned which was communicated to him by a medical friend, of apparently pure neuralgic pain over the left eyebrow, " which occasionally extended over the same side of the forehead and temple, and also down as far as the zygomatic arch." [After a little aperient medicine had been given, bark was tried, toge- ther with leeches over the orbit, with hardly any good effect; the tinct. aconite was then tried per se, and the pain very soon yielded.] Of the preparations of aconite, the tincture of the root and'the alcoholic extract are the most to be depended upon. The preparations, as ordina- rily met with, are not to be relied upon. In general one may form a pretty correct opinion as to the probable strength of the preparation, by the tingling sensation it produces upon the lips, and the degree and dura- tion of numbness which follows. Those preparations which do not pro- duce both these effects I have found to be almost inert. Mr. E. concludes by saying: From my own observations, I would thus sum up the most remarkable symptoms, as exhibited by animals ; weakness, staggering gradually in- creasing insensibility of the surface, slowly increasing weakness of the voluntary muscles, ending perhaps in paralysis, great languor of the rmlse, more or less blmdness, and convulsive twitchings before death. Part xi., p. 19. Physiological and Medicinal Properties of Aconite.—The practical ACONITE. 39 inferences which Dr. Fleming deduces from a consideration of the actions of aconite on the circulation, are as follows : 1. That it is a powerful antiphlogistic. 2.- That it is calculated to be of great value in all cases where there is an inordinate activity of the circulation. 3. That it is contra-indicated, when there is obvious mechanical impediment to the passage of the blood, particularly through the heart or lungs. It is requisite, therefore, in every case, to ascertain that no such obstruction exists before commencing its use. 4. That it is contra-indicated when- ever there is irritability of the circulation, with great diminution of power, such as occurs after severe venous hemorrhage. The diseases in which aconite is said by Dr. Fleming to he useful are neuralgia in various forms, hemicrania, angina pectoris, cephalalgia general pains of fever, certain diseases of the heart, acute rheumatism, .lumbago, erysipelas, .cancer, pruritus, and hysterical spasmodic asthma. Those in which its use is most satisfactorily established, are neuralgia and rheumatism. It is decidedly objectionable in several of the above- named affections, particularly in the general pains of the typhus and other fevers, where the vis vitce is at a low ebb. Neuralgia of the Thoracic and Intercostal Nerves—Spinal Irritation. —I have found the topical application of the tincture extremely successful in the treatment of the neuralgic pains, so frequently complained of by females, as occurring about the seventh, eighth, and ninth ribs of the left side, as well as of spinal irritation, both when coexisting with, and inde- pendent of, these pains. Neuralgia of the Extremities.—In a case of crural neuralgia of the right side, where the pain was chiefly seated in a circumscribed spot on the inside of the patella, the external application of the tincture was, in eight days, followed by a complete cure. The disease, which occurred in a female of thirty years of age, was of three years' standing, and the part had been frequently leeched and blistered without effect—the potential cautery having been the only application which had afforded any relief. Dr. Cormack has communicated to me a case of severe neuralgia of the right hand, which was at first treated successfully by the internal use of the tincture. The pain afterward returned in two of the fingers, to a slight extent; but the patient could not be prevailed upon to resume the remedy, in consequence of its having formerly produced some dim- ness of vision. Two cases of neuralgia of the fingers, in which the aconite was had recourse to with success, are noticed in the table of neuralgic cases. As far as my own experience goes, I believe it will be found most useful in those cases of sciatica, which appear to owe their origin to a congested or inflammatory condition of the nerve. Aconite was recommended in acute rheumatism by Dr. Storck, and various other physicians have since followed the practice. The improvement following the administration of aconite is often very speedy, some alleviation of the pains being occasionally experienced in the course of an hour after the first dose has been taken, while there are few cases in which decided relief with abatement of the redness, tension, and tenderness, is not obtained in a few hours. A longer period seems to be required to disperse the inflammation in the smaller joints than in the larger ones. Av>nite not only effects a cure in a shorter period than any *0 ACONITE. other mode of treatment, but appears to possess the great negative advantage of not increasing the liability to extension of the disease to the membranes of the heart. Indeed, it seems rather to protect the patient from that dangerous complication. It may be thought that as aconite weakens the heart, it is probable that it will predispose that organ to suffer in the same way as blood-letting ; but this distinction must be borne in mind, that aconite acts as a pure sedative to the vascular and nervous systems, whereas blood-letting—although it produces a similar action when practised to a moderate extent—when performed largely and re- peatedly, has a peculiar effect in increasing the irritability of the heart. In a strong and healthy subject, with high inflammatory fever, a free blood-letting, practised at the outset, will not only be of service in afford- ing a more rapid relief to the patient's sufferings, but will place his system in & more favorable condition for the action of aconite, which, if properly- administered, will prevent reaction, and remove the necessity of abstract- ing more blood. Chronic Rheumatism.—Aconite may be used both internally and ex- ternally in this disease. The internal administration seems to be prefer- able, in what has been termed the active chronic rheumatism: that variety which is, perhaps, properly speaking, only a very mild form of the acute rheumatism, being attended with some heat and swelling of the part affected, and slight constitutional disturbance. On the other hand, I would recommend the external application of the tincture in what is termed the passive chronic rheumatism, " characterized rather by coldness and stiffness of the painful joints, with entire absence of con- stitutional fever." In every case, however, should the mode of treatment adopted fail to afford relief, the other should be had recourse to; while it is frequently of service to combine the internal and external use of the remedy. Administration of Aconite.—The alcoholic tincture of the root, pre- pared according to the following formula, is the best preparation of the drug for internal administration. It may be given simply with water, or it may be prescribed along with antimony, opium, or other remedies. Tinctura Acoxiti.—Take of root of A. napellus, carefully dried, and finely powdered, sixteen ounces, troy; rectified spirits, sixteen fluid ounces ; macerate for four days; then pack into percolator; add rectified spirits until twenty-four ounces of tincture are obtained. It is beautifully transparent, of the color of sherry Avine, and the taste is slightly bitter. As an anodyne, anti-neuralgic and calmative, five min- ims ought to be given at first, three times daily, to be increased daily to the extent of one minim each dose. The best method of administering the remedy in diseases of the heart, is to give it in smaller doses than those recommended for its use as an anodyne, but more frequently repeated, as three or four minims five times daily. Sickness may be avoided or checked bv an effervescing draught, administered with, or immediately after, the dose. External Use-The aconitina may be applied' externally, either in the form of solution in alcohol, in the proportion of one or more grains to the drachm, or of ointment made in the following manner : P. Aconitina}, gr. xvi.; spir. rectif., m. xvt, tere optime. Deinde addo axungize, 3j., ut fiat unguentum. If, as occasionally happens, this ointment, after two or three applies* AIR. 4JL tions, fail to produce its ordinary effects, the proportion of aconitina must be increased to three, four, or even eight, grains to the drachm. It is much to be regretted that the difficulty of preparing the akaloid, and its con- sequent high price, should prevent its more general use. A preparation of inferior quality, or, as is frequently the case, totally inert, is very com- monly substituted for it in the shops—a circumstance which fully accounts for the low estimation in which it is held by many who profess to have tried it. The tincture, however, will be found an excellent substitute. One or more drachms of it are to be rubbed over the affected part three times daily, the friction being continued at each time for a quarter of an hour, or, indeed, until the topical effects of the drug are fully developed. It is hardly necessary to add, that, when there is any abrasion of the skin, the external application of either of these preparations may be attended with danger. Part xii., p. 37. Dr. Fleming^ Tincture of.—Recommended in cases of tetanus. It acts mainly on the spinal cord, inducing muscular paralysis, and affecting the brain but little, if at all. Pari xxxix., p. 70. AIR. Air—Exclusion of, in the Treatment of certain Diseases.—A favorite application in France, in cases of internal inflammation, is a large poultice. This is very useful, for example, in pleuritis and peritonitis. On this mode of treatment Dr. Marshall Hall makes the following remarks: It is probably by the exclusion of the atmospheric air that other reme- dies for inflammatory diseases act; the various plasters, the nitrate of sil- ver, even blisters, have this effect. I do not, however, mean to insinuate that they have no other. Cataplasms may further act by their warmth and moisture. The nitrate of silver possesses some extraordinary power over the actions which constitute or coincide with inflammation. But, certainly, mere adhesive plasters have an efficacy in cases of chronic chest affection, in lumbago, sciatica, and other forms of rheumatism, in neuralgia, and even of scirrhus, which cannot be easily explained. One of my patients, a martyr to extensive sciatica, was desired to enve- lop the limb in adhesive plaster. He was a joiner, and an ingenious man. He prepared the common stocking material with glue, dissolved in the proportion of one ounce to two pints of water, and had it spread over, when dry, with galbanum plaster, and if this exuded it was dusted with flour. By the steady application of this plaster his severe rheumatism was cured. I was once informed by a celebrated physician that he had prescribed adhesive plaster-to be applied over a scirrhous tumor of the mamma. It remained adherent for years, and the disease remained stationary. The plaster then separated and from that period the disease pursued its devas- tating progress. Certain modes of the treatment of burns consist in excluding the influ- ence of the atmospheric air. Some affections of the face are remedied by applying a layer of gela- 42 ALBUMEN. tine. Isinglass is dissolved in water, and the solution is jP}^ ^» camel's-hair pencil and allowed to dry. ALBUMEN. Detection of Albumen in Urine.-ln cases of ^™>u8 "™e» " necessary to bear in mind the recent investigations of Di Rees lhe copulation of urine by boiling, has hitherto been considered a sufficient proof of the presence of albumen ; but this is not the case ; urine may con- tain not only the albumen but also an alkali, and in this case boiling will not coagulate it. Albumen, therefore, may be present and not detected, accord- ing to the-hitherto received mode of detection ; it is necessary, according toDr. Rees, to add nitric acid, in which case, a copious precipitate will be produced, if an alkali be present. Dr. Rees asserts, that the knowledge of the acid or alkaline condition of urine cannot assist us m determining whether or not it contains albumen, by applying heat alone, it a positive result be obtained, " for the coagulum may be caused by the earthy phos- phates, whether the urine be alkaline or acid; but the case is different when the result is negative, since acid urine never prevents the precipita- tion of albumen by heat, though alkaline urine may, and therefore a speci- men, if shown to be acid, and not coagulable by heat, may safely be declared free from albumen." But nitric acid may also mislead the prac- titioner, unless perfectly conversant with' the changes produced by other substances; thus, when the lithates exist in the urine in excess, a mineral, acid will cause a deposit of lithic acid; but this is generally of a brownish red color, and very different to that of albumen produced by nitric acid. Part n\.,p. 53. Circumstances influencing the Coagulation of Albumen.—Mr. Badley remarks as follows: A short time since some urine was left me for exami- nation, containing pus. It was filtered, and heat applied to the clear fluid, jvhich was acid, to ascertain the quantity of albumen it contained; but it was boiled without effect. The non-occurrence of coagulation being unusual under such conditions, I added some nitric acid, which immediately caused a precipitate that became floccnlent by heat. It is stated by Dr. Rees (whose researches in this department have deservedly given much authority to his name), that "acid urine never prevents the precipitation of albumen by heat," and that " a specimen shown to be acid, and not coagulable by heat, may safely be declared free from albumen." Here, however, was acid urine containing a considerable quantity of what I could not but consider albumen, yet unaffected by a boiling temperature, and therefore quite at variance with the above statement. On inquiry, the only thing I ascertained was, that some nitric acid had been previously poured into it. These two reagents, heat and nitric acid, are generally considered not only indispensable in examining urine for albumen, but when used together, certain in their indications. The acid is thought by some to aid the effect of heat; its tendency is, to a certain extent, how- ever, to oppose it. The one is undoubtedly essential to correct the fallacies of the other ; but care should be taken that what is intended to correct ia not itself a cause of error. Dr. Watson states that nitric acid " wul ALBUMEN. 43 detect albumen when the tested urine is alkaline;" this is well known, " and by restoring its acidity, wall make the albumen discoverable by the test of heat." This, however, is a condition which will as effectually pre- vent the coagulation by heat as the previous alkalinity ; a drop beyond what would neutralize the alkali being sufficient for such a result. When the urine, therefore, is alkaline, the acid should always be employedas the precipitant, and never with the intention of " restoring acidity." Part xn.,p. 115. Singular property of Albumen.—The following is valuable, as pointing out one of the sources of fallacy which may occur in testing for albumin- ous urine. Professor Wunderlich remarked that any albuminous fluid loses the pro- perty of coagulating by heat, when the free alkali contained in it is neu- tralized by a few drops of nitric or muriatic acid. Even if a slight tur- bidness should result from the addition of the acid, this disappears on heat- ing the liquid. Remarks.—We have observed a similar effect on the addition of acetic acid to an albuminous liquid : but it appeared to depend on the quantity of albumen present. It was long ago shown by Magendie, that when acetic acid was added to serum, the mixture might be heated without coagulation taking place. It merely became opaline; and on cool- ing, if not too dilute, it became solid; on again heating it, liquid. Part xii., p. 115. New Test for Albumen.—The highly acid liquid obtained by dissolving mercury in its own weight of nitric acid, constitutes an extremely delicate reagent for albumen and albuminous compounds. This mercurial solution communicates to albuminous substances an intensely red color, by means of which a very minute proportion of albumen in water may be detected. To give an idea of the delicacy of this reagent, and to show its applica- bility to the study of vegetable organization, it may be stated that starch and gum acquire by its action a very distinct rose tint. Urine almost always becomes colored of a rose tint after the nitro-mercurial solution has been mixed with it, and the mixture has been warmed. The albumen of the blood, that of serous effusions, of plants and fibrin, casein, gluten, legumin, silk, wool, feathers, horn, epidermis, gelatin, chondrin and pro- tein, are equally affected. Protein rendered soluble by the prolonged action of an alkaline ley, or by sulphuric acid, is also colored red, but no preciptate is thrown down. This mercurial solution is most readily prepared by dissolving mercury in its weight of nitric acid (1.4) in the cold. When reaction has ceased, a gentle heat may be applied to facilitate the solution of metal. When the solution is complete, the liquid is to be diluted with two parts of distilled water by measure. After some hours the liquid is to be de- canted from any mixed crystals of nitrite and nitrate of mercury, that may subside. One or two drops of the test liquid are sufficient for the detection of albumen. Albiynen has been detected in the liquid of cholera, when nitric acid and heat have failed to demonstrate its presence. This reagent acts on albuminous substances at low temperatures, but not so completely as at a temperature of from 140° to 150° Fah. Part xx., p. 96. 44 ALBUMINURIA. ALBUMINURI A.—(Vide "Kidney Affections.") Large purgative doses of cream of tartar, given two or three times a week,"in eases of this almost invariably fatal disease, were found to afford more relief to the uneasy sensations of the patient than any other remedy. Suggested to combine some diuretic, especially the infusion of diosma combined with sweet spirits nitre and tincture of squill. The tincture cantharidis was not found serviceable. There seems to be a certain analogy between various organic diseases of certain viscera, as tubercle in the lungs, cirrhosis of the liver, granular degeneration of the kidney, and opacity and thickening of the valves and membrane of the heart, all of which are regarded as the result of a deposit of lymph of an imperfectly organizable character, such lymph showing a strong tendency to induration and contraction subsequently to its deposition. Hence we may suspect that when one of these diseases is present, we will find analogous affections in the other organs which arc disposed to receive these depositions. And in the cases detailed, granular disease of the kidney was found to be connected with tubercle of the lungs, and with a cirrhose state of the liver ; also with diseased valves of the heart, and with tubercular deposit on the peritoneum. When the proper texture of the kidneys is thus sup- planted by a deposit of lymph of an imperfect character, we can easily see how their functions may be-changed. If these organs possess the property which Dr. Prout assigns to them, of exerting a disorganizing influence on the materials to be discharged from them, this morbid deposit -will so alter their powers that the fluid part of the blood will be poured out as through a mere filter, retaining more or less of its albuminous character. Part ix., p. 9. Treatment of Albuminuria.—The treatment of a case of ordinary al- buminuria will depend in some measure on its complications—especially with cardiac disease. If it be an acute case, in which there is reason to suspect an inflammatory and congested state of the kidneys, the first step will often be to diminish the quantity of unhealthy blood by bleeding ; this should be accompanied or followed by hydragogue purgatives. Some practitioners prefer giving large doses "of bitartrate of potass, as half an ounce or an ounce every morning; others prefer elaterium when the stomach will bear it. Some prefer acting entirely on the alimentary canal, for the purpose of relieving the renal congestion and diminishing the quantity of liquid in the system, while others combine the use of diuretics of a more or less powerful nature. This latter mode, however, can only be admissible when the acute stage of inflammation has subsided, and when their use can have no irritating effect on the parts. The com- bination of the infusion of digitalis, as pointed out in Dr. Munk's paper, may probably be useful in all stages of the disorder, and especially as car- diac disease is so frequent a complication. Part x n 14. Compression of the Renal Vessels as a cause of Albuminuria -Mr. George Robinson, from experiments which he instituted to ascertain the cause of the appearance of albumen in the urine, has found that " ob- struction to the return of blood through the renal vein," give rise to the escape into the urinary passages, not only of liquid albumen and blood ALBUMINURIA. 45 but also of coagulating lymph or fibrin. Similar results were obtained when an increased quantity of blood was directed to one or both kidneys, no obstruction being offered to its return. In the first class of experiments, seven in number, a ligature was tightly applied to the renal vein ; in one case the urine, at the end of six minutes, was found highly albuminous, with traces of fibrin, whilst in another, after an hour's compression, it wa3 merely bloody. In four out of the seven, however, albumen was present. From these experiments Mr. R. infers that the degree of obstruction is only one of the conditions necessary for the exudation of the more viscid parts of the blood, and that various kinds of effusion may result from the same amount of obstruction. He explains these different degrees of exu- dation to be dependent upon the amount of arterial impulse at the moment of tying the ligature, and says he observed throughout that in these ani- mals which recovered most speedily from the operation, the effects of compression were manifested in the most intense degree. In the second class of experiments, increased determination of blood to one or both kidneys was effected in some cases by the removal of one of the kidneys, in others by tying the aorta below the spot where the renal arteries arise, and this was found much the most effectual way. In four experiments the urine contained more or less albumen. Mr. Robinson considers that his experiments prove— 1. That simple compression of the blood in its smaller vessels, will, in a direct ratio to the degree of intensity of that compression, cause the eru- dation of an albuminous fluid, of coagulating lymph, or the extravasation of blood. Its immediate effects, therefore, precisely resemble thpse of in- flammation ; and as it is well ascertained that both the essential causes of undue compression (viz., an obstruction or impediment to the flow of blood through the vessels of the inflamed part, and excessive action of the heart) coexist in that disease, it seems but reasonable to infer that the primary effects of inflammation, being identical with those of undue com- pression oCthe blood, are the mere consequences of that physical cause. 2. That there is no relation between the composition of the effused matters and the extent of the dilatation of the coats of the vessels, as measured by the quantity of blood they contain. These experiments of Mr. Robinson seem, therefore, to offer an easy ex- planation of the existence of albuminous urine in pregnant women ; and in future it would be well for medical men when they meet with cases of oedema of the face, eyelids, etc., or disordered states of the kidneys, to examine minutely for albumen, and where this is present to be on their guard for fear of puerperal convulsions. These will probably be found to be more severe when the urine has been albuminous during pregnancy, than when it only becomes so during labor. In this latter case the con- vulsions will generally be milder, and the urine will be albuminous tor a shorter time than in the former case. In the sthenic form we must have recourse to active depletion, tartarized antimony and purgatives ; taking care to interfere as little as possible with the os uteri. Part xi., p. 68. Albuminuria treated by Vapor-Baths and Extract of Rhatany.—The patient had been the subjectof anasarca for fifteen years, with an exception of a short interval, when the symptoms had been relieved by warm baths, aromatic fumigations and iodide of potassium. In the beginning of last December he presented the following symptoms: 46 ALBUMINURIA. The legs and scrotum were considerably infiltrated, and ascites was present: a general sensation of lassitude, and pain in one, sometimes both sides of the abdomen, were complained of; the bowels were con- fined, the appetite preserved, and frequent paroxysms of cough were ob- served ; the urine was pale, slightly acid, abundant, and contained a large quantity of albumen—coagulable by heat and nitric acid. Every day 3ss. of extract of rhatany was exhibited in a mixture ; vapor baths were or- dered, and low diet/ Under the influence of this treatment a gradual amelioration occurred, and on the 10th of January the urine contained no more albumen. On the 12th, the patient left the hospital, if not completely cured of his renal disease, at least cured of the symptoms which he had labored under, and which are generally looked upon as characteristic of granular disease of the kidney. Part x\.,p. 135. Albuminuria— Chronic.—Give elaterium as a purgative; it will relieve the dyspnoea and assist the action of the diaphoretics. Insert a seton or an issue, but do not let the discharge be too profuse. When all inflam- matory symptoms have subsided, give iron ; either the mist, ferri comp, or the ammonia citrate, taken in soda or Seltzer water. [Or give pulv. potass, bitart. |ss.; pulv. jalapae ~ss., in a tumbler of water every morning, or every other morning, counteracting the prostrat- ing effects by some gentle stimulant, as a little weak whisky and water, or diluted chloric ether.] Part xvi., p. 160. Indications of Treatment—Are, 1st, to remove the exciting and pre- disposing causes where they exist, such as intemperance, and residence in an unwholesome atmosphere; 2d, to oxygenize the blood by active exer- cise in the country and in the open air; 3d, to avoid fatty and all other non-nitrogenous articles of food ; 4th, to administer alkalies in free doses, which, by their action on the animal fats, will probably render their elimi- nation more easy of accomplishment; and, 5th, to administer purgatives, so as to keep up a tolerably free action of the bowels. Part xviii., p. 137. Use of Purgatives and Tonics.—Speaking of the employment of hydra- gogue purgatives in the treatment of this disease, Dr. Ileaton observes: I find none more convenient than croton oil, which produces copious evacuations, and with less sickness and discomfort than are caused by ela- terium. Some of the neutral salines, as sulphate of potash, are likewise useful for this purpose; these should be given in rather a concentrated solution, which then determines an endosmosis of the watery part of the blood into the intestine from the blood-vessels, which, thus deprived of their natural tension, become actively absorbent of the dropsical effusion which they had before allowed to escape. But if the saline be given much diluted, or, what is in effect the same, if followed by much diluent drink, it then enters the blood and acts upon the kidneys. Cream of tartar is likewise useful as a hydragogue purgative of mild operation, when given in full doses, and what enters the blood acts favorably upon the kidneys [When there are no febrile symptoms, and it is required to give tonics to improve the general health, Dr. Ileaton says:] In this disease, no medicines are equal to the preparations of iron and of these I know none so suitable as the tincture of the muriate which combines diuretic with its chalybeate properties. In many cases 'i have found most marked benefit from the use of this remedy, both to the gene- ALBUMINUEIA. 47 ral health of the patients, and in producing a more healthy condition of the urine, which is the best proof of actual improvement. The effect of this disease upon the blood is very marked and characteristic; besides the accumulation in the blood, of urea which should be excreted by the kid- neys, and the diminished proportion of albumen in the serum, there is a very great reduction in the amount of red globules which it contains. This is evident in the pale leucophlegmatic appearance of those who have been long the subject of albuminuria ; and we know that no medicine has an effect equal to chalybeate preparations, in restoring the red globules to blood in which they are deficient. Part xix.,p. 110. Use of Gallic Acid in Albuminuria.—Give gallic acid in doses of eight or ten grains every six hours, in some convenient vehicle; not neglecting the use of other remedies to relieve occasional symptoms. Part xxi., p. 173. Albuminuria.—The presence of pus in the urine may obscure the diag- nosis in this disease. The pus corpuscles float in a fluid containing albu- men ; it thus becomes mixed with the urine and renders it albuminous. A good test for pus is the addition of liq. potassae, by which it is converted into a mucous fluid, and when poured from a vessel exhibits its glairy character. We must endeavor to obtain the urine free from pus, and if the urine then ceases to be albuminous, it is evident it has no connection with Blight's disease, and vice versd. If, then, albumen exists in the urine independently of pus and blood, and if we have excluded puerperal fever, gestation and cholera, as possible causes, we may conclude the patient to be subject to one of the forms of Bright's disease. Now, as owing to the drain of albumen, there is an excess of water in the blood, we must endea- vor to render the specific gravity as nearly proper as possible. To pro- mote this, experience has decided upon the use of hydragogue cathartics, vapor baths and iron. Iron should not be given in the active stages of the disease. As regards the use of iron in anemia generally, we are advised to persevere with its use, notwithstanding the frequent complaints of the patient that it does not agree with him. Abstract, then, the excess of water from the blood by saline purges, and persevere in introducing iron into the system. Part xxiv., p. 136. Albuminuria.—Albumen is to he detected by nitric acid and heat. Albumen may be present in cholera, puerperal fever, pyelitis, gestation, or inflammation of urinary mucous membranes, but especially in 1st. Acute Desquamative Nephritis.—Here is inflammation or conges- tion characterized by fibrinous casts with blood discs, nuclei, and epithelial cells, united by fibrinous matter. 2d. Chronic Desquamative Nephritis.—A chronic form of last. By long-continued shedding of epithelium with the urine, in a more or less disintegrated state. 3d. Waxy Degeneration of Kidney.—By the discharge of waxy casts in urine, varying in size. All the cases of this kind, which Dr. Johnson has seen, have recovered. 4th. Non-desquamative Disease.—The elimination of some poison, as scarlet fever. There is congestion or inflammation and escape of serum, but no exfoliation of epithelium. 6th. Fatty Degeneration.—Large quantities^of oil globules, mixed with 48 ALBUMINURIA. epithelial cells and tube casts. Oil cells are known by their rounded, uniform shape, and by their broad, black margins, produced by their strong refractive power. ^>art xxvn-i P- 92- Albuminuria.—In that form which occurs after scarlet fever, it win generally disappear by the rigid adherence to a milk diet; if this should not suffice, urea given in doses of one-third of a grain, occasions an abund. ant secretion of urine and rapid disappearance of the dropsy. Part xxxiv.,p. 118. Albuminuria.—The happiest effects frequently follow the treatment of cases of albuminuria, early in the disease, by iron. It acts not solely by imparting red corpuscles to the blood, but by counteracting the commenc- ing deterioration of the liquor sanguinis, which constitutes the very es- sence of the disease. It should be given for a long period, extending over many months, and combined with nutritious diet, and occasional use of jalap purges. A vapor bath may be given once or twice a week, and flannel worn next the skin. A case is recorded in which, under the use of iron, anasarca entirely disappeared ; the urine became perfectly clear, and nine years after contained no albumen, though previously loaded with albumen. Part xxxviii.,_p. 112. Albuminuria—Scarlatinal.—As the renal disorder which succeeds to scarlet fever is identical with the acute form of morbus Brightii, it fol- lows that the principles on which these cases should be treated must be the same. They are summed up by Dr. Basham as follows: lessen the watery or dropsical state of the blood, and diminish the local blood stasis in the kidneys. The first is obtained by acting briskly on the intestinal track of mucous surface, by which a large amount of fluid is rapidly elimi- nated from the system. The second object is secured by calling into activity the functions of the skin by diaphoretics, warm clothing, and warm, or hot-air baths. The functions of the skin are vicarious of those of the kidney, and whatever augments the first, lessens the activity of the latter. The congestion of the kidneys is further alleviated by dry cupping, and occasionally by abstracting blood, by cupping, from the loins; but the cases are exceptional which will require the abstraction of blood. If these objects can be successfully attained—indicated by the disappearance of the dropsy and the absence of blood from the urine—no time should be lost in placing the organism in a condition to regain those qualities and powers, the loss of which are most plainly manifested by the impoverished state of the blood. Amongst medicinal remedies, the ferruginous are the most essential; and amongst these, the tincture of sesquichloride of iron is the most valuable and efficacious. But chalybeates are useless without a well- ordered diet. Nutrition must, therefore, be promoted, and it may he aided by a limited allowance of wine. Our best-directed efforts are, how- ever, often frustrated by the intensity of the disease and rapidity of its progress. Part xxxix., p. 20. Albuminuria in Cases of D^htherite.—Dr. Wade ur. 119. Hemostasis.—To prevent hemorrhage in certain cases of amputation, the employment of hemostasis is recommended. This consists in the application of ligatures to the extremities, sufficiently tight to arrest the venous circulation, while they allow the arteries to pul- sate. A large proportion of the blood may thus be temporarily withheld from the general circulation. Vide "Hemorrhage." Part vii.,^>. 67. Amputation at the Ankle Joint.—Case cited from disease of the astra- galus, os calcis, and other tarsal bones. It has been too frequently the custom for surgeons to amputate the leg below the knee in cases where neither Mr. Hey's amputation between the tarsus and metatarsus, nor that of Chopart's, which leaves only the astragalus and os calcis, could be of use. So long as the disease exists in the foot below the astragalus and os calcis, Chopart's operation would be invaluable, and when it exists still lower down, that of Mr. Hey's must be equally, if not more so, but even where the astragalus oros calcis, and even where the ankle joint is impli- cated, amputation of that joint, and taking off the diseased extremities of the tibia, is now practised with success ; thus enabling the patient to walk with very little artificial assistance, and to a very considerable extent diminishing the danger of amputation below the knee. When we consider that the diseases which have hitherto required amputation of the le«- below the knee seldom affect the leg itself, because when they do so, amputation above the knee is generally required, we shall see at once that an opera- tion by which the leg is saved, is not only practicable, but of the greatest consequence: and this observation extends also to diseases of the foot for which amputation at the ankle joint will often be found exceedingly useful. In cases, therefore, of compound dislocation of the astragalus and caries of this bone, with its adjoining articulating surfaces, amputation at 'the ankle joint ought generally to supersede the old practice of amputation below the knee : and even when the whole ankle joint is diseased, and the articulating extremities of the tibia and fibula are implicated, these dis- eased portions may be safely removed by the saw, as the caries seldom penetrates to any great depth into the cancellated texture, and much more frequently exists almost exclusively between the astragalus and os calcis, and not between the astragalus and bones of the leg. Three very impor- tant advantages, therefore, result from this operation : 1st. A more com- fortable stump is formed. 2d. The risk of life is much less. 3d. The limb will be much more useful and seemly. Part vii. p. 126. Hemorrhage after Amputation.—Two cases mentioned, of venous 58 AMPUTATION. hemorrhage occurring immediately after the arteries had been tied, from obstruction to the venous circulation by the retraction of the fascia or integument, a free incision through which caused an instant cessation of the Toss of blood. lart lx->^' m- Disarticulation at the Ankle.—This operation, which has been so strongly recommended by Mr. Svrac, is certainly a great improvement in surgery, and will be available when neither of those recommended by Hey and Chopart can be useful. It will, in fact, leave the patient a very useful leg. How many cases do we now see in the country, in whom amputation below the knee has been performed for disease and accidents below or at the ankle joint, when amputation of this joint, and the preservation of the hard skin on the heel might have secured to the patients the use of limba almost as useful as the perfect ones. We have to thank Mr. Syme for bring- ing this subject repeatedly and prominently before the profession; and more especially for making such a flap of the under part of the foot and heel, as to enable the ends of the bones to bear the necessary degree of pressure. In his earlier operations, Mr. Syme seems to have made the flap too long, and now gives directions to perform the operation somewhat different. " The incisions across the instep and sole of the foot should be curv- ed, with the convexity forward, and exactly opposite each other. A line drawn round the foot, midway between the head of the fifth metatarsal bone, and the malleolar externus, will show their extent anteriorly, and they should meet a little further back, opposite the malleolar projections of the tibia and fibula. If the ankle joint is sound, the malleolar processes should be removed by cutting pliers; but if the articulating surfaces of the tibia and fibula be diseased, a thin slice of these bones should be sawn off." The stump is conical, and has for its apex the thick skin of the heel. When we consider how rarely amputation below the knee is performed for disease of the leg, and how much oftener for diseases of the foot and ankle joint, we may expect to see this operation come into much more general use. In compound dislocation of the ankle joint, for example, will it not be safer to have recourse to disarticulation, than to attempt to preserve the whole limb ? Many lives have been lost in attempting to retain the foot in these cases; only two out of thirteen cases in the Royal Infirmary of Edinburgh recovered ; and even when the foot is saved it is so stiff and weak as to be rather an incumbrance. There is some reason in running considerable risk, when the only alternative would be amputation below the knee, but none when we remember that amputation at the ankle would not only considerably diminish the risk to the patient, but would secure as good a limb as in the other case. Mr. Lyon, of Glasgow, points out the risk of sloughing to the under or posterior flap when it is made too long, as in some of Mr. Syme's earlier cases, and hence the necessity of adjusting its edges very carefully to those of the anterior flap, in order that it may receive blood from this as early as possible ; and hence also the necessity of keeping up the temperature of the part by carded cotton, warm water dressing, or the like. It seems that in many cases the head of the femur itself may be excised, instead of having recourse to amputation at the hip-joint. Dr. Bonino draws the at- tention of the profession to this subject. Part x » 107. Amputation at the Knee.—There are few operations in surgery which have excited much more discussion, or afforded room for the exercise of more ingenuity, than amputation of the thigh. And although the various AMPUTATION. 59 modifications which have been introduced have certainly had the effect of restraining the hemorrhage, diminishing the suffering, and promoting union of the wound, the average frequency of deaths is still not less than from 50 to 70 per cent., whilst protrusion of the bone is a frequent sequela. Mr. Syme says that: Having seen the circular incision give place to the flap operation, and having witnessed the results of these methods variously modified in the hands of many surgeons possessing every degree of operative skill, I am at length led to the conclusion, that there is something radically wrong in the principle of the operation. This error I believe to be, dividing the thigh-bone through its shaft instead of the condyles or trochanters. The most frequent occasion for amputation of the thigh is afforded by disease of the knee-joint. Next to this may be ranked compound fractures of the leg and thigh; and then tumors growing from the bohes of the leg and thigh. Now, in regard to diseases of the knee-joint, it is well ascer- tained, that the warrant for amputation lies in the bone, and not in the soft parts, which, however much altered through scrofulous degeneration or suppuration, readily admit of restoration to their natural condition, as is clearly shown by what happens after excision of the elbow, or amputa- tion at the ankle joint. In so far, therefore, as removal of the disease is concerned, it is plain that amputation through the condyles of the thigh bone would in this case prove sufficient. As to compound fractures of the leg, it will be admitted that if the integuments and muscles admit of the limb being removed at the middle, or lower third of the thigh, they cannot present any obstacle to a few inches more of the bone being preserved, while similar injuries of the thigh obviously require amputation at the trochanters. The same observation will apply to tumors of the bones, those of the tibia and fibula not requiring any more of the thigh-bone to be removed than may be suggested by convenience, and those of the thigh- bone itself demanding the highest practicable point of section. From this analysis it appears that taking merely the morbid condition into account, all the cases admitting of amputation at or below the middle of the thigh- bone, would admit of the operation being performed through the condyles. The superiority of this operation to the one formerly practised, consists in the less amount of liability to exfoliation of spongy in comparison with dense bone; the medullary membrane, not being interfered with, is not likely to inflame and suppurate, and phlebitis is not likely to occur, and thus the chances of a favorable issue of the operation are very much in- creased. Protrusion of the bone, we may expect, will hereby be avoided, and thus the neatness of the stump will not be interfered with. The first case was a young man, 21 years of age, admitted January 29th, 1844. The left knee had occasionally been painful for five years, and for the last twelve months had increased rapidly in size. A large abscess, pointing on each side of the ligamentum patellae, was opened, but the local uneasiness continued to increase, and the general health declined. The operation was thus performed : Having applied a tourniquet, so as to compress the femoral artery where it enters the popliteal space, I made an incision across the knee on a line with the upper edge of the patella—then pushed the knife from one side to the other under the joint—cut a flap from the calf of the leg—and finally sawed through the condyles of the thigh-bone, so as to remove the whole articulating surface which was ulcerated and carious. On bringing the 60 AMPUTATION. edges of the wound together, I found the flaps were scarcely gently long, as they required a little stretching to meet and when st chcd appeared moVe tense than is usually consistent with adhesive union It w^as, therefore, with considerable surprise, and no less pleasure, that we saw the healing process proceed without retraction of the covering from the bone. Thl edges of the akin indeed separated from each other to the extent of nearly two inches, but the subjacent textures remained adhe- rent, until the superficial sore gradually contracted and cicatrized. Ihe recovery, though thus rendered slow, was ultimately completed, and the patient returned to his distant home on the 31st of Ma}'. The result of this case tends to confirm the expectations that had been previously formed with regard to the advantage of amputating through the cancellated extremity instead of the shaft of the thigh-bone, since there could be no doubt that exfoliation of the surface to any extent, how- ever small, would have been attended Avith separation Of the flaps and projection of the bone. The second case was a young woman, 22 years of age, with disease also of the left knee, of nearly three year's standing. Frequent application of the moxa and other means having failed of affording relief, and the general health rapidly declining, amputation was resolved on. Profiting by former experience, I on this occasion made the anterior semilunar incision on a line with the lower edge of the patellae, and had the integuments retracted, before cutting into the joint above this bone. In other respects the operation was conducted as the first one had been, and when the edges of the wounds were approximated, they came easily together, presenting a proper degree of fullness, without any straining or tension. The union was nearly completed by the first intention without any local or constitutional disturbance ; the flaps, instead of showing any tendency to retraction, rather becoming more full and soft; and the patient presenting the aspect of one who had sustained some trivial injury, rather than undergone a capital operation. On the 14th day she was sit- ting by the fire, and took the dressings off without any assistance. This case should, I think, remove any doubt that may have existed^ as to the safety of amputating at the knee, and consequently as to the expediency of doing so with a view to avert the danger of operating through the shaft of the thigh bone. It is upon this ground that I wish to found the operation, and I therefore have said nothing of some other advantages which might be mentioned—such ^ as the greater length of stump which, especially in females, must be desirable for the sake of appearance, and may, perhaps, be made available for using a support admitting of flexion at the knee—or the facility afforded to employ the tourniquet, which causes serious embar rassment in removing the limb at any higher point. I may remark, that the posterior flap must be made very long, and indeed to the full extent of the fleshy part of the gastrocnemii muscles—care being taken, however, to avoid preserving more than a moderate portion in regard to thickness. Part xx.,p. 111. Amputation of the Elbow and Shoulder Joints.—In many of the dis- eases of the elbow and shoulder joints, amputation is not required. The diseased bones may easily be taken out, and a considerable decree of motion may be retained. Park and Moreau first adopted this valuable mode of operating, and it is now become pretty general. AMPUTATION. 61 Mr. Liston says : It is a troublesome thing to separate the articulation in a sound state and get the bones out; but when the joint is in a diseased condition, the parts may be easily separated from each other. You are not entitled to operate unless the joint is disorganized, and you are then able easily to thrust out the bones of the humerus and forearm, and cut them off. The principal point to be attended to is, to avoid including in your incision the ulnar nerve. You so make the flap that you guard against interfering with it, and at the same time expose the joint through- out. All sort of flaps have been made, but the most simple plan is to make an incision along the nerve toward its radial side. In this way you turn the nerve over the condyle, and then make a cross-cut right into the joint. In this operation you cut at once through muscles and everything else, fairly down to the diseased joint. Having exposed the joint thor- oughly, you have no difficulty in opening it. There is no looking for the lateral ligaments'; you cut them across ; and in the living body there is, as I have said, no trouble whatever in getting out the end of the humerus, applying the saw, and cutting off its extremity. You then denude the other bones, always taking care to cut toward them, thus saving the mus- cles and their tendons, the vessels and nerves; you will forthwith saw off the ends of these bones. In operating on a young subject, you can cut these bones with pliers, and in very young subjects there is no occasion whatever for the saw under any circumstances. After the removal of these bones you bring the wound together, having put the bones of the forearm at right angles with the humerus, and in a state betwixt supination and pronation. After the wound is in a great measure healed, you may employ passive motion; and in young subjects the motion of the joint may, as I have said, be to some extent preserved. The shoulder-joint is sometimes affected with a similar disease. The apparatus of the joint is destroyed, the upper part of the humerus is, per- haps, in a great measure, denuded by an abscess, and sometimes there is a corresponding disease in the glenoid cavity. Your object must be to get the patient out of the hectic condition into which he has fallen, and this you cannot effect without removing the diseased bones. Here you will make the incision at the back part of the joint, and carry it fairly down to the articulation, pretty nearly along the posterior border of the deltoid. Having thus cut down at once upon the diseased head of the bone, there is nothing to prevent you from displacing it and taking it out of the socket. The capsule is all destroyed, the head of the bone is probably a good deal diminished in size, and by cutting open the joint you at once dislocate it. You carry the limb across the chest, and by pushing it up a little you get to the neck of the bone, and by applying your saw you may take away all the diseased articulating surface. You have thus made a large cavity, and if on examining the surface of the scapula you find that also diseased, you can easily, By detaching the soft part, and applying cross-cutting pliers, cut that off. By this means you get rid of the disease, the cause of the discharge and hectic. It is of great conse- quence to take away all the diseased bone, and the probability is, that if you succeed in doing so, the discharge will cease, and the sinuses heal up permanently. And you may be told, or you may have read in books, that you ought to be guided, in making your incisions, by the sight of the openings—that you ought to lay the various papillae and sinuses into one wound. This, however, is a cruel and unnecessary course; the fact is, 62 AMPUTATION that upon removing the cause of the discharge, the openings will all heal up without your troubling yourselves about them, lhe same lemark applies to operations in other'parts of the body, to amputations of portions of the hand, foot, etc. The patient, after losing the head of his humerus, though he may not be able to use his arm above his head, will still have all the motions of his hand and forearm. Part xl-> P- 114- Amputation at the Hip-joint.—-Mr. Struthers reports a case of success- ful amputation of the hip-joint, for osteo-medullary sarcoma of the os femoris, which occurred in the practice of Dr. Handyside. The mode in which Dr. II. operates is by the formation of anteropos- terior flaps, as improved by Mr. Liston. It is commonly believed, that this operation is in itself much more severe and dangerous than that of amputation through the trochanters, or at the upper fifth of the thigh; lmt the difference between them is not so great as might at first sight appear. The flaps formed, the vessels divided, and surface exposed, are nearly the same in both ; whereas in the former, the operation is much more easily and more rapidly executed, and the removal of a few inches more of the bone is attended with less shock and danger to the patient, than is the division of the bone by the saw, in its tronchanteric region. Lastly, any greater fatality which may have followed the former, is due to the fact that the cases in which it has been performed, have been much more complicated and dangerous, as well as more hopeless, than those in which the latter operation has been practised. The superiority, also, of the operation of disarticulation, in a case of disease of the bone, where there is suspicion of the upper end being affected, is sufficiently evident. In regard to the easiest, safest, and best method of performing an ope- ration of such magnitude and importance as amputation of the hip-joint, surgeons are not yet entirely agreed. Very many different methods have been proposed and practised, but these may be referred to three principal methods, with their modifications; excluding that by the circular incision, which was recommended and even practised by Mr. Abernethy. It is also almost unnecessary to notice the old preliminary practice of securing by ligature the common femoral artery, as practised by Baron Larrey, this being now superseded by compression, effected by the fingers of an assistant. First, There is the method of making directly lateral flaps by transfixion and cutting from within outward; the disarticulation being effected between the formation of the flaps, as practised by Larrey—the internal flap being first formed. This method has been varied by different surgeons. Thus, Langenbeck reverses the order of forming the flaps, by beginning with the external; and Dupuytren begins with the formation of the internal flap by cutting from without inward. Secondly, The method by the formation of postero-external and antero-internal flap?, effected also by transfixion, and then cutting from within outward, begin- ning with the external flap, but leaving the disarticulation till the end. This method is practised and recommended by Lisfranc, and has been followed by Mr. Syme. It has also been varied by cutting from without inward. Thirdly, The formation of anteroposterior flaps, the disarticula- tion being effected after the formation of the anterior flap The anterior flap is derived partly from the inner side of the thigh, and the posterior one partly from its outer side. * AMPUTATION. 63 The last described method was practised by various surgeons, so far back as the year 1806, but in such a manner as not to have been generally adopted by subsequent operators, the anterior flap having been made of great length, and the posterior one cut very short. An improvement on this method, adopted by Mr. Liston, is that which was practised in the present instance. As to which of these methods the preference should be accorded, the surgeon must be guided principally by the nature of the case. However, when circumstances will allow of it, the antero-posterior flap method will be found, I believe, to be the preferable one. The vessels divided are the same, and they are more easily secured than when the surfaces exposed are lateral—the flaps are of more equal dimensions, and lie afterward more accurately in apposition—the articulation is more rapidly reached, and is exposed at a more favorable part for being opened —the head of the bone is more easily dislocated, and the division of the ligaments more easily effected ; the removal, too, of the limb is completed with one instrument only, and, finally, by this method the whole operation can be much more easily and rapidly completed, than by practising any of the other methods. Part xi., p. 115. Amputation at the Knee.—J. R. aet. twenty-four, had for seven years had disease of the left knee-joint. About a year before admission into hospital, an abcess formed, which burst, and has since continued to dis- charge matter. He was kept four or five months in hopes of a change for the better, but instead of that he grew worse, so it was resolved to amputate, in accordance with the man's own wishes. This was done as follows: The operator, standing on the outside of the limb, placed the heel of a common flap amputating-knife upon the«kin on the inner side of the joint, immediately over the condyle, and made a semi-lunar sweep across the ^ ont, extending below the apex of the patella until the point of the blade ras opposite the external hamstring, when it was thrust straight across he limb, through the popliteal space, and made to appear at the part where the incision in front was commenced; the blade was then carried downward so as to form a flap, from the muscles on the calf of the leo-; the skin in front was now drawn above the level of the upper margin of the patella; the quadriceps extensor was next divided; a circular sweep was then made round the bone, immediately above the condyles, and the saw was used to complete the separation of the limb. A tourniquet had been applied previous to the operation, and little blood was lost during the incision; a good deal was lost, however, before all the bleeding vessels could be secured, and this seemed principally on account of the difficulty of applying a ligature to the popliteal artery, which, owing to the thickened and hardened condition of the tissues around it, could not be seized and drawn out with the forceps in the ordinary manner. At last, after the application of several ligatures, the bleeding here seemed arrested, and the other smaller vessels were next secured; the large pos- terior flap was then brought forward, and a few stitches were employed to hold the surface and margin together. The wound was lightly covered with lint wetted with cold water, and the house surgeon was desired to bring the edges more accurately together in the course of six or eight hours, when it might be concluded that there would be no more bleeding. Nothing very unusual occurred; the ligatures were discharged at the usual time; the flaps, which were at first thick, hard, and nearly inflexible, from 64 AMPUTATION. their proximity to the disease, speedily assumed a more healthy condition, and appeared as if they had been cut originally from parts perfectly sound. Union by the first intention took place throughout the greater part of tho wound, the open sores were left gradually to close, and although there are still several small points of open surface, aud the cicatrixes slightly (edema- tous, the patient moves about, is greatly improved in appearance and health, and has no complaint whatever connected with his former ailments. In his clinical remarks on this case, Mr. Fergusson stated that he had been induced to select the site of this operation chiefly by the published recommendation of Mr. Syme, of Edinburgh, in its favor. Mr. Syme favored this operation chiefly on the supposition that in con- sequence of the femur being cut across so close to the epiphysis, there would be less risk of inflammation of the medullary canal, and consequent necrosis of the bone ; and it wras well known that this result (necrosis) was more likely to follow an injury of the hard portion of the shaft than of its spongy extremity, there was on this account great inducement to apply the saw thus low down. But there were other good reasons for choosing such an operation, and not the least of these was, that amputation for certain injuries and diseases in the leg, necessitating the section above the knee, might nevertheless be done so low down—so far from the trunk, comparatively, as to lessen the risk on that account as well; for it was a maxim, that the danger of amputations increased as they approached the trunk. Hitherto, when an operation of this kind had been done above the knee, the knife had been so applied as to reserve all the soft parts to form the stump from the thigh alone; but here it would be remarked, that the flap for a stump of the thigh had been taken from the leg, where in such an instance as that which was at present un,der notice, there was ample material for making a flap of any extent that might have seemed desirable. The swelling of a joint, wherein the articular surfaces and ends were in a state of ulceration and caries, had been proved to depend entirely on these diseased conditions, as had been evinced by excisions of such j>arts, and it was a doctrine of modern surgery, that in removing caries, there was no necessity for reaching beyond the actual seat of the disease. There were many examples of incurable affection of the knee-joint which might possibly be best treated by such a mode as had been followed in this instance. One objection to the operation was apparent at the time it was done, and that was, the difficulty of securing the popliteal artery. The vessel was so surrounded by effused lymph, and condensed cellular tissue, that he had to slit up the tissues ere he could seize the vessel with the forceps, and even then it was with no inconsiderable trouble that he could get a ligature placed so as to stop the flow of blood. Part xii., p. 144. Mode of Amputating the Superior Maxillary Bone—-The following plan of operation is recommended by Mr. O'Shaughnessy, in performing amputation of the upper jaw : The patient is to be placed in a strong arm-chair, with his head resting against the breast of an assistant, or on a crutch attached to the back of a chair. A second assistant stands at the patient's side, preparing to make pressure on the carotid artery, should it be necessary to do so in the course of the operation. The operator then takes his place in front of the patient, and should the extent of the disease require the removal of the whole of the malar and maxillary bones, he makes an incision commencing at the zygo* AMPUTATION. 65 matic arch, and terminating in the angle of the mouth. This incision should be first drawn over the zygoma as far as the malar eminence, then down- ward over the surface of the tumor, to within half an inch of the angle of the mouth and into the cavity of the mouth, through the centre of the commissure of the lips, the knife being guided by the fore and middle finger of one hand, placed for the purpose in the mouth. By dissecting this flap upward, the whole of the attachments of the tumor may be laid bare ; by detaching the upper lip and ala of the nose, the nasal process and hard pa- late are exposed. The zygomatic process is to be freed from the temporal fascia superiorly, and from the masseter muscle inferiorly at the point to be divided by the nippers. The orbital process is next exposed by raising the conjunctiva of the eye with the inferior oblique muscle. All these incisions and dissections, except the last, should be made with rapidity, as there are no parts of any importance endangered before arriving at the orbit. The cheek is next dissected dowmward and backward for a little way, and then the hard attachments are severed with the bone nippers in the following order: Th« zygomatic arch is first to be cut through; the malar bone is next to be separated from its connection with the external angular process of the os frontis, by cutting backward into the spheno-maxillary fissure, taking care to guide the forceps with the fore-finger, so as to save the eye from injury. The nasal process must now be cut through by inserting one blade of the nippers into the nostril, and the other into the angle of the or- bit ; from this the floor of the orbit may be divided by cutting it across with a strong knife to the spheno-maxillary fissure. An incisor tooth or two, if necessary, is next to be extracted, and the palate process as far back as its junction with the palate bone, cut through with the nippers, keeping close to the tumor, in order not to remove more healthy bone in this situation than is absolutely necessary. The whole of the hard attachments being now divided, the tumor is found to be movable, and in general, slight pressure is found sufficient to displace it ;/when the knife is again resumed, and the external pterygoid muscle posteriorly, and the masseter muscle anteriorly, and the mucous membrane at the back of the mouth and cheek cut through, and the tumor removed. No matter how large the tumor, and how great the consequent distention of the cheek may have been, I recommend most strongly that no portion of the skin of the face, if healthy, be cut away. It almost invariably contracts to very nearly, if not completely, its natural di- mensions, and if any of it have been removed with the tumor, no matter how small that portion may be, the want of skin enough is much more likely to be complained of when the cure is completed, than of there being too much if the whole has been left. Mr. Liston's directions for forming the flap are, to make an incision over the external angular process of the frontal bone, to be carried downward through the cheek to the corner of the mouth. A second incision is made along and down the zygoma, falling into the other. Then the knife is pushed through the integuments to the nasal process of the maxilla, the car- tilage of the ala is detached from the bone, and the lip is cut through in the mesial line. With great deference to so high an authority on all points of operative surgery, and particularly with reference to this operation, I ven- ture to differ with Mr. Liston as to the necessity of making three incisions through the integuments of the face, at least in the generality of cases, viz., one from the os frontis to the mouth, a second meeting this at right angles over the malar bone, and a third along the side of the nose, and 5 06 AMPUTATION. through the „pper lip. I think*, single^cjsio,^bed ahov, will U found°to answer all the purposes proposed By it the «ten,. Of course e^ occasion a ly P™;™ £,^a ^ ^fc^ tional incisions, but I think when the} can ul vvantage the majority of cases they are not necessary), it v,m beiounu ot advantage n°Mr° L^rs^and Mr. Fergnsson recommended that the saw should he applied to all the bony processes before attempting to cut through them with the nippers; but this I think quite unnecessary, as with the latter in- strument they may be divided with perfect ease and smoothness, and certainly with far greater dispatch, and less pain to the patient, than by using the saw, whose action can with great difficulty be confined to the hard parts, and in fact its use is only necessary in the case before pointed out, viz., to divide the malar process where the malar bone may be saved. In all the cases detailed the tumor was of a large size. In the first, a fibrocartilaginous tumor of the upper jaw, the mass removed weighed four pounds ; and in the last, a case of osteo-sarcoma of the lower jaw, the tumor was as large as a child's head, necessitating the amputation of all the lower iaw, excepting the left ramus. All the patients did well. J r Part xii., p. 146. Excision of the Upper End of the Femur in Morbus Coxarius.— A lad of fourteen had suffered fifteen months from hip-disease, and was in the last stage of hectic. The head of the femur was displaced on the dorsum ilii, and could be felt by the finger, to have passed into a large sinus. The affected limb was four or five inches shorter than the other, and much bent at the knee and hip. There was no indication of pelvic Mr. Fergusson made a longitudinal incision on the hip over the head and neck of the bone, and those parts, with a portion of the shaft, including the trochanters, were removed, the bone being cut across with a common saw. The patient bore the operation well; the previous bad symptoms soon disappeared, and in two months he was able to move about the wards of the hospital on crutches, the wound being nearly closed. Part xii., p. 147. Re-section of the First Metatarso-Phalangeal Articulation.—In 1836, Dr. Pancoast removed the entire metatarso-phalangeal joint of the first toe, preserving two-thirds of the first, and the whole of the second pha- lanx. The case was one of caries from a nail run through the joint; which was much swelled, and had two fistulous openings low down on the sides of the foot. " I made a semicircular incision, which traversed these openings, and dissected the flap, the base of which was toward the heel, so as to turn it backward upon the foot. This exposed completely the inner surface of the joint, and about half the length of the metatarsal bone. The joint was next opened, the metatarsal bone isolated from the tendon and the sur- rounding parts, and divided across near its middle with the metacarpal gaw. On the removal of the fragment, the end of the phalanx was found carious; this was pushed out through the wound, and a portion a quarter AMPUTATION. 67 of an inch long removed with the saw. The interior structure of the ad* joining part of the phalanx, which was soft and spongy, was scooped out with the end of the scalpel. The ends of the divided bones were then put in contact, and the flap brought down and secured with adhesive straps and a retaining bandage. Some suppurative discharge continued for three weeks at the posterior angle of the wound; but it ultimately healed up well. Solid union took place between the divided bones, and the patient preserved his toe, which was found after the cure about three-quarters of an inch shorter than the other. The only difficulty encountered in the after-treatment, was the tendency of the extensor muscle to elevate the point of the toe. Should I again have occasion to excise this joint, I would prefer to divide this tendon, in case I approximated the bones, inas- much as the necessity for its use would be greatly diminished afterward, the middle phalangeal joint, in regard to position and office, supplying the place of the one excised; and there would be reason to expect that the reunion of the divided tendon would be sufficiently perfect to prevent (in conjunction with the dressing) the flexor muscle from drawing the point downward." Part xii., p. 148. Remarkable Change in the Bones of Stumps.—Mr. Adams mentioned to the Pathological Society of Dublin, some remarkable and interesting facts connected with the pathological anatomy of stumps. Mr. A. has found that when amputation of the forearm is performed whilst the patient is young, and the stump be used, a strong osseous union is formed between the radius and ulna, with its convexity downward, by which they are firmly united together. In another case, where the hand had been taken off at the wrist-joint, a similar formation was found. The same condition is figured in the Sandiforts' work, as above mentioned, but theirs are of the tibia and fibula, near the knee-joint. Part xii., p. 149. Prevention of Venous Hemorrhage during Amputation.—The occur- rence of venous hemorrhage in amputations, is in some cases attended with the most serious results. Dr. Hannay considers the tourniquet as rather favoring than preventing venous hemorrhage, and he recommends the application of a skillful and experienced hand,, where practicable. Dr. H. also adopts another mode of preventing this hemorrhage. It is the application of a roller or bandage, very equally and neatly, very firmly and perfectly, so as to compress, with all bearable firmness' the limb from its very extremity up as high as the points of amputation wil1 adrait- Part xiii., p. 205. Circular Amputations—Hint on Dissecting back the Skin.—The most painful and tedious part of circular amputations is the dissecting back the skin to form a sufficient covering to the stump. Dr. Ilannay recommends that an assistant should dissect back the skin on one side, while the opera- tor does that of the other, and thereby shorten materially that most pain- ful and unseemly part of the operation. ******** * Sutures after Amputation.—Whenever, says Dr. Hannay, stitches are put in the edges of flaps that are rather short, and so made to effect a stretemng or dragging of the parts, they are inevitably mischievous. I therefore offer it as the result of my observation, that when a flap is of 68 AMPUTATION. sufficient length to meet without the least dragging or stretching, then and there are stitches beneficial, and seldom to be omitted ; but on the other hand, if the flaps be scanty, and if the employment of a stitch would keep them on the stretch in the least degree then will they prove mis- chievous, and should not be employed. I need hardly say that the intro- duction of the stitch through the muscular structure of the flap is never admissible. ********* An Opiate before the First Dressing after Amputation.—Br. Ilannay recommends a large dose of laudanum (30 or 40 minims), to be given before the first dressing after amputation, particularly of a large extremity. There is no doubt the shock to the nervous system is very great, and we should endeavor by every means to alleviate it. Part xiii., p. 206. Excision of the Head of the Humerus.—Dr. Stratton describes an interesting case of excision of the head of the humerus. His patient, an Indian boy, about six years of age, received the contents of a musket, loaded with swan shot, in his left arm, he being at the time about six feet from its muzzle. In the upper half of the arm, the soft parts are much injured, part of them seem to have been shot away, and in the margin of the wound there are several shot-holes in the integuments; two inches of the shaft of the humerus is destroyed ; there is a thin glairy discharge from the upper part of the wound; a part of the shaft of the humerus two inches long, and several other loose pieces of bone, were removed, and also a quantity of moss, which the Indians had applied to -stop the bleeding, which they say was not great at the time of the accident. There is but little constitu- tional disturbance ; the skin is cool, the tongue moist, and the appetite moderate. The patient was laid on a table, with his left shoulder project- ing over its edge. Of the lower part of the humerus the projecting extremity had been broken very obliquely, and on bending the arm at the wound, this sharp and almost pointed end was removed, partly with a saw, and then with the nippers. I then took hold of the lower extremity of the upper part of the humerus, and with a small double-edged scalpel cut along it upward toward its head, from the side of which a small splinter was removed. The head was then turned out of the socket by using the scalpel around it, and turning the other end toward the chest; the part thus removed measured two inches; no vessels required to be tied. Search was made in the soft parts for any pieces of bone that might have been driven in by the shot; lint, wet with water, was for the day put in the socket, the soft parts were adjusted so as to make the breach as small as possible; with a sling the elbow was raised up so as to aid nature in shortening the arm, in order that the loss of bone might be less felt; a single turn of a bandage confined the arm to the side, and a cloth, dipped in cold water, was applied over the wound. In one hundred and twelve days after the operation the wound was closed, the left arm being a little shorter than the right. Eight months after the operation, he could use the left arm as well as the rio-ht, but could not elevate it quite as high: its motions were free, and he "could use it with ease in lifting weights. The left shoulder was a little flattened, which was quite concealed by his dress. part Xlyu ' 2o7. AMPUTATION. 69 Amputation of the Thigh.—Mr. Syme says he is now satisfied that there are circumstances in which the circular incision ought to be preferred. The perfect condition of the stump, where there is nothing but integuments to protect the bone, as at the ankle, led him to conclude, that if the circular operation could be performed with the certainty of providing such a cover- ing, it might be employed with advantage in the lowdr third of the thigh. There is plenty of skin and plenty of room to employ the tourniquet, with- out impeding the incisions or retraction of the muscles, and the size of the wound is much smaller than at the middle of the thigh. Apply the tour- niquet close to the groin ; use a middle-sized knife, such as is employed for the flap operation. Make the incision of the skin as near the knee as possible ; not in a circular direction, but so as to form two semilunar edges, which may meet together in a line, from side to side, without pro- jecting at the corners, and divide the fascia with the integuments. Draw these up by firmly clasping the limb, and not by dissecting and turning back. Divide the muscles by a circular sweep of the knife down to the bone, and retract with the utmost care. This should be at least two inches ; and, before using the saw, protect the muscles, and freely expose the bone by means of a split cloth. Mr. Syme adds, as the soft parts required to form the stump in amputa- tion at the knee, are apt to be so deranged, in their texture, as to delay, though not prevent, recovery, and thus in some measure counter- balance the advantage of exposing the cancellated instead of dense bone, together with the contents of the medullary cavity, " I do not persist in advocating amputation at the knee, now, when satisfied that the ope- ration by circular incision, if performed with due care on proper prin- ciples, may be employed at the lower third of the thigh safely and advan- tageously." Part xiv., p. 155. Quain's Method.—In amputation, Mr. Quain makes the flaps short in the first instance, and adds to their length, subsequently, by circular incisions through the deeper muscles. Modifications, are, however, required, according as the parts to be amputated are not clothed with muscle, e.g., the leg and fore-arm. • Part xiv., p. 158. Flap Amputation.—According to Mr. Bulley, the disadvantages of flap amputation are: 1. It is more painful from the extent of integument divided, and oblique division of nerves. 2. More protracted in its per- formance, in consequence of the difficulty of obliquely cut arteries collaps- ing. Part xiv., p. 158. Comparison of the Circular and Flap Operations.—In the thigh and leg, after amputation, it not unfrequently happens that everything looks well for a few days, but that then some matter forms, or the limb jerks, or is hot, or the skin gets just a little tight at one part over the bone. In these cases the flap operation succeeds better than the circu- lar, for it rarely happens that the skin of the circular operation can be got well forward again after it has once begun to retract, or become tight, whilst the mass of muscle and soft parts of a flap can often be brought down again after they have retracted very considerably. In the thigh, puncture of the artery, above its division, is readily avoided in the flap operation, and cannot well be done in the circular. In the leg, the rtery may readily be punctured in passing the knife behind the limb, 70 AMPUTATION. and wounded above its division; still this is no real objection to the flap operation below the knee, as the same accident may happen from the use of the catlin. The rapidity of the flap operation, as compared with the circular, is some advantage, but the whole operation is not necessarily shorter, for the number of arteries to be tied in the former case is generally greater than in the latter. During the last few years, the double-flap operation has been performed upon a large number of patients at St. Bartholomew's, by Mr. Stanley, and with the best result. In many of these cases, at their termination, the full soft condition of the face of the stump, the complete depression of the bone in the line of the union of the flaps, or beneath the front flap of the thigh, have been most marked, whilst the effects of inflammation, in rendering the stump tense, have been very much less than where the same accidents occurred after a circular operation. Part xv., p. 176. Amputation of the TJiigh.—Dr. Cotton observes: In largely developed muscular limbs, from the extent of surface requiring to be exposed, and the difficulty I have sometimes witnessed and experienced in securing the vessels, particularly in amputations immediately below the knee, it has struck me that in forming the flaps the muscles might be advantageously transfixed less deeply, and the operation completed by circular incisions. Whether circular amputation at the lower third of the thigh, " where cir- cumstances afford room," ought to supersede the division at its centre, as advised by Mr. Liston, for securing the most efficient and convenient stump, time and experience must decide. Part xv., p. 177. Question of Amputation in Mortification.—Professor Cooper says: With respect, first, to amputation, all practical men agree that, in cases of bad mechanical injuries, this is best done early, before mortification begins, or even inflammation comes on. The usefulness of this practice must be obvious; for, if you defer amputation till mortification comes on, you take the patient just when his system is least able to bear the opera- tion ; whereas, by prompt action you may anticipate these effects, and give the patient the best chance of recovery. Another rule is to attend to the line of demarcation. Where mortifica- tion arises from internal causes, you would never be justified in amputating until this line is clearly marked, because by the absence of this line the system is shown to be still in that unfavorable state which induced disease in the limb, and, should you operate under these circumstances, you would have the stump attacked; it is therefore a rule in surgery, that where mortification arises from internal causes, you must never amputate till this fine is formed. When the line exists you can see that the parts are dead on one side, and that the other exhibits a bright red color, as if from the presence of the arterial blood. You will then endeavor to strengthen the patient with nutritious diet; he will go through the operation better, and the results will be more likely to be favorable. At the same time, you should distinctly understand that this rule of waiting for the appearance of the line cf demarcation is intended to apply only to mortification from internal causes: if we were to act on it in cases of mortification from external injuries, as gun-shot wounds for instance, the patient would either die before mortification had ceased, or sink into a low state in which amputation would not be practicable—a state which very rapidly follows AMPUTATION. 71 these injuries. Now and then the gangrene will go down to the bone and no operation will be required at all. Part xvi., p. 179 New Mode of Bandaging Wounds and Stumps.—M. Baudens sub- mitted a method which he had lately devised, of bringing together the edges of wounds in order to unite, and which he is now daily employing with success at the hospital. For instance, in order to unite the two flaps of integument, after the operation for removing the foot at the ankle, as practised by him, a bandage is fixed circularly above the stump, and in it are inserted two strong pins, one in front, the other behind, leaving their heads and points free. Around the two ends of the pins thus left exposed, a long and thick cotton thread is looped; the threads from both sides are next brought down to the edge of the stump, and crossed over the lips of the wound, which are held together by the fingers of an assistant. The thread being crossed over to the opposite side, is now passed under the ends of the pin of that side, from which, again, it maybe made to recross. By this crossing of the threads of both sides over the wound a support is given to it similar to that afforded by a barfdage. The crossing of the threads may be repeated as often as is deemed necessary; and the course of the threads of opposite sides may be parallel, or across, so as to make a figure of eight. The ends of the ligatures applied to the arteries, being also made fast to the pins, are in no danger of being torn away in remov- ing any applications from the stump, as will sometimes happen with the old plan. The advantages this plan offers are—the gentle pressure exercised by the thread; the avoidance of impregnation by the discharged matter, which cannot long remain in contact with the end of the stump; the open spaces left between the threads allows of a ready discharge of fluid mat- ters from the wound; and the constant pull upon the circular bandage above the stump tends to draw the flesh toward its extremity, and so render it conical. This mode of bringing about the union of parts is, according to M. Baudens, applieable to all kinds of wounds, a suitable support being first contrived for the- pins, on which the traction is exerted. The bandage should not be tight enough to obstruct the circulation. Part xvi., p. 181. Case of Excision of the Ankle-Joint.—The patient, a man twenty-three years old, had the astragalus and os calcis affected with caries, and as he objected to amputation either below the knee, or at the ankle, Mr. Wakley resolved to dissect out the diseased bones. The operation was performed with the patient under the influence of chloroform. The diseased foot (the left) having been drawn forward so as to be free of the operating table, Mr. Wakley standing directly in front, and holding the scalpel in his left hand, made an incision from the prominence of the internal malleolus, backward and downward to the middle of the heel. A similar incision with the right hand was then made from the external mal- leolus, downward and backward to join the foregoing. A third incision was next carried along the edge of the sole, from the middle of the first to a point opposite the astragalo-scaphoid articulation ; and a fourth on the opposite side of the sole, from the vertical incision to the situation of the calcaneo-cuboid joint. These latter incisions enabled the operator to make a flap of about two inches in length from the under part of the sole. In 72 AMPUTATION. the next place a circular flap of integument was formed between the two malleoli, posteriorly, the lower border of the flap reaching to opposite the insertion of the tendo Achillis. This flap being turned upward the ten- don was cut through, and the os calcis having been disarticulated from the astragalus and cuboid bones, was removed, together with the integument of the heel included between the two incisions. The lateral ligaments con- necting the astragalus with the tibia and fibula were now divided, and the knife was carried into the joint on each side, extreme care being observed to avoid wounding the anterior tibial artery, which was in view. The astragalus was then detached from the soft parts in front of the joint, and from its articulation with the scaphoid bone, and the malleoli of the tibia and fibula were removed with the bone-nippers. The only artery requir- ing ligature was the posterior tibial. During the few minutes the opera- tion occupied, the patient did not manifest the slightest symptom of pain or uneasiness. The case did well, and in a few months the man was able to walk very well with the aid of a stick and a high-heeled boot, and returned to hia employment. Part xviii.,/>. 161. Compound Fracture and Dislocation of the Astragalus.—The patient, a lad 14 years old, was riding a vicious horse, which fell over on its side and crushed his left ankle. The astragalus was dislocated from its connection with the os calcis, and this articulating surface turned outward through the lips of the wound. -The bone was not separated from its attachments to the tibia and fibula, nor from the scaphoid anteriorly, but to allow the bone to turn half round, the neck had given way transversely. Both the anterior portion of bone which remained in situ, attached to the scaphoid, and the other larger portion, were clipped or broken more or less. Treatment.—After a very careful examination of the parts, the foot, the vessels, and the boy's state generally, it was resolved to try and save the limb. The dislocated portion of the astragalus (amounting to four-fifths of the whole of that bone), was carefully detached from the tibia and fibula, and these bones let down upon the calcis. The edges of the wound were brought together with three or four stitches and plaster; a compress of lint was placed over them, covered with oiled silk, confined with a turn or two of the bandage, and the whole secured in Macintyre's splint. During the first week he suffered from irritative fever, but much less so than might have been anticipated. He took salines and aperients, etc., as required. There was very little oozing of blood after the first few hours, but synovia was discharged in considerable quantities. The treatment was persevered in, the wound being dressed still with dry lint under oiled silk, as often as necessary until about fourteen days, and the splint itself was of course re- applied. This was done continually until about seven weeks from the date of the accident, when it was discarded, and an inside wooden splint with a foot-piece substituted for it, and a bread-poultice employed. At the expi- ration of another week this support was removed, the limb bandaged (a pad of lint only being used for dressing) and a stirrup of pasteboard passed under the foot, and continued up either side of the leg. He now got up and walked about, aided with crutches, the foot being supported in a sling. Seven days after this time he began to try and accustom himself to bear slightly on the foot. He soon left off one crutch and used a stick. The AMPUTATION. 73 wound was touched with sulphate of copper from time to time, and only covered with lint. November 6th.—He now walks with a crutch and stick, when going any distance, and walks well. The ankle is almost motionless as regards flex- ion and extension. April 10, 1848.—Walks well with a stick, frequently without one ; the limb is nearly an inch shorter than the opposite one. Flexion and exten- sion movements of joint increase. Part xviii., p. 162. Amputation of the Fingers and Toes.—If a portion of a finger is to be removed at the articulation of the phalanges, a common narrow, sharp- pointed bistoury is pushed from one side of the finger to the other, in front of the joint, and the flap made; the knife is now laid perpendicularly upon the lateral ligament, then brought across the joint, and the other lateral ligament cut; by this proceeding the joint is at once opened, and nothing remains but to divide the skin posteriorly. In ampu- tating between the first and second phalanges, transfixion is made opposite to the large fold in the integuments in front, and the joint is at once come upon, as the two exactly correspond. The articulation between the second and third phalanges is one line in front of the fold. By cutting into the joint posteriorly, there is always considerable difficulty in getting the knife between the bones, so as to make the flap in the palmar aspect; in consequence of the extensor tendon having been divided, the flexor eon- tracts and drags the phalanx which is to be removed in front of the one which remains. The flap in the palmar aspect being made first, that diffi- culty is avoided, and the operation is performed with more rapidity and ease. In removing the whole of the finger, the method adopted is this : The point of the knife is laid on the skin, half an inch above the articulation, carried down straight over it, and then brought by the side of the finger into the large fold in front, and continued upward on the opposite side to join the incision on the dorsum. This incision is performed by one continuous sweep from left to right, without removing the knife. The finger is now pressed well out, so as to put the ligaments on the stretch, the joint entered, and the operation concluded. Having determined previously to remove the head of the metacarpal bone along with the finger, the same mode of proceeding is adopted, with- out, however, opening the joint. The incision is commenced on the dorsum, about an inch and a half above the joint, carried straight down, then brought round into the large fold in the palm, and continued up- ward to where it began ; the blade of the knife is now placed parallel with the metacarpal bone, and carried round its head from right to left, and brought back in the reverse manner, and the bone divided by the forceps. By this method there is no cicatrix in the palm, the flaps are smooth and regular; the operation is also quicker in its perform- ance, and leaves a much better and neater covering than by the mode usually followed. When amputating the thumb and metacarpal bone, Mr. Williamson considers it more convenient to stand on the inner side of the arm. The point of a long, narrow, straight bistoury is entered opposite to the articulation of the metacarpal bone and the trapezium, passed under the adductors, and its point made to appear in the folds of integuments betwixt the thumb and fore-finger, and by cutting 74 AMPUTATION. outward a flap is formed; the knife is now laid upon the angle of the incision, between the thumb and finger, and continued over the dorsum of the bone to the part where it was entered to transfix. The thumb is then firmly grasped by the operator, and the soft parts divided down to the articulation, which is now disarticulated with great facility. _ For the removal of a whole toe, the same oval method, as it may be called, is adopted. It is here of still greater advantage, as there is no cicatrix left in the sole of the foot to annoy the patient when walking. The metatarso-phalangeal articulations of the small toes are deeply seated in the ball of the foot, and the knife must be carried, by the method usu- ally practised, to the extent of two inches into the sole, to reach the joint, and, on disarticulating the bone, the integuments are notched and cut ia a very awkward manner ; in the method recommended, these objections are removed. In amputating the finger, the head of the metacarpal bone should always be removed; but in the toes it ought, if possible, to be preserved, especially that of the great toe, for the purpose of giving greater support in walking. The toes, with the whole of the metatarsal bones, can he removed in the same manner; the great and little toes are those that most frequently require to be amputated; this can be effected by making a straight incision along the dorsum, brought down into the fold in the sole, and terminating in an acute angle near its commencement. The bone ia then cleared and disarticulated. Part xviii., p. 163. Amputation at the Ankle Joint.—The following modification of Mr. Syme's operation has some advantages. After making the anterior incision from one malleolus to the other, mark out the form of the flap by carrying the knife deeply across the plantar aspect of the heel from the internal to the external malleolus: then disarticulate the joint, divide the tendo Achillis, and turn out the os calcis from the plantar flap by carrying the knife closely around the back and sides of the bone : lastly, remove the malleoli with the saw. This method is more easy and rapid than the usual plan of dissecting the flap from below upward, before disarticulating. Part xix., p. 131. Amputation.—In dressing the stump, instead of compresses and ban dages, apply two long and broad strips of wetted lint, in a crucial manner, and support them by a circular strip, so as to support and press the flap against the bone. Part xix., p. 132. Military Surgery—Mr. Guthrie's Lectures on. — Mr. Guthrie com- mences some very important observations upon this subject, by consider- ing the necessity of a tourniquet. He says: As a tourniquet cannot be applied in amputation at the hip joint, nor even at that of the shoulder joint, Avithout doing harm, its inutility is proved in the greatest operations; and recourse should not be had to it in the smaller or less dangerous ones, provided sufficient assistance can he obtained. When the surgeon has only one assistant, he should apply a tourniquet; or even if he should have several bad ones on whom he can- not depend. There is always more blood lost, and particularly in secondary amputa- tions, when a tourniquet is used, than when the principal artery is com- pressed by one assistant, and two others are ready to press on the outsida AMPUTATION.. 75 of the flaps, or upon the divided vessels, with tae ends of their fingers; the force necessary to prevent the passage of blood through the common femoral, or the axillary artery, being merely that of the finger and thumb, applied in a very gentle manner, or even of the end of the fore-finger of a competent person. I have rarely applied a tourniquet since 1812, and few persons have done more formidable operations under more difficult cir- cumstances. A tourniquet is useful when loosely applied after an operation, and the attendant should be taught how to turn it, so as to suppress any serious bleeding which may take place until the surgeon can be procured. It may be, although it rarely is, necessary on the field of battle. A thoroughly useful tourniquet can be made in a moment with a pebble and a pocket- handkerchief, or a roller. The great point is to know where and how to apply it. If after a fracture in course of treatment, the principal artery should be wounded by some accidental motion of the bone, amputation should in general be resorted to. A ligature on the artery higher up would fail, and the operation of seeking for both ends of the injured vessel would cause so much mischief in an unsound part, that the consequences would in all pro- bability be fatal. When the femur is suffering from a malignant disease, commencing in the periosteum, or its cancellated internal structure, I am reluctantly obliged to say that the removal of the whole bone at the hip joint offers the best, perhaps the only, chance of success. In such cases, the operator has in general the power of selecting his mode of proceeding. It may be laid down as a principle in all cases of accident, whether from shot, shell, or railway-carriages, that no man should suffer amputation at the hip joint when the thigh-bone is entire. It should never be done in cases of injury when the bone can be sawn immediately below the tro- chanter major, and sufficient flaps can be preserved to close the wound •Hius made. An injury warranting this operation should extend to the neck or head of the bone, and it may be possible, as I have proposed, even then to avoid it by removing the broken parts. The principle being established, as a general rule, in all cases of recent injury, that the femur must be broken at least as high as the trochanter to constitute an imperative case for this operation, the next point of import- ance relates to the manner of forming the first incisions. My first successful operation, performed in 1815, was done from without inward, the flaps being anterior and posterior, the artery being compressed against the pubes. Professor Langenbeck, when lately in London, informed me he had per- formed amputation at the hip joint, in the Holstein war, several times, and he believed more than once successfully, making the anterior flap by the pointed knife, cutting from within outward, but the posterior one by cutting through the integuments from without inward, as I have recommended, in order to make it of a more equal and proper thickness. One point to be attended to is to leave as little as possible of the internal tendinous struc- ture of.the great glutaeus muscle, which does not readily unite with other parts; a second, not to leave too much muscle behind: and a third, to remove as much as possible of the ligamentous structure about the joint. The after treatment will be the same as in other formidable cases. The shock, however, of the injury, and of the amputation, will rarely render 76 AMPUTATION. Wood-lettin. necessary. CordL*, in -J?^,*^ light nourishing diet, should be given, lne wounu si cold water, and the patient constantly watched. „mnntnticm • it A protrusion of bone is a disagreeable occurrence afte» amp«totion it will Jometimes happen after sloughing- ^s -^^ "lon^a" n^t « covel^ at once sawn off, and the erWh7iitheeLe protrudes at a subsequent period to the extent of an inch or more, it should be removed by operation, an incision being made on, and down to, the bone, and the saw applied where it is sound lhe chain-saw, when at hand, answers well, and some should be supplied for the use of the principal hospitals with every army. The protruded end of bone should be held steadily by pincers, or it may be introduced into a hollow tube, which fixes it firmly. . When the bone is badly sawn through, or split m the act of dividing the last layer, or the periosteum is unduly separated, the end will often exfoliate with the split, which may extend up for three or more inches, causing much suffering, and occupying a great length of time before the stump becomes quite sound. A splinter of this kind may even require to be removed at a late or even distant period, from the nervous irritation and suffering it may occasion. Wounds of the knee joint, with fracture of the bones composing it, from musket-balls, require immediate amputation; for although a limb may be sometimes saved, it cannot be called a recovery, or a successful result, where the limb is useless, and is a constant source of irritation and distress after several months of acute suffering have been endured, to obtain even this partial relief from impending death. For one limb thus saved, ten lives will be lost; and the sufferer is often glad, after months and years, to lose the limb thus saved, more particularly when the ball has lodged in the articulating surfaces of either of the bones. Amputation at a secondary period, in these cases, does not afford half the chance of success, for many will not outlive the inflammation and the fever which ensue, lhe amputation should therefore be immediate, unless excision can be substi- tuted for it. Compound fractures of the patella, without injury of the other bones, admit of delay, provided the bone is not much splintered. If the ball should have pierced the centre of the patella, and passed out in nearly an opposite direction behind, the limb will not be saved. If the ball have struck the patella on its edge, and gone through it transversely, opening into the joint, it wall very rarely be saved ; but if it be merely fractured, there is hope under the most rigorous antiphlogistic treatment, and delay is proper. A ball will occasionally penetrate the capsular ligament, and lodge in the knee-joint, without fracturing the bone; if it cannot be extracted without opening extensively into the cavity of the joint, and the extraction of the ball is absolutely necessary, amputation had better be performed at first, for it will be ultimately necessary. The condyles of the femur and the lower part of the bone being spongy, a ball may pass through them or between them, and fall into the knee-jjint, or it may make a prominence on the side of the patella, without passing out, or immediately interrupting the motion of the leg, for the soldier may walk some distance afterward. The popliteal artery may also be divided in AMPUTATION. 77 addition, and either of these cases will render amputation necessary; for the ball must be taken out on the forepart, and the general inflammation of the joint will either destroy the patient in a short time, or, after much distress and hazard, leave him no alternative but amputation. If a ball lodge in the condyles of the femur, within the capsular ligament, and can- not°be easily extracted, amputation is advisable ; for the limb, if preserved, will not be a useful one. If the ball, on the other hand, lodge without the capsular ligament, and cannot be readily extracted, the wound should be healed as soon as possible ; and although it may cause some little incon- venience to the knee-joint, the limb and life of the patient may be saved, as I have seen in many instances, when a continuance of persevering efforts to extract it would have exposed both to great danger. _ Many cases of wounds of the knee joint, in which the capsular ligament is wounded, and the articulation opened into without injury to the bones, do well, such as simple incised wounds made with a clean cutting instrument. The success attending all wounds of the knee joint depends entirely upon the antiphlo- fistic mode of treatment being rigidly enforced, and to a very great extent. he limb is to be placed in the straight position, a splint is to be put underneath it, in order to prevent any motion, and cold or iced water is to be applied, especially in summer, to diminish the increasing heat. Gene- ral bleeding may be had recourse to in sufficient quantity to keep all general inflammatory action in due bounds; but, it is on local blood-letting that the surgeon must principally rely for the prevention of inflammation. Cupping can sometimes be performed with marked effect; but leeches are more serviceable when they can be procured in sufficient numbers; from twenty to forty, or more, may be applied at a time ; and whenever the sensation of heat is felt, and is accompanied by pain, they should be repeated until these symptoms subside. The necessity for the local abstrac- tion of blood is so great, that it should never be lost sight of for a moment; for if suppuration take place throughout the cavity of the joint, it is fol- lowed, in most instances, by ulceration of the cartilages and caries of the bones. By local and general bleeding, the application of cold, rigid abstinence, and the straight position, a recovery may sometimes be effected ; but wounds of the knee joint, however simple, should always be considered of a very dangerous nature, infinitely more so than of the shoulder, the elbow, or the ankle. When a poultice is applied to a gun-shot wound of this kind, I consider it the precursor of amputation. Colonel Donnellan, of the 48th Regiment, was wounded, at the battle of Talavera, in the knee joint, by a musket-ball, which gave him so little uneasiness that he could scarcely be persuaded to proceed to the rear. At a little distance from the fire of the enemy, we talked over the affairs of the moment, when, tossing his leg about on his saddle, he declared he felt no inconvenience from the wound, and would go back, as he saw his corps was very much exposed. After he had staid with me a couple of hours, I persuaded him to go into the town. This injury, although at first to all appearance so trifling, proceeded so rapidly as to prevent any relief at last being obtained from amputation, and caused his death in a few days. When the nature of the injury renders amputation necessary at or immediately below the tuberosity of the tibia, the operation may be done with safety. Baron Larrey recommended the removal of the head of the fibula in such cases, which I have done with impunity, and made thereby a better stump than if it had not been done; but as the articulating surface 78 AMPUTATION. of the head of the tibia does sometimes enter into the composition of the knee joint, and this cannot be known beforehand, the removal of this poi- tion of the fibula is not advisable, neither must the tibia be sawn above the tuberosity, lest the capsular ligament be implicated. As an operation by which the knee joint is saved, it is important, for although the stump is very short, it forms a solid support for the body and enables the patient to walk without the aid of a stick, and admits of the adaptation of an arti- ficial W. The skin, in these cases, must be saved, m every direction, by flaps, to form a covering. When in sufficient quantity, the operation may be done by the circular incision, as much muscle as possible being saved, to aid in forming a covering on the under and outer sides. The posterior tibial artery will be found to have retracted behind the head of the bone, from whence it, or others which may bleed, must be drawn out. The nerves must be cut as short as possible. A musket-ball will seldom pass through the foot without injuring a joint of some kind, or wounding a tendon or nerve; and the injury to the fascia, which is very strong on the sole of the foot, and frequently covered by much thickened integument, is always attended with inconvenience. The extraction of balls, of splinters of bone, of pieces of cloth, and the dis- charge of matter, become more difficult, and often cause so much disease as ultimately to render amputation of the foot necessary. ^ Tetanus is a frequent consequence of these injuries, and is a disease, in its acute form, certainly remediable by no operation or medicine at present known. Amputation has always failed in my hands, although it was strongly recommended by Baron Larrey. The operative surgery of the foot should be done as soon after the injury as it can be conveniently accom- plished ; for a large, clean, incised wound is a safe one, compared with a torn surface and splintered bone, with extraneous substances, of much less extent; and as a ball lodged in the foot is always very dangerous, great attention should be paid in the examination of even slight wounds. A cannon-shot can seldom strike the foot without destroying it altogether; it may, however, strike the heel, and destroy a considerable part of the os calcis, without rendering amputation necessary, if the ankle-joint be untouched ; for by due attention in removing the spicula of bone at first, and by making free openings for the discharge of matter in every direc- tion in which it may appear inclined to insinuate itself, the limb may be preserved in a useful shape. Wounds from cannon-shot injuring the fore part of the foot are better remedied by amputation at the joints of the tarsus with the metatarsus, than by sawing these bones across; but when the injury affects only one or two toes, they may be removed separately, recollecting that it is of greater importance to preserve the great toe than any other, and this toe is worth preserving alone, when any of the others would be rather trouble- some than useful. Musket-balls seldom commit so much injury as to re- quire amputation as a primary operation, although they frequently render it necessary as a secondary one. The splinters of bone are to be removed, the ball and extraneous substances are, if possible, to be taken out; and if the bones, tendons, and blood-vessels are so much injured as to render the attempt to preserve them useless, amputation is to be performed; but if the preservation of the limb be thought practicable—and it generally will be so in wounds from musket-balls—the attempt must be made under the most rigid antiphlogistic treatment, the local application of leeches and AMPUTATION. 79 cold water from the first, and with free openings for the subsequent dis- charge. Musket-balls seldom injure the metatarsal bones so as to require their removal with their toes, and under the treatment above mentioned, these wounds will in general be healed without further operation. Wounds from grape-shot occasionally render the removal of the metatarsal bone^of the great toe at the tarsus necessary, although much should be done to save it. The little and adjacent toes are also sometimes removed at the tarsus, the middle ones but seldom, as it is not an easy operation to per- form, in consequence of the naturally close attachment of these bones, and the additional compactness they have acquired from the pressure of the shoe. Hemorrhage from the arteries of the foot authorizes in a very slight degree amputation, even when superadded to other causes; for the incisions necessary to secure the bleeding vessels will not, in general, add much to the original injury, unless they are very extensive; on the con- trary, they will render the wound less complicated and more manageable. Amputation of the foot, leaving the astragalus and calcis, may, in certain cases of injury anterior to these bones, be performed with advantage, care being taken to make the under flap so large that the line of cicatrization may be on the ujjper and anterior edge of the stump, rather than trans- versely across the face of it, hi order to render it firmer and better able to resist and sustain any pressure which may be applied to it. As the posterior tibial artery must be divided, the preservation of the anterior one is essentially necessary; the success of the operation depends upon it. This artery, accompanied by its vein and nerve, lies close upon the astragalus ; the artery may be said to be even attached to it, a point requiring the greatest attention in dissecting out the bone without injuring this vessel, which is seen under the scalpel. Amputation of a single metatarsal bone, on the outside or inside of the foot, is to be done by an incision round the root of the toe, terminating in a line on the outside of the foot, which is continued down to the joint of the tarsus. The integuments are turned back above and below from the metatarsal bone, which is to be dissected out, with the toe attached to it, and the flaps brought together, so as to leave but one line of incision. In military surgery there is always a wound ; and when the removal of the bone is necessary, it is in general an extensive one, and with loss of sub- stance, so that a covering cannot be saved in this way, especially on the upper part of the foot, where the ball or piece of shell strikes. The sur- geon, therefore, must be prepared to look for his covering on the under part, where he will occasionally not be able to procure it in sufficient quantity, and it must not be forgotten that the neighboring parts will often be injured. The object must then be to save the integuments from such parts as are uninjured, so as to cover in the wound as nearly as pos- sible when the bone is removed. In doing this the first incision should commence at the upper and inside of the toe, and be carried round so as to separate the toe from its attachment to its fellow. If the injury be entirely on the upper part, the continuation of this incision must be so regulated as to form the whole of the flap from below, and the commence- ment of it above must be continued round the injured part, so as to meet the lower end near the articulation of the bone with the tarsus, and vice versd. If the ball have gone directly through, destroying the integuments above and below, the incisions must surround the injured part in such manner, on the upper and under side of the foot, as to allow the flaps to 80 AMPUTATION. be formed in every other part, except where the injury was inflicted, and from whence granulations must arise. By saving skin everywhere else, the wound will be much diminished in size, will heal sooner, will be less liable to suffer from external violence, and less obnoxious to the subse- quent pain, which generally at intervals attends wounds of this kind. An upper extremity should not be amputated for almost any accident which can happen to it from a musket-shot; and there is scarcely an injury of the soft parts likely to occur which authorizes amputation as a primary operation. If the head or articulating extremity of the bone entering into the com- position of the shoulder joint be merely or slightly injured by a musket- shot, the arm ought to be saved with some defect of motion in the joint. The wound should be enlarged in the first instance, to allow of a sufficient examination with the point of the finger, and any loose 'pieces of bone should be removed. Inflammation is to be restrained within due bounds until suppuration has been established, when, if a clear depending opening should not exist for the discharge of the matter poured out, it should be made, and any loose portions of bone removed. The principal points to at- tend to are, the prevention of sinuses around the joint, by the formation of dependent openings, position, perfect quietude, due support, the methodical application of bandages, and occasional mild stimulating injections into the wound. A simple incised wound penetrating the joint, and even injuring the bone, does not call for any immediate operation. An attempt should be made to effect a cure by the first intention, which can only be effected by means of a proper position and support. If the head of the bone be much splintered, or if a ball have gone through it, that portion should be sawn off; for a part thus injured has often been a source of great inconvenience and suffering for many years afterward—during, in fact, the remainder of the life of the sufferer; which misery would have been avoided by the excision of the bone in the first instance—an operation which ought, in fact, to be done even at a later period, if it has not been performed at the time when the injury was received. When the splinters extend far into the shaft of the humerus, it may be proper to amputate the whole extremity, especially if the great artery be also wounded; but the shaft is seldom broken in such accidents to any .great extent, and amputation should be confined almost to injuries from cannon-shot or shells, or heavy machinery, destructive of the soft parts as well as of the bone. When the injury done to the upper arm is so extensive that it cannot be saved, although the head of the humerus is not injured, the amputation should take place immediately below the tuberosities, and not at the joint, which latter operation always renders the shoulder flatter, and the appear- ance of the person more unseemly, than when the head of the bone is left in its place. It will frequently happen that the arm may be irrecoverably shattered, and the thorax partake in a less degree of the injurv, there being apparent only some slight contusion or grazing of the skin ; if low down, the elasti- city of the false ribs may have prevented the integuments being much injured in appearance, although the blow has been violent, yet the force of the large shot may have ruptured the liver or spleen. If higher up, it may perhaps fracture the ribs, in addition to a more severe contusion of AMPUTATION. 81 the integuments. When these accidents occur, the symptoms arising from the wound or contusion of the trunk of the body are to be first considered. If they do not indicate a speedy dissolution of the patient, or the prospect of such an event in two or three days, the operation ought to be per- formed, and a chance of recovery given the sufferer, which he would not have, the arm being retained, and the injury of the chest remaining tho same. The danger to be apprehended in the more favorable cases is from inflammation, and this will be rather diminished than increased by the operation; the danger of deferring which is manifest and certain, whilst the injury committed in the thorax or abdomen is not ascertained, and its effects may be obviated. If the termination should be unfavorable, it can only be a matter of regret for the sake of the individual, and not for the non-performance of a duty. If the cavity of the chest be laid open, or several ribs beaten in, or a stuffing of the lungs take place from a large ruptured blood-vessel, all of which circumstances are obvious, and cannot be mistaken, the operation would, in all probability, be useless. A hemor^ rhage of short duration, or the expectoration of blood in moderate quanti- ties, although a dangerous symptom, is not to be considered as depriving the patient of a reasonable chance of life, for it frequently follows blows from more common causes, and from which many people recover. If the operation be delayed to ascertain what injury may have been done to the chest, from the symptoms that will follow, the danger resulting from both will be increased; and even when it is ascertained that there is but little mischief existing in the thorax, the operation can no longer be performed with the same propriety, in consequence of the inflammation which has supervened; and the patient will probably die, when he would have re- covered under a more decided mode of treatment. A round shot or flat piece of shell may strike the arm, after rebounding from the ground, or when nearly exhausted in force, without breaking the skin, or only slightly doing it, yet all the parts within may be so much injured as not to be able to recover themselves: the bone may be con- siderably broken or splintered, the muscles and nerves greatly contused. The injury may not, perhaps, be quite so extensive. The bone may be merely fractured, and yet the soft parts will often be so much destroyed as not to be able to carry on their usual actions. A ruptured blood-vessel may, with an apparently slight external wound of this nature, pour out its blood between the muscles, and inject the arm to nearly double its size, all of which are causes that render an operation necessary, and require decision, for inflammation will, and mortification may, ensue in a short time, when the most favorable moment for operation will have been lost. Amputation at the Shoulder Joint is an operation of little surgical im- portance. The fear formerly entertained of loss of blood has passed away, and every surgeon now knows that if he should happen to cut the axillary artery unintentionally, it can be held between the forefinger and thumb, without difficulty or danger, until a ligature can be placed upon it. No accomplished surgeon of the present day should give himself the least concern about compressing the subclavian artery. It is, on the contrary, better, when the arm is raised from the side preparatory to entering or using the knife, that the surgeon should then feel the pulsation of the ar tery in the axilla, that he may the more easily avoid, and subsequently command it. The axillary artery does not throw out much blood at each pulsation, and a little pressure with the end of the forefinger will a.1 ways 6 82 AMPUTATION. prevent bleeding until the surgeon is prepared to take hold of the vessel ■with the tenaculum or forceps. The irreat point to be attended to in performing the operation is to save skin to cover the stump. The directions, therefore, which are usually given for doing it after anv particular method, can only be occasionally useful, for the surgeon may "not always be able to select the parts to be divided or retained. In cases of malignant disease of the bone and periosteum of the middle of the arm, the operation should be for the removal of the whole of the bone at the joint, and not the amputation of it below the bead, although the appearance of the integuments, and of the bone itself, would seem to encourage the attempt to preserve the roundness of the shoulder. In such cases the removal of the extremity at the joint may be done by any one of the many ways which have been recommended for its performance. In none should the acromion or cora- coid processes be exposed, unless previously injured. Neither is it neces- sary to lose time, or to give pain, by depriving the glenoid cavity of its cartilage ; but it should always be borne in mind, that if the nerves are not shortened after the removal of the arm, they may be included in, or adhere to the cicatrix, and cause, during a long life, much distressing pain to the sufferer. Amputation at the shoulder joint, performed immediately after the receipt of an injury, is now a very simple operation. As a secondary operation, or done at a later period, when the parts are all impacted together, it is somewhat less so. In both stages it is abso- lutely necessary to remember—1st, that except in cases of disease, and not of injury, the shaft of the bone must be broken; and that all the directions usually given for rotation of the arm inward and outward during the operation, are unnecessary cruelties not to be attempted with a broken bone; 2d, that the arm should always be raised from the side and supported by the hand of an assistant, who can feel, if he pleases, at any time of the operation, the pulsation of the axillary artery ; and all operative methods are condemned, in which this precau- tionary measure is not the first step. Amputation of the Arm immediately beloio the Tuberosities of the Humerus is similar to amputation of the joint, which, in many cases it is intended to supersede. Excision of the Head of the Humerus.—The point governing the modus operandi of this operation is, and ought to be, the fact that under the most favorable state of recovery which can take place, the shoulder joint usu- ally becomes so stiff that its ordinary motions may be considered to be lost. Operative processes which have for their principal object the sparing of the deltoid muscle are unnecessary, for, if spared, it is as useless as if it had been cut; and it seems to have been forgotten that, when cut, it reunites, and becomes nearly as strong as before it was injured. It is the joint which cannot be moved, not the muscle which has lost its power. I prefer, therefore, in doing this operation, where the injury will permit of it, to make a short crescentic flap by an incision across the'anterior part of the shoulder, as in the operation of amputation, which, on being turned up, leaves the joint exposed. The edge of the knife being applied to the head of the bone in a line below, but immediately under the acromion process, divides the capsular ligament, and with it the long tendons of the biceps, on which the arm drops from the socket, or glenoid cavity and IMPUTATION. 83 allows the finger to be introduced, when the three muscles inserted into the great tuberosity may be cut through, and the sub-scapularis, inserted into the small tuberosity, should also be divided. The head of the bone is then readily brought out, and may be readily detached from any sur- rounding connections, and sawn off with little or almost no loss of blood. The elbow is to be supported, so as to briug the end of the sawn bone in apposition with the glenoid cavity. The flap may be allowed to unite with the parts below as soon as it will, the shot holes, if any, being in general sufficient to allow of such discharge as may be necessary. In cases, of recent injury, some aid will be obtained in keeping the sawn end of the humerus in apposition with the glenoid cavity, by not dividing the long tendon of the biceps. This must be done by dissecting it out of its groove in the humerus, between the tuberosities, and by cutting through the capsular ligament vertically, so as to follow it up to its attach- ment to the upper edge of the glenoid cavity, when it is to be drawn aside with a blunt hook, until the operation has been completed: a proceeding difficult of accomplishment in old cases of disease or injury, and in them not necessary nor advisable. Whenever the head of the humerus is broken, with even considerable injury to the soft parts around, it will be always better to saw off the broken part of the bone in the first instance, and to retain the remaining portion as closely as possible in apposition with the glenoid cavity. The suffering will in the end be less, and the cure be effected, in general, without the loss of the arm. If, from some complication of injury, the axillary, or other artery should give way during the treatment, the extremity is not to be amputated. The artery is to be secured by one ligature applied above the opening in it, and another below it; the surgeon always bearing in mind the fact, that the proper way to get at the axillary artery is by cutting across the fibres of the pectoral muscle, and not in the direction of them; and that the ligature of the subclavian is not to be resorted to until nothing else remains to be done by which the hemorrhage is likely to be suppressed. Amputation of the Arm by the common circular incision should only be practised in the space between the lower edge of the insertion of the pectoralis major and the elbow joint; and rarely in cases of injury from musket-balls. No common flesh-wound, made either by cannon or musket shot, oven including a division of the artery, absolutely demands this ope- ration, the bone being uninjured. If, in addition to such a destructive flesh-wound, the bone be broken, or if it be mashed with the muscles by an oblique stroke of a round shot, or the fore-arm be carried awTay or destroyed, it is admissible. Excision of the Elbow Joint.—An incised wound into the elbow joint, of moderate extent, cutting off with it a part of the condyle of the humerus, or the head of the radius, or a part of the ulna, demands the removal of the injured piece of bone only. The fore-arm should be bent and the antiphlogistic treatment fully carried out. A ball fracturing the olecranon, or otiier portion of a single bone, although opening into the joint, does not immediately require any operation. If a ball should lodge in the lower part of the humerus, or in either of its condyles, it should be removed, if necessary, by the trephine, or other appropriate instrument. 84 AMPUTATION. When the articulating ends of the humerus, radius, and ulna are wholly or in part injured by a musket ball, it was formerly the custom to ampu. tate the arm, in such instances of great mischief—an operation which should be superseded by that of excision of the joint, by which the fore- arm will be saved, and considerable use of it retained. Amputation of the Fore-arm is seldom required after wounds from musket balls. The bones can be readily got at, and large pieces removed with ease. The arteries can be cut down upon and secured without diffi- culty, except at the upper part, and even there with some little sacrifice of muscular parts, which are not to be spared. The fascia may be divided freely in every direction, and as mortification from defect of nourishment rarely takes place in the fingers, as it does in the toes, when the great arteries are injured, every effort should be made to save a fore-arm, how- ever badly it may at first appear to be injured. The flap operation is to be preferred to the circular, particularly when a little above the wrist; to which operation Baron Larrey and the surgeons of France particularly objected during the late war. Having done it most successfully since 1806, however, it is recommended as preferable to any other, even when the injury admits of it being done near the carpus. When the nature of the injury does not admit of two equal flaps beinc; formed, it must be done by two unequal ones, or even by one, it being important for the fixing of an artificial hand or other help, to have a long stump. When the operation is to be performed above the middle of the arm, it may be done by the circular incision. In all Injuries of the Hand, the value of a thumb and a finger, or of two fingers, or even of one, should be borne in mind, and no part should be removed that can be saved, and appears likely to be of use. When cannon-shot, large splinters of shells, or grape-shot have struck the hand, amputation will often be necessary, but the foregoing precept should never be forgotten. A musket-ball fairly passing through the hand, generally fractures two metacarpal bones, although a small ball may pass between without breaking either. The wounds should be enlarged, and the broken ends of the bones sawn off, or the splinters removed, and the points of bone smoothed off, the tendons to be carefully preserved, and vigorous antiphlogistic measures adopted. The tendency to tetanus or trismus will be best obviated by such measures, the incisions, when necessary, being made in the direction of the bones and tendons. Any hemorrhage which can ensue will be readily commanded by ligature, by torsion of the vessel, or by a small graduated compress 'and bandage, when these are inap- plicable. When one or more fingers are destroyed, and the metacarpal hones injured, they are to be sawn or cut off, but not removed at the carpus, although an opening into the joint of the carpus will generally do well, if skin can be saved to cover it. In all eases of amputation of one or more fingers, the metacarpal bones, if-injured, should be left as long as possible, and particularly that of the index-finger, when the thumb remains. In all cases it is better, if possible, to leave the heads of the metacarpal bones in their places, rather than open into the joint of the carpus, if it can be avoided. If the articulating heads must come out, a strong thin scalpel is to be pushed in between the bones, the ligaments cut through above, AMPUTATION. 85 below, and at the sides, and care should be taken in removing one or two of these bones, not to dislocate the others, and the joint should be covered by a flap or flaps made for the purpose, the sides of the remaining fingers being covered in a similar manner. This succeeds admirably, when the two outer bones and fingers only are taken away. The phalanges of the fingers may be removed by making a flap from the upper or under part, or from both, or from the sides. The square flap from the upper part of the finger is preferable, when the joint with the metacarpal bone is to be operated upon, the commencing points of the flap being united by a transverse incision on the under part of the joint. It should be recollected, that in all these incisions the larger end of bone belongs to that which is not removed, as may be shown by bending the finger, and that the ligamentous attachment between the metacarpal bones, connecting a middle one to its fellows on each side, should be cut through, when the joint will be easily dislocated. Attention should be paid to the division of the lateral ligaments in the removal of any of the bones of the fingers. Professor B. Langenbeck has operated in some instances, and he says successfully, without the loss of the finger, by sawing off, in the first case, the articulating ends of the first phalanx and of the metacarpal bone of the fore-finger, in consequence of an injury from a rotating piece of machinery; in another, the ends of the first and second phalanges of the middle finger after a severe laceration; and in a third case, by sawing off the end of the second phalanx, and removing the whole of the bone of the third of the fore-finger from the soft parts, leaving the nail; the man recovering with a shortened but useful finger. In all these cases, the flexor and extensor tendons were, from the first, uninjured. M. Langenbeck has also removed the metacarpal bone of the thumb; a new bone as a substitute being subsequently formed in its place, although the periosteum had been removed with it, which, however, he is always desirous of separating from the bone, and leaving behind, if possible, although he does not consider its remaining in the wound to be essentially necessary for the reproduction of the bone. To do this operation, he directs an incision to be made along the whole length of the bone toward the palmar aspect, thus avoiding the tendons. Then free both articulating extremities, and separate the soft parts from the body of the bone. If the thumb were to be left to itself, it would be drawn inward toward the palm and shortened, but this is to be prevented by a splint and apparatus to keep the thumb extended until the wound is healed. But little reliance can be placed on the means indicated for separating the periosteum from an otherwise healthy bone after an accident. When bones are softened by inflammation, it may, perhaps, be done. Part xxvi., p. 141. Secondary Amputations.—According to Mr. Guthrie, these are not so successful in military as in civil hospitals, because in the former they gene- rally take place within a short time after the primary operation, while the parts are still in a very irritable condition. Besides, the inflammation of the veins and sloughing of the stump are in some degree dependent upou 86 AMPUTATION. the season; viz., the autumn, in which military operations are usually conducted. In secondary amputations in parts which have partaken of the exten- sive irritation which accompanies the original injury, a larger portion of the flaps will require to be preserved, although the integuments and mus- cles cannot be said to be unsound. In other words, the bone must be cut shorter, or the stump will be conical and bad, and particularly if sinuses containing pus are found to run up between the muscles, or between them and the bone itself—a state very likely to give rise subsequently to caries. In sawing the bone, it may be again stated, the point of the saw should incline downward, and when two-thirds of the bone are divided, it should be made to cut perpendicularly, whereby the side next the operator is the last part divided ; and the hazard of splintering the bone at that moment will be avoided, particularly if the limb to be removed is held with great steadiness. In secondary amputations, twice, nay three times the number of arteries will bleed as in primary ones. In the thigh, the femoral artery should be drawn out with a tenaculum or spring forceps, and tied firmly with a single thread of dentist's silk, one of the two ends being cut off close to the knot. The smaller the vessel, the smaller the thread required. Torsion or twisting the smaller vessels, so as to rupture their inner coats, answers very well in cases in which many small ones bleed. When a nerve is known to accompany an artery, it should be carefully separated from it. If bleeding should continue from above the ligature on the extremity of an artery, it is generally caused by some small branch given off from it, and which has been cut so close to the trunk of the vessel as not to have been observed. In this case the artery itself is to be drawn out by the tenaculum or spring forceps until the bleeding point can be seen, and a ligature placed above it, when the piece below should be cut off with the first ligature applied. This inconvenience will be in general avoided by taking care to divide the principal artery at one stroke of the knife, and with it half an inch at least of the surrounding substances, if the operation is done by the circular incision. If by flaps, the extent of the exposed arteries should be carefully examined, and the ligature applied at tho highest point of exposure, when all below should be removed. When a tourniquet is used, and applied close to the incised parts, it often prevents, even when loosened, the principal vessel from being found, from having pressed on the ends of the muscles. If one is used, it should be removed as soon as possible after the principal artery has been secured. The repeated tightening and loosening of the tourniquet will cause more vessels to bleed in the end, and more "blood to be lost, than if it had not been used, and it ought not to be resorted to when good assistance is pro- curable. In cases of this kind, in which the stump may not cease to oow, the circulation being good, and sponging with cold water is not effectual, the wound should not be finally closed for two, four or more hours, until the oozing has ceased, and the parts can be freed from the coagulated blood, and brought together. In cases in which union is not expected to take place, both ends of the ligature should be cut off; for union is not to be desired of the external parts in many instances of secondary amputation, particularly after serious AMPUTATION. 87 injuries; the inflammation consequent on which has in some degree im- plicated the structures divided in the operation, rendering them less liable to take on the healthy action of adhesion. The soft parts should be simply approximated by two or more sutures, the edges of the wound having a piece of lint between them. This precaution should be particularly at- tended to after a great battle, when it is perceived that from the air, the crowded state of the hospital, or the season of the year, the stumps, al- though they may appear to unite in the first instance externally, do not in realify do so internally. Part xxvi., p. 163. Amputation at the Ankle.—Professor Syme states his having performed this operation above fifty times with complete success, the essential point of success being, his preserving entire the nourishment of the flap. As this can only be effected by the anastomosing branches of the integuments, the greatest possible care should be taken not to divide them. To the neglect of this caution Mr. Syme attributes the want of success which has attended some of the London surgeons in performing this operation. Part xxvi., p. 164. Amputation above the Knee.—In making the flaps in this operation, Mr. Luke makes the posterior flap by piercing and cutting from within out- ward ; but the anterior flap is made in the opposite manner, by carrying 'the knife in a curved direction antero-posteriorly through skin and muscle down to the bone. The flaps can be thus made with the greatest regularity, exactly to the size best calculated to make a good stump, forming a thick, symmetrical, and clean cushion for the bone. Part xxvi., p. 165. Excision of the Proximal Phalanx of the Thumb.—In this case an ab- scess formed on the palmar side of the first phalanx, which was opened and the bone found to be bare. Mr. Teale proposed to remove the diseased phalanx, and to leave the terminal one. For this purpose, he made an incision, rather more exten sive than the phalanx, along its radial border. The ligaments and capsule connecting it with the terminal phalanx were next cautiously divided ; the shaft of the bone was then separated from the surrounding soft parts; and, lastly, it was detached from the metacarpal bone. The thumb was dressed with wet lint, and the patient confined to bed. The case pro- ceeded well, without any unfavorable occurrence. The disease in this case was caries, and not necrosis; and at the time of the operation what remained of periosteum being adherent, was removed with the bone. The latter circumstance accounts for there having been no reproduction of an osseous shaft. The success of the operation with so unhopeful a form of disease is the more satisfactory. In some cases of diseased metacarpal or phalangeal bones, a genuine necrosis of the shaft takes place, and a thin shell of new bone is formed by the periosteum. The success of an operation is of course much more probable in such a condi- tion than in one of caries. Part xxix., p. 196. Amputation by flaps.—If the circumference of the limb be twelve inches, for example, the anterior flap should be three inches, and the pos- terior six inches long; the knife having transfixed the soft parts, so as to make the anterior, or shorter flap, seven inches at its base; and the pos- 88 AMPUTATION. terior, or longer flap, five inches. By this method the measured cut snr. faces of the two flaps are exactly equal. ********* Stumps—Rules for the Formation of—In the leg, amputation should be performed at the upper portion of the lower third, so that the patient may have a complete command over the artificial limb, without the stump being too long. The leg should not be amputated above the upper third, and where one-third cannot be saved it is better to amputate at the lower third of the thigh; so that a stump may be left of sufficient length and power. A good stump above the knee is far preferable to an indifferent one below. " In the thigh the lower third is the best part. As a rule, in all cases, the larger the stump the better, unless, as in the case of the leg, the extreme length might interfere with the mechanical arrangements. The leg should never be amputated in children, but the lower third of tho thigh always selected, because the amputated limb ceasing to grow in proportion with its fellow, the knee-joint will in time be elevated some inches above the other, imparting to the gait a peculiarly grotesque ap- pearance. Part xxix., ji;. 198. Thigh—Amputation of—The longer the stump the better, and, if cir- cumstances warrant, operate at the knee-joint. Progression is greatly im- proved by the long stump thus left, the limb does not describe the semi- circular curve which it does with a short stump. The walk is altogether better. Part xxx.,p. 113. After-Consequences of Amputation.—The first and most pressing danger after amputation, says Dr. Hamilton, is hemorrhage. u It may arise from half an hour after the operation to any number of hours or days, till union in the stump is effected. It is this that makes the surgeon careful to have his patient watched by an assistant always at hand. If the bleeding is only trifling, I would have you not interfere ; compression on the face of the stump and the application of cold is often sufficient to check an in- considerable bleeding, which your opening of the stump would only tend to render a considerable one; but should the blood flow freely, the stump be swollen, and clots appear betwreen the spaces of the sticking-plaster, you must open it forthwith, and search for the bleeding vessel. Before, however, the dressings are removed, firm pressure should be applied over the femoral artery, by a steady assistant. This is much better than the tourniquet; it causes the veins to become turgid and add to the bleeding, which sometimes even comes from the femoral vein itself. When you have no one to help you, there is no choice but to apply the tourniquet. Then carefully clean the face of the wound of the clots which you will nearly always see covering it. The blood will now be found to come in three ways: first, in a general oozing from the stump. In this case, if there are one or two spots whence the blood flows with more rapidity, you may take up the vessels; but, in this general bleeding, it is best to cover the part with shreddy lint, and press steadily with your fingers on it for some time. The bleeding will usually stop, or at least that bleeding which comes from small branches, temporarily increased or excited by the inflam- matory action which has begun in the end of the amputated limb. Those of larger size will then be more readily found and secured. Then put together the sides of the wound with sticking-plaster, or compress and bandage, giving up all hope of union by the first intention. AMPUTATION. 89 " A more serious hemorrhage, though happily very rare, is from the fe- moral artery itself. This may occur early, from the slipping oft' of the ligature, from its not having been tied sufficiently tight; or at a later period, when the ligature has been drawn off, but no proper clot or union exists at the end of the vessel. " The third kind of hemorrhage is from the femoral vein, and is some- times very profuse. At the time of the operation there is occasionally troublesome bleeding from the femoral vein, which ceases oh the slacken- ing bf the tourniquet and removal of the tourniquet bandage ; oris readily restrained by putting a small compress of lint over the cut end of the vein. Most surgeons dislike applying a ligature round a vein, but if the other means fail this must be done. I removed the leg of a young man below the knee, for disease of the tarsus and ankle-joint; on the twentieth day after the operation, when all the ligatures had come away for several clays, he was seized in the middle of the night with violent hemorrhage, not per saltum, but in a free flow, and of a dark color. Pressure on the femoral artery did not stop it. All the stump had united except a small portion in the ham, which went like a large fistula high up, and from which the hemorrhage came. Pressure over this part with lint saturated in a strong solution of alum and in turpentine, stopped the hemorrhage, which, how- ever, returned again and again, but was finally completely arrested by laying open the unhealed cavity from whence the hemorrhage came, and laying the compresses over an ulcer in the popliteal vein, from "which the blood was seen to flow. " The smaller ligatures come away about the tenth day ; the ligatures on the larger arteries, as the femoral, humoral, or posterior tibial, after the fourteenth, or longer; I have know even a month elapse before the last ligature came away. " If the wound docs not unite by the first intention, its progress is pretty much as follows : for the first two days all goes on well, but the third day you hear that the patient has passed a restless night; he complains of pain in the stump, and his face is flushed, skin hot, pulse quick, and the tongue loaded. After removing the lint dressing, the stump appears swollen and red, and the bandage looks too tight; you slit it up and remove one of the strips of plaster, when the wound at once gapes, no union having taken place, and a quantity of thin, bloody matter gushes out; the patient complains of much tenderness, and can scarcely bear the gentlest compression by the sponge. Two things should be observed; first, not to put too many strips of plaster on, or too tightly, as room should be left for the matter to escape; and second, not to put the ban- dage on too tightly, or it will cause much uneasiness; let it be applied merely firmly enough to give support. "The Bone.—The usual course is for a lymphy exudation to cover the surface oT the bone, which becomes adherent to the soft parts__this is when the greater part of the stump heals by the first intention ; when it does not, the surface of the bone, particularly the cancellous structure, throws up granulations, and union by the second intention is accomplished. Finally, the end of the bone is covered by a firm, fibrous material, its edges are absorbed, and it becomes ?onical. There is, however, trouble from the bone in two ways: first, the action of the saw sometimes seems to kill the sawn surface of the bone; and after the stump has refused to heal for a long time, the centre remaining open and discharging thin mat- 90 AMPUTATION. ter, the bone can be felt hard and distinct at the bottom of the wound. At length it is perceived to be loose, and can, with a forceps be with- drawn through the unhealed opening, or if not, an incision should be made, and it should be withdrawn. It sometimes presents a curious appearance; a perfect flat ring of exfoliated bone, about one-eighth of an inch or less ol the end of the bone having become dead or separated entire. Another way is this ; you see that the end of the bone is pressing against the upper part of the stump, and that the integument there is strained and tense in consequence; the bone being drawn upward and forward by the action of the psoas and iliacus muscles, while the soft parts are drawn downward and backward, partly by their own weight and also by the powerful trac- tion of the hamstring muscles. You will best counteract these forces by- putting a splint of wood, either flat or scored, at the under and back sur- face of the limb, with a well applied bandage, and the tension against the end of the bone is at once relieved. If you do not do this or it does not answer, the part against which the end of the bone projects and presses becomes white and glossy, then red and painful and very tender, then fluc- tuates, and finally ulcerates, and the end of the bone can be felt with a probe ; but though you would think the bone would exfoliate, it generally does not, but unites by granulation with the neighboring parts, and all goes on well. A stump that unites by the first intention, or, at least, that heals soon, is more likely to be a good plump one; when the healing is tedious from unhealthy action, or diseased bone, no matter how well the operation has been done, the stump will be conical. " Now, with regard to the nerves—they rarely give any trouble. Nerves in a stump are, as was ascertained long ago by Mr. Langstaff, found, after the lapse of some time, to have bulbous extremities. " If therefore, you find the ends of the nerves in an old stump ending in bulbs, you are not to consider them as diseased; nor, if any pain has been felt, that they are the cause of that pain ; nor can I say that cases where they have been removed by operation have been satisfactory. Stumps are usually not very sensitive; but occasionally, from a con- stitutional, I believe, rather than a local cause, the most violent pain is experienced,—a pain, apparently the most intolerable, and resembling tic-douloureux—absent for a time, but returning in paroxysms of dreadful severity. "The case of the Marquis of Anglesea, whose leg was amputated at Waterloo, will be familiar to you; nothing that was tried gave him any permanent relief. The great Nelson, also, suffered from this nervous affec- tion, after removal of the arm above the elbow, and many years of his life were rendered miserable by it." Part xxx., p. 118. Amputation of the Thigh.—In the upper part of the thigh the flap ope- ration answers well, but at the lower third, the circular, or a modification of it, is preferable. Mr. Syme often modifies the circular operation as follows: form two short flaps of skin by semi-lunar incisions on the anterior and posterior surfaces—then retract the skin so as to expose two inches of the muscles above the angle of union of the flaps, and divide the muscles in front as high as they are exposed, and those behind as low as they are exposed, to compensate for their greater contraction. Take care to retract the muscles an inch and a half or two inches before sawing the bone, as it is not the length of the flaps that prevents the future pro- AMPUTATION. 91 trusion of the bone, but the height at which the bone is divided above the angle of union of the flaps. Part xxxi., p. 119. Amputation at the Ankle—Prof. Syme's Operation.—Make a transverse incision across the sole of the foot, from the tip of the external malleolus, or a little posterior to it (rather nearer the posterior than the anterior margin of the bone) to the opposite point oirthe inner side, which willbe rather below the tip of the internal malleolus. If the incision be carried further forward, considerable inconvenience is experienced from the greater depth of the flap, the operator, getting into the hollow of the os calcis, cuts and haggles in striving to clear the prominence of the bone. Another incision is then to be carried across the instep joining the ends of the former. In separating the flap of skin from the os calcis, you must cut parallel to the bone. This is of the greatest consequence, as the flap is supplied with blood only by those vessels which run through it parallel to the surface—consequently if you are not careful you divide these vessels, and deprive the flap of nourishment. In dressing the wound afterward, be careful to avoid all pressure, as this will kill the flap. In this operation don't leave the astragalus, but take it away, as it is very likely to be involved in the disease, and even if not carious then, it is very disposed to be so, and you had better remove all the bones which are liable to caries, not excepting the os calcis. Part xxxi, p. 120. Amputation of the leg—Prof. Syme advises this to be done about an inch and a half below the tuberosity of the tibia. Take the head of the fibula or the tuberosity of the tibia as your guide, and make a short, anterior and posterior flap of integument only, entering your knife about a hand's breadth below the bony prominence at the point which is to form the angle of junc- tion of the flaps at one side. Having dissected up the integuments to an inch and a half below the tuberosity of the tibia, divide the muscles behind about an inch lower down, to allow for their retraction, and then saw through the bones as high as the skin has been dissected up. The nicest kind of artificial leg is made of tin with a wooden pin—something like an inverted quart-bottle without a bottom. Part xxxi., p. 122. Hip Joint—Amputation at the.—Of the several modes of operating, that by a large anterior flap is considered by Mr. Tatum the best, because the artery can be grasped with the flap, by an assistant, before the vessel is divided. The flap falls by its own weight into its proper place, purulent collections escape more readily, and. the wound consists of one continuous surface. During the operation the nates of the patient must project over the edge of* the table, and the thigh must be slightly flexed on the abdomen: then take a knife fourteen or sixteen inches long, and transfix the limb to. form the anterior flap, by making the knife enter about two inches below the anterior superior spine of the ilium, carrying it beneath the vessels to emerge immediately above the tuberosity of the ischium. The limb must now be forcibly abducted and everted, and the capsule opened, when the head of the femur will start out of the acetabulum. The remainder of the capsule is then cut, and the posterior flap made by carrying the knife downward and backward. A good deal depends upon the assistant slipping his fingers under the anterior flap as it is being formed, and com- pressing the femoral. Part xxxii.,p. 107. Painful Stumps after Amputation.—From considerable experience we 92 AMPUTATION. know that painful stumps are much more common after flap amputations than circular amputations; in the latter the nerves are cut off short and buried in the stump, while, in Ion- flaps, the nerves are cut obliquely, and are more likely to be pressed upon. When very troublesome you must dissect out the bulbous extremity. Par/! xxxin.,;). 147. Amputation after Injuries.—The main artery of a limb may be suddenly obliterated, or the chief nerve be rent asunder without danger to the vitality of the limb. But if the muscles at the seat of tho injury are very much contused, and the collateral channels for arterial as well as venous blood, are involved in the injury, it is more than probable that the limb will fail in nourishment, the indication of which is the loss of its temperature. Several hours, or even a day may be required to determine the affirmative on this evidence. To justify amputation for muscular injury, this must be very great, and the investing integuments not capable of replacement. Undue importance has been attached to exposure of the cavity of a joint and fractures into joints, although these must always be considered as serious complications, yet they often recover with good motion. Part xxxi\.,p. 121. Amputation through the Knee Joint.—The French have recourse to this mode of operating only in those cases in which the heads of the bones of the leg are fractured into the articulation, but in which the injury has not extended to the femur. In many cases which occurred in the English army the operation performed was not strictly through the knee joint, but the low amputation recommended by Mr. Syme in disease of the articulation. The practical advantages of this are such as would seem to recommend its more general adoption in any future campaign. The obtaining of a longer and firmer stump, and one to which a false limb can be more easily attached, than when amputation in the continuity of the bone has been performed, is in itself no small advantage, presented by this operation. Few now participate in Liston's opinion of along thigh stump. The rectus, with its point of insertion remaining entire, is a mat- ter of vast importance to the power of progression. The non-interference with the medullary canal obviates many of the dangers of amputation, ac- cording to Cruveilhier ; while the extremity of the femur, which is largely supplied with blood-vessels, being retained, there is less risk of exfoliation than when the dense substance of the bone has been opened by the saw. There is little fear but that the flaps will adhere over the cartilaginous ex- tremity of the bone. Of the many ways of performing this operation, none appear so good as the old one of Hain. part xxxi\.,p.V2Q. New Operation in Surgery—Disarticulation of the Scapxda.—The entiro scapula, with its processes and glenoid cavity, were removed, in the Hoyal Infirmary of Edinburgh, on the first instant, by Mr. Syme, on account of a systic-sarcomatous tumor. The patient, an elderly female, is doing well, and the arm promises to be wonderfully little diminished in usefulness through the absence of the shoulder-blade. Part xxxis.,p. 128. Knee Joint—Amputation at the.—This amputation has lately been per- formed by Mr. Fergusson several times, and he believes that of all the thigh amputations it is really the best, as such a good flap and stump are obtained. Part xxxv., p. 09. AMPUTATION. 93 Flap Amputations—-Cut from without inward, but at first only down to the fascia, to allow for the greater retraction of the skin than of the mus- cles. Separate these superficial flaps from the subjacent muscles to a suffi- cient extent; then divide the latter by two incisions so as to form flaps. In the after-treatment of the part, Mr. Paget bandages the stump from above downward, the soft textures being at the same time drawn by an assistant over.the ends of the bone. Part xxxvi., p. 124. Amputation at the Ankle Joint.—In performing this operation, after making an incision from malleolus to malleolus under the os calcis, at first suggested by Professor Syme, make a straight incision at right angles with the first to the back part of the heel, on the outer side of the foot, a little above and parallel with its outer margin, between, therefore, the point of the outer malleolus and the margin of the foot. By this means the opera- tion is considerably facilitated, and pus does not subsequently collect in the cup-shaped flap. The principal bloodvessels lie at the fore part and inner side of the ankle joint, and beneath the foot. Part xxxvi., p. 147. Turpentine as a Detergent.—We noticed in use at the Dreadnought, the oil of turpentine as a wash for stumps, etc., which may have got coated with plaster or other adhesive material. It is, we believe, also used at several other hospitals for the same purpose. The part is freely washed with tow dipped in turpentine. It does not appear to unduly irritate, but restores a healthy glow to the cutaneous surface, and the patients describe its effect as being pleasant rather than otherwise. Part xxxvii., p. 267. Amputation by a Long and Short Rectangular Flap.—The excellence of a stump is not to be judged by its seemly form and its being not offen- sive to the sight; we ought to inquire whether it is well adapted to loco- motion, by being able to bear a considerable portion of the weight of the body on its end. Now as a general rule, it may be stated that stumps are not able to bear even the slightest pressure on their extremities where amputation has been performed by the circular or ordinary double-flap transfixion methods. Mr. Heather Bigg and Mr. Grossmith, of London, and Mr. Thomas Eagland, of Leeds, surgical mechanicians, who have had extensive experience in the adaptation of artificial limbs, state that press- ure can never be borne upon the end of the stump formed by the circular or transfixion methods, on account of the pain produced; and that, as a general rule, the cicatrix is found adherent to the end of the bone. To procure a more useful stump, and in the hope of somewhat diminish- ing the mortality of amputations (which in the London and Provincial Hospitals together is nearly one case in three for the last thirty years), at the Leeds General Infirmary amputation has been performed by a long and short rectangular flap. " The size of the long flap is determined by the circumference of the limb at the place of amputation, its length and its breadth being each equal to half the circumference. The long flap is therefore a perfect square, and is long enough to fall easily over the end of the bone. In selecting the structures for its formation, such parts must be taken as do not contain the large blood-vessels and nerves. A flap so formed will be for the most part anterior in position as far as regards the general aspect of the body, but superior when the patient is in the recum- bent posture, as during the after-treatment. The short flap, containing the chief vessels and nerves, is in length one-fourth of the other." Thus, if the 94 AMPUTATION. limb be 16 inches in circumference, the long flap will be 8 inches by 8, and the short flap 8 inches broad by 2 long. The flaps are united lightly by sutures, one or more of which may be subsequently removed if tension come on. No dressing whatever is required in the early part of the treat- ment ; thus disturbance of the stump is avoided ; for in all these kinds of cases the non-disturbance of the plastic process is the chief point on which the future safety of the patient depends. Stumps obtained by this method of operating have a soft mass of tissues, devoid of large nerves, movable over the sawn end of the bone, which enables them to bear pressure on their extremity. This operation has been performed 56 times altogether, with a mortality of 1 in 7. Amputations of the leg for disease show a mortality of 1 in 27 : in the London hospitals these amputations are attended Avith a mortality of 1 in 3|-. Mr. Teale strongly recommends the surgeon, on first practising this ope- ration, to mark out the lines of intended incision, in ink, lest the long flap should be made too small. Part xxxviii., p. 127. Resection and Excision of the Phalanges.—In appropriate cases, such as caries of the head, ungual phalanx, or of the whole bone, excision of the head, is the proper treatment. In removing the head of a phalanx for disease of the joint, do not use the bone nippers, but a fine watchspring saw, as the parts will heal more rapidly, and take care to extend the parts whilst healing, to prevent anchylosis. Supposing the whole of the ungual phalanx to be diseased, do not amputate, but remove the whole bone; the sides of the tip of the finger should then be slightly compressed against each other, and the part retained in an extended position. Part xxxviii., p. 141. Amputation at the Carpo-metacarpal Articulation—By amputating at the carpo-metacarpal articulation, instead of at the wrist joint, as generally done, you preserve uninjured the motor power of the wrist joint, which is lost in the latter operation; the flexion and extension is perfect, and a useful substitute for a hand may be adapted to it. Mr. Rudall says: I have performed this operation between the years 1828 and this time, on four different occasions, the results of injuries from fire-arms and machinery. The last case will suffice for the present notice. A boy, aged thirteen years, on the 20th of January of this year, sustained an injury of the right hand, from its passing between two wheels of a power- ful machine, by which the fingers and lower portions of the metacarpal bones were literally ground to atoms. The shock upon the system w:is intense ; ten hours elapsed, during which stimulants were freely admin- istered, before I felt myself warranted in operating. I feared the use of chloroform, and proceeded to the operation, which of itself is very simple, and may be done four or five times while describing it once. I made my first flap on the thenar and palmar aspect, commencing on the dorsal half of the articulation of the thumb with the trapezium, carrying my flap so far into the palm of the hand as was well savable ; the dorsal flap was not so large. Having divided the integuments of each flap with the muscles, tendons, etc., disarticulation was effected, by bending the hand on the wrist, and separating the articulations from the dorsal aspect of the joint. Ligatures are not necessarily required in this operation, torsion effected with Liston's common artery forceps being sufficient. The thins were brought together by three sutures, and cold water dressings, which were ANEMIA. 95 the only means resorted to for tho perfection of the cure. Duration four- teen days. -Part xxxix., p. 145. —»-*-•— AN2EMIA. Treatment of Ancemia—In treating anaemia, Dr. Turnbull recom- mends the use of remedies which improve the general health and strength of the patient, and tend to increase the quantity, and improve the quality of the blood: these are, the vegetable bitters, the sulphate of quinine, and other tonics, but- especially the preparations of iron, which have a powerful effect in increasing the quantity of that constituent of the blood which is deficient in anaemia. Iron forms the chief part of the haematosin which is contained within the external envelope of the red globules; therefore, this is one of the most important medicines by which to increase the quantity of the glo- bules. It is better to give iron in small quantities for a long time, than in large doses for a short time. The sulphate of iron is one of the most useful and active preparations, and it may be given in the form of pill, with a bitter extract, such as that of gentian, or a sedative, such as hyoscyamus or conium, or with an aperient powder or extract, such as aloes or rhubarb, or with any of these combined. It may also be given in solution, with a bitter infusion, to which a little sulphuric acid has been added, to hold the iron in solution ; or it may be exhibited in combination with the sulphate of magnesia or potass, the solution being acidulated with sulphuric acid. It may thus be given in combination with several of the medicines required in anaemia; and from this circumstance have I used it more frequently than any of the other preparations, and I have also found it one of the most efficient. The ses- quioxide of iron is a convenient form when we have to treat anaemia in children, to whom it may be given with compound cinnamon powder, or with rhubarb, or mercury with chalk, where the secretions are deranged. I have also given it to adults along with the confection of senna, bitar- trate of potass, and sulphur. This combination possesses several advantages, inasmuch as it increases the secretions from the skin, kidneys, and intestinal canal, while it exerts a tonic effect by the introduction of iron into the system. The compound mixture of iron is a good prepara- tion. It is milder than the sulphate, but it scarcely equals this, and the tincture of the muriate, in efficacy. This last preparation is one of the best, but it does not admit of being administered in so many forms as the sulphate. Several of these preparations seem to me to be often given in larger doses than is necessary, where we wish to obtain little effect beyond the absorption of the iron which they contain into the blood. This observation applies especially to the sulphate and the muriated tinc- ture. That the efficacy of the preparation is not in proportion to the quantity of iron it contains, is proved by the fact, that many mineral waters are very powerful, though they contain less than a grain in the pint. The preparations made from combination of iron with the vegetable. acids are less efficient than those with the mineral acids, and Dr. Williams 96 ANEMIA. observes that the citrate and tartrate are more tardy in their operation. These are, however, milder in their action. The potassio-tartrate of iron may be given, along with the bitartrate of potass, when there is oedema of the ankles, or of the cellular tissue gen- erally, and when we wish, therefore, to produce a diuretic effect. Dr. Williams states, that in many comparative trials he found the iodide of iron, in solution with syrup, the most speedily efficacious of the prepa- rations of iron, and that by its use he has seen females restored from extreme pallidity to a rosy hue of health in less than three weeks. There are other tonics which are useful in anaemia, such as the vcgeta- ble bitters, gentian, eascarilla, calumba, which may be given in conjunction with iron. In many cases, too, where there is much irritability of the sys- tem, the preparations of iron cannot at first be borne, as they cause heat, of skin and thirst, or sickness, or headache; and when this occurs, it is neces- sary to promote the secretions, and to give the vegetable tonics with seda- tives, in order to prepare the system for the exhibition of iron. Quinine is very useful in many cases: It is most useful in the anaemia from lactation and from profuse men- struation, and in some of these cases it may be given in solution along with sulphate of iron and sulphuric acid. In most cases of profuse menstrua- tion the preparations of iron are hurtful, and in these, quinine and the shower-bath are preferable. When there is much depression or irritability of the nervous system, we must administer stimulant and antispasmodic, or sedative medicines; such as carbonate of ammonia, camphor, valerian, hydrocyanic acid, and hyo- scyamus. The carbonate of ammonia is exceedingly useful in equalizing the circulation, which is very often irregular in anaemia, and in restoring the temperature of the extremities when they are cold. The first organ to be attended to will often be the stomach and diges- tive organs. When the tongue is pale and clean, without redness at the point, and there is only weight and uneasiness during digestion, with or without eructation, but without sickness and vomiting, and the extreme sensibility of the nerves of the stomach, we may commence with the compound iron mixture, or with the muriated tincture in a bitter infusion, or with pills of the sulphate of iron, constipation being, however, in all cases, removed by some of the means that have been pointed out. In many such cases the preparations of iron in a short time remove the dyspeptic symptoms. In those where the sensibility is greater, where there is severe pain after taking food, and occasional sickness and vomiting, and when there is an extremely anaemic state, it will be well to lessen the sensibility, and res- tore, in some degree, the tone of the stomach, by sedatives and stimulants, combined with the vegetable bitters, before exhibiting any of the prepa- rations of iron. The infusion of calumba may be given with carbonate of ammonia, or with soda and hydrocyanic acid, or with tincture of hyoscya- mus or the muriate of morphia. The addition of compound tincture of cardamoms, or of some aromatic tincture, will also, in many instances, prove useful. In this way we shall gradually lessen the sensibility of the stomach, and prepare it for the milder preparations of iron, or for the sul- phate, which, in these cases, may be given in the form of piii with hyo- Bcyamus and aloes, and in this way its action will be exerted less upon tha stomach than upon the intestinal canal. ANEMIA. 97 Where there is pyrosis, a similar plan of treatment must be adopted, but the secretions from the liver and intestinal canal must be more fre quently promoted by rhubarb, magnesia, or carbonate of soda and mercury with chalk, or by colocynth and blue pill at night, followed in the morn- in" by a draught with the infusions of senna and gentian, and the sulphate ofmagnesia, or tartrate of potass. In the cases of gastrodynia, with pain of neuralgic severity occurring at intervals, especially after taking food, hydrocyanic acid and the muriate of morphia are the remedies most gen- erally useful. The nitrate and the oxide of silver are also of service ; and a plaster of belladonna applied over the stomach will often remove, and will almost always relieve, the pain : belladonna, in fact, affords relief from almost all the neuralgic pains of ansomia, and is a most valuable remedy. Stimulating liniments, blisters, and the external application of croton oil, and tartar emetic, may also be tried when the pain is severe and obstinate; but leeches, though they may occasionally give a little tempo- rary relief, should never be employed, unless there be some inflammatory irritation of the mucous membrane. When there is irritative dyspepsia, with redness at the tip of the tongue, thirst, feverishness, and pain, or rather soreness at the stomach, it some- times becomes necessary to apply a few leeches, and even to repeat the application in order to prepare the stomach for tonics. The nitrate of potass, and the .muriate of ammonia, when given in these cases along with hydrocyanic acid, produce a feeling of coolness at the stomach, and assist powerfully in removing the inflammatory state of the mucous membrane. These medicines may be given at first in water, and afterward in infusion of calumba or quassia, until the stomach can bear the milder preparations of iron in solution, or the sulphate in the form of pill. Milk and farinace- ous food constitute the most suitable diet in the early stage of these cases. When, from the severity and persistence of the pain at the stomach, or from the occurrence of hematemesis, we have reason to suspect the pre- sence of ulceration of the gastric mucous membrane, our treatment will not differ materially from that recommended for gastrodynia. Chalybeates should still, ifpossible, be given, and counter-irritation should at the same time be employed. Sulphate of iron, given according to the formula of Dr. Abercrombie, is, perhaps, .the best remedy we possess; two grains of the sulphate of iron to be taken three times a day, in combination with five of aromatic powder and one of aloes. Much will also be gained by attention to diet, which should be easily digestible, and at the same time nourishing. In cases where there is relaxation and increased secretion from the bron- chial mucous membrane, the combination of the mineral acids with the other tonics is desirable. I have occasionally found the .tincture of cubebs useful in checking the secretion, and have been in the habit of giving it, com- bined with oxymel of squill and compound tincture of camphor. Coun- ter-irritation should also be used ; and the following is the formula I employ: One drachm of croton oil, with four and a half of olive oil, and half a drachm of cajeput oil, made into a liniment, and rubbed upon the chest twice a day. Little modification of the general plan of treatment is required for palpitation of the heart, and for anaemic pulsation of the aorta. The removal of any complications connected with the digestive organs, and the use of chalybeates are generally sufficient to take away these symptoms. The compound galbanum pill may be given to remove flatu- lence ; and when the circulation is feeble, with disposition to faint, the m ANffMIA. carbonate of ammonia, with valerian or ether, will counteract this, and tend to restore the circulation in the extremities. When the nervous system is in a very irritable and easily excited state, so that the slightest noise is sufficient to startle the patient, camphor, in combination with the extract of hyoscyamus, with be found serviceable, or the carbonate of ammonia may be given with tincture of valerian in cam- phor mixture or a bitter infusion. Sulphate of quinine in solution, along with sulphuric ether, may also be found of use. The vertigo, noises, and headache, are in general removed only by degrees, in proportion as the quality of the blood is improved, and unless unusually severe, they do not require any special treatment. It lias been already observed, that in some , cases the preparations of iron increase the head symptoms, and when this occurs to any considerable extent, or when the pain in the head is unusually severe, or the vertigo so great as to endanger the patient falling, we must proceed, in the exhibition of chalybeates, in the same gradual manner as where there is much irritability of the digestive organs. These symptoms of congestion are too often treated by depletion with leeches, Avhicli fre- quently increases the pain and feeling of giddiness, and necessarily proves always more or less injurious in a state of anaemia, owing to the removal from the system of a portion of all the constituents of the blood. In these cases, if the symptoms are urgent, or if a mild stimulant plan of treatment with purgatives, and followed by the cautious use of some of the preparations of iron, do not remove the unpleasant symptoms, a blister should be applied to the nape of the neck. This will seldom fail to give relief, and it is the remedy best suited to these cases, as it removes con- gestion of Jhe vessels by producing depletion, without, however, taking from the blood the part which is deficient in anaemia. I may also ob- serve, that in all cases of congestion, and even acute inflammation, occur- ring in anaemic persons, we should be sparing in the use of blood-letting, general or local, which is the most direct means of lessening the globules ; and Ave should give preference to the application of blisters. A spirit lo- tion is a suitable application in cases of pain in the head from anaemic con- gestion of neuralgia. The periodic neuralgic pains of the face are to be treated by the ex- ternal application of belladonna, and by quinine, and the carbonate and other preparations of iron. The pains in various parts of the body, in the spinal column, and in the nerves issuing from it, are to be treated by stim- ulating and anodyne liniments, the belladonna plaster, and occasionally, blisters. We have stil\ to notice those cases of anaemia in females, where suppressed, irregular, or scanty menstruation forms a prominent symptom. The secretions from the intestinal canal having been first evacuated by means of mild mercurial medicines, the bowels are to be kept open once or twice daily by means of the aloes and myrrh, or compound aloetic pill, or by the compound decoction of aloes. Dr. Ashwell regards the combination of cordials with asperients as im- portant, and recommends the following draught to be taken twice or three times a week : Powdered rhubarb; carbonate of magnesia; of each half a drachm; aromatic confection, one scruple ; cinnamon water, nine drachms ; compound tincture of cardamoms, one drachm. lie recom- mends that the sulphate of iron should be taken three times a day, in the dose of one or two grains, combined with extract of hops, aromatic con- fection, and a single grain of poppy or hyoscyamus extraet. I frequently ANEMIA. 99 prescribe pills made with sulphate of iron, powder or extract of aloes, and extract of hyoscyamus, of each, one scruple, divided into twelve pills, and one taken three times a day. The superior efficacy of the iodide of iron in many of these cases has been already adverted to. Where other preparations of iron have been injurious, Dr. Ashwell has found the carbonate in the following combination agree with thepatient: Carbonate of iron, eight grains ; powdered ipecacuanha, one grain ; mer- cury, with chalk, two grains. This powder to be taken once or twice a day. He also recommends, when the general health is somewhat re- stored, the use of the mustard hip-bath, or the local salt shower-bath, or the injection into the vagina of a drachm of liquor ammonia to a pint of milk. Where the uterus has seemed to require to be stimulated, after the restoration of the general health, I have in many cases found effectual, a draught with turpentine and castor oil. The slight oedema of the ankles and of the cellular tissue generally, which is occasionally met with in anaemia, and chiefly in that form under consideration, viz., chlorosis, requires that the treatment should have especial reference to this complication. Our first object must be to increase the secretions from the bowels, the kidneys, or the skin, or from all of them, so that the specific gravity of the liquor sanguinis may be increased, and the natural relations between this fluid, the chyle, and the fluid of the globules, restored. The aperient best suited to these cases is the com- pound powder of jalap, alone or with calomel, or the bitartrate of potass. The potassio-tartrate of iron may also be given, along with the bitartrate of potass, to act as a diuretic. The sulphate of magnesia or of potass, given along with sulphate of iron, will act upon the bowels and kidneys, besides introducing iron into the system. Where the bowels have been very obstinate, I have combined a small quantity of elaterium with the sul- phate of iron and aloes, in pills. The restoration of the healthy action of the skin is of the first importance in these cases, and the cutaneous transpiration should be promoted by baths, friction and exercise. In several cases of chlorosis I have seen a single warm bath completely refnove the oedema of the ankles. Part xiii., p. 69. Diagnosis of Chlorotic Ancemia.—Every instance of anaemia is not always discoverable upon inspection of the tints of the skin, nor upon a survey of the state of the patient as to her embonpoint, since in some anaemic individuals, the cheek and the lips retain a considerable degree of freshness and vivacity of color from a natural exuberant vascularity of the tissues composing them ; and there are not a few anaemic patients who even grow fat during the malady. Dr. Meigs would test the state of the lungs by asking the patient to make several forced inspirations, in order to discover whether the capacity of the lungs for atmospheric air were at all lessened by disease ; and should she appear to be able to inhale fifty or sixty cubic inches at an inspiration, would have a right to conclude that the air-cells of the lungs were free from pressure or obstruction, and duly expansible. This view might be confirmed by percussion and by auscultation of the chest. Still the respi- ratory difficulties remain to be accounted for, especially those resulting from every muscular effort. Dr. M. would next examine the frequency o£the pulse, which, in a state r/f rest, might be sufficiently quiet—as at 70, 80, or 90, beats per minute. 100 AN.EMIA. If now the patient be requested to walk to the head of the stairs, and re- turn immediately to her seat, she will, if anaemic, be found to have the pulse greatly accelerated and beating in the most troublous manner, to the number of 120,and even 160 pulsations per minute, while the respiration may amount to 40 and even to GO per minute. Part xiv., p. 69. Remarkable Form of Anaemia. — At a meeting of the South London Medical Society, Dr. Addison described a form of anaemia which has not hitherto attracted much attention. It affects adult males, and comes on most frequently in an insidious manner. Its approach is first indicated by a certain amount of languor and rest- lessness, to which presently succeed a manifest paleness of the counte- nance, loss of muscular strength, general relaxation or feebleness of the whole frame, and indisposition to, or incapacity for, bodily or mental exer- tion. These symptoms go on increasing with greater or less rapidity : the face, lips, conjunctivae and external surface of the body, become more and more bloodless, the tongue appears pale and flabby; the heart's action gets exceedingly enfeebled, with a weak, soft, unusually large, but always strikingly compressible pulse ; the appetite may or may not be lost; the patient experiences a distressing and increasing sense of helplessness and faintness; the heart is excited, or rendered tumultuous in its action, the breathing painfully hurried by the slightest exertion, whilst the whole sur- face bears some resemblance to a bad wax figure; the patient is no longer able to rise from his bed; slight oedema perhaps shows itself about the ankles; the feeling of faintness and weakness becomes extreme, and he dies either from sheer exhaustion, or death is preceded by signs of passive effusion or cerebral oppression. With all this, the emaciation or wasting of the body, though sometimes considerable, is not unfrequently quite dis- proportionate to the failure of the powers of the circulation—relaxation and flabbiness, rather than wasting of* the flesh, being one of the most re- markable features of the disorder. Dr. Addison next proceeded to give the details of several cases which had fallen under his own immediate observation. In only two of these did the patient recover: the one, a man below the middle period of life, who was looked upon as past all hope, and suspected to be suffering from some latent malignant disease, slowly but steadily recovered under the free use of brandy, but with the singular result of the hair on one side of the head turning permanently grey, whilst the other retained its original brown color. The second case of recovery occurred in a gentleman above middle age : it was by no means far advanced, but was sufficiently well marked to excite alarm. He left his business, quitted London, and sought recreation in the country. After a time he returned, and appeared to have shaken off the disorder entirely. In three cases only was there an inspection of the body after death, and in all of them was found a diseased condition of the supra-renal capsules. In two of the cases no disease whatever could be detected in any other part of the body. Dr. Addison inquired if it were possible for all this to be merely coincidental ? On the contrary, he could not help entertaining a very strong impression that these hitherto mysterious bodies—the supra-renal capsules—may be either directly or indirectly concerned in sanguification; and that a diseased condition of them, functional or structural, may interfere with the proper elaboration of the body generally, or of the red particles more especially. Part xix,p. 38, ANAEMIA. 101 Relation beticeen Anaemia and Goitre.—Dr. Begbie states, that in coun- tries where bronchocele prevails in an endemic form, the exsacguined countenances, protuberant eye-balls, and other signs of bloodlessness mani- fested by those infected with the bronchocele, render it probable that both are effects of the same cause—anaemia. Bronchocele, we are also told, develops itself rapidly during confinement in childbed, and undergoes a temporary augmentation during the flow of the menses. Dr. Parry has often seen goitre follow functional disorders of the heart—disorders known to depend very frequently on deficient san- guification. It is a form of the hydropthalmia of systematic writers—per- haps that form of dropsy denominated buphthalmus, or ox-eye, which accompanied the enlarged thyroid gland as a concomitant symptom of anaemia, in the cases related by Dr. Begbie. He found this enlargement of the globe of the eye the result of congestion and effusion, intimately connected with that condition of the system in which the blood is deficient in fibrin and coloring matter; and yielding to a plan of treatment adapted to such a state. This treatment consisted in the use of carbonate of iron with aloetic pur- gatives, and soothing doses of hyoscyamus; with sea-side residence, full diet of animal food, and exercise in the open air. With regard to the treatment of anaemia and its secondary disorders, first ascertain the exciting cause ; and having arrested or removed this, give the preparations of iron freely, and for a great length of time, with a liberal allowance of animal food, and porter or ale, in preference to wine. Recommend also change of air and travelling. Part xix., p. 39. Treatment of Ancemia.—Give nourishing diet, with as much animal food as the patient can bear; let the patient be exposed to the pure air and light of heaven as free and as long as the strength and sensibility will bear; promote the natural excretions by appropriate means; and give tonics, especially iron, the syrup of the iodide, preceded or not by some mild bitter. Employ diffusible stimulants, sedatives and narcotics, external stimulants, rest in the horizontal posture, and warmth to the extremities, when special circumstances point out the necessity for these means. And if the nervous symptoms do not cease with the removal of the anaemia, give the metallic tonics, zinc, silver and copper. Part xx.,p. 32. Ancemia as a Consequence of Rheumatism.—In commenting on some cases of acute rheumatism at St. Vincent's Hospital, Dr. O'Ferrall stated that he was induced to believe that this disease had a tendency, in its latter stages, to produce phenomena connected with a diminution of the globules of the blood. The attention of Dr. O'Ferrall was first called to the subject by observing that, in cases with endocardiac complications, after the employment of depletion and mercury, a cardiac bruit of a differ- ent character from that which originally presented itself, continued to persist, notwithstanding the steady employment of the usual means for subduing inflammatory action. By and by, cases terminating fatally came under his observation, in which, although this bruit was present to the last, no morbid appearances could be detected in the heart upon post- mortem examination. Afterward, he found that a rale musicale in the cervical vessels very constantly accompanied this peculiar cardiac bruit; and he was led to suspect, that after the subjection of the inflammation by 102 ANESTHESIA. bleeding and mercury, an anaemic condition followed the use of these remedies, Avhich would require a very different treatment for its subdual. He accordingly ordered chalybeates, as in an ordinary case of chlorosis, and found the cervical and cardiac bruits to disappear under the use of this remedy. This observation is one of very great practical importance, teaching us the necessity of discriminating between those cardiac sounds produced.by the participation of the heart in the general rheumatic disease, and those arising from deterioration of the blood. The treatment in the two cases must obviously be of a totally different nature. Part xx., p. 34. Employment of Manganese in Anamic Affections.—In those cases of anaemia Avhich are not benefited by iron, give salts of manganese. The carbonate or phosphate may be given in the form of pill, to the extent of three or four grains daily; or the phosphate or iodide may be given in the form of syrup, according to the formula. Vide " Manganese." Part xx., p. 35. Tannin in Anaemia.—Give a grain or tAvo of tannin tAvice or three times a day, dissolved in water or any simple vehicle, flavored Avith syrup to conceal the taste. The use of tannin does not prevent the employment of other remedies, such as iron, cod-liver oil, etc., but rather promotes their efficacy. Part xxi., p. 326. Chlorotic Ancemia.—In chlorotic ancemia especially, give the saccharine carbonate of iron and manganese. This preparation is much more power- ful than the simple carbonate of iron. In the chronic ancemia of children, the extract of bullock's blood, in doses from 9j. to 5j-, may be given with great benefit. In infantile anc&mia we may gi\'e 15 grains of this extract with three grains of the above double salt with great advantage. Part xxix., p. 324. Anaemia.— Vide Selections from favorite prescriptions, Art. "Medi- cines." ---•-•-•— ANESTHESIA. Anaesthesia treated by Electro-magnetism.—This patient had been laboring under a slight leucorrhceal discharge, for Avhich she had been directed to use a cold hip bath every morning. Every time she left the bath there Avas a loss of feeling in the skin, Avhich gradually subsided in about half an hour ; after the tAvelfth bath, hoAvever, it became permanent. She was in good health Avhen Mr. Christophers was called to her, and had taken a walk that day; she had no feeling from her toes upward as far as the water had extended; she complained of not being able fully to eva- cuate the rectum, and of the urine sloAvly dribbling aAY-ay. The tempera- ture of the parts Avas beloAV that of the rest of the body ; numerous remedies were resorted to Avithout benefit, Avhen the application of electro- galvanism Avas resolved upon. The method adopted was—first to pass a current doAvn the whole spine for half an hour ; then from each side of the sacrum to each foot for half an hour; then from the spine to the abdomen for the same period. At ANAESTHETICS. 103 the end of the twenty-two days the patient was quite restored ; no trace of the malady remained. Part xiv., p. 58. Ancest/iesia.—Dr. T. Cattell thinks the folloAA'ing principle, being in alt cases acted upon in the induction of anaesthesia, would obviate most of the dangers attendant thereon, viz., that no anaesthetic agent should be allowedingress to the lungs, of a higher specific gravity than the air Ave breathe. Part xxiii., p. 340. Anaesthesia—Arrest of.—Anaesthesia is a momentary disturbance of the cerebro-spinal system. To remedy it, apply electricity to various parts of the body, especially over the cerebro-spinal axis. Part xxw, p. 328. Action of Anaesthesia.—Dr. Detmold favored the N. Y. Academy with a Avritten exposition of his \deAvs of the rationale of the action of chloroform, sulph. ether, and nitrous oxide, the three agents employed for the purpose of producing anaesthesia. He attributes the action of all of them to the production of carbonic acid gas in the system. The first two supply the carbon, which absorbing oxygen from the blood, and the last supplying oxygen, Avhich absorbing carbon, in either case carbonic acid is the result, Avhich by its action on the living organism produces anaesthesia. This theory, though not absolutely susceptible of demonstration, i3 yet apparently based on a logical foundation, and finds a seeming confirma- tion in a number of well-known facts. Part xxxvii., p. 263. ANESTHETICS. Anaesthetics—CIdoroform.—The use of chloroform in operations is not contra-indicated by any state of the patient as to age or constitution, nor by any disease Avhich does not itself forbid the operation. In administer- ing chloroform, always use an inhaler, and watch carefully the effects pro- duced ; and do not seek to produce insensibility in less time than two or three minutes. When the margin of the eyelid can be touched Avithout causing contraction of the orbicularis muscle, or even when it causes but slight contraction, any operation can be performed without pain. At this time, as the effects of chloroform continue to increase for a few seconds after the inhalation is discontinued, it is advisable to intermit the vapor for a few inspirations, or to dilute it with more air, so as not to carry the insensibility too tar. When the operation is over, do not disturb the patient prematurely, but await the complete return of consciousness. Part xix., p. 338. Dutch Oil.—The chloride of defiant gas, or Dutch oil, is a safe and efficient anaesthetic. The dose required is smaller that than of chloro- form, and its effects are more agreeable. Part xix., p. 340. Anaesthetics.—Bromoform, Dutch liquid, and common coal gas, are safe and powerful anaesthetics; and the latter, as being cheap, deserves a further trial. Sulphuric ether should be given Avhen there is much con- stitutional debility, or Avhere the operation is likely to be long and tedious, or where it is likely to produce considerable shock and depression. Chlo- roform, though very agreeable and powerful, requires more care in its 104 ANAESTHETICS. administration than has usually been employed. The principal precan- tions to attend to in its administration are : not to give too much at once, and not to let the temperature be too high, to take care that the air can pass freely in and out of the lungs—not to give the vapor in too concen- trated a form at first—to Avithdraw the anesthetic as soon as there are indi- cations of unconsciousness and insensibility being produced—and then to give the vapor much more diluted, so as just to keep up the condition of insensibility. Remedies for an Overdose.—Remove the anaesthetic; dash a small quantity of water upon the face and chest, possibly alternating with heat to the latter; use moderate interrupted compression of the lungs, so as to change the air in the lungs, and so get rid of the vapor there remaining; or, with the same intention, blow a stream of air, not too forcibly, through a small tube into the larynx for a minute or tAvo. It is important, in the present state of our knowledge, not to attempt to do too much. Part xx., p. 244. Dutch Liquid.—According to Dr. Snow, Dutch liquid possesses no advantages over chloroform but such as are connected with its sloAver action and more persistent effects. It is, therefore, only on a feAV occa- sions that its use is to be preferred. Part xx.,p. 300. New Anaesthetic.—This agent, AAhich Dr. Snow has been recently using with great success, and" which he believes had not been administered be- fore, is the chlorureted hydrochloric ether. " The substance is called by its discoverer, M. V. Regnault, Vether hydrochlorique monochlorure. It is the first of a series of five bodies which he formed by decomposing mu- riatic ether by means of chlorine gas in the sunshine. A liquid Avhich is a mixture' of these bodies, has been used for some months in Paris by M. Aran, a very zealous experimentalist, as a local application to relieve and prevent pain. Dr. Snow having procured a quantity of this through the kindness of Mr. Morson, chemist, of London, separated the first and more volatile of the liquids by distillation, and he thinks that it possesses some advantages over chloroform." Part xxiv., p. 349. Carbonic Acid as an Anaesthetic.—iEther, chloroform, and carbonic oxide determine anaesthesia by robbing the arterial blood of its oxygen, so as to produce carbonic acid, thus making the blood venous. Carbonic acid itself may be respired (if sufficiently diluted Avith air) with safety. An animal Avas put to sleep for 87 minutes by it; the sleep AA-as perfectly tranquil; directly the inhalations are stopped the animal awakes. Death has never resulted as yet from this proceeding, as its approach is slow, pro- gressive, and can be predicted for some time by observing the condition of the heart and pupils. Part xxxviii., p. 260. Anaesthetic Properties of the Lycoperdon Proteus, or Common Puff- ball.—Mr. Richardson's attention Avas first directed to this subject from a friend mentioning to him that bees were sometimes stupefied Avith the Bmoke of this fungus before the contents of the hive Avere removed. They gradually recover from the insensibility, and thus the cruel necessity Avas obviated of destroying them by the fumes of sulphur. He then com- menced a series of experiments, illustrating its effect upon animals. He sways: A gentleman had a favorite dog, which was very old, was constantly ANAESTHETICS. 105 troubled with cough, and had a large and painful tumor over the abdomen. As the owner of the dog Avished to have this tumor removed, Dr. Willis thought there Avould be a good opportunity for trying the anaesthetic power of the fungus during an operation. He therefore kindly undertook to cut out the groAvth, if I chose to produce narcotism. I did so with the impure smoke of the fungus. The animal was narcotized in six minutes ; and the operation, which occupied ten minutes, wa& done AArithout the merest sign of pain until the last suture Avas being put in, Avhen wincing took place. Neither the heart nor the respirations seemed much affected in this instance. The recovery Avas so rapid, that, in six minutes, it would have been impossible to tell, without previous knoAvledge of the fact, that the animal had been subjected either to narcotism or operation. I need not occupy time in giving the details of several more similar experiments. To sum up the results of these experiments: There is, it is evident, a principle in the fumes of the puff-ball capable of causing anaesthesia in animals. The physiological effects brought out by this anaesthetic are also very marked. In a liberal dose, it narcotizes rapidly and effectually, without unpleasant symptoms; and the narcotic effect soon passes off, leaving the animal in perfect health. In diluted doses, it produces in- toxication and convulsions ; is longer in causing anaesthesia; sometimes excites cough and vomiting, and leaves the animal for a long time stupid and unwell. When it is carried to the extreme, the respirations cease before the beat of the heart. Indeed, in observing animals under the in- fluence of the narcotic, it is only necessary toAvatch the respiratory move- ments ; if these remain, even though reduced to the loAvest, the animal will certainly recover on removing it from the cause of the narcotism. In this respect the narcotic principle of the fungus resembles the Woorali poison. Experiments with the fungus may be performed in various ways. If the impure smoke is to be used, it is only necessary to let it pass freely into a box, through a hole in the bottom. A large tin funnel fixed, beneath the box in an inverted position, Avill readily convey the smoke. The box having been filled with the smoke, the animal is placed in it, and the lid is laid lightly on. Narcotism will generally take place in eight or ten minutes, often sooner. To clarify the fumes arising from the fungus, two small tin funnels are made to fit mouth to mouth, and the nozzle of one funnel is connected Avith a Wolff bottle containing a solution of caustic potash. Another tube, con- nected with the Wolff bottle, will convey the clarified fumes away. If, now, a piece of the fungus be placed in a burning state between the funnels, the smoke can either be drawn by the mouth from the exit tube of the bottle through the ordinary double valve apparatus for chloroform, or it can be driven over into a bell jar, by fixing the nozzle of a pair of bellows to the free end of the funnels, and bloAving gently. The glass bell into Avhich the vapor is received should be placed on a nicely fitting board, and the animal must be passed into the bell quickly, after it is charged with the narcotic vapor. Part xxviii. p. 322. Remedial and Anaesthetic Uses of Intense Cold.—First make a freezing mixture as follows: Pound a piece of ice as big as an orange, and put the material on a sheet of paper; mix this thoroughly, with a paper folder, with half its weight of common salt. Put this mixture into a net of the 10G ANCHYLOSIS. size required, and as soon as it begins to melt it is ready for use. The net is now to be placed upon the part required, and frequently to be raised in order that fresh particles of the mixture may be brought into contact Avith the skin. The skin is benumbed by this application in a few seconds, it first becomes Avhite, showing that the skin is influenced ; if prolonged, the adipose matter under the skin begins to freeze, and the part becomes hard as Aveil as Avhite. The freezing may be extended even to deeper parts if necessary. Remedial Uses.—In acute lumbago, chronic rheumatism, sciatica, acute rheumatism, except Avhere the head is implicated, ophthalmia, glandular inflammation in the neck and groin, orchitis, erysipelas, painful nodes, neuralgic headache, cancer, etc. Part xxx., p. 24V. Amylene as an Ancesthstic.—Sulphuric ether is perfectly safe in what- ever Avay it is used, because the dose of ether occupies so much space in the form of vapor that it cannot enter the system except by degrees, and its effects are necessarily produced gradually. A fatal dose of chloroform, however, occupies a very small space in the form of A'apor, and unless largely diluted Avith air it may act AArith dangerous rapidity, and the point of safety be easily overstepped. The quantity of amylene vapor Avhich requires to be inhaled occupies a volume intermediate betAveen that of the vapors of chloroform and that of ether. Amylene has the advantage of preventing pain Avith a less deep stupor than is occasioned by other agents, and a further advantage is the almost entire absence of struggling and rigidity. Amylene for Children.—1. It is respired more easily. 2. The effect is more rapid. 3. The sleep is more natural. 4. They return more rapidly to their former condition. 5. There is no after inconvenience. Part xxxv., p. 283. ---in ANCHYLOSIS. Effects of Immobility on the Articulations.—Cases mentioned of anchylosis of the patella Avith the femur, to Avhich naturally there is no predisposition. Hence 1st. It is dangerous to imprison for several months, in an immovable apparatus, the articulations of a fractured limb. 2d. That the joints should be left free to execute movements sufficient to induce the synovial exhalation. 3d. That Ave should commence gentle motion as soon as the callus is formed. Part iv., p. 110. Anchylosis of the Hip and Knee Joints.—Cured by operation. In the first case, the operation Avas performed on the person of a sailor, Avhose hip joint Avas perfectly anchylosed, and the limb so situated as to overlap the unaffected one. The thigh bone was divided with a saw, through the great trochanter and a part of its neck. This being done, the limb was readily straightened, and bony union having been prevented by daily movement of the limb, ligamentous attachments Avere formed, and an arti- ficial joint resulted. After the lapse of sixty days, the patient stood ANCHYLOSIS. 107 erect upon his feet, and finally did well, having a very tolerable use of his limbs. Second case, a man Avhose leg was bent backward upon the thigh so as to be completely useless, the knee joint being quite destroyed. The last operation consisted in cutting down upon the thigh bone a little above the knee, and removing a portion, of it of a wedge shape with .the saAV—the base, of the wedge shaped portion .being anterior and the apex posterior, so that when the leg Avas brought gradually downward and forward the edges of the two extremities of the femur would be in a tolerable state of juxtaposition, Avhich approximation, hoAvever, Avas not accomplished all at once, but very gradually, and apparently Avithout much force or extension being at any time employed. Part vi., p. 132. Anchylosis—Peculiar Mode of obtaining.—In cases of diseased joints, attended by suppuration, and also in chronic diseases of the joints, namely, where destruction of the articulation has taken place, and nothing oan be obtained (supposing amputation be not performed) but a stiff joint, the best plan is that of freely opening the joint at once. In the first place, the con- sequences of opening diseased joints are not so serious as are usually repre- sented, but, on the contrary, are so slight as scarcely to deserve notice; in the 2d, the process by which nature cures a joint in Avhich the cartilages are removed by disease, is anchylosis, but this eventual result demands th-? absence of cartilage; and lastly, the articulation is placed in the condition of a sinus Avhich has been slit up. The after treatment consists in fixing the joint in the most useful posi- tion, and keeping it steady by bandages, etc. Part xxii., p. 197. Treatment of Contractions of Anchylosis by forced Rupture.—In true anchylosis, the callus may be broken up. Langenbeck's plan Avas as follows : The patient is placed upon his back, and chloroform administered until complete anaesthesia is induced; until, in fact, the muscles cease to offer any resistance. As soou as the muscles become entirely relaxed, the patient is turned round on his belly; an assistant holds the head in a raised position, to prevent respiration being impeded, and to facilitate the further -analation of chloroform, if necessary. If the anchylosis be of the knee (the most favorable joint for the opera- tion), an assistant, or assistants, fix the pelvis, and the surgeon commences gradual flexion, if the joint be in an extended state, or 'extension if in a flexed state. The patient must be so placed, that the patella of the bent knee rests on the anterior margin of the operating table. The pelvis is fixed by the hands of assistants. The operator then clasps Avith one hand the femur just above the popliteal fossa; with the other, the leg, just above the ankle, and by alternate flexion and extension, practised Avith more or less power, according to the nature of the case, restores the mobility and the normal position of the joint. A loud crepitus attends the rupture of the adhesions. Should the strength of one hand of the operator prove insufficient, the femur is held down by an assistant. The operator clasps the leg with both hands, and produces, either by strong gradual pressure, or by sudden jerking movements, the rupture of the more powerful impe diment. Even firm osseous bridges are thus made to yield Avith a loud snapping sound. This Avas once, in a case of undoubted osseous anchy losis, so loud as to cause the mother of the patient, Avho was sitting in an adjoining room, to swoon. If, in course of the operation, the tibia I.'»S ANCHYLOSIS. threatens to luxate backAvard, and particularly, as is often the case, a con- secutive subluxation is already present, especial care must be taken to sup- port the joint by pressure on the posterior surface of the upper end of tho tibia. Still, luxation is often unavoidable, its mechanism depending or pathological conditions of the part, Avhich art is unable to change. We refer to those cases Avhere, in consequence of large defects of the inferior and posterior surfaces of the condyles of the femur, consecutive sublux- ation has supervened during the course of the inflammatory disease. A perfect luxation is in these cases more probable during the violent forced extension, if the patella is so firmly anchylosed Avith the femur as to pre- sent an invincible impediment to the pressure of the anterior surface of the tibia against its inferior margin. The force to be employed must be regulated by the surgeon himself. In cases of many years' standing, the force required, as might be supposed, is considerable; sometimes the Avhole weight of the body is necessary, but it must ah\rays be applied with care. When the callus yields to the ex- ternal force, the amount of flexion is preserved until the next trial, the limb being exercised, passively, during the interval. A great degree of flexion is not to be desired at once; and the more cautiously and patiently the limb is managed, the less danger of violent reaction, and the greater probability of success. When managed with due care, the inflammation set up is very trifling, indeed seldom sufficient to retard the cure. Fre- quently no reaction is perceptible. Every tAvo or three days the patient is again subjected to the same treatment. Sometimes a couple of months are necessary to restore the functions of the joint perfectly, but three or four weeks are frequently sufficient. Although many years have elapsed bctAveen the occurrence of the anchylosis and the attempt at restoration, yet in most cases the callus may be broken up, and the integrity of the joint restored. It is absolutely requisite, hoAvever, that the patient should exhibit no tendency to scrofula, and this the more especially if the anchy- losis be the result of scrofulous inflammation or ulceration. From the Avant of exercise of the joint, the limb is usually much smaller than the sound one. Sometimes almost total atrophy of the muscles is the consequence, but a short time suffices to restore them to their original volume. The after-treatment is based on two indications: the first, to preserve the degree of extension obtained; the second, to endeavor to restore the normal functions of the joint. After forced extension has been practised, the muscles have a decided tendency to return to their former condition. We have seen, that muscles Avhich have been contracted during a space of ten years, are not exempt from this tendency—a fact which sufficiently refutes the opinion of those Avho assert that muscles under prolonged con- traction utterly lose their vitality. In most cases we have to have recourse to a bandage of gutta percha, or to Avhat is better still, Stromeyer's apparatus for the extension of the knee joint—an apparatus Avhich, in the further treatment, is as indispens- able as it is efficacious. Where a subluxation of the tibia backward existed, the apparatus of Bonnet for extension of the knee joint was applied with obvious success. In the two cases where the luxation Avas perfect, and in others where it was very considerable, ail attempts at reposition proved in vain. Mr. Langenbeck has expressed it as his opinion, that the subcutaneous ANEURISM. 109 division of the t vn lateral ligaments might be of some service in these seemingly hopeless cases. Should an evident contraction of the external lateral ligament be present, a subcutaneous division which we have several times seen practised with eminent success by Mr. Langenbeck, in the treatment of genu vulgum, is here advisable. In those cases Avhere large defect in the articular surfaces of the external condyles of the tibia or femur exist, every treatment directed against the abduction will of course prove ineffectual. Part xxviii., p. 161. Old Contractions and Anchylosis.—Place the patient under.chloroform to relax the muscles, then forcibly bend or extend the limb; it will most likely crack, as the ligamentous structures and adhesions are broken through, but there is no danger. The limb must then be put in a splint, kept quiet, and evaporating lotion applied. Generally this plan suffices, though in some very obstinate cases it may be necessary to divide the hamstring tendons before the limb can be straightened. Part xxxii., p. 137. Partial Anchylosis of the Hip.—Even in a strumous patient, partial anchylosis, the result of inflammation of the hip joint, may be successfully removed by rupture of the uniting medium, provided the case be favor able. All pain must have ceased and the disease be quite quiescent. In a case operated upon by Mr. Brodhurst, the pelvis being fixed Avith one hand, the thigh Avas suddenly flexed, the limb being jerked without much force being used. Very slight pain followed, and passive motion Avas not commenced till the expiration of eight days. Ultimately the patient entirely regained the use of the leg, Avhen before she Avas only just able to touch the ground with the toes of the affected limb. The patient was a girl of 13 years of age, light haired, and of a strumous complexion. Part xxxviii., p. 130 —•-•-•—■ ANEURISM. Popliteal Aneurism.—Recommended, upon opening the sheath of tne femoral artery, instead of the usual mode of draAving the saphenous nerve outward and then passing the aneurismal needle, armed with the ligature, betAveen the artery and vein, to pass an aneurismal needle, unarmed and blunt-pointed, so as to avoid Avounding, under the Avhole of the contents of the sheath, and then gradually tilt the nerves over the exposed end of the aneurismal needle, leaving only the artery and vein lying on the needle. Having insinuated betAveen these the blunt edge of a small probe, remove carefully the needle from its former position and pass it through the space thus made. In this situation the needle may be armed by an assistant and the ligature secured in the usual Avay. The artery, in various operations requiring exposure, is not always seen to pulsate. The carotid has been seen to lie so perfectly quiescent after exposure, that a surgeon has thought, from the total absence of pulsation, that it could not be an artery. The Avhitish-colored vessel Avhich is ex- 110 ANEURISM. posed iii these operations is only discovered to pulsate by being pressed between the finger and thumb. As to the tightness Avith Avhich the ligature should be draAvn, the sur- geon should exercise his discretion, and "is best taught by experience. It is frequently stated, that the inner and middle coats of the artery should be felt by the operator to give way under the ligature; but in a very great majority of cases this cannot be detected. In old persons, where the coats are more likely to be indurated or ossi- fied, a less degree of force will of course be proper. Part \.,p. 127. Aneurism of the External Iliac Artery—Use of TranVs Aneurismal 'Needle.—The recovery of the patient in this case shoAvs that a large artery may be successfully tied at the distance of half an inch from the point at Avhich a branch nearly of equal magnitude comes off. Another circum stance connected Avith this case is the value which attaches to Mr. Trant'a aneurism needle, Avhich instrument will be found of essential" service Avhere a ligature has to be applied to any deep-seated vessel. When the instru- ment, armed Avith the ligature, has been passed under the vessel, a spring hook is gradually projected from the handle by the operator, and passes direct to the point of the needle, Avhere it takes hold of the ligature, which is then draAvn up from the bottom of the Avound by the surgeon and tied in the usual way. Part vii., p. 117. False Aneurism.—Case cited of a child nine years old, in Avhom there seemed to be an abscess over the carotid artery at the angle of the jaw on the right side. " Its most prominent point was posteriorly and superiorly at the outer border of the stemo-mastoid. Indistinct fluctuation could he felt, and there Avas slight pulsation in it immediately over the carotid ar- tery, but on grasping the sides of the tumor no pulsation could be disco- A'ered, nor could any be felt inside the mouth." On puncturing this tumor a gush of blood issued out, and Mr. Liston then detected the mischief, and next day determined to tie the carotid artery. The patient ultimately died. Part \i\.,p. 154. Popliteal Aneurism—Cured by Compression.—Three cases successfully treated, from Avhich it would appear that this plan of treatment has been too hastily abandoned by the profession, probably from the compression employed being so excessive as to render it quite insupportable to the patient. The least possible pressure Avhich may be sufficient to close the vessel should be used, and Avhen this cannot be sustained, it will prove of use to partially compress the artery, so as to lessen the impulse of the cir- culation. Part vii., p. 172. Simulated Aneurism.—Case of hysteria mentioned, in which there was a strong local pulsation of the aorta, in the epigastric region, simulating aneurism, Avhich disappeared as the general health improved. Part viii., p. 61. Cure of Aneurism by Compression.—The application of well-regulated pressure on the artery, between the aneurismal sac and the heart, recom- mended. The pressure should be so regulated that the current through the artery would not be completely arrested, it having been found that a partial cur- rent through an aneurismal sac leads to the deposition of fibrin in its interior, and to cause it to fill and become obstructed. ANEURISM. HI Valsalva's treatment should also be conjoined, viz.: perfect rest in the horizontal position, very low diet, and frequent blood-letting. Part viii., p. 114. Aneurism of the External Iliac Artery.—A remarkable feature in this case was the extreme and unusual rapidity of its progress, only three Aveeks having elapsed from its first appearance, of the size of a hazel-nut, before it occupied the whole of the left iliac fossa, itsbase projecting considerably beloAV Poupart's ligament inferiorly, and superiorly extending to within less than an inch and a half from the navel, being six inches across from above to below, and six inches and a half from side to side, projecting also from the plane of the abdomen fully three inches. It was decided to take up the common iliac artery. Mr. Hey describes the modus operandi as follows : The patient Avas placed on his back on a mattress, his shoulders moderately raised. The incision was commenced two inches and three quarters above the navel, and exactly three inches to the left of the median line. This was carried down, moderately curved, to the base of the tumor about six inches, and Avas afterwa*rd enlarged by an angular continuation, one inch and a half in length. The fibres of the ex- ternal and internal oblique muscles and transversalis being successively divided, the transversalis fascia Avas readily raised by means of a director, and carefully opened out through the whole length of the incision. The peritoneum now protruded in some measure; it Avas, hoAvever, kept down without much difficulty, and being gently drawn toAA'ard the opposite side, I was enabled slowly to insinuate my fingers behind the peritoneum, gra- dually separating it from its cellular attachment to the parts beneath. The common iliac artery was easily reached, and upon compressing it with the fingers, the pulsation in the tumor ceased at once. A lfttle time was occu- pied in scratching through the sheath of the artery Avith the point of the aneurism needle; this being accomplished, the needle Avas passed under the artery from Avithin outward, armed with a double ligature of stay- maker's silk, waxed. By holding aside the peritoneum and viscera, we now obtained for a moment a view of the artery, and ascertained that nothing else was included in the ligature; this being tied with the fingers close down upon the artery, all pulsation in the sac entirely ceased, and never afterward returned in the slightest degree. The exact position of the ligature Avas, I believe, an inch beloAV the bifurcation of the common iliacs. The wound was closed with six sutures and strips of adhesive plaster, and over the whole a coating of lint dipped in strong mucilage. Time, twenty-five minutes. The subsequent treatment was upon general principles. Particular attention is directed to the situation of the incision, as in this case the operator was relieved from all chance of embarrassment by the chord. Suggested, that in any case in Avhich it might be advisable, to take the chance of tying the aorta. This mode of doing it will he found in every respect far more safe and facile than that adopted by Sir Astley Cooper." Part ix.,p. 142. Aneurism of the Aorta.—When aneurism arises from the posterior part of the aorta, we generally Avant the evidence of a palpable tumor to indicate the disease. When the tumor is resisted in its development by unyielding structures (as is the case Avhen it arises from the posterior part 112 ANEURISM. cf tht aorta), it produces a peculiar character of pain, which, if not^ exclu- sively confined to this disease, exists so much more frequently in it than in any other, as to be enough at all times to awaken a suspicion of aneur- ism. * If this pain be connected Avith the loAver dorsal and lumbar verte- brae, and depend upon abdominal aneurism, there Avill be bruit de soufflet in the course of the artery. If the pain be connected Avith the upper, or thoracic dorsal vertebra?, and be oAving to aneurism, it seldom occurs that- there is not some diffi- culty in deglutition, or some obstruction in the respiratory apparatus. The character of the pain consists in a constant, aching, boring sensa- tion, and a sharp, lancinating pain. To relieve the agonizing pain of aneurism, there is scarcely a limit to the amount to Avhich Ave may exhibit opium, without producing narcotism. In the treatment of aneurism, low diet should be avoided, as lessening the prospect of a radical cure of the disease, and as increasing a nervous irritability—the constant accompani- ment of it. The interval betAveen the fatal termination and the bursting of an aneurism is various, and is much influenced by the importance of the organs Avhich the hemorrhage may affect. If it burst into the peri- cardium, and compress the heart, such interval "will, of course, be shorter than if it compress a less vital organ. If there have been an adhesion betAveen the laminae of the pericardium, the effusion Avill be more gradual, and therefore the interval will be longer than if no such adhesion existed. Part ix.,p. 175. Treatment of Aneurism by Compression.—Dr. Bellingham, one of the surgeons of St. Vincent's Hospital, when he first brought this subject before the Surgical Society of Ireland, had only met with three cases in which compression had been employed; that number has noAv increased to tAvelve. Of these, eight were treated in Dublin, and in all the cure has been permanent. With regard to this mode of treatment, he says: The principal improA'ement Avhich has taken place in the treatment of aneurism by compression, consists in the mode of applying the pressure; that is, instead of employing a single instrument, Ave employ two or three if necessary; these are placed upon the artery leading to the aneurismal sac, and Avhen the pressure of one becomes painful, it is relaxed, the other having been previously tightened, and by thus alternating the pressure, we can keep up continued compression for any length of time. By this means the principal obstacle in the way of employment of pressure has been removed; the patient can apply it Avith comparatively little inconve- nience to himself; time will not be lost, OAving to the parts becoming painful or excoriated from the pressure of the pad of the instrument; and as the pressure need not be interrupted for any length of time, the dura- tion of the treatment Avill be necessarily considerably abridged. Some of the success of the improved method of applying pressure must, hoAvever, be referred to the improvement of the instrument used. It consists of an arc of steel covered Avith leather; at one extremity is an oblong padded splint; the other extremity terminates in a nut, contain- ing a quick screAA", to Avhich a pad similar'to that of the tourniquet is attached. The principle of this instrument is exceedingly simple, so much so, that the patient can regulate its application himself, and it can be made of every size, so as to compress any vessel within the reach of compression. ANEURISM. 113 The following conclusions embrace, in a few Avords, the chief things to be remembered on this subject: 1st. That the arteries to Avhich pressure is applicable, being far more frequently the subject of spontaneous aneurism than those to which it is inapplicable, compression promises to supersede the ligature in the great majority of cases. 2d. Pressure has several obvious advantages over the ligature, being applicable to a considerable number of cases in which the ligature is contra-indicated, or inadmissible. 3d. The treatment of aneur- ism by compression does not involve the slightest risk; and even if it should fail, its employment not only does not preclude the subsequent operation by ligature, but renders the chances of the operation by ligature more favorable. 4th. Such an amount of pressure is never necessary aa will cause inflammation and adhesion of the opposite surfaces of the vessel at the point compressed. 5th. Compression should not be carried even so far as completely to intercept the circulation in the artery at the point compressed; the consolidation of the aneurism will be more certainly and more quickly brought about, and with less inconvenience to the patient, by allowing a feeble current of blood to pass through the sac of the aneurism. 6th. Compression, by means of tAvo or more instruments, one of which is alternately relaxed, is much more effectual than by any single instrument. 7th. Compression, according to the rules laid doAvn here, is neither very tedious nor very painful, and can be maintained, in a great measure, by the patient himself. 8th. An aneurism cured by compression of the artery above the tumor, according to this method, is much less likely to return than where the ligature has been employed. Part xi., p. 141. Spontaneous Cure of Tubular Aneurism.—Mr. Luke gives the fol- lowing : The patient was a stout, healthy man, of temperate habits. About a year before his admission into hospital, a tumor appeared on the upper part of the right thigh, which extended from Poupart's ligament, three or four inches down the course of the femoral artery. Pulsation Avas strong and uniform over the whole surface. The tumor was compressed Avith ease, and emptied, but refilled on the withdrawal of pressure. There Avas no pain, nor bruit, but weakness of the limb of the affected side, Avhich was, however, equal in temperature to the sound limb, and the arteries low down pulsated Avith equal strength on both sides. It had not increased in size from its first appearance, and for six months produced no uneasiness. Cramp and pain in the groin were then brought on by running, and are since easily induced by slight exercise. With a conviction that the tumor Avas aneurismal in its character, it was thought improper to place implicit credence in the patient's state- ment, that it had not increased in size since its first discovery. He was therefore placed in bed, AAUth the intention of determining by personal observation whether or not it underwent any increase in its dimensions; the determining of this point being necessary to guide the opinion and the advice as to the course best to be pursued m his case. It was thought that the application of a piece of adhesive plaster spread on leather, and of a spica bandage over it, Avas quite compatible Avith these intentions. They were accordingly applied over the tumor, March 3d, and not again disturbed until the 8th. On then- removal, on thus day, it 8 114 ANEURISM. was found that a considerable change had been effected in the tumor. Instead of being soft and compressible, and capable of being emptied of its contents, it Avas hard and unyielding, and slightly painful on pressure. It was further observed that its pulsation had entirely ceased, as well as the pulsation of all the arterial trunks of the limb; the femoral, popKteal, and anterior -and posterior tibial arteries, having in turn been examined. The foot and leg felt colder to the hand than the opposite, although the thermometer did not indicate any actual diminution of temperature. While collecting information respecting a state of things so unexpected, the patient stated that when the plaster and bandage Avere first applied, he experienced considerable pain in the tumor for about half an hour, attended by an unusually violent throbbing, Avhich perceptibly raised the bandage. At the end of that time the throbbing ceased, and there had not been any return. The plaster and bandage Avere reapplied, and the limb Avas Avrapped in wool. On the 22d of March, the tumor was still hard, consolidated, and Avithout any pulsation. There Avas apparently an obliteration of its cavity, the contents of Avhich had undergone some diminution from absorption. Mercurial ointment, spread on lint, was applied, and the patient alloAved to move out of bed. April 2d.—He Avas walked about, and, he states, Avith greater ease and freedom than Avhen admitted ; but the pain in the calf remained. 19th.—Has left the hospital for about ten days, but, as requested, paid the hospital a visit to-day. He still complained of pain in the calf, especially when going up-stairs. There Avas almost numbness of the foot at times. The circulation was apparently restored sufficiently for the proper nourishment of the limb, yet pulsation had not returned in any of the arterial trunks. The size of the tumor had undergone very considerable diminution, and the aneurism had been without doubt cured. [Mr. Luke then notices the indefinite nature of the terms true, false, and diffused, as applied to aneurisms, and thinks they may Avith advantage be allowed to become obsolete, as others more distinctive may easily be sub stituted.] Thus the different kinds of aneurisms, may conveniently be thus desig- nated : 1st, To the most common kind, characterized by the existence of a sac, the term"" saccated " may Avith propriety be applied as simply indi- cative of that fact, Avithout entering into any speculations as to the means by which the sac is produced. If we Avish to make distinctions of the saccated form, Ave might use the term " traumatic " for those forms of it Avhich are the result of Avound. 2dly, There is a form of aneurism char- acterized by a pretty nearly uniform dilatation of the tube of the artery, of Avhich the case above related forms an example. This, by some sur- geons, has been considered not to be aneurism at all; while by others it has been regarded as the true form of that disease. From the circum- stances of the tube of the artery undergoing a pretty uniform dilatation, I think that the term "tubular" Avould not be inappropriate, and Avould express adequately the kind of disease meant to be designated. 3dly and 4thly, The terms " dissecting aneurism " and " varicose aneurism " are suf- ficiently expressive of the forms of disease to Avhich they are at present applied, and need no further observation. But 5thly, the term " aneurism by anastomosis," as it involves a hypothesis, may be advantageously changed for "capillary aneurism," as merely conveying an idea that the minute or capillary vessels are the structures affected. Thus Ave have— ANEURISM. 115 1. Saccated aneurism, including traumatic. 2. Tubular aneurism. 3. Dis- secting aneurism. 4. Varicose aneurism. 5. Capillary aneurism; under which terms may be embraced every known variety. Part xii., p. 155. General Principles of Treatment of Aortic Aneurism.—Dr. Chevers considers the following to be the chief general indications which it is necessary to fulfill in conducting a rational plan of medical treatment in cases of aneurism of the aorta. To encourage, as much as possible, the deposition of thin layers of plastic coagula Avithin the aneurismal sac; to render the circulation through the visceral arteries, general capillary sys- tem, principal venous trunks, and lungs, as free as possible ; to diminish, as far as practicable, the Arolume of the circulating fluids, but in such a manner as to reduce the proportion of their Avatery constituents Avithout impoverishing the fibrin, or producing debility in the system; to main- tain the muscular power of the heart. Valsava's plan of treatment was calculated to prove eminently benefi cial under the direction of able surgeons, and even to obtain a cure; but Avhen practised by the incautious and unscientific, instead of tranquillizing the system, etc., it had the directly opposite effect, " impoverishing the blood, rendering the heart weak and irritable, and exchanging the proba- bility of a sudden death for the certainty of a painful and lingering one." The only natural process by which the cure of aneurisms of the aorta can be effected is, of course, by procuring the obliteration of the sacs by firm layers of adherent coagulum. In aneurisms of the limbs it appears to be merely sufficient that the sac should become completely plugged with clots, it matters little of what form, providing only that they be firm enough entirely to prevent the flow of blood through the diseased part, and to divert its course to the collateral arteries; but in aneurisms of the aorta, or, at all events, of its upper portion, a far more delicate process requires to be effected, as here the sudden formation of loose coagula in an aneurismal sac will always be liable to occasion rupture of the walls of that cavity, for Avhen the pouch has already become filled to distention— the passing current of blood still maintaining its pressure upon the mouth of the sac—every additional drop of fluid added to its contents will begin to act upon its Avails Avith the distending force of the Avater in a Bramah's press. Such loose coagulation will also be liable to stop the Aoav of blood through the aorta (an occurrence which, it is needless to say, is all but cer- tainly fatal, whether suddenly or gradually produced), or, at all events, it can scarcely fail to cause fatal obstruction and embarrassment to the heart's action, as coagulation of this kind would never be limited merely to the interior of the sac. The trial should be, by tranquillizing the circulation and preserving the blood in as highly fibrinized a state as possible, to pro- cure the obliteration of the sac, and of the sac only, by layers of coagu- lum so firm, organized, and even, that'they may resist the infiltration of the blood, and present internally a smooth but resisting surface past wdiich that fluid may glide easily in its passage through the vessel. The importance of removing all congestion of the liver, spleen, and kidneys, and keeping up a healthy action, cannot be too strongly enforced. The reduction of the volume of the circulating fluids has long been con- sidered as a necessary means in the treatment of all organic diseases of the heart and its appendages; but, unfortunately, depletion has too often been the course adopted to effect this nurpose. In a person reduced by organic 116 ANEURISM. disease, a full bleeding, to say nothing of its influence in depressing and rendering irritable the functions of the nervous and vascular systems, has the effect of removing from the body a quantity of vitalized and organic matter, which, it is probable, the weakened poAvers of nutrition may never succeed in reproducing; and, so far from this plan of treatment having the effect of relieving the blood-vessels from distention, I doubt much whether, in a weakly person, AVhose absorbents are active, the vascular system does not, in a few hours after a free depletion, either by the lancet or by purging, contain as large, nay, it may even be a larger, bulk of fluid than it previously did, much watery matter having been rapidly absorbed to supply the place of that Avhich Avas removed. Still, in these cases, as much as possible of the thinner part of the blood must be drained off. In every instance of arterial and cardiac disease, the weakened struc- tures become oppressed with the load of fluid which they have to convey, and nature often attempts to relieve them by visceral engorgements, dropsical effusions, and hemorrhages. The desired effect may be far more successfully produced by gradually diminishing the quantity of the fluid ingesta, than by the employment of any system of active depletory evacuation. It is, of course, by no means requisite that a patient suffering from arte- rial or cardiac disease should be suddenly deprived of either fluid or solid food, or should at any time submit to absolute privation by hunger or thirst, but no injury can be done by reducing the quantity of the ingesta to the smallest reasonable standard, while care is taken that their quality shall be of the most nutritive kind. I believe that by far the best mode of removing fluid in these cases is by keeping up a gentle action upon the skin and kidneys. . Diminution of the fluids, rest and gentle tonic treatment, tend to pre- serve the muscular power of the heart, and to maintain the due capacity of its cavities, and may, to a certain degree, restore these properties when they have failed in consequence of disease. The administration, under these circumstances, of digitalis, the acetate of lead, and other medicines which have a direct tendency to lower the action and depress the power of the heart, cannot, I submit, be too earnestly deprecated. I believe that the former of these medicines is generally used in organic diseases of the heart and great vessels, with very mistaken views of the pathology of those affections. The great error appears to be still often committed, of regarding palpitation as though it were itself the disease, and not, what it really is, the sole means by which an obstructed and overloaded heart is enabled to propel its contents—and hence of employing medicines which check the palpitation Avithout remov- ing its causes. But the rational plan of treatment here obviously is, to remove the causes of obstruction from which the heart suffers, where they are not of a permanent nature, or, if that be impossible, to diminish the load of fluid Avhich embarrasses the heart, and then the palpitation, being no longer requisite, Avill abate of its own accord. Part xii., p. 160. Operation for Femoral Aneurism.—The folloAving is a different mode from that usually adopted for securing the external iliac artery in cases of femoral aneurism. H. S., set. 51, healthy-looking, spare, of phlegmatic temperament, ad- ANEURISM. 117 mitted into hospital with aneurism of the right femoral. The disease began about four months before, in the usual way, after a heavy stumble; pain for a Avhile, and afterward the appearance of a pulsating tumor, which gradually increased. The tumor, at the period of his admission, was raised about two inches above the level of the thigh, and it Avas about five inches in diameter^ entirely occupying that triangular space, the apex of Avhich is formed by the junction of the sartorius and rectus, and the base by Poupart's liga- ment, Avhich the tumor slightly overlapped. The pulsation is equally dis- tinct in every part, and can be checked by pressure upon the external iliac artery ; but the tumor, from the solid nature of its contents, cannot be emptied. Upon auscultation, a loud Avhizzing sound is heard accompany- ing each pulsation, A\rhich also communicates a vibratory sensation when pressure is made Avith the fingers. He complains of pain in the tumor, especially at night, and of numbness down the fore-part of the thigh and inside of the knee. Mr. Cooper thus details it: In this operation an incision is made through the skin and superficial fascia of the abdomen, commencing immediately on the outer side of the external ring, and terminating Avithin an inch of the anterior superior spinous process of the ilium, and no part of this incision should be more than half an inch above Poupart's ligament. In depth it should extend only to the tendon of the external abdominal oblique, without dividing any of its fibres. In this step some hemorrhage may occur from the circum- flex ilii, external epigastric, or external pudic branches, which, although naturally small, may have become distended from the obstruction of blood through their parent trunk ; and should the bleeding be troublesome, the vessel ought to be at once secured. The next object is to lay open the inguinal canal, which is effected by cutting through the tendon of the external abdominal oblique to the full extent of your first incision. The spermatic cord is then to be drawn upward and inward toward the linea alba, and the cremaster muscle pressed doAvnward toAArard Poupart's ligament. When this is effected, the fascia transversalis is completely exposed, partly passing down beneath Poupart's ligament to form the anterior layer of the sheath of the femoral vessels, and on the outer side firmly attached to that ligament. The next step is to open the cavity of the abdomen, and this should be effected by dividing the fascia on the outer half of your incision, where it will be found that the peritoneum is very easily pushed upward ; Avhile, on the contrary, if you make your opening on the inner side of the internal ring, the peri- toneum, in its course to the scrotum, Avhere it forms the tunica vaginalis, is so firmly united to the fascia as to be Avith difficulty separated, and liable to be torn in the attempt. All that remains now to be done, is to separate the artery from the vein, by dividing with your finger-nail the fascia iliaca which covers them ; and then, passing your aneurismal needle betAveen the two vessels, its point is directed from Avithin to without, and the ligature tightened Avith that degree of force necessary to cut through the two inter- nal coats of the vessel. What is the precise degree of force to be em- ployed is impossible to be described by words, and is only to be acquired by practice. I would dAvell particularly on the necessity of passing the aneurismal needle from Avithin to Avithout, for if an attempt be made to pass it in the opposite direction, the vein is almost sure to be wounded. The edges of the wound are now to be brought together, either by liga- 118 ANEURISM. ture or strapping, and the patient placed in bed Avith the aneurismal lime well wrapped in flannel. Some surgeons recommend hot Avater to be ap- plied to the foot, Avhich, in my opinion-, is Avrong, as it excites too rapid a floAv of blood through the capillaries. Part xii., p. 172. Popliteal Aneurism—Gangrene followitig Operations for.— Vide Art. " Gangrene." Treatment of Aneurism by Compression.—According to Dr. Belling- ham, such an amount of compression is not necessary as to cause inflamma- tion and adhesion of the opposed surfaces of the vessel, nor should the circulation in the artery at the point Avhere it is compressed be entirely intercepted. To apply it successfully, the velocity of the current should be diminished, and the amount of blood in the sac be diminished?; so as to encourage the deposition of fibrin, until the sac is quite filled. It has this advantage over the cure of aneurism by ligature, that the artery is oblite- rated at the seat of the aneurism, by which the chances of gangrene are diminished. The cure is also more effectual, as the sac and also the artery leading from it, become filled with fibrin, Avhereas, after ligature, a loose coagulum remains Avhich does not fill the sac. Part xiii., p. 209. Popliteal Aneurism—Compression of the Arterial Trunk on the Car- diac Side of the Tumor.—It is not unfrequently found that the artery and its accompanying vein have become adherent, Avhich is a great source of embarrassment to the operator, Avhen tying the artery ; this is avoided by adopting the treatment by compression. A moderate degree of pressure is all that is necessary throughout, so as not entirely to intercept the cur- rent of blood through the vessel. Part xiii., p. 211. Aneurism of the Carotid Artery.—The patient in this case was a deli- cate man, 34 years of age, and of intemperate habits. A small tumor made its appearance three or four months ago, which had gradually increased in size. In consultation it was agreed that it was an aneurism of the carotid, and that it Avas possible to tie the vessel beloAV the tumor. The patient being laid on a table, in such a position that the light fell directly on his neck, an incision, about tAvo inches long, was made through the integuments in nearly a perpendicular direction, and terminating at the inner margin of the attachment of the sterno-mastoid muscle to the ster- num, the upper part of the incision being betAveen the tumor and the tra- chea. This exposed a large vein, round Avhich tAvo ligatures Avere placed, and the vein divided betAveen them. The fascia and some loose cellular tissue were next divided, and the edge of the sterno-hyoideus brought into vieAv. Crossing the upper angle of the Avound Avas just seen the omo- hyoideus. At this stage of the operation, very moderate pressure with the point of the finger at the bottom of the wound arrested the pulsation of the tumor ; but the beating of the carotid could not be felt'. The sides of the Avounds were held asunder by blunt hooks, and the Avound kept clean by small bits of sponge, put to the botton of it by means of forceps. With forceps and scalpel the sheath of the artery Avas noAv scratched through, a nerve (descendens noni) Avas seen, and pulled aside by the blunt hook, and the artery was fully exposed. An armed aneurism-needle Avas, Avith some difficulty, passed behind it from the outer side. The artery, as it now lay on the aneurism-needle, was compressed Avith the tip of the finger, and the tumor's pulsation was found to be commanded. The needle being Avith« ANEURISM. 119 drawn, and the ligature firmly tied, the edges of the wound Avere brought together by two points of suture, and some strips of Macord's plaster. The patient wras then put to bed, and the wound and tumor kept covered by pieces of linen wrung out of cold water. Scarcely an ounce of blood was lost during the operation. The ligature employed Avas a firm round hemp one of moderate thickness. Before commencing the operation, the patient was desired to exhale completely, and to keep his chest as empty as possible. While in this state, the upper part of the chest Avas closely sur- rounded Avith a very long firm bandage, and he Avas instructed to respire, as much as practicable, by the diaphragm and abdominal muscles. Part xiii,,/). 218. Aneurism by Anastomosis of the Scalp.—The aneurismal condition of the extreme blood-vessels, named by the older surgical writers ncevus ma- ternus, is, by the moderns, still so called in its superficial forms; in its deeper seated, aneurism by anastomosis, tumeur erectile, tumenrvariqueuse, pl.acentary tumor, and in all its forms talangiectasis. Previous to the time of John Bell, the deeper forms, or such as lie beneath the skin with- out involving it, Avere neither designated by name, nor was their nature understood; they were, probably, confounded Avith a variety of other diseases, or described as anomalous. Mr. Bell first pointed out their dis- tinctive properties, and denominated them aneurisms from anastomosis: this appellation I, on the present occasion, retain, not because I think it the most proper, but because by it the disease is best understood. [Dr. Fraser's case is chiefly interesting in relation to the question of treatment. The patient was a young man, twenty years of age. He first consulted Dr. F. on the 19th of June, on account of a small tumor situated over the posterior and superior angle of the right parietal bone.] About twelve years previously he fell on his back, that part of the head occupied by the tumor striking a log, which produced a bruise of the scalp. This spot became Arery hard, then commenced throbbing, and has been gradually enlarging; during the year preceding the above date, it had increased more than during any former one, and so troublesome had the Avhizzing pulsation he then experienced become, that it occasionally pre- vented him from sleeping ; in other respects he enjoyed good health. To the eye, pulsation in the tumor Avas very apparent; the scalp cover- ing it was thinner than natural, but not discolored; to the ear, aided with the stethoscope, the aneurismal bruit Avas distinctly perceptible; to the feel it Avas soft, communicated a peculiar thrill to the finger, and could be nearly emptied by pressure,'when the bone beneath felt deeply and irregularly indented; on removing the pressure it filled almost immediately. The oc- cipital and temporal arteries on the same side were greatly enlarged, and imparted a vibrating sensation to the finger placed over them. The bone beneath them also Avas channelled out, evidently by the continued stream of blood passing through the enlarged and excited vessels, having caused its absorption. In consultation with several eminent men, Dr. Fraser determined to treat this tumor by means of setons, and small ones were passefl on the 19th of June: next day he passed another through, and two through the occipital artery, between the tumor and mastoid process. Dr. F. next endeavored to obliterate the occipital and mastoid arteries by twisting around them a hare-lip suture, and painted the tumor with 120 ANEURISM. iodme. When the setons were removed, hemorrhage took place, which was arrested by pressure. As there Avere still seAeral large branches of arteries supplying the tumor, and a bruit could still be detected in it, he treated them in the same way, by needle and hare-lip suture. The tumor now became flaccid, and Avas strapped doAvn Avith a compress of sheet-lead and a bandage. By the 27th of September there was scarcely any percep- tible enlargement of the part. Part xiii., p. 225. Traumatic Aneurism of the Temporal Artery.—Electro-galvanic action has been successfully employed to effect the consolidation of aneurism, by Dr. Petrequin, chief surgeon to the Hotel Dieu at Lyons. Case.—D., aged nineteen, a locksmith, was brought to the hospital sense- less, on the 4th of August, 1845, immediately after a violent fall on the head. The lower maxilla Avas fractured at the symphysis and the left orbit Avas the seat of considerable ecchymosis. The symptoms of cerebral com- motion had given way in a great measure, when Aariola declared itself. The rupture fever accomplished its periods in the usual manner, and it Avas only on September 9th, five weeks after the accident, that M. Petrequin could direct his attention tOAvards a tumor occupying the leit temporal region, and Avhich he had noticed long before. The SAvelling Avas of the size of an almond, soft, and almost indolent on pressure; it was seated on the course of the temporal artery, and presented pulsations isochronous with those of the arteries. These pulsations ceased when pressure Avas exerted on the temporal artery beloAV the tumor, and reappeared on the pressure being removed. These signs left no doubt of the nature of the case, and aneurism of the temporal artery, probably due to the injury ex- » perienced by the vessel during the accident, Avas diagnosed. * On the 10th of September, gahvano puncture was performed by the introduction of two sharp steel pins crossing each other at right angles in the tumor; the heads of the pins Avere then placed in communication with the Avires of a voltaic pile, and a shock and a sharp pain Avere experienced by the patient, the pain increasing with the intensity of the electrical action. The operation lasted ten minutes, and fifteen plates Avere employed. The pulsations gradually diminished in the tumor during the operation, and at its close had nearly disappeared. No accident followed the experiment, but a solid indurated swelling took the place of the tumor, the temporal artery ceasing to beat above the aneurism, while its pulsations remained distinct below. On the 20th of September, absorption had achieved the cure, and neither tumefaction nor pulsations could be detected in the spot Avhere the malady had existed. M. Petrequin gives the folloAving precepts, which he deems wdll insure the complete coagulation of the blood contained in aneurismal tumors: 1. Compression of the artery between the aneurism and the heart during the application of the galvanic agency. 2. The pins intro- duced into the tumor should be numerous, cross each other at right angles, and their surface should be protected by a coat of varnish, in order to prevent unprofitable loss of the electric fluid. 3. After the operation, ice should be applied to the tumor. This is the first case on record of aneu- rism cured *>r even treated by this method, Avhich has been of late em- ployed in the treatment of a large number of diseases. Part xiii., p. 230. Case of false Aneurism.—The patient was twenty-eight years of age, and exceedingly corpulent. On the 23d of May, 1845, he received a pistol-shot in the upper and outer part of the right thigh; the ball tra- ANEURISM. 121 versed the course of the femoral vessels, and passed out at the left groin. The hemorrhage Avas very profuse, and it Avas Avith great difficulty he could be roused from a state of syncope into AAdiich he had fallen. A large tumor formed at the lower part of the abdomen, from the extravasation of blood ; as this increased in size, a pulsation could be detected in it; it Avas of an oval form, firm, but elastic ; the skin covering it was discolored and thin; the opening in the groin had closed with a very thin cicatrix. The appearance of the patient indicated extensive loss of blood. Mr. Liston observes: The nature of the case Avas very apparent. A large false aneurism, not Avell bounded, rapidly increasing, and arising from a wound of the femoral artery, or some branch divided close to its origin, had to be arrested, otherwise the patient must be left exposed to the risk of perish- ing suddenly, and at no distant period. After consultations on the even- ing of the 30th, and morning of the 3lst, the external iliac artery Avas tied, with the loss of not more than a tablespoonful of blood, and with the imme- diate effect of arresting the pulsation, and removing, in a great measure, the tension of the tumor. Symptoms of peritonitis supervened the evening of the second day, and on the folloAving afternoon the patient sunk. The author subjoined an account of the post-mortem examination by Dr. Allen. The course of the bullet was traced from the outside through a dense layer of fat, about tAvo inches in thickness. It had divided one of the superficial branches of the femoral artery, about half an inch below Poupart's ligament, and about an inch from the main body of the femoral artery, which had caused a false aneurism. The sac contained about three ounces of blood. No other artery appeared to have been wounded. A con- siderable quantity of sero-purulent fluid was found in the abdominal cavity, and patches of acute inflammation were observed on the intestines. The peritoneum adjoining theAvound of the operation Avas inflamed. It had not been injured by the knife. The ligature had been properly applied to the external iliac artery. The abdominal viscera Avere healthy, but loaded to an extraordinary degree Avith fat. There Avas some enlargement of the right limb, apparently no mortification. The femoral artery was pervious. The blood in the aneurismal sac was firmly coagulated, and there Avas no mark of recent oozing from the injured artery. The ball had passed immediately oyer, and along the course of the artery for about half an inch before dividing it. The artery, although not actually detached, Avould not have borne a ligature. Part xiii., p. 231. Diagnosis of Aneurism.—Recent events have no tendency to increase our confidence in the diagnosis of aneurism. Dr. Kerr and Dr. Engel- hardt have lately erred in their diagnosis. Perhaps it arises from too great reliance being placed on one or two diagnostic signs, such as a dias- tolic impulse felt in all parts of the tumor, and a diminution in its size, when either it, or the artery on its cardiac side, is compressed. The former symptom occurred in a malignant tumor of the foot—described by Dupuytren, and the latter in a pulsating tumor of the femur, lately under the care of 31. Nelaton. Mr. Teale adds: In a case, under my own care, of a large serous cyst of the neck, extend- ing downward behind the clavicle in the vicinity of the large vessels, there was such a strong and apparently distensile unpulse perceptible in all 122 ANEURISM. parts of the tumor, as to induce myself and several other surgeons, for a considerable time, to regard it as aneurism. In this case, the hands applied to the sides of the tumor Avere forcibly separated at each pulsa- tion ; and, by compression, the tumor was diminished in size (undoubtedly from a portion of its contents being forced beloAV the clavicle tOAvard the chest.) and when the pressure \Aras discontinued, the tumor gradually resumed, by pulsatile stages, its original size. Hypertrophy of the left ventricle, and dilatation of the abdominal aorta, tended still further to obscure the case. After the tumor had been reduced in size, its true character became apparent. The exploratory puncture, hitherto regarded as a test of aneurism, can no longer be received as such, since I have shown that a malignant cysto-A'ascular tumor of the femur, on tAvo occa- sions, after an exploratory puncture, gave issue to a pulsatile column of florid blood, which was projected to the height of several inches. Part xiii., p. 234. Pain as a Diagnostic Symptom of Aortal Aneurism.—1st. Intense pain in cases of internal aneurism is the most certain symptom of erosion of the bodies of the vertebrae. 2d. In addition to its severity, the pain presents tAvo other well-marked characters—viz., 1st. It is referred not to the exact size of the lesion hut to parts at some distance. 2nd. The patient suffers more from it at night than during the day. 3d. That unless erosion of bone occurs, the pain maybe absent or com- paratively slight, except in the cases already alluded to, where large nerves are compressed. 4th. That in aneurism of the descending thoracic, or of the abdominal aorta, where the pain has the characters mentioned, the aneurismal sac almost ahvays springs from the posterior Avail of the aorta, and has caused erosion of the vertebrae ; whereas, when pain is absent, or com- paratively slight, the sac will be found to spring from the anterior wall of the vessel, and the bodies of the vertebrae Avill be little or not at all engaged. Part xiv., p. 177. Galvano-puncture in Aneurism.—The galvanic current should be directly transmitted through the blood itself by tAvo opposing points. Employ fine steel needles, three inches long, and as they burn or cauterize the skin, or lose their electricity, coat them, before application, Avith gum lac or cutler's varnish. The extremities of the needles should cross each other in the tumor, and when the latter is of large size, multiply the points, so that the nuclei of coagulation may pass into one common clot. They should pass into the tumor obliquely or perpendicularly, opposed to the current of blood. The application of the galvanic current may be made each time ten or tAvelve minutes ; by this time the tumor will feel hard, and the pulsation cease : after this, apply compression, or a bladder of ice, to complete the cure. It is suggested for the cure also of varix, erectile and sanguineous tumors, etc. " Part xiv., p. 182. Galvano-puncture in Aneurism.—Mr. Hamilton has tried it in a case of carotid aneurism, lie passed fine gold needles coated Avith shell lac, an inch long, through the inner and outer sides of the tumor, and made them to touch in the centre; then used Smee's battery, with tAvelve pairs of plates, gradually applied. After fifteen minutes, pulsation became less, the ANEURISM. 123 tumor firmer, and, at the end of twenty minutes, complete coagulation was evident, as the tumor was solid and the pulsation was imperceptible. Part xiv., p. 184. Ligature of the left Subclavian Artery within the Scalenus Muscle, for Aneurism.—Although this case proved unsuccessful, yet Dr. Rodgers was convinced that the operation is practicable and proper. Directions.—Lay the patient on a Ioav bed, wTith the head and shoulders raisad, and the face turned to the right side. Make an incision three and a half inches long, on the inner edge of the mastoid muscle, terminating at the sternum, and dividing the integuments and platysma myoides. Make a second incision from the last, horizontally, toward the sternal extremity of the clavicle, two and a half inches long. Dissect the flap of integuments and platysma upward and inAvard, so as to lay bare the sterno- raastoid. Pass a director under this muscle, and divide the sternal and half the clavicular attachments Avith a bistoury. Turn these portions up, so as to show the sterno-hyoid and sterno-thyroid muscles, and the jugular vein beneath the fascia; also a portion (in this case) of the aneurismal sac, strongly pulsating. Divide the fascia Avith the handle of the scalpel and fingers, and pass down the inner side of scalenus anticus, carefully avoiding the internal jugular vein, thoracic duct, and phrenic nerve, until the finger reaches the artery and recognizes Avell its pulsation. Detach the artery very deliberately, so as to avoid Avounding the thoracic duct and pleura, and pass the aneurismal needle (in this case, Sir Philip Crampton's) under it, Avith the point and ligature upward. Catch and secure the ligature (tying it securely Avuth the point of the fore-finger, in the bottom of the wound), and, to be satisfied that the artery is secured, take care to examine the distal part of it for the cessation of all pulsation. Part xiv., p. 187. Treatment by Compression.—Dr. Bellingham gives the folloAving sum- mary : 1. The arteries to Avhich compression is applicable being far more fre- quently the subject of aneurism than those to which it is inapplicable, compression is calculated to supersede the ligature in the great majority of cases. 2. The cure of aneurism by compression upon the artery betAveen the aneurismal sac and heart, according to the rules laid doAvn here, is accom- plished by the gradual deposition of the fibrin of the blood in the sac, until both the latter and the artery at the part is completely filled. The process is in fact exactly similar to that by Avhich nature effects a spon taneous cure of aneurism. 3. Such an amount of pressure as would cause inflammation and adhesion between the opposite sides of the artery at the point compressed is never required. 4. The pressure should not be so great as to interrupt the circulation in the artery at the point compressed ; an essential agent in the cure being that a current of blood should pass through the sac. 5. Compression by means of two or more instruments, one of which is alternately relaxed, is much more effectual than by any single instrument, and in many instances the pressure can be maintained by the patient himself. 6. The treatment of aneurism by compression does not involve the 124 ANEURISM. slightest risk to the patient, and if persevered in cannot fail of effecting a cure. . 7. A cure of aneurism effected by compression, according to the rules laid down here, must necessarily be permanent; and in every case in which a cure has been accomplished, the patients have remained well subsequent 1 A'. 8. The femoral artery remains pervious after the cure at the point at which the pressure has been applied, and no morbid change of any kind ia to be detected in either the artery or vein at the site of the compression. 9. When a cure is effected by compression, the vessel is obliterated only at the seat of the aneurism, and the artery at this part is eventually con- verted into an impervious ligamentous band. 10. Compression effects the cure of aneurism by more simple and safer means than the ligature, while it is applicable to a number of cases in which the operation is contra-indicated or inadmissible. 11. Compression is not necessarily a more tedious or more painful method of treating aneurism than the ligature, Avhile it is much more cer- tain, more likely to be permanent, and is free from all danger. 12. Compression, according to the rules laid doAvn here, has little ana- logy with the old method which went by this name, and, in fact, has no greater resemblance to it than the Hunterian operation had to the opera- tion for aneurism which it superseded. Part xv., p. 187. Treatment of Popliteal Aneurism by Ligature.—Mr. Syme gives the folloAving instructions regarding this operation : With regard to the ligature, it appears that this operation admits of being performed so as to be nearly, if not entirely free from danger. I have undertaken it in every case that presented itself, although the circumstances were often \Tery unpromising, and even Avhen erysipelas aa well as hospital sores invested the clinical wards of the Royal Infirmary. There is noAV, I believe, no difference of opinion as to the proper princi- ples of the operation. They are—1st. To dissect Avith the knife and forceps, instead of tearing or scratching Avith a blunt instrument, to expose the artery. 2d. To denude no more of the vessel than Avhat is requisite for passing the needle. 3d. To use for ligature the smallest silk thread possessing sufficient strength, and tying it as tightly as possible. 4th. To treat the wound so as to favor union by the first intention. As to the performance of the operation, I believe that there is no arterial trunk in the body which requires for its ligature so little anatomical skill, or manual dexterity, as the femoral artery. The angle formed by the sartorius and adductor longus affords a sure guide to the vessel; and in the event of any error as to the position of the external incision, the fibres of these muscles by their different directions at once shoAV the operator on Avhich side he has exceeded. But Avhile the mere detection of the artery is abundantly easy, it must be admitted that the subsequent part of the operation ia beset Avith extreme danger from any Avant of caution or nicety, since, if the vessel be roughly detached from its connections, hemorrhage will probably result; and if the vein be wounded, the patient will almost certainly perish from inflammation of the vessel, or mortification of the limb. Care is always required, and must be employed in a degree proportioned to the intimacy with which the artery is connected to the neighboring parts. I have completed the operation in less than a minute, and on other occasions ANEURISM. 125 have found nearly half an hour requisite for the purpose. If all operators had paid as little regard to the time occupied, I believe that the unfavor- able results on record would not have been so numerous as they are. The operation, therefore, I believe, being performed upon proper principles and with sufficient care, may be regarded as perfectly safe. Part xv., p. 189. Aneurism by Anastomosis in the Anterior Nares.— Vide Art. " Nose." Sounds of Aneurism of the Aorta.—[The following conclusions respect- ing the sounds of the heart and of aneurism of the aorta, have been arrived at by Dr. Bellingham :] 1st. That a double, not a single sound, characterizes aneurism of the arch of the aorta, Avhich closely resembles the double sound of the heart, and may be termed its normal sound. 2d. That the normal double sound of aneurism of the arch of the aorta has its cause in the friction between the blood and the lining membrane of the orifice and parietes of the sac, because there is no other agency to which it can be referred. 3d. That the normal second sound of aneurism of the arch of the aorta is caused by the regurgitation of the blood into the sac from the aorta and large vessels which arise from it. 4th. That the first, or the second, or both aneurismal sounds, may be re- placed by a murmur, which may have either a bloAving, saAving, or filing character, and that such murmurs may be regarded as the abnormal sounds of aneurism of the arch of the aorta. 5th. That the first aneurism sound is much more frequently superseded by a murmur than the second, because the force with which the blood is transmitted to the sac by the left ventricle is much greater than that with Avhich it regurgitates into the sac at the period of the ventricular diastole. 6th. That the abnormal sound of the aneurism of the arch of the aorta, equally as its normal sounds, are caused by friction between the blood and the orifice or parietes of the sac ; and that they are nothing more than ex- aggerated formal sounds—exaggerated, because the degree of friction is then increased. 7th. That in aneurism of the arch of the aorta pointing externally, the sound is not only always double, but a double impulse is frequently also perceptible to the hand. 8th. That the second impulse of aneurism of the arch of the aorta has its cause in the same agency which gives rise to the second sound; conse- quently neither a double sound nor a double impulse is perceived in aneu- rism of the abdominal aorta, or of any of its branches. 9th. That the phenomenon knoAvn under the name of fremissement cataire, or purring tremor, Avhether it occurs in an aneurism or a large ar- tery, is nothing more than the pulse of aortic regurgitation on a large scale, consequently that it is a sign of regurgitation into the ventricles of the heart, into an aneurismal sac, or into a large or dilated artery. 10th. That the remarkable resemblance betAveen the normal and abnor- mal sounds of aneurism of the arch of the aorta, and normal and abnormal sounds of the heart, renders it probable that the mechanism of their pro- duction is the same. 126 ANEURISM. 11th. That the abnormal sounds of the heart, having their seat at tho orifices of the ventricles, and being the result of increased friction betAveen the blood and the parts through Avhich it passes, are (like those of aneurism of the arch of the aorta) to be regarded as nothing more than exaggerated normal sounds. 12th. That the impulse of the healthy heart, like that of aneurism of tho arch of the aorta pointing externally, is double, not single; and that in certain abnormal conditions of the heart, this second impulse becomes very distinct, when it has been termed "the back stroke of the heart," or "the diastolic impulse." 13th. That the second impulse of the heart (like that of aneurism of the arch of the aorta), is felt exactly at the period of the second sound; and both sound and impulse appear to be produced by the same agency. 14th. That as sounds almost precisely similar to those of the heart are de\reloped in an aneurismal sac, AAdiich has neither muscular Avails nor a valvular apparatus at its orifice, the latter do not appear to be as essential to the production of the normal sounds of the heart as most Avritera suppose. 15th. That the ordinary theory of the heart's sounds, which refers the normal sounds to one cause, and its abnormal sound to a totally different cause, fails to explain several phenomena connected with the heart's action and sounds. 16th. That the theory of the mechanism of production of the heart's sounds laid down, satisfactorily explains every phenomenon connected with the normal and abnormal sounds of this organ. Part xviii.,/). 165. Aneurism—False, of the Bend of the Elbow.—If the brachial artery ia unfortunately Avounded in performing venesection, the proper practice is by no means to cut down upon the artery immediately, but apply a compress over the aneurismal sac, letting it extend upward in the course of the artery, and carefully bandage the entire limb, beginning Avith the fingers and thumb, and extending to the axilla; and let the limb be kept elevated on an inclined plane, and perfectly quiet. If this does not succeed, cut into the sac, and tie the artery above and beloAV ; or Avhat is better, tie the artery above the tumor, and then, the impetus of the bloodJbeing taken off by the ligature, employ slight pressure upon the tumor. Part xx., jo. 118. Aneurismal Varix.—Aneurismal varix, or a communication between an artery and vein, occurs, Mr. Cooper observes, not merely from acci- dent, as in venesection, but may arise from disease, and may be found be- tween any artery and vein lying in close proximity. Tie the brachial artery in the middle of the upper arm, and apply gentle compression over the tumor, and in the course of the radial and ulnar arteries. If this plan fails, the following operation, a much more dangerous one, must be per- formed : place a tourniquet on the brachial artery, so as completely to compress it, and then make a free incision into the aneurismal sac; turn out the clot of blood, and seek for the upper and lower openings of the artery. Pass the end of a probe into the upper opening, to serve as a guide in separating the artery from the surrounding parts, and secure the vessel ; then repeat the same process upon the distal end. Part xx., p. 123. ANEURISM. 127 Aneurism of the Radial Artery.—[Prof. Syme gives the folloAving case of a man who had, at the root of the thumb, a tumor about the size of a flattened gooseberry, and -stated that ligature of the artery at the Avrist had been recommended as the remedy.] The swelling looked so much more like a ganglion than an aneurism, that I supposed there must have been a mistake as to its nature; but, upon a more attentive examination, finding that there Avas a distinct expansive pulsation, I could not doubt that there Avas a sac communicat- ing with the radial artery, pressure upon Avhich instantly lessened the swelling, and deprived it of the pulsating character. I therefore had a little spring constructed, upon the principle of a rupture truss, so as to press upon the vessel at the wrist, and at the end of tAventy-four hours alter it had been applied could not detect any trace of pulsation. It may appear inconsistent in me to apply pressure at the wrist, instead of tying the radial artery, as I have strenuously contended against the substitution of pressure for ligature of the femoral artery. But the two cases are A'ery different, since the latter-mentioned vessel has accompany- ing it the great venous trunk of the limb, Avhich the utmost extent of human skill and care cannot prevent from being compressed along Avith the artery, and necessarily occasioning a degree of suffering to the patient which must, if at all prolonged, infinitely exceed the trivial disturbance Avhich attends ligature of the artery—Avhile the radial artery lies directly under the skin, rests upon the bone, and has no associate disposed to resent the effect of compression. I may add, that it has ahvays been an established principle Avith me, that the radial artery and its branches at and below the Avrist are completely under the command of pressure. Part xxiii., p. 149. Novel Treatment of Aneurism.—Displacement of the fibrin in the clot of an aneurism sometimes happens with consequent interruption to the current of blood, and sometimes spontaneous cure. Mr. Fergusson, in imitation of this process, by manipulation, dislodged a portion of fibrin in the case of an aneurism of the subclavian, Avith the effects of instantaneously stopping all pulsation of the upper limb. In four days a slight pulsation Avas perceptible at the Avrist, but all pulsation had ceased in the axillary. The tumor Avas diminished considerably in size, and became firmer to the touch, so that there is ground to hope it may be successful. Part xxv., p. 193. Treatment of Aneurism.—Recorded facts seem to prove the folloAving conclusions: 1. That in popliteal aneurism, skillful compression of the femoral is capable of curing the disease, and that Avith comparative and almost absolute safety to life and limb. 2. That the time expended in euro is, on an average, not greater than in the treatment by ligature. 3. That failure by compression does not compromise subsequent recourse to deli- gation. 4. And that consequently, compression, when skillfully employed, being equally certain, far more safe, and not more tedious than the liga- ture, should, in the great majority of cases, be preferred. The only dis- advantage of compression is the care and trouble necessary on the part of the attendant, with irksomeness and sometimes suffering on the part of the tatient. The obvious and only advantage of deligation, on the other land is the facility and dispatch of its execution, Avith probable ex- J 28 ANEURISM. emption from suffering afterward by the patient, in the successful cases. The formidable disadvantage is, its proved risk to life and limb. Part xxvii., p. 119. Injection of a concentrated Solution of Perchloride of Iron into Aneurismal 'Tumors.—It has recently oeen attempted to cure aneurismal tumors by injecting into them a feAv drops of a concentrated solution of the perchloride of iron. Several cases have been recorded in Avhich the operation avus successful. Part xxviii., p. 171. False xlneurism of the Posterior Tibial Artery, from a Wound.—The in- jection of perchloride of iron caused coagulation of the blood in thespurioua aneurismal sac, produced by division of the posterior tibial artery in a child aged four weeks. The firm clot squeezed out the serum, Avhich was seen oozing from the surface of the Avound. The instrument used for in- jection Avas a glass syringe, with a long and slender tube, Avhich Avasmade to penetrate the clot, and convey the perchloride to the fluid blood below. Part xxviii. p. 172. Cure of Aneurism of the Subclavian Artery, by the External Applica- tion of the Chloride of Zinc.—M. Bonnet announces the complete cure of an aneurism of subclavian artery by the application of chloride of zinc paste. The caustic penetrated by imbibition into the deeper part of the tumor, and produced complete coagulation of blood, Avhich was detached without any hemorrhage. The eschar separates in about eight days after the application of the caustic, but by successive applications it may easily be retained for a month or longer, or the superficial portions may be re- moved by a bistoury. Part xxviii., p. 173. Treatment of Aneurism by Peroxide of Iron.—Dr. Pavesi, of Bergamo, has lately injected a strong solution of the above-named salt into an aneurism of the temporal artery affecting a young man. The sac Avaa about one inch from above dowinvard, eight lines transversly, and might contain a drachm of fluid. A puncture Avas made into the tumor, and bright arterial blood escaped ; the glass pipe of one of Charriere's syringes was then introduced, and about sixteen drops of the solution thrown in. The tumor Avas ten minutes afterward quite solid, and in one month no trace of the aneurismal tumor was left. Part xxx.,p. 131. Aneurism, Popliteal—Treatment by Ligature.—Take if you please, half an hour, or a Avhole forenoon about it, but do not pass the needle till the artery has been sufficiently separated from the contiguous structures to enable you to avoid all risk of injury to the vein, Avhich is the great source of danger to be dreaded. The femoral vein is more intimately connected with the artery than most veins. If, therefore, you do not separate the one from the other with the greatest nicety, jrou will very likely either pierce or bruise the vein, and Mr. Guthrie says, that the artery alone might be obstructed Avithout death of the limb, but that this Avas the invariable result if both artery and vein Avere obstructed together. The femoral artery varies in its origin from the common femoral, and it is very im- portant that the ligature should be considerably beloAV its lowest origin. Therefore, cdways tie low enough, i. e., where the artery has become over- lapped by the sartorius muscle. If, however, you go beloAV this muscle, you will be too near the aneurism. _part xxx\ ? pm 143, ANEURISM. 129 Treatment of Aneurism by Compression.—It is not necessary to cut off the entire flow of blood to the tumor, neither is it necessary to con- tinue the pressure always in one spot, hut it may be shifted from one place to another. In many cases,, it is only necessary to modify the flow of blood through the main artery.' Carte's circular compressor is a good instrument. It has an ingenious addition to the common screw, in form of bands of caoutchouc, Avhereby a certain resiliency is acquired, which keeps up effectual pressure and modifies the screw. Elasticpressure is the latest improvement in the treatment by compres- sion. The screw apparatus seems to have, been discarded in popliteal aneurism. The elastic spring seems to be quite enough to restrain the current of blood, Avhich is sufficient. Part xxxi., p. 146. Aneurismal Tumor (Ncevus).—Puncture the tumor, and immediately plunge into it the canula of a glass syringe filled with acetate of lead, and inject eight or ten drops or more. Then withdraw the syringe, and apply the finger to the Avound for about a minute. Part xxxi., p. 148. Aneurism and Varix.—Make use of galvano-puncture, acupuncture with zinc, or with needles covered Avith a layer of this metal instead of steel. Insert a certain number of needles into the aneurism or varix, and. connect them with the positive pole of the galvanic battery. The negative pole should be supplied Avith a plate of platinum, which must be put upon the skin adjacent to the aneurism, after having augmented the conductibility of the epidermis by moistening it Avith. a saline or acidulated solution. , Part xxxi.,^. 151. Subclavian Aneurism.—When the usual method of treatment is inad- missible, you may succeed by pressing the sides of the aneurismal sac toge- ther with the thumb, so as to displace a portion of the lamellated fibrin in the aneurism ; these clots will be directed fonvard by the current into the axillary and brachial, so as to block up the distal end of the artery. If followed up by local pressure, most striking and satisfactory results may be obtained. Part xxxii., p. 138. Aneurism of the Innominata.—These are cases where you can do no good by operative interference. If the tumor projects, you must apply steady firm pressure over it, by means of a suitable pad; the effect of thia Avill be to thicken and strengthen the coats of the artery, and may be very beneficial in preventing its increase. Part xxxiii.,^. 167 Aneurism, Popliteal.—There are few or no cases of popliteal aneurism in which the cautious use of pressure is not justifiable. The contra-indicationa to its continued use are: a shattered, irritable constitution, its close prox- imity to the knee-joint, and a very free communication with the artery by a large opening, which may be judged of by the loudness of the murmur and the time which the tumor requires to fill. Part xxxiv.,p. 134. Sub-Arterial Cysts of the Wrist.—M. Chassaignac calls attention to a form of ganglion Avhich, placed beneath the radial artery, unless properly understood, may give rise to very serious errors. From excess of labor, or the exertions necessary to raise heavy burdens, the small tumor may acquire considerable development. The fingers of the surgeon when ap- plied over tho cyst,'are raised by the pulsations, which are remarkable for their energy, and the breadth of space they extend over. This extent of pulsatile surface immediately suggests the idea of radial aneurism, and if 9 130 ANEURISM. the examination be continued, with the limb remaining m its ordinary at- titude, an error can scarcely be avoided. The differential diagnosis may be established bv bringing the wrist into a state of forced flexion, when, whether it is that the artery is displaced, or that it ceases to be stretched over the eminence formed by the cyst, the pulsations no longer exist, and it is evident that no aneurism is "present. In treating these cases, M. Chassaignac employs the iodide of potash ointment, rubbing it in every two hours during a week. On the dorsal surface Ave may treat ganglia Avith advantage by crushing them, by subcutaneous puncture, seton, or iodine injection; but in the case of these sub-arterial cysts of the wrist, Avhich are in communication Avith the radio-carpal articulation, these means of treat- ment are not applicable. The iodine frictions give rise to no accident, and seem possessed of all desirable efficacy. Part xxxi\.,p. 136. Treatment of Aneurism by Manipulation.—In cases in which both the operations of Hunter and Wardrop have never been successful, as in aneu- rism of the subclavian artery, between and outside the scaleni, in which there is much knoAvn danger in the usual modes of treatment, Mr. Fer- gusson's plan of compression may be tried. The flat point of the thumb must be laid on the aneurism, and when the sac is emptied of fluid blood, the surfaces and supposed contents must be forcibly rubbed against each other; the fibrin will be displaced, and block up the distal end of the aneurism, and so a cure be effected. Part xxxv., p. 88. Superficial Aneurisms and their Treatment.—M. Broca has cured seve- ral cases of those congenital nsevi, known vulgarly under the name of wine spots, and which it is well known are refractory to all modes of treat- ment. The proceeding consists in removing the epiderm by a blister, and then touching the denuded derm with a pencil of charpie, Avetted Avith perchloride of iron, at 30° of the aerometer of Beaume. By one applica- tion of the perchloride on the denuded dermis he rendered definitively solid a circoid aneurism of the scalp, that had already existed four months and Avas making alarming progress. On the fifth day the tumor Avas ob- literated, and the patient, who Avas seen seven months after, continued per- fectly cured. Part xxxvi., p. 169. Aneurisms—Cases in which their Treatment by Compression and Ma- nipulation is proper.—In his observations on a case of popliteal aneurism, successfully treated by compression and manipulation, Mr. Teale, surgeon to the Leeds General Infirmary, said : "Let me guard you against adopting this practice in aneurism of the ca- rotids or of the innominate artery ; or, in other Avoids, in aneurism of arte- ries leading to the brain. In such cases you might run the risk of detach- ing small portions of fibrin, which being carried along the current of blood to the brain, might then produce the serious mischief of that organ, and the consequent paralytic affections described by Dr. Kirkes in a paper of great value published in the 'Medico-Chirurgical Transactions' for 1854. And this is not a mere speculative evil, as you will perceive from the follow- ing case which I will briefly notice. "In the year 1847 I Avas one of a numerous consultation on a doubtful case of carotid aneurism. The subject of it was a middle-aged female, in good health in other respects. She was seated in a chair Avhile the tumor was examined by several persons in succession, and subjected by them to repeated handling and compression. While this Avas going on, she sud- ANTIMONY. 131 denly became pale and slipped off the chair. On being raised she was found to be hemiplegia After lingering in this state for a few Aveeks she died. The tumor was found after death to be aneurismal. It was not, howeA-er, until I read the paper by Dr. Kirkes, that I fully appreciated the patholo- gical bearings of this case. Now that we do understand it, let me urge upon you to bear it in your minds, and let it be a warning to you, in carrying out Mr. Fergusson's valuable suggestions, to limit the.treatment by mani- pulation of the tumor to aneurism of the extremities. I may also add that in one of the two cases of aneurism of the subclavian artery, Avhich are published by Mr. Fergusson, hemiplegia occurred very shortly after mani- pulation." Part xxxix., p. 161. »*» ANTIMONY. Preparations of Antimony.—[The following practical remarks are made in a communication to the Pharmaceutical Society, on some of the preparations of antimony. It seems to be the general impression among medical men, that most of these preparations are inert and nearly useless; and owing to the expense of Dr. James's fever powder, that preparation is seldom used. Mr. Tyson makes the following observations on this sub- ject :] After torturing antimony in all ways, and trying, in the course of my practice, all its forms, in all doses, in all febrile diseases, in patients of all ages and all temperaments, I became satisfied that we had only tAvo pre- parations Avorthy of notice, and that these two were invaluable, viz.: the tartrate and protoxide ; and that the protoxide was the base of every use- ful preparation of antimony: proving the truth of the remark in " Dun- can's Edinburgh Dispensatory," that " oxide of. antimony, with phosphate of lime, is one of the best antimonials we possess." In comparing the effects of James's Powder Avith Pulvis Antimonialis, I sometimes found their virtues so alike, in all their combinations, as not to be distinguished. Sometimes I had occasion to prefer James's PoAvder to the Pulvis Antimonialis, at other times I had reason to give the Pulvis Antimonialis the preference, finding that in the James's PoAvder there was considerable variation. Profiting by the idea set forth by Chenevix, I began with his prepara- tion, which I soon found would not do, for I never was certain of the quantity of antimony. I then tried the oxide procured from emetic tartar, and mixing it Avith phosphate of lime, I found I had a very useful antimo- nial, but it did not quite ansAver my expectation. At length I made my experiments on the pulvis algarothi, as ordered by Duncan; and upon adding to it, Avhile in a state of hydrate (that is, after the supernatant liquor had been poured off), a solution of carbonate of ammonia, I Avas surprised to find a considerable effervescence, shoAving me that the beau- tiful Avhite pulvis algarothi still contained a quantity of muriatic acid. I therefore continued to add solution of carbonate of ammonia, as long as any effervescence continued, and thereby deposited a straAA'-colored protoxide, Avhich I washed with distilled water upon a filter, and carefully dried. 132 ANTIMONY. The next thing I had to do was to ascertain the effect of this, and I soon found that in this straw-colored oxide I had a medicine of great poAverand efficacy, and that I could only give it in dose from one-tenth of a grain to a grain ; that a grain often vomits and purges; that half a grain, combined with five grains of calomel, given at the commencement of all febrile dis- eases, and followed by the neutral salts, cut short those diseases; that smaller doses, given every six hours, after proper evacuants, proved a mild but certain sudorific, without the nausea which emetic tartar pro- duces ; that when combined with small doses of calomel, it proved a Sowerful alterative. Comparing these effects with the best samples of ames's PoAvder, I found it easy to form a compound similar thereto ; and by experience I found I had obtained a preparation far superior, as being always the same and always certain. The following No. 1, and No. 2, are the forms in which I use it: PULVIS ANTIMONIALIS. No. 1. $ Protoxidi Antimonii, gr. ij.; Phosphatis Calcis, gr.xviij. Misce. Dose, from five to ten grains, if taken alone; but if combined with calomel, one grain to five grains. Here we have a preparation totally soluble in dilute muriatic acid, ten grains containing one grain of protoxide of antimony. No. 2. # Protoxidi Antimonii, gr. ij.; Sulphatis Potassce, Phosphatis Calcis, aa. gr. ix. Misce. Dose the same. Another form may be made in the same proportions, with calcined hartshorn shavings; but I prefer the above, as being entirely soluble in weak acids. To the second form, you observe, I have added sulphas potassa, for three simple reasons: 1st. Because, in the best analyses of James's PoAvder, sulphate of potass has been found, which probably arises from fusing together sulphuret of antimony and nitrate of" potass. 2d. Because it is more economical, in saving my phosphate of lime, which being procured by solution, is troublesome to obtain, and ex- pensive. 3d. The third reason is the most sound of all: it acts with more cer- tainty, and gently, upon the secernents of the alimentary canal. The practitioner may use which form he pleases; but, after many years' expe- rience, I prefer that with sulphas potassae. PKOTOXYDUM ANTIMONII. # Sulphnreti Antimonii, |j.; Acidi Muriatici, |iv.; Acidi Nitrici, gsa. Misce. Boil together for an hour, in a glass vessel; filter through paper; pour the filtered solution into water; pulvis algarothi, i. e., submuriate of anti- mony, is precipitated; pour off the supernatant liquor, and add to thia precipitate a solution of the carbonate of ammonia, as long as any effer vescence continues; wash upon a filter with distilled water, and dry by a gentle heat. Here we have about five drachms of beautiful straw-colored protoxide. PHOSPHA8 CALCIS. # Cornu Usti (vel, Earth of bones), §iv.; Acidi Muriatici, §iv.; Aqna Purse, ?x. Misce. ANTIMONY. 133 Let them stand together for several days, occasionally shaking the vessel; filter, and then add to the filtered liquor, Liquor Ammonia? Purse, §iv., vel. q. s. Wash upon a filter Avith distilled water, and dry. When giving my Pulvis Antimonialis with calomel, every six hours, as an alterative, I have been occasionally obliged to reduce the dose to one grain of the compound, as mentioned before; for such is the deoxygenat- ing power of this protoxide, and such is its affinity for acids, that Avhen made into a pill with calomel, it decomposes the calomel, turns it black by taking up the muriatic acid, and will occasionally excite vomiting and diarrhoea. To obviate this inconvenience, I am noAV in the habit of giving it in combination Avith the blue pill. But my blue pill is not the blue pill of the Pharmacopoeia, which, under the best management, is a very uncer- tain preparation. I make pilulae hydrargyri Avith the protoxide, and to complete the usefulness of this communication, I will give you a form of that also. PILULAE HYDRARGYRI PROTOXYDI. P Hydrargyri Protoxydi, 3j.; Confectionis Rosae Gallicae, 3iij-; Pulvis Florum Anthemidis, 3ss. M. s. a. et fiat massa. Here Ave have a preparation with only half the quantity of mercury, far superior to, and of the same color, as the blue pill; always the same in effect, and always certain, and made in a feAV minutes. I have been obliged to leave out half the quantity of mercury, in order to approximate it to the strength of the blue pill of the Pharmacopoeia, finding that the whole quantity Avas too active. I use the powdered chamomile, instead of the liquorice poAvder, as it keeps better, and sits more pleasantly upon the stomach : four grains and a half contain one of protoxide. But the great secret that remains, is to procure the slate-colored pro- toxide. Aqua calcis will not do, as it produces an ash-color, from a mixture of the muriate of lime: liquor potassae alone will not do, nor will liquor ammoniae. PROTOXYDUM HYDRARGYRI. # Calomelanus, %iv.; Liquoris Potassae Purae, §iv. vel q. s. tere simul, et adde Liquoris Ammonia? Purae, |ss.; Aquae Destillatae, q. s. Wash well upon a filter; dry with a gentle heat, and use immediately. The liquor potassae produces a brownish-black powder, but there still remains a portion of submuriate of mercury undecomposed, which no ad- dition of liq. potassae will act upon, but by the addition of a small quantity of liq. ammoniae, the slate-colored protoxide is immediately produced, and the calomel completely decomposed. HYDRARGYRUM CUM CRETA. # Hydrargyri Protoxydi, p. j.; Cretae P. p. ij. M. Always the same, and always certain, a form which can never be pro- duced by trituration. UNGUENTUM HYDRARGYRI. # Hydrargyri Protoxydi, §ij.; Adipis Suillae, lb j. M. s. a. Equivalent, for most purposes, to the ung. hydr. fort., and a great saving of mercury. But, N.B., for this purpose, the protoxide should be obtained from the hydrargyri muriatis mitis of the old Pharmacopoeia, washing the precipitated submuriate while in a state of hydrate, as above. The 134 ANTISEPTIC!--ANUS. color completely resembles mercury, but for internal use, I prefer the decomposition from calomel. Equal parts of protoxide of mercury and sulphur, unite and form a fine black poAvder, similar to ^Ethiop's mineral, for which I originally intended it; but finding it too active for internal use, I noAV employ it as one of the best applications to chancre. It is a sulphureted protoxide. The above forms of Pulvis Antimonalis and Pilulm Hydrargyri Pro- toxydi, I have now used upAvard of twenty years ; and such is my estima- tion of their value in the cure of diseases, that if I Avished to leave a legacy to my country, I think I could not bequeath to her a greater boon. I have long found it unnecessary to use either James's PoAvder or the Pulv. Antim. of the Pharmacopoeia. Part v., p. 26. Cautions Regarding the Use of Antimony.—Never give tartar emetic to a child under a year old ; never give it to naturally delicate and scrofu- lous children, and never give continued doses. It is the sedative effect which is injurious, therefore the drug should only be employed in diseases which will bear this, as croup and pneumonia. Dr. Beck says : Emetics are \'ery efficacious, and may be given safely to the youngest child, if ipecacuanha is used. Part xv., p. 123. ANTISEPTIC. Employment of Sulphate of Zinc as an Antiseptic.—M. Falcony states, as the result of his experimental researches, that sulphate of zinc is not only eminently antiseptic, preserving animal substances from decay, but that it actually arrests the progress of putrefaction Avhich has once com- menced. The injection of four or five quarts of the solution of this salt in water, through the arteries, suffices for the preservation of a human body, in a state of perfect flexibility, for upAvards of forty days. Anatomical preparations thus made, will serve for dissection for a considerable period, the use of the solution not affecting the steel instruments employed. M. Falcony has also found, that preparations which have undergone change by maceration, resume their original character when immersed in a solu- tion of sulphate of zinc. Part xxv., p. 343. • > • ANUS. Fissure of the Anus—Treatment of by Rhatany Root.—The mode in which M. Trousseau employs the rhatany root is the following: He ad- ministers to his patient every morning a clyster of marsh mallows decoc- tion, or simply of water, Avith the addition of olive or almond oil, in order to clear out the intestines. Half an hour after the intestine has been emptied, he gives an injection composed of thirty-eight drachms of water; one to tAvo drachms and a half of the extract of rhatany; and five drachma ANUS, 135 and a half of alcohol, which the patient is desired to retain, if possible. The same styptic injection is repeated in the evening. _ When the pain is once moderated, only one clyster is given daily ; and when the cure appears to be completed, every alternate day only, for a fortnight longer. He says he has derived considerable advantage from the employment of an ointment composed of one or two parts of the extract of rhatany to five of the butter of cacao. Part iii., p. 110. Artificial Anus—Operation for.— Vide Art. "Intestinal Obstruction." Formation of Artificial Anus.—M. Amussat would extend his opera- tions to almost every variety of malformation of the rectum. He would apply it in every case of true imperforation of the rectum, in which it Avas possible to reach the gut, with the exception of those only in which the anus, otherwise well formed, is obstructed by a mere superficial membrane; but if the septum, hoAvever thin and yielding, hoAvever it may be distended by the accumulation of meconium, is situated above the anus, he insists that it is insufficient to destroy the septum, which method fails because of the difficulty of keeping an opening above the anus dilated; and M. Amus- sat therefore lays it down as a rule, that in such cases Ave should operate as if there was no anus, as if the rectum Avas completely deficient through- out the entire extent of its anal extremity ; and cut backward, and draw the rectum, not doAvnAvard to the anus, but directly backward. When there is any considerable interval between the gut and the external parts, it would be difficult, if* not impossible, to draw the rectum doAvnward, so as to make it adhere to the external orifice, but the sigmoid flexure of the colon will enable it to be drawn doAvn more or less from one to two inches. This elongation, therefore, will frequently extend to the neigh- borhood of the coccyx, and M. Amussat, in his third memoir, recommends that the artificial orifice should generally be made as near the coccyx as possible. The revieAver of his work, however, does not agree with thia opinion, but maintains that whenever the natural situation can be taken advantage of, it is better to do so, in order to make use of the sphincter muscle. Another mode of forming an artificial anus is that Avhich is com- monly called Callisen's, which consists in opening the colon in the left lumbar region, Avhere it is not entirely covered by peritoneum. M. Amus- sat has also improved this method, as Avell as extended it to the ascending colon. Instead of making a verticular incision in the left lumbar region, he makes a transverse one, four or five fingers' breadth long, midAvay between the last false rib and the crest of the ilium; and he divides the deeper parts, or even the skin, if the patient is fat, crucially, in order to gain room. The advantages of this mode of operating are—1st, that it makes the operation easier and more certain, and avoids the danger of dividing the lumbar vessels and nerves; 2d, that it facilitates finding and opening the intestine Avithout wounding the peritoneum; and 3d, it enables us to establish the artificial anus more anteriorly ; Avith a vieAV to which the opening in the intestine should be draAvn forward and secured to the anterior angle of the AA'ound. M. Baudens, another French Avriter, objects to this mode of operating, and recommends an oblique incision instead of a transverse one. He also speaks of having discovered a certain way of ascertaining which is the colon, a step Avhich is sometimes exceedingly 136 ANUS. difficult. His method consists in introducing a very fine needle, furnished with a canula, and on Avithdrawing the needle, either the gas escapes or the canula is soiled AA'ith faeces. Part x., p. 101. Artificial Anus.—The operation for artificial anus has excited as much interest as most other points of operative surgery; especially the opening of the colon in the lumbar region. In a very able review of the whole subject, written by Dr. Williams, of Dublin, in the " British and Foreign Medical Review," a very important question Avas left undecided, viz., when an artificial opening into the rectum was made in the perineum, or on one side of the sphincter muscle, would the patient be able to retain his faeces? Sir P. Crampton, in an interesting discussion at the Dublin Surgical Society, supplies this desideratum by giving the result of a case operated on by Amussat nine years ago, at a point betAveen the coccyx and anus. In this case the artificial anus contracted to such a degree that it was necessary at last to enlarge the orifice, and even daily to employ dilatation to keep the passage open; so that the danger in this case was not in the opening being too large, but, ultimately, in being too small; and Ave suspect that this must generally be the case unless the greatest care be used to keep the orifice dilated. Part xi., p. 109. Peculiar Ulcer of the Anus.—The symptoms which characterize this disease may be summed up in a very few words. It is ushered in by an uneasy sensation at the anus, increased on going to stool; as the disease progresses, the sufferings during the act of defecation become daily more aggravated, conveying to the patient a sensation of scalding, or of a red- hot iron being introduced into the gut; on the completion of the act of defecation some relief is felt by the patient, but after the lapse of a few minutes the sufferings are renewed, and continue unmitigated for a length of time, varying, in different cases, from four to nine or ten hours, Avhen they gradually abate, and at length leave the patient at perfect ease, until a reneAval of the necessity for the passage of the faeces causes a return of the sufferings. On proceeding to the examination of the anus, Ave are first struck by the absence of that permanently contracted state of the orifice Avhich is an almost invariable accompaniment of fissure. Generally speaking, in the disease under description, the orifice is as lax as in the healthy state, or if it be in any case contracted, it is but slightly so; this lax state of the ori- fice alloAvs the examination to be made with much less pain to the patient^ and equally less difficulty to the surgeon, than in the case of fissure—cir- cumstances Avhich cannot fail to attract the attention of any one Avho has had experience in those diseases. If the finger be now introduced sufficiently far to bo on the level of the upper part of the sphincter, laid flat on the mucous membrane, and carried over its lateral and posterior parts, its extremity will sink into an ulcer, rather deep, and of a size varying from half an inch to an inch in diameter; the dipping of the extremity of the finger, and the sensation which the rough surface of the ulcer conveys to it, indicate satisfactorily the existence and situation of the ulcer, Avhich is confirmed by the sensations of the patient. We also find in this disease, that, immediately on the pressure being made on the surface of the ulcer, the finger is grasped by the con- traction of the sphincter muscle. The treatment Avhich this ulcer demands is identical also with that so sue- ANUS. 137 cessfully practised in cases of fissure, the symptoms of which it so closely resembles, namely, division of the sphincter muscle, an operation, the per- formance of Avhich is devoid of danger, and, in the present disease, OAving to the laxity of the anal orifice, of difficulty also, the only instrument re- quired being a long probe-pointed bistoury, either slightly curved or straight, Avhich, having been placed flat on the index finger of the left hand, is, by the introduction of the finger, carried into the rectum; the extremity of the finger having sunk into the ulcer, is carried to its upper edge, where it is allowed to rest; with the right hand the bistoury is now pushed upward, until it also touches the upper edge of the ulcer, the bis- toury is then carried boldly doAvnward and outAvard, cutting completely through the substance of the muscle, and making the wound and the ulcer one continuous surface, as recommended by Mr. Colles. The after-treat- ment is sufficiently simple; a dossil of lint dipped in oil, or smeared Avith simple cerate, is to be introduced into the gut, which, in a few days, should an ichorous discharge, which in some cases occurs, demand it, is to be re- placed by a lotion of ol. olivar. et. liq. plumbi subacet. This will, generally speaking, be sufficient to complete the cure; in some cases, other mild applications may become necessary, but never any of a severe character. Part x\\.,p. 205. Artificial Anus.—After the bowel has been strangulated so long that gangrene of a portion has taken place, and an artificial anus is formed, either by the knife or by sloughing, and the stools are passed out of the opening, try the very ingenious method adopted by Mr. Trant, of Dublin, which consists of introducing a small silver tube (made by Mr. Millikin, of Dublin), and pressing back the intermediate portion of the intestine lying betAveen the abdominal and anal position of the artificial opening, and thus bring the parts into such relation that the stools can pass into the natural channel. In this way the opening may be gradually closed, and the functions of the part restored to the normal state. Part xiii., p. 2G2. Anus—Fissures of, with a Condyloma.—This was a most satisfactory and efficient cure of a most troublesome affection by nitrate of silver. A daily application Avas made of the solid nitrate, from the 29th of May, to the 19th of June, when the case was cured of both the fissures and the condyloma. Part xiv., p. 205. Fissure of the Anus in Children.—Give an enema daily for six or eight days, composed of extract of rhatany, one scruple; and water, three ounces. Part xiv., p. 206. Prolapsus Ani.—Dr. Hake advises the employment of Weiss's instru- ment—an ivory nipple upon a coil of wire of moderate power; this fixed upon an understrap and attached to a belt. Or, carefully return the bowel after the daily motion, and place upon the anus a pad formed of a piece of sponge, four inches by one and a half, and half an inch thick, rolled up tightly into a coil; and immediately bring the nates together with a broad strip of plaster. Vide " Prolapsions." Part xv., p. 215. Treatment of Fissures of the Anus.—M. Diday recommends the patient to apply to the anus, night and morning, Avith the end of the finger, a por- tion of ointment, about the size of a cherry stone, composed as follows: 138 ANUS. Axungiae 15 grammes, tannin 1 gramme, increasing the portion of tannin gradually to three grammes or more, according to its effect on the sensi- bility of the part. To apply it efficiently, the patient should push his finger as far as possible Avithout forcing the sphincter, and there leave tho ointment. Where fissures are situated higher, a solution of tannin may be injected into the rectum Avith a small syringe. The quantity of liquid introduced should be as small as possible, in order that it may be retained for some time. In both cases, the patient should experience some degree of heat, and smarting, continued for some time after the application. Part xvi., p. 331. Treatment of Prolapsus Ani.—Keep the patient in bed, and daily after cleansing the bowel out, let a small quantity of solution of sulphate of iron, a grain to the ounce, be injected and retained. If the stomach -will bear them, give balsams. Part xvii., p. 171. Treatment of Prolapsus Ani.—Apply a ligature round a portion of the mucous membrane, for about twenty minutes, and then release it. Give then an anodyne every night and an aperient every third day, the boAvels being kept confined in the meantime. Aftenvard the rectum pessary may be used for fiATe or ten minutes after each motion. Part xvii., jt>. 171. Prolapsus Ani.—Some cases will be benefited by destroying a portion of the mucous membrane with the strongest nitric acid. Or remove a fold or two with curved scissors, and immediately touch the surface of the wound Avith the acid; care having been previously taken to compress the base of the portion removed, so as completely to prevent any of the divided vessels from bleeding. When an operation from any cause cannot be undertaken, use frequent ablution Avith cold water, or apply the folloAving ointment: R. Pulv. hydrarg. nitr. oxyd. 3hj.; pulv. capsici, gr. v.: ung. cetacei, § j. M. In many old cases, however, mechanical support is tha only means that will afford relief. Part xviii., p. 188. Prolapsus Ani.—[In mild cases the improvement of the general health by tonics, and attention to diet and regimen, together Avith the use of mild aperients, and astringent injections into the rectum, will afford relief. But, Mr. Cooper observes:] In very protracted cases of prolapsus, palliative means may not prove sufficient, and mechanical contrivances may be requisite to return the pro- truded membrane within the anus; bougies or the finger may be employed for this purpose ; but in some instances, the tone of the sphincter may be so completely destroyed that it Avould be incapable of retaining the intes- tine even after it is returned; a pessary should in that case be passed into the rectum, and alloAved to remain there for a few hours, so as to maintain the loose portion of membrane sufficiently long in situ to allow of its recovery from the congestion arising from its protrusion and exposure to external agency. I have seen an instrument Avhich is worn by the Chinese, Avho are very liable to prolapsus ani, for the purpose of retaining the bowel within the anus. It consisted of a ball of silver, perforated with holes, to permit of the escape of flatus, and made to unscrew in the middle, so that it could be easily cleaned ; this instrument appeared to me to be admirably r.uited to the purpose for Avhich it was intended. When a pessary is ANUS. 139 employed, it should be passed into the boAvel above the sphincter muscle. And at the same time that mechanical contrivances are made use of, con- stitutional means should also be adopted for the purpose of improving the tone of the health. A radical cure may be attempted by pinching up several small portions of mucous membrane, at about equal distances from each other, a little above the sphincter, and tying a ligature round each. In obstinate cases, the anal extremity of the sphincter may be divided, with a view of diminishing the opening of the anus. The after-treatment consists in keeping the patient in the recumbent posture, and maintaining for a few days a constipated state of the boAvels, to enable the parts to recover from the effect of the operation. Part xviii., p. 194. Anus—Fissures of.—Having introduced the left fore-finger into the rectum, make a small opening at the verge of the anus, and through this wound introduce a straight knife (Blandin's knife), guarded at its point and edges, into the submucous cellular tissue, betAveen the mucous mem- brane and sphincter. Turn the cutting edge toAvard the muscle, retract the guard, and cut through the muscle as the blade is withdrawn. Then close the external wound, and keep the boAvels lax by means of conf. senna?. Part xx., p. 145. Anus—Imperforate.—If it could be ascertained beforehand that the rectum was absent in a case of imperforate anus, it Avould be easiest to per- form Amussat's operation, and open the colon in the left lumbar region. But as the absence of the lower part of the rectum, or its distance from the surface cannot be known before operating, the perineal incision is the ope- ration that ought to be chosen. One point in the operation ought especially to be attended to, viz., to bring down the mucous membrane of the gut, and fix it to the lips of the external wound, if it be possible to do so. Part xxi., p. 204. Prolapsus Ani.—The disease so called generally depends upon morbid enlargement of the mucous membrane of the bowel. It is easily, safely, and effectually remedied by the use of the ligature; in the application of which it is only necessary to remember that the whole of the diseased growth should be comprehended, and that the threads should be drawn so tightly as completely to arrest all circulation through the included parts. Part xxi., p. 205. Anus—Fissure of.—It is now well known that a small incision, slightly exceeding the length and depth of the little ulcerated fissure, is sufficient for its remedy, without any after treatment, or restriction from exercise, beyond a day or two of quiet. Part xxvii., p. 348. Artificial Anus, treated by Mechanical Pressure within the Rectum. —In a case where the operation for artificial anus had been performed as a temporary resort, the greatest discomfort arose from the faeces passing invariably through the artificial opening, and not through the rectum. At length, Avhen life had become a burden to the patient, it Avas suggested that some substance, as a piece of brown soap, introduced into the rectum, might induce the return of peristaltic action, and the necessary tenesmus for the expulsion of the contents of the canal. The expedient Avas per- fectly successful, and at the end of two weeks the artificial opening Avas quite healed and the faeces passed by their natural outlet. Part xxviii., p. 200 140 ANUS. Fistula in Ano.—The opening into the rectum from the fistula Avil] generally be just above the internal sphincter, although the probe may easily pass upward to a considerable distance outside the gut; about five or six lines high up will generally be the situation of the orifice through the boAvel—we might, therefore, almost detect it Avith the eye by separat- ing the sides of the anus sufficiently. In operating, pass a director through the fistula into the rectum, and Avhere the internal aperture is near the anus, the director, by being a little curved, can be brought out again at the anus. Then pass a probe-pointed bistoury along the director and divide all the parts betAveen the two openings, including the sphincter. Then stop up the Avound for forty-eight hours Avith dry lint. If the wound heal indolently touch it with a solution of nitrate of silver (3j. to §j.) In blind internal fistula, it is best to make it a complete fistula, by making an open- ing at the side of the anus, in the hard, tender, red part, and then operate as for complete fistula. Sometimes the external point where the fistula exists is not Avell marked; in this case, a probe or curved director can sometimes be passed through the opening from the rectum till its point is felt through the skin, so as to guide the knife accurately. In blind exter- nal fistula a probe bistoury Avith the front of the end a little sharp and projecting, is passed up the fistula till its point presses against the wall of the rectum, the nail of the fore-finger in the rectum scratches against the end of the bistoury till it pierces the boAvel, and then is drawn doAvnward with the finger on the end, dividing the sphincter and all the parts below it. Part xxx., p. 141. Diagnosis of Fistula in Ano by means of Iodine.—To ascertain whether the fistulous opening communicates with the rectum, inject a little tincture of iodine up the orifice, and at the same time introduce a finger up the rectum. If there be a communication the finger will pro- bably be stained Avith the tincture. Part xxx., p. 144. Fissured Anus.—Introduce a speculum into the anus so as to bring the fissure into vieAV. Then make an incision through the ulcer, beginning a little above its upper edge and carrying it through its base to a little beloAV its lower edge. These fissures are in reality narrow oval ulcers at the margin of the anus, Avhich look like fissures in consequence of the plicated arrangement of the end of the rectum. In slight cases, touch the fissure Avith a solution of the nitrate of silver, a drachm to the ounce, or touch it slightly with solid nitrate. This should be done every second or third day, soon after the morning motion; and a bit of dry lint applied well to the fissure after each application. The bowels should be kept open by rhubarb or some mild laxative. ******** In those very painful ulcerations and fissures of the anus, which used formerly to be relieved by division of the sphincter muscle, Mr. Copeland merely divides or cuts through the mucous membrane by a slight incision; a feAV of the muscular fibres of the sphincter are necessarily divided. Part xxx., p. 157. Prolapsus Ani.—When the integuments around the anus are relaxed and thickened, remove the redundant folds of skin by repeated applica- tions of the scissors, not in a circular direction, but pointed from the circumference toAvard the centre of the orifice. The horizontal position ANUS. 141 must afterward be strictly maintained, the bowels kept quiet for some days. By the contraction Avhich will take place in the treating of the wounds the boAvel will be retained. Part xxxiv, p. 164. Artificial Anus—AmussaVs Operation.—The region in which the ope- ration is performed is bounded above by the last false rib; beloAAr, by the crest of the ilium ; behind, by the lumbar spine ; and in front, by an imaginary mesial lateral line. In this oblong quadrilateral space, a hori- zantal incision should be made, commencing tAvo fingers' breadth to the left side of the spinous processes of the lumbar Arertebrae, and carried hori- zontally outvvard for about four inches, midAvay betAveen the last rib and the crest of the ilium. The dissection is carried down until the transversalis fascia is reached: the anterior and middle lamellae of this are opened, and the edge of the quadratus lumborum exposed. The real difficulties of the operation noAV commence: the layers of cellulo-adipose tissue Avhich cover in the colon, and the contiguous reflexions of peritoneum must be carefully dissected. If the gut is distended, this tissue will be pushed Avell aside, and the intestine may easily be reached; but if it be contracted and empty, it will be found to recede someAvhat from the surface and to lie at a great depth. The gut can at once be recognized from any other struc- ture, by its greyish-green hue, the longitudinal stria? on its posterior surface, and its thicker feel. When exposed, a needle, carrying a strong whip- cord, should he passed through it in a vertical direction, and the gut being thus draAvn well to the surface (that its contents may not be extra- vasated into the loose cellular tissue around it), may be properly opened and stitched to the edges of the wound. Part xxxv., p. 105. Imperforate Anus.—The rectum having been opened, two modes of procedure have hitherto been in vogue : either to leaAre the parts to granu- late and a passage established when the mucous membrane is not directly continuous Avith the skin outside,—or to seize the gut (Avhich may be situat- ed an inch or two in depth from the surface) and drag it down to the external parts. In the first case, gradual contraction takes place, and the passage often again becomes obliterated. In the second case, death often ensues, from peritonitis, or pelvic cellulitis. You will avoid both these evils by extending the process of drawing the rectum doAvnward over a considerable time, using gentle traction, introducing the forceps at certain intervals, and gradually endeavoring to accomplish the end. Part xxxvii.,p. 152. Treatment of Pruriginous, Papulous, and Eczematous Eruptions of the Anus, etc.—Modern observers have classed resinous and empyreumatic substances, so extensively employed by the ancients, among the most pow- erful local applications in the treatment of herpetic eruptions. Thus, puri- fied tar, mixed with lard, in the proportion of from fifteen to forty-six grams of the former to an ounce of the latter, is daily used in the wards of the Hospital St. Louis, as the resolvent, par excellence, of scaly eruptions, and as a valuable desiccative in chronic, eczematous, and impetiginous affections. Since the introduction of glycerine into therapeutics, M. Gibert employs this substance as an excipient, in preference to lard. To facilitate its use, the mixture is thickened by the addition of starch. This prepara- tion possesses the advantage over ordinary ointments made with a fatty excipient, that it is removable by water. 1^2 APERIENTS. The following is the formula of the glycerole de goudron: Glycerine one ounce; purified tar, half a drachm; and, with the aid of heat, powdered starch, half an ounce. With this quantity of starch, we obtain an oint- ment of thin consistence^ and easily spread. The mixture should be per- fectly homogeneous. This application allays itching, dries up excoriations, checks exhalation, dissipates slight cutaneous phlegmasia? ; it acts, in a Avord, as an astringent and resolvent, AAuthout producing irritation. Thus, eczema rubrum, im- petigo, intertrigo, prurigo of the scrotum and anus, acne rosacea, and subinflammatory mentagra, are, under its influence, most advantageously modified. Another product, the huile de cade (oil of pitch) M. Gibert uses fre- quently ; but as the empyreumatic properties Avhich this resinous oil possesses in a much higher degree than tar, are such, that it can seldom be applied in a state of purity, he usually mixes it Avith oil of SAveet almonds, or with cod-liver oil. The folloAAring preparation is used, under the name of huile cadee, in the Hopital Saint Louis: Cod-liver oil, twTo parts; oil of pitch, one part. This application possesses A'ery efficacious resolvent and drying properties. M. Gibert has seen eczemas, Avhich.had continued for months in a stationary, red, excoriated, and oozing condition, notwithstanding the external and internal use of preparations of sulphur, heal under the influence of this combination. It is particularly in cases of obstinate pruriginous, papulous, and eczema- tous eruptions of the anus and genitals, which are so often such a source of annoyance to both the patient and the practitioner, that M. Gibert has most frequently derived benefit from the local use of oil of pitch. He adds, in such cases, the diligent use of cold hip-baths, and, in order to alter the diathesis on which the eruption depends, the internal employment of Dr. Boudin's arsenical liquor, modified in the following manner: Distilled water, one pint, arsenious acid, three quarters of a grain ; dissolve Avith the aid of heat. The mixture is dxvided into six vials, each of Avhichis marked for tAvo days; half a bottle to be taken for a dose each morning, fasting, with the addition, at the moment the medicine is SAvalloAved, of a cup of chicory, sweetened with honey. M. Gibert states that he has seen erup- tions of several years' standing, and which had resisted the use of thermal waters, and of many other remedies, yield in a few weeks to this mode of treatment. Part xxxix., p. 185 —•-•-•— APERIENTS. Aperient Biscuits.—# Scammoniae, 3j.; Saponis Venet., gr. v.; Sacchari Albi, gr. ix. M. These ingredients are to be rubbed down to a fine pow- der, and mixed with one ounce of poAvdered biscuit. The mass is then to be kneaded, with the aid of a few drops of water, to a stiff paste, then dried in the air, and weighedout into portions of 3x. Of this mass 3j. contains gr. vj., of scammony resin. Scammony resin is not unpleasant to take, rubbed down with sugar. Eight grains of the resin are sufficient to produce several evacuations in an adult; six grains are sufficient for an individual of about fifteen years; four grains for a child of seven or eight APHONIA. 143 years; two grains for a child of two years. Scammony is one of the best anthelmintics. Part xii. p. 94. Agreeable Mode of taking Senna.—Dr. Linthner says, that senna leaves (one or two drachms to one or tAvo cups of water) should be allowed to infuse all night in cold Avater. With the strained infusion coffee is prepared next morning, as if with water ; and an aperient which does not taste of senna, and does not cause griping, is thus pro- duced. Part xxxv. p. 307. Aperient.—Employment of Rhammus Frangula. Vide Art. " Con- stipation." *•*— APHONIA. Hysterical Aphonia.—Allusion is made to various forms of hysterical paralysis; you may have numbness in the course of particular nerves, or paralysis of motion, in some cases putting on the features of hemiplegia —in others of paraplegia. Hysterical aphonia must be regarded as of the same kind, the palsy or weakness affecting the muscles of the larynx. The patient is unable to speak, except in a Avhisper, and even then not Avithout effort. It often begins and ends suddenly. Sometimes it.remains after a severe hysterical paroxysm has passed away. This is a form of local hysteria of very common occurrence, and not likely to be mistaken for any laryngeal disease, for respiration remains quite unimpaired. Treatment similar to other forms Of hysteria. Part viii., p. 62. Treatment by GalvanUm.—Case cited of entire loss of voice, fol- lowing a violent fit of epilepsy, in which other means having failed, at length, about sixteen months after the attack, the voltaic pile Avas thought of, and a battery of fifty pair of plates was employed. The posi- tive pole was placed over the cervical vertebrae, and the negative upon the parts affected. On the first day tAvo hundred shocks Avere given, and on the second three hundred, but no perceptible effect folloAved. Two days were suffered to elapse, and a battery of seventy pair of plates Avas then used, with which about three hundred shocks Avere given. The pa- tient Avas found acutely sensitive to the action of electricity, and a lapse of five days was permitted to intervene before its fourth application, which consisted of four hundred shocks with the latter-named battery. After six more days the battery of fifty pairs was again employed, and three hundred shocks were given. The same treatment wras repeated every tAvo or three days, and then, at similar intervals, four hundred shocks were given with the seventy-pair battery. The voice, meanwhile, and the motive powers of the tongue and larynx, gradually returned to their normal condition, and after the tAvelfth application the patient had completely recovered. The deduction draAvn by the surgeon who has re- ported the case, is, that no nervous affection Avhatever should be regarded as incurable till the electricity in some form has been tried and found to f^l- Part viii., jo. 76. Causes and Treatment of Aphonia.—A cold or moist atmosphere very 144 APHONIA. frequently induces this affection in Aveak and relaxed habits of body, par. tieularly in females. Other causes, as well as humidity, may bring it on, as over exertion of the vocal organs, nervous excitement, etc. The disease is evidently of an asthenic character, hence antiphlogistic treatment is contra-indicated. Stimulants and astringents are mostly to be depended upon, and Mr. Bishop recommends a strong solution of nitrate of silver, applied Avith a camel's hair brush, before every other application: and he illustrates its beneficial action by the following case, in which he made use of it:. Mrs. H., a professional singer, suffered occasionally from loss of voice, which often lasted from six to eight weeks. On one occasion she was en- gaged to sing at a concert in the course of a few days, when one of these attacks came on ; and she was greatly alarmed at the prospect of not being able to fulfill her engagement. Underthese circumstances, I applied to the fauces a solution of nitrate of silver, of the strength of- ten grains to one ounce of distilled Avater, and repeated the application the following morn- ing. Under this treatment the power of the voice returned, and she was enabled to sing at the concert on the third day. When aphonia arises from nervous excitement, we must look for the origin of the affection beyond the mere office of the soft parts of the vocal tube. This condition may often be traced to the nervous centre, most commonly arises from an asthenic state, and is often associated Avith a hysterical disposition. In some hysterical cases, however, an opposite state to that of aphonia presents itself. A patient was placed under my care, who uttered a constant involuntary bark, like that of a dog, very loud and discordant. It need scarcely be mentioned that no benefit can be expected to result, in such a case, from merely local treatment. Sud- den alarm and over excitement will often cause aphonia. When this is produced by an altered state of the nervous functions, galvanism is said to be beneficial. Part xiii., p. 45. Loss of Voice—Inhalation of the Fumes of Ammonia for.— Vide Art. "Bronchitis." Aphonia of Five Months'1 Duration, Successfully treated.—The pa- tient was placed under medical care, January, 1846, for catarrh, which terminated successfully, except for the entire loss of voice ; for which she was treated Avith emetics, aperients, mercurials, iodide of potassium, cin- chona, and astringent acidulated gargles, until June 25th; and on being sent to the sea-side, the inhalation of the vapor of iodine, from a Wolffs bottle, for fifteen minutes twice a day, and the following mixture : R. Quiniae disulph., gr. j.; acid iodic, gr., iij.; tinct. aurant., gss.; syr. aurant., 5j.; aq. destillat. 3viss. M. ft. haust. ter die. July 2d. Voice audible. 10th. Voice natural, and enunciation full and clear; after this, the voice continued permanently good. . Part xiv., p. 132. Case of Loss of Speech Cured by Galvano-puncture.—In 1813, R. P., then aged forty-seven, was affected with a loss of sensation and movement, in consequence of a great fright. Recovering by little and little, she re- gained the use of her legs, but did not recover that of her arms and head, which remained paralyzed from that time. From that moment she could APHONIA. 145 not articulate a single word. The tongue, which remained immovable between the teeth, appeared also to be atrophied. On the 21st of May, 1836, a metallic needle was introduced into the neck, directing its point toward the occipital branch of the first cervical nerve ; then it was brought into connection-Avith the zinc pole of a voltaic pile; and holding the tongue, elevated and stretched out on a sheet of the same metal, the circle Avas closed by presenting to that organ the knob of a brass director. The patient shoAved, by quickly drawing herself aAvay, that she had felt the shock. The experiment Avas repeated and the effect Avas more marked than before. She gained immediately the power of lifting her tongue. At the end of three other shocks the patient exclaimed: "Oh, Dieu!" and could answer some questions in an intelli- gent manner, although Avith some difficulty. She also became able to move her tongue from side to side. The next day, after some shocks given in the same manner, M. Camino commenced to vary the points of contact, and to give the electricity different directions. Two days of repose employed in exercising the organs, sensibly ren- dered the faculty of pronouncing and articulating sounds easier and more accurate. On the 10th of June, she complained, without obvious cause, of pain in the head and a general feeling of Aveight, an ailment Avhich was dissipated by a bleeding. After some more sittings, not only was her speech re- covered, but also the activity of the other paralyzed parts, which became quite fit to exercise their functions. Part xvii., p. 61. Aphonia Cured by Inhalation of Benzoin Fumes.—[A lady who had never been able to speak above a whisper for more than tAvelve years, the larynx at the same time appearing to be quite healthy, wras advised to in- hale the fumes of benzoin burnt upon a card. After a most persevering continuance of the remedy for nearly four months, she spoke in a good laryngeal tone, not SAveet indeed, but tolerably strong.] The fumigating cards are made in this manner: A sheet of thick white blotting paper is brushed over Avith a saturated solution of nitre until it is thoroughly Avet, and Avhen dry the compound tincture of benzoin is applied in the same manner. Each of these applications is repeated more than once if necessary. When thoroughly dry, the paper is cut into slips, three inches long by one and a quarter wide. One of these being lighted at the cor- ner, burns Avithout flame like tinder, emitting a dense AAThite smoke, con- sisting principally of benzoic acid and some particles of nitre, Avhich are throAvn off by the crepitation of the crystals. When used for remedial purposes, this smoke should be inhaled by holding the head over the burn- ing card. Part xvii., p. 93. Aphonia.—In cases of aphonia arising from chronic inflammation of the larynx and fauces, paint over the throat, externally, a strong alcoholic solution of iodine (3j. to §j.). Where there is a thickened and mammillated state of the pharyngeal mucous membrane, a solution of silver, topically, is more preferable. % Part xxviii., p. 96. Aphonia.—If you have reason to believe that it depends upon paralysis of the genio-glossi and the muscles connected Avith the chordae vocales, you 10 116 APHTHA—APOPLEXY. may derive wonderful benefit from inductive electricity, one pole being placed on the tongue and the other on different parts of the neck. Part xxxiv., p. 30. ---++-•--- APHTHA. Aphthous Ulcers of the Mouth.—Vide Art. "Mouth." Treatment of Aphtha.— [Speaking of that form of aphtha Avhich depends upon impaired nutrition of the system generally, and often arises as a con- sequence of artificial feeding, Dr. West says :] " One point of considerable moment, and to which less care than it de- serves is usually paid, is the removing from the mouth, after each time the infant is fed, all remains of the milk or other food which it has taken. For this purpose, Avhenever the least sign of thrush appears in an infant, the mouth should be carefully wiped out with a piece of soft rag, dipped in a little Avarm Avater, every time after food has been given. Supposing the attack to be but slight, this precaution will of itself suffice in many instances to remove all traces of the affection in tAvo or three days. If, hoAvever, there be much redness of the mucous membrane of the mouth, or if the aphthous spots be numerous, some medicated topical application is useful. Various detergents have been recommended, among which the mel boracis, and a mixture of the Armenian bole, with honey, are very fre- quently employed. An objection, hoAvever, has been raised to any appli- cation into the composition of which honey or other saccharine matters enter, on the ground that the tendency of those substances to pass into a state of fermentation will make them favor rather than prevent the for- mation of confervae in the interior of the mouth. Without determining the precise value of this objection, it Avill yet, I think, be found that water is the best menstruum for any local application to the mouth. It is my custom to dissolve 9j.-5ss. of borax in §j. of water, and to direct that after the mouth has been carefully cleansed with Avarm water, the lotion should be applied to it on piece of lint or soft linen. In the milder forms of the affection, this borax lotion usually answers every purpose. Should it, however appear insufficient, a solution of gr. v. of the nitrate of silver in g-j. of distilled water, may be employed in the same Avay twice a day, while at other times the solution of borax may be used in the manner just di- rected . Part xviii.,p.\\\. APOPLEXY. In no case of apoplexy or paralysis should a careful examination of the heart's action be omitted. If we are called to a case of diseased brain, accompanied by hemiplegia, or symptoms AAjhich Avould at first sight indicate congestion or inflamma- tory action, it is our duty immediately to ascertain if these symptoms may not be OAving to disease of the heart or valves; and if Ave* suspect that there is disease of the aortic valves, causing hypertrophy of the left ventri- APOPLEXY. 147 cle, and preventing the blood reaching the brain with sufficient ease; or if we suspect either a too open or a too contracted state of the mitral valves, causing in the former case a regurgitation of blood from the ventri- cle and in the latter case a difficulty in its course into the ventricle from the auricle—Ave must be on our guard not to deplete but to stimulate; as is very clearly shown to be correct practice by Dr. LaAV in several cases Avhich he relates. He affirms that if there be obstruction to the floAv of blood before the arteries going to the brain are given off, that disease of that organ will not be owing to a fullness of blood in it, but to a deficiency; but, on the other hand, if obstruction exist beyond the origin of the cere- bral arteries, then the regurgitation of the arterial blood may very proba- bly be toward the brain. Part i., p. 67. Treatment of Certain Diseases of the Brain.—There are no cases which require more careful discernment of pathological condition than those which simulate apoplexy from compression of the nervous centre. Dr. Corrigan Avas the first to point out that many cases which were usually treated by antiphlogistic means were in reality better cured by stimulation. These cases were chiefly OAving to a diminution of blood in the brain, from valvular disease of the left ventricle, and other diseases Of that viscus. From his cases Mr. Copeman draAvs the folloAving inferences: 1. That apoplectic and paralytic affections may take place in an extreme degree Avithout organic disease of the brain. 2. That they often occur from other causes than pressure on the brain. 3. That bleeding, so far from being always necessary, is in many in- stances prejudicial. 4. That the effort of vomiting is not so prejudicial in these diseases as is generally supposed. 5. That counter-irritation, both external and internal, is a valuable means of affording relief to the symptoms immediately succeeding the attack. Mr. C. offers the following opinion: " If I may be allowed to give an opinion, I should say that bleeding is unnecessary or prejudicial where the patient is 60 years of age or up Avar d; AA'here the pulse is feeble, very fre- quent, intermitting, slow, or large, and inclined to double beat; (I haAre always found a pulse with double beat indicative of a state of system best relieved by diffusible stimuli;) where the respiration is labored and accom- panied Avith cold perspiration ; where there is great mobility of the nerv- ous system Avith weak muscles, Avhether the body be thin or corpulent; and when the attack comes on soon after a full meal, or after great bodily or mental fatigue." Part iii., p. 34. Apoplexy Caused by Inanition, Dyspepsia, Gout, Diseases of the Heart, Diseases of the Capillaries, etc.—The intimate connection between plethora and apoplexy Avhich exists so often, has too long blinded the eyes of practi- tioners to the fact that exactly opposite causes may produce similar effects; and hence Ave too often find, that when a patient is seized with a fit of apoplexy, Avhatever be the cause, Avhether owing to plethora or exactly the reverse, the practitioner thinks he is neglecting his duty if he do not bleed the patient copiously, and employ other means of depletion. It is now, hoAvever, becoming better knoAvn, that inanition and anaemia, morbid conditions of the stomach and intestines, dyspepsia, cachexia, gout, hyper- trophy Avith augmented impulse given to the arterial blood, or indilatation 14^ APOPLEXY. of the heart and disease of the valves impeding the reflux of the blood along the veins, may all be causes of the affection, and will require differ- ent modes of treatment. Even in cases of injury of the brain, as in concussion, too much vene- section may give rise to symptoms which it will be difficult to distinguish from those produced by the accident itself. Sir Benjamin Brodie remarks on this subject, "Where bleeding has been carried to a great extent, symptoms frequently occur Avhich in reality arise from the loss of blood, but which a superficial observer will be led to attribute to the injury itself. Repeated copious blood-letting, is of itself adequate to produce a hardness of the pulse Avhich Ave shall in vain endeavor to subdue by depletion." And almost every practitioner is awrare, hoAV many cases of paralysis, appa rently resulting from apoplexy, arise from a Avaste of nervous matter, or from a too great exertion of the mental power. The treatment, then, should consist in carefully restoring the system to its state of equilibrium by recourse to those means adapted to the particular cause. Part vi., p. 37 Apoplexy Dependent upon Disease in Remote Organs.—The depend ence of apoplexy upon disease in remote organs is a subject of much interest. Its occurrence in this kind of connection with pneumonia, is illustrated in the following case: A. B., a large, full, healthy-looking man, aged 54, in the spring of 1843, was brought into Carroll's ward of the Marylebone Infirmary, in a state of insensibility, and died almost immediately. It appeared that he had been employed in the workhouse in bodily labor, and seemed in good health up to the moment of his seizure with apoplexy, that morning. He was described as having the day before eaten an enormous dinner of pork, etc. He went to bed apparently Avell. Autopsy.—The membranes of the brain were healthy, but the convolu- tions flattened. A very large coagulum, with some fluid blood, distended the lateral ventricles. The basilar artery Avas of great size; slight appear- ances of ossification in many arteries of the brain. The aorta was of great size, but healthy; the heart normal. The right lung almost uniformly in a state of red hepatization ; portions from every part of it sinking in Avater The left lung gorged Avith blood, but perfectly crepitant. The stomach very large; no solid contents in it: its Avails thin : its surface having a color exactly similar to that of coffee-ground vomiting. The other viscera healthy. Part ix., p. 26. Apoplexy of New-born Infants—May arise from want of duly oxygenat- ed blood in consequence of imperfect closure of the foramen ovale. After birth, then, a portion of the lungs alone becomes filled with air, while the remainder continues in a foetal state. In cases of this kind, and indeed in all, there is one general rule to be observed, never to tie the cord as long as pulsation exists in it, until respira- tion is Avell established; and never to rest satisfied in any case, until the child, by its loud cry, the "vagitus intra muros" of the Scotch law, con- vinces us that its lungs are fully able to perform their function. At a later period, in instances such as those recorded, our treatment must consist in the use of stimulants internally and externally, together with remedies directed against tho apoplectic and inflammatory consequences to which the brain and lungs are both liable. In detracting blood from the chest, tlie best situation to apply leeches is under the axilla, as the subcutaneous APOPLEXY. 149 venous plexus there communicates directly with the vessels of the thoracic cavity. Vide Art. "Asphyxia." . Part ix., p 89. Asthenic Puhnonecry Apoplexy.— Dr. Byron advocates the treatment of cases of asthenic pulmonary apoplexy by tartar emetic combined with opium..... " It is Avell knoAvn to medical men," says Dr. Curry, " that Avhen either emetic tartar, antimonial wine, or ipecacuanha in powder is given, joined with opium, each counteracts the effect Avhich the other would have had, if administered alone; the opium generally preventing the emetic tartar, etc., from exciting vomiting, and the latter, in their turn, entirely suspend- ing the stupefying poAver of the opium. The consequence generally is, that they operate upon the skin, and occasion a Arery copious sweating." Part xi., p. 49. Congestive Pulmonary Apoplexy.—This form of pulmonary apoplexy usually falls upon individuals who have passed the meridian of life, those Avhose constitutions have been more or less impaired by over exertion; by intemperance, or by the inhalation of damp, noxious, or unwholesome atmospheres. A gentleman, aet. 43, of sanguineous temperament, accustomed to Ariolent exercise, suddenly changed his mode of life, discontinued all but carriage exercise. The first indication of this mode of life disagreeing with him, Avas the appearance of furunculi on the hands and body. After about four years his legs felt less strong, and he had general lassitude, Avith aching pains about the knees and ankles. He one night awoke shortly after falling asleep, finding his mouth full of blood; this Avas followed by five or six discharges of the same kind in quick succession: the entire amount of blood discharged Avas probably about three ounces. His pulse at this time Avas 70, moderate and regular; had no heat of skin, hurried respiration, nor the slightest indication of indisposition beyond Avhat has been mentioned. His chest was perfectly clear on percussion; his respiration natural, except a mucous rattle in the large bronchi, owing to portions of blood which were discharged in a coagulated manner during the night. About fourteen ounces of blood were taken from his arm without producing any sensible effect upon his pulse, or in any other Avay ; his bowels were open and a blister laid upon his chest; the acet. plumbi, with P. ipec. C. and mineral acids, were also giAren. Animal food and Avine Avere laid aside; he was confined to bed for the folloAving Aveek; his head and shoulders were elevated, and his apart- ment ordered to be kept cool. In this Avay he progressed most favorably. On the second and third days there Avas a slight return of fresh bleeding; but although pieces of coagula Avere thrown up for about a fortnight, they appeared to be portions of coagulated blood Avhich lodged in branches of the bronchi; this Avas evident from their bearing the impress of the air- tubes which contained them. Small bleedings from the arm were resorted to every eight or ten days, followed by a small blister for upward of two months, Avhen he gradually resumed his ordinary avocations. The bleed- ings, however, and the blisters, Avere resorted to from time to time, but at longer periods of intermission, for six months afterward. Little more than twelve months from the first seizure, a second discharge of blood, in all respects resembling the former one, took place ; he aAVoke as he did then, Avith his mouth filled with blood, which also soon coagulated. 150 APOPLEXY. No fresh discharges of blood took place at the end of three weeks, and only three previously; and on no occasion did the quantity spit up amount to more than two ounces. Fearing the existence of some organic disease, of which the hemoptysis was but a symptom, his chest Avas closely examined by almost every medical man of eminence in Dublin, but no disease could be discovered. In addition to the plan of treatment adopted on the first occasion, wine and beer Avere* altogether prohibited; he Avas ordered to remove his dwelling to a dry, elevated locality ; avoid fatigue or great bodily exertion ; and should a sense of pain, formication; or constriction arise in any part of his chest, a moderate bleeding should be taken from his arm; a blister laid upon the affected part, and the other means of relief formerly resorted to, derivatives, etc., resumed and repeated as might seem to be necessary. An occasional blister Avas laid . upon his chest during the following year; no Avine nor malt liquor Avas used by him for five years, and then but sparingly. The foregoing rules were strictly adhered to ; and noAV, thirteen years from the date of the first attack of hemoptysis, he is in the enjoyment of perfect health, and possesses greater vigor of mind than at any former period of his life. • Part xi.,p. 50. Prevention and Treatment of Apoplexy.—[There are feAV diseases, the pathological diagnosis of which is of more consequence than apoplexy; the different kinds of this affection requiring diametrically opposite modes of treatment—sometimes an antiphlogistic, and at other times a stimulat- ing kind of management. In speaking of the causes of apoplexy, and its effect, Dr. M. Hall first mentions mental emotion, and illustrates it by tho folloAving cases:] A lady parted Avith her son, on his appointment to India; she became afflicted Avith apoplectic symptoms, and most complete hemiplegia. Another lady Avatched a daughter in a dangerous illness ; she was seized with hemiplegia of the arm. A gentleman under the immediate influence of painful tidings in reference to property, Avas seized with ptosis, para- lysis of the rectus externus, and immobility of the pupil of one eye. \Muscular effort is next mentioned as one of the causes of cerebral seizure—also a morbid condition of the stomach—and in illustration of the latter, Dr. M. Hall observes:] A short time ago I was requested to see a young man, AA'ho, after eating heartily of pork at supper, had gone to bed and risen the folloAving morn- ing free from ailment, but suddenly lost the mental powers, the power of articulation, and the use of the arm and leg. It Avas a case of severe hemiplegia. In many cases, the effect follows the exciting cause more speedily: in this instance, the hemiplegic seizure occurred soon after rising. [A constipated and loaded state of the large intestine is also to be classed among the exciting causes—of the predisposing causes Dr. M. Hall classes hyperemia, or a state of plethora, as the first; but it may also be caused by just the opposite of this, viz.: anaemia, or more correctly, hypoaemia ; in speaking of this state of the system as a cause of apoplexy, he observes :] A lady, Avho was a patient of the late Dr. Denman, was absolutely blanched by the hemorrhage proceeding from a polypus uteri of an in- tractable character: in the midst of this anaemia she suffered from an APOPLEXY, 151 attack of apoplexy, and hemiplegia, which terminated fatally ; and on a post-mortem examination, it Avas found that laceration had taken place in one of the hemispheres of the brain, with the effusion of blood ! A patient of Mr, Hammond, of Brixton, had severe uterine hemorrhage during par- turition, succeeded by hemiplegia. A lady, drained by intestinal hemor- rhage, has greatly lost the use of the left arm and leg. It is plain that a state of general anaemia does*not protect the patient from local congestion of the brain. Of all the secretions, the inefficient or abnormal separation of which from the blood induces the most marked predisposition to the apoplectic seizure, that of the urine is the most momentous. In diabetes, in albuminuria, the patient frequently passes suddenly into the apoplectic state. In other affections of the urine, there are other scarcely less formidable tendencies to cerebral disease. And if the blood may be in an abnormal condition for Avant of the processes of purification, it is also subject to be unhealthy in those cases in which the supplies are not healthy. Such are those states of defective and abnormal digestion and assimilation which occur in dyspepsia, with its effects, gout, furunculus, carbuncle, and urinary deposits, and other affections, etc. In all these cases there is danger of apoplexy and para- lysis from cacosemia. [On the preventive treatment, Dr. Hall remarks :] The real principle of prevention of the apoplectic or paralytic seizure, is that of inducing a state of equilibrium, in regard to plethora or inanition ; and of health, in regard to the general tone, habits, and secretions. [With respect to actual treatment, we must pay especial regard to the cause of the malady; under this head Dr. M. Hall observes:] Besides that of the condition of the general system, the questions— whether the cerebral affection be one of intravascular congestion or extra- vascular effusion—Avhether the substance of the braiu be compressed or lacerated—is of the utmost moment. In the former case, there is great tolerance of loss of blood, and the detraction of much blood is requi- site; in the latter, blood-letting is neither Avell borne nor required; the system is under the influence of shock, and much cautious watching and treatment are requisite. When there is plethora or hyperaemia as the cause of the threatening of an attack of apoplexy or paralysis, the remedy, the safety of the patient, consists in—depletion. How are we to be cer- tain of the fact ? There is a symptom of great importance, Avhen it can be clearly ascer- tained to exist. It is the occurrence of vertigo—1, in the stooping, or, 2, in the usually erect position, especially Avhen these are suddenly as- sumed. One patient turned giddy Avhen he pulled on his boots ; another could not bear to look up to the ceiling of the room. In both these cases the diagnosis Avas pretty distinct; but in another case, no such event has been noticed. What is then to be done ? There is a resource, in such a case, Avhich is of immense value. There is no case in Avhich the patient, if bled from a good orifice, in the erect posture, bears to lose so much blood before syncope takes place, as that of real hyperaemia and congestion of the cerebral vessels: there is no case in which the full, not to say the lavish, detraction of blood is so urgently necessary. On the other hand, the case of vertigo, and other symptoms of cerebral affection arising from dyspepsia, neither bears the loss of much 152 APOPLEXY. blood, taken under similar circumstances of posture, etc., nor requires ?t. In a doubtful case I propose to adopt this mode of blood-letting: 1st, as a guard at once against the inefficient and the undue loss of blood ; and, 2d, as a diagnosis, and as a prompter of our ulterior proceedings. Part xiii., p. 46. Threatenings of Apoplexy and Paralysis—These threatenings consist in a seizure of vertigo, loss of recollection, confusion of ideas, with a tumid purple countenance, which may pass off and be forgotten, or may again and again recur, until it ends in the organic apoplectic seizure. When these " threatenings of apoplexy " occur, corresponding to what Dr. Hall terms " paroxysmal apoplexy "—in the actual attack, bleed in- stantly, and give an effectual emetic, enema, and purgative. Afterward let the diet be more carefully regulated, any discoverable source of irrita- tion removed, business entirely suspended, and all emotion avoided. " The remedy of remedies is travelling." Part xviii., p. 92. Treatment of Apoplectic Symptoms arising from Disordered Liver.— When Ave revieAV the comparative analysis of the effete matter thrown off by the liver and kidneys, and observe the large amount of carbon and nitrogen which these organs separate from the circulation, it need not be matter of surprise that similar disturbances arise in the head and the nervous system, generally from a gorged and torpid liver, as are seen to occur from urea and other elements of urine being pent up in the system, from degeneration of structure in the secreting portions of the kidneys. Why should not the elements of bile, so long as they circulate in the system, and are not duly and actively eliminated by the lobules of the liver, be considered equally as poisonous to the nervous system as is urea in ischuria renalis, or is laudanum when taken for a suicidal purpose ? It has repeatedly happened that a bulky, strong, and perhaps plethoric laborer seeks relief amongst the casual patients in the out-door department, complaining of a distressing sense of giddiness, fear of falling down in the streets, tinnitus aurium, sleepless nights ; or else the very reverse, heavi- ness, and disposition to sleep at all hours of the day, if he only sits down for a few minutes. Such symptoms, it must be acknoAvledged, are too often assigned as the precursor of apoplexy, and the man is actively bled, cupped, and blistered. No observing practitioner will deny that such alarming features of a case demand some vigorous and active treatment; but the question at issue is simply this: do such symptoms fade away under the active antiphlogistic treatment so readily pursued by many? Doubtless they do not. Whereas, if, as is usually the practice here, the patient is ordered to take a full dose of calomel, for instance ten grains, and the same quantity of extract of colocynth, and that the latter is re- peated three or four times a week in smaller quantities, followed by a cathartic draught; and, further, if the alvine secretions are observed to pass from a dark mahogany color to that of an ochrey tint, the usual result is the disappearance of all the cerebral symptoms in proportion to the clearing of the loaded gall-bladder and its adjoining ducts. Part xviii., p. Ql. Apoplexy, Simulated.—When symptoms simulating those of apoplexy arise from mere cerebral irritation, or from anaemia, treat them (after re ARSENIC. 153 moving the cause, Avhen practicable) by giving tonics, and especially chalybeates, Avith good diet. Let the patient take moderate open-air ex- ercise, and use such purgatives as AA'ill secure gentle and regular action of the bowels. In extreme cases even give stimulants. When the symptoms are of doubtful origin, blister and purge for a feAV days, at the same time alloAving a generous diet, until the exact nature of the disease is ascer- tained. Vide Art. " Brain." Part xix., p. 52. Apoplexy.—As there are evidently two distinct kinds, plethoric and anaemic, Ave must judge, in a great measure, from the distinctive charac- ters. But if neither of these indications are present, it will be most pru- dent to use local bleeding. Apply cold to the head, administer an active purgative, and, above all, enjoin quietude. Part xxiii., p. 68. Apoplexy.—Dr. Todd cautions us against being led away by the popu- lar opinion that in all cases of apoplexy we must bleed. If the patient be full and plethoric, with a strong heart," you may bleed; but if he has been intemperate, or has organic disease of the heart or arteries, or of a gouty or rheumatic disposition, do not bleed. In the majority of cases bleeding is improper ; they may be better treated by purging, shaving the head, keeping it cool, and perhaps blistering it. Part xxxi., p. 04. ARSENIC. Medicinal Action of Arsenic—The unfavorable states of the system to the administration of arsenic are: 1st. A febrile state, especially the sthenic form of pyrexia, indicated by the usual signs. 2d. A condition the very reverse of this febrile state is likewise unfavorable. 3d. A syphilitic tamt. 4th. The existence of organic visceral disease, as a complication of eruptions, an attack of diarrhoea, bronchitis, cynanche, coryza, or severo irritation in any mucous membrane. Certain conditions of the nervous system, especially those connected Avith dyspepsia, and nearly all other dis- orders of the general system, generally contra-indicate the use of arsenic • but it the health can be restored by other means, it may afterward be administered Avith advantage. Mr. Hunt also gives some cautions as to the mode of giving it He says, as we wish it to enter the general circu- lation, it should be taken on a full stomach, as it then directly enters the circulation with the chyle, being absorbed by the lacteals ; if it is taken on an empty stomach it would be chiefly absorbed by the venous capillaries and enter the portal circulation. It should be taken after a meal, also to obviate any irritation it might produce in the stomach and bowels \o-'im as arsenic is a cumulative medicine, it should never be administered in .ZT"lrS; f s'.ot^eTSe a S?dden and sometimes an alarming develop- Z1\!L ti T* ef"C-S ™? necessitate an ^tire suspension of the medic me. 1 he best plan is to begin with five minims of Fowler's solution taiSVrM " ?-alV,and ™ntlnue *he dose ste*<% «"til the conjunctiva or vZlf S}g fV affGCted ; then reduce the dose aSain ™* again, asthe cumulative action becomes apparent in the state of the tarsi. Part xxii., p. 250. 154 ARTEKIES. Arseniate of Soda.—It is stated by many who employ the officinal pre- paration of arsenic that it is uncertain in its action, a small dose in some cases acting Avith violence, and in others a larger dose producing little effect. This is rather referable to peculiarities of constitution in the pa- tient than differences of preparation of the drug. Mr. Bullock recommends the employment of the arseniate of soda, a salt which has all the required characters of great solubility, definite form, and the additional pharmaceutic advantage of being readily made into pills, in such a manner as to insure every pill containing any given frac- tion of a grain with perfect accuracy. Moreover, it may be kept in a crystalline form, and dissolved readily, as it is required. The use of arseniate of soda in medicine is nothing neAV. It is the basis of Pearson's solution, which consisted of one grain of arseniate of soda to one ounce of water. The best method of administering the arseniate of soda is in the form of pills, made up Avith crumb of bread, or some inert poAvder., Part xxiii.,p. 283. Arsenic—Therapeutical Uses of.—The lameness' and deformities of chronic rheumatism frequently disappear under a prolonged use of arsenic. It is generally given up too soon. Two cases of this nature are related, in which the most marked benefit was derived from this mode of treatment. About five drops of the liquor arsenicalis should be given after each meal, and continued till the characteristic effects of this drug are produced, Avhen it may be intermitted for a time. Many and obstinate forms of neuralgia are in a similar manner found to yield to arsenic. Arsenic holds the " foremost place " amongst the remedies employed for the cure of chorea. Besides the various forms of skin disease in which its use is so well knoAvn, it has been used A'ery extensively and successfully by Dr. Simpson in amenorrhcea and other disorders of the uterus, where iron appeared to be contra-indicated, as Avell as in that peculiar affection of the boAvels which he has described as prevalent among females, and characterized by copious discharge of membranous shreds, and accompanied by great emaciation and a long train of neuralgic and other nervous symptoms. Dr. Simpson places most reliance upon small and very long-continued doses of arsenic, as two drops of Fowler's solution, or a pill containing the sixtieth of a grain of arsenite or potass, taken three or four times a day. Part xxxvii., p. 282. ---»>» ARTERIES. Torsion of the Arteries.—Dr. Remak recommends a modification of the operation of torsion of the arteries, which consists in seizing the vessel transversely Avith a pair of sharp Avedge-shaped forceps, and then pressing forcibly, so as to divide the internal coat. The extremity of the artery is then seized with another pair of forceps and twisted, while the torsion is prevented from extending up the artery by the first pair. Tlie vessel is thus less injured than in the common proceeding, and the internal coat, which shrinks after being divided, offers an effectual barrier to the blood. The operation was tested experimentally upon a horse; the carotid was ARTEEIES. 155 divided, and torsion, performed as recommended above, Avas sufficient to restrain the hemorrhage, even when the horse was made to trot briskly. Part 'n.,p. 128. Bleeding from the Temporal and other Arteries.—Mr. Hugh Carmichael suggests a very simple method of obtaining as much blood from the tem- poral artery, and other small arteries, as Ave desire. We knoAV that all divided arteries have a strong disposition to contract, and that the divided extremities separate and retract Avithin the sheath, Avhile the orifices ulti- mately close altogether; at the same time *the blood clots both in the vessel itself as far as the next branch, and also in the sheath, so that a complete stoppage is put to the flow of blood. The artery should now be fillipped in different parts with the finger, and at the same time pressed along its course Avith the back of the nail, so as to squeeze out any clot which may be lodging ; the jet of blood Avill be again renewed, and will again diminish as at first; the same course must be again adopted, and repeated sd long as it may be required. In opening the artery, it is neces- sary to divide it completely across. When a sufficiency has been procured, nothing more is required than to wait the next stop, Avhich, if necessary, may be expedited by a gentle pressure Avith the thumb on the bleeding section of the artery. A small dossil of lint then placed over the Avound, and secured with a fight band- age, is all that is required to prevent further bleeding. Part v., p. 124. Ligature of the Carotids.—It seems to be a general opinion that the carotids and vertebrals may all be tied with safety, provided that sufficient time intervene between each operation, so as to allow of the formation of the anastomosing circulation. But " may both carotids be tied at once with- out immediate danger to the brain, and with the prospect of a favorable result?" The French Academy have answered this question in the affirmative, and have, moreover, stated that the danger is not Avith the brain but the lungs. M. Robert states that the vertebral arteries are suf- ficient for the cerebral circulation, and that ligature of both carotids produces no disturbance, either primary or consecutive, of the nervous system of the senses. Dr. John Reid also proves that " in asphyxia, cessation of the sensorial function does not arise from diminution of the arterial supply of the brain, but from the circulating blood being of a venous character, and so failing to afford to that organ the excitation requisite for the performance of its functions." M. Robert concludes from his experiments that one great object in treating these cases is in venesection, provided the patient is sufficiently strong. This practice diminishes, in a great measure, the risk of extensive lesion of the lungs In horses, the ligature of the carotids caused death in a few hours, OAving probably to the vertebral arteries diminishing remarkably in size in these animals as they enter the cranium, being there no larger than those of the dog. The result is a congestion of the lungs, which, unless relieved by bleeding, produces fatal apoplexy of these organs. This prophylactic principle need not be confined to deligations of the carotid alone. In operations on other vessels of the first class—subcla- vians, iliacs, femorals—important internal organs may be saved, and the number of successful issues materially increased, by a precautionary bleed- ing to a moderate extent, before the operation, and by a more Avatchful 156 ARTERIES. and better directed surveillance than heretofore, during the aftei treat- ment. Part v., p. 139. Points connected with the Ligature of Arteries.—Mr. Spence, of Edin- burgh, has pointed out an important omission, by different authors and experimenters, on the process Avhich nature adopts, after the application of a ligature, to close the divided ends of an artery. The use of the exter- nal coagulum and the deposit of coagulable lymph has never been insisted on as particularly essential to the success of the process. While all Avriters are now convinced of the utility of the divided internal coat, many of them disagree as to the use of the lymph or coagulum outside the vessel, some, as Mr. Allan Burns, supposing that it is necessary, up to a certain stage of the process, viz., until by its pressure it shall have excited such a degree of irritation as to give rise to adhesive inflammation betAveen the opposite surfaces of the internal tunics of the vessel, to a greater extent than the presence of the ligature alone could produce ; others, as Jones, Travers, Guthrie, etc., look upon the clot as merely an adventitious circum- stance, Avhich, Avhen it takes place, may assist, but is not essential to the completion of the process. Now although these opinions are more or less correct, Ave think with Mr. Spence that sufficient stress has not been laid upon the changes Avhich take place outside the vessel. If the changes are attentively observed, it will be found that on the 13th day, when the ligature has fairly come away, the lymph has assumed the appearance of a firm connecting medium uniting the divided ends of the vessel, not unlike the exuberant callus in a fracture; on the 28th day this lymph has become firmer, and the vessel has the appearance of a firm impervious cord. So that we may perceive that this deposit of lymph is not only useful in connecting the divided ends of the vessel, and thus supporting the adhesion of the internal coats at the period of separation of the ligature, but by its pressure it will also diminish the calibre of the vessel, and thereby lessen the impulse of the blood in the neighborhood of the ligature. The conclusion becomes more obvious when Ave remember the success which attended the application of a ligature at a very short distance from the point Avhere a large branch Avas given off (case of Dr. Belling- ham), where it Avas applied to the external iliac Avithin half an inch of the bifurcation of the common iliac. Part viii.,_p. 120. Arched Tourniquet for Wounds of the Brachial Artery.—A man presented himself to Dr. Craig, AArho had had the brachial artery Avounded the previous day in bleeding; the usual signs of aneurismal varix Avere present. Compression and bandaging were tried to no purpose. Mr. C. Avished on principle to avoid operating, which in this case would have been easj By pressing the artery Avith the finger in its course, about the middle of the inside of the arm, pulsation at the tumor and in the Avrist was quite suspended. As the patient could bear the necessary pressure, all that was needed Avas a substitute for the finger. With this vieAv, says Dr. C, I made a quadrangle with four pieces of wood, sufficiently large to encircle the arm; also a piece of wood two and a half inches broad, and long enough to reach from the shoulder to the elbow. This was laid on the outer aspect of the arm. One side of the quadrangle Avas fixed to the wood thus placed, at a point opposite to that where compression was to be made on the vessel. A pad was placed over ARTERIES. 157 the artery a little below where the superior profunda is given off, care being taken not to involve the nerve in the compression. The pad was pressed firmly there by means of a rude sort of screw passing from the side of the quadrangle opposite'to the one fixed to the Avood placed along the arm. The patient Avas put to bed and placed in a recumbent position, and the arm raised in a perpendicular direction, and supported there by beinf* suspended to the bed-post, and the pad made to press with such force as to suspend pulsation both in the tumor and at the Avrist. The pressure Avas unremittingly maintained during tAventy-four or thirty hours, at the end of Avhich time the pulsation and bruissement had completely subsided. The arm Avas kept raised for some days afterward, Avith a pad over the tumor, and all excitement and stimulation avoided. One pecu- liarity of this application is, the proAdsion for preventing any compression of the limb except that which is indispensable OArer the artery. The piece of wood placed along the arm on its outer side, extending from the shoul- der to the elbow, causes the counter-pressure to be diffused over a large surface of the arm, thereby rendering it nearly imperceptible to the patient. jPar^xii., p. 165. Punctured Wound and Ligature of the Posterior Tibial Artery.—Dr. Arnott advises to take the wound as a centre, and cut doAvn upon the vessel, and tie it both above and below the seat of injury. Mr. B. B. Cooper advises, if it be a case of secondary hemorrhage and there is a good deal of coagula in the parts surrounding the vessel, to tie the femoral artery. When there is a wound in the calf of the leg, Avith sufficient bleeding to warrant a belief that the posterior tibial artery is wounded, separate the soleus from its attachment to the tibia, cut through the deep fascia, and secure the vessel. Part xiii., p. 216. Subclavian Artery—Ligature of—When there is extensive swelling and suppuration, after the lesion of an artery, it is not advisable to cut doAvn upon it, to tie it at the seat of injury; and when this is the case after wound of the subclavian, it is better to secure the artery beneath the scalenus, before it approaches the tubercle of the rib; it is much higher and more accessible there. Part xiii., p. 222. Application of Ligatures to Arteries.—Mr. Guthrie gives the folloAving conclusions, as being a bird's-eye view of his extensive experience on one of the most important subjects connected with surgery : 1. The Hunterian operation for the cure of an aneurism is not appli- cable to the treatment of a wounded artery, inasmuch as the wound of the artery communicates with the external parts, and nothing intervenes to prevent blood flowing from the wound in its side, or from its cut extremities. 2. When a large artery is divided and bleeds, the wound should be en- larged if necessary, and a ligature placed on both the divided ends; but it the artery be only injured and not quite divided, the ligatures should be applied, one immediately above, the other below the injured part. lhe artery may or may not then be cut across, at the pleasure of the operator, but the limb or part should be placed in a relaxed position. A bandage should not be applied, and the edges of the wound should be simply brought together by adhesive plasters, which do not extend com- pletely round the limb. 3. No operation is to be performed on any artery unless it bleeds at the 158 ARTERIES. moment of its performance, inasmuch as hemorrhage once suppressed may never return. 4. The intervention of muscular fibres, or of whole muscles, is not a sufficient reason for tying the artery at a distant part. They must be divided, if it be possible, to the extent required for a due exposure of the injured artery and its accompanying veins and nerves. 5. If the Avound pass indirectly to the principal artery, from the back of the thigh, for instance, to the femoral artery in front, or from the out- side of the arm to the humeral artery on the inside, the surgeon may (on satisfying himself of the part likely to be injured by the introduction of a probe) cut down on the vessel opposite that supposed to be wounded, by the most simple and approved method. When the artery is exposed, the probe AA'ill point out the spot at which the vessel has in all probability been Avounded. Pressure made below this spot on the artery Avill cause it to be distended and to bleed, if the flow of blood be not prevented from above ; the artery is then to be secured by two ligatures, and the lower nne should, if possible, be applied first. 6. The tourniquet should never be applied in an operation for aneurism or for a Avounded artery. Compression by the hand in the course of the wounded vessel is allowable.. , 7. The blood from the upper end of a divided artery, or that nearer the ieart, is of a scarlet arterial color. 8. The blood from the loAver end of a divided artery, or that Avhich is further from the heart, is of a dark or venous color, Avhen it happens to floAv immediately after the division of the Aessel. At a subsequent period it may assume more of the color of arterial blood, but it rarely does so for several days after the receipt of the injury, and always flows, or at least until a very late period, in a continued stream. 9. This regurgitation or flow of blood from the lower end of a di- vided artery is a ftrvorable sign, inasmuch as it shoAvs that the collateral circulation will probably be sufficient to maintain the life of the extre- mity. 10. The collateral circulation is in almost every instance capable of main- taining the life of the upper extremity when the axillary artery is divided, and the color of the blood Avhich Aoavs from the end of the artery, on its being divided, is not always as dark as in the loAver extremity, and it sooner resumes its arterial color. 11. The collateral circulation is not ahvays capable of maintaining the life of the limb when the femoral artery is injured. The best assistance which art can give is to rub the foot aud leg in the gentlest manner between the hands for several hours, or even for the first three or four days; relaxing this process very little, even during sleep. When the vein is divided at the same time, or rendered impervious, the limb usually mortifies. 12. The collateral circulation is sufficient to maintain the life of an ex- tremity in almost every case in Avhich an aneurism has existed for eight or ten Aveeks, although it may be incapable of doing this if the principal artery have been suddenly divided, without any previous disease having existed in the part. 13. The theory and the operation for aneurism are never to be ap- plied to the treatment of a wounded artery Avhich has caused a diffused or circumscribed aneurism, Avhilst the external wound communicates with ARTERIES. 159 the artery, unless it be impossible or impracticable to tie the bleeding vessel. 14. When an artery has been wounded, and the external opening has healed for "Aveeks or months, so as to give rise to a diffused or circum- scribed aneurism, it may be treated according to the theory of aneurism occurring from an internal cause, if the case Avill permit it AA'ithout danger, although Avith this difference, that as the artery is sound the operation may be performed close to the tumor. If any doubt exist as to the capability of the collateral circulation to support the life of the lower extremity, Avhen the external iliac is secured by ligature, the operation should be performed at the injured part by opening the swelling and en- larging the wound, as in the case of a wounded artery. 15. When a circumscribed or diffused aneurism which has formed after a Avound has been opened, whether by accident or design, it is placed in the situation of a wounded artery, and should be treated as such. If the aneurism has arisen from disease of the vessel, and the wound or opening into it cannot be permanently closed, the limb is in a worse state than if the artery had been Avounded by accident; because a ligature or ligatures placed on a diseased artery are little likely to be successful. They are liable to all the difficulties and inconveniences attendant on the old opera- tion for aneurism. If a case of the kind should occur in a popliteal or femoral aneurism, situated at or below where the artery passes betAveen the triceps and the bone, amputation, if it can be done Ioav doAvn, Avill be the best remedy. If the aneurism should have formed higher up, and the opening can be closed with any prospect of its healing, a ligature may be placed upon the artery above it; but on the.recurrence of hemorrhage, which cannot be restrained by moderate pressure, the artery must be tied beloA\r, or recourse had to amputation. It is, however, to be obserAed, that amputation under these circumstances, when resorted to as a third opera- tion, rarely succeeds. 16. When an artery is wounded Avith a simple fracture of a bone, or Avith a comminuted fracture of the smaller bones, Avith an external communicat- ing opening, both ends of the artery should be secured, and the limb treated in the usual manner. 17. When the bone broken is the femur, and the artery divided is the femoral artery, the operation of amputation will generally be advisable. It will ahvays be so if the fracture is a comminuted one, or the shaft of the bone is extensively split. 18. When the broken bone injures the artery and gives rise to an aneu. rism, the treatment is to be first of the fracture and then of the aneurism, as soon as circumstances render it advisable or necessary to have recourse to the operation for aneurism, and which can only be after time has been given for the collateral branches to enlarge, so as to maintain the life of the limb. 19. When mortification takes place in addition to, or as a consequence of, a Avounded artery, amputation should be had recourse to forthwith. 20. The place of operation should be in almost all cases at the seat of the original Avound ; but there may be an exception, viz.— 21. When the injury has been a mere cut, just sufficient to.divide the artery and vein immediately beloAV Poupart's ligament, and mortification of the foot supervenes, amputation should be performed below the knee, or at the part where the mortification more usually stops for a time. 160 ARTERIES. This rule is founded on the observation, that great efforts are made by nature to arrest mortification a little beloAV the knee. Sometimes they succeed; Avhen they fail, death is almost inevitable. ^ The advice to amputate at this part; is founded on the fact of its being infinitely less dangerous, when done there, than on the thigh, independently of saving a joint. 22. When mortification has continued for several days, and is spreading Avithout having once stopped, the constitution of the patient being impli- cated as marked by fever, amputation should not be performed until the mortification has been arrested and the line of separation has been well formed. In many cases, where there is great Aveakness or irritability of constitution, it will be advisable to defer the operation to a later period, particularly if there be hope of the patient's becoming stronger and more tranquil. 23. If the mortification has once stopped and then begins again to spread, it will never again cease to extend, and amputation may give some chance of life. 24. Amputation of the arm should never be had recourse to, in conse- quence of a Avound of the axillary artery, unless mortification takes place. 25. When mortification takes place after operation for aneurism, the sur- geon must be guided by the state of the patient's constitution, in resorting to or refraining from amputation. 26. When hemorrhage takes place from the surface of a stump, the ar- tery should be tied at the part from Avhich the blood comes in the first instance, if it can be easily done. If this should not suffice, the artery must be tied higher up, just at such distance as to afford a fair hope of its not having been affected by the derangement of the stump, Avhich has led to the failure of consolidation in the extremity of the artery, and yet not too high to admit of the junction of any large collateral branches. If the bleeding proceeds from seAreral small vessels, and cannot be arrested, the principal trunk should be tied above the diseased part, and the patient re- moved to a purer atmosphere, Avithout Avdiich the operation rarely succeeds m any case. 27. When an aneurismal tumor mortifies, it is unnecessary and improper to tie the artery above the tumor, because it Avill be obliterated if the mor- tification be arrested by the efforts of nature, which the operation may interfere Avith, and even prevent, whilst, if the mortification spreads, it will be a matter of supererogation, and only hasten the patient's dissolution. When an aneurism inflames, is opened by ulceration, and bleeds profusely, it is a proper case for amputation, if such an operation can be performed. Part xiv., p. 160. Hunterian Method of tying Arteries.—Mr. Wilkinson King shows that the Hunterian method of tying vessels was not really by cutting ligatures, as are noAV generally used, and that the operations were not the less successful. Mr. Hunter observed, " that in dogs, the mere exposure of the tibial artery to the air for about an hour, excited such a degree of inflammation and thickening of its coats, as completely to obstruct its canal." We see inflammations, granulations, and contractions, closing up Avound- ed arteries of limited size, and shutting up the vessels in vomical cavities. A certain hypernutrient action, or a subsequent contraction, may, in spite ARTERIES. 161 of aortic distention, close up the orifice of the coronary artery, the carotid or intercostals, and narrow the aorta itself as Avell as its main branches. It has a similar effect when the tissues of organs become condensed almost to the exclusion of blood, and it is a momentous reflection that very little more than granulations about an artery may contract to the blocking up of the channel. Part xiv., p. 162. Ligature of Arteries, without dividing the Middle and Internal Coats. —Chelius considers it unnecessary to draw the ligatures so tight as is commonly recommended, but only so much so, that the Avhole of the inter- nal coat be brought in close contact, and that the ligature should indent the external coat of the vessel. Part xiv., p. 167. Torsion of Arteries.—Torsion, by producing obliteration of the vessel, either by coagulation and simultaneous assimilation of all the three coats at the spot, or by the sIoav and insensible contraction, as by ligature, con- verts the arterial tube into an irnpeiwious cord. It is adapted to small arteries of the fourth or fifth order, radial, ulnar, tibial, intercostal, cervi- cal, thoracic, external pudic, spermatic, digitals. Seize them with forceps, close the instrument, and twist in the fingers, three, four, or six times in the same direction, and then abandon them, or return to the operation if not sufficiently twisted. Care must be taken to seize the Avhole calibre of the vessel; to take sufficient hold ; not to include the surrounding texture ; and so to twist them that the proper coats are ruptured, but not so much that the cellular coat is also broken. Its advantages are simplicity and celerity, no assistance being necessary, and its not leaving foreign bodies in the Avound. Part xiv., p. 177. Wounds of Arteries—Ergotine suggested as a Styptic.— Vide Art. " Wounds." Ligature of the Subclavian Artery for Axillary Aneurism.—Profes- sor Syme thus describes his method of tying the subclavian: In performing the operation I made an incision along the clavicle, so as to extend over the edges of the sterno-mastoid and trapezius muscles, and another from the centre of this upward, parallel Avith the edge of the latter muscle. The dissection was conducted entirely by the knife and forceps. The needle wras passed under the artery, with its convexity upward, and- the ligature Avas tied by the unaided effort of the fingers. It has been ad- vised to pass the needle with its convexity doAAmward, or tOAvard the clavicle, with a vieAV to protect the vein from injury. But this vessel is not at all in the way, Avhile the cervical nerves are so situated in regard to the artery, as in general to render it nearly, if not quite, impossible to convey the ligature from below upward. It has also been advised to em- ploy the assistance of some mechanical contrivance for tightening the knot. But I feel persuaded that the thread will ahvays be within reach of the fingers, and may be more safely tied by them simply, than with the inter- vention of any instrument. Part xvi., p. 182. Opening the Temporal Artery.—The best mode of performing the oper- ation is to make an incision into the skin, so as carefully to expose the artery, Avhich must then be raised from the aponeurosis of the temporal muscle by a probe passed beneath the vessel, Avhich is then punctured by a lancet, as in venesection. When the necessary quantity of blood has 11 162 ARTERIES. been withdrawn, the artery is to be completely divided by a probe-pointed bistoury, and the truncated extremity compressed by a dossil ol lint, so as to prevent the recurrence of the bleeding. If the artery be not divided, but a compress merely applied over the puncture, an aneurismal tumor ia almost certain to form, rendering a surgical operation necessary for its cure. The treatment consists in applying pressure on the temporal artery, both on the proximal and distal side of the aneurismal sac, Avhicb is to "be laid open, so that the Avhole of the coagulum can be turned out, after Avhich each end of the artery is to be secured by ligature. Part xviii.,/). 168. Treatment of Wounded Arteries.—When bleeding cannot be restrained by moderate compression on the trunk of the A'essel, and perhaps on the injured part, apply a ligature to both ends of the divided artery, or, if the artery is not completely divided, one above and one below the Avound. (The search for the lower end of the divided artery will be facilitated by remembering that the blood flows from it in a continued stream, and is, in the lower extremity, of a dark color.) If the loAver end of the vessel can- not be found, try compression upon the track of the artery beloAV the wound; but if this fails to arrest the bleeding, expose the vessel and tie it as near to the Avound as practicable. Part xix.,/?. 135. Secondary Hemorrhage Treated by Ligature at a Distance from the Seat of Injury.—In cases of secondary hemorrhage, Avhere the parts are covered by granulations Avhich conceal the bleeding point, and break down under the forceps—Avhere there is an inflamed and sloughy condition of the parts, and the patient is so enfeebled by previous hemorrhage that fur- ther loss of blood Avould be fatal—and Avhere uncontrollable arterial he- morrhage occurs in a case of compound fracture which is, in other respects, likely to do Avell, pass a ligature round the main artery Avhere it is in a healthy state. Part xix., p. 137. Ligature of the Subclavian.—In performing the operation of tying the subclavian artery internal to the scaleni muscles, after exposing the vessel and encircling it Avith the ligature in the usual Avay, carefully s:uv through the clavicle, at its middle, taking care to guard the subjacent parts with a spatula. The intention of this is to alloAV of the approximation of the shoulder to the trunk, that there may be no tension upon the artery. • Part xix., p. 141. Arteries— Wounds of—Many arteries should be tied at once when Avounded, but this does not apply to all. When the brachial artery is Avounded in venesection, squeeze the edges of the Avound accurately toge- ther, and place over it a sixpence or similar firm body, rolled up in apiece of soft rag; then apply something to press upon the radial, ulnar, and hu- meral arteries, a little beloAV and a little above the wound, and apply a bandage. Bandage the arm to a splint, and keep the patient perfectly quiet. By this means the Avound of the artery will sometimes heal; at any rate the wound in the integuments AA'ill, and then, if aneurism form, can be treated subsequently. j>urt xx.,/;. 118. Deep Punctured Wounds of the Palm.—In deep punctured wounds of the palm, Avhere it is Avished to stop the bleeding by compression, apply a bandage round each finger separately, and then continue it round the ARTERIES. 163 hand, placing a compress immediately over the wound. Continue the bandage up the forearm, having placed small compresses of cork over the radial and ulnar arteries, and make sufficient pressure to diminish, without wholly stopping, the supply of blood. Lastly, carry the bandage Avith a moderate degree of tightness up to the shoulder, keep the patient recum- bent, and apply cold to the arm. Part xx., p. 120. Employment of Forced Flexion for arresting Hemorrhage in Wounds of the Palmar Arch.—Mr. Dunvell, in a case of wound of the palmar arch from the fragments of a broken bottle piercing the palm, found him- self, on arriving at the cottage of the patient, Avith no means of securing the artery; and— While controlling the hemorrhage by pressure on the brachial artery, the following sentence in M. Malgaigne's " Anatomie Chirurgicale " oc- curred to his mind : "The only points at Avhich obliteration of an artery can be obtained by position alone, without the aid of external compression, are at the bend of the arm and knee—a fact which is of great importance in reference to the arrest of hemorrhage." Acting upon this statement, Mr. Durwell immediately bent the arm on the forearm at an acute angle; the hemorrhage Avas instantly arrested. Advantage Avas taken of the cir- cumstance to effect a definite cure. The arm Avas retained in its flexed position by bandages, so that the pulsation of the radial artery was com- pletely intercepted. The wound of the hand Avas treated as an ordinary wound, and for the sake of precaution, compresses Avere laid over the course of the arteries of the forearm. The cure progressed favorably. On the third day, as the patient complained of the posture, the arm was slightly extended, and it was noticed that a small portion of florid thin blood oozed from the Avound. The arm was restored to its flexed position, and in a short time the vessels and the external Avound had perfectly healed. Part xxii., p. 212. Method of making the Incision for the Exposure of Arteries.—Mr. Skey almost invariably adopts an oblique incision, generally at an angle Avith the artery of 45°. His reasons for doing so are : that in fat subjects it is difficult to ascertain the exact line of the vessel, and that, hoAvever true the first incision may be, it .does not follow, in the course of a slow and bloody operation, that the same line will be preserved ; that if, from accidental circumstances, the precise position of the artery be lost, the operator is equally uncertain Avhether he is dissecting on the inner or on the outer side of the vessel, or upon it; that, by dividing across the di- rection of. the vessel, he acquires a confidence, from the conviction that the artery is really under his knife; and, lastly, that he makes an external wound, within which the ligature needle is more readily carried round the artery in a fat subject, in Avhich the vessel lies deep, than in a Avound parallel to it. His objection to a directly transverse wound is, that the artery is exposed only in a transverse line, by Avhich nothing is gained, but much may be lost. In the femoral, brachial, radial, ulnar and posterior tibial, indeed, he considers the oblique incision to be an important element of success in finding the artery with facility. Part xxiii., p. 150. Treatment of Wounds of the Palmar Arch.—From the Avritings of Sir Astley Cooper, Ave find that in cases of this kind he recommends steady and continued pressure on the brachial artery. If this fails, he says it may 164 ARTERIES. be necessary either to secure the radial or ulnar artery, or both. Mr. Lis- ton recommends us to enlarge the wound, and tie the vessels divided above and below. If inflammation and sloughing come on, then the humoral must be tied ; because if both the radial and ulnar are secured, bleeding will still continue from the interosseous communication. ^ Mr. Skey's opinion is, that the trunks of the radial and ulnar should be tied above the wrist. This was the opinion of Mr. Abernethy also. Mr. Butcher gives a case of a strong athletic man Avho Avas admitted into the hospital bleed- ing profusely from the right hand. The wound Avas inflicted by a pen- knife, Avhich bad been thrust deep into the palm—three-quarters of an inch internal to the cleft betAveen the thumb and index finger. Mr. Butcher advises, Avhen an artery is dived in the palm, to apply pressure as folloAva: Let each finger and the thumb be separately bandaged to the metacarpal bone, then, the finger of an assistant being still kept upon the divided ves- sel, apply compresses to the remaining space in the palm, reserving that over the bleeding vessel for special pressure. Press a small dossil of lint into the Avound ; over this a compress; over this another, and so on, until these are elevated over the surrounding integuments. Then let a roller be applied over the compresses, and carried as far as the elboAV, placing a small compress over the radial and ulnar arteries to moderate, but not in- terrupt, the flow of blood. It is important that the palmar aponeurosis should be flexed so as to alloAV the pledget of lint to come in contact with the divided artery. -The treatment by pressure to be successful should be applied early, and the bandaging be evenly employed over the entire limb ; at the same time the arm must be kept constantly elevated. Part xxvi., p. 167. Wounds of Blood-vessels of the Loicer Extremities.—When arteries under the calf of the leg are wounded it is difficult to follow the Avell- founded and generally-received rule of exposing and securing the injured vessels, even under the most favorable circumstances; that is, if we see the case at an early period, when no considerable swelling has occurred, and the natural relations of the surrounding parts are not obscured by ecchymosis. Frequently Ave do not know what vessel is Avounded, nor the precise locality of the mischief. Sooner or later, and often Aery quickly, the Avhole limb becomes SAVollen by extravasation of blood, Avhile all the soft structures may be lacerated, contu'sed and infiltrated "with blood. Exploratory incisions for discovering the injured vessel, Avould be under- taken Avith very little chance of success ; in such a state of limb, they might be attended with dangerous loss of blood, and would certainly involve the necessity of extensive and deep incisions in the injured parts. Thus Ave come to the conclusion, that amputation is necessary in some of these cases, in order to prevent Avorse consequences. Part xxviii., p. 168. Palmar Arch— Wounds of the.—In primary hemorrhage, ligature is gen- erally effectual, but if moderate exploration fail to discover the bleeding vessel, it may be completely controlled by properly-adjusted pressure. If secondary hemorrhage occur, exploration ought not to be attempted, judicious and properly-applied pressure will be found quite effectual; and under no circumstances whatever is deligation of the arterial trunks on the cardiac aspect to be deemed necessary or attempted. Apply the tourniquet to the brachial artery, strap up the wound Avith plaster, and place upon it a firm compress of lint, bandaging the hand and forearm ASPHYXIA. 105 moderately tight; also keep the tourniquet sufficiently pressing upon the brachial artery to moderately check the impetus of the circulation through the limb. Vide Art. " Hand." Part xxxii., p. 140. --------»>« ■ ASPHYXIA. On Asphyxia, and on the Resuscitation of Still-born Children.—The experiments of Dr. Edwards of Paris, respecting asphyxia, are already known to many members, though not probably all of the profession, and have proved that asphyxia takes place much sooner in a warm than in a cool medium. He. has found that new-born mammiferous animals die most slowly in Avater at about 60°, which is ordinarily cold Avater; and «* that they die more rapidly as the Avater approaches blood heat. He advises that persons in a state of asphyxia should be exposed to the cool air, and that the application of heat should be avoided. Mr. Snow very inge- niously explains this circumstance by supposing that the deleterious effects of heat in suspended respiration depended on " its stimulating the capillary circulation, and thus promoting the deoxygenation of the blood " in a more rapid manner than Avould be the case Avhen the surface was cool; in other words, Avhen the surface is cool the capillary circula- tion is less energetic than usual, and consequently there is a preservation in some degree of the oxygen of the system. When Ave consider the great number of still-born children, some Avriters affirming that one child in twenty is so, it is of the greatest consequence that a safe mode of prac- tice be adopted in these cases, and Ave are strongly disposed to think that hitherto, the practice of applying heat, and especially in the form of hot baths, is pernicious; for Ave must remember that the hot bath has not only the bad effects of heating the surface, but prevents that surface from being acted upon by the oxygen of the atmosphere, Avhich it will be more or less when exposed freely to its influence. Dr. Marshall Hall does not agree in this practice. Although he approves of the sudden application of cold to the Avarm surface as an effectual means of exciting respiration, he does not recommend the con- tinued application of it. On the contrary, he says " That it is not the mere application of cold, but the sudden "application of cold to a warm surface, which is the effectual means of exciting respiration. It is the sudden alternation. To apply cold to a cold surface would only be to sink the general powers of life. The infant should be kept warm ; the Avarm bath may be required ; and then cold Avater must be applied, in moderate quantity, but Avith force:'' He recommends Avhat must strike every ono as being a truly practical method of accomplishing resuscitation, namely —exciting respiration by stimulating the excitors of that function, the trifacial, the pneumogastric, and the spinal nerves—the trifacial by forcibly blowing or dashing cold water in the face, stimulating the nostrils by ammonia, snuff, pepper, or the point of a needle, etc.; the spinal nerves, by forcibly dashing cold Avater on the chest, thighs, tickling the sides, soles of the feet, and verge of the anus. M. Baudelocque states that since he has followed the opinions of Smellie, Scoret, Chaussier, etc., Avith respect to tying the navel string, he has not lost a single case from 166 ASPHYXIA. asphyxia. This opinion is to delay tying it for some time, when asphyxia is present; as the blood circulates for some time in the umbilical vein when it has ceased to be perceived in the arteries. Part iv., pp. 47, 12G. Acupuncture of the Heart suggested in Asphyxia.—This experiment was performed on a cat. It Avas kept under water till apparently quite dead, and after remaining in this state three quarters of an hour, Avithout the least signs of reanimation, a needle was pushed through the heart: in five minutes it Avas observed to move, which showed the heart had recom- menced its action ; it rapidly recovered. Dr. Carraro recommends this as a safe operation, and trusts that it may be tried in cases of asphyxia. But we should certainly hesitate before we adopt such an experiment in the human subject. Part iv., p. 53. Further Observations on Asphyxia—Treatment after Drowning by Artificial Respiration and Moderate Cold.—We cannot but agree with Dr. EdAvards and Mr. Snow in their vieAvs respecting the best mode of resuscitating drowned persons, and children that have been still-born. Dr. Edwards has certainly shoAvn, that asphyxia takes place more rapidly at blood-heat than at inferior temperatures; and he has, moreover, shown, " that the quantity of oxygen consumed, and the necessity for respiration, keep a direct ratio Avith the development of natural heat; and, likewise, that the application of heat to the body increases its power of developing caloric, whilst the abstraction of heat by any cold medium had a contrary effect." By putting a patient into a warm bath during a state of asphyxia, therefore, Ave cause the system to require more oxygen, and must, therefore, increase the asphyxia and hasten death, unless respiration is, by the stimulus, reestablished. This seems to be very much confirmed by the Avant of success in the Royal Humane Society, where Avarmth is generally employed; Avhereas, some time ago, when less energetic mea- sures Avere taken to restore the warmth of the surface, persons were fre- quently restored who had been submerged ten minutes, and in one case even twenty minutes. And, in the report of a society at Amsterdam, persons are said to have been restored avIio had been a quarter of an hour, half an hour, and one a Avhole hour, under Avater ; this is reported by a scientific society; and Avhen Ave remember that Avhen a person has been only five minutes under Avater, and may be often ten or fifteen minutes without breathing, Ave may easily suppose it possible for him to be this length of time under Avater and still be restored. To promote respiration, therefore, ought to be the great object in resuscitating droAvned persons or still-born children, and this ought to be done immediately, by perform- ing artificial respiration; and, at the same time, the surface of the body should be kept cool till respiration is reestablished, in order that as little as possible of the oxygen that remains in the system may be consumed. Part v., p. 48. Treated by Galvano-puncture.—While on the subject of asphyxia, we may refer to the experiments of M. Leroy d'Etoiles, Avho has suggested galvano-puncture in a manner Avhich at first sight appears formidable. "He introduces an acupuncture needle on each side, between the eighth and ninth ribs, until it reaches the fibres of the diaphragm. He then establishes a galvanic current betAveen the needles, by means of a pile of 25 to 30 pairs of plates, an inch in diameter. In his experiments tho ASPHYXIA. 16T diaphragm was instantly made to contract, and an inspiration Avas taken, then by interrupting the circle and gently pressing on the abdomen, the diaphragm again ascended, and an expiration Avas accomplished. Leroy was thus successful in restoring animals Avhich had been under Avater above five minutes; but, upon the whole, the experiments Avere more interesting than really practical, and could only be brought forward in aid of the more usual means of inducing artificial respiration. Part v., p. 63. Treated by Tracheotomy.—A very extraordinary case of resuscitation is related by M. Trousseau, Avhere the patient had breathed his last a feAv moments before the operation of tracheotomy was commenced. The heart commenced beating in about a quarter of an hour, and in 57 minutes a deep inspiration was taken. This operation would, no doubt, be advis- able as a last resource in many cases of droAvning, as Avell as in those cases of asphyxia caused by actual disease. When the practitioner is called in haste to such a case, he may adopt the practice of M. Maslhieurat, of drawing aside each lip of the division of the cricoid cartilage Avith «a bent pin, to which a string may be attached, and tied behind the neck so as to keep the wound open. The cricoid cartilage and three rings of the tra- chea may be divided Avith a probe-pointed bistoury, introduced through a wound previously made in the thyroid membrane ; or, the trachea having been laid bare, " it may be punctured at the inferior angle of the Avound with a sharp-pointed bistoury, and the rings and cricoid cartilage may be immediately divided by directing the same instrument upward. Part v., p. 137. The Effects of Caloric.—The instantaneous application of a burning match along the spine, suggested in cases of asphyxia while waiting for other remedies. Part vi., p. 86. Electro-Magnetism—Considered useful in cases of asphyxia, especially where death seems to be caused by an obstruction of the functions, or organic movements which support life, more than by an exhaustion of the orgauie functions, or of life itself. In such cases, electro-magnetism might communicate an impulse which would renew the sympathetic actions betAA'een the organs (if no positive lesion exist in any of them), upon which the continuance of life depends. Part vii., p. 3.4. Congenital Asphyxia.—The sudden alternation of the cold douche Avith warmth, recommended as valuable auxiliaries to other measures, in cases of congenital asphyxia, poisoning by prussic acid, etc. Part viii., p. 45. Asphyxia from Hanging.—The cause of asphyxia in such cases, is stated to be a combination of suffocation and apoplexy. So much pressure is made by the cord round the neck as to prevent inspiration, so that immediately the lungs, right side of the heart, and veins, become congested ; part of the venous blood sent to the lungs through the pulmonary artery is* oxygenated during the first inspiration, but when the next systole of the heart takes place, it is venous, and Avhen throAvn out of the left ventricle, it acts as a poison to the brain, and prevents the respira- tory nerves from exciting the muscles of respiration ; at the same time the ligature round the neck prevents the venous blood returning from the brain, and thus produces apoplexy. 168 ASPHYXIA. The great object in such cases is to bleed the patient as soon as possible from a vein so as to relieve the brain of some of its poisoned venous blood, and to relieve congestion of the lungs. By opening a vein at the bend of the arm, and immersing the arm in hot water, together with hot water fomentations and brisk frictions to the sur- face of the body and extremities, the stagnant circulation may be rouBed and the congestions relieved. If you cannot get blood from the vein, open an artery. Cold applications should be kept to the head, especially during the con- tinuance of the hot fomentations and friction to the other parts of the body. Suggested, also, to stimulate the mucous membrane of the boAvels by croton oil. Care is requisite to regulate and restrain the violence of the reaction when established—which, in the cases here cited—resulted in phrenitis. Part ix.,p. 27. Congenital Asphyxia.—In the treatment of asphyxia in new horn infants we ought accurately to discriminate betAveen that produced by actual con- gestion in the vessels of the brain and that produced by the violent shocks and actions of the Avomb, the first causing the symptoms of compression, and the latter concussion of the brain. When a child is born with its face of a purple or blue color, its features bloated, and sIoav or totally impeded respiration, we suspect the cause to be congestion, and by allowing a little blood to escape from the cord, the symptoms are often relieved in a re- markably short time ; on the other hand, when the child is born pallid and relaxed, Avith a very feeble circulation, we must be careful not to take aAvay blood till the circulation has been stimulated to increased activity by the alternate use of the Avarm bath, and the cold douche, quickly followed by friction with warm flannels; also, ammonia applied to the nostrils, galvanic shocks passed through the cardiac region, etc., and as Joerg has pointed out, that in a rapid delivery the lungs "will sometimes not have time to be prepared for their iicav function, Ave ought in such cases never to tie the cord, so long as pulsation exists in it, till respiration be established, lie conceives that in such cases, in consequence of the inferior degree of com- pression to which the placenta "is subjected, a sufficient tendency is not given to the foramen oA-ale to close, nor is a necessity for respiration felt by the system. After birth, then, a portion of the lungs alone becomes filled with air, while the remainder continues in a foetal state, a condition to which he has given the name of atelectasis, and which may, amongst other ill consequences, give rise to apoplexy, depending on the Avant of duly oxygenated blood. part ix., p. 35. Inflammation and Gangrene of the Lungs produced by Partial Asphyxia.—A case is related by Dr. Ileaton, which shows very remarka- bly the power of partial asphyxia, by whatever cause produced,"in causing that state of congestion of the lung which must frequently end in inflamma- tion. The partial asphyxia in this case was produced bv a woman taking a large dose of laudanum. The immediate effects of the poison were counteracted, but in a few days pneumonia appeared in the right lung, 'which ultimately ended fatally. Part ix. p. 59. Asphyxia from Various Causes.—Asphyxia by Vacuum, Strangxdctr twn,and Occlusion.—The first and the most pressing demand'isto remove ASPHYXIA. 169 the obstacle which opposes itself to the introduction of the air; to cut the cord which strangles, or withdraAv the foreign body or parasite Avhich blocks up the trachea. An emetic, in these cases, is often successful. This result obtained, AA-e must hasten to rub the body of the patient, the neck, between the shoulders, on the chest and abdomen Avith an aromatic ointment (camphor ointment, for instance), and place a compress of sedative water over the region of the heart, on the cranium and around the neck. Our sedative Avater, Avhich has ammonia for its base, has the property of penetrating speedily into the circulatory current, and there dissolving the coagulated albumen; in fact, of impregnating the blood Avith ammonia and sea-salt, Avhich are two of its most poAverful vehicles. We may, also, gently inflate the lungs with hot air, containing the vapor of myrrh, cam- phor, etc., to reestablish the respiratory movements, and obviate all ten- dency to decomposition. Directly the patient gives a sign of life, make him swallow hot broths and strongly spiced liquids. Asphyxia by Submersion.—Dry the body ; then bathe it with the strong- est camphorated spirits. The alcohol, AA'hich passes by imbibiiion through the living tissues, removes from the blood the aqueous quality which it ac- quires from too long a stay in the water; now, the circulation is arrested as much by excess as by deficiency of its menstruum. Also, inflate the lungs with air impregnated with camphorated spirits, etc. Asphyxia by the Vapor of Charcoal and by Acid Emanations.— Abundant lotions of the sedative water, so as to re-dissolve, by the vehicle of the ammonia, the congestions caused by the chemical action of the acid vapor. Constant frictions along the course of the spinal marrow, and the abdominal region, with camphorated liniment; insufflation of air rendered slightly alkaline with ammonia. Asphyxia by Ammoniacal Gas, Sidphureted Hydrogen and other Basic Gases.—General frictions with camphorated or aromatic vinegar; application of camphorated spirits, to absorb the aqueous portion ofthe blood and diminish its liquidity; acid lotions to neutralize the exaggerated effects of the alkaline vehicle, and to decompose the poisonous gases by precipitating their bases. Acid Exhalations and Emanations—Marsh Miasmata.—In the neAV process of gilding by dipping, and in the manufacture of vitriol and other acids, the Avorkman is constantly surrounded bvan atmosphere of nitric or hydrochloric acid, Avhich he respires through all his surfaces. The trades in Avhich mercury is employed are perhaps less injurious than this. Mer- cury attacks the nerves ; acids corrode the parietes of the intestinal canal and of the chest. The men should here take care to work only under low and glazed chimneys, and to be surrounded by free currents of air. They should also frequently bathe their hands with ammoniacal water, and wear a cravat impregnated Avith it around the neck, so that the mouth and nose may be constantly enveloped Avith a vapor capable of saturating the acid emanations, and neutralizing their effects. A mask might also be worn in such cases, containing similar antidotes. Those who labor in sewers, and on marshy grounds, should adopt similar precautions, or employ cigarettes containing particles of chloride of lime. The smoking of tobacco, otherwise very hygienic, can here serve only as a vehicle and auxiliary to the corrosive action of the acids and the miasmata. Fires on the borders of marshy grounds purify the air, not only by decomposing the chemical principles of the miasm by the flame, but also bv converting 170 ASPHYXIA. them into a saponaceous ccmpound by the essential oil, and neutralizing them by the pyroligneous acid Avhich is disengaged. Part x., p. 138. Treatment of Asphyxia.—In giving the outlines of the treatment of asphyxia, as described in Mr. Erichsen's paper, it will not be necessary to do more than refer to those points which may be called for in practice. It may be useful to remember that asphyxia may be caused or attended by tAvo circumstances : 1st, When the impression is first made on the nervous system causing syncope rather than real asphyxia. In this case, the heart will continue to pulsate feebly for some time, sending the blood through the lungs sloAvly to consume the remains of the oxygen which there exists; this state finally terminating in real asphyxia, the blood being no longer able to stimulate the heart to action. This accounts for those cases of recovery after a submersion of four minutes and upward. The face is pale and bloodless, the features sunk and contracted, and the eyes partially or entirely closed. 2d, When the impression is first made on the respi- ratory and circulating systems, the brain and medulla oblongata being only secondarily affected. In this case the blood rapidly becomes venous, and the heart seldom continues to pulsate above four or five minutes: the face is livid and bloated, the lips swollen and the eyes open. But in actual practice it is often impossible to draAV these distinctions, both kinds running into each other. It is obvious that Avhen a distinction of causes is evident, "in the one case Ave should endeavor to re-oxygenize the blood ; in the other, to rouse the sensibility of the brain and medulla oblongata." Mr. Erichsen first recommends that a certain degree of warmth (from 85 to 90 degrees) be applied, but not the high temperature of 98 or 100 degrees, Avhich is too often used. This advice is agreeable to the experi- ments of EdAvards, Avho has proved that the higher the temperature of the body, Avhether natural or artificial, the more oxygen is consumed—and therefore in a case of asphyxia, a Ioav or moderate temperature will cer- tainly be safer than a high one. Moreover the hot bath is not so favorite a mode of applying heat as it used to be. Both Dr. Kay and Dr. Carpen- ter disapprove of it, considering that as the skin is a valuable medium of conveying oxygen to the blood, the bath renders this adjunct compara- tively useless. The hot-air bath is, therefore, a better mode of accom- plishing the purpose ; and with this, friction in various ways may be better applied than Avhen the hot bath is used. There are tAvo facts which seem to be so far established, viz., that artificial respiration cannot cause reaction of the ventricles of the heart Avhen they have entirely ceased, but that by means of this operation the circulation through the lungs them- selves can be reestablished to some extent after it has entirely ceased, and after they have become congested Avith asphyxial blood. By means of artificial respiration, however, Mr. Erichsen has several times observed the auricles to contract regularly and forcibly. This process ought therefore never to be neglected, as it can do no harm even if the action of the ven- tricles has ceased, and, by supplying the left side of the heart Avith a fresh quantity of oxygenated blood, it is one of the most likely means of exciting it to increased action. Now the experiments of Mr. Erichsen clearly prove that even Avhen the lungs are loaded Avith asphyxial blood, artificial respi- ration is able, in some measure, to decarbonize it, and to excite the pul- ASPHYXIA. 171 monary circulation to some degree of activity, even when that circulation has ceased. Perhaps the best mode of causing artificial respiration is by compressing the chest and abdomen and alloAving them again to expand— a certain quantity of air is sucked in, and by the Avell-known laAV of the diffusion of gases, if fresh air be only taken into the larger bronchi, it becomes rapidly diffused. In several experiments it Avas found that even Avhen the contractions of the heart had entirely ceased, they could be reexcited by making use of oxygen gas in the Inflation of the lungs—an important fact to be known. It seems eA'ident that if we had a large and ready command of this gas, many fives might be saved. Dr. George Wilson, lecturer on chemistry, Edinburgh, points out a method by Avhich this may be accomplished. It consists in a modification of the Avell-known process of preparing oxygen from chlorate of potass. It consists in mixing the chlorate Avith a tenth of its Aveight of the black oxide of manganese, the black oxide of copper, or of certain other oxides, and applying heat as is done in the ordinary process with the unmixed chlorate. Dr. Wilson states "' that Avith a small glass retort heated by a single spirit lamp, con- taining the chlorate of potass mixed with a tenth of its Aveight of oxide of manganese, it is easy to obtain 200 cubic inches of oxygen Avithin four minutes of the first application of the flame. The gas begins to come off in a few seconds after the light is applied, and literally gushes in a full stream till the Avhole is evolved. This subject has been discussed in the recent part of "Taylor's Scientific Memoirs." It has been estimated that 100 cubic inches of air may be thrown into the lungs each time, so that if 300 or 400 cubic inches of oxygen could be supplied each minute, the process could be kept up artificially for a considerable time. But we suspect that a much less quantity would be very useful and even sufficient. 0-Aving to the diffusibility of gases, it would be sufficient to force a quantity of oxygen into the larger tubes of the lungs: this Avould soon be diffused through the remotest air cells, and in a much more rapid manner than is generally supposed. The mixture of chlorate of potass and metallic oxide, should be kept ready for use at all public hospitals, lying-in institutions, police offices, and Avherever cases of asphyxia may be readily conveyed. " There should also be provided glass or metallic retorts, with suitable arrangements for heating them, and one or more gas holders to receive the gas." It would be advisable " to pass the gas through an intermediate vessel containing a little caustic potass in solution, both to detain any car- bonic acid resulting from the presence of combustible matter in the original mixture, and to arrest any of the latter carried over mechanically in the current of the oxygen." A complete apparatus for this purpose Avould be especially useful in lying-in hospitals. It might also be useful iu cases of poisoning by opium. ''The best form of gas holder, I believe, Avould be that adopted at the gas-works, viz., a cylinder or drum of sheet metal, closed at one extremity, suspended with the mouth downward in a cylinder like itself inverted, filled with water. The drum being hung Avith chains passing over pullies and terminating in counterpoising Aveights, is filled Avith water by sinking it in the lower cylinder or Avell, AA'hile the air is permitted to escape. When oxygen or any other gas is poured into the drum, the latter rises out of the well to a height proportionate to the quantity sent into it. The con- venience of this form of arrangement is, that gas can be draAvn off by a properly arranged tube from the upper part of the drum, Avhile it con 172 ASPHYXIA. tinues to be throAA-n in from beloAV. To the exit or delivering tube a flex- ible pipe of convenient length and dimensions should be attached at one of its extremities, and at the other made to screw or otherwise fit into the aperture provided for the entrance of air in the belloAVS to be used for in- flation. A valve in the pipe of the belloAvs opening outward, Avould pro- vide a complete security against any return of the oxygen Avhen the handles of the instrument Avere separated, so as to produce; a vacuum Avithin it ; but it Avould not be absolutely necessary. With gas holders of the construction recommended, kept full of Avater, and the rest of the apparatus and the mixture ready for immediate use, inflation Avith oxygen might be commenced Avithin a few minutes after a case Avas brought in, and might be carried on for any length of time." Part xi., p. 41. Asphyxia by Strangulation—Immediate Treatment—Sir B. Brodie resolves the treatment into the following simple indications, observing that there are necessarily but feAV cases in which the surgeon has an op- portunity of hopeful interference. 1. If the ligature is removed before the efforts of the diaphragm have ceased, "all that you have to do is to Avatch the patient carefully; if natural respiration continue, leave him to himself; if it cease, supply the Avant by inflating the lungs artificially." 2. If the efforts of the diaphragm have already ceased, have recourse to artificial respiration Avithout delay. There is no time to lose. In two or three minutes, after the last heave of the chest, the heart's action Avill have ceased, and then all hope is over. 3. In successful cases, so soon as normal respiration is established, inflation is desisted from. But treatment is not to cease. The patient is not safe. Dark blood has been circulating in the brain ; and symptoms like those of poisoning by a narcotic may exist. Coma may remain. By and by the respiration may cease. Then has arrived a second period at Avhich artificial respiration may be necessary to preserve life. And, in truth, the practitioner may expect to be called upon to inflate the lungs more frequently at this second period than at the first. As to the mode of inflating the lungs, it is obvious that in the hurry and excitement of the emergency, we are not to trust to syringes, bellows, tubes, elastic gum bottles, or other contrivances AAdiich may be constructed very ingeniously and suitably for this express purpose. They are not to be had. And the surgeon is lucky if he can secure a common bellows. And if that cannot be had, look for a tube of any kind which may be in- serted into the nostril—a large elastic catheter is very suitable; if this cannot be got, roll up a piece of card into a cylinder, and Avith this and one's OAvn lungs a tolerably efficient substitute for bellows may be put in play. Then the folloAving practical points require attention : 1. Avoid undue forcing of air into the lungs; otherwise the air-cells may be burst; air may enter the blood-vessels, and the result is certainly fatal. 2. Inflate at proper intervals, imitating as clearly as possible the rhythm of natural respiration. 3. There is no necessity for Avarming or oxygenating the air; the attempt is just time lost. And it is fortunate that such manoeuvres are not essential, seeing that the surgeon is not likely to be provided with f either a pocket-stove or a portable gasometer. 4. The upper part of the body is exposed, so that the movements of the chest may be accurately noted. 5. The inflating tube is introduced into one nostril. There is no necessity for opening the trachea; that is only required Avhen previous ASPHYXIA. 173 disease has obstructed the larynx. 6. The other nostril and mouth should not be closed. They are' safety-valves, by which over-distention of the lun^s is prevented. 7. An assistant presses the box of thejarynx against the^vertebra, so as to prevent inflation of the stomach. Were this cavity tilled, the descent of the diaphragm Avould be prevented, and no air could enter the lungs. 8. Electricity and galvanism are inferior to the belloAvs, for they waste time in application. And the folloAving assertion—repeat- ing more broadly the opinion already stated—hurries him Avho believes it, to the best employment of tfte very feAV moments he has to spare. If that action of the heart by Avhich the circulation is maintained should cease, as a consequence of the suspension of respiration, it can never be restored. This I positively assert, after having made it the subject of a verv careful investigation. If others have held a different opinion, it is because they have confounded those feeble and irregular contractions of the heart, Avhich may last for a long time, but which mean nothing, Avith those regular and poAverful movements which are necessary to propel the . blood through the system. After-treeitment.—In the after-treatment—natural restoration having been restored—it may he necessary to abstract blood, on account of conges- tion ; but this must be done with extreme caution, seeing that the poAvers of life have been brought Ioav by the faulty circulation in the brain. The warm bath is not essential. But the patient should be kept in an atmos- phere of a moderately Avarm temperature, " to compensate for the insuffi- cient generation of animal heat, Avhich is the consequence of the impaired state of the functions of the brain, AA'hether arising from the influence of a narcotic poison, or from another cause. Part xiv., p. 77. Suspended Animation.—[An interesting case in which recovery took place after artificial respiration had been kept up for five hours and a half, is related.] Part xxi., p. 359. Treatment of Asphyxia Infantum.—Dr. Tott states, that he has often succeeded in restoring life in the asphyxia asthenica infantum after the failure of the usual means, by causing a person to stand on a table, and pour cold Avater from a tea-kettle oh the pit of the stomach. In this way, Professor Ilasselberg saved many lives. Part xxv., p. 109. Asphyxia of Infants.—Galvanism is most useful in exciting respiration in this condition. Part xxix., p. 26C. Asphyxia. — The term asphyxia, which ought to be exchanged for apncea, designates that condition of the animal system which results from the suspension of respiration. Respiration involves two processes—the inhalation of oxygen, and the exhalation of carbonic acid. The remedy for the suspension of respiration is, on every principle of common sense, the restoration of respiration. This view might be consi dered, irrespective of physiological inquiry and proof, as self-evident; but that proof is amply supplied by physiology. Of the tAvo functions suspended, it is certain, from physiological inquiry, that the retention of the carbonic acid is by far the more fatal, and that, in a word, asphyxia is the result of carbonic acid retained in the blood, Avhich becomes, in its excess, a blood-poison. If this vieAv be correct, it is evident that restored respiration is to the 171 ASPHYXIA. blood-poison in asphyxia what the stomach-pump is to poison in tho stomach ; and that it is the special remedy, the sine qud non, in asphyxia. But this blood-poison is formed Avith a rapidity proportionate to the circulation, which is, in its turn, proportionate to the temperature. To elevate the temperature, or to accelerate the circulation, without having first secured the return of respiration, is therefore not to save, but in rea- lity to destroy life ! The only remedy is artificial respiration ; and the only method of effect- ing this properly is to place the patient on his belly, in the prone position, so that the tongue may fall fonvard, and not obstruct the passage through the glottis, AA'hich it Avould do in the supine'position, by falling backward. Again, Avhen the body is in the prone position, the thorax and abdomen va ill be compressed, and expiration Avill take place; let the body be now turned gently on the side, through rather more than the quarter of a circle ; by this the pressure wall be remoA'ed, and effectual inspiration take place. Instead of the rules adopted by the Royal Humane Society, the following are proposed by Dr. Marshall Hall: 1. Send for medical aid, clothing, etc. 2. Treat the patient on the spot. 3. Place the patient gently on the face, to allow any fluids to flow from the mouth. 4. Raise the patient, and endeavor to excite respiration by snuff, harts- horn, tickling the fauces, etc.; if these fail, lose no time, but— 5. Replace the patient on his face, that the tongue may fall forward, and leave the Avindpipe free, then turn the body completely on the side and a little more; and then again on the face, alternately, to induce inspiration and expiration, sixteen times in the minute. Rub all the limbs and trunk, energetically, with the warm hands, upward, making firm pressure. 6. Omit the warm-bath, until respiration is reestablished. Part xxxiii.,/). 88. Linear Cauterization in Asphyxia.—M. Fame's proposal is founded upon numerous experiments on animals asphyxiated, in a variety of modes, and on one case of asphyxia by charcoal, occurring in a girl. The actual cautery, he observes, has long since been employed in distinguishing real from apparent death, and for the purpose of resuscitation; but it has not succeeded, OAving to the absence of proper method and due perseverance. When properly used, hoAvever great the danger, as long as even the feeblest respiratory movements continue, it Avill establish a favorable reac- tion, and to this end is far superior to all other means. The folloAving are the conclusions arrived at: l.-When the heart has entirely ceased to beat, or when the pulsations are feAver than three in five seconds, death is cer- tain, whatever may be done; but, excopt in these very extreme cases, cau- terization may restore life. 2. Deep and long parallel lines must be traced by a strongly-heated iron, along the upper and lateral parts of the chest, opposite the four or five first ribs, this being the part of the body that longest retains the faculty of being stimulated. 3. The first effect is a mus- cular contraction, AA'hich is quite local and Avithout a sign of pain: the ribe then move, the thorax enlarges, and inspiration becomes more ample. Sometimes more than a minute elapses before any sign of sensibility can be induced, even by the most intense burn. 4. When the general sensibility ASPHYXIA. 175 has become aroused, it is of the highest importance to keep it excited for a lono- time ; and to this end flngellatfon is the easiest and -most certain means. It must be persisted in for a long time, and the patient must be well Avatched. 5. Frequently asphyxiated persons die after having been restored ; but this must be referred rather to the shock sustained by the economy, in consequence of the suppression of respiration, than to the in- troduction of any poisonous principle, inasmuch as such death has occurred in persons who have not been exposed to any toxical influence, as in those drowned. Part xxxiii., p. 91. Suspended Animation.—A very convenient and useful instrument for inflating the lungs of neAvly-born infants, is a vulcanized india-rubber ball, about the size of an orange, to which is attached a German-silver tube, nve inches long, slightly curved at the end, with tAvo eyes like a female cathe- ter. This must be introduced into the larynx, and by compressing the ball, the air AA'ill rush into the lungs: on removing pressure, it becomes in- stantly refilled Avith air, but to prevent its being the same which has been into the lungs, there must be a hole in the tube near to its connection AA'ith the ball, to admit fresh air. This opening must he guarded by the finger during compression. Part xxxi v., p. 249. Asphyxia of Still-born Infants.—Dr. Marshall Hall gives the following directions : 1. Place the infant in the prone position. 2. Sprinke the sur- face briskly Avith cold AArater. 3. Make gentle pressure on the back; re- move it, turn the infant on the side, and again place it prone Avith pressure. 4. Rub the limbs with gentle pressure upward. 5. Repeat the sprinkling with cold and hot water alternately. 6. Continue these measures, or renew them, from time to time, eA'en for hours. ********* Dr. Ramsbotham says: If the A'essels of the funis are beating, do not divide it, but give the infant a feAV smart smacks on the back ; if there be no pulsation, separate immediately, and immerse for tAvo or three minutes in Avarm bath of 96° or 98°. It is dangerous to keep the infant in Avarm water for any length of time together; for it has been proved that animals will drown much more quickly in hot than in cold Avater. While in the bath, place a drop of spirit on the root of the tongue. If in three or four minutes these means do not succeed, artificial respiration must be resorted to. Wrap the child in warm flannel, put a bit of flannel over its mouth, and inflate the lungs by breathing into them, taking care that the nostrils are closed ; then all hands must be removed, and gentle pressure made on the chest: this alternate action must be continued so long as there is the least tremulous pulsation of the heart. Part xxxv.,p. 43. Banger of all Attempts at Artificial Respiration, except in the Prone Position.—According to Dr. Marshall Hall, artificial respiration can only be certainly, effectually, and safely performed in the prone position. In the supine position the larynx is apt to be obstructed by the falling back of the tongue and epiglottis. Fluids may be fatally inhaled into the wind- pipe from the stomach or mouth, AA'hen inspiration is mechanical. All other measures are subsidiary: all Avhich exclude respiration are destruc- tive, and warm bath is doubly fated, first, by excluding rotation, and secondly, by promoting the circulation of carbonic acid. Part xxxv., p. 47 176 ASPHYXIA. Asphyxia from Chloroform.—In a case where the usual means had failed to excite respiration, the prone position and rotation Avere after- wards tried Avith almost immediate success. When ammonia was inhaled and cold water noAV sprinkled on the face, inspiration Avas excited. It is very evident, that if the patient is to breathe, Ave must cause the fluids to floAv out and the tongue to fall forAvard, and this can only be accomplished with the patient in the prone position. Part x\xv.,p. 51. Jugular Venesection in Asphyxia.—In asphyxia the brain is poisoned by the circulation of venous blood Avithin its structure, and artificial respi- ration, Avhich is the great resuscitating means, must be performed till the brain is again arterialized. But restoration of the action of the heart does not quicky follow Avell-performed artificial respiration, because the pulmo- nic heart is paralyzed by a mechanical cause : it is distended and engorged Avith venous blood. Artificial respiration partly tends to relieve this, but it is generally possible to relieve it more quickly by jugular venesection y this should be performed as early as possible, and the vein should be opened about an inch above the clavicle. The great danger is the entrance of air into the veins : this is only likely to occur during respiration, and it cannot so long as the veins are distended and full; therefore, as soon as the active regurgitation ceases (which the valves permit) the wound must be carefully closed, and artificial respiration immediately commenced. "The escape of even 1 oz. of blood would afford very material relief. Part xxxv., p. 52. Permeation of Gases.—Mr. Osborn gives the folloAving: When a per- son has been exposed to the fumes of a charcoal fire, asphyxia may be pro- duced either by carbonic acid or carbonic oxide. The former gas having a poAverful affinity for ammonia, we may succeed in removing a portion of it from the lungs by means of that alkali; but if asphyxia be caused by car- bonic oxide, ammonia would only act as a stimulant, but not as an anti- dote. In that case, Dr. Marshall Hall's valuable process for restoring sus- pended animation might, in all probability, be advantageously adopted. Some years since, I had an opportunity of trying ammonia in a case of asphyxia caused by exposure to the fumes of ignited charcoal. A baker had been engaged for some hours in his bakehouse over a charcoal fire, and fell down suddenly in a state of insensibility. I Avas sent for, and hear- ing the nature of the case, procured a bottle of dilute solution of ammonia, free from carbonic acid, of course. On my arrival, I found a man about twenty-seAren years of age stretched upon his back, quite insensible; coun- tenance pale, and somewhat shrunk. I poured a little of the ammonia on his tongue, and applied it to his nostrils. In less than a minute, he jumped up like one suddenly roused from a sound sleep, Avalked a feAV yards up the passage, and then fell back Avith a dead Aveight in the same state as I found him. I applied the ammonia as before, and he rallied again, but Avent off the third time, and after Avard recovered Avith no other treatment than the ammonial, and a little cold water which I gave him to drink. In this case, no tAvitchings of the muscles Avere observable, and there was no irritation about the glottis exciting cough. When carbonic acid gas is disengaged from a lime-kiln, I believe no irritation of the glottis takes place, but a sense of oppression about the chest ; and that arising from a coarcoal fire causes constriction across the forehead, or a sensation of dryness about the throat—at least such are the early symptoms ob- ASTHMA. 177 served. But whenever I have accidentally inhaled carbonic acid disen- gaged from chalk by means of an acid, irritation of the glottis and cough are instantly produced. It would appear, then, that carbonic acid gas acts as an irritant in the cold state, but when its temperature is raised, no irri- tation is produced, thus rendering it more insidious. Part xxxv., p. 305. -•-•-*- ASTHMA. Nature and Treatment of Asthma.—-It seems now generally acknow- ledged, that the phenomena attending a fit of asthma are to be attributed to spasm—to a spasmodic action, especially of the different fibres which encircle the air-tubes, and which may be distinctly seen, Avhen hyper- trophied, encircling the larger bronchi, and which have been traced by Heissessen in tubes of a very small diameter. Laennec states that he has seen them in tubes less than one line across. Some anatomists doubt their musculiarity; but Ave must attribute to them the action of muscles, and suppose that they are slender muscles like those which surround the in- testines and urinary bladder; this view is corroborated, not only by the experiments to prove the contractility of the lungs and air-tubes, as men- tioned by Dr. Watson, but also by the circumstance mentioned by Valentin, Avho found that the rings of the trachea could be made visibly and distinctly to contract, by irritating the par vagum. A fit of asthma, therefore, may be considered a spasmodic affection, during AA'hich it is very difficult to inflate the lungs: hence, the respiratory murmur is generally absent. An ingenious method of expanding the chest, in cases of spasm, is that recommended by Mr. Gr. Robinson, Avho orders the patient at the end of every inspiration, or just before he is about to empty his chest, to close his nostrils and mouth so as to prevent the act of expiration; the patient will be instantly compelled to inspire again, Avhen the fingers are withdrawn from the mouth, and nose, and thus "the chest will be effectually expanded. But this- practice is not yet sufficiently corroborated by the experience of other practitioners, to alloAv of full confidence being placed in it; it may, hoAvever, be tried with impunity. Narcotics, perhaps, are our best remedies ; opium is generally used in one form or another, but some patients place the greatest reliance on stramonium, provided that it be taken at the very commencement of the attack; but if the spasmodic action be once fairly established, neither stramonium nor any other anti- spasmodic Avill have a very poAverful effect. Perhaps the lobelia inflata will be found a valuable addition to our remedies, not only from its pos- sessing the soothing properties of tobacco, but from exciting that copious expectoration, Avhich is sure, in many cases, to give relief. Formula.—Take 3 ounces of the lobelia inflata, and macerate it for 14: days in 3 pints of proof spirits. Give from 15 minims to half a drachm t. 85. Apyrexial Asthma.—The following combination of iodide of potassium has been found very serviceable in certain forms of apyrexial asthma, dys- pepsia, chorea, etc.: R. Iodide of potassium, 5 grains; sesqui-carbonate of soda, 10 grains; camphor julep, one and a half fluid ounce. This dose to be taken three times daily for a month or six Aveeks. Its good effects in these cases is attributed to its poAver of invigorating the system. The iodide of potassium is ahvays inadmissible when there is any febrile disturbance, or Avhen the tongue is coated. Part ix., p. 62. Treatment of Asthma.—Dr. Debreyne says: For the last tAventy- five years we have seldom prescribed any other formula but the follow- ing: R. P. inulce elecamp. |ss.; flor. sulphuris §ss.; p. rad. belladonnas 9iv.; p. rad. scilke 3j.; kermes min. 9j. M. To be divided into ninety powders, of which one is to be taken three times a day. Dr. D. assures us that he has witnessed excellent effects from this remedy, not only in asthma, but also in a variety of chronic pectoral affections, when they are unaccompanied with fever or inflammatory irrita- tion : as, for example, in what has been called catarrhal phthisis. To allay the cough in such complaints, he combines the use of the Iceland moss jelly Avith the anti-asthmatic poAvders. When these fail—Avhich, according to his report is not often the case—he advises a trial of the stramonium inhalation, and also of a strong infusion of the camplirfe of Montpellier (camphorasma monspeliaca)—Avith the medicinal virtues of Avhich he Avas first made acquainted by a Avriter in the "Revue Medicale" for March, 1821. During the paroxysms of asthmatic dyspnoea, he recom- mends a mixture contaiiring the extract of belladonna, oxymel of squills, kermes mineral, and orange floAver-water. Part x., p. 27. Spasmodic Asthma—Inhalation of the Fumes of Nitrate of Potass. The patient, subject to spasmodic asthma, made use of a piece of blotting- paper, about the size of his hand, dipped in a saturated solution of the nitrate of potass, and afterAvard dried. This was placed on a common plate, and being ignited, the fumes Avere speedily sensible in the room. He described its operation •' as clearing the passages and gradually opeD- ASTHMA. 179 ing the air-tubes." The effect was always produced in about a quarter of an hour, and though he had used the same remedy nearly twenty times, he had never been disappointed in the result. Part xi., p. 55. Iodide of Potassium in Asthma.—Dr. Casey describes the effects of this remedy as being highly satisfactory; he has administered it in more than five-and-twenty cases, and in no one instance, where a fair trial has been made, has it failed to afford unequivocal and decided relief. The dose varies from two to five grains three times a day. A long-continued use of the iodide of potassium will in some subjects occasion an eruption, generally of a pustular form (almost always ecthyma); and I have been twice disposed to attribute to it the occurrence of a slight conjunctivitis; the omission of the medicine for a few days, together writh a feAV doses of rhubarb and soda, will be found sufficient for the removal of these incon- veniences. Part xii., p. 76. Ammonia in Asthma.—M. Guerard has used ammonia with success in a hundred eases of asthma. M. G. applies the remedy in the following manner: He dips a small pencil of charpie into pure liquid ammonia, and then instantaneously into a glass of water, after which he immediately passes it to the back of the throat, touching rapidly the velum, uvula, and oesophagus to a greater or less extent. He seldom has occasion to repeat the operation ; Avhen there is merely simple emphysema the improvement has been permanent. The pencil should be neither carried too deeply into the throat, nor alloAved to remain too long in contact Avith the soft parts, more especially the pos- terior wall of the pharynx ; the reaction resulting from such an application is, at times, followed by the most frightful symptoms, menacing instant death. The inhalation of the fumes of ammonia may be used in poisoning by prussic acid, when the patient cannot swalloAv. The same remedy may also be used in asphyxia, and in many other cases where its influence is required in the lungs, as for example, in cases of chronic pneumonia and bronchitis, where the parts Avill often be bene- fited by its stimulation. In cases, too, where the voice is almost lost, we have found that the fumes of ammonia have acted most beneficially, even when, probably, at the same time Ave were giving tartar emetic. Part xiii., p. 89. Asthma—Spasmodic.—Give tincture of lobelia, with hydrocyanic acid. For an adult the following will do: R. Tr. lobelise infl. 3j.; acid, hydro- cyan, gtt. j.-ij. ter vel quatuor in die. But if the paroxysm be severe, larger doses of the lobelia may be given. Part xvi., p. 134. Chloroform in Spasmodic Asthma.—Mr. Chandler relates the case of a lady 56 years of age Avho had been subject for twenty years to attacks of spasmodic asthma, for the relief of AA'hich " the resources of the Phar- macopoeia had been exhausted in vain." Having had the prevailing influenza, she Avas attacked by her old com- plaint, extreme dyspnoea, Avith great sense of constriction, and acute darting pains through the chest and epigastric region. Mr. C. admi- nistered half a drachm of chloroform on a sponge, hollowed to fit the mouth and nostrils, and held it at first close to, but not touching the face. In less than half a minute she became excited, Avaving the; arm about, and uttering incoherent expressions, accompanied Avith loud hysterical laughter. He then placed the sponge in contact with the face, Avhen the limbs gra- 180 A8THMA. dually relaxed, the arms dropping on the bed, quivering of the eye-lids and twitching of the muscles of tlie face took place, and she fell back on the pilloAV, drawing deep and prolonged inspirations, betAveen each of which, perhaps eight could be counted. He hoav Avithdrew the sponge, opening the curtains to admit air. Respiration gradually became more regular, and she lay Avithout motion, the body well throAvn back on the bed, not the slightest vestige of spasm remaining. She enjoyed a quiet sleep of some hours' duration, and the folloAving morning she Avas quite quiet, no return of spasms, and no ill effect from the inhalation; she is noAV comparatively well. Part xvii., j>. 02. Asthma of Old People.—[Pure nervous asthma is said to be hardly ever met with in old people; asthma in them, according to Dr. Day, depending either on organic change in the heart or lungs, or on impurity of the blood. The latter is thus described by Dr. Day:] Cachectic Asthma.—The impurities contained in the blood seem here to be the exciting cause of the paroxysm. There is an attempt on the part of nature to make the bronchial mucous membrane eliminate the effete matter of the blood in the form of expectoration. Asthma is very often associated Avith a deficient or morbid action of the kidneys. I have seen so many cases of this form of asthma, that I cannot doubt the inti- mate connection between*the state of the respiration and the morbid con- dition of the kidney, and, for the sake of convenience, shall term this urinous asthma. The term has been already used by Schonlein, Canstatt, and other continental Avriters. Urinous asthma seldom occurs before the sixtieth year, and is most common at and beyond the seventieth year. On examining a patient with this affection, Ave usually find a general suppression of the secretions, the skin being dry arid rough, and the boAvels acting slightly about twice a week. The urine is scanty, rather turbid, of a reddish-brown color, and so acrid as to produce a sensation of scalding in the urethra, and to give rise to frequent calls to make Avater. There is usually a feeling of dull, deep-seated p"ain about the loins. The skin is the seat of intolerable itching, and presents the appearance of prurigo, AA'hich, like the asthma, arises from the retention of the urinary constituents in the blood. The eyelids are red, and discharge an acrid humor, and ulcers often form on the loAver extremities. The paroxysm of asthma usually occurs an hour or two before midnight, and lasts some hours, terminating most commonly in a copious expectoration of viscid and very salt mucus, Avhich frequently has a strong urinous odor. Another cachectic form of asthma is connected Avith the gouty diathesis. It sometimes comes on as early as the fiftieth year, in persons suffering from asthenic or anomalous gout. The premonitory symptoms are the same as those of a fit of regular gout. The patient is led by these symptoms to expect a fit of gout; but instead of this he is seized, usually about mid- night or a little before, Avith a feeling of intense and terrible suffocation. The paroxysm lasts, with slight remissions for some hours, and toward its close a considerable amount of thick mucus, frequently mixed with blood, is ejected. The fit is often succeeded by other efforts to depurate the blood by copious sweats, urinary sediments, etc. If they do not occur, a second paroxysm of asthma may be shortly expected. Part xix., j). 89. ASTHMA. 18J Asthma, Spasmodic.—Let chloroform be inhaled during the paroxysm, so as to produce a moderate degree of anaesthesia, when the breathing will become easier. Part xix., p. 91. Tartar Emetic in Asthma.—M. Bernardeau advises very minute doses of tartar emetic (from three to six pills, each containing 1-25th of a grain of tartar emetic, every twenty-four hours). Part xxii., p. 146. Asthma.—Dr. Todd winds up his lecture on this subject Avith the fol- loAving conclusions: That asthma is primarily humoral; that it is caused by a poison or mor- bid matter acting on that portion of the nervous system which ministers to the function of respiration ; that it leads to dilatation of the lungs and walls of the chest, to emphysema, and ultimately to dilatation of the heart; that the habit may pass off, the morbid matter being no longer created, the patient ceasing to be asthmatic, just as a person ceases to be gouty or epileptic ; and that, ceasing to be asthmatic, the patient may remain, or may not remain, emphysematous, according to the severity and duration of his previous attacks. Treatment.—Give a quarter to three grains of the extract of stramo- nium, or from ten to thirty minims of the tincture, or the various parts of the plant may be smoked in a pipe, or the leaves alone rolled up in the form of a cigar. Ether, in combination with opium, Avill often prove of great service. Part xxvi., p. 112. Hay Asthma.—With regard to the pathology and treatment of hay asthma, it may be remarked that little.is known; and in many cases all treatment has proved of no avail. From the state of the mucous mem- brane, in the case of a gentleman who consulted Dr. Mackenzie, he was led to employ arsenic, from the analogy which appeared to him to subsist between its pathological condition and that of the skin in some forms of prurigo. In six days nearly every vestige of the complaint had disappeared. The cases of hay fever chiefly benefited by arsenic, are of a catarrhal, rather than of an asthmatic character. Five drops of the solution may be given three times a day. Dr. Fowler recommends the folloAving rules for its administration: Patients from 2 to 4 years old, may take tAvo to four drops of the solution ; from 5 to V years, may take from five to seven drops; from 8 to 12 years, may take from seven to ten drops; from 13 to 18, may take from ten to twelve drops; and from 18 and upAA'ard, may take tAvelve drops as a dose. If the medicine fails to do good, it may then be alternated with quinine, or they may be given concurrently. Part xxiv., p. 27. Thymic Asthma.—[Mrs. M., residing in London, was sent to Gravesend with her child, aged five months, for change of air. A short time after- ward, Dr. Armstrong was sent for, in consequence of the child being seized with something like a fit. . Three weeks before, the child Avas sud- denly seized Avith great difficulty of breathing, while out of doors, becom- ing almost livid in his countenance, and seeming as if. he would be strangled before he could get his breath; on the present occasion there had been s«me slight "crowing." A feAV weeks after, the child had a similar s^ck, apparently brought on by cold.] ' The child—continues Dr. A.—Avas attacked with symptoms of catarrh, 183 A8TOMA. which were slight, and were not considered to require medical attendance. After a feAv days he experienced another and more severe seizure than any former one, and I was sent for in great haste. The history given was the following: The child became suddenly dark about his mouth, held his breath, his eyes seemed starting from their sockets, and his limbs became violently stretched. He appeared to recover his breath, began to cough, and when I arrived the attack had passed away. He looked frightened ; his face pale and bathed in perspiration; pulse weak, intermitting, and quickened; skin cold. There Avas considerable fullness of the veins of the neck ; the chest resonant throughout; sibilus and rhonchi heard over the left lung, and partly over the right; most distinctly heard on each side ol the dorsal spine. That night I Avas summoned to the little sufferer, Avho was stated to be dying. The attack was much the same : he had been sleeping, awoke up, became livid, convulsed, and apparently gasping for breath. I found him pale, Avith his head and face bathed in perspiration, Avith a feeble intermit- tent pulse, a loose, frequent cough, troublesome at the termination of the attack. There had been no croAving respiration. The attacks of dyspnoea now became frequent; he rarely went to sleep Avithout an attack on awak- ing. They Avere noAV invariably accompanied Avith convulsions of an epileptic character. The countenance during the attack, lips especially, was quite livid, the tongue protruded, eyes turned in toward the nose, and nearly constant carpo-pedal contractions. The sides and centre of the lower part of the throat SAVollen, the jugular A'eins much distended; and the respiratory murmur Avas harsh or indistinct at the posterior part of the thorax. As each convulsive attack subsided, there Avas a peculiar, harsh, incessant, convulsive cough, by which small portions of frothy whitish phlegm Avere expelled from the trachea; and after some time about a teaspoonful or two was discharged, and the child seemed relieved. The difficulty of SAvallowing, especially of semi-fluid substances, continued, ap- pearing always to excite coughing. Nothing gave relief; he continued to get Avorse, arid died after an attack—about a fortnight after the catarrhal seizure. Post-mortem Examination Sixteen Hours after Death.—In the examina- tion of the body, the chest chiefly attracted attention. There Avas a large thymus gland, extending from the thyroid gland to the pericardium, and laterally filling the space betAveen the trachea, clavicle, and first rib. It was dense, firm, lobulated, of a fleshy color ; contained no fluid ; it Avas upAvard of an ounce in Aveight; its greatest density and development ap- peared on the left side ; the large veins almost flattened by the pressure; the par vagum and recurrent were pushed aside from their usual course, and must have been much pressed. The heart was of ordinary size, nearly empty. The foramen ovale closed. Internally the larynx and trachea were pale, except at the part Avhere the thymus pressed, Avhich was red- dened ; the remainder Avas natural; and Avithout inflammatory appearances. The lungs, anteriorly, were natural; posteriorly, extensively caraified. Abdominal viscera healthy. The head Avas not examined. . Treatment.—Apply leeches occasionally on the upper part of the chest, and iodine externally and internally ; pay strict attention to every source of irritation Avith a view to its immediate removal, causing the child tolifl with its head Avell raised during sleep. Select light food and a healthy atmosphere...... ASTHMA, 183 Diagnosis.—Dr. Copland says male children are chiefly liable to it; pale, Avhite, soft countenance; permanent fullness about the upper part of the sternum, extending upward nearly to the thyroidal region ; an almost constant fullness of the A-eins of the neck, particularly after any effort, dull- ness on percussion over that part of the sternum. Signs of congestion of the lungs, and from an early period, difficulty of swalloAving ; the croAving sound is either entirely absent or only partial, the pulse is weak and inter- mittent, and there are copious perspirations over the head. Part xxiv., p. 90. Spasmodic Asthma.—Under this head, Dr. Walshe states the following remarkable and important fact, with regard to the hygienic treatment of the disease. " Change of air is most important; but the kind of change that shall prove most beneficial can only be learned by experience. Some sufferers lose their paroxysms south of the olive line, others are easiest in a cold atmosphere; ^moisture, the bane of some, greatly mitigates the disease in others. The air of towns suits some, that of the country others; the clear suburban air of London is infinitely more noxious to some asthmatic persons than the foul atmosphere of the Avorst cleansed and most densely peopled localities of the metropolis ; occasionally an individual will be found Avho is tortured Avith asthma in one room of a house, free from it in others^ and this AAdthout any distinct explanation being found in the aspect, the drainage, or any other knoAvn condition." Part xxv., p. 109. Asthma.—Twenty drops of chloroform inhaled in the handkerchief and repeated carefully, taking care not to produce stupefaction, produced marked relief in a case of severe asthma. Part xxix. p. 93. Use of Lobelia in Asthma.—Ten minims of tincture of lobelia, with sedatives, expectorants, or stomachics, is very useful in chronic bronchitis, with tendency to paroxysmal asthma. If the nausea be very excessive, combination, with a few drops of hydrocyanic acid is often useful. Part xxix., p. 93, Nervous Asthma.—Brown paper soaked in a solution of nitrate of pot- ash and burnt in the room of an asthmatic patient will give instant relief. The following pharmaceutical paper is still better: pasteboard broken down in hot water, four ounces; nitrate of potash, two ounces; belladonna, stramonium, digitalis, lobelia inflata, all in powder, each twenty grains • myrrh and ohbanum, of each tAvo and a half drachms. Incorporate all these with the paste, divide the mass into sheets of the thickness of three lines; dry and divide in little square pieces. Burn them in little saucers in a well shut-up room. Part xxix ? p 93 Spasmodic Asthma.—Vide Selections from favorite prescriptions Art Medicines." Anti-asthmatic Cigarettes.—AM nitre to the leaves'of belladonna and of stramonium, by-watering these plants, dried and conveniently spread out with a solution of nitrate of potash, in the proportion of three ounces ot the salt to rather more than two pounds avoirdupois of the plants. It will be easily understood, that as this solution penetrates the entire vege- table tissue, the latter will, when dry, burn completely, without the forma- tion of pyrogeneous products. 184 ASTHMA. M. Dannecy, of Bourdeaux, prepared cigarettes according to this for- mula,and the benefit derived from their use by a great number of patients induced him to publish it, and to call the attention of practitioners to the mode of treatment, consisting in the smoking of narcotic plants combined with nitre. Fart *xxvii.,/>. 252. Asthma.—Tlie remedies at our command, either remove the exciting cause (as emetics to empty the stomach of an undigested meal), or dimin- ish nervous irritability (stramonium), or directly lower nervous and mus- cular poAver (ipecacuan, tartar emetic, tobacco), or stimulate to activity the cerebro-spinal and voluntary nervous action, and proportionally diminish the organic and reflex (strong coffee, violent emotion), or seem to act as specifics, which some Avay or other diminish the asthmatic ten- dency, but Avhose true modus operandi is obscure (the airs of certain localities). Remedies may be applied indirectly, that is, through the medium of the blood, or directly to the mucous membrane of the bronchi by inhalation. In cases of a purely spasmodic nature, relief from tlie agonizing parox- ysms will frequently be derived from the inhalation of the fumes of burn- , ing nitre-paper. The paper used should be blotting-paper of moderate thickness, and free from any ingredients Avhich Avould cause the smoke to be of an irritating kind. The strength of the solution of potash employed should be about four ounces to half a pint of Avater. If a piece of paper saturated in this solution and dried, be burnt in the bed-room of a patient before going to sleep, a threatened attack may frequently be warded off. Tobacco, Avhich acts as a depressant, of all remedies gives the most speedy and complete relief, and Avould be much more extensively used but for the profound depression and collapse Avhich it is liable to induce. But the mere sedative influence of tobacco is of no use Avhatever unless some degree of collapse is induced. An asthmatic may cut short the attack, by, directly the symptoms supervene in the early morning, overcoming the tendency to droAvsiness, getting up and inducing a slight degree of tobacco nausea. Ipecacuan giA-en in a large dose, never less than twenty grains, Avill frequently relieve the paroxysm directly a slight degree of nausea comes on. It maybe taken in the form of lozenges, which can be made so strong that three will induce vomiting. Antimony acts in the same Avay as ipeca- cuanha, but the nausea and collapse it induces are long and tedious. If an attack be promptly treated it will generally yield, Avhilst, if alloAved to proceed for an hour or two before treatment is adopted, great difficulty will frequently be experienced in relieving it. Part xxxviii., p. 52. Connection between the Stomach and Asthma.—From a careful con- sideration of the relation of the stomach to the asthmatic paroxysm, the following simple rule is most important: Let no food be taken after such a time in the day as will allow digestion being completed and the stomach empty before going to bed. Certain articles of diet have a special tendency to oppress and tighten the breathing of those liable to asthma, as anything in any Avay preserved—as potted meats, seasoning, etc.; cheese is had, especially if old and decayed; also heavy malt liquors. The quantity of food the asthmatic takes should be small; therefore it should be highly nutritious, but still of the plainest kind. Part xxxviii., p. 325. BALDN ESS—B ATE S. 165 BALDNESS. Remedy for Baldness—As a remedy for baldness which follows herpes or pityriasis, Dr. Neligan recommends the following pomade, from Avhich lie has found great benefit: Prepared lard, two ounces; white Ayax, two drachms; melt together, remove from the fire, and Avhen the mixture is beginning to thicken, add, Avith constant stirring, balsam of tolu, two fluid drachms, and oil of rosemary, twenty minims. In very chronic cases, or where the baldness has* long existed, a drachm of tincture of catharides may be added. Part xix , p. 209. Baldness—Treatment by Fumigation.—In cases resulting from atony or disordered nutrition of the hair bulbs. Vide Eruptive Diseases of Scalp, Art. " Skin Diseases." ---»-•-•--- BATHS. Steam Apparatus.—The apparatus in appearance is somewhat elegant, is comprised in so small a space that it may readily be carried in the hand, and may be applied either locally or generally, as circumstances may re- quire, with equal facility. It consists of a reservoir for the Avater, capable of containing a little more than a pint, supported upon three metallic rods, and having a coverlid which is furnished Avith two openings, one at the centre and one toward the side. From that in the centre arises a tube, terminating in a IioIIoav globe, having attached to it, and communicating with its interior, three short branches furnished with moveable lids. A similar branch is connected with the opening at the upper edge of the reservoir. Beneath, on a pan supporting the parts already described, is placed a spirit-lamp, having four burners, and these, Avhen lighted, quickly vaporize the Avater in the reservoir above. The steam is then conducted to the globe, and thence, by means of short pipes slightly curved, and which may be connected Avith any one or all of its branches at pleasure, to the part of the body required. The force and the quantity of vapor expelled, is regulated by a key at the side of'the principal cylinder, and which will diminish or enlarge its diameter much on the principle of the ordinary stopcock, while its escape upAvard is entirely and instantly pre- vented by exposing the opening at the edge of the reservoir. The Avay in which it has been used for affections of the joints is simply this: the patient covers the wrist, for instance, with a piece of flannel, large enough for its edges to fall on a pillow, Avhich is placed to support the fore-arm. The nozzle of one of the tubes is then placed beneath the flannel, and the steam allowed to escape. The joint thus enveloped in steam, has usually been alloAved to remain for about half an hour; the application being made once a day, or oftener, as the circumstances require. Various modifica- tions of the tubes for different purposes are capable of being adjusted to the openings in the reservoir. The apparatus is thus used: The patient lies supine in bed, and three or four slender arches of wood, or other convenient material, are placed across the body, so as effectually to raise the blanket from any contact 1S6 BATHS. with it. The apparatus is supported on a stool at the foot of the bed, and one of the pipes alloAved to project into rim arched cavity, Avhich soon becomes filled Avith the vapor..- In this way all the inconveniences attend- ing a removal to and from the bed are of course got rid of. Part iii., p. 108. Local Paths.—M. Mayor, of Lausanne, presented to the Royal Aca- demy of Sciences in Paris, an apparatus for bathing any limb, or any part of one, separately, and in any possible position. This apparatus consists of a hollow cylinder of copper, the tAvo extremities of which are provided with caoutchouc discs, each of Avhich has at its centre a large opening through Avhich the limb is introduced. Varied according to the parts to AA'hich they are to be applied, these apparatus form a kind of sleeves, or gloves, or boots, according as they have to inclose the arm, the hand, or the foot and leg. This kind of portable bath has, M. Mayor states, numerous advantages. It is cheap. It permits the limbs to be bathed Avithout obliging the patients to keep in an irksome position. When, for instance, tlie elbow joint is to b'e bathed, tAvo pieces corresponding to the arm and the fore- arm may be articulated together (by caoutchouc tube, Ave suppose), so as to be capable of movement on each other, and the patient suspending the apparatus in a sling may Avalk about, and even make use of the movement of flexion and extension of his arm. Only a small quantity of water is needed, and this advantage, though unimportant in the case of simple baths, is considerable AA'hen medicated baths are ordered. The liquid will preserve its temperature a long time, and this, added to the convenience of employing it, Avill enable the bath to be used longer than is customary. The fluid may be removed or added to by small openings made above and beloAV through the wall of the cylinder. The apparatus may also be used for constant irrigation by making one of these openings communicate with a tube conveying Avater to the cylinder, and the other one to carry it off. Part iv., p. 55. A Cheap Substitute for a Vapor Path.—Dr. Serre (d'Alais) recom- mends the folloAving means of inducing abundant transpiration: Take a piece of quick-limC, about half the size of your fist, and Avrap around it a wet cloth, sufficiently Avrung to prevent Avater running from it. A dry cloth is to be several times wrapped around this. Place one of these packets on each side of the patient when in bed. An abundant humid heat is soon developed by the combination of the lime Avith the Avater, which quickly induces copious transpiration ; the effect of the apparatus lasting for tAvo hours at least. When sweating is fully established, Ave may withdraAv the lime, which is now reduced to a poAvder, and is easily removed. In this Avay, neither copious drinks, nor loading the bed with coverings, is required. Part xiv., p. 140. Hot-Air Path.—A convenient and efficient hot-air bath may he thus extemporized : The patient being in bed, fasten a blanket loosely round the body ; place two chairs upon the bed, so that their backs form an arch over the person, tie them side by side, and over them throw several blankets. A spirit lamp, held beneath the arch for a few minutes, Avill raise the temperature to 130° or more. If a spirit lamp is not at hand, one maybe made out of a tea-pot, letting the Avick pass through the spout. Part xx., p. 322 BEBEEBINE—BED -SOKES. 187 Turpentine Bath.—Dr. Moreau speaks highly of a bath of turpentine vapor in catarrhal affections, rheumatism, and severe neuralgias. The patient is shut in a room, into which the Vapor is introduced from without, varying in temperature from 45° to 102°. It produces copious perspira- tion, Avhich greatly diminishes the temperature of the body. Vide Art. "Turpentine." Part xxxii.,p. 85. —in BEBEERINE. Bebeerine.—Another communication on the same subject has been made by Dr. Maclagan, in Avhich the experience of several eminent practitioners is o-iven, which seems to confirm the good opinion which was entertained respecting its virtues. Its poAvers may, perhaps, in some cases, be inferior to quinine, but in others it is more to be relied upon; and AA'hat is of some consequence is, that it is only about half the price, being manufactured at about six shillings the ounce. Dr. Watt thinks that the bebeerine is supe- rior to. quinine, in its not affecting the head or causing irritation of the stomach, even AA'hen given in very large doses, as much as 96 grains hav- inc been taken hi three and a half days. It is found, also, that the bebee- rine is tardier in its operation !te an anti-periodic, acting more particularly on the blood, while quinine, perhaps, acts more on the nervous system. Its tardy operation, hoAvever, renders its effects more permanent, some- what like the sIoav but durable action of arsenic in ague. Another ad- vantage is, that bebeerine is gently cathartic. Dr. Anderson, another respectable physician, has also tried this remedy with advantage, as an anti-periodic in intermittents. When the time of the paroxysm was known, the medicine was given in three grain doses every hour, till from 18 to 24 grains Avere taken. It was managed so that the last dose was taken immediately before the expected return of the fever, and was found to be nearly equal in its power to quinine. At any rate, although it may not be quite so powerful a remedy as the latter medicine, it will prove to be a very valuable substitute in many cases; and in some cases of utero- gestation, Avhere neither arsenic nor quinine would be advisable, Professor Simpson has been able to give the bebeerine with confidence and success n some very severe attacks of neuralgia of the face and forehead, and has bund that it did not possess the irritating and stimulating effects of qui- nine. Part xi., p. 94. hi— BED-SORES. As soon as any part which we suspect may be the seat of such sores, exhibits the slightest appearance of inflammation, a solution of the nitrate of silver, ten grains to the ounce of water, should be applied to it by means of a camel hair brush, tAvo or three times a day, until the skin has become blackened, and afterward only occasionally. Part vii., p. 167. Treatment of Bed-sores.—Dr. Graves recommends a nutritious diet, 188 BED-SOKES. wine, and the sulphate of quinine. The sores to be washed night and morning with a solution of chloride of soda, in the proportion of 20 or 30 drops to an ounce of Avater. A liniment composed of tAvo ounces of cas- tor oil and one of balsam of Peru, is to be applied on pledgets of linen, and covered Avith a poultice of linseed meal tAvo or three times a day. A writer in the " Medico-Chirurgical ReA ic-AV " recommends as a prophylac- tic a solution of creasote, one part in eighty of Avater; if the skin should break, the zinc or lead ointment, to Avhich camphor has been added ; and in still more obstinate cases, an ointment composed of four parts of fresh prepared tannate of lead and thirty of lard. A German Avriter recom- mends equal parts of camphorated spirit and liq. plumbi subacetatis. Part xi.,p. 189. Means of Preventing Ped-sores.—The thicker the cuticle, the more it will protect the parts beneath ; you may, if you attend to it in time, add to the thickness of the cuticle by stimulating the surface of the skin. Nurses knoAV this very Avell, for Avhen patients are bed-ridden, they wash the parts subjected to pressure with brandy. What is still better, is a lotion composed of two grains of bichloride of mercury to an ounce of proof spirits. When you think that a patient is likely to be confined so long in bed that sloughs may be formed on the os sacrum, begin at an early period to Avash the parts two or three times a day Avith this lotion. I have found it useful in other cases where^a patient suffers from pressure. For example, in a case of hernia, Avhich requires to be supported by a very poAverful truss, the truss galls and frets the skin, and may at last cause inflammation and sloughing; but, under the use of a stimulating lotion, a thicker cuticle is generated, and such mischief is avoided. Part xiv., p. 325. Mortification from Pressure—Bed-sores.—[This occurs, as is well knoAvn, in patients who are reduced to a bad condition by typhoid or scarlet fever, or by long confinement to bed for compound fractures or diseases of the hip joint. Mr. Cooper says:] When you consider the cause of this kind of mortification, you will see the difficulty of curing it, as it not only proceeds from pressure, but also from a Ioav state of the constitution, and hence you may remove the press- ure and yet not be able to stop the disease. Still you must endeavor to take away the pressure, and you may employ for this purpose pillows or air-cushions, placed under the patient so as to relieA'e the prominent parts, or better still, the hydrostatic bed—Mr. Arnott's water-bed—Avhich acts upon the principle of equalizing the pressure. When long confinement has taken place, you must be on your guard: examine the parts of the skin, see that they are AA'ashed Avell Avith astringent lotions—the lead lotion, liquor plumbi, and also a preparation of camphor—camphorated spirit. By altering the position of the patient, you may sometimes suc- ceed in preventing this mortification. I have often applied the soap- plaster—either Avhite or brown—which is a very good application, though not so good as bathing the parts frequently during the day Avith strong astringent lotions. When sloughing comes on, the modes of treatment are very different amongst different practitioners. Some poultice, some apply camphoratfd spirit, and some the liquor plumbi lotion ; others a strong solution of the chloruret of soda. These are only secondary means in the treatment of this kind of mortification. Part xvi., p. 304. BED-SORES. 189 Bed-sores.—In order to prevent bed-sores, moisten and oil a bladder, and partially distend, it with air; wrap it up in a soft napkin, and place it un- der the part subjected to pressure. In the case of fractures, to preserve the heel from the effect of pressure, a bladder may be introduced beneath it in a flaccid state, and then inflated. Part xvii., ». 294. Prevention and Treatment of Bed-sores.—When the first blush of un- healthy inflammation makes its appearance (Avhich is indicated by a livid color in the integuments) we should take care that all pressure from the parts be immediately removed. This can be done either by the patient's position being changed, or by the aid of bolsters or air cushions. M. Purefoi uses a cow's bladder softened in warm water; this being oiled, and partially inflated, is placed under the part suffering from continued pressure. The effect of this support (in a case of fractured leg) exceeded his expecta- tions. What renders this contrivance A-aluable, is its simplicity and cheapness; it forms a very manageable substitute for the hydrostatic bed of Arnott. In addition to these preventives, others, to stimulate the surface and excite the dormant capillaries to more healthy action, should be dib>ently used. The lotion recommended by Sir B. Brodie is admirable for this pur- pose. It consists of tAvo grains of bichloride of mercury to an ounce of proof spirit. These two contrivances, if used at the same time, will be found invaluable in the prevention of bed-sores. If, in spite of our efforts, sloughing takes place, we may divide the pro- gress of the case, for practical purposes, into three parts. The first is the period before the slough is detached, during which we must employ stimu- lating applications, as a carrot poultice morning and evenin<>-, sprinkled with a solution of chloride of soda. Pressure must also, of course, be pre- vented. r When the slough falls out, a deep, unhealthy-looking ulcer is presented to our notice, forming the second stage of these sores. This ulcer is gene- rally round or oval. The integuments at the circumference are undermined so that you can readily pass a spatula beneath them, showing that the sub- jacent cellular tissue has lost its vitality even to a greater extent than the cuticle. 1 he margin of the ulcer is consequently found to overlap its base lhe base presents a flabby, uneven surface without granulations, and in- terspersed with shreds of adherent slough. From this surface a thin sero- saugumeous or ichorous discharge is secreted, having a most fetid odor. In order to promote healthy granulation, and stimulate the parts to cast oft the remaining shreds of slough, warm dressings, consisting either of equal parts of gum elemi and spirits of turpentine, or of castor oil and Pe- invian ba.sam may be applied, dipped in lint, to the bottom of the ulcer, over thlT Vft rU^1Ce' ^tfo-P^e, or a carrot poultice, placed ZZ n ii. / teW -dayS' the Ulcer wiU assume a more florid appear- sa^'tonll V a dlSl)0SItl0U t0 form granulations. It will now be neces- saiy to make a change in the dressings. a 5minn°UfW-?01lSlstin ,applying e™T morning with a camel's-hair brush a solution ot nitrate of silver (ten grains to an ounce of distilled water) to i.«„ „ J fa" 'T' then covei'ing the surface of the ulcer, and filling it up^uth fine carded cotton. A piece of oiled silk, large enough to cove? oSS if,? SaCr'T' Sh°uld then be Placcd over the dressings. The oiled silk thus applied serves a double purpose ; it will, by preventing the 190 BENZOIC ACID. evaporation of the discharge, keep the cotton soft, and permit its easy re- moval at each dressing; it will also add to the cleanliness and comfort of our patient, bv preventing the bedclothes being soiled. Under this sim- ple treatment," the surface of the ulcer soon begins to assume a more healthy appearance, the granulations at the margin become amalgamated with those at the base, until the cavity is filled up by luxuriant granula- tions. We have hoav the third stage of these bed-sores to treat. As in the second stage our object Avas to stimulate the surface to healthy action, in this we have to control inordinate action, and repress luxuriant granula- tions. A concentrated solution of sulphate of copper (applied every morn- ing) will be found most useful for this purpose. The carded cotton and oiled silk, as above recommended, may be also continued until the ulcer is perfectly healed. Part xviii., p. 235. Use of Collodion in Bed-sores.—Air-cushions and water-beds are not obtainable by the poor, and it has been the practice to protect parts sub- jected to injurious pressure either by poAvdering them Avith some inert substance, or covering them with diachylon. The first of these measures is of little use, and the other does more harm than good, as by softening the tissues to Avhich it is applied, it only renders them more susceptible to the influence of pressure, especially if the leather on Avhich it is spread gets into folds. Collodion adheres far more closely than diachylon, and is quite exempt from moisture; and in the cases in which it has been tried in the French hospitals, has answered well. Part xx.,p. 177. Bed-sores—Tannate of Lead.—Mr. Leclerc, senior physician of the civil hospitals at Laon, indicates a method which is calculated to prevent mortifi- cation over the sacrum. As soon as the skin reddens or becomes painful, he prescribes a layer of tannate of lead in a humid state, to be spread over the threatened part, and the following is the formula for its preparation : Corticis quercus-eontusae, 1 oz.; aquae, 8 oz.; reduce by boiling to 4 oz.; strain ; add liq. plumbi diacetatis q. s. until no further precipitate is formed. The deposit is collected upon a filter. Mr. Leclerc asserts that of all the topical remedies which he has used for the treatment of this most troublesome complication of protracted disease, none is preferable to tannate of lead employed as described. Part xxxix., p. 232. ---Ml BENZOIC ACID. Benzoic Acid.—Benzoic was formerly administered in the expectation that it Avould prove a preventive of gout stones or tophaceous deposits: but as it has no influence in preventing the formation of uric acid, it'ean- not, of course, prevent these deposits. We are informed by Dr. Garrod that it is very serviceable in increasing the acidity of the urine, to which it imparts slightly irritating properties, and is often of use in cases where there is a deposition of a granular kind of mucus mixed with phosphates. Dr. Golding Bird has long since ascertained that benzoic acid is incapable of converting uric acid into hyppuric,and is, therefore, not a chemical remedy BITES—BLADDER. 191 for gout. He thinks it may be of benefit in some forms of uric acid de posits, by combining Avith the azotized elements of the blood to form hip- puric acid. It is, he says, of no value in phosphatic deposits, but is often of service in catarrh of the bladder. Part xi.,p. 8S. HI BITES.—(Vide "Snake Bites.") Bite from an Adder.—In a case in the General Hospital, Birmingham, the parts Avere excised, and the surface cauterized by a strong solution of ammonia. Dry cupping Avas afterward resorted to, and the parts well smeared with olive oil. The pain and SAvelling still coLtinuing,he was or- dered sesquicarbonate of. ammonia 3iss.; decoction of cinchona, gviij., |j. every half hour. A tablespoonful of brandy to be taken every ten minutes; a mustard cataplasm was applied to the abdomen, followed by fomentations of chamomile and poppies. The patient recovered. Part xxiv.; p. 349. Alcoholic Stimuli in Snake Bites.—Dr. Addy writes, that on the western frontier, where rattle-snakes are numerous, and where physicians are often called upon to treat poisonous Avounds by these and other venom- ous reptiles, they almost exclusively rely upon alcoholic stimulants, given in quantities sufficient to produce intoxication. The patient is not consi dered safe until drunkenness is produced, this being regarded by the prac titioners as evidence of the effects of the poison being overcome. Part xxxix., p. 57. » —•-•-•— BLADDER. Irritability of the Bladder.—When benzoic acid is combined with bal- sam copaiba, it has been found to be superior to uva ursi and pareira brava in many cases of great irritability of the bladder, accompanied with muco- purulent discharge. • formula—fy. Benzoic acid, one drachm; balsam copaiba, half an ounce; yelk of egg, enough to form a mixture with seven ounces of camphor mix- ture. M. Two tablespoonfuls to be taken thrice a day. Part vi., p. 140. Catarrhus Vesical.—The decoction or infusion of the leaves of matico, half an ounce to a pint, suggested in catarrhus vesicas. Dose—A table- spoonful thrice daily. part y^., p. 37. Hysterical Paralysis of the .Bladder.—-Sir B. Brodie lays doAvn the rule that m these cases the catheter should not be had recourse to, and the only exception to it is in those extreme cases in which actual paralysis has taken place and the bladder is likely to become diseased if not artificially relieved. A similar Avant of power over the rectum may occur in hysteri- cal women. Vide " Hysteria." part viii., p. 62. Paralysis of the Bladder cured by Cantharides.—A patient was ad- 192 BLADDER. mitted into the Ilopital de la Pitie with paralysis of the bladder, for the relief of Avhich all ordinary methods of treatment had failed. M. Lisfranc ordered the direct application of tincture of cantharides to the bladder by the folloAving mode: One drop of the tincture Avas let into the organ through a catheter, and folio Aved by an injection of simple lukewarm water. Next day two drops were similarly instilled, and the like operation was repeated night and morning for several succeeding days, an additional drop of the tincture being added on each successive occasion. By this method of treatment a cure Avas soon effected. M. Lisfranc found no per- ceptible local irritation to result from the use of the tincture in an undiluted form, Avhile the direct application of the remedy to the organ affected was clearly preferable, in every respect, to its internal administration. Part viii., p. 75. Case of Rupture of the Bladder—Recovery.—[There are feAv cases of recovery from rupture of the bladder on record. The following case oc- curred in the practice of Mr. Chaldecott. At midnight on the 7th of April last, a A'ery respectable, temperate, and healthy man, after passing two or three hours at a concert ran across the street to empty his bladder"; he came in contact Avith a post, the top of Avhich hit against the lower part of the abdomen. Mr. Chaldecott observes:] I saAV him about half an hour after the accident. He Avas faint and siff- fering severe pain over the stomach and belly, Avith desire but no poAverto pass his urine. I ascertained that none had escaped into his clothes, and my suspicions as to the nature of the mischief Avere confinned by the cir- cumstance of nothing escaping through a full-sized catheter which was passed easily and completely into the bladder. He Avas placed in bed, and hot fomentations were used to the belly until reaction took place, with AA'hich came increase of pain over the stomach and abdomen. Twenty leeches Avere also applied ; and I noAV passed a gum catheter, but Avith the same unsatisfactory result as before, not a drop of the urine escaping through it. The catheter was passed every three or four hours, although up to tAvo o'clock r.M., fruitlessly. [The friends of the patient wTere apprised of the extreme danger of the case, and Mr. Key AAras called in. When he arrived, sixteen hours after the accident, there were most decided and alarming symptoms of perito- nitis; the belly was painful, swollen, and tender; pulse rapid and feeble, and the countenance anxious. A catheter Avas passed, and nearly an ounce of bloody urine Avas draAvn away. Mr. C. observes :] At ten o'clock, I gave him tAvo scruples of liquor opii sedativus, Avhich, after a feAV hours, produced some comfortable sleep; and about four hours from the time of Mr. Key's visit I again passed the catheter, and drew off about four ounces of clear urine. From this time, the pain, swelling, and heat in the stomach and abdomen gradually lessened, and it Avas evident that the bladder now held, as on each introduction the catheter brought aAvay clear urine. From this time until the 13th (that is the sixth day from that on which the accident happened), all Avent on Avell, excepting that a smart attack of gout occurred on the 10th, although the patient had never before suffered one ; but on the 13th, from a strong desire to become inde- pendent of the catheter, he made straining efforts to pass his ay a tor, and ho had scarcely passed a tablespoonful, when he felt (to use his own expres- BLADDER. 193 sion) something give way, and a burning pain all over his stomach and bowels, as if boiling water had been poured over them; and the same symptoms of faintness and distress occurred as AA'hen the accident first hap- pened. I saw him within a few minutes of this reopening of the Avound of his bladder, for I could not doubt but such had been the consequence of his attempts to pass his Avater. On using the catheter, not more than a teaspoonful came through the tube. He had jioav again the symptoms of peritonitis, Avith the 'addition of incessant sickness. The same plan^ of treatment was again adopted—viz., fomentations, leeches, and a full opiate with calomel. In about four hours after, on the introduction of the catheter, urine was found in the bladder; and by passing the instrument for a fortnight, amend- ment gradually occurred; a second attack oft gout came on, probably from the absorption of the urine into the system. This case may range with many, in proof of what severe injuries the peritoneum may sometimes sus- tain, and the patient yet survive. Indeed, out of the evil of peritonitis, which usually renders this accident fatal, came the good of such an effusion of lymph, as no doubt glued the bladder where Avounded to the contiguous viscera. The fact of gout occurring upon the absorption of the urine which first escaped into the peritoneum, and its aggravation upon its second ex- travasation, is interesting as connected Avith the pathology of that disorder. Part xiv., p. 235. Treatment of Chronic Cystitis.—This disease, by whatever cause excited, is one of the most painful and miserable affections which we have to deal with. In consequence of the difficulty of successfully treating it, the highest authorities have considered it the opprobrium of surgery. Dr. Macdonnell recommends the folloAving ; 9. Infus. buchu, §vss.; tinct. buchu, 3j.; bals. copaibae, liq. potassae, tincture hyosciam. aa. §ss.; an ounce thrice a day. And inject the bladder thus : the patient being either erect or recumbent, inject warm water at 98° Fahr. through a No. 9 or 10 elas- tic catheter, by means of a caoutchouc bag, or a syringe AA'ith a three-way valve. When the bladder is cleansed, inject in the same manner a solution of from eight to sixteen grains of nitrate of silver in four ounces of dis- tilled water (at 98), Avith or without two drachms of tincture of hyoscia- mus. Compress the urethra so as to keep the injection in for one minute. Then give the patient a warm bath; and if the pain, etc., remain long, employ fomentations and anodynes. If required, repeat the injection at intervals of two or three weeks. Part xvi., p. 202. Cystitis—Scrofulous.—Be particular to rectify any disorder of the di- gestive organs, and enforce great care as to the diet. Then give, especially if the urine is alkaline, small doses of mineral acids in bitter infusions, of iodide of potassium, or chalybeates. If the disease is obstinate, apply a perpetual blister, or, still better, insert a seton above the pubes, or in the ,oins- Part xxi, p. 25. Strychnia in Paredysis of the Bladder.—M. Lecluyse has published some cases in Avhich all ordinary means appearing useless in removing this affection, he gave strychnia internally, but without any benefit to the paraly- sis. He then dissolved six grains in alcohol, mixed it Avith a pint of water, and ordered four injections of gij. each to be introduced through the catheter, the bladder being previously emptied. It Avas folio Aved by complete suc- 13 194 BLADDER. cess. But in another case under M. Robert, this gentleman ordered throe grains in six ounces of water. This not being soluble, the pupil in charge substituted the sulphate of strychnia for the alkali itself. The injection Avas given, but symptoms of poisoning soon came on, and the patient ulti- mately died from "the ejects of the strychnia upon the system. No appre- ciable change Avas remarked in the muscular coat of the bladder; it remained perfectly paralyzed. . 2*art xxii., p. 187. Electricity in Paredysis of the Bladder.—Great benefit will be found to result in this disease from the application of electricity as folloAvs: A silver catheter is introduced into the bladder, and a female catheter intro- duced into the rectum, and made to rest upon the recto-vesical parietes; each of these catheters is connected with one of the poles of an electric machine, which is put at first into gentle action, and then continued briskly for two or three minutes. 2* art xxii., p. 188. Bladder, Chronic Catarrh of.—M. Ricord uses caustic injections, 3ij. of nitrate of silver to §iv. of distilled water. He repeats the injections every three, four, or six days. Part xxii., p. 263. Paracentesis Vesical in Retention of Urine from Stricture of the Urethra.—[Mr. Cooper, in a clinical lecture delivered at Guy's Hospital, remarks, that although the operation of puncturing the bladder per rectum is recommended as the most simple and safe operation for the relief of re- tention of urine depending upon stricture of the urethral canal, yet its indiscriminate use Avould be highly prejudicial. He then proceeds to point out the cases in which he considers it ought, and in which it ought not, to be resorted to. He says :] Surgeons admit three Avays of performing the operation of paracentesis vesicae, namely puncturing above the pubis ; puncturing through the rec- tum—or A-agina in the female ; and, lastly, cutting through the perineum. Of these three, I shall exclude the first, as being in my opinion, the most dangerous, the most liable to lead to extravasation of urine, and the consequent formation of abscesses, and the most likely to be followed by injurious consequences, from the pressure of the canula on the coats of the posterior parts of the bladder, Avhen allowed to remain for some time, as is frequently requisite. If the stricture have existed for a long time,—if the walls of the urethra have become thickened and cartilaginous, so as per- manently to constrict and destroy the function of the canal—if, indeed, from the circumstances of the case, you believe the stricture likely to per- sist, although the patient be, pro tempore, relieved of his retention—I say, in such an instance, I recommend cutting through the perineum. If, on the contrary, you have reason to believe, that, by alleviating his present symptoms, you may afterward be able, by proper medical treatment, to overcome the stricture, then I advise the operation per rectum; so that your conduct must be guided by a consideration of the nature of the case you have to treat. In describing the operation, it will be necessary just to advert to, and bring to your recollection, the anatomical relation of the parts in the peiyio region. The posterior surface of the bladder is entirely covered by peri- toneum, the continuation of the layer descending on the anterior Avail of the abdomen, which, being prolonged to the posterior portion of the base or fundus part of the bladder, is reflected backward to the anterior part BLADDER 195 of the rectum, thus forming a cul de sac, knoAvn as the recto-vesical pouch. In front of this reflected membrane, the base of the bladder comes closely in contact Avith the rectum, being separated only by fibro-cellular tissue and recto-vesical fascia, a portion of the pelvic fascia which descends into the pelvis to retain its contained organs in place. The bladder here pre- sents a triangular surface corresponding in its situation to the trigon in its interior, the apex of the triangle being directed forward to the prostate gland and its sides bounded by the vasa deferentia and vesiculse seminales. It is in this triangular space that the trocar and canula should be intro- duced, and where, it Avill be seen, it can be employed with scarcely any danger of wounding the peritoneum ; for, as the bladder becomes distended in retention, it carries Avith it the peritoneum, thus placing it almost out of the reach of the instrument, and there will be little fear of injuring the vasa deferentia or vesiculse seminales, if the point of the trocar be kept in a direction toward the median line. Bearing these considerations in mind, place your patient on a table, with his pelvis well raised before you, and in the same position as that required for the operation of lithotomy ; then, introducing the index finger of the left hand into the rectum, pass along it the canula, furnished with a " pilot-plug," until it reach opposite the triangular space of the bladder Avhich I have just described to you; withdrawing the pilot, and depressing the canula, until it assumes the direction of a line with the umbilicus, pass in the trocar, and force the two omvard into the bladder. The operation is attended Avith but little pain, indeed, the chief pain is occasioned in endeavoring to introduce the canula Avithout the " pilot-plug," an addition to the instrument Avhich is of grea,t practical advantage; for, without it, the end of the canula seems to catch in the mucous membrane, and to produce such contraction of the bowel as to prevent its onward progress; Avith it, however, no such difficulty exists, for its smooth, rounded extremity readily passes within the rectum, and pilots the way for the canula. To insure success in the operation, the chief circumstance to be attended to is, in thrusting the trocar and canula for- ward, to keep the point well elevated or the handle depressed; othenvise, it may pass betAveen the bladder and rectum, and, on Avithdrawing the trocar, the operator may be extremely mortified to find no fluid following it. Part xxiii., p. 196. Retention of Urine in a Child twenty Months old, from Injury— Puncture of the Bladder above the Pubis.—[The ordinary cases of reten- tion of urine are chiefly arising from obstinate strictures in adults, and have certain rules of treatment. But if it is produced from injury, the treatment must be determined by the circumstances of the case, and more especially so, if, as in this case, the patient is a child of tender years. Two days previously the child had fallen down an area, the perineum coming in contact with the ground. On admission, the countenance is described as being full of anxiety, the limbs motionless, and the pulse 115 and weak. All the ordinary means to favor the introduction of the catheter were of no avail, and the instrument could not be passed.] The child Avas now quite insensible; the respiration rapid and labored; the pulse 125, very Aveak, and almost imperceptible. Mr. Wakley there- fore considered that no more time should be lost in attempts to render the urethra pervious, and determined to puncture the bladder above the pubis. A glance at the situation of the child will sIioav that the pubic 196 BLADDER. operation was almost the only one which could be selected. As there was no stricture, there existed, of course, no distended membranous portion of urethra which could conveniently be punctured, and as for the rectum, the "soft mass at the commencement of the prostate gland," whieh stopped the catheter, Avas no encouragement to resorting to the rectal operation. Mr. Wakley, therefore, punctured the bladder over the pubis in the usual manner. A very considerable quantity of high-colored offensive urine Avas drawn off, and the canula kept in its place by a bandage running round the Avaist. A large poultice Avas placed over the abdomen and peri- toneum, and the child carefully placed in bed. In the evening the little patient became conscious and restless for two or three hours, but he soon fell asleep, and slept nearly the Avliole night. The canula Avas kept in the bladder for three days, and the urine drawn off at intervals. After this period a catheter was easily introduced into the bladder, and the canula being now no longer required, Avas Avithijrawn. The wound healed very rapidly, the urine continued to flow through the urethra, and in eight days the child left the hospital. Part xxiii., p. 198. " Chronic Inflammation of the Bladder.—In obstinate cases of chronic cystitis, Mr. Acton has recourse to the following plan of injecting the bladder with nitrate of silver. To effect this, pass a gum elastic catheter into the bladder, and draw off the urine, and then, with a glass syringe, which fits accurately to the instrument, inject the whole of the following solution into the viscus: 1£. Argent, nitrat. 3ij.; aquae destill. §iv.; M. ft. inject. The immediate consequences are, increased pain, which for the moment is very severe, the vftine that is first passed is bloody, and some tenesmus is experienced. In a short time, hoAvever, these symptoms abate, on the patient keeping his bed, and paying great attention to his diet; at first no liquids should be taken, nor for the first feAV hours preceding tho operation; subsequently the usual quantity of tea or barley-water maybe indulged in, and the various balsams, particularly turpentine or spruce, should be prescribed. In a very feAV days the urine will contain less of this ropy mucus, and ultimately none will be noticed ; in other cases, tho injection may again be resorted to, at the end of four or five days, and repeated until a complete cure is effected. We Arery rarely observe any of the ill consequences Avhich probably might be expected to arise Avhen injections are throAvn into this important organ. Part xxiv., p. 241. Dilatation of the Bladder.—Hypertrophy is the great change to Avhich the prostate gland is obnoxious, and is so common after the age of fifty, that Mr. Adams says it may be almost regarded as one of the necessary contingencies of old age, supervening in a manner wholly independent of inflammation. The condition of the bladder varies remarkably in this dis- ease; occasionally it is so contracted and thickened as to hold but a very small quantity of water, and in other cases is so much expanded as to hold many pints. In the first of these conditions, Mr. Adams belicA'es that there has been inflammation of the prostate, extending to the bladder, and sudden increase in the size of the gland ; and in the second that the increase has been gradual, and accompanied by compensative dilatation of the bladder. This dilatation, proceeding in every direction, presses sometimes on the rectum, and produces obstinate constipation, giving rise to that pouch which is sc BLADDER. 197 convenient a receptacle for small putrefying quantities of urine, or for cal- culi. There often happens, also, a hernia of the mucous coat of the blad- der through its thickened muscular fibres, AA'hich materially aggravates the patient's danger; for these cysts, or supplementary bladders, answer admirably to contain the urine, but, being destitute of muscular fibres, are unable to expel their 'contents, which, rapidly decomposing, inflame the bladder, and not unfrequently set up the peritoneal inflammation, which finally kills the unfortunate patient. The author lays particular 6tress upon what is called the fluttering blow of the bladder, as a pathogno- monic sign of this condition; and as this is an important practical point, we shall present our readers Avith his exact Avords: "As this is a subject in a great measure passed over by writers on dis- eases of the urinary organs, I shall take the liberty of dAvelling someAvhat upon it. So far as I have observed, these cases are usually attended Avith pain about the region of the pubes, and in the perineum, and along the urethra, especially after the evacuation of the bladder; there is generally more or less irritability of this viscus evinced by a frequent desire to pass wafer; hence the surgeon's attention is directed to the state of the blad- der ; the catheter is introduced—it may be without difficulty, or at any rate with no more difficulty than commonly attends its introduction Avhen the prostate gland is hypertrophied; and on the escape of some urine, the flow of water suddenly stops, and a fluttering blow is struck against the point of the instrument, as if a solid body came in contact Avith it: the surgeon, believing that he has draAvn off the Avhole of the urine, is about to Avithdraw the catheter, Avhen a small quantity more escapes, and perhaps the blow is repeated. The impression first.conveyed to the mind of one unaccustomed to it is, that there is a stone in the bladder; but the expe- rienced hand at once detects the nature of the case, or at any rate the idea of the existence of stone is at once removed from his mind. " It is not long since that I was in attendance on a valued medical friend who was laboring under all the symptoms of hypertrophied prostate, with its concomitant horrors, the disease approaching rapidly a fatal termina- tion, when his medical attendant in the country assured me that he had detected the cause of his disease in the existence of a stone in the bladder. On introducing the catheter, I was at once convinced that the opinion was erroneous: I felt the fluttering blow upon the catheter, and ventured to diagnosticate a considerable pouch in the bladder: my opinion was veri- fied on the examination of the body after death, which took place soon ter'" Part xxv., p. 216. Treatment of Nervous Affections of the Bladder.—Irritability and neu- ralgia of the bladder have many points in common; indeed, few authors devote a distinct chapter to the latter affection. Neuralgia of the bladder is described by Dr. Gross to have many symptoms in common with neural- gia attecting other parts ; sometimes the pain is located in one spot, at other times it extends to neighboring organs. There is frequent desire to pass water, and the urine is thrown out in jets, and in small quantity; a distressing soreness is left behind in the urinary passages. A systematic course of cathartics seems most beneficial. If the disease be complicated with amenorrhcea, the cathartics should be combined with aloetic and emmenagogue preparations. A systematic course of purgation is valuable also in neuralgic affections 198 BLADDEK. of other parts of the body, accompanied by inflammatory symptoms. Then carbonate of iron may be employed; but if arising from malarious influ- enee, quinine and arsenic are to be preferred gr. iv. of quinine may be taken every three hours, until 15 or 20 grains have been taken. To eradi- cate both vesical and other forms of neuralgia, em ploy the following:— Acid, arseniosi, gr. ij.; strychnine, gr. j. ; ext. aeoniti, gr. viij.; pulv. opii, gr. v. M. These ingredients are to be carefully incorporated and divided into 16 pills of equal size, of which one may be given every 6 hours, or 4 in the 24 hours. When nausea begins, the pills must be given less frequently, or \ or f of a pill may be employed at a time. Tlie exhibition of thcvpills also should not be continued longer than a week or ten days at a time, to alloAv the stomach a short recess, when they may be again resumed. To moderate the violence of the paroxysms, large doses of narcotics are frequently indispensable. Of these the best are the salts of morphia, either alone or in combination with nauseants, according to the state of the vascular system. When the pain is very violent, or Avhen narcotics can- not be taken by the mouth, opiate injections or suppositories should be used. An emetic of ipecacuanha, or tartrate of antimony, at the approach of the paroxysm, -will sometimes have the effect of cutting it short, or mate- rially abridging it. The remedy is particularly indicated Avhen the disease is associated, as it often is in malarious districts, with gastric and biliary disorder. Much benefit may also accrue, in many cases, from the warm bath, or the application of steam to the affected part. This can be readily effected by connecting one end of a gum-elastic tube Avith the spout of a tea-kettle, filled Avith hot Avater, and placing the other under the bed-clothes. Fomen- tations Avith hops, opium, or laudanum, va ill also be highly serviceable. Part xxvi., p. 109. Treatment of Paralysis of the Bladder.—A clear and practical distinc- tion can be established betAveen paralysis of the neck of the bladder and paralysis of the body of that organ ; the first form being attended -with incontinence, the second with retention. Dr. Gross cautions the surgeons against evacuating th,e Avhole of the urine, accumulated in an over-distended bladder, at one time, as he is satisfied that he has seen several patients die from the severe depression induced by the sudden removal of the distention. In all such instances, he alloAA-s a small quantity of urine to remain in the bladder; and also applies a bandage to the abdomen, as after tapping or parturition. Cathar- tics he considers to be of the utmost service in all descriptions of paralysis of the bladder; and of these, calomel, Avith castor oil and turpentine, in his favorite. Emetics also are not to be neglected. Of remedies acting especially on the nervous system, strychnine, cantharides, and arnica, are the most potent, and are best given in the folioAving formula: Strychnine l-16th of a grain, cantharides l-8th of a grain, arnica from 3 to 5 grains three times in the 24 hours. Of arnica in paralysis of the bladder from fever, masturbation, and general exhaustion, Dr. Gross speaks very favorably. He prefers the tincture, in doses of from forty to sixty drops thrice daily. Counter-irritation, such as a succession of blisters over the dorso-lumbar region, is useful in almost all but the inflammatory form of vesical paraly- sis. The actual cautery is also a proper remedy. Part xxvi., p. 110. BLADDER. 199 Paralysis of the Bladder.—In a case of this affection from over-disten- tion, the patient, a female, Avas ordered to be electro-galvanized three times a week, and to take ten minims of the tincture of the sesquichloride of iron, three times a day, in infusion of quassia. The catheter to be used twice a day. In a fortnight the patient was able to pass the urine volun- tarily, and in a few days more was completely recovered. Part xxvi., p. 342. Puncture through the Rectum for Retention of Urine, from Stric- ture,—After detailing cases in which the bladder Avas punctured through the rectum with perfect success, Mr. Hilton concludes thus: "Let me now, in a feAv Avords, place before you the objections Avhich have been brought against an operation, the useful application of which these lectures have been intended to exemplify. "1st. It has been alleged that there is a great danger of wounding the peritoneum and of causing peritonitis; hut you know, at present, that, in puncturing the bladder through tlie rectum, the peritoneum is not wounded at all. " 2d. Wounding the vesiculae seminales or the vas deferens. The expe- rience of Guy's Hospital shoAvs that this accident happens very seldom, and when it does occur, it is not of much importance. "3d. It is objected that it is very difficult to retain the instrument in the bladder and rectum; but this apprehension need not be entertained, for you have seen hoAv steadily our patients now retain the canula in the rec- tum, thanks to the improvements in our instruments. " 4th. The operation is opposed, because a communication between the bladder and rectum may persist for an indefinite period. This, indeed, may happen, but is very rarely the case. Indeed, I may safely say, that most of those who uprightly and without prejudice find fault Avith the operation, are but very imperfectly acquainted with the actual results of the numerous cases AA'hich have thus been treated.^ Between tAventy and thirty operations of this kind have been performed in this hospital Avithin the last few years, with a success as to result, the most encouraging ; and I doubt whether a. like success could have been attained in cases of equal severity by any other mode of treatment; and that, after all, is the impor- tant point for our consideration. " If the operation of puncturing the bladder through the rectum be, as I believe it to be, devoid of most of the dangers which have been, perhaps, only theoretically attached to it, and also free from many of the dangers and difficulties of the other or substitute operations, it is surely time that surgeons should give it more consideration and more credit for good on its own merits than it has received of late years." Part xxvii. p. 148. Paralysis of Bladder from over-Distention after Delivery, Simulating Peritonitis.—In this case, tAventy-four hours after delivery, symptoms resembling peritonitis supervened. The labor had been tedious and pro- tracted, but no manual or instrumental interference had been required. Dr. Lever passed the catheter and dreAv off seven pints of urine, by which the symptoms Avere speedily relieved. The bladder, however, from over- distention, Avas afterAvard found to have lost its contractile power, aiid the catheter Avas required tAvice daily for its relief. Nine Aveeks aftei her confinement she Avas admitted into the hospital. She Avas ordered to be electro-galvanized three times a Aveek. Water 200 bladder; to be drawn nocte mancque. R. Tinct.ferri scsquichloridi, minim, x., ex. inf. quassia?, t. d. The patient was restored to health. Dr. L. Avas afterward called to this patient, her attendants supposing she was suffering from puerperal peritonitis, but the diagnostic symptoms were wanting; pain there was and increased by pressure; the pulse quickened, but not tciry; the skin moist, and the perspiration had a urinous smell; her position was peculiar, but was that Avhich is often remarked in over-distended bladder ; the hand pressed upon the perineum. The introduction of the catheter soon solved the doubt, and her recovery of the poAver of micturition was due to that valuable agent recommended by Dr. Radford of Manchester.. - 2'urt xxvii., jo. 217. Bladder—Gout in the.—In this disease the mucous membrane of the bladder readily secretes pus. If this is not freely evacuated, the urine be- comes alkaline from the retention of a small portion of it, and the subse- quent formation of ammonia by the decomposition of the urea. This alkaline urine again keeps up the irritability of the bladder, Avhich thus goes on secreting pus. There is also, in this disease, frequently incontinence of urine, not because the sphincter vesicae is paralyzed, but because.the bladder Avill not alloAV the accumulation in it of even a small quantity of urine. In other cases there is an opposite condition; the patient may have retention of urine. This is easily explained : in the former case, the gouty poison was irritating the mucous membrane; in the latter it has affected the muscular coat. Noav, if, in there cases, Ave find it clearly proved that the man has the gouty diathesis, and that there is no stone in the bladder, we may consider the eruptions to arise from gouty inflammation attacking the bladder. In the treatment, Ave must first counter-irritate, but not with turpentine or cantharides, for obvious reasons, but Avith mustard or strong ammonia. To relieve pain, if it be that form of the disease in which pus is generated, Ave may apply opium endermically, or apply an opiate liniment over the bladder, or we may give an enema containing opium by the rectum, repeated or not according to the relief obtained. In these Avays all kinds of irritability of the bladder, even that produced by cantharidine, may be relieved. It should be borne carefully in mind, that, whenever gout attacks internal organs, it is a disease of an asthenic character, and therefore depletory measures should in no case be employed. Part xxviii., p. 141. 'Irritability of the Bladder treated by Nitrate of Silcer Injections.— A patient, of nervous temperament, with soft and flabby muscles, had irritability of bladder, which ordinary remedies had failed to relieve. A solution of nitrate of silver, twenty grains to the ounce, was introduced into the bladder, and so great was the relief that the symptoms entirely disappeared for six months. At that time the same treatment repeated completely removed the symptoms. Part xxviii., p. 208. Irritable Bladder.—[The bladder is frequently made irritable by differ- ent states of the urine and various concretions, but it may be irritable without these being the primary cause. Dr. Jones gives us some of the most interesting examples of direct and of sympathetic irritation of this organ.] The most simple instance of direct irritation may be observed when some irritating liquid substance, as cantharides, turpentine, or copaiba, BLADDEE. 201 exists in the water, or when some solid body, as a calculus, is lying in the bladder. These act as, for example, chlorine or a foreign body in the bronchial tubes Avould do in producing cough. I need not read you ex- amples of irritation thus produced; I may, hoAvever, repeat, that simple excess of acid or alkali in the urine alone, rarely, by itself, causes irritable bladder, though most decided instances of their effect may be observed. Here, for instance, is an example of the effect of acidity. I Avas sent for one evening to a gentleman Avho Avas suffering intense abdominal pain, which came on at intervals of a minute, and which he attributed to indi- gestion. The fits of pain, on reaching to the greatest intensity, relaxed, soon again to recur. With a full dose of calomel and opium, ether and sal volatile, in three hours this colic subsided; but he began then to com- plain of scalding and difficulty of passing the water. During the night he had constant calls, passing only a teaspoonful of urine at a time. For this he took nitre, carbonate of potass, and barley-water. The folloAving morn- ing the irritability of the bladder had diminished very much, and during the day it disappeared. On examining the urine made during the time the bladder was so irritable, I fouad no trace of blood-globules, mucus, or pus-globules, but only a state of very high acidity, which, in twelve hours, gave rise to a very large deposit of uric acid. I believe this ex- cessive irritability of the bladder arose only from the intensely acid state of the urine. Sometimes, instead of the direct irritant being applied inside the blad- der, it acts from the outside. As examples of this, I • may mention the irritable bladder of pregnancy, of abdominal tumors, and even of faeces which have accumulated in the bowels. In a case of irritable bladder arising from this last cause, the patient's- general health being good, except irregular action of the boAvels, Dr., Jones advised some camphor and henbane at night, Avith cold Avater enema, and an aloetic aperient. A month afterward, the patient considered him- self cured. Dr. Jones next proceeds to consider that direct irritation Avhich depends on idiopathic inflammation, independent of the irritating qualities of the urine. Idiopathic inflammation of the bladder is the most common in advancing years, Avhen the prostate gland ceases to be healthy; then some very slight cause is sufficient to determine the commencement of the inflamma- tory action Avhich gives rise to most urgent symptoms of irritable bladder. Exposure to cold, the fatigues of a journey, inconvenience causing volun- tary retention of the urine too long, each of these I have known to be the immediate cause of acute inflammation of the bladder, in consequence of which the Avater has been passed every hour, and even oftener. At first it is scanty, high-colored, with blood-globules, and quickly pus-globules are found; and these continue when the inflammation is subsiding, and the frequency and urgency of making Avater are much lessened. Such an attack I have Avatched through its Avhole course ; the symptoms rapidly becoming more and more serious, constant hiccough and nausea, producing prostration, which threatened the life of the patient. These symptoms, however, I have seen yielding after treatment; and in two months no trace of blood or pus remained in the urine, and the patient in all respects entirely recovered. More commonly the acute attack passes into chronic disease, and then Avith more difficulty is removed; or, after months and 202 BLADDER. sometimes years of suffering, the kidneys become affected, and the patient sinks. [He illustrates this irritability by some very interesting cases, such as by crushing a calculus, cutting for stone, and from a stricture.] In most cases, as the mucous membrane becomes diseased, the urine gradually becomes so also, and then it also nets on the bladder, greatly. increasing the suffering and the difficulty of the -cure. Thus the two causes acting together, react also on one another. The same result is pro- duced when the irritable bladder is caused at first by the state of the urine alone, as, for example, Avhen it is highly acid or alkaline, then it slowly acts upon the mucous membrane, and finally, both the state of the mem- brane and the state of the urine together hasten on the disease. In distinction to these cases of direct irritation, there an; others which J may class together under the head of sympathetic irritation, in Avhich ap- parently neither the urine nor the mucous membrane of the bladder are perceptibly different from the healthy state. The most frequent cause of this sympathetic irritation is probably dis- ease of the kidney itself, although it is by no means the fact, that in all diseases of the kidney irritation of the bladder is produced. Most com- monly the irritation occurs when some calculus or inflammatory action exists in the pelvis of the kidney; then a small quantity of purulent matter mixed with the urine may indeed pass into the bladder, but this usually bears no proportion to the amount of irritation which occurs. The first explanation of this irritation that presents itself is that the inflammation extends doAvn the ureter to the bladder; but on post-mortem examination this cannot usually be proved, and hence these cases must be classed under the head of sympathetic, and not of direct irritation. Hysterical irritation of the bladder belongs to the class of cases of Avhich I am now speaking. In all supposed hysterical diseases, the first thought should be, Avhether the hysteria is the cause or the consequence of the disease. Is the hysteria idiopathic or symptomatic ? Often it will be found that hysteria is but one symptom of a complaint, which, in addition to other effects, produces irri- table bladder; but occasionally no other complaint can be detected, and no cause for the irritable bladder can be found except the hysteria itself. The previous history will often assist in giving the true ansAver to the question Avhich you must ask before you can commence your treatment on reasonable grounds. Moreover, Avhatever may be the cause of the irritable bladder, yet in all cases, whether of direct or sympathetic irritation, both in men and in women, a smaller or a greater part of the irritability may be always traced to nervousness. This is usually seen in the fact, that in such patients a passing thought will suddenly cause the most urgent desire to empty the bladder, and that while the mind is fully occupied, the irritability will be less distressing. In irritable bladder, more perhaps than in most diseases, it is requisite that, before any method of treatment is begun, you should endeavor to obtain clearness as to the cause of the disease. It is produced by so many different causes, that specific treatment of the irritation w ill rarely suffice. You may palliate it as you would a cough by opiates and sedatives; but to effect a cure, the cause of the disease must be found, and be capable of removal. Ask yourselves, then, first, is the irritation direct or sympa- thetic ; if the former, is it simple or compound, internal or external ? BLADDER. 203 While endeavoring to remove the cause, you will often find palliatives of great importance. Of these, the most important are camphor and opium. Three grains of camphor and half a grain of opium made into a pill, taken twice or three times daily, will often prove beneficial. In some cases, palliatives fail, and cure is impossible. In these, .mechanical contrivances of the present day do aAA^ay with much of the discomfort and annoyance Avhich otherwise would have to be endured. Part xxx., p. 78. Irritability of the Blaelder.—1. As a Consequence of Gonorrhcea.-^Give iodide of potassium, and active tonics, as cinchona, Avith doses of Plummer's pill; or colchictim, combined Avith blue pill; or ten grains each of pow- dered guaiacum and calcined magnesia once or tAvice a day. 2. As a Consequence of Diseased Prostate.—Pass a catheter occasionally, i.e., Avith intervals of tAvo or three days or longer. If there be some little purulent discharge, apply a little nitrate of silver to the prostatic portion of the canal. 3. When accompanied by more or less Mucus in the Urine, or Muco- purulent Deposit.—Apply stimulating injections to the bladder. Nitrate of silver from half a grain to two grains to the ounce, increased, if need be, to ten and even fifteen grains to the ounce. Give half a grain to a grain of acetate of lead, Avith two grains of extract of opium. Give nitric acid, one or tAvo minims to the ounce of water, Avhen the urine is loaded Avith earthy phosphates. Creasote and copaiba are also recommended in some cases. The injection of simple Avarm water is often useful, and when the urine is very offensive, a solution of chloride of soda, from six to ten grains to the ounce of Avater, used once a'dayj is recommended. The vulcanized india-rubber bottle, fitted with pipes and valves, is the best instrument. In non-inflammatory cases, give infusions of diosma or buchu, or uva ursi, combined with hyosciamus or camphor, and even copaiba or chios turpen- tine. Pareira brava is also strongly recommended, but often disap- points us. Part xxx., p. 83. Bladder—Apparatus for Injecting.—Adapt a short bit of india-rubber tubing to the end of the catheter before its introduction. After intro- ducing it, the conical nozzle of a common ear-syringe is easily admitted into the other end of the elastic tubing, and the thing is ready for use. This keeps the catheter more steady. It prevents joggling. It saves the use of a stopcock, as the tube is compressible, and lastly, it connects any sized catheter Avith the syringe. Part xxxi., p. 168. Bladder—Injection of.—Take a piece of elastic tubing, the diameter of a quill, and about four feet long. To one end must be attached a small india-rubber funnel, the other end grasps the end of the catheter. When ready, the funnel end is held up at arm's length, and water poured in; the pressure of the column of fluid fills the bladder, Avhich may be emptied again by depressing the tube. This tube might conveniently be attached to the end of the female catheter to prevent the need of having any utensil in bed. Part xxxii., p. 176. Method of Removing Foreign Bodies from the Urethra and Bladder:— Mr. M. II. Collis recommends incision in the mesial line, in front of the anus, for the removal of foreign bodies from the bladder. He says : "The membranous part of the urethra is not more than an inch to an inch and a half distant from the verge of the anus; hence we can strike it with ease 201 BLENORRIIAGIA. and certainty, when the perineum is in a healthy condition. By drawing the rectum down Avith the forefinger, while an assistant raises the bulb tOAvard the pubis by the staff, the knife can be inserted with salety to tho depth of an inch or so in the mesial line, and then, by depressing the curve of the staff, the point of the knife comes directly in contact with the mem- branous portion. If the incision be made accurately in the mesial line, no vessels Avill be wounded; and as the membranous portion only is opened, there can be no extravasation of urine forward. The incision in the integu- ments might be enlarged by commencing it further forward, if necessary, to give room for the extraction of a larger substance, or for the introduc- tion of the finger and forceps together.....Even Avhen the fragment of catheter or foreign body has slipped into the bladder entirely, the central incision would seem to be the easiest and least dangerous operation for extracting it." Part xxxii., p. 177. Irritable Bladder.-—Where there are all the Avorst symptoms of stone, without any appreciable cause, if the usual remedies fail, you may perforin cystotomy, by making an incision in the mesian line of the perineum, in the manner of Allarton's operation for stone, the object being to cut across the nervous plexuses and irritable parts of the neck of the bladder. Part xxxiii., p. 209. Bladder and Uterus—Reciprocal Sympathies of. — VideAvt. "Uterus." Irritable Bladder.—The greatest relief will often be obtained from the injection of the bladder with carbonic acid gas. This may, if desired, be combined with the vapor of chloroform. A caoutchouc bag holding four ounces, and an ordinary catheter, may be conveniently used for this pur- pose, a space being left in the neck for a piece of sponge soaked in chloroform. Part xxxviii.,^?. 161. —•-♦-•---- BLENORRHAGIA. Monesia.—The extract of monesia, in the form of pills, in doses of from twelve to forty grains, during the day, recommended in cases of blenor- rhagia. Part \\.,p. 77. Seat of Blenorrhagia in Females.—" In females," says Dr. Gilbert, " the seat of election of blenorrhagia is the meatus urinarius, as in the man; but in all cases Avhere I have used the speculunij I have seen a uter- ine discharge accompanying that of the urethra, and continuing after the latter is cured, so that the neck of the uterus may be consielered theprin cipal source of the blenorrhagic flux in women. Nevertheless, some modern writers have designated the female clap by the term vaginitis or inflamed vagina; but in the immense majority of cases, the vagina does not secrete the discharge, and if it be sometimes red, this appearance is transient, and yields rapidly to repose and cleanliness. It is only in a few rare cases that Ave meet Avith a milky or purulent discharge, really fur- nished by the vagina; on the contrary, in every woman who has con- tracted a clap, there exists, during the tAvo or three Aveeks, a characteris- tic suppuration, together with a discharge, originating iti the neck of the BLOOD-LETTING. 205 uterus, which last, by its continuance after the cessation of the urethral symptoms, maybe confounded with leucorrhoea." Part \\.,p. 137. Blenorrhagia of Vulva.— Vide Art. " Vulva." Blenorrhagia of the Excreting Duct of the Vulvo- Vaginal Gland.— Dr. Salmon directs attention to the affection very common among prosti- tutes, yet little known to the generality of practitioners, namely, purulent hyper-secretion of the excretory duct of the vulvo-vaginal gland, a disease first pointed out by M. Huguier, and described by him as the occasional source of blenorrhagia in the male. It is noAV universally known, that there exists on each side of the A'agina, at the orifice, and imbedded in the labia, a glandular body, the duct of which, half an inch long, opens just at the base of the hymen,' or by the caruncnlse myrtiformes. During erotic excitement, a viscid fluid, similar to the prostatic fluid in the male, is abundantly poured forth to lubricate the female external organs.- The signs by which the disease may be known are derived from exami- nation only. The Avoman experiences no inconvenience, nor does she think that she needs medical aid. Moreover, she may, if she pleases, con- ceal her disease, by making water, or by using as an injection a strong solution of alum, shortly before the visit of the inspector. This discharge of pus may be easily overlooked, OAving to the narroAvness of the duct. It is necessary that the surgeon should first make moderate pressure of the labia against the rami of the ischia, by the thumb applied in front of the anus, that it may be ascertained Avhether the gland be tumefied. In the natural state, it cannot be detected by the touch; if swollen, it feels like a rounded body, the size of a nut, or larger. Firmer pressure made against the ischium from within will cause the contents to escape. The normally constituted fluid is thick and clear, and appears at the extremity of the duct in not larger quantity than a drop or tAvo. The fluid from the inflamed gland is either thick, more abundant, and mixed with mucus, Avhen the girl should be put under surveillance ; or yellow and puriform, Avhen she should be removed to a hospital. The treatment resembles that of blenorrhagia in other situations. The result is much more rapid. Absolute rest; injections of nitrate of silver, with Anel's syringe; cauterization with the tincture of iodine; baths. The duration is about twenty days. Part xxxi., p. 208. m BLOOD-LETTING. A low feverish state is apt to be induced by a^too long protracted us>e of depletory and debilitant remedies. Part \.,p. 23. Efects of Excessive Blood-letting in cases of Injury of the Brain, as in Concussion.—Sir B. Brodie remarks, that where bleeding has been carried to a great extent, symptoms frequently occur which in reality arise from the loss of blood, but which a superficial observer will be led to attribute to the injury itself, and concerning Avhich, indeed, it is some- times difficult even for the most experienced surgeon to pronounce, in the first instance, to which of these two causes they are to be referred. Re- 206 BLOOD-LETTING. peated copious blood-letting is of itself adequate to produce a hardness of the pulse, Avhich Ave shall in vain endeavor to subdue by persevering in the same system of treatment. In many individuals it will produce head- ache and confusion of the mind, not very different from what the injury itself had previously occasioned. The pallor of the countenance, the effects of position, the effects of fasting or of an active purgative, the his- tory of the ease, must be carefully considered in forming our diagnosis The treatment Avould then consist in carefully restoring the system to its state of equilibrium. Part vl, p. 38. Pain in the Head.—Advised not to bleed an old person merely be- cause the pulse is hard and full, in cases of pain in the head, as it is pos- sible that this state of arteries may arise from ossification of their coats. Effusion.—Bleeding in a moderate degree prevents effusion, but Avhen carried to extreme depletion, it has a decided tendency to promote effusion. Part viii., p. 66. In detracting blood from the chest, in cases of apoplexy, congestion of the lungs, etc., in neAv-born infants, the best place to apply leeches is un- der the axilla, as the sub-cutaneous venous plexus there communicates directly Avith the vessels of the thoracic canity. Part ix., p. 39 Blood-letting, and other general antiphlogistic remedies, says Dr. Wil- liams, if they do not remove inflammation, may render its products more injurious, by lowering their plasticity, and approximating them to tubercu- lous and other aplastic deposits. Thus chronic inflammation continuing after the full application of the antiphlogistic treatment, almost surely tends to produce degenerated changes of structure, over which remedial art has little poAver. In connection with this subject, therefore, we see hoAV desirable it is that inflammations should be removed before they be- come chronic ; and when there is a risk of their becoming so, it should be an indication to improve the condition of the blood by a tonic and nutri- tive plan, at the same time that local antiphlogistic measures may be neces- sary for the lingering inflammation. Part ix., p. 75. Tlie Hcemospasic Method of Treatment suggested as a Substitute for Blooddetting.—Haemospasia is a means of producing a poAverful revulsion of the blood from the one part, and an equally poAverful derivation of the blood to another part of the body, by removing the atmospheric pressure from a large extent of surface, as from one or both extremities at the same time. It is, therefore, so to speak, quite the same as dry-cupping; only on a large scale. " To produce an intense raptus of the blood from the deep-seated to the superficial parts of the body, to dissipate congestions, to counteract morbid fluxionary accumulations, and to relieve any organ or organs that may be oppressed with a surcharged circulation—such ie the aim and object of the new therapeutic agent. By its means, we are enabled to Avithdraw, or displace, or accumulate, or concentrate a part of the mass of blood, according as the varying circumstances of the consti- tution, age, existing disease, and so forth, may render expedient." Part ix., p. 79. Blood-letting.—On this subject Mr. Travers says: The choice of mea- sures, i. e., local or general blood-letiing, is determined partly by the rela- BLOOD-LETTING. 207 tion of the parts affected to the centre of the circulation, and in part by the more or less urgent necessity that exists for disembarrassing the general functions, and arresting destructive inflammation. In visceral inflamma- tion, venesection is indicated to the utmost extent that the powers of life Avill bear; for here the mass of blood is so altered and spoiled for its pro- per and healthy purposes, by the direct implication of the blood-making and blood-preparing organs in the disease, that relieving the system of its presence to the extent that can be borne, is the main resource Ave possess for its preservation. As Ave Avould remove a poison, a materies morbi, in such cases Ave take aAvay blood. Its altered condition is palpable when eliminated from the body; it undergoes a peculiar separation of its parts, and presents other appearances not manifested by healthy blood. The dif- ference of the blood Avithin the A'essels from that of health, is not less, if we could fully appreciate it. If inflamed blood be transferred into the vessels of a healthy animal of the same species, as his own is Avithdrawn, instead of supporting, it rapidly destroys life. A freer circulation through the smaller vessels, and those of the excretory glands especially, ensues almost immediately upon a full blood-letting; the sense of overwhelming oppression is relieved, and the inflammation, if not abridged by its effects, is disposed to a kindlier termination. There are two false doctrines concerning blood-letting for inflammation, Avhich cannot be too strongly condemned: the first, anticipatory blood- letting, by which I mean, the large and repeated detraction of blood be- fore inflammation, being considered inevitable, has actually manifested itself—on the hypothesis of starving the action, and thus rendering it trac- table—which is a direct attack upon the vitality, and fatally prevents the action, if it do not destroy the resisting powers of the system. The second, continuing the employment of the lancet so long as the last drawn blood exhibits the signs of inflammation, Avhich, if drained to the last drop, it would do ; or, in other Avords, not reflecting that there is a line beyond Avhich the practice becomes destructive instead of remedial; and that there are many inflammations Avhich do not admit of arrest by deple- tion, and upon which other modes of treatment are efficient to this end, even though not an ounce of blood be drawn. Many lives have been sacrificed to the prevalence of these irrational and absurd notions, and many preserved in their extremity by being fortunately placed beyond the reach of the surgeon; especially, I am induced to believe, in military practice. Part xi.,p. 36. Mode of Diagnosing Buffy Blood.—Mr. Wharton Jones has pointed out a very ingenious method of determining Avhether the blood is buffy, or not, from the examination of a very minute portion of this fluid. It consists of quickly inclosing a drop betAveen two pieces of glass, and ob- serving Avith the naked eye the quickness Avith Avhich it assumes a mottled appearance, and the smallness or largeness of the interspaces. In buffy blood the mottling is almost instantaneous, and the interspaces large, Avhile in healthy blood it is delayed for half a minute or more, and the reticu- lation is minute. Part xii., p. 254. Venesection from the Foot, is capable of affording great relief in many affections of the generative organs, the portal system, etc., Avhen its ab- straction from a vein in the arm is either difficult or impossible. Immerse the foot in hot Avater to swell the veins. Put on a bandage an inch 208 BODLB. above the ankle. In puncturing either of the veins before the malleoli, bo careful not to touch the bone with the point of the lancet. If the vein bleed in a stream, catch the blood in a vessel; but if it only dribble, tho foot should be put into the hot Avater, and judge of quantity by the color. Part xiv., p. 193. Criterion for the Regulation of Blooddetting.—The time for the dis- continuance of blood-letting should be determined not by the blood drawn ceasing to be buffy, but by its coagulating more rapidly than in the nor- mal state. Part xxi.,p. ni, Ml--- BOILS. Use of Yeast in the Treatment of Boils.—To an adult afflicted with this painful furuncnloid eruption, give a tablespoonful of yeast Avith some Avater three times a day. Smaller doses may be given for children. Part xxvi., p. 294. Treatment of Boils and Acne—Mr. Starting Treatment.—We have classed these diseases together because they appear to depend ATery fre- quently on similar states of the constitution, and are also amenable, for the most part, to similar plans of treatment. The great degree of success Avhich we have observed to accrue from that pursued at the Hospital for Diseases of the Skin, makes us desirous of attracting to it the attention of the pro- fession. It consists, essentially, in the combination of ferruginous salts with saline aperients. In the common forms of acne, as acne simplex and punc- tata, Mr. Startin usually prescribes ferri sulphat. gr. ij., magnes. sulph. 3j.,« ter die sumend.; ordering also a small portion of an ointment, containing the ammonio-chloride of mercury, gr. x. ad §j., to be applied to each pim- ple every night. The acne indurata is characterized by much more of in- flammatory condensation of tissue, for the removal of Avhich it is usually necessary to excite the absorbents to increased action, and the iodide of iron, in doses of gr. iij., three times daily, appears to be its most efficient remedy. All A\rho have attentively watched the phenomena attendant on the furunculous epidemic Avhich has been so rife of late years, will be aware that its outbreak in individuals has been very frequently preceded by head- ache, giddiness, lassitude, dyspepsia, and other evidences of a disordered state of the circulating fluids. This granted, and we have at once a scien- tific basis on Avhich to ground the requisite treatment. By the exhibition of full doses of iron, in combination Avith saline purgatives, the blood is at once depurated and renovated. The usual prescription at this hospital ismist. ferri acid. 3iij. ter die, and under its use the improvement in the general health is often no less manifest than the rapid subsidence of the local dis- ease. With greater care in regard to purgation, the same plan may be adopted in cases of small carbuncles. Part xxvii.,jt>. 161. Boils— Use of tlie Acid Nitrate of Mercury.—A solution of the nitrate of mercury in strong nitric acid is in very common use at the Hospital for Cuta- neous Diseases, and constitutes a very convenient form of caustic. Its for- mula is—IJ. Hydrargyri §j., acidi nitrici (specific gravity 1.50) §ij.; solve. The solution produced is a clear, colorless fluid. BOILS. 209 Mr. Startin thinks there can be little doubt as to the superiority of the caustic treatment over that by the knife, even in the case of very large boils. The pain of the incision, the large sore caused, and the unsightly scar which follows, constitute very formidable draAvbacks to a prac- tice for Avhich there is no real necessity. At this hospital, where cases of boils are very common, the knife is never resorted to. The general treatment consists in giving aperients and steel conjointly, and the local in applying to the apex of the furuncle a full-sized drop of the acid nitrate solution. The morbid action generally terminates coincidentally with the application, and the core is thrown off through a comparatively small open- ing, the resulting cicatrix being insignificant. Part xxxi., p. 240. Observations on Anthrax.—Mr. Lloyd, who acted a long series of years with the late Mr. Abernethy, stated that anthrax and boils were almost unknown in Mr. Abernethy's time, but that, of late years, from the impor- tation of much bad corn into England, he is inclined to believe, and per- haps from meteorological causes, anthrax has assumed almost the character of an epidemic. Like Mr. Syme, he thinks anthrax, or carbuncle, to be a circumscribed inflammatory condition of the true skin, attended with con- siderable constitutional derangement, as Avell known to most practitioners; Mr. Lloyd disapproves of the stimulating plan of treatment, and prefers salines, Avith Mindererus, to diminish fever, with large free crucial incision made early in the inflamed part. The object of the incision is to diminish the inflammatory action, which, he believes, is of a low specific kind, and that by plugging the parts subse- quently with lint, this carbuncular inflammation gives way to common healthy inflammation and granulation. He does not advise the external use of either caustic or Avhat are called warm digestive ointments; they are very old-fashioned, and merely protract unnecessarily the period of reco- very, and destroy more of the skin than is expedient. In cases of anthrax as well as large boils, the evil is aggravated, Mr. Lloyd believes, by giving patients too much food of a stimulating kind. The core of an anthrax, or boil, is perhaps not so often dead cellular matter, as a new morbid deposit, like the morbid deposit in the pleura, or in or around joints, and pointing to an inflammatory action going on in the system. Simple milk diet, poul- tices, salines, and diaphoretics, with free crucial incisions, ansAver every purpose, Avith the subsequent exhibition of a light bitter, with iodide of potassium, during the period of convalescence. Part xxxiv., p. 196. Boils and Carbuncles.—As these depend on a constitutional cause, the constitutional treatment must be combined with the local. The application of concentrated tincture of iodine rarely fails to abort an incipient boil. Nitrate of silver and sesquichloride of iron have been used for the same purpose. If gangrenous, apply strong nitric acid to the sloughing margin. If there he a large amount of sloughing, but not unless, make a free crucial incision. Water dressing is the simplest and most soothing application,. and the most scrupulous cleanliness must be observed. ********* The best way of treating all these boils and carbuncles is to pinch up a little of the skin when the carbuncle is just commencing, and to carry a sharp-pointed bistoury, Avith the cutting edge upAvard, through the base 14 210 BOILS. of the little hard substance, and so divide it completely. This is almost a never-failing mode of arresting carbuncle, if done early enough. Iiart xxxv., p. 149. Treatment of Boils and Carbuncles!—Dv. Shillitoe gives his plan of treatment as folloAvs: " My plan is to order a thick solution of the aqueous extract of opium, of theconsistence of treacle, to be painted on and around any suspicious spot that may arise. This soon dries, forming a coating, Avhich requires reneAving three or four times a day. Generally tAventy-four hours' appli- cation is sufficient to arrest the further spread of the inflamed spot. I then order a plaster of equal parts of soap, mercury, and opium, spread on thick leather, to be placed on the spot. If there is a pustule, I evacuate it, and leave a small hole in the centre of the plaster to allow of the escape of any matter, or if painful, for the application of the opium and poultice. When it is desirable to poultice, I take care that the plaster is large enough to protect the surrounding skin, and I discontinue the poultice as early as possible. In this Avay, Avith early attention to small spots and a limited amount of poulticing, combined Avith ordinary care in diet, occasional ape- rients, and tonics, of which last I prefer bark and nitric acid, I seldom find any difficulty in preventing the successive crops of boils now so com- mon. " When called in at a later period, or if in spite of treatment a boil or carbuncle will have its course, I think strong nitric acid to be the best ap- plication, using it freely two or three times, removing the dead tough slough before each application, supporting the margins Avith the plaster, and poulticing freely." Part xxxvii., p. 270. Boils and Carbuncles.—Paint the whole mass of indurated tissue Avith at least three coats of the common pharmacopoeia tincture of iodine for several nights in succession, and unless the boil has been on the point of bursting, the progress will be arrested in nearly every instance, and the hardness, SAvelling, and tenderness of the part will quickly subside. ********* The local use of belladonna to carbuncles or boils, and other painful cutaneous affections, will be found to afford the greatest relief to the patient. ******** The great pain arising from carbuncles is in many cases relieved Avith re- markable rapidity by the application of the following ointment spread upon a linen rag: Take of opium half a drachm, white ointment two ounces, and mix. This treatment is applicable to any stage of the affection. Vide Art. "Carbuncle." Part xxxviii.,/). 175. BONES. 211 BONES. Difference between Syphilitic and Scrofulous Affections of Bone.— [M. Bicord enumerates the following points of difference:] Syphilitic Affections of Bone. Scrofulous Affections of Bone. 1. Very rare with young people. 1. Very frequent in youth. 2. Syphilitic precedents. 2. Scrofulous precedents. 3. Compact texture of bones attacked. 3. Spongy or cancellated texture of bones attacked. 4. Superficial part of the bone. 4. Deep parts of the bone. 5. Little tendency to hyperostosis. 6. Much tendency to hyperostosis. 6. The pains which precede the develop- 6 The tumefaction precedes the pain, but ment of the affection increase and become the latter soon increases and becomes more very intense, until they decrease again, and and more intense as the disease advances. entirely disappear in the latter periods of the disease. 7. A tendency to circumscription. 7. A tendency to diffusion. 8. Exostosis. 8. Hyperostosis. 9. Tendency to ossification and eburna- 9. Tendency to softening, to suppuration, tion, but very little to suppuration. caries, and necrosis, and not to ossification. 10. A chain of syphilitic symptoms, either 10. A chain of scrofulous symptoms widely concomitant or antecedent.. differing from those of syphilis, either con- comitant or antecedent. 11. Rapid cure under appropriate treat- 11. Very difficult cure, often incomplete, ment. and sometimes impossible. Syphilis may, however, be superadded to scrofula; we must, then, in combating any lesion, endeavor to find out to which of the tAvo diatheses it is mostly OAving, and select our therapeutic means accordingly. Part xviii.,/). 151. Suppuration in Bone.—In every healthy inflammation the process of adhesion precedes that of suppuration, and pus when formed is conse- quently limited and circumscribed by lymph previously effused; but in unhealthy constitutions, the requisite poAver may be wanting to carry out the process of adhesion ; and should suppuration then take place, the puru- lent fluid may permeate from cell to cell in the surrounding parts. These two processes are exemplified on the surface of the body by a common abscess and a diffuse cellular inflammation. In the cancellous structure of bone, the actions are strikingly analogous, though somewhat more tardy in their development. The products of the inflammation may be limited by the effusion of bony matter,Avhich fills up and obliterates the surround- ing cancelli; or the secretions of the part (when the adhesive process is imperfectly developed) may infiltrate the structure of the bone to an un- limited extent. We have thus a natural division of the cases of suppuration in bone into those Avhich are circumscribed, and those Avhich are not; into cases of abscess, properly speaking, and into those of purulent infiltration. These tAvo classes of cases differ in their causes, progress, and termina- tion. The simple abscess usually originates in young and healthy persons: the infiltration of purulent matter rarely takes place Avithout some present depressing influence, or some former cause of constitutional Aveakness. The simple abscess is marked in its progress by excessive pain, and may continue in much the same condition for many months and even years. Diffuse suppuration, on the other hand, may be attended with little local Buffering, but very soon becomes the cause of much general excitement, 212 BONES. and leads to the formation of disease in other parts. Tlie termination of circumscribed abscess is generally favorable, hoAvever long it may have lasted, provided the matter be evacuated externally; whereas purulent infiltration in bone is usually fatal. Chronic abscesses require, moreover, to be carefully distinguished from cases of softened tubercle, Avith which they appear to have been con- founded. M. Nelaton published the following description of encysted tubercle in the extremity of long bones: "When an encysted tubercle is developed in the extremity of a long bone, it is at first confined in the centre of the cancellous structure, not far from the articular extremity. It gradually increases, and approaches on one hand the cartilage, and on the other the circumference of the bone, external to_the joint. If in the progress of its development it reaches the exterior of the bone, it escapes into the surrounding cellular tissue; an abscess is there formed, which increases and empties itself externally, leaving a fistulous communication with the interior of the bone. But if, on the contrary, it makes its way toward the articular surface, the cartilage Avith Avhich it comes in contact is perforated, and the tubercular matter empties itself into the joint." M. Nelaton says that he has seen several examples of this unfavorable ter- mination of the disease. But the cases of crude tubercle in ackrlt bone to be found in our museums are so rare, Ave cannot but think that the fre- quency of its occurrence has been greatly exaggerated, and that M. Nela- ton, and other continental writers, have included cases of softened tuber- cle and chronic abscess under one common description. Chronic abscess may probably occur in any bone of the body. In th« museum of the College of Surgeons there is a specimen where it had taken place in the clavicle ; and Mr. Arnott has mentioned an instance of its having occurred in the femur. At King's College Hospital a case lately presented itself, where a circumscribed abscess had formed in the loAverjaAV, the bone around being greatly condensed and thickened. By far the majority of cases of chronic abscess, however, occur in the tibia, and almost always in the upper or lower extremity of that bone. When an abscess is formed in bone, important changes occur in the sur- rounding parts. The periosteum and adjacent bone become inflamed and thickened. This is folloAved by the formation of neAV bone, both in tho cancellous structure, and on the surface of the original bone. The bony matter thus secreted corresponds to the deposition of lymph around an abscess in soft parts. This deposition may go on, as the bone in immediate contact with the pus is absorbed ; so that, although the abscess is gradually making its way externally, it remains covered with the same thickness of bone as before. Deposition of neAv bony matter occurs much more readily around the spongy extremities than upon the compact shafts of bone. In. the former situation, it may take place to such an extent as to render it very difficult to say precisely what part of the bone was originally affected, and a trephine applied under these circumstances may fail to reach the seat of the disease. After a circumscribed abscess is formed in bone, the parts around appear to accommodate themselves to its presence. This is accomplished, not by the fibres of the bone being pressed asunder, but by an actual absorption of the osseous substance. The intense pain experienced depends, doubt- less, upon the extreme tension maintained upon the unyielding structure, and every fresh accession of pain results from a fresh secretion of fluid. The BONES. 213 influence of some medicines in restraining the symptoms may probably depend upon their power of promoting the absorption of the more fluid part of the abscess. Thus we find that the iodide of potassium, given in doses of three or four grains, will sometimes be followed by a temporary abatement of the pain ; and it would appear from the.cases recorded, that, after the first attack of pain, the symptoms may remain in abeyance for almost an unlimited period, until some accidental cause produces a fresh secretion of fluid. The cavity of the abscess then again becomes distended, and the pain of compression returns. A process analogous to the pointing of an abscess in soft parts not unfrequently takes place; the ulceration affects one point of the Avails of the abscess particularly, and an opening may thus be formed, through which its contents are evacuated externally. In other cases, the process of deposition goes on in the whole circumfer- ence of the bone as rapidly as that of absorption, and the abscess cannot then make its way externally. The compact structure of the shaft of the bone also prevents its extending in that direction; the articular surface ia then the only one toward Avhich the abscess can extend. No fresh layers of bone can here be deposited, and the fluid consequently makes its way toward the joint. The cartilage has been observed, in such cases, to be affected in two ways: either perforated, so as to alloAv the matter to escape directly into the articulation, or absorbed over a large surface without suppuration. In a case of the latter kind, recorded by Sir B. Brodie, the cartilage cover- ing the head of the tibia in some places was perfect in its structure, but it existed only in narrow stripes; in other parts it had degenerated into a substance something like condensed cellular membrane; in others, the only vestige of it Avas a kind of membrane, so thin, that the bone could be seen through it; and in other parts, the surface of the tibia was completely exposed, but not carious. Part xxv.,p. 187. Simple Mode of applying Pressure in Chronic Enlargement of certain Bones, etc.—[Dr. Inman records the following case: M. C, a delicate girl, three years of age, had a SAvelling of the left knee-joint, which Avas three- quarters of an inch larger than the right, due to an enlargement of the head of the tibia and condyles of the femur.] I directed the mother to procure a piece of thin vulcanized india-rubber cloth, Avhich she was to shape to the knee, allowing an interval in front of about three-quarters of an inch. The edges were to be bound by a piece of thin leather, and a piece of wash-leather was to be placed as a tongue between the laced portion and the knee. Holes were to be made in the cloth behind the binding, and the whole was to be laced like ladies' stays. The elastic was to be worn during the day and night. Exercise was not pro- hibited, and no medicine Avas ordered. I saAV her again in ten days. The bandage had been Avorn for fourteen hours daily, and taken off at night. The knee Avas reduced a quarter of an inch in circumference. In ten days she called again, complaining of pain and cedema of the leg, in the evening, from pressure. On removing the elastic, Avhose edges now overlapped, I found the knee restored to its normal size and shape. The child could run about Avithout pain or inconvenience. I directed the dis- use of the bandage, unless the swelling should return ; and told the mother that, though I could not promise that there would be no return of the complaint, I considered the child as cured. 214 BONES. It is unnecessary to make any long comments upon this case. The fact of a morbid deposit in bone being absorbed, or, I might almost say, a threatened white-SAvelling, cured in three weeks, Avithout blisters, issues or caustics, without confinement, or even complete rest, is sufficient to speak for itself. Of course, such a plan can only be adopted when there is no reason to believe that active inflammation or purulent deposits are present, and where there is no severe pain. Part xxvi., p. 140. Pathology and Treatment of some obscure Cases of long-continued Pain in Bone.—It appears that long-continued pain in bone may arise from a variety of different pathological conditions, and that the chronic irritation, which precedes the deposit of new bone, may depend, among others, upon the folloAving local causes: 1. Upon the formation of pus within the bone. 2. Upon the deposition there of more solid material arising from the poisons of mercury, or syphilis. 3. Upon a collection of tubercular matter in bone ; or, 4. Upon the presence of a necrosed portion of cancellous structure. Whenever there is reason to suspect that pain in a bone is kept up by the presence of some morbid or foreign matter in its interior, or by the pressure produced by a redundancy of bony deposit, it appears evident that the removal of a piece of the shell of the bone is the rational mode of treatment. An opportunity is thereby afforded at once for the escape of any confined matter, and the tension of the parts is relieved; and it ap- pears not improbable, from the favorable effects hitherto obtained by this mode of treatment, that it may hereafter be extended to the relief of many cases of protracted and obscure affections of the osseous system. Part xxvi., p. 141. Pedunculated Exostosis of the Long Bones.—Prof. Syme remarks as folloAvs: As the expression exostosis literally implies merely an inordinate groAvth of bone, it has been employed to denote a great variety of morbid conditions in Avhich this circumstance happens to exist. The "callus" that repairs a fracture, the new osseous shell which supplies the place of a dead shaft, the spina ventosa or expansion caused by the accumulation of pus or other fluid, the spicular of foliated excrescences that shoot into the substance of an osteo-sarcomatous tumor, and the bony prominences of morbid groAvth resembling the natural processes connected Avith the origin and insertion of muscles, have all been included Avithin this comprehensive title. It is to a particular form in which the last mentioned of these pro- ductions appears, that I now Avish to direct attention. [Puberty is the period of life Avhen these simple growths are chiefly developed. Indeed, in young and groAving persons, the symmetry of the bone is often lost from the processes and articulating extremities growing more rapidly than the other parts, but as a rule Ave may always express an opinion, that in time the proper proportions will be restored.] The constitution of these growths is quite similar to that of the spongy extremities of the long bones, being composed of a thin, osseous lamina externally, and a more or less compact, consolidated texture within it. While enlarging, they have an incrustation of cartilage, Avhcnce they havo been called by Sir A. Cooper and others—in my opinion, very improperly—the cartilaginous exostosis, since any bone in the body might with equal propriety be designated cartilaginous: and as this nomenclature is sure to occasion confusion betAveen the truly osseous groAvths and those BONES. 215 of a fibrocartilaginous nature, which anatomically, pathologically, and practically require to be carefully distinguished. Thus Sir A. Cooper describes, under the same title, well-marked cases of these tAvo most dis- similar conditions, and in his lately published Avcrk, Mr. Paget has pursued this course, with, if possible, still less regard to the diversity of the tumors thus associated together. Anatomically, they differ in consti- tution, which, in one case, is the simple bony texture incrusted externally, so long as it is groAving, by a plate of cartilage; and, in the other, it is a fibro-cartilaginous growth inclosed within the expended bone, or dispersed through the interstices of its honeycomb-looking structure. Pathologi- cally, they differ in the one sort of growth being limited in its tendency to increase, and producing no inconvenience except from the peculiarity of its position, as Avhen seated under the nail of the great toe, while the other has no bounds to its enlargement, Avhich depends upon the fibro- cartilaginous substance, and not upon the bone. Practically, they differ in this important respect, that Avhile the one may be removed by division of its neck or base, the other cannot be extirpated except by taking away the whole bone, or dividing it at a sound part beyond the confines of the disease. It Avas from not attending to these distinctions that Mr. Liston, who first drew professional attention to the exostosis of the toe, insisted upon amputation as essential for the patient's permanent relief; Avhile due regard to them led me to practise removal of the growth alone, as suffi-' cient for attaining the object in view—a procedure which, though for a time reprobated by Mr. Liston and his followers, has long since become the established rule of practice. On the other hand, a knowledge of the depth to Avhich the fibro-cartilaginous growth strikes its roots into the bone affected, has put an end to those painful scenes which surgeons of the present day witnessed in their youth, Avhen attempts were made, of course in vain, to dig out such tumors from the upper and lower jaws. By disarticulation or division of the bone, where ascertained to be sound, the patient is noAV effectually relieved in a few minutes, instead of being subjected to the prolonged torture of hours, without the chance of benefit to his case, and Avith the greatest risk of its aggravation. Under the title of cartilaginous tumor, have been comprehended tAvo morbid conditions of the osseous system, of the most different natures, which require to be distinguished for the establishment of their proper treatment. In regard to the osseous groAvths, associated with malignant tumors, serous cysts, and abscesses—as the new-formed bone is always per fectly sound in its textures, and owes its production to the influence of another morbid condition, I think the disease in such cases should be named, not from the exostosis, but from the cause which has occasioned it, Avhether this may be a groAvth, a cyst, or an abscess. The expression exostosis Avould thus be restricted to its proper sense of denoting the change effected in the bone itself, and Avould only require to be further divided into the solid, hollow, and spicular forms. Attention would thus be directed to the disease essentially requiring remedy, and not to an accidental concomitant. I may iioav proceed to the special object of this communication, which is to explain a circumstance in the constitution of the simple exostosis when it proceeds from the long bones of the extremities, which may be of considerable consequence in regard to both its diagnosis and treatment. The most frequent situations of this groAvth are the inner side of the thigh 216 BONES. bone a little above the condyle, and the neck of the humerus just below the tuberosities into Avhich the scapular muscles are inserted. It has a neck from half an inch to an inch in length, which is usually placed obliquely in relation to the shaft, and beyond this expands into an irregu- larly rounded form, nodulated on the surface, which is covered by a thin incrustation of cartilage, that presents a shining pearly lustre, and has no communication with the surrounding parts. About five-and-tAventy years ago I >vas consulted by a gentleman resid- ing in this city, on account of a very large exostosis, in the usual situation, on the inner side of the thigh. He Avas a tall, strong, active man, and, in consequence of over-exertion, was suffering from SAvelling, redness, and pain of the limb at the seat of enlargement. I advised soothing measures, and expressed the opinion that an operation Avould not be requisite if he abstained from undue exertion in future. I frequently afterward saw this gentleman, apparently in the enjoyment of perfect health, and had no reason to entertain any doubt as to his being so for more than twenty years, when Dr. Handyside asked me to see him, on account of an alarm- ing change that bad taken place in the condition of the tumor. The thigh was considerably swelled and painful, especially Avhen pressure was applied on the seat of the exostosis, Avhich could not be felt distinctly in conse- quence of the thickening around it that had taken place, together with the effusion of some fluid that Avas detected by a deep fluctuation. In expla- nation of this circumstance, it was stated that the patient had lately been leading a life of much greater exertion, particularly in walking, than he was previously Avont to do, and Dr. Handyside enjoined rest, and, after a time, applied a blister. We thought that there was something seriously wrong, and Avere not free from the apprehension of cerebriform degenera- tion, but resolved to try the further effect of rest, Avith gentle pressure. In the course of a feAV weeks the SAvelling and tenderness disappeared, the fluctuation could no longer be perceived, and the exostosis was felt no less distinctly defined than in former times. I felt quite at a loss to account for this case, until the following one completely explained it: Dr. Duncan asked me to take under my charge, in the hospital, a female servant who had received a bloAV, which was sup- posed to have detached an exostosis from its usual seat of attachment, above the knee, on the inner side of the thigh bone. As the limb was very much swelled and extremely painful, I feared that delay might lead to suppuration, and therefore cut freely down to the exostosis; but in doing so Avas surprised to find a quantity of serous fluid, tinged Avith blood, lying betAveen it and the surface immediately surrounding it. The whole truth at once appeared, and I no longer felt any difficulty in accounting for the smooth shining surface presented by groAvths of the kind in ques tion, or for the fluctuation which, in the former case, had so much per- plexed Dr. Handyside and myself. It was plain that a synovial mem- brane surrounded the exostosis, and Avas reflected from its neck, so as to afford a double covering, just as on the joints—the half of one being thus represented by the osseous groAvth, its crust of cartilage, and investing membrane. I hope that the condition of Avhat may be called the pedunculated exos- tosis, thus fully ascertained, may be of service, not only in its diagnosiB, but also with reference to the means of remedy, since the complete.insula- tion from surrounding textures, except at the comparatively small point BONES 217 of its attachment to the bone, affords great encouragement to attempt removal, even under circumstances apparently much opposed to success. Thus, in the case of a young lady I saw lately Avith Dr. Simpson, there was an exostosis at the neck of the humerus, which pressed upon the axil- lary nerves, so as to occasion great and increasing distress; and, from this position, had been deemed beyond the reach of removal. But, having ascertained that the point of attachment Avas at the posterior surface of the bone, I made an incision between the deltoid and triceps, exposed the neck, detached it by cutting pliers, and extracted the exostosis, wuth hardly any bleeding, and no injury to the neighboring parts. Part xxix., p. 161. Deformed Bones.—In cases of deformity of the bones, Avhether from accident or disease, perform Avhat is called subcutaneous osteotomy, which is a much less dangerous operation than resection of bone exposed by a large external Avound. Make an incision rectangular with the longitudi- nal axis of the bone, dividing the integuments and periosteum—apply a fluted chisel-drill (tAvo lines in breadth, attached to a centre-bit) in the centre of the incision, and perforate the bone (the tibia, for example,) transversely from Avithin outward. The cessation of resistance safely denotes the accomplishment of the perforation—a narroAv saw is now introduced into the aperture drilled through the bone, and the greater part of the hone divided. The bone is directly straightened by fracture of the remainder. The normal position need not be restored at once, but can be accomplished during the consolidation of the bone. Part xxxi., p. 126. Diseases of the Bones.—[In this paper Mr. Bishop enters on the subject of exostosis, such tumors as are situated immediately under the periosteum, and are at first disconnected Avith the bone, but nevertheless, after having been formed for some time, become sooner or later firmly united Avith the contiguous bone. They are liable to form on the internal table of the bones of the head.] A tumor of this kind presents to the eye the appearance, and to the touch the form, of a nodule, Avith an abrupt margin, and is frequently separated at its base from the subjacent bone, by a furrow of variable thickness; and sometimes there is a deep fissure betAveen the nodule and the bone lying beneath. The density of these compact nodules is very great, and in this state the disease is termed the ivory exostosis. These ivory tumors are of greater density and specific gravity than the normal bone Avith Avhich they are associated, unless they happen to be connected with bone already in a state of induration. They are always composed of laminae, and seem never to be intermixed with spongy tissue. The density of the tumor is owing to the greater number of laminae contained in a given space, when compared Avith the number of laminae found in the same space in normal bone. The Haversian canals are small and few in number, but a Avell-defined lamellar system is found surrounding them. The bone corpuscles are irregularly scattered in the substance of the tumor, and in some places they are clustered together, while in other parts larger tracts are found entirely destitute of them. The color of these exostoses is of a yclloAv-white, and they are of a lighter hue than the bone to Avhich they are attached. Rokitansky appears opposed to the hypothesis that the origin of these 218 BONES. tumors has any relation to syphilis, and he believes the cause of their at- pearance to be entirely unknoAvn. AVhen the exostoses are of a spongy texture, they are connected Avith a rarefaction or expansion of the spongy bones, termed by the German pathologists osteoporosis. They present many varieties in their structure, and may arise either from the spongy or from the laminated structure, or from both together; they are then compounded of an inFernal spongy, and an external laminated layer of the compact tissue. These mixed osseous tumors are not unfrequently found near the joints, at the head of the tibia, or on the shin, and on any of the other long bones of the skeleton. In the skull, the disease is accompanied with an expansion of the diploe, in Avhich case there may be an exostosis on both the external and internal tables corresponding in situation Avith each other. In the spongy forms of exostosis, the structure may remain permanent after its development; but more commonly neAv matter is formed in the interior, and the structure of the bone is more or less condensed ; but this altered structure is often succeeded by the bone being again rarefied, and thus the groAvth of the spongy exostosis out- Avard may be affected, and may increase to a considerable size. When this disease affects the spongy bones of the face, it has been known to produce the most hideous appearance. Some examples of-"these cases are to be seen in the Hunterian Museum. When the exostoses have acquired a certain magnitude, they usually continue through life un- changed. The ivory texture of the excrescence, in this disease, some- times diminishes in size by condensation, or it may become necrosed, and thrown of. The spongy exostoses sometimes degenerate into caries, and in this way disappear. These appear to be the processes by Avhich the system may be spontaneously released from the osseous growths of exostosis. Independently of exostosis, the bones, during inflammation, exude a fluid which ossifies, and forms a layer on their compact surface; this substance has received the name of osteophyte. At the commencement of this process, the exudation is soft and gelatinous ;vit afterAvard becomes tough and elastic, resembling cartilage, and in the end it ossifies. It ap- pears that this exudation is associated with nearly all inflammatory con- ditions, Avhether of abscess or necrosis of the bones. There are many variations of form assumed by these osteophytes, as Avell as differences in structure. They sometimes appear to be composed of " delicate fibrils and lamella, which are fixed at acute angles on the surface of the bone, and give it the appearance of velvet, or felt with a very fine nap." Though these osteo- phytes are at first in contact with the bone, yet they may be easily raised from it in large pieces, and although for some time separated by a layer of cellular substance, they become fixed to the bone when this membrane disappears. The exudations Avhich terminate in osteophytes, sometimes form plates, and often anchylose some of the vertebrae, by the ossification of the anterior common ligament. They occur also in the inner table of the skull, and, indeed, wherever inflammatory processes are going on in the bones. Osteophytes have been knoAvn, in a feAV cases, to cover large portions, or nearly the Avhole of the skeleton ; they are sometimes associated with atrophy, and at others with hypertrophy, of the bones. Although we BONES. 219 generally find the exudations accompanied with ah inflammatory condition of the bones and periosteum, the precise condition of the system that gives rise to the inflammation and exudation, is not yet determined. In the imperfect union of fracture, these plates then constitute the union of the ends of the bone. The bones of the skeleton are likeAvise liable to anomalies in number, size, and form. The absence or addition to the number is not very com- mon, but is coincident Avith conditions of the system in a state of perfect health, and not referable to any pathological conditions : it is not, there- fore, my purpose to give any detail of cases of variations of number. With regard to variations in size depending on pathological states of the bones, the case is quite different, and deserves a feAV remarks. In hyper- trophy of the bones, they may increase in size by the addition of new osseous matter deposited on their surface beneath the periosteum, Avithout any change taking place in their density or specific gravity; the size of the medullary canal remains the same, but the compact substance acquires a considerable augmentation of thickness. When the increase of sub- stance takes place in the interior of the bone proceeding from the Haver- sian canals, and involving the whole of the medullary system, the bone be- comes more dense, both in the compact and cancellous tissues. In the latter, the Avails of the cells increase in thickness, and the medullary cavity diminishes in size ; the diploe disappears, and the Avhole bone becomes in- durated. When the hypertrophy takes place both internally and exter- nally, the bulk and density of the bone are both increased. The increase of the bones, both internally and externally, is preceded by the deposition of a superabundance of cartilaginous matter, in which the salts of lime are deposited, as in normal bone. When the disease attacks the bones of the skull, or Avhen it affects con- siderable portions of the skeleton, it becomes a serious disorder. It is a remarkable circumstance, that when the bones of the skull become hyper- trophied, those of the face often diminish, so that there are actions oppo- site in their effects—namely, hypertrophy and atrophy, going on in the system at the same time. The conditions of the system that give rise to these change s in the bone are not yet determined, nor do the bones themselves give any premoni- tory signs of the advent of the disease. The surface of the bone continues smooth, and the periosteum natural, even Avhen the bone has acquired the compactness of ivory. In other cases, the increase in the volume of the bone is preceded by an inflammatory condition. The seat of the inflam- mation may be either the periosteum and the compact tissue, or the medullary membrane. When the external surface is affected, an exuda- tion takes place on the surface of the bone, Avhich becomes ossified into lamina): this forms a layer, Avhich is sometimes separated from the surface of the bone by a layer of spongy tissue. When the inflammatory process has its seat in the medullary membrane, it leads to increased density either of the compact or of the spongy tissue, or of both these structures. It may be easily imagined that these organic changes cannot take place Avith- out affecting the texture of the diseased bone ; and it is found accordingly, that the substance of the bone becomes hypertrophied in consequence of the expansion and infiltration of the tissue connecting the capillaries of the medullary canals and cells. The result of these organic changes is a thickening at the affected portions, the other sections of the bone remain 220 BONES. ing free, so that the surface often presents a rough and uneven appearance. The inflammatory state of the bones under consideration is frequently ex- perienced by persons laboring under a rheumatic, syphilitic, or gouty con- stitution, and the treatment must depend on the nature of the causes that are associated in the production of the disease ; the local treatment is that common to other organs affected Avith chronic inflammation. The opposite state to that of hypertrophy, is atrophy of the bones. Whatever causes lead to the undue nutrition of hone, tend at the same time to diminish its volume. There are, consequently, many states of the system Avhich may lead to atrophy, such as indifferent diet, want of action, .exhausting diseases, palsies, fractures, anchylosis, and, indeed, anything Avhich tends to impede the flow of blood to the bones, are all accompanied Avith atrophy. From the nature of the various causes just mentioned, any of the bones of the skeleton may be affected. In many cases, the bones diminish both in length and thickness, and the medullary canal becomes contracted ; this condition of the bone is termed concentric atrophy. Independently of special causes, the bones of aged persons often become atrophied ; they are then brittle, and break Avith a comparatively slight force. It appears that atrophy always begins in the medullary canals and in the diploetic structure, the cells of Avhich enlarge, and the Avails and lamellae of the cancellous structure become attenuated, and finally disap- pear. The compact tissue becomes changed, and resembles the spongy diploetic structure ; and the outer layer only remains unaffected, but almost as thin as paper. As the atrophy of the spongy substance advances, the external layer only remains, and incloses a cavity, Avith mere traces of spongy tissue at its periphery, or a soft substance Avith large cells. When the spongy substance is entirely removed, the thin external Avails of the bones approach each other, and form a single plate. When the cavity within the bone is enlarged, it is called by Mr. Curling ex-centric atrophy. The con-centric form of atrophy occurs in the larger medullary canals, the ex-centric in the, bones of the pelvis, ribs, and vertebrae. It will be easily imagined, that Avhen such great organic changes take place in the bones, their physical characters alter in proportion ; and accordingly, the bones thus affected become flexible, and crack when they are bent. As the loss of the internal portion of the bone proceeds, the external portion becomes diminished, and hence the skeleton, in senile atrophy, together with the whole Aveight of the body, is less than in the normal state. The volume of the bones may be also diminished by continual pressure, such as that produced by tumors and aneurisms ; but to these purely mechanical causes I do not Avish to engage your attention. Having now given a description of the nature and groAvth of osseous tumors, I shall occupy a few minutes with some very brief remarks on the nature and diagnosis of the soft tumors affecting the bones. Perhaps there is no subject in Avhich the microscope has been of greater utility to the practical surgeon, than in determining the structure of the soft tumors of the osseous system. Up to a very recent period, tumors of the bones of the most heterogeneous and diversified character haVe been assembled together, and no distinction has been made between those of the mildest and those of the most malignant tendency. Thus, the older writers grouped together, under the term " osteosarcoma^ the cartilaginous and osseous, the osteoid, the myeloid, and tie enchondromatous tumors, and BONES. 221 confounded these non-malignant with the scirrhous, medullary, and alveolar tumors. Under these circumstances, Ave cannot wonder that much discussion should arise amongst surgeons on the propriety of, and the varied success resulting from, the removal of these mixed forms of tumors. When we look into authors on osteo-sarcoma, Ave find that they had no very precise idea of the nature of the tumors comprised under this term. Some wished to restrict the term to those Avhich are decidedly scirrhous, while others describe them to be of a cartilaginous texture, and none seem to have satisfactorily determined whether they are or are not Avholly malig- nant. With such a state of confusion and complication, Ave need not be surprised that some operations have been attended with complete success, while in other cases the diseases have returned and destroyed the patient. To give an idea of the complete difference in the views entertained by sargeons on this subject, it is only necessary to refer to one or two of those Avho have confounded together^the malignant tumors with those of the non- malignant character. Thus, according to Callisen, osteo-sarcoma is a disease by which the tex- ture of the bones is converted into a lardaceous substance, having a ten- dency to carcinoma. Boyer considers it a disease analogous to cancer. Dr. Cuming, of Glasgow, considers that though all varieties of osteo- Barcomatous tumors are highly formidable, yet he says " they are not all really cancerous." Mr. Mayo observed of these tumors, that they have not " much malignity;" so that if all the portion of the bone involved, with part of the adjacent sound bone, be removed by amputation, the complaint seldom reappears, either in the part, or in another bone. It would be an almost endless task to enumerate the different opinions, with the various results, of these tumors ; but we see hoAV little dependence can be placed on the results respecting the cases that have been detailed, unless Ave could be secure of the real nature of the tumor removed. But the diagnosis of the character of the tumor is in some cases by no means easily made, and I have occasionally been in consultation with the most dis- tinguished surgeons of the metropolis without arriving at anything like a satisfactory result. The diagnosis of the nature of many tumors connected with the bones is one of the problems in surgery most difficult to solve ; the data in many cases are not sufficient for the purpose. The hereditary tendency to dis- eases of an organic type, the aspect of the patient, the situation of the tumor, its character to the touch, and the history of its formation, are all circumstances to aid in the research ; but all these are often insufficient to enable the surgeon to arrive at more than a hypothetical conclusion. An example will suffice to shoAV the truth of these remarks. A few years ago I Avas solicited by a gentleman to remove a tumor situated at the back of the thigh. On examination, I found it was deep- seated, soft to the touch, and apparently movable on the bone; it was of a considerable size, and had only been recently detected by the patient. Having some suspicion of its character, I advised his having another opinion before its removal, and Mr. Guthrie was consulted ; but that gentleman being of the same opinion as myself—namely, that it presented a formida- ble aspect, it Avas agreed to take the opinion of the late Sir Astley Cooper. In this consultation, Sir Astley stated, that although he was of opinion it Avas very likely to turn out maUgnant, yet that 'ts removal Avould give the 222 BONES. patient a greater chance of a prolonged life. However, considerable alarm having been excited in the minds of the patient and his family by these consultiftions, he Avas advised to take the opinion of Mr. Lawrence, and subsequently that of the late Mr. Earle. The result of their several opinions avus, that it Avas a tumor of uncertain character, but all agreed on the propriety of its removal. At length the family decided that Mr. Earle should be selected to per- form the operation. On cutting doAvn on the tumor, it Avas found to be a medullary cancer connected Avith the bone, with ramifications so extensive that its complete removal could not be accomplished. The consequence was that the Avound did not heal, and the patient sunk from exhaustion at the end of about three months. In this case it Avill be observed some of the best surgeons in London were consulted, notwithstanding Avhich nothing but an uncertain knowledge could be formed of the character and connections of the tumor, and it Avas, as the result proved, a case Avhich required either amputation at the hip-joint, or to be left unmolested. In order to assist us in forming a correct diagnosis of the nature of tumors, it has been suggested, and attempts have been made, to ascer- tain their character by means of a grooved or hooked probe, but with Avhat success this plan has been attended I am not prepared to state ; still it seems to hold out a feasible prospect of enabling us to form a better opinion of such cases before operating for their removal. It is the opinion of many surgeons that malignant diseases in the bones are not so liable to return after operation, as those of the soft parts; but as these opinions Avere given when the real nature of tumors Avas less understood, it will re- quire further investigation to determine this question. Myeloid and enchondromatous tumors Avere, until very lately, considered malignant; and this may have given rise to many of the opinions formed of the cura- bility of the patient suffering under malignant tumors of the bones by means of their removal. Part xxxi., p. 128. Case of Malignant Disease of the Pium.—[The following interesting case gave rise to some valuable clinical remarks by Mr. Fergusson.] Present condition : The patient is in a state of great debility, Avhich has been sloAvly coming on for the last tAvo years. BoAvels much confined; appetite good ; sleeps well; pulse 90 and weak. There is a tumor situated on the posterior part of the left dorsum ilii, above and slightly over the great sacro-sciatic foramen. The crest of the ilium can be felt distinctly above it. The dimensions are, five inches in one direction, and four in the opposite ; its circumference is nearly circular, and it stands out from the surface of the body about an inch*. When the fingers are placed upon the tumor, it may be distinctly felt to pulsate, each pulsation being synchron- ous Avith one at the wrist. If the stethoscope be applied to it, a blowing sound in successive puffs is plainly audible. It is not tender to the touch. The skin over it is freely movable, and not discolored. A bladder filled Avith ice is kept for tAvo or three consecutive hours over the tumor, till the skin becomes quite numbed. This has a very decided effect on the tumor, causing it to become hard, with the pulsation diminished. From the history, I think you Avould naturally suppose the case to be one of aneurism of the gluteal artery; and for such it Avas taken by the sur- geons who sent the patient to me from Birmingham ; indeed, so certain were they, that it was considered a proper instance for ligature of the BONES. 223 internal iliac artery. I have never seen an aneurism of the gluteal artery, and I believe spontaneous aneurism of that artery to be extremely rare. After the admittance of the patient into the hospital, I made a careful examination; and this is Avhat struck me,—here Avas a man lying in bed, with a large pulsating tumor, resembling in many ways an ordinary aneurism; pallid, thin in the limbs, hardly able to walk, and experiencing great pain in and about the region of the tumor. Noav, contrast this A\rith a case of spontaneous aneurism of the popliteal or other large artery of the extrem- ities, but especially with one situated Avithin one of the large cavities." Tlie patient laboring under the disease is much annoyed at being kept to his bed; he imagines that little is the matter Avith him, for he may be capable of undergoing great fatigue, perchance Avalking great distances to seek opinions regarding his malady. In fact, it is not a feature in ordinary aneurismal disease for the patient to be out of health. I mentioned that great pain was very early complained of in the tumor, whereas it is rare for those laboring under an aneurism of a large artery to make such a com- plaint at so early a period. Regarding the character of the tumor: when I made pressure in the site of the gluteal artery, as it leaves the sciatic notch, and turns up on the outside of the pelvis, all pulsation in the tumor ceased, which fact cer- tainly seemed Arery strong in favor of the supposition of a gluteal aneurism, and an indication Avhich, taken by itself, was not unlikely greatly to bias the surgeon in his diagnosis; but I confess this had little or no weight Avith me, for I have met AArith malignant tumors of bone in Ararious parts of the body possessing great pulsation, which could be arrested by pressure on the main artery supposed to lead to the disease. The size of the tumor and its situation Avere very much against it being considered an aneurism of any one branch of the gluteal ; indeed I could not fancy such constitutional disturbance to be dependent upon such a source. It is seldom that the surgeon is consulted about an aneurism at so early a period as this case came under notice; but, if he should meet with such a disease, at what is termed its first stage, it is generally possi- ble to empty the blood out of the tumor; but, as you saw during my visits to the patient, I frequently tried so to do, but Avas aHvays unsuccess- ful. In the earlier stage of the disease, the crest of the ilium could be distinctly traced above the upper border of the tumor; but, after a short time, the part became entirely involved in the disease. There was one fea- ture in which common-place anatomy greatly assisted me. I noticed that the insertions of the long extensor muscles of the back, as the disease in- creased in its dimensions, became elevated above the surface of the tumor; whereas, if the SAvelling had been an ordinary aneurism of the gluteal artery, they would doubtless have been beneath. These were, then, the principal points from which I framed my diagnosis, in the early stage of the disease; and I came then to the conclusion, that the man Avas not the subject of a gluteal aneurism, as was at first supposed, but that he was la- boring under malignant disease of the ilium, and that the tumor was what is commonly called a pulsating tumor of bone, possessing more vascularity than was usual in such cases ; and hence the well-marked pulsation. This so-called aneurism of bone is, in my opinion, nothing more than aneurism by anastomosis in hard structure, someAvhat modified in its con- dition and symptoms, and which might, in many instances, be called me- dullary sarcoma, or fungus hematodes. There is generally a very large 224 BONES. expansion of bone, seeming as if the bone itself had been blown up, tho interior of which may contain a quantity of medullary or melanotic matter, or resemble a sarcomatous mass, containing cysts Avith fluid blood, and pos- sessing great vascularity. Though thoroughly satisfied in my oAvn mind as to the nature of the disease, I Avas anxious, nevertheless, to avail myself of the advantage of other opinions ; and, accordingly, after requesting the • opinions of my colleagues, I invited surgeons of the highest eminence in London to see the case, the majority coming to the same conclusion that I have already expressed. It was quite evident that an operation could in no Avay benefit the pa- tient, and that the only treatment that could avail was rest and kind attention to his Avants. He daily grew weaker, until at length, becoming delirious, he ultimately died from pure exhaustion. Here let me impress upon you how important it is to avoid all surgical interference in those in- stances in Avhich such a proceeding is unlikely in any Avay to better the the patient, but which, on the other hand, is calculated to bring discredit on the surgeon, and the Avorst possible result to the sufferer. This disease so nearly resembles gluteal aneurism, that surgeons of experience have actually mistaken its true nature, and treated the case as if it really had been an ordinary aneurism. Some time before the patient's death, Avhile paying my visit one day, 1 found that the left thigh-bone had spontaneously broken just below the trochanter, no cause being assigned for the accident. Now, in malignant affections, or certain forms of cancer, it is not by any means uncommon for bones to become friable, and break with the least possible exertion. This was, therefore, another very conclusive proof in support of the malignant nature of the disease. These were the principal points of interest in this remarkable case ; and the post-mortem examination proved the correctness of the leading opi- nions that had been formed during life. Most of you saw that examination; but I will briefly detail the morbid appearances Avhich were presented. When the body Avas put on the table, you saAV the extreme emaciation to which the patient had been reduced by the malignant tendency of the dis- ease. On reflecting the skin from the left buttock, and dissecting back the gluteus maximus, which wras greatly Avasted, a large tumor Avas found, reaching from the sciatic notch to the brim of the pelvis—in fact, covering the whole of the haunch bone, and resembling more the substance of brain than any I remember to have seen. The tumor, I think, might Avith pro- priety be called by half a dozen different names, each being equally appli- cable, as medullary sarcoma, encephaloid disease, soft cancer, etc. The disease had evidently commenced in the cancellated structure of the ilium, and found its way into the cavity of the pelvis, as Avell as out- Avardly. That part projecting into the pelvis had elevated the iliac ves- sels, and put upon the stretch the large nerves of the sacral plexus, which fully accounted for the constant pain complained of in the thigh, extend- ing to the foot. That portion of the ilium in AA'hich the disease commenced was entirely destroyed, the free margin of the bones being left rugged and bare. The gluteal artery, much enlarged, could be traced, shortly after leav- ing the sciatic notch, Avinding over the lower part of the tumor, and dis- tributing large branches Avhich ramified freely over the surface, and fully explained the reason of the well-marked pulsation during life. The large BRAIN. 225 sacro-sciatic nerve was pressed upon by the lower part of the tumor, Avhich doubtless caused the excessive and frequent pain to the patient. The dis- ease had extended to the left side of the two loAver lumbar vertebrae, sac- rum, crest of the ilium, and upper part of the femur. The remaining bones of the body were not found similarly affected, but the kidneys and luuo-s presented Avell-marked specimens of cancerous deposits. ° l . Part xxxi., p. 133. Pulsating Tumors of Bone.— Vide Art. " Tumors." BRAIN. Extract of Conium.—Recommended by Mr. Judd as likely to prove a valuable remedy in the treatment of three very fatal diseases for Avhich Ave possess no specific, viz.: hypertrophy, of the heart, phrenitis, and inflam- mation of the medulla spinalis. " The latter disease is one that, like Atropos in the dark, cuts the thread of life in many cases Avherein the cause of death (the theca not being opened) is never discovered. In the treatment of such disease, after depletion, I should recommend that small doses of the extract of conium, Avithout waiting for the action of purga- tives, be steadily repeated every two hours, until the action of the remedy is manifested in the system, or mitigation of the symptoms ensue. In hypertrophy of the heart, the remedy should be given rather more cautiously; and by properly-graduated doses, I imagine we might regu- late the hurried and forcible contractions of that viscus, and bring its action almost to nature's standard. Lastly, habitual costiveness, and Avant of secretion in the bowels, may often be remedied by two or three grains of extractum conii, Avith as much pilula hydrargyri given at bed-time; this will be slowly followed by regular evacuations. The above combination of drugs acts particularly upon the rectum ; and, Avhen the dose is too often repeated, produces in some, a sort of chronic dysentery. I throw out these hints to the profession after having witnessed the power of conium in reducing the action of the heart, to exsanguine the brain and medulla; and may safely assert, if physiological experiments teach us anything as to the nature of remedies, that then is conium a valuable auxiliary in these diseases." Part i.,p. 59. Diseases of the Brain dependent on Diseases of the Heart.—Dr. LaAv brings before the profession his vieAvs of. those diseases of the brain which are chiefly owing, not, as is generally supposed, to the excess of blood in the brain (which excess may arise either from too great a determination to it, or from a congested state of it, owing to obstruction of the blood in the lungs or other parts, from diseases of the heart), but to the deficient supply of it, arising from diseases either of the sigmoid or mitral valves. He affirms that if there be obstruction to the Aoav of blood before the arteries going to the brain are given off, that disease of that organ will not be owing to a fullness of blood in it, but to a deficiency : but on the other hand, if obstruction exist beyond the origin of the cerebral arteries, then the regurgitation of the arterial blood may very probably be toward the brain. 15 226 BRAIN. Recommended, Avhen called to a case of diseased brain, accompanied by hemiplegia, or symptoms which would at first sight indicate congestion or inflammatory'action, to ascertain if these symptoms may not be owing to disease of the heart or valves ; and if Ave suspect that there is disease of the aortic valves, causing hypertrophy of the left ventricle, and prevent- ing the blood reaching the brain with sufficient ease: or if Ave suspect either a too open or a too contracted state of the mitral valves, causing in the former ease a regurgitation of blood from the ventricle, and in the latter case a difficulty in its course into the ventricle from the auricle—Ave must be on our guard not to deplete but to stimulate and employ a tonic mode of treatment. Dr. LaAv says : We selected our tonics from among chalybeates Avith which Ave associated, but very sparingly, digitalis. The stimulants Ave employed Avere camphor, ammonia, infusum arnica), our hospital formula of cardiac mixture, composed of camphor mixture, carbo- nate of ammonia, and Hoffman's anodyne, etc., etc. We combined James' powder (as recommended by Dr. Cheyne in cerebral affections), Avith car- bonate of ammonia. But the combination Avhich seemed to us especially useful in these cases was that of James' poAvder, and extract of mix vomica ; the former ingredient being determining to the surface, produc- ing an equalization of the circulation, while the latter stimulated the heart, as a muscular organ. Part i.,p. 67. Purgatives in Inflammation of the Brain and its Membranes.—Bleed- ing and the application of cold to the head are well knoAvn and valued in inflammation of the brain and its membranes. The use of strong and con- tinued purgatives is perhaps as Avell knoAvn but not so regularly adopted. Dr. Watson observes: There is a great tendency to obstinate consti- pation in most cases; and this must be overcome, and free and frequent evacuations from the boAvels obtained: five grains of calomel and fifteen of jalap should be followed in three or four hours by a strong black dose; and after that I should give, in such cases, three or four grains of calomel every four hours, and repeat the black dose at least every morning, until the symptoms gave Avay. If the mercury thus exhibited affects the gums, so much the better ; but Ave must not, in this disease, combine it with opium, to prevent its passing off by the boAvels. Dr. Abercrombie uses this strong language in reference to the value of purgative medicines in acute inflammation of the brain. "In all forms of the disease active purg- ing appears to be the remedy from which Ave find the most satisfactory results; and although blood-letting is never to be neglected in the earlier stages of the disease, my OAvn experience is that more recoveries from head affections of the most alarming aspect take place under the use of very "'strong purging than under any other mode of treatment. In most of these cases, indeed, full and repeated bleeding had been previously employed, but Avithout any apparent effect in arresting the symptoms." He has found the croton oil the most convenient medicine for this purpose. Part iii., p. 59. Aphorisms of Practical Surgery.—Hemorrhage from the ear, accom- panied with coma (consequent upon severe injuries), almost invariably indicate fracture of the base of the skull. ******** Generally in affections of the brain, the effects of purgatives on the bowels are much less powerful than usual.- BRAIN. 227 Five or six grains of tartar emetic and several ounces of epsom salts Avill often not produce either vomiting or purging. In these cases the oleaginous purgatives, as castor oil, croton oil, etc., succeed better. Part iii.,/). 115. Concussion of the Brain.—Bransby Cooper observes: When one or both pupils remain contracted, I am induced, from my experience, to con- sider this as an unfavorable symptom, characterizing lesion of the brain. In those cases in which I have observed contraction of one pupil, and have had an opportunity of making a post-mortem examination, I have invari- ably found injury of the brain on the side opposite to that of the contracted pupil. The same violence Avhich produces concussion, may cause fracture of the base of the skull; and although the constitutional treatment em- ployed may subdue the symptoms of concussion, during the progress of reparation effusion may take place, and evidence of compression super- vene. Such a complicated injury, however, is generally denoted by bleed- ing from the ear at the time of the accident; and I have known a discharge of serum from the external meatus continue for many days after the acci- dent; and yet these cases ultimately did well. Even when this discharge is profuse, it is to be regarded as a favorable symptom, and therefore should not be checked by astringents. The case alluded to was treated success- fully, by general and local bleeding and calomel. Part v., p. 128. Cerebral Lesion—State of the Iris.—In the examination of cases of in- jury to the brain, it is considered extremely important to enter minutely into all those signs which indicate the extent and nature of the injury. First, the mental condition; next, the state of the pupils—the iris is placed before that expanded surface of the optic nerve, the retina, as an in- telligent curtain to guard it from injury. The vital contrivances byAvhich it acts, and by which its action is directed, are so beautifully perfect that the extent of the opening of the curtain is indicative of the state of the nervous apparatus it is destined to protect, by preventing such an amount of light impinging upon it as Avould be liable to injure it. In diseases of the globe of the eye, the dilated pupil indicates more or less pressure on the retina by some cause in the globe itself, such as a permanently turgid choroid, etc. But if with a healthy eye, but in connection with a blow on the head, we find a dilated pupil, then Ave have the sign of some pressure or injury to the nerve in its course within the skull, or the ganglia in which it terminates. The dilated pupil, then, indicates very serious injury to the optic nerve, or the nervous centres writh which it is connected, though it may happen, as in the case of very severe concussion, the injury is reme- diable. The contracted pupil, on the contrary, indicates an irritability of the nervous instruments, an undue excitement of their natural function— not an obliteration of it. You AA'ill sometimes see, in the case of injury to the brain, dilatation of one pupil and contraction of the other; Avherethisis the case, you will find the most severe injury of the brain on the side op- pj^ite the dilated pupil. part viii., p. 73. Powerful Counter-irritation, especially the Long Issue on the Calva- rium.—Dr. Wallis received the first hint on this subject from Mr. Richard Smith, the present senior surgeon of the Bristol Infirmary, who, in many cases of severe injury of the head, is accustomed to make an incision through the scalp, whether or not there^be symptoms of fracture or depression; 228 BRAIN. and this he does for two reasons, viz., to cause a local loss of blood, and to produce an advantageous counter-irritation. Dr. Wallis has used the same means in a variety of cases of organic affections of the brain, both chronic and acute ; in paralysis, impending effusions, convulsions, erysipe- las of the head and membranes of the brain, in fever in the very advanced stages, etc. He says that "its effects are more permanent and its disad- vantages are fewer than those of any other remedy noAV in use." It is not, hoAvever, to be used in the first onset of disease, but Avhen all the ordinary means have been fairly tried, and have failed to produce relief. In acute diseases, the greatest discrimination Avill be required to make use of this remedy at the proper time ; for if, in serous effusions, for example, it be delayed till the ventricles are filled Avith fluid and pressure has commenced, it rarely happens that absorption can be promoted sufficiently to effect a cure. The circumstances Avhich are necessary to be attended to in making the longitudinal incision or issue on the calvarium are these: Let the head be shaved entirely, and have the patient brought near the right side of the bed ; raise the head by a hard pilloAAT, and put a toAvel round his neck to receive the blood; let an assistant keep the head steady; at the same time draAV the scalp downward in all directions, so as to strain the calvarium as much as possible; the scalp will divide Avith so much more ease. In this your oAvn left hand will materially assist, by placing it at the upper and back part of the head, commencing the incision betAveen your thumb and fore-finger as far back as the lambdoidal suture; press the scalpel sufficiently down so as to divide the scalp entirely through at oncey carry on the in- cision directly along the sagittal suture as far as the hair grows on the scalp, and wrhicb will cover the cicatrix after the issue is healed up. The length of the incision thus made will be in the adult about seven or eight inches; take care that the scalp be divided entirely and perfectly through, so that the edges of the incision will separate so far as to enable you to in- troduce a dossil of lint, rolled up hard, as thick as two fingers, and which should be well soaked in spirits of turpentine ; this answers the double pur- pose of increasing the effect of the incision, and makes suppuration come on earlier, and will usually assist in stopping a further loss of blood. The arteries very soon retract and cease to bleed ; there is seldom more than six or eight ounces of blood lost, and this quantity may be very readily curtailed if it be desirable to do so, by applying the actual cautery for an instant to the arteries. By means of poultices, spirits of turpentine, blis- ter ointment, and other irritants, suppuration may be maintained as in any other issue. In a few days, a double i-oav of peas, seventy or eighty, strung together, may be used to prevent granulations filling up the issue. The repeated use of caustic may be necessary to effect this. Part viii.,_p. 122. Disease of the Brain following the Application of a Ligature to the Carotid Artery.—This patient Avas a yc ung man, twenty-eight years of age; he Avas admitted to St. BartiioiomeAv's Hospital, April 9, 1845. Whilst smoking a pip<', a few hours previous to admission, he stumbled against a door, and drove the stem of the pipe into the tongue, a little anterior to the left tonsil. The bleeding Avas trifling; no foreign body could be found in the Avound, but the parts were much SAVollen, Avhich for five days increased so as to interfere with deglutition and respiration. On the 16th, hemorrhage took place to tbe amount of twenty-four ounces; BRAIN. 229 it was arrested by pressure, and Mr. Vincent proceeded to tie the carotid artery. . . It was observed during the operation that the patient made violent ef- forts with his right side, but that he never moved the left extremities. Durin" the night the left extremities Avere frequently convulsed. His pulse,Avhich had been 132, sunk to 96. During the next two days, the twitchings of the right side and paralysis of the left side continued. About midni'dit of the 18th, Avhilst coughing, about an ounce of arterial blood flowed through the nose and mouth, and from the Avound in the neck. He was sensible. On the 21st, a fit of coughing, Avith hemorrhage, to the extent of two or three ounces, from his nose and mouth, terminated his existence. On examining the brain, the convolutions on the right side were flat- tened and softened, and in its substance there were cavities filled with ash- colored effusion, Avith shreds of a greenish hue. Mr. Teale, in his " Retrospective Address," mentions two instances in which hemiplegia folloAved the tying of the carotids. The one occurred to M. Sedillot, the other to Dr. Fairfax; in the former the patient became paralyzed on the left side, and died in nine days; a post-mortem examina- tion showed that the right side of the brain had been deprived of its due supply of blood. In the latter, the right side was paralyzed, and death took place on the fifth day. Part xiii., ^. 221. Hypertrophy of the Brain in Children.—Let the child's head rest upon a horse-hair cushion, Avith a hole cut out to receive the occiput, and let it wear a thin linen cap, changed as often as the perspiration demands. Do not use counter-irritation to infants ; but older children may have tartar- emetic ointment rubbed into the back of the neck. Leech Avhen cerebral congestion requires it; but tonics are rather indicated, as extract of bark, vinuin ferri, syrup of iodide of iron; or Avhere there is marked tendency to rickets, cod-liver oil (a drachm twice a-day for a child three years old). Sponge the child with salt and Avater, or sea Avater, or immerse in a tan- bath made by boiling three handfuls of bruised oak bark tied up in a linen bag, in three quarts of water, for half an hour, and adding the decoction to the water of the child's bath. Get a healthy Avet nurse; and, after Aveaning, give milk diet with an egg Once or twice a day, and a little veal- broth or beef tea. Part xvi., p. 77. Application of Cold in active Congestion of the Brain in Children.— We sometimes Avish to use the sedative effect of cold, when the shock is not needed. Dr. West tells us that feAV methods of applying cold to the head are better than that which consists in half-filling two bladders Avith pounded ice or cold Avater, and placing them, each Avrapped in a napkin, the one under, and the other upon, the child's head. By pinning the corners of the napkins to the pillow, you can secure them from being dis- placed, and can also prevent the Aveight of the upper bladder from resting too heavily on the child's head, Avhile all danger of the bed or of the dress becoming Avet is avoided. Part xvi., p. 78. Cerebral Affections simulating impending Apoplexy.—After mentioning the hydrocephaloid disease of children, Dr. Hughes refers to a similar affection in adults. He says: Every practical surgeon of large observation, and every practical ac- 230 BRAIN. coucheur of extensive experience, is well aware that giddiness, headache, dimness of vision, singing in the ears, throbbing of the temples, restless- ness, sopor, and even the disposition or approach to coma, are symptoms which occasionally folloAV extensive hemorrhage as Avell as accompany plethora, or." determination of blood to the head." We are reminded by Dr. George Burrows, that even Hippocrates ob- served that repletion and depletion of the vascular system Avere accom- panied Avith similar symptoms of disturbance to the nervous centres. I Bhall quote a 1'«av Avell-authenticated instances, illustrative of this fact. A lady, aged 25, had been frequently bled on account of symptoms in the head which had supervened upon an injury. Considerable relief had followed each bleeding, but the symptoms had soon returned, so as to lead to a repetition of the bleeding at short intervals for several months. When Dr. Abercrombie saw her, " she had a death-like paleness, and her pulse was very rapid, and as small as a thread;" but still she complained of fre- quent headache, violent throbbing in the head, confusion and giddiness. " It Avas agreed as a last experiment to make a trial of an opposite system —nourishing diet and tonics. In a fortnight she was restored to very tolerable health." The same author reports the case of a lady who, after leeching and other depletory treatment employed with benefit for a pain- ful abdominal hardness following delivery, was, after three weeks, when reduced in strength, alarmed and agitated, and began to talk wildly and incoherently, and, " after a restless night, Avas in a state of high excitement, talking incessantly, screaming and struggling, with a wild expression of countenance, and a small, rapid pulse." Leeches, cold applications and purgatives, Avere employed Avith little or no benefit. A full glass of white Avine was afterAvard given every hour, and after the fourth hour she Avas found composed and rational, her pulse 90 and of good strength, and from this time there Avas no return of the symptoms." He also observes, "that in the last stages of exhausting diseases, patients frequently fall into a state resembling coma ; and I have frequently seen children lie for a day or two in this kind of stupor, and recover under the use of Avine and nourishment. It is scarcely to be distinguished from the coma Avhich accompanies dis- eases of the brain. It attacks them after some continuance of exhausting diseases, such as tedious and neglected diarrhoea." "I have seen in adults the same affection, though it is perhaps more uncommon than in children. A man considerably advanced in life, in consequence of a neglected diar- rhoea, fell into a state closely resembling coma." An elderly lady, from the same cause, had loss of memory and squinting. " Both these cases recovered by wine and opiates: in the former blistering on the neck was also employed." lie adds the very remarkable case of a gentleman, about thirty years of age, Avho had been reduced to a state of extreme Aveakness and emaciation. As debility advanced he had become considerably deaf; and " Avhen I saw him," says the doctor, " he Avas affected in the following manner: he Avas very deaf while sitting erect or standing, but when he lay horizontally he heard perfectly. If when standing he stooped forAvard so as to produce flushing in the face, his hearing was perfect; and upon raising himself again to an erect posture, he continued to hear distinctly so long as the flushing continued; as this went off, the deafness returned." Dr. Marshall Hall states that " he is persuaded that the loss of blood is by far the most frequent and influential source of delirium and mania occur- ring in the puerperal state." BRAIN. aui Richter and Mr. Travers relate cases of amaurosis resulting from loss of blood; and the latter author says, "A country lad, of robust constitution, became the alternately favored paramour of tAvo females, his felloAv- servants, under the same roof He Avas the subject of gutta serena in less than a twelvemonth." He refers to another lad Avho had palsy of retina as a consequence of secret indulgence. " When bleeding," says Sir Ben- jamin Brodie, " has been carried to a great extent, symptoms frequently occur which in reality arise from loss of blood, but Avhich a superficial observer will be led to attribute to the injury itself (concussion of the brain), and concerning Avhich, indeed, it is sometimes difficult even for the most experienced surgeon to pronounce, in the first instance, to Avhich of the two causes they are to be referred." Many quotations bearing upon the same point might be added ; but it may be presumed that sufficient, and perhaps more than sufficient evidence has been adduced from authors of high repute, to show that a great variety of symptoms which are com- monly, and under certain circumstances, correctly considered to be indica- tive of the consequences of inflammation of the brain, or of oppressed cerebral circulation from repletion or pressure, may, and not unfrequently do accompany conditions of the brain which are the direct reverse of these—such as loss of blood, or amemia and debility, from whatever cause arising. It is of importance to recollect that, before deciding upon a plan of treatment, the heart as Avell as the pulse should be always examined ; and that the force of the two should be compared; otherwise serious mistakes may arise and injurious consequences may result; as the heart may be beating Avith unusual force wdiile the pulse is feeble, or the strength of both heart and pulse may be diminished, though serious organic disease may exist in the former; and the brain may be seriously, gravely, and even dangerously oppressed with blood, though the impulse of the central organ of the circulation may be diminished. The treatment will consist in the removal of the cause when practicable, the administration of tonics, especially chalybeates, and moderate purga- tives to secure gentle and regular action of the bowels, good diet, fresh air and moderate exercise. In very advanced cases direct stimulants will be needed. In cases which are of a doubtful nature, we should blister the nape and purge, while Ave allow a generous diet; until we are able to ascertain the exact character of the affection. Part xix., p. 52. Cerebral Diseases of Infancy.—In taking a general view of what has been Avritten on cerebral diseases, Ave shall be struck, not so much with a deficiency^of knowledge as to their character, pathology, or symptoms, as with the indefinite and unsatisfactory methods of treating them. This defect is probably due to the excessive desire manifested to base principles of treatment upon post-mortem appearances; but, Avhilst the latter, although fully known and accurately described, vary so much in relation to the symptoms they are supposed to occasion, hoAV can the former be depended upon for safely averting the great dangers Ave have to encounter? There is yet much—very much, to be learned in the treatment of these diseases. In what manner can such knowledge be most readily and perfectly obtained ? The investigations hitherto made upon this subject, enable us to determine certain generalizations, and to state a few esta- blished facts, Avhich afford useful hints for practical application. 232 BRAIN. 1. Cerebral diseases occur most frequently in children of a scrofulous habit, or born of scrofulous parents. 2. Scrofula greatly modifies the char acter of cerebral as Avell as other diseases. 3. Cerebral diseases may exist independently of scrofula. 4. Headache, vomiting, constipation, and more or less pyrexia, are a combination of symptoms denoting, in children, serious, and often unmanageable cerebral disease. 5. A species of hydro- cephalus, chiefly indicated by the preceding symptoms, is gem-rally accom- panied with, or depends upon, tubercular disease of the brain or its mem- branes. 6. There exists another species of hydrocephalus, attended with the usual symptoms of phrenitis, of a strictly inflammatory nature, and curable by strictly antiphlogistic remedies. 7. Hydrocephalus resulting from tubercular disease may assume an active inflammatory type, and bo scarcely distinguishable from the last variety, except from its not being so amenable to antiphlogistic treatment. 8. Symptoms similar in many respects to those of acute hydrocephalus in one or other of the above forms, may arise from a system diametrically opposed to inflammation ; these are curable only by a nourishing and mildly-stimulating plan of treatment. 9. Hydrocephalus, generally speaking, does not occur before the age* of two years ; and boys are more liable to it than girls. 10. Treatment, to be effectual, must be commenced at an early period of the disease. 11. The symptoms of cerebral diseases in children, and the post-mortem appear- ances, have not a definite or constant relation to each other; and the for- mer are more to be depended upon than the latter for indications of treat- ment. 12. Constipation is not essential to the phrcnitic variety of hydro- cephalus. 13. Certain cases, accompanied with symptoms so constantly in connection Avith tubercular encephalitis as not to be distinguishable from the latter form of disease, admit of being cured ; and may, therefore, be fairly considered as instances of the curability of a disease Avhich is gene- rally supposed to be incurable. The treatment of diseases of children requires considerable tact and dis- crimination, both as to the nature of the remedies to be used, and the mode of employing them. We have tender bodies to deal with; their period of life greatly modifies the action of medicines; errors of judgment in prescribing are of more serious consequence, and life is altogether in greater jeopardy. It is often necessary to reduce arterial action, and blood-letting is sometimes attended with success, but in very young children this is a dangerous remedy, and probably not a few have fallen a sacrifice to its depressing influence. The usual method of draAving blood in children is to apply leeches, and children have bled to death from leech-bites. Cupping is an operation not easy to perform in children, but it is prefer- able to" leeching, because by it the quantity of blood to be abstracted can be regulated, and the bleeding can be stopped as soon as enough blood has been removed. Blood-letting, as a remedy, is foi tunately seldom indis- pensable at the period of life in Avhich children are most frequently affected by cerebral diseases, my OAvn experience would almost say never / for in a period of more than fifteen years, I have never myself drawn blood, either locally or generally (save by scarification of the gums or eyelids), from a child under six years of age, for any complaint Avhatever. How then are inflammatory complaints to be treated ? What are Ave to do in a case of phrenitio hydrocephalus, if we are not to bleed ? Are Ave possessed of any other effectual means of combating inflammation ? Yes, we have many other resources for lessening vascular action in children Avhich will often- BRAIN. 233 limes enable us to spare a fluid so necessary to existence, and so often wanted in later periods of diseases, when it is difficult, if not impossible, to supply it. The warm bath is a powerful agent for relieving the circulation in infancy ; antimonial medicines will reduce power to almost any neces- sary amount in children ; purgatives also ; but owing to the extreme sus- ceptibility of the intestines of children to take on irritation Avith Avhich the brain very quickly sympathizes, it is not often advisable to use them freely; we may, however, safely employ enemata, which have the effect of reducing the pulse and lessening heat of skin in a very satisfactory manner, as Avell as removing offending matter, and encouraging a flow of bile. But there is another class of medicines both safe and effectual for abating inflamma- tory affections in children, provided the stomach be not too irritable to retain them. I mean diuretics, and I have repeatedly observed, Avhether in fevers or inflammations, that promoting a copious Aoav of urine has, in a striking manner, produced an antiphlogistic effect. These measures may be employed also in combination, and Avhen they are thus combined and judiciously applied, I have yet to learn that they are not capable of effect- ing as much for the removal of febrile action Avith scarcely the possibility of doing harm, as is usually effected by blood-letting. In the more advanced stages of inflammation, calomel for the removal of lymph, and iodine (liq. potassii iodidi comp.) for the absorption of effused fluid, are Avell known and trustworthy remedies. [Dr. Copeman remarks upon the difficulty there often is in distinguish- ing those cases Avhich require stimulants from those which require an antiphlogistic plan of treatment, and recommends a minute attention to symptoms, as the only means by Avhich this difficulty is to be overcome. He considers that the occurrence of febrile disturbance is generally a very good indication that simple remedies will not be sufficient, and that active treatment is required. After referring to the symptoms in thoracic and abdominal affections, he says :] In head affections, unattended with fever, Ave ought not to resort hastily and actively to depletory measures, however much Ave may be inclined to suspect the existence of certain pathological conditions supposed to require antiphlogistic treatment. But there may be febrile excitement in a case where antiphlogistic treatment Avould be fatal. How are Ave then to judge ? If the fever be of an intermitting character, leaving the patient feeble and depressed in the intervals, the pulse being unsteady and variable, it behooves us to be guarded in our employment of loAverin<* remedial measures. ° The following circumstances seem especially deserving of attentive con- sideration in the treatment of the diseases of infancy and childhood: 1. The delicate, perhaps only partially developed, structure of tlie vital organs, the intolerance, for the most part, of powerful medicines or closes, and the great restorative powers of nature at an early period of existence. pitancy, by the gentlest means 3. W hilst entertaining a just idea of the nature and history of the disease we nave to treat, we must at the same time observe particular symptoms minutely, and vary our plan of treatment according to the information which those symptoms are capable of affording 234 BRAIN. 4. The importance of endeavoring to the very last to preserve life, how- ever desperate the circumstances may appear, keeping always in remem- brance that " Avhilst there is life there is hope." Part xxi., p. 74, Cerebral Disturbance resulting from Uterine Disorders.— Vide Art. " Uterus." Syphilitic Meni/igitis.—[Among the most remote and latest, but exceed- ingl'y important signs of constitutional syphilis, are those of a cerebral origin. Little notice, however, appears hitherto to have been paid to this fact. M. Ricord, speaking of "the action of the osseous affections on neighboring parts," says, that one consequence of this species of compres- sion is epilepsy, the fits seizing the patient as the osseous growth gets more considerable and irritating. He also mentions paraplegia as a casual effect of tertiary syphilis in the bones. Mr. Acton quotes this extract from M. Ricord, but upon the disorder of the mind they are both silent.] Dr. Thomas Read, of Belfast, gives the following: Case.—Syphilitic Meningitis ; Paraplegia y Hemiplegia ; Amaurosis; Difficulty of Articulation, with Mental Hebetude.—Mr. ¥., in July, 1847, Was accompanied to my house by a surgeon of Belfast, Avho Avas naturally alarmed by the rapid advances of paralytic and other cerebral symptoms in his case. The patient required to be supported on his feet Avhile his clothes were removed from the upper part of his person. Bis speech, from difficulty in articulation, Avas very imperfect; his powers of arranging his ideas and memory were sIoav and defective; vision very imperfect in both eyes. The gentleman Avho accompanied him had knoAvn him for some time. He had been treated for years by another surgeon for secondary syphilis—chiefly intractable ulcers on the limbs, face, and head; and on these parts there were several large cicatrices. He had placed himself under the former gentleman's care for progressively increasing amaurosis; • the paralytic symptoms supervened, and rapidly advanced until he exhibit- ed the aggravated and almost hopeless state of general paralysis in which I saw him. The history of the case, his countenance, and general appear- ance, led me to the impression that all the symptoms might be assigned to compression of the brain by development of syphilitic tumors of the dura mater; but as this could not be a certain diagnosis, and to guard against an error in judgment, I considered the rapid exhibition of mercury to be the safest course. I therefore advised the entire scalp to be shaved, a blister applied immediately over it, and one drachm of strong mercurial ointment to be rubbed in on any convenient surface twice a day. But I apprehended a speedy appearance of coma, and a necessarily fatal result. Some eight clays afterward I saAV his surgeon, avIio told me that our patient had made a rapid recovery, and was then able to run up and down the steps of a very steep staircase. To my additional surprise, a well- looking dark man, Avith clear and expressive eyes, addre-sed me one day in the street, and, asking me if I did not knoAV him, brought to my recol- lection the visit of himself and his medical attendant to my house, less than three weeks before. He Avas completely recovered, looked in full health, had perfectly regained his powers of motion, vision, and articula- tion, and Avas in full possession of all his faculties. Mercury here released every oppressed organ, gave flesh and strength by restoring the animal functions, and afforded one of the happiest triumphs of medical art over BRAIN. 235 disease I ever witnessed. Death must rapidly have closed the scene, had not this powerful and efficient agent arrested its course. The practical conclusions deduced by Dr. R. from this and other forma of syphilitic cachexia, are : 1st. That a single symptom of cerebral disturbance, such as some torm of mental disorder, may alone indicate the intra-cranial organic mischief m progress; a cachectic countenance may excite suspicion of its nature, but a close investigation of the patient's antecedents is required to affix its true character. # _ . 2d. That the employment of. mercury m this late stage of syphilis is unattended Avith those formidable consequences particularly liable from its use in the primary forms. Dr. 11. believes that no measure of bodily exhaustion should deter from the prompt employment of mercury, once the disease is discriminated, and that the more advanced the stage—the wider the range of involvement— the more signally does mercury, if appropriately and judicially employed at the right juncture, exhibit its strange conversion into a tonic, and its decided action as a restorative. Part xxv., p. 63. Vital Spot of the Medidla Oblongata.—At a meeting of the Academy of Sciences of Paris, M. Flourens took occasion to speak of the actual locality of the vital spot, or primum mobile of the respiratory act. By several experiments he has noAV determined that that spot is situated ex- actly at the point of the calamus scriptorius, betAveen the ventricle of Aurentius and the j unction of the V -shaped grey matter of the pyramids. This spot is, according to M. Flourens, about the size of a pin's heady above or below the same a sharp instrument maybe thrust in without caus- ing the respiratory movements to cease; but Avhen the exact spot is trans- fixed, life ceases immediately. M. Flourens had made this communication in order that the precise locality of the nodus vitse should be well under- stood. Part xxv., p. 83. Diagnosis of Cerebral Diseases.—1. When a person suffers from con- stant and dull pain in the head, Avith or Avithout convulsions, the pain being limited to a certain region, the external surface of the head being cool and the pulse regular, the digestive system not much or not at all disturbed, and the intellect unimpaired; if any thickening of the bony structure can be perceived, or if the patient has suffered from syphilis, it may be conjec- tured as probable that there is thickening of the skull, and that the symp- toms are due to that cause. In such a case, a moderate diet should be enjoined; leeches maybe occasionally employed; the bowels should be kept gently open; but our chief reliance should be upon the internal administration of iodide of potassium in increasing doses, and continued for a long period. 2. When there is pain and heat of the head, vomiting, nausea, want of appetite, foul tongue, derangement of boAvels, rapid and full pulse, squint- ing, delirium, thirst, and subsequent coma, and if the blood drawn be buffed and cupped, there can be little doubt that the case is one of menin- geal inflammation.' In such a case, there is no time to be lost; the Avarm bath must he used in the case of a child ; cold must in all cases be applied to the head ; leeches are always necessary; calomel is to be freely admin- istered, and alterative aperieuts must be given at the same time. By the adoption of such measures many valuable lives may be saved. 236 BRAIN. 3. When the head is cool, the pulse moderate, the tongue clean, the motions healthy, then, although there may be the most violent and long- continued convulsions, squinting, draAving in of the thumbs toward the palms of the hands, and all other symptoms indicating deranged action of the nervous centres, there is nevertheless an absence of serious centric disease. We may here reasonably hope for a favorable termination by the use of ordinary hygienic means; such as lancing the gums, if the patient be undergoing the process of dentition ; attending to the quality of the breast-milk in very young infants ; correcting any acescences in the prima} vice; change of air, and the judicious use of stimulants and tonics; and the adoption of all such other means as are calculated to improve the poAvers of the system in general. It cannot be urged in too strong terms, that the mere existence of con- vulsions, however alarming they may appear, does not indicate, alone, a serious disease of the brain; these movements are merely the external manifestations of cerebral irritation, and are often caused by circumstances comparatively trivial. On the other hand, it must be remembered that, at all periods of life, the cerebral membranes, especially the. pia mater, are apt to take an inflammatory action; and that, slight and Aveb-like as this membrane is, and insignificant in appearance as are the lesions Avhich it exhibits to the scalpel or to the microscope, yet upon its integrity or its unsoundness often depends the brightness, the perversion, or the obscurity of the intellect; and that an inflammatory disease of its texture is one of the most frequent causes of death. The most energetic treatment often fails to rescue the patient from the grave; but it is nevertheless of para- mount importance to detect the malady during life, and, if possible, to arrest its progress. Part xxix., p. 59. Cerebritis.—When fever is present, of a typhus character, don't be afraid of the symptoms of inflammation in the exhibition of wine. When typhus is present, there may seem to be local inflammation either in the brain, heart, or other organs, but this is not real inflammation, and will really be aggravated by depletion. Part xxix., p. 21. Cerebral Diseases.—There are three different states of the muscles in hemiplegia, indicating different conditions of brain, and requiring different treatment. If the' paralyzed muscles be p>erfectly flaccid, the cerebral lesion is atrophic in its nature, the very opposite to inflammatory; the vital poAvers are beloAV par. If the muscles exhibit any resistance to motion, the lesion is of an irritative kind, as a small apoplectic clot, with laceration of healthy brain tissue around. When the muscles are hard and rigid, the brain lesion is decidedly irritative, sometimes inflammatory. In the/first, a supporting plan of treatment is required; ammonia, wine, and quinine. In the last, bleeding, or, at all events, mercury is necessary. A clot, however small, will invariably give rise to coma ; if very small indeed, it may be merely a lethargic state; if large, the coma will be long and profound, and accompanied by snoring. If the hemiplegia be from white or atrophic softening merely, there w ill be no prolonged, if any, loss of consciousness, and the intellect will generally speedily recover. Part xxx\ii.,p. 30. Value of Tonic Treatment in some Diseases of the 2>rain.—The fol- lowing is an abridged lecture, delivered by F. C. Skey, Surgeon to St, BartholomeAv's Hospital: BKAIN". 237 I Avish to speak of Avhat is called " ramollissement," or softening of the brain. I do not wish to speak of its pathology ; I know very little about that, as to Avhether it is inflammatory or febrile, or what not. All that I pretend to know or to tell you is that the disease, as we see it, begins insidiously by loss of muscular poAver, and it occurs most frequently in men about the middle period of life ; the gait or Avalk of such a patient is unsteady, and it seems natural to ask a surgeon what may be the cause of this unsteadiness or irregularity. A banker or a banker's clerk finds his style of writing changes ; he has power, quoad poAver, he can use a dumb- bell, but he cannot regulate this poAArer so as to write a letter, as he pre- viously had done ; his urinary system becomes affected, and his urine drib- bles away, and even the rectum, from forgetfulness on the part of the patient, becomes partly paralytic ; there is loss of memory or incoherence of ideas; small eccentricities appear. This man will spell some Avords badly ; these are signs of recent cases : there is little or no implication of the reasoning poAver, at least to any extent, but the loss of poA\rer, as in handling a pen to write, is most peculiar, as Avell as the irregularity of spelling of monosyllables badly or backward in Avhat is written. But if you Avish for a more minute description of the disease, you will find it in the works of Rostan and others. Noav these cases are common ; this train of symptoms occurs in men Avho have undergone long anxieties in business, or this disease will occur in men who have had exhausting fevers or other maladies; or again, in the case of a man who rides with hounds five days a Aveek, four hundred miles a Aveek, and it may be, drinks Avine, eats very little, marries late in life, suffers from venereal exhaustion !—his nervous system becomes " broken doAvn," as it is called. What is the con- dition of the brain then ? Is it a condition of excess of vascular or vital force, or the opposite ? Can any of you recall a case of " ramollissement'' as it used to be treated a few years ago ? Happily for yourselves, per- haps not; but the principal point was to keep always in mind, " chronic inflammation," and to treat it accordingly. This poor gentleman must first be reduced, made to keep quiet, his diet regulated, his wine and fox- hunting stopped, and three grains of grey powder with rhubarb given at cloek-work intervals, for what Avere called the " secretions," or to touch the gums for this chronic (?) inflammation. Next, his skin Avas steadily looked to, and that great catholicon of surgery lads, mindererus spirit, with anti- mony, Avas ordered, spoiling Avhat little appetite the unfortunate patient may have had. He was rigidly confined to the house—but, mind you, with all this excellent drugging, his speech does not improve; he progresses, but it is from bad to Avorse. Very well! Noav that is one view—now for another. Mark that there is a sIoav pulse, everything is beloAV par, as I call it. In this, then, " chronic inflammation," some people count on their ten fingers all the drugs I use or adopt. I am very glad of it, for Ave have too much routine and rubbish in what is called " general practice." The eyes of the public are upon us; are you then justified in lowering this man with your antimony and your grey poAvder, and your mindererus spirit ? Oh, no! But some Solon says you Aveaken the patient in order that he may get strong. In these cases I could never understand that kind of logic; believe me, if you Avish to succeed in practice, you must give up such an idea; you must study nature a little more, and books and journals less. All the medical world of Europe is progressing ; but we are still tied down to grey powder, and oceans of physic, and bleeding, Avhereaa 238 BRAIN. what is required is that we folloAV the vis medicatrix and take advantage of the hints she affords us ! Well, then, so much for that; now for a case of "ramollissement" as it is called. About tAvo years ago, a physician called on me ; he said, " You are Avantcd doAvn to so-and-so (150 miles in the country). Mr. So-and-so (a rich country nobleman) has forced a catheter through his urethra; the poor gentleman has got ' ramollissement;' you knoAv that Ave are not so uneasy about; that is incurable of course ; if you can do any thing for it, Avell and good ; but his faculties are com- pletely gone." Well, to make a rather long story short, Sir B. Brodie and I saw him, and a fortnight after he came up to tOAvn, to his residence in Belgrave Square, and I had nearly the entire management of the case. It is exactly in this sphere of life, of rich noblemen, merchants, or politi- cal men in the fashionable West End squares, that Ave can alone catch glimpses of these tAvo opposites—viz., the excess of high living, and the excess of Sangrado bleedings and starvation or Ioav living of us the doc- tors ! Many of these cases are probably "heart disease," and a patient dies of a fainting fit, called Aveak brain, but it is weak heart ! Well, the more I came to look at this case of this gentleman, the more I said to my- self, the man is dying of exhaustion. I noticed he AAras better after dinner; I heard that he had had convulsions; this did not frighten me. Now, I Avant to ask you a curious question ; have you ever seen a sheep killed ? If not, I Avould advise you the next time you are near Aldgate market, just to look at the thing for yourselves. Just before all the blood is gone from the sheep, it is horribly convulsed ; remember that fact also in weak children who are convulsed. Convulsions, in fact, as you will meet them in prac- tice, are eight times out of ten the result of a Arery irritable state of the medulla oblongata or chord, Avhich causes very slight irritations elsewhere to excite violent reflex or convulsive movements; thus, worms or indiges- tible food Avill cause coiiAiilsions where the nervous centres are Aveak or irritable. This condition of convulsions to my mind is almost always one of " exhaustion" rather than congestion ; just mind that fact Avhen you go into practice—convulsions, as caused by anaemia, or " exhaustion." But to go on Avith the case, I could not find that this gentleman had had any tonic treatment. I knew that if the brain be anaemic, it cannot go on long in a normal manner, for nine out often cases of " ramollissement" •xre due to anaemia; so I decided to let him go back to his old mode of living. I gave him a pint of claret a day, that he Avas accustomed to, in place of water-gruel! He seemed to improve on it. The ratiocinations of his friends did not come true that it would kill him, so Ave let him have also quinine and iron in place of leeches and water-gruel, and grey powder, and antimony, and mindererus ! I studied the case for a short time ; there Avas a manifest improvement every Aveek. I Avas called on one day; he was a little Avorse ; did I bleed him ? No : I had the experiment Avith the sheep in my mind ; he is a gen- tleman of .very great eminence. It would have appeared very brilliant in a " bulletin," like the brilliant operations elseAvhcre, that Ave came up the fifty-ninth minute of the last hour of his sad existence and opened the carotid or temporal, but I did nothing of the kind : I increased his wine. Well, at the expiration of three months, that gentleman made a political speech that utterly astonished his constituents. He can now ride to the fox-hounds as well as ever he did, and in the changes and chances of Par- BEEAD. 239 (lament has filled a very important place; he is in fact, to-all intents and purposes, cured! 1 have had noAV nine or ten of these cases of ramollissement; tney all have bad sIoav pulse—a condition always improved by tonics. The heart, is perhaps at the root of the disease rather than the brain ; some of these patients- had alarming syncope—that is heart, depend on it, not brain. I met Dr. Latham and Dr.'Fergusson with one case, and we had a good deal to do to give force to the heart and pulse. Now, 1 do not want at all to say—that in some of these very cases we may not have had " ramollissement." I merely contend for the position, that leeches, oceans of physic, and starvation, are not the proper remedies. I will only say a few Avords relative to another case, which was seen by three of our ablest physicans in London—two pronounced it " ramollisse- ment," and the third " tubercle." I think tubercle in the brain is a very rare disease in adults ; this patient had excessively Aveak pulse; he had married late in life. I gave him Avine and the ferro-citrate of quinine in large doses—a remedy I have great faith in. Well, in three months he Avas quite recovered. I have said already I do not believe this disease to be of the nature of inflammation; Avith heat, pain, redness, swelling, etc., it strikes me as rather of the nature of gangrene, and as arising from anaemia, not hyper- emia. This last gentleman, I ought to say, had an issue ordered for him in Dublin. Well, I have no-objection to an issue in these cases, nor am I frightened at stopping an issue. There is something of the fabulous about what is Avritten and taught in lectures as to stopping issues. This gentle- man's issue healed up, or rather I took off the plaster, and never had that abiding faith, in its efficacy that would induce me to put it on again. In the earlier stages an issue may do good; it can at least do no positive harm, like other things Avhich have had more than a questionable charac- ter, as specifics for " ramollissement;" indeed, specifics so called, which unquestionably have hurried many patients to their graves, and which I would implore you to consider well in all their bearings before you adopt them. Part xxxvii., p. 34. BREAD. Pharmaceutical Bread.—f)c. Flour 3 lbs. Imperial; cold water, 1 1-2 pint Imperial; sesquicarbonate of soda, 1-2 oz. (troy Aveight) ; hydro- chloric acid, 5 fluid drachms ; a small quantity of salt, if required. Mix the soda perfectly Avith the flour, and the acid with the Avater, then the Avhole intimately and speedily together, using a flat piece of Avood or spaddle for that purpose, in preference to the hand. It may be made into two loaves, and put into a quick oven immediately. It will require about an hour and a half to bake. Part v., p. 81. ^ The Bran Loaf for the Use of Diabetic Patients.—Dr. Garrod, in his lectures on diabetes, recommended the following formula : Take a sufficient quantity (say tAvo or three quarts) of A\rheat bran, boil it in two successive waters for ten minutes, each time straining it through a sieve, then Avash it well A\rith cold water (on the sieve), until the water 240 BREAST. runs off perfectly clear; squeeze the bran in a cloth as dry as you can, then spread it thinly on a dish, and place it in a slow oven—if it be put in at night let it remain until the morning, Avhen if perfectly dry and'crisp, it will be fit for grinding. The bran thus prepared must be ground in a fine mill, and sifted through aAvire sieve of sufficient fineness to require the use of a brush to pass it through ; that Avhich does not pass through at first, must be ground and sifted again, until the Avhole is soft and fine. Take of this bran-poAvder 3 ounces Troy, 3 fresh eggs, 1 1-2 ounce of butter, rather less than half a pint of milk; mix the eggs with part of the milk, and Avarm the butter Avith the other portion ; then stir the whole well together, adding a little nutmeg and ginger, or any other agreeable spice. Immediately before putting it into the oven, stir in first 35 grains of sesquicarbonate of soda, and then 3 drachms of dilute hydrochloric acid. The loaf thus prepared should be baked in a basin (previously well buttered), for an hour or rather more. Biscuits may be prepared as above, omitting the soda and hydrochloric acid, and part of the milk, and making them of proper consistence for molding into shape. If properly baked the loaves or biscuits will keep several days, but should ahvays be kept in a dry place, and not be prepared in too large quantities at a time. Part xxxv., p. 303. ---»•• BREAST. Engorgement of.—Iodide of potassium, recommended by Lisfranc. Vide Art. " Iodic Preparations." Painful Affections of the Breasts—Acetate of Lead.—Dr. Smyth, in directing the attention of the profession to the use of acetate of lead in certain cases of obstinate diarrhoea, remarks as follows : It has been found, that a solution of acetate of lead is capable of almost immediately stopping the Arermicular movement of the intestines, if brought in contact with their coats; and it is well known that it possesses also the power of allaying the pain of inflammation when directly applied to an inflamed surface. Indeed, the quietude, and immediate relief from suffer- ing, Avhich I have occasionally observed to folloAV its application in some painful affections, especially of the mammae, occurring in Avomen about the middle period of life, have often astonished me. Even the lancinating and burning pain of carcinoma is sometimes greatly mitigated by the steady application of the diluted solution of diacetate of lead of the Phar- macopoeia. These effects, then, it must be admitted, are evidently the result of a sedative action exerted directly on the nerves of the parts to Avhich the remedy is applied. The officinal preparation is decidedly much too Aveak. For painful affections of the breasts, it should be made at least double or treble the strength of that ordered by the colleg- ; and it is likeAvise of great ail- vantage to apply it a little warm. If these precautions be attended to, it will be found much more effectual as a sedative. Part xiv., p. 87. Lymphatic Tumor of the Breast.—The absorbent vessels on the upper BREAST. 241 part of the breast leading to the axilla, are subject to a disease character- ized by a painful, tender, and irritable swelling, and-consisting of several cord-like indurations, at some times disposed in parallel toavs, at other times connected after the manner of an anastomosis. Other parts of the breast are occasionally the seats of this affection ; and in whatever situa- tion it occurs, the swelling is transverse, following the direction of the absorbents toward the axilla. On a superficial examination, the tumor may escape detection; but it can always be discovered by taking the sus- pected parts between the fingers and thumb. When the pain and tender ness are extreme, the absorbent glands in the axilla, and more rarely be- low the clavicle, become enlarged from irritation. These glandular en- largements always disappear after the original disease has subsided: the lymphatic swelling in the breast also frequently retires, leaving no vestige behind it. In extreme cases, however, a permanent thickening takes place, occasioned by the deposit of lymph in the cellular membrane. This disease usually attacks females betAveen the ages of fifteen and thirty-five, and is liable to recur repeatedly, where the constitution is in the peculiar state predisposing to it. The condition to Avhich I allude is that of comparative emaciation, ac- companied with irregular or deficient menstruation, depression of spirits, and general debility. Hence suckling and chlorotic Avomen are most fre- quently the subjects of attack. In some instances the patients are inclined to attribute the origin of the disease to external violence ; in the majority of instances, however, if not in all, it has appeared to me to proceed from imperfect menstruation. The size of the tumor in the mamma varies from that of an almond to that of an adult thumb; and the pain and tenderness attending it are of a remittent character. In some rare cases it attains nearly the size of a pul- let's egg in large and plethoric mamma?. The natural termination of the disease, in severe cases, when the special treatment adapted for its cure is not employed, is in a painful and obsti- nate ulceration, Avhich, in external appearance, has a considerable resem- blance to that proceeding from scrofula, the absorbent glands in the vicinity being enlarged, tender, and painful, and the discharge copious. Before ulceration commences, the cellular membrane subjacent to the skin becomes indurated ; this induration is gradually softened, the skin assume! an inflamed appearance, and a small chronic, scrofula-like abscess is tht result. The ulcer Avhich follows resists all local treatment until the propei constitutional remedy is adopted. Diagnosis.—The discrimination of this disease from others resembling it is not difficult. From the chronic mammary tumor, described by Sir A. P. Cooper, it may be distinguished by the pain and extreme tenderness, by the vitiated state of the patient's health, by the absence of lobes and of any cyst, and by the disease invading the breast of suckling Avomen, more frequently than those of virgins. The condition of the uterus, too, is widely different; in the mammary tumor, a state of excitement prevails, in the lymphatic tumor, a deficient circulation takes place in that organ, manifested by the discharge of an imperfect secretion, or false membrane, from its mucous surface. *'- From the irritable tumor, and neuralgic state of the breast, this disease may be known by the transverse, parallel, or anastomosing, cord-like bands, which are ahvays present, by the remission of the pain and tender- 16 242 BREAST. ncss, and by the latter symptoms being confined, as far as regards the breast, to the immediate locality of the tumor. The diagnosis in the ex animation of very large breasts is sometimes difficult. Treatment.—When the pain and tenderness are excessive, leeches and evaporating poultices may be applied to the integuments over the tumor. In general it AA'ill be found unnecessary to adopt any local remeilies, as the pain is not acute, but usually of an aching kind, like that accompanying rheumatism or phlegmasia dolens. The patient should take some prepa- ration of iron tAvice daily, have the boAvels relieved by an aloetic aperient, if needful, and use a generous diet, and gentle exercise in the open air. Should suckling have been long continued, the infant should be weaned, especially if the patient has been the mother of many children. l>y attend- ing to these directions, the tumor will entirely disappear in a few Aveeks, or all uneasiness Avill be so far removed that the patient Avill feel no incon- venience from it, unless the constitutional and uterine derangement should recur. Part xviii., p. 304. Sero-cystic Sarcoma of the Mammary Gland.—In this case, Mr. Law- rence states, a lady aged 55, of naturally pale complexion and nervous temperament, noticed, 30 years ago, a small tumor in the right breast, the size of a filbert, which remained stationary, however, causing no inconve- nience, until four years ago, Avhen it slowly increased, and became occa- sionally painful. About the spring of the present year it had attained considerable size, the integument covering it being raised into irregular prominences, and discolored. Then ulceration ensued, and from the open- ing protruded a red fungous mass, from which rather free bleeding took place on three or four occasions. Mr. LaAvrence removed the tumor, Avhich he describes as follows : The right breast is enormously enlarged, the increased bulk being caused by a diseased state of the mammary gland. About one-half of the SAvell- ing at its base is covered by integument, thinned by distention, but not unhealthy nor morbidly adherent. The other half is a vast fungous pro- trusion, measuring about eight inches, in its transverse diameter, by five or six in the vertical direction. This is bounded by a raised collar, the thickness of the thumb, in AA'hich the integument and the diseased mass are completely blended. The exterior and the convexity of this elevated boundary are covered by a thin and perfectly smooth epithelium. The interior surface, and the excavation Avhich it bounds, are nearly smooth and raw. Before removal it Avas a pinkish red, and not very sensitive; it yielded a thin yellow discharge, not offensive, but so abundant as to re- quire change of dressing three or four times in the day. The mass, being pendulous, lay over the loAver part of the chest and neighboring portion of the abdomen, of Avhich the integuments, constantly Averted by the dis- charge, Avere bright red and partially excoriated. The breast, which Avas not painful Avhen examined, Avas movable upon the subjacent parts, and there Avas no glandular enlargement, nor any trace of disease in the axilla. The health Avas good ; the patient slept well, had a fair pulse, and ate and drank Avith appetite. The patient having assented, the operation Avas performed October 0. She was placed on a couch in the recumbent posture, and chloroform was administered. The breast having been draAvn up and well supported, in consequence of its size and overlu nging position, by a folded towel, the BREAST. 243 under incision Avas first made and the skin turned hack: then followed the upper incision, carried along the body of the swelling, so as to form a flap nearly three inches Avide, Avhen the Avhole mass was readily separated, by a few strokes of the knife, from the loose and healthy areolar tissue Avhich connected it to the subjacent pectoral muscle. Several arteries bled freely, but were quickly secured, so that there was no considerable loss of blood. The edges of the wound came nearly together, and the patient Avas put into bed. There Avas some bleeding in the evening, caused by sickness, Avith vomiting; but it ceased on the application of cold, and she passed an excellent night. The breast, Avhich weighs 2 lb. 6 oz., presents, at its base, a firm lobu- lated mass. I now cut into it through the middle, to show you the internal structure. You see that it has undergone that morbid change called cystic sarcoma. It is a firm lobulated mass, composed of various sized cysts, filled, in the specimen now before you, Avith a soft, friable, vascular substance of light yelloAvish grey color. The cyst-walls, having been distended and thinned, have given aAvay, and have allowed the pro- trusion of the red fungous groAvth, which, Avith everted edges, occupied the front of the patient's breast. The nipple is concealed amongst the folds of integument. The disease, which is of innocent nature, commences by enlargement of the lactiferous tubes in the substance of the gland. These become tortuous and varicose, and the naturally oily secretion which they contain is con- verted into a thin Avatery fluid. Upon dividing a breast so degenerated, we observe escaping from the different cysts fluids differing in consistence and color—in some parts thick and glutinous, in others oily, in others limpid and Avatery. The fluid may be either clear and transparent, or of various shades, from a light yellow to a deep brown tint, from admixture of blood. As contrasted with the extirpation of a breast affected with scirrhus, the operation of removing one of these innocent tumors, which are ahvays loosely connected to the neighboring structures, is comparatively easy. In the present case, the diseased parts Avere firmly connected Only in one spot, where the areolar tissue Avas thickened, probably from the weight of the mass. Iu malignant diseases, the infiltration of morbid deposits always ex- tends beyond the structures first affected. Hence it is often necessary to make the incisions at some distance from the obvious circumference of the tumor, and to include a considerable portion of integument, the removal of which prevents the approximation of the edges of the wound, and in- volves the necessity of our leaving an open surface of considerable extent— a condition Avhich adds to the patient's danger, especially Avhen the Avound is situated over a cavity containing such important organs as those of the cnc'st- Part xxii., p. 295. Scirrhous Degeneration of the Mammary Gland.—The patient in this case was a nervous irritable Avoman, aged 45, a sufferer from rheumatism". 1 he disease in the breast was discovered by accident, giving no uneasiness f'>. i am also in the habit of using the chloric ether pretty freely in Dionciiial attacks, either alone or conjointly with ammonia. It is a valuable e; if i forn poly; 254 BUNION. senega is much lauded for its influence on bronchial affections; I have given it very freely, and, except for its unpleasant taste, can find no fault with it, nor can I bestow upon it any very strong encomiums. With the use of sedatives you require caution, especially with opium. Conium, hyoscyamus, hops, etc., are well borne on the Avhole; but nothing relieves irritable cough so effectually as opium; yet AA'hen there is much bronchial congestion, you -will beAvare of using it too freely, as it unques- tionably tends to increase that, and to endanger the life of the patient. On the-other hand, Avhen expectoration is free or too profuse, a moderate dose of opium often exercises the most beneficial influence, procures sleep, mo- derates expectoration, and relieves the cough. The reputation of the old paregoric elixir, modernized into compound tincture of camphor, is likely to last even through these days of skepticism. In the more advanced stages, and especially if there be SAAreats, tonics are useful, and sometimes astringents containing tannin, or even the tannic or gallic acid. Part xxv., p. 91. Chronic.— Vide Selections from favorite Prescriptions. Art. " Me- dicines." Chronic Bronchitis.—We believe the attacks of this disease to be often nervous and spasmodic-rather than inflammatory, and the aim of our treat- ment should not be to increase the secretion, but to remove the nervous condition on Avhich the cough, secretion, dyspnoea and tightness depend. For this purpose, banish expectorants, and give small doses of morphia, say the one-sixteenth of a grain, four times a day. As a preliminary step, remove all sources of irritation, and attend to the liver and boAvels. Part xxxvi., p. 101. Chronic Bronchitis.—In cases of bronchitis of long standing, the folloAV- ing mixture is very useful: Take of tannin three grains; extract of bella- donna three quarters of a grain ; extract of conium two and a half grains; infusion of senna three ounces ; fennel-water and syrup of marsh-malloAvs of each one ounce.and a half: M. A tablespoonfnl to be taken every two hours. Part xxxvi., p. 55. Chloroform in Bronchitis.— Vide Art. " Chloroform." Chronic Bronchitis, Asthma, etc.—In a considerable number of cases of chronic bronchitis, asthma, irritable cough, etc., striking relief has fol- loAved the inhalation of carbonic acid, and " in several chronic instances the,benefit has been at once both speedy and permanent." A common wine bottle, Avith a perforated cork and caoutchouc tube attached, and con- taining crystallized tartaric acid, and carbonate of soda, Avith a little Avater, are the materials required. The end of the tube may be placed in the patient's mouth and respiration be freely performed. The carbonic acid acts as a local anaesthetic. Part xxxviii., p. 256. BUNION. Treatment of Bunion— Recommended that the bunion be kept con- stantly covered with lint dipped in warm water, this being Avell defended BUNION. 255 also by oiled silk. The best mode of applying the latter is to cut a strip about half an inch in Avidth, and three or four inches long, turning it round the affected member. The lint should be changed night and morning, and any hardened cuticle should be gradually peeled off. When matters are improved, the contiuued application of the lint will not be necessary, - but the oiled silk should be constantly Avorn, to prevent a return of the disturbance. Part ix., p. 187. Bunion, Ganglion, etc.—Diagnosis and Treatment.—In certain situa- tions in the body, says Mr. B. Cooper, it is extremely difficult to form a diagnosis of bursa; mucosa?; they are sometimes so hard as to be mistaken for small exostoses; and by the enlargement of the bursa betAveen the latissimus dorsi muscle and the inferior angle of the scapula, a tumor may be formed which might be readily mistaken for chronic abscess, steatoma, or eAren malignant disease; but a surgeon conversant Avith the character of ganglia in their natural state Avould soon discoArer the real cause of the swelling. On the feet, and more particularly on the inner side of the root of the great toe, an adventitious bursa, termed a bunion, is very frequently formed; it is produced by tight and ill-made shoes, Avhich force the great toe into an unnatural position, out of the line of the axis of its metatarsal bone and under the other toes, in such a manner that the bone of the first phalanx presses forcibly on the capsular ligament of the joint, and induces the inflammation and acute pain inseparable from this distortion. Unless the deformity be remedied, the continued pressure of the bone tends to increase the inflammatory action, and ulceration would be the ultimate result, were it not for the compensating provision of nature, Avhich leads to the formation of a ganglion between the capsular ligament and the skin. If, however, the pressure be still continued, it may induce inflammation of the adventitious bursa, and an inflamed bunion is the consequence; this so completely cripples the sufferer, and the pain is so excessive, that surgical aid is here usually sought, although, however, various mechanical con- trivances have been proposed, and also many different kinds of plasters, the object of all being to remove the pressure which has been the original cause of the disease. No treatment can prove successful unless the great toe be restored to its natural relative position parallel with the others, and the most simple and effectual means of effecting this is the one adopted by Mr. Key; he recommends that the stocking of the patient should be furnished Avith a division or compartment resembling the finger of a glove, to receive the affected toe, a similar compartment being also constructed in the inside of the shoe ; into these the toe passes, and is preserved in a direction parallel to that of the others; but it may be necessary before resorting to the use of this contrivance to subdue the local inflammation by the application of leeches, blisters, or evaporating lotions. A ganglion on the dorsum of the foot or instep sometimes produces even a more serious form of the disease than the bunion. It may cause contrac- tion of the extensor tendons of the small toes, permanently extending the latter, so that the Avhole of the Aveight of the body falls during progression upon the first phalanges, in which situation ganglia are found precisely similar to that just described as occurring at the point of the great toe. If these become indurated by neglect or continued pressure, so that the effused contents cannot be let out by puncture, the only alternative left to the surgeon is to divide the implicated tendon or tendons, so as to relieve 256 BURNS--SCALDS. the permanent extension of the phalanges, and to restore the toes to their natural position. I have known exfoliations of the phalanx to occur as the result of this affection, but immediately upon the removal of the ex- foliating bone the deep ulcer Avhich had been produced in the sole of the foot healed, and the patient at once recovered. Vide Art. '■ Bursal Affec- tions." Part xvii, p. 131. ---•-•-•— BURNS —SCALDS. Mode of preventing Contraction after Burns.—Mr. Earle remarks: To take the upper extremity as an example, I will suppose a case where the Avhole integuments on the inner and front part of the arm and forearm have been destroyed. If such extremity be kept carefully extended on a splint, not only during the whole process of healing, but long subsequent to the perfect cicatrization, you will find that the- cicatrized surface will diminish in a circular direction, drawing the healthy integuments together from side to side, but that no contraction Avill take place in the long axis, in which alone it can impede the due motions of the limb. This permanent extension should be persevered in during the day and night, until all changes have ceased and the cicatrix has contracted to its smallest dimen- sions. Care, howeArer, should be taken during this time to give passive motion to the different joints, by which the proper secretion of synovia will be kept up, and the eventual free use of the limb will be insured. This plan of maintaining the limb in a state of permanent extension should be commenced as soon as the wound has begun to granulate. Part iii., p. 106 Unguentum JEruginis in Burns and Scalds.—Recommended by Mr. Gaozey as folloAvs: The best treatment that I have found, as the first to be adopted in the above injuries, is the application of the unguentum aeru- ginis, spread thickly on linen and the injured parts to he completely covered Avith it. This ointment affords immediate relief, taking out the fire (as it is in common parlance called) sooner than any other application; and if early applied Avill prevent vesication. My second application is either equal parts of olive oil and lead plaster, chalk ointment, or lead liniment. This latter I have successfully used in extensive burns as the first application, but shall noAV abandon it for the unguentum seruginis, to Avhich it bears no comparison. The formula for the lead Avash liniment is as follows: R. Superacetate of Lead, 9ij.; Water, Ibj.; Olive oil, Ibss. M. To be spread Avith a feather over the part and covered Avith a linen cloth, and renewed occasionally; the granulations to be touched daily with a caustic lotion. This is also an excellent application to the injuries of hands AA'hen burnt by the explosion of gunpoAvder. Part iii.,p. 111. Aphorisms of Practical Surgery.—The sudden extension of the fingers when they have been long bent, as from contraction of the cicatrized in- ternments after a burn, is frequently folloAved by gangrene. The exten- sion should therefore be sIoav and gradual, and we should avoid dividing or excising the bridle caused by the contracted cicatrix. BUBNS—SC1LDS. 257 Very severe bums often induce fatal tetanic symptoms. Part hi., p. 114. Aphorisms of Practical Surgery.—Patients suffering from extensive and severe burns, have almost always a very constipated state of bowels. We should not be too anxious to remove this state, as it does not seem to give rise to any inconvenience, and Avhen strong purgatives are used, a most troublesome diarrhcca often ensues. In the majority of cases of fatal burns, the internal surface of the stomach and intestinal canal is found to be highly injected. In the treat- ment of severe injuries of this sort, the surgeon's attention should be directed to the condition of these parts. Part hi., ^.117. Treatment of Burns by Soap.—The mode in which Dr. Williamson has been in the habit of employing soap, in the treatment of burns, has not only been found to be successful, but, on account of its simplicity, and of its being at hand in cases of emergency, will no doubt be generally adopted. |\ A common sffiaving-box may always be procured, from which a good lather may, in §gfe course of a minute or two, be easily obtained. This lather is then gilg'ly laid over the burnt surface by means of a shaving- brush, and repefSPfd as soon as the first coat begins to dry, or the pain re- turns. This practice ought to be repeated occasionally during the day, or until such time asuie pain is relieved. The benefit accruing to the patient is immedieile, and the result of the practice highly satisfactory ; for in the most superficial burns, if early applied, vesication is prevented, and, in the course of a feAV days, desquamation of the cuticle follows, without Reaving a raAV surface. Of course, this, as a remedial measure, is most applicable to superficial burns f'Jbut even in such cases as involve destruction of the more deep tissues, is not used Avithout advantage, in so far as the personal com- fort of the patient is concerned. In such cases, after a lapse of afeAV days, the crust formed by the soap is easily removed, so as to permit the em- ployment of otheamedicines, if necessary. Part iv., p. 101. Treacle anel JWtter.—Recommended in equal parts, spread on rags, and kept constantly applied, as a lotion to burns and scalds. Is serviceable in excluding air, afj^rding relief, expediting cicatrization, and in preventing the unsightly puckering and contraction which so often follow. Part v., p. 142. Operation of Autoplasty for the Relief of Contraction from Burns.— Dr. Mutter makes the folloAving observations on autoplasty: The opera- tion Avhich is most entitled to our confidence, especially in cicatrices of the neck, cheek, eyelids, nose, and lips, is that in which " autoplasty" is brought into service. In all such operations we are governed by the same principles, and pretty much the same mechanical details. They consist in: 1. Dividing the cicatrix so as to produce a raw surface, in some part of its extent; or cutting it out entirely, as proposed by Hildanus. 2. In applying to this raAV surface a piece of healthy skin, taken from the neighboring parts. * 3. In attaching this skin by suture to the margins of the wound in which it is inserted. 4. In approximating the edges of the wound, from which the skin has been removed. 1? 258 BURNS—SCALDS. 5. In separating, by appropriate agents, the parts too closely approxi- mated, and keeping them in this condition, some time after the flap has united. 6. In applying oleaginous frictions and motion to the neAV made parts, to give them flexibility and softness. Many shocking deformities from burns have been relieved by the per- formance of operations conducted on these principles; for example, the eye-lid, the cheek, the nose, and the lip, have all been restored. Part vi.,p. 130. Solution of Gum Arabic in Scalds and Burns.—Amongst the various ingenious methods of protecting the injured surface from the contact of the atmosphere, in cases of scalds and burns, the application of a solution of gum arabic, from its simplicity and readiness of application, is worthy of notice. It is, perhaps, not so readily and universally obtained as the solution of common soap, or the treacle and Avater, yet avhen it can be readily and quickly obtained, it will no doubt prove equally serviceable. When the skin is not destroyed, the parts are to be repeatedly smeared over with a solution ; as often as one layer is dry, another is to be applied, and this may be repeated several times. Mr. Rhind says : In those distressing cases of the extensive burning of the bodies of young children, I Avould not hesitate applying the solution over the Avhole body, at about the warmth of 96°. It does not cool doAvn the system by sudden evaporation, or sudden abstraction of heat, like a common cold fluid, a circumstance in most cases to be dreaded, for gum is a bad con- ductor of heat; neither does it preclude an exposure to moderately cool air, Avhich seems to keep down the excessive irritation consequent upon extensive scalding of the skin. I am inclined to think that the exclusion of atmospheric air influences very much inflammatory action, and in this Avay, perhaps, the gum solution checks the .inflammation of the skin in burns. Inflammation caused by touching the skin Avith the nitrous acid and other irritants, appears to be suddenly allayed by a solution of gum arabic; erysipelatous spots on the skin seemed also, in some trials, influenced by this application. And I may here suggest, that it might be tried in the first stages of the pustules of small-pox, especially those of the face, Avith a vieAV to modify their devel- opment, and prevent pitting. Part vi.,p. 145. Nitrate of Silver.—Mr. Jackson mentions its great utility in the treat- ment of burns and scalds, in which he had found great benefit resulting from its application, and instanced several cases of superficial burns in children, in which he found that in a very short time after its application the pain ceased, and vesication was totally prevented. In the deeper burns he uses it, not that he finds that it can produce any effect upon the charred parts, but that, as Mr. Higginbottom has said, he finds the superficial burn healed, and the extent consequently circumscribed. The form \vhich he uses is in the proportion of ten grains of the nitrate of silver to one ounce of Avater, applied by means of a camel's hair brush over every part exhibiting the slightest appearance of inflammation, two or three times a day, until the skin has become blackened ; afterward only occasionally. Part vii., p. 167. Chloride of Soda.—Lisfranc strongly recommends a solution of the BURNS--SCALDS. 259 chloride of soda, which, he affirms, acts as an astringent and sedative, affording rapid relief to suffering, preventing an increase of inflammatory action, and dissipating this when it already exists. The strength of the solution is to be regulated according to the irritation produced. This should be but slight, subsiding in ten minutes or a quarter of an hour. It acts far more efficaciously Avhen the mucous substance of the skin is laid bare than through the epidermis. Part vii., p. 212. Creasote in Burns.—Dr. Sutro having witnessed the very valuable effects of creasote applied in cases of burns and scalds, recommends the folloAving preparation to be kept ready under the name of " Burn Ointment:" R. Creasot. drachmam dimidiam ; carbon, anim. praep. drachmam; spir. vin. drachmam et dimidiam ; ung. spermacet. unciam et dimidiam; m. ft. ung. for adults. This might be modified, according to age, in the following manner:— For children under five years, the ointment should be weakened by mix- ing it with four times its bulk of spermaceti; for children from five to ten years, with tAvice its bulk of spermaceti; and so on, gradually increasing the strength of the ointment, according to the age of the patient. In cases requiring protracted treatment, the dose of creasote should be gradually and carefully increased in the successive applications. Part xi., p. 188 Creasote in Burns—Creasote is one of the most valuable of those remedies Avhich the ancient writers designated as incarnatives, i.e., pro- moting cicatrization. M. Mascharpa has used it also in several cases of burns with the most satisfactory results: it soothes the pain of the injury at the time, and accelerates the subsequent progress of the cure. The best mode of using it is in the form of lotion—made by adding twenty or thirty drops of it to two or three ounces of water, and applied with pledgets of linen to the injured surface. Part x.,p. 172. Treatment of Burns by Ammonia.—M. Guerard recommends in burns the application of caustic hartshorn; the application of cloths steeped in ammonia immediately relieves the pain, and must be continued for one hour after the accident. When the burn has produced any destruction of the skin, ammonia should not be used; but in the erythematous form, or Avhen phlyctenae are present, it is of the greatest advantage. Part xvi., p. 225. (Edema of the Glottis, from swallowing Boiling Water.— Vide Art. " CEdema." Treatment of Burns.—According to Prof. Cooper, burns may be classed in six varieties. In the first there is just a redness of skin where the degree of heat Avhich has been applied has not been intense, and there is little or nO sloughing, and some erythema; and hi a very feAV hours, or, at most, in a day or two, the effects will subside, and the cuticle peel off, leaving no remains of injury in the part. It is very true that even this degree of heat may produce great injury, and even danger Avhere it is very extensive, as it suspends the functions of the skin, very much to the loss of the whole system; the pulse is quickened, the tongue red, and the mucous membrane of the alimentary canal is excited. In the second variety, the 260 BURNS--SCALDS. degree of heat has been greater, the redness is darker, and sloughing more considerable, but what marks it more particularly, is the formation of vesicles, which sometimes rise immediately after the application of heat, and in other instances, Avithin twenty-four hours afterAvard, contain serous fluid. In the third class, the surface of the cutis suffers, and is more or less destroyed; the vesicles attending this injury contain turbid blood and serous fluid ; you may knoAV it by the appearance of the part, it having a yelloAvish or light-brownish discoloration. These parts are converted into eschars, from Avhich the patient suffers no pain, unless pressure be applied, Avhich produces suffering by affecting the living parts betAveen the eschar. In the fourth class, the whole surface of the cutis is destroyed, and more or less of the subcutaneous texture is injured ; the discoloration of tho eschars is also of a deeper color. You may observe that these eschars are stiffer than those in the preceding classes and also more brittle, and the skin around them is puckered and Avrinkled. Upon the separation of these eschars, you find ulcers, from AA'hich granulations are formed, and they spread in great luxuriance; there is also profuse discharge of pus. In the fifth class of burns, the textures more deeply situated are involved, as the fascia and muscles; sometimes nerves and vessels, not destroyed, are included. The eschars are thicker, cold, black, and brittle; they are longer in separating, but Avhen they do separate, there is a very rapid discharge of pus, and quick granulations. In consequence of the muscles being involved, their action is impeded, and it often happens that the Avhole functions of a limb are suspended by a burn of this kind. In the sixth class, the limb itself is turned into a black, insensible mass, as sometimes occurs in large iron foundries, Avhere the hot metal comes in contact with the lower extremities; the foot, for instance, is placed in the groove or gutter Avhere the hot metal runs, and is at once converted into an eschar, Avhen, indeed, it is not at once annihi- lated. I need not tell you that in the former case, you must amputate the member. The constitutional symptoms of bums may vary much ; I may tell you they are divisible into tAvo classes ; those arising from the shock and irri- tation of the system produced by the action of heat; and those Avhich come Avith the reaction that takes place, such consequences implying hectic dis- turbance and its usual concomitant circumstances. A burn may be only superficial, and yet, from the extent of its surface, highly dangerous, and perhaps fatal, from the shock experienced by the system. It may produce such depression of the circulation, that you can scarcely feel the beating of the arteries of the wrist, and the Avhole body may be in a state of utter prostration. Now, all the danger arising from the first and second variety of burns, is in the first stage, a fact which you will take notice of, as it does not apply indiscriminately to the rest; and, if the patient get over the first stage, there is small danger to be appre- hended from the rest; resolution will take place, and Avithin twenty-four hours the danger Avill have passed aAvay. Not so Avith burns of the third, fourth, and fifth degree ; involving the deeper textures, they are not at once attended AA'ith all that constitutional danger attending burns of tho first and se'ond degree; but in three or four days, when the process com- mences by Avhich the eschars are separated from the living parts, a great degree of constitutional disturbance takes place. This process may take three or four Aveeks for its accomplishment, but it commences within BURNS—SCALDS. 261 three or four days of the injury; and that period is always one of great danger in burns of this degree. Dupuytren called this dangerous disturbance, the irritation from the injury, or, as we should say, the shock. The second period of danger is during the inflammatory stage. The third period of danger is Avhen suppuration is going on, and the great dis- charge tends to produce hectic. Tlie following is an abstract of the treatment which Professor Cooper recommends: Burns of the first degree, except when occurring on the head and face, or extensively on the trunk, may be treated by cold appli- cations, or flour, or carded cotton may be applied, and suffered to remain until cleanliness, or the patient's sensations, dictates their removal. Burns of the second degree may be treated with the same applications: and if the vesicles are large, the fluid may be let out by a puncture Avith a very fine- pointed instrument. When burns are of the third and fourth degree, they should be treated Avith lime-water and oil liniment, turpentine liniment, or poultices, until healthy pus begins to be secreted, and granulations form, when a mild astringent ointment, as the calamine cerate, should be used. When there are high fungous granulations, nitrate of silver should be applied, or a powder of myrrh and calamine sprinkled on the part, or straps of adhesive plaster applied. The great point in the local treatment of burns is, to prevent the access of air to them, by keeping the parts Avell co\Tered, and removing the dressings as seldom as possible. When the dressings of a large burn are to be removed, only one part of the surface should be exposed at a time. As to constitutional treatment, it consists, in the period of shock, in the administration of opium and stimulants, Avith external warmth ; and, for children, the Avarm bath. When reaction takes place, it must be moderated, if requisite, by antiphlogistic treatment: opium being still however useful. Again, in the period of profuse suppuration, bark, Avith acids, opium and Avine, together with mild purgatives, are to be employed. Mr. Erichsen says: " On taking, then, a general review of the consti- tutional treatment of burns, it may be stated that the first object should be to relieve the system of the abnormal quantity of fluid that must have accu- mulated in it, in consequence of the arrest, to a greater or less extent, of so important a secretion as the perspiration. This may be accomplished either by the administration of diuretics, by guarded blood-letting, or by encou- raging the process of suppuration, if it be deemed prudent to A\rait till this be established. Secondly, that any appearance, however slight, of the supervention of inflammation in the organs contained within the head, chest, or abdomen, should be watched Avith the utmost anxiety, and treated, if it do occur, as the circumstances of the case will admit. And, thirdly, that the process of suppuration should be maintained or arrested Avith a due regard to the state of internal organs, and the condition of the poAvers of the system." ..... Mr. T. M. GreenhoAv, senior surgeon to the Newcastle Infirmary, observes: When slight and superficial, any plan will prove successful. When very extensive and deep, none will succeed in saving life, though suffering may be alleviated ; and it is in intermediate cases chiefly that discrimination is required in the choice of remedies. To slight burns, cold applications, flour, or cottOn, are equally useful. 262 BURNS—SCALDS. To more severe ones, apply lawn paper dipped in warm turpentine thick- ened Avith ung. restore; Avhere there is free suppuration, use chalk ointment; and when the healing process goes on very slowly, apply a lotion with camphor mixture one pound, tincture of opium and solution of lead, each one drachm. Never apply escharotics. When the injury is so severe as to forbid all hope of recovery, envelop the entire person in cotton, as the most comfortable and convenient application. During the stage of shock, give stimulants and opiates ; afterward liberal diet and quinine. ********* Mr. Doming recommends to apply flour of the best quality Avith a " dredger," and allow it to " cake," Avhen detached, repeat the process till a healthy surface is left. When the burn is on the back, keep the flour in apposition by means of long flakes of carded cotton applied round the Avaist. Treat the ulceration remaining after severe burns by cer. cala- minae, except on the hands and face, where the use of flour may be con- tinued. ******** According to Mr. Higginbottom, we should make the surface as clean and dry as possible, remove any vesications or loose cuticle; then apply, with a small sponge, secured to the eye of a silver probe, a concentrated solution of nitrate of silver (arg. nitr. 9iv. acid, nitric, gtt. vj., aq., destil. 3iv.) so as to form an adherent eschar. If on the back, after applying the nitrate, cover with plasters of ung. plumbi comp., and dress every third or fourth day. Reapply the nitrate, if the eschars fall off too soon. ******** Dr. H. Barker, as dresser and house surgeon under Mr. Liston, used to apply the best flour Avith a dredger, as above described, and Avhen the caked masses came off, apply Averted lint and oiled silk, If cicatrization is tardy, use a Aveak solution of sulphate of zinc, instead of water; and il there are exuberant granulations, rub them lightly Avith a piece of sulphate of copper. Muriate of morphia is the best anodyne. ******** Mr. Newnham, of Farnham, thinks the dressing by cotton more useful than by flour, " because it more effectually covers and protects the ex- posed nerves." When the sensitive nerves of the skin are exposed to any great extent, he thinks a fatal result inevitable. Dr. G. Black, of Torquay, remarks that the great point in the treat- ment of burns Avith cotton wool, is never to remove that which covers the surface of the sore : he says "the outer portions which are saturated with the discharge may be cut off, and clean applied, but that covering the Avound never." Part xvii., pp. 189-195. Burns—Contraction from.—[In this case, in which there was extensive contraction of the integuments on the front and side of the neck, Mr. Grantham divided the cicatrix thoroughly. And afterward.] The treatment consisted in the application of folds of lint dipped into hot Avater, and secured by a roller passed round the throat, over the head, and under each axilla, at the same time securing a layer of avooI wadding over the wound, so as to maintain a temperature of the wound equal to the temperature of the adjacent integuments. This dressing Avas con- tinued, varied only occasionally Avith zinc ointment, for upward of two years, a period no doubt, seeming long to those who may not have expo- BURNS—SCALDS. 263 rienced the great difficulty of healing such wounds as have the derma imperfect. As is my usual practice where there is much purulent dis- charge, I endeavored to support the patient on a milk diet, the utility of which practice has been attested in the cure of the most extensive burn ever published in the annals of surgery—in which case is also proved the necessity of maintaining an equilibrium of animal heat, with a firm and easy pressure on the granulating surfaces, believing, as I do, that these two principles are the chief essentials as external agents, in the healing process of Avounds generally. I wish this remark to be understood as only applicable after the reaction of'the part has taken place, and all dead portions removed by exfoliation. Part xviii., p. 236. Contraction from Burns, cured by Division of the Cicatrices.—Mr. Whitehead brings forward this case as an example of the good effects (apparently permanent, for the case remains in a satisfactory state at the end of four years) of careful division of the contractile tissue of the cicatrix. The right fore-arm was immoA'ably contracted upon the arm to the degree of an acute angle, in which posture it Avas maintained by a web of cicatrix extending between the distal extremities of the two portions of the limb, and occupying, of course, the whole intermediate space. The corresponding limb Avas similarly fixed, the displacement being, however, less considerable. The skin of the neck was also deeply furrowed, and the head distorted. At this time (14 years after the aeeident), the head was dragged down to the right side, and the right arm rendered almost useless. Mr. Whitehead says : The fibrous band subtending the angle at the elbow-joint, was equal in thickness to and tangibly as firm as, the tendo Achillis. The first opera- tion Avas performed upon the neck, the incision commencing beloAV the ear, the lower part of which organ was merged in the folds of the cicatrix; it was thence continued below the line of the jaw to a point opposite the middle of the chin. Division of the skin simply appeared to afford no relief whatever to the distortion, there being immediately beneath numbers of bands of a bright fibrous aspect, AA'hich effectually prevented the parts from resuming their natural position. These being successively divided with the bistoury upon a grooved probe, and the head raised, other sets presented themselves to view, Avhich, when extended, still produced a tractive effect upon the cicatrix beloAV. Bundle after bundle was in turn dragged forAvard and divided, from one extremity of the Avound to the other, until caution suggested a cessation. The wound, Avhich appeared dreadfully large, Avas cleansed and covered with simple dressing; it AA'as quite healed in four weeks. The relief afforded by the above operation encouraged confident hopes of a successful issue from a like procedure upon the arm ; this was accord- ingly practised. The bistoury Avas plunged through the structure at the angle of flexure, as close upon the joints as safety to the neighboring parts Avouid admit, and thence carried forAvard, emerging at the free edge. But this incision, Avhich might, a priori, have been looked upon as all that Avas necessary, constituted comparatively but a small share of the opera- tion. The divided parts immediately retracted considerably; but when extension was attempted, even but to a limited degree, a number of shining fibrous bands started forward, completely hindering further move- 264 BURNS—SCALDS. ment. These Avere also divided and extension again attempted, Avhen others of similar character were brought into view, occupying an elevated position in front of the joint, and opposing like resistance. In this manner successive groups of fibres had to be separated, layer after layer, before the limb could be brought into a straight line, which was not accom- plished until all the deep-seated bands reaching across the joint on each side of the large A'essels, and outAvard toward the condyles, had been com- pletely divided, including, of course, the fascial insertion of the biceps muscle. During the operation, the median basilic vein was accidentally wounded ; this it was found necessary to ligature on each side of the puncture, before further steps could be taken. The wound, Avhich measured eight or nine inches in the long direction, and upward of four inches transversely, was cleaned and covered with simple dressing and a bandage. A splint Avas applied to the back part of the limb on the fourth day, but this appeared unnecessary, as there was no difficulty in easily maintaining an extended position; the apparatus was altogether abandoned at the end of three Aveeks, and never afterAvard required. The wound was completely cicatrized in six weeks. About three months afterward, I divided, in a similar manner, the cicatrices bounding the axilla, on the same side of the body, with nearly equal success. The successful issue of the operation was undoubtedly attributable, mainly, to the perfect division of all the facial fibres traversing the elbow- joint anteriorly from the arm to the fore-arm, or at least, all that could be exposed Avith safety. It is not a little remarkable that the clboAV-joint which had been almost totally unused for twelve years, appeared in no way injured, as no pain was complained of, nor difficulty experienced, in the attempts that were made to move it. The limb is noAV plump and well shaped, and apparently as strong and useful as though it bad not been materially injured. Part xviii., p. 237. Burns and Scalds.—In burns and scalds of the first and secend degree, apply solution of nitrate of silver as directed for erysipelas. See " Ery- sipelas." Employment of Charcoal.—For the suppurating sores which follow extensive burns, one of the best applications is powdered charcoal. If the burn is on the back, the charcoal may be freely strewed over the bed. Part xxi., p. 260. Contraction from Burns.—When a Aveb of cicatrix exists in the axilla, or between the fingers, or in similar situations, pass a needle carrying a skein of silk through the base or proximal extremity of the web, and allow the silk to remain as a seton. When sufficient inflammation and in- duration has been excited, the web may be divided in the usual way with great hope that the contraction will not return. Part xxi., p. 263. Scalds and Burns.—If there be the feeling of burning heat in the part, we can understand hoAv cold applications Avould be grateful, and how the case would get well, even though they Avere not the best, for the poAvers of the nervous system Avould, in this case, be intact. But no one would recom- mend the continued application of cold to a patient laboring under the depression attendant upon a severe burn. It has been held that external applications do good by excluding atmospheric air; but the injury arises BURNS—SCALDS. 265 not from the irritation of the air as air, but from its coldness. Warm air soothes and is beneficial. It is from their effects in soothing the nervous irritability of the injured part, by preserving the nerves from feeling the variations of temperature in the currents of the air Avhich Avould act upon the surface, that such applications as cotton, treacle, flour, etc., are of such great value. Part xxiii.,^. 333. Use of Collodion in Burns.—This fluid, when applied to burns, pro- motes healing and prevents suppuration. Blumhardt has tried it, with great success, in three cases, one of them caused by explosion of gunpoAV- der, and two by the ignition of spirits of Avine, Avhere the breast, neck, face and hands Avere all severely scorched. Collodion Avas applied to the skin an hour and a half after the accident, by a hair pencil; the redness, pain and swelling Avere thereby diminished, and the patients soon experienced no inconvenience save the tension occasioned by the firmly adherent pel- licle. The inflammation completely subsided and the recovery Avas rapid. Part xxix., p. 251. Deformities from Burns.—The chief attention ought to be paid to these cases just at the time Avhen they are most usually AvithdraAvn from treat- ment; it is then that splints, bandages, and other mechanical contrivances should be resorted to and rigidly persevered Avith, in order to preserve the part or limb in its natural position. Operations for the relief of these con- tractions generally fail, because the surgeon's attention has been directed more to the cicatrix itself than the newly-formed structure underneath, Avhich is really the active agent in the production of the contraction. Part xxxiv., p. 209. Burns and Scalds.—Having cleansed the parts, and punctured the vesications, paint over the entire surface an application of two parts of collodion and one of castor oil, Avhich repeat three or four times the first day, so as to form a covering entirely excluding all contact with the at- mosphere. When suppuration sets in apply a linseed poultice over the whole surface, and Avhen the slough has separated, an ointment, composed of an ounce of prepared chalk, tAvo drachms of olive oil, and half an ounce of spermaceti ointment, sp'read on lint. The above is an outline of the treatment at present pursued at King's College Hospital. Part xxxvii., p. 179. Gunpowder Burns—Treatment of.—When a charge of poAvder is fired near an exposed part of the body, a portion of the unburnt powder is de- posited in the skin, proportionately to the imperfection of the combustion and the coarseness of the granules. The inflammation which results is not sufficient to procure the elimination of the grains, and the person remains tatooed for life. Hitherto the only means for preventing such a deformity has consisted in the picking out by the fine point of a knife or needle each separate granule. This, though a very tedious and painful process, answers well enough in burns of a limited size; but in a recent case, in Avhich the whole side of the face Avas completely blackened, Professor Busch resolved to try a plan he had seen Hebra adopt for the removal of freckles, viz., exciting an eczematous inflammation by means of a solution (5 gr. ad 8 oz.) of corrosive sublimate. This Avas kept applied during several hours for five days, Avith the effect of exciting a smart eczema, and detaching the 266 BURSAL AFFECTIONS. grannies. The burn wan quite recent, and whether the means used is applicable to burns of an older date, remains to be tried. Part xxxix., p. 232. —»-»-»----- BURSAL AFFECTIONS. Treatment of Eilarged Bursce Mucosae and Synovial Sheaths of Tendons.—Professor Williams, of Dublin, has cured several cases of chronic tumors of the bursse mucosae and synovial sheaths of tendons " by the subcutaneous division of the sac of the tumor and the subsequent aj>- plication of pressure." A cataract needle Avas passed into the tumor (an enlarged bursa over the knee), and the entire thickness of the sac divided by several parallel and longitudinal incisions. A portion of the fluid escaped into the cellular tissue, but the greater part found exit externally on the withdraAval.of th« needle. The knee Avas then strapped Avith adhesive plaster, and the limb kept at rest. Part iii., p. 86. Enlarged Patellar Bursa dispersed by Subcutaneous Incision.—An in- cision, to the extent of one-eighth of an inch, Avas made along the outer margin of the tumor; then a very small bistoury was introduced obliquely into the cyst, at such a distance from the superficial cutaneous incision as prevented the escape of the fluid. The sac Avas then cut in several places, chiefly on the anterior surface, and the instrument withdrawn, all the fluid having been evacuated. A small compress was then applied, and several straps of adhesive plas- ter, and a roller which extended from the toes to the knee. A splint Avas also applied, which extended from the middle of the back part of the thigh to the same point of the leg. If the incision, or rather puncture into the sac, be made with care, the internal surface of the cyst then cautiously scored after it, the fluid evacu- ated by firm pressure, so as to prevent the ingress of air into the cavity, no danger need be apprehended of unpleasant effects succeeding to this measure. The only instances in which the subcutaneous incision might fail, are those where the sac is much thickened, its interior loculated, and the cells filled with a thick gelatiniform substance; still, in such instances, it is a means which should be kept in vieAV. Part vi.,p. 150. Patellar Bursa.—In some cases of enlarged bursa? we may adopt all the usual and simpler modes of treatment, and fail in dispersing them, or the treatment may be so tedious as to Aveary the patience of both surgeon and patient. We may blister and compress them, or pass a seton through, or make a valvular opening into them, and, after letting out the fluid, incise the inner surface of the sac, or Ave may extirpate them Avith the knife. One of the best and safest plans of treating these bursa; is by blistering them, or by using the tincture of iodine as a counter-irritant. Where they are small, as over the wrist, the fluid may be let out Avith a needle and compression applied. In a case of inflamed bursa of the patella, in which the usual treatment had failed, Mr. Hale Thompson cut doAvn upon it, and BURSAL AFFECTIONS. 267 carefully dissected it away. The coats of the bursa were at least a quarter of an inch thick. Part viii., p. 188. Bursal Swelling of the Wrist and Palm of the Hand—Division of the Annular Ligament.—Prof. Syme gives the folloAving case : J— P—, aged 20, Avas admitted on the 13th of February, complaining of pain and weakness in her left hand. The wrist and palm of. the hand were much swelled, but not discolored, and pressure on these parts caused distinct fluctuation, Avith the jarring sensation that characterizes effusion into the bursal sheaths. She stated that pain had been first felt about tAvo years before, and that for the last tAvelve months she had had hardly any use of the hand, in consequence of the SAvelling, and weakness attending it. I made a free incision from the Avrist into the palm of the hand, dividing the annular ligament. This gave vent to a quantity of glairy fluid, Avith many small flat cartilaginous-looking bodies, and exposed to view the flexor tendons, separated and surrounded by thickened bursal membrane. The cavity was filled Avith dry lint, supported by a bandage moderately compressing the hand and wrist. In the subsequent treatment, care Avas taken to prevent protrusion of the tendons, by drawing the edges of the wound together, and applying a compress over the seat of the annular lig- ament. Not the slightest disagreeable symptom followed the operation, and three days after it the patient was able to sew, which she had been prevented from doing for many months previously. In the course of afeAV weeks the wound healed, and the limb Avas in every respect perfectly sound. Part x., p. 160. Bursal Swellings of the Wrist and Palm of the Hand.—Till lately, incision, folio Aved or not by the use of the seton, was the chief mode prac- tised for the cure of enlarged bursa?. Dupuytren contented himself Avith merely slipping a seton under the annular ligament, but the effects were much the same as the former mode. Mr. Syme more lately proposed making a free incision into the bursae and through the annular ligament. He has related one case treated in this way, but it is evident that even this is not free from danger. A new mode of treatment is now proposed by tAvo Parisian surgeons. On the one hand M. Gerdy has tried subcutaneous puncture, preceded and followed by the application of leeches and methodical pressure ; the result has been successful, but we cannot state Avhether or not there has been relapse, the patient having left the hospital before there Avas suffi- cient time to ascertain if the cure were permanent. On the other hand, M. Velpeau has been trying injections with iodine, and has obtained speedy cures, free from all accidents. Others have followed the prac- tice, and have had reason to be satisfied with it. M. Chassaignac informs us that he has cured one case by this method, and has operated on another. The case is that of a man, aged 40, Avho for some years has had a double tumor on the palmer surface of the right hand; it is fluctuating, and Avith- out change of color on the surface. One of these tumors, of the size of an egg, Avas above the annular ligament; the other, of the size of half an orange, Avas situate in the palm of the hand. The fingers could not be extended ; on pressing alternately on either tumor, that sensation of jar- ring peculiar to hydatid cysts AA'as not present; but this negative character arose from the circumstance of the two tumors not freely communicating, 268 BURSAL AFFECTION8. m consequence of AA-hich the displacement and friction of the corpuscles on each other Avas prevented. The hydatic bodies, hoAvever, may be alto- gether wanting, but this does not in any Avay change the nature of the disease ; besides, they are sometimes present in small quantity. In this case there AA'as no doubt of the true nature of the complaint. M. Chas- saignac operated in the folloAving manner: After causing the tumor to project, by means of lateral pressure, he plunged a trocar into the palm of the hand; a small quantity of viscid fluid escaped. By means of strong pressure on the tAvo tumors a prodigious number of hydatic corpuscles escaped through the canula; several of these Avere larger than the diame- ter of the instrument, Avhich proved them to be elastic and compressible. Examined by the microscope, these productions appear to be true hyda- tids Avith vesicular bodies, and not merely those hard, simple, albuminous concretions usually found, Avhich Avould lead us to believe in the existence of two varieties of these tumors, the one truly hydatid, the other only hydatiform. After having completely emptied the tumor, M. Chassaignac Avashed out the sac tAvice or thrice Avith warm water; he then injected a solution, composed of one-third tincture of iodine and tAvo-thirds of Avater. After allowing it to remain a few minutes, the fluid Avas completely with- draAvn. It Avas remarked during the process of these injections that the subannular opening serving as a communication betAveen the tAvo sacs Avas very small, so that the fluid passed from the palmar sac into the superior only when the former aa as full; and this appears to explain the obscurity of the fluctuation betAveen the tAvo sacs. The tumors were again filled a feAV days after the operation, but in a much less degree. M. C. is of opinion that the cure will be effected by spontaneous absorp- tion of the fluid, as in hydrocele; and he founds this opinion on a case he lately observed, in which there Avas a large serous cyst in the left groin; the tumor reappeared after injection Avith iodine, but Avas gradually ab- sorbed ; in its latter stage the tumor felt like a compact knot, but at length entirely disappeared. At the last scientific congress in Italy, a case Avas communicated by Gherini, surgeon to the great hospital at Milan, of a large bi-lobular hyda- tid cyst, situated at the posterior part of the elbow, cured by incision alone, and from which there escaped fifty-tAVo barley-shaped corpuscles. The sac suppurated, it is true, but the cure Avas complete, Avithout any unfavorable symptom. The bi-lobular form in this case Avas remarkable from the absence of the annular ligament, which is sufficient to account for it, at the wrist; it may be also remarked that the barley-shaped con- cretions are not confined to the latter region. Gherini states that he is certain that neither of the cavities communicated Avith the articulation. The extraction of the hydatid corpuscles is, of course, essential to the cure of these affections. Part xii., p. 248. Treatment of Effusion into the Bursa Patellae.—Effusion into the bursa patella? is a very common affection, familiarly knoAvn by the name of " housemaid's knee." In its usual form the effused fluid is pellucid, and the Avails of the sac are thin. Having remarked on the division into vesi- cular, or cyst-like, and vaginiform, or complicated bursae, Mr. Johnson proceeds : The former compose the majority of the subcutaneous bursas; the latter a e bound up Avith tendons. They are especially seen in connection with BURSAL AFFECTIONS. 269 the flexor and extensor tendons on the wrist and ankle, are of considerable extent, imperfectly divided into several compartments, and placed beneath the annular ligaments and fascia, so as to plunge deeply amidst the ten- dons of the limb. It is obvious that inflammation in the vaginiform bursas is a very different affair from inflammation in the simple ones. In the latter, if suppuration ensues, it is superficial, accessible, limited, or if it escapes the precincts of the bursa, it is into the subcutaneous cellular membrane. In the former, the inflammation is in a larger cavity and in- volves a deep and inaccessible one; if suppuration ensues and is confined within the bursa, it is still deep and hard to be got at; but if it extends, as it is apt to do, among the neighboring parts, it is in the deep cellular membrane, stretching under the fascia} and between tendons and muscles, where it defies the most skillful and daring surgeon. Need it be said, that suppuration of the vaginiform bursa? is a thing to be religiously avoided, that it is always dangerous, and too often fatal. Mr. Johnson Avarned the pupils against puncturing these bursa?, or resort- ing to any measures calculated to give rise to inflammation in them. He mentioned some cases illustrative of the dangers of operative interference with them, and deprecated it in the most earnest terms. At the same time he advised, if suppuration did occur, as prompt and as bold an open- ing as could be ventured on. The principal object, hoAvever, of this re- port, is to point out the advantage of puncturing the subcutaneous \'esi- cular bursa}, especially that on the patella, when enlarged from simple increase of secretion, Avithout much inflammatory action, or consolfdation of their walls. The plan adopted by Mr. J. consists in introducing, a grooved needle, perpendicular to the surface, into the cavity, the bursa being rendered prominent and tense by properly directed pressure. The needle having entered the cyst, its convex side is kept pressed against the sides of the opening, which, of course, tends to free the groove from obstruction, and to render the channel more patulous. The exit of the fluid is assisted by maintaining firm compression on the SAvelling, and holding the handle of the needle Ioav, so as to direct the stream down- ward. In this manner, without pain, and Avith great rapidity, the bursa is emptied of ils fluid. A dose of senna is directed to be taken immedi- ately, its repetition is prescribed as circumstances may require, and the patient is ordered to apply a blister to the knee the same evening, and is cautioned against more exercise that day than is absolutely indispensable. In slight cases, one puncture, and a blister or tAvo, folioAved by strap- ping and a bandage Avhen the effusion has nearly disappeared, aie usually sufficient for a cure. But Avhen the case is of longer standing, or the disease has proceeded further, a repetition of these means is required. Part xii., p. 250. Treatment of Bursal Disease of the Knee Joint.—[Mr. Skey's remarks relate to that form of disease which affects the bursa placed anterior to the patella, and the ligament beloAV it, commonly known under the title housemaid's bursa. The bursal disease of the knee presents itself for treatment in the form of a general swelling of the sac, containing serous or puriform fluid. If unattended Avith pain, the contents will probably be serous merely, and the tumor soft. It is in this stage that blistering may be objectionable. As the disease advances, the mass consolidates by re- peated attacks of inflammation, more or less acute, till the swelling be- 270 BURSAL AFFECTIONS. comes a large tumor of nearly solid consistence. As to the communication of bursae Avith the contiguous joint, any operation, in such case, would be very objectionable. But such communications arc exceedingly rare, nor can"Mr. Skey call to mind any example of the kind, except that betAveen the tendons of the subscapularis and the shoulder joint, which might rather be deemed an extension of the synovial membrane of the joint under the tendon.] When not communicating with a joint, they may be opened Avithout danger in all situations and in every stage. The effect of a^eton is like that through a hydrocele or ranula, viz., the secretion is absorbed without being discharged by a wound, and the sac is obliterated. In a hard and consolidated form of the disease, it breaks down into a common abscess, which, AA'hen punctured, discharges its contents and heals. Pass the thread (common silk) through the centre of the tumor, and keep it in until the end is accomplished. If inflammation supervene, re- move the thread, foment or poultice; when sufficient inflammation has been set up, it is indicated by the oozing of pus from the punctures, and may be continued four or five weeks. If the morbid bursa be too deep for the application of the above treatment, injection and pressure may be used. Foe ganglions or adventitious cutaneous cysts, puncture with the lancet is a less painful and more certain remedy than a blow. Let the puncture be no larger than to evacuate the contents of the cyst. Bind doAvn the part afterward Avith a pad of lint and adhesive plaster, to promote the ob- literation of the cyst. Part xiv., p. 151. Bursm, Diseased.—Dr. Adams recommends to make a longitudinal in- cision from above doAvnward, throughout the whole extent of the bursa; inspect the cyst, and detach any small adherent bodies where the cyst is thick and capacious, and bulges from the incision, remove an elliptical portion. Introduce an oiled dossil of lint as a dressing, and apply light compresses and a bandage. When suppuration is fairly established, apply poultices if necessary. The advantages of this method over puncture, subcutaneous incision, injection, seton, extirpation, etc., are: 1. It is easily and quickly done. 2. It is less painful. 3. It produces little or no constitutional disturbance. 4. It is more satisfactory in its results, producing a radical cure, and removes all foreign bodies at once. Part xiv., p. 152. Consolidated Bursa.—Rub in a strong solution of iodine, and cover the part Avith lint and sticking plaster, to prevent the volatilization of the iodine...... Introduce a seton of eight or ten threads, and poultice. Part xv., p. 172. Acutely Inflamed Bursa.—Keep the limb quiet and in an elevated po- sition, apply poultices, and rub in the tartar emetic ointment combined with mercurial ointment. Part xv., p. 174. Treatment of Enlarged Subcutaneous Bursce.—When matter has formed in them, the only means is the evacuation of the fluid by a free opening: this is unattended with danger, and followed by a rapid and complete cure. When, however, the bursa is recent, the skin thin, and the fluid probably a mere increase of the natural secretion of the cavity, BUKSAI. AFFECTIONS. 271 the employment of blisters, or the external application of the tincture of iodine, is the best means of lessening the SAvelling, but it will probably return. For a complete cure, or in those cases Avhere the SAvelling does not yield to the application of blisters, or to the external application of iodine, more especially if the swelling be not large,- the best plan of treat- ment is to introduce a fine thread through the SAvelling, and use it as a seton. On the second day, this thread generally causes considerable pain, and requires withdrawal. A small quantity of puriform fluid passes, for a few days, through the opening, after Avhich the swelling gets gradually less, and contracting, is completely cured. Very frequently the bursa suppurates so freely as to require a free opening, the hole for the thread having closed. Although this is an extra source of pain, yet the cure is more complete, and quite compensates for this accident. Removal of bursa} simply for their inconvenience is a serious matter. Part xv., p. 175. Death following the Removal of a Bursal Tumor from the Patella.— Dr. Smith relates a case of the above description Avhich terminated fatally from the supervention of erysipelas. It is this circumstance Avhich has determined many surgeons to be very chary about using the knife in cases of diseased bursa of the patella. Mr. Samuel Cooper, in his " First Lines," says : " We ought not to open bursa? mucosae Avithout a real ne- cessity for it, for Ave occasionally hear of cases in Avhich patients lose their lives in consequence of the limb being attacked with phlegmonous erysipe- las. Part xv., p. 175. Vaginal, or Deep Bursal Mucosal.—Mr. Coulson explains his meaning of the term " deep bursa? mucosae " to be the synovial membranes, usually vaginiform, interposed betAveen tAvo or more tendons, between tendon and bone, or between tendon and ligament, for the purpose of protection from the effects of friction, and for facilitating motion. In the treatment of tumors of these synovial sacs, the plans recommended for their cure have been extirpation ; incision, either simple or combined with irritation of the surface of the cyst; subcutaneous puncture ; and iodine injections. Mr. Coulson has generally contented himself with in- cising the tumor longitudinally, and evacuating the contents. Some amount of inflammation ensues, Avith obliteration of the cavity, but some- times the inflammation proves very severe, inducing great constitutional disturbance, and in some cases even death has ensued from the attack. Part xxiv., p. 172. Treatment of Bursal Tumors.—In a case of enlarged bursa over the wrist joint, after the usual vesicant and stimulating applications had been employed Avith no good effect, Mr. Stanley made a free incision into the swelling, the glairy fluid was evacuated, tents of lint were introduced into the Avound, and the Avhole hand enveloped in a poultice. In the common enlarged bursa patellce, perhaps the best plan is to draw off the contained fluid by means of a small trocar, then apply a small blister or a strong solution of iodine, and ultimately support the part Avith a mercurial plaster and bandage. The practice, by means of setons, of converting these en- largements into acute abscesses, very often produces disagreeable conse- quences, and it Avould appear that recently formed cases are especially ill adapted for this mode of treatment. The most suitable are, perhaps, the 272 CACHEXIA. very chronic ones which have resisted ordinary measures. In all cases of enlarged bursa where the knife is resorted to, it is important to remember that the incision can scarcely be too free. Part xxvi., p. 121. Enlarged Superficial Bursa and Ganglion.—Make a free incision into the bursal tumor and let out the contents, and then apply a strong solution of iodine by means of a camel's hair pencil to the interior of the sac. Insert a strip of lint into the wound, and keep it there, so that inflammation and suppuration may ensue and the cavity be obliterated. Part xxvi., p. 122. Bursa of Flexor Tendons of Wrist.—This affection sometimes renders the fingers quite useless ; its removal was formerly considered impractica- ble. It may be cured easily and certainly by making an incision about an inch or a little more in length, through the integuments and subjacent textures, including the annular ligament of the wrist. Part xxvii., p. 352. Inflamed Bursa of the Patella—Evacuation of the Fluid.—This patient presented herself with effusion in the bursa? of both knees ; the distention Avas considerable and painful, and distressed the patient very much, wholly incapacitating her for her usual aA'Ocation. She was in good general health, but rather plethoric. Mr. Cooke having introduced the grooved needle, at the same time rotating it, and pressing gently upon the SAvelling, an ounce and a half of unctuous, synovial-like fluid was obtained from one bursa, by which procedure it Avas totally emptied. A bandage was applied very lightly, and she expressed herself as being much relieved by the tap- ping. A blister was ordered to be applied the same evening to the knee, and the patient desired to take a purgative. The other dropsical bursa was subjected to the same treatment. At the end of a month the patient returned to her occupation, with a caution always to use a pad when kneeling. If a ■strumous or otherAvise unhealthy tendency exist, a second tapping and blistering are occasionally required, with the addition of the applica- tion of iodine ointment to the blistered surface, and of course, if necessary, constitutional treatment. Part xxix., p. 184. Housemaid's Knee.—There is no form which this disease assumes that is not amenable to treatment, by means of a single thread of silk passed through its centre. Sooner or later (from two to ten or fifteen days), sup- puration in the cyst will follow, and the case assumes the form and charac- ter of an ordinary abscess, which the lancet will effectually relieve. Part xxxiii.,jo. 147. Enlarged Bursce.—Mr. Coulson, of St. Mary's Hospital, believes—even when bursa? are inflamed, and the skin over them red, instead of making any incision into them it is preferable merely to puncture them with a grooved needle. After e\racuation of the contents, apply pressure by means of soap plaster and bandage, reneAving this from time to time and repeat- ing the p'uncture of the sac also if necessary. The result is generally a safe and permanent cure. Part xxxvii., p. 269. ---n> CACHEXIA. Cachexia.—In the treatment of that class of cases so frequently seen iii children, characterized by large heads, tumid bellies, and pasty com- OESARIAN SECTION. 273 plexions, nothing is so efficacious as a simple combination consisting of from five to ten grains of phosphate of lime three times a day, in chalk mixture. Where there is palpable ana?mia, some simple chalybeate must be added. Part xxxvi., p. 39, Cachexia Eczematosa in Children.— Vide Art. " Skin Diseases." OiESARIAN SECTION. Case of Ccesarian Section.—Mr. James Whitehead gives the following description of the steps of this important operation. In a consultation of several of his professional friends, regarding the subject of the folioAving operation, Mr. W. stated his opinion to be, that the greatest available space at the upper aperture of the pelvis, in its antero-posterior diameter, was not more than one inch and a quarter. In this opinion, several who had also seen the patient before, fully coincided. It was with great diffi- culty, however, that an efficient examination could be made, as the con- traction in the cavity of the pelvis, and at its outlet, precluded the introduction of the hand to a sufficient extent. The tuberosities of the ischia Avere found to approach anteriorly to Avithin a very short distance of each other, and the outlet was much encroached upon by the apex of the sacrum, Avhich had advanced considerably tOAvard the arch of the pubes. After each had again made a careful examination, the conclusion Avas, that the dimensions of the pelvis Avere too small, not only for instru- mental interference by the natural passages, but also for the fragments of the fcetal cranium to pass, had perforation and separation of the bones been practicable. The Caesarian section was therefore decided upon, and recommended to be performed without delay. Catheterism, and other necessary preliminaries, having been attended to, the patient was placed upon her back, her shoulders a little raised on pilloAvs, and the knees flexed over the edge of the bed. Mr. W. placed himself in the kneeling posture. Assistants were stationed to keep her still—supply instruments, sponges, etc. The external incision Avas made in the line of the uterine axis, commenc- ing about four inches above, and extending nearly the same distance below the umbilicus, and running a little obliquely from within outward; its upper extremity being hal? an inch, and its lower an inch and a half to the left side of the linea alba. A short incision Avas first made through the whole thickness of the abdominal parietes, Avhich were extremely attenuated, and continued by means of a director and probe-poiuted bistoury. The cut into the uterus corresponded in direction with the external one, and was about seven inches long. A small incision was first made Avith the scalpel, and continued Avith the probe-pointed bistoury, the fingers being used to direct it instead of the grooved probe. The placenta being attached at this part of the womb was immediately torn through with the fingers, and the child and it extracted Avithout the slightest diffi- culty. The uterus, the parietes of which, in its distended state, were not thicker than shoe-leather, immediately contracted to the size of a child's head, and its walls became about three-quarters of an inch in vhickness. Some of the small intestines now protruded at the upper part of the 18 274 OESARIAN SECTION. wound, but Avere immediately replaced, and held in. The parts were then sponged, the external wound brought together, and secured by six inter- rupted sutures, adhesive plaster in long straps, and a broad, circular band. age. The lower fifth of the Avound Avas left uncovered by adhesive pfasters, in order to allow any discharge to pass freely from the interior: a piece of spread lint, and a fold of the bandage being all that Avas thought necessary at this part. The loss of blood amounted to about eighf or ten ounces; it issued principally from the placenta Avhile being torn throuo-h. There Avas very little discharge, indeed, scarcely an oozing of blood from the divided edges, either of the abdominal parietes or the uterus. The woman bore the operation almost Avithout a murmur, and said she had not suffered more than she should have done from tAvo or three ordi- nary labor pains. The child, who was alive and healthy, Avas extracted in less than tAvo minutes after the first incision Avas made, and the Avhole operation completed, and the patient in bed, in tAvelve or fifteen minutes alier the commencement. The pulse Avas not materially affected, and the patient was lively and talkative directly after being put to bed. A quar- ter of an hour after the operation, Avhich was nine o'clock, p.m., three grains of solid opium were administered, and directed to be repeated every four, five, or six hours. She passed a comfortable night: slight uterine pains came on three or four hours after the operation, and she had some lochial discharge at the same time per vias naturales. There has been a little oozing from the lower part of the wound. [For some time the case seemed to be going on favorably, but eventually ended fatally, thirty-two days after the operation.] Part iv., p. 122. Co2sarian Section Successfully performed.—A woman, thirty years of age, had already been three times delivered by means of the perforator and crotchet. Pregnant for the fourth time, and having suffered ex- tremely from the 12th to the 15th of August, Avithout a prospect of the head passing the pelvis, the patient consented to the Caesarian operation, which had been proposed to her early in the course of the 14th. The operation was done in the usual Avay, in the linea alba, and the only diffi- culty experienced was in disengaging the head from the isthmus of the pelvis, into Avhich it Avas firmly Avedged. The child, Avhen sprinkled with cold water, began immediately to cry, and moved freely. The mother declared the pain of the operation nothing, Avhen compared with the suffering she had already endured. It was begun and completed in a quarter of an hour. 16th.—Belly distended Avith flatus; some pain; no fever. A suppository was folloAved by the discharge of much flatus, and complete relief to the pain. A little soothing electuary Avas all the medi- cine that Avas prescribed or required. The mother nursed her child, and in four Aveeks avus going about her ordinary household affairs. Part vii., p. 182. Ccesarian Section.—A Avoman, aged thirty-one, who had borne five children naturally, Avas attacked with violent arthritis, during her sixth pregnancy. The pelvis became so deformed that the finger could scarcely be introduced between the tuberosities of the ischium and the ascending rami, on either side; the pubes also formed a very prominent angle, the sacrum projected much forward, and the <*s uteri could not be reached. CALCULI. 275 On the 27th of July, 1840, labor having commenced, and the contraction of the pelvic diameter being well ascertained, the Caesarian section was determined on, and Avas performed in the linea alba by Dr. Arnoldi. The results Avere most fortunate: the mother nursed the child herself, and the Avound healed by the beginning of September. Part viii., p. 168. Cmsarian Section.—At a meeting of the Royal Medical and Chirurgi- cal Society, Dr. Lee, after enumerating many cases, all of which showed the dreadful fatality of this operation, dAvelt on the great advantage to he derived from the induction of premature labor in such cases, as proved by the experience of the best midAvifery practitioners. Dr. Lee himself induced it twelve times in one woman, with perfect safety ; and had read that morning an account of fifty other cases similar in result. Dr. Merri- man remarks, respecting the induction of premature labor, that nothing is more easily done, and that it renders the Caesarian section unnecessary and unwarrantable. Dr. Lee, in continuation, observed that Dr. Denman mentions a whole family in the Strand born by this process, and remarked that it is not a thing Avell knoAvn, viz., its induction in cases of high dis- tinction. He said, in cases where the pelvis was so much distorted that the child could not pass at the seventh month, labor should be induced at the fourth or fifth; for that it Avas consistent with reason and humanity to preserve the life of the mother and produce abortion. He (Dr. Lee) did not con- sider pelvic deformity the only case applicable to this line of practice, but also cases Avhere tumors or cicatrices obstructed delivery as Avell as in cases of organic disease of the heart. Dr. Lee said his object was to show the society that the operation of inducing premature labor was both safe and easily performed. Part xxiii.,^?. 232. ♦-•-•■ CALCULI. Solution of Urinary Calculi.—Dr. Charles Petit has made numerous experiments on the solvent powers of the Avaters of Vichy over urinary calculi. The result of these researches is, that calculi of uric acid, and of the ammoniaco-magnesian phosphate, Avhen placed in this mineral Avater, lose, the first 53 per cent, and the last 60 per cent, of their weight. The loss is in the inverse ratio of their hardness and their cohesion. A very important result, however, is that the calculi of the ammoniaco-magnesian phosphate suffer from this mineral water a true disintegration of particles, and become more friable. M. Berard has repeated these experiments, and arrive! at the same conclusions. Numerous experiments were also per- formed on patients afflicted Avith various calculous complaints, the result of which Avas highly satisfactory. Those afflicted simply with gravelly com- plaints were, by the use of the mineral water of Vichy, relieved of all their uneasy feelings, and the formation of calculi was prevented. In those,