T iTiTnTi ■ t i ■ ■ ^ *■ ■ ■■ ■ ■ ■ ■ ■- i i " ■■'■ -- -- -^»4^kl4#M ^w-V^J* -"^t «^3f*VCXl*,. ^V*' *■•*«* *-■*• v »* Vol. I. 317 to Vol.11. 257 Physical Continuity . . 5 Vol. II. 258 to 586 DIVISION III. Diseases dependent on Unnatural Coherence . Vol. III. 13 to 92 DIVISION IV. Diseases dependent on the presence of Foreign Bodies 93 to 377 DIVISION V. Of Diseases which consist in the Degeneration of Organic? _ _ Parts, or in the Production of New Structures 3 ° DIVISION VI. Loss of Organic parts . . . . . 576 to 596 DIVISION VII. Superfluity of Organic Parts ... 597 DIVISION VIII. Of the Elementary Proceedings of Surgical Operations . 599 to 770 ERRATA VOL. I. Page Line 198 *t->for caoutchouc, read gelatine. 242 13, dele and Gonorrhreal opthalmia 343 1, for feather, read spring 546 28, for except, read as 552 26, for fish-bone, read whale-bone VOL. II. 21 48, for Wolf's-jaw, read Wolf's-throat, 40 17, read habitual costiveness is not 40 32, dele, where 59 49, for graphit, read plumbago, 65 15, for scarabaei, read scabiei, 101 (c) for potass. lod. gr. $, read potass. lod. 3ss. 103 50, point thus, return more readily, make 151 1, for rosin, read gum, 315 7, for down-lying, read lying-in 241 7,/or Upwards, read Downwards 258 8,/or intestine, read viscus 278 40, for sore, read sac 343 29, for veins are, read vein is VOL. III. 441 20,/or the naked eye, read a magnifying glass, 488 27, after with, insert that part, 491 22, for rose-crown, read rosary 515 22, for plaster, read layer 555 43, for with, read without 609 28,/or hips, read lips, INTRODUCTION. I. DEFINITION OF SURGERY.—ITS RELATION TO THE HEALING ART IN GENERAL.--DIVISION OF SURGICAL DISEASES. All diseases to which the animal organism is exposed, are the ob- ject of the science of healing, the purpose of which is their prevention, cure, or alleviation. The means we employ to these ends are either dietetic or pharmaceutic, or they consist in the application of suitable me- chanism, which we call surgical means, and the doctrine of their proper employment, which is called surgery. Every mechanical influence employed with skill upon the diseased organism is called a surgical operation. This influence consists either in a direct interference with the form and natural connexion of the part {Bloody operations, Akiurgie (a,) Germ.;) or only in a momentary or continued application of mechanism fitted to the surface of our bodies; to which belong bandages and machines, simple manipulations for restoring the natural position of parts, and the employment of suitable mechanism for repairing parts which have been destroyed (Kosmetik (b,) Germ.) There are diseases which specially require the employment of one or other class of the means just mentioned : the purpose, however, of the healing art is in most cases but imperfectly attained, if the medical man be not possessed of the requisite knowledge for deciding upon the neces- sary connexion of these means, so as properly to conduct their operation by a sufficient acquaintance with the laws of our organism, whence it necessarily follows that there cannot be established any true separation between the so-called medical and surgical treatment. The employment of surgical means calls for peculiar dexterity and aptness which natural talents and disposition and long practice can alone confer. " Esse autem chirurgus debet," says Celsus (c,) " adolescens, aut certl adolescentice propior, manu strenud, stabili nee unquam intremis- cente, edque non minus sinistra quam dextrd promptm, acie oculorum acri clardque ; animo intrepidus, immisericors, sic, ut sanari velit eum, quern accepit, non ut clamore ejus motus, vel magis, quam res desiderat, properet, vel minus, quam necesse est, secet; sed perinde facial omnia, ac si nullus ex vagitibus alterius ajfectus oriretur." Only in reference therefore to the physical and psychical characters of the medical man, can there be any division in the practice of medicine and surgery: in their attain- ment they cannot be separated, and, by the union of medical and surgi- (a) 'A** the edge of a knife, t^yor, an ope- (b) Koo-n'tu, to set in order. ration. (c) De Medidna, praef. ad. lib. vii. Vol. i.—2 14 INTRODUCTION. cal study alone, can the foundation be destroyed upon which so much bungling, and so many practices unworthy of the spirit of high art, have hitherto been supported. The study and practice of Surgery are connected with great difficulty. The dexterity and exactitude with which surgical operations must be performed, can only be attained by long practice on the dead body, the opportunity for which is rare; and still rarer the perseverance necessary to overcome the various disagreeables therewith connected. How much does this practice on the dead body still leave imperfect when we have to meet operations on the living! In how many instances does the life of the patient depend momentarily on the hand of the operator: the rest- lessness of the patient, his cries, a peculiar sensation to which no prac- titioner is a stranger in operating on the living subject, and particularly in the beginning of his career, easily disturb his needful equanimity, render him anxious and incapable of perfecting his work with firmness and certainty. Therefore are we not surprised on reading the open con- fession of the great Haller. " Etsi chirurgice cathedra per septemdecim annos mihi concredita fuit, etsi in cadaveribus difficillimas administrations chirurgicas frequenter ostendi, non tamen unquamvivum hominem incidere sustinici, nimis ne nocerem veritus." In the employment of surgical means the practitioner can only be guided by the most perfect anatomical knowledge. That knowledge of the structure of our body, with which the general practitioner is content, is insufficient for the operator. He must be most intimately acquainted by careful dissection with the position of every part, its relations to others, and the variations which in this respect may occur, so that this definite knowledge may direct him in every moment of an operation. Mere descriptive anatomy is not sufficient for the surgeon without that comparative anatomy which is directed to physiology, and which has in view the early developmental periods of the several organs, by which alone a true insight into the nature of so many diseases is possible. All these difficulties connected with the acquirement and practice of Surgery, are sufficiently rewarded by the great superioiity which, on the other hand, the piactice of them offers. In most cases where surgical assistance is necessary, the possibility of preserving the patient depends upon it: we must, therefore, in desperate cases take bold measures, and the advance of Surgery within the last few years in this respect, has raised our astonishment at the heroism of art, as wrell as at the immea- surable resources of nature. In this point of view has Marcus Aure- lius Severinus most correctly entitled his book on surgical disease, Be Medicind Efficaci. The inadmissibility of dividing Medicine from Surgery is most palpa- ble, when we endeavour to determine the object of the latter, and the diseases comprehended within its boundaries, as it never can have a perfectly determined limit in opposition to the other. All diseases which are cured by the application of mechanical means have been called surgical diseases, a definition at once too narrow and too comprehensive, as many so-called medical diseases are removed only by the application of surgical means, and many diseases are evidently within the jurisdic- tion of Surgery, which very often can be cured only by internal or ex- INTRODUCTION. 15 ternal pharmaceutical means. The distinction between external and internal diseases, which has been established as the ground of division between Surgery and Medicine, is entirely without meaning. Let us endeavour to find out some general characters of disease which to a certain extent might legally serve as the law for a nosological divi- sion, and to distinguish those diseases to which we would assign the name of surgical. As the phenomena of life present to us by the relative predominance of powers and organs, a dynamic, potential and organic material phase, on the intimate harmony of which health depends, so do we observe also in the diseased states of the organism, that sometimes the powTer, some- times the organ, varies more from the natural type, whence arises the difference between dynamic and organic diseases. This distinction can, however, only indicate a relatively predominant suffering of one or other phase of life, since the organic body presents in itself an entire whole, of which the several parts and phenomena are in the closest mutual connexion with each other. The organic diseases are especially those which originate in a de- struction of the natural condition, form, and structure of organized tissues, and therefore may generally depend, 1. on the disturbance of organic connexion ; 2. on the unnatural union of parts; 3. on the presence of foreign bodies ; 4. on the degeneration of organic parts, or on the pro- duction of new structures ; 5. on the entire loss ; and, 6, on the superfluity of organic parts. Organic diseases must be distinguished into such as have their seat in parts inaccessible to mechanical contrivances, and to our organs of touch, and whose cure therefore can only be attempted by dietetic and pharmaceutic remedies, or whose seat permits the employment of ex- ternal means, and regulated contrivances, and which in most cases can be brought to heal only by these contrivances, with the assistance of dietetic and pharmaceutical aids. We may therefore distinguish as belonging to the province of Surgery all those organic diseases which have their seat in parts accessible to our organs of touch, or which allow of the employment of mechanical means for their cure. Although inflammation is excluded from this general definition, we must, however, still enumerate it generally, and particularly among the manifold origins of surgical diseases, when it attacks external parts. Inflammation in its course and results produces for the most part organic changes, and requires, when attacking external parts, almost always the employment of the so-called surgical means : further, among the surgical diseases soon to be more particularly described, there is not one of which the cause is not inflammation, which in its course does not produce inflammation, or the cure of which is not to a certain extent singly and alone possible by inflammation. After these observations, we therefore prefer the following division for the setting forth of surgical diseases, which, if it be open to many objections, is, however, an arrangement of diseases according to their internal and actual agreement:— 16 INTRODUCTION. I. Division.—Of inflammation. 1. Of inflammation in general. 2. Of some peculiar kinds of inflammation. . „f, ., n, a. Of erysipelas; 6. Of burns; c. Of frost-bite ; d. Of boils ; e. Of carbuncle. 3. Of inflammation in some special organs. a. Of inflammation of the tonsils; b. Of the parotid gland ; c Of the breasts; d. Of the urethra; e. Of the testicle ; /. Of the muscles of the loins ; g. Of the nail joints ; h. Of the joints, viz. a. of the synovial membrane; b. of the cartilages; c. of the joint- ends of the bones, viz., aa. in the hip-joint; bb. in the shoulder- joint ; cc. in the knee-joint; and so on. II. Division.—Diseases which consist in a disturbance of physical con- nexion. i. Fresh solutions of continuity. a. Wounds ; b. Fractures. ii. Old solutions, a. Which do not suppurate, viz. a. False joints ; b. Hare-lip; c. Cleft in the soft palate; d. Old rupture of the female perineum. b. Which do suppurate, viz. i. Ulcers. 1. In general. 2. In particular. a. Atonic ; b. Scorbutic; €. Scrofulous; d. Gouty; e. Impe- tiginous ; f. Venereal; g. Bony ulcers or caries. ii. Fistulas. a. Salivary fistula; b. Biliary fistula ; c. Faecal fistula and artificial anus ; d. Anal fistula ; e. Urinary fistula. in. Solutions of continuity by changed position of parts. 1. Dislocations ; 2. Ruptures ; 3. Prolapses ; 4. Distortions. iv. Solutions of continuity by unnatural distention. 1. In the arteries, aneurisms; 2. In the veins, varices; 3. In the capillary-vascular system, teleangiectasis. III. Division.—Diseases dependent on the unnatural adhesion of parts. 1. Anchylosis of the joint-ends of bones; 2. Growing together and nar- rowing of the aperture of the nostrils; 3. Unnatural adhesion of the tongue ; 4. Adhesion of the gums to the cheeks ; 5. Narrowing of the oesophagus; 6. Closing and narrowing of the rectum; 7. Growing together and narrowing of the prepuce; 8. Narrowing and closing of the urethra ; 9. Closing and narrowing of the vagina and of the mouth of the womb. IV. Division.—Foreign bodies. 1. Foreign bodies introduced externally into our organism. a. into the nose; b. into the mouth; c. into the gullet and intestinal canal; d. into the wind-pipe. HISTORICAL SKETCH. 17 2. Foreign bodies formed in our organism by the retention of natural products. a. Retentions in their proper cavities and receptacles. a. Ranula; b. Retention of urine ; c. Retention of the foetus in the womb or in the cavity of the belly (Caesarean opera- tion, section of the pubic symphysis, section of the belly). b. Extravasation external to the proper cavities or receptacles. a. Blood swellings on the heads of new-born children; b. Hae- matocele ; c. Collections of blood in joints. 3. Foreign bodies resulting from the accumulation of unnatural secreted fluids. a. Lymphatic swellings ; b. Dropsy of joints; c. Dropsy of the bursae mucosae; d. Water in the head, spina bifida; e. Water in the chest and empyema ; f. Dropsy of the pericardium ; g. Dropsy of the belly; h. Dropsy of the ovary; i. Hydrocele. 4. Foreign bodies produced from the concretion of secreted fluids. V. Division.—Diseases which consist in the degeneration of organic parts, or in the production of new structures. 1. Enlargement of the tongue; 2. Bronchocele ; 3. Enlarged clitoris ; 4. Warts; 5. Bunions; 6. Horny growths; 7. Bony growths ; 8. Fungus of the dura mater; 9. Fatty swellings; 10. Encysted swellings; 11. Cartilaginous bodies in joints ; 12. Sarcoma ; 13. Me- dullary fungus; 14. Polyps; 15. Cancer. VI. Division.—-Loss of organic parts. 1. Organic replacement of already lost parts, especially of the face,, according to the Tagliacozian and Indian methods. 2. Mechanical replacement: Application of artificial limbs, and so on. VII. Division.—Superfluity of organic parts. VIII. Division.—Display of the elementary management of surgical' operations. General surgical operations: Bleeding, cupping, application of issues,, introduction of setons, amputations, resections, and so on. II. HISTORICAL SKETCH OF SURGERY. First period... to the time of Hippocrates. Second period . from Hippocrates to Galen. Third period^. . from Galen to the fifteenth century. Fourth period . the sixteenth century to the middle of the seven- teenth. Fifth period . . the second half of the seventeenth century to the present time. 2* IS HISTORICAL SKETCH. The origin of Surgery is founded on the relation of man to external nature, and on his disposition to alleviate the sufferings of his fellow men. In ancient Egypt and Greece the history of Surgery lies in dark- ness, and it begins in a special sense with Hippocrates who collected the previously scattered facts, arranged them, and published rational views, drawn from his own experience. It appears from his wnlings— xaB' lr,Tpito>—*ep) awiSi—Trtp) rSi n Ketpxtf) rp^xrm—met *ete*>v—*ept i*x£,—*tp) rvpeyyZv—that he was acquainted with a copious apparatus of instruments and bandages, and several operations exhibit an actual (echnical tendency. In different parts of his Aphorisms he treats of surgical subjects. In the Alexandrian school Surgery became more prominent, as it rested on its proper basis, anatomy. Erisistratus and Herophilus made the first examinations of human bodies. We know of their fol- lowers and their performances only from subsequent writers. Aurelius Cornelius Celsus is the sole writer after Hippocrates (a period of 400 years intervening between them.) Although Celsus lived at Rome, his writings for the most part belong to the Greeks. In his seventh book he specially treats of surgical operations. After Celsus deserve to be mentioned Soranus, Archigenes, and Rufus. Claudius Galenus, born a. d. 131, lived at Rome under the Emperor Marcus Aurelius : such of his writings as treat of Surgery are, for the most part, commentaries on those of Hippocrates—as his T7rop.v)if*.ctTci r^ix etc. to jS//3Ai«v 'Itt^o^drove. x«txi xXTxe-x-XF/U-ov—%ep\ t<£v irxpx (puo-iv oyxaiv—and 6eget7rev tw; neiohv jS(/3a/o». After Galenius there is a complete stand-still, and up to the sixteenth century there are but few writers: Oribasius, Aettos, Alexander of Tralles, and Paulus of iEgina. With the fall of the Roman Empire and the invasion of the Arabs, came a period of darkness and barbarism. We find Surgery, at this time, in the hands of the Arabian physicians, characterized by the neglect of anatomy, with a copious instrumental apparatus, fear of the knife, and frequent employment of the cautery iron. The most remarkable men of this period were Ebn Sina and Abulcasem. The practice of Medicine and Surgery was, during this time, in Chris- tian Europe, in the hands of the clergy, and sank down to such imper- fection, that the knowledge of operations, possessed by the Greeks, was no longer to be met with. In the twelfth and thirteenth centuries, indeed, art and science raised themselves by the foundation of literary institu- tions; but as their most special object was the education of ecclesiastics, there was little gain to Surgery. The latter was, at a subsequent period, completely separated, by two decrees of the Pope, from Medicine, and the priests were forbidden every bloody operation on pain of excommuni- cation. At this time arose the barbery system, under which the barbers of the priests were employed by them for the performance of the lesser operations of Surgery. In Italy alone was there yet any striving towards improvement, and Surgery still partially remained in the hands of better practitioners. In the year 1311, Pitard, of Paris, collected the Surgeons into a com- HISTORICAL SKETCH. 19 pany, which formed itself into a college; but, owing to the long-con- tinued disputes with the medical faculty, and without advance in anatomy, Surgery remained in its restricted condition. [During a large portion of the fourteenth century flourished in England John of Arden, who was born in 1307, and certainly lived till after 1377, as, in a manuscript (MSS. Sloane, No. 75, in Brit. Mus.) which, he says, " propria manu mea exaram," he declares himself 70 years old, " regni regis Richardi 2di primo." From examination of his works, written in Latin, several manuscripts of which, together with many English translations in MSS. of the whole or part of his works, are in the library of the British Museum and in the Bodleian Library at Oxford, it is probable that he did not know much about anatomy, though perhaps he was not more ignorant than his contemporaries. But he was certainly an attentive observer and a careful recorder of what he saw. He wrote specially upon anal fistula, which was translated by Read in 1588, and also a Practice of Surgery, in which, among other things, he speaks of sores on the penis, also of gonorrhoea, and describes what is to be done when a stone gets into the urethra. From the number of manuscripts and translations it is quite evident he was long held in great repute by his countrymen, and his works are quite equal and much more original than those of surgical writers of the early part of the sixteenth century. It is much to be regretted that the several manuscripts have not hitherto been collated and published, as they present an excellent view of the state of Surgery in England at this period.—j. f. s.] With Guido de Chauliaco (who lived at Avignon) first commenced a period of independent exertion and reference of Surgery to the basis of anatomy. [In 1542 the Surgeons, who had previously existed in London as one if not two distinct bodies or brotherhoods, were united without any very good reason beyond, perhaps, Henry the Eighth's pleasure, by act of Parliament, to the Barbers' Company of London; but they were only paired, not matched, as it appears that their Court of Assistants was equally divided between the two professions, the Barbers having their side, the Surgeons theirs, but neither interfering with the other's depart- ment. This act of Parliament encouraged dissection by directing that " the masters or governors of the said mystery" should have, " at their free liberty and pleasure," the bodies of four felons, " to make incision of the same * • - for their further and better knowledge, instruction^ insight, learning, and experience in the said science or faculty of Suro-ery." From the destruction of the books it cannot be ascertained whether dissection was forthwith pursued ; but, in 1566, public demon- strations and dissections were enacted by the Company of Barbers and Surgeons to be held in their hall at stated periods, and conducted by two masters and two stewards of the " anathomies/' There was also a readership of anatomy at the hall, which was long held by physicians appointed by the Court of Assistants, but when instituted is doubtful. Wadd says that Dr. William Cunningham lectured there in 1563; but the first appointment I can find is that of Dr. Paddy, who was appointed reader of the anatomy lectures on the 11th July, 1596. The study of anatomy does not seem to have been so little thought of at this time as generally believed, in proof of which it may be mentioned 20 HISTORICAL SKETCH. that Sir Edward Arris, an alderman of London, who was also warden in 1642, and master of the Company of Barbers and Surgeons in 1651, founded on the 27th October, 1645, six anatomical lectures, to be pub- licly read every year between Michaelmas and Christmas, and endowed them with 300/., on condition that the Company should pay for the lectures 20/. a-year: subsequently he exchanged this sum for an annuity of 30/. charged on his estates, and at a later period redeemed this charge by paying 510/. to the Company, which was by them paid over at the dissolution to the Surgeons' Company, and, when the latter merged into the College of Surgeons, the same was handed over to them. Arris's good example was followed by Mr. John Gale, who, on the 30th June, 1698, founded one anatomy lecture every year, to be called Gale's Anatomy, and endowed it with a rent-charge of 16/. a-year out of certain landed property, which was subsequently sold for 432/. sterling, and the interest thereon now produces rather more than 20/. The two endowments are now consolidated, and the lectures on human anatomy and Surgery are called Arris's and Gale's Lectures. —'J. f. s.] In this way, assisted by the advance of anatomy, was Surgery raised, by Pare, Franco, Fabricius Hildanus, Fabricius ab Aqua- pendente, Severinus, and Wiesemann, in the sixteenth century, to a high station. In the second half of the sixteenth century actually commences the brilliant period of Surgery. Numerous wars and the establishment of public hospitals presented a rich field for observation, and the founda- tion of the Academy of Surgery at Paris collected scattered powers and aroused a general emulation. In France shone out Dionis, J. L. Petit, Mareschal, Quesnay, Morand (a), Louis, Ledran, Garengeot, Lafaye, Lecat, Lamotte, Ravaton, David, Pouteau, Levret, Saba- tier, Desault; in England, Wiseman, Cheselden (6), Douglas, the two Monros, Sharp, Cowper, Alanson, Pott, Hawkins, Smellie, and the two Hunters; in Holland, Albin, Deventer, Camper ; in Italy, Molli- nelli, Bertrandi, Moscati, Scarpa ; in Germany, Heister, Plattner, Bilguer, Brambilla, Theden, Richter, C Siebold, and Mursinna. _ By this general cultivation has Surgery been brought up in modern times to an elevation which cannot be displayed generally but only in the history of the several operations. Boldness grounded on the pro- gress of anatomy and physiology, simplicity in the methods of treat- ment, and scientific culture, distinguish it. The equal participation of all civilized nations in these efforts keeps up amongst them a contest for intellectual superiority in the ranks of improvement, while it makes any decisive award impossible. (a) He was secretary to the Academy of any mechanics" «loi precieuse," says he, fnU1?Ay,/i°Y ^nin?.of,t1he «*ools "qui faisant une des epoques les plus me. ui 1743, delivered a most admirable address, morables pour Illustration de notre art, doit "Discours dans lequel on prouve qu'il est immortaliser celui (Da la Peyronie^ qui la necessaire au Chirurgien d etre lettie," i„ S0Ilicitee et dont les titres eminens sont which he shows the necessity of a literary soutenus par un merite suncrieur." Onus- education for a Surgeon and mentions inci- cules de Chirurgie, P. 118. Paris 1768 dentally that the royal declaration founding 4to theAcademy required "that the Surgeons (t) He established the first School of of Paris should be Masters of arts before Anatomy in London, independent o? the admission into the community, and that they Barbers' and Surgeons' Company at St should then pursue Surgery without mixing Thomas's Hospital about the year 1714 LITERATURE. 21 III. LITERATURE. A. History of Surgery. Goelicke, A. 0., Historia Chirurgiae Antiqua. Halae, 1713. 8vo. ----, Historia Chirurgiae Recentjor. Halee, 1713. 8vo. f Freind, John, M.D., The History of Physic from the time of Galen to the begin- ning of the Sixteenth Century. London, 1725—26. 2 vols. 8vo. Recherches Critiques et Historiques sur l'origine, sur les divers etats et sur les pro- gres de la Chirurgie en France. Paris, 1744. 4to. Sammlung einiger kleinen Schriften von den Schicksalen der Chirurgie. Erfurt, 1757. 8vo. Dujardin, Historie de la Chirurgie depuis son origine jusqu'a nos jours. Vol. I. Paris, 1774. Vol. II. par Peyrhile. Paris, 1780. 4to. Portal, Historie de l'Anatomie et de la Chirurgie depuis son origine jusqu'a nos jours. 6 vols. Paris, 1700—1773. 8vo. Black, William, M.D., An Historical Sketch of Medicine and Surgery from their origin to the present time. London, 1782. 8vo. von Haller, A., Bibliotheca Chirurgica. Bern, et Basil. Vol. I. 1774. Vol. II. 1775. 4to. von Creuzenfeld St. H., de Vigiliis, Bibliotheca Chirurgica. Vol. II. Vindob., 1781. 4to. Riegel, N., De Fatis faustis etinfaustis Chirurgiae necnon ipsius interdum indisso- lubili amicitia. cum Medicina. caeterisque Studiis Liberalioribus ab ipsius origine ad nostra usque tempora, Commentatio Historica. Hafn. 1788. 8vo. Sprengel, K., Geschichte der Chirurgie. Vol. I. Halle, 1805. Vol. II. von W. Sprengel. Halle, 1819. von Walther, iiber der Verhaltness der Medicin zur Chirurgie und die Duplicitat des aerztlichen Standes. Frieburg, 1841. 8vo. Strehler, M. J., Randbemerkungen zu von Walther's neuester Schrift uber das haltniss der Medicin zur Chirurgie und so weiter. Niirnberg, 1812. 8vo. Rust, Theoretisch-praktisches Handbuch der Chirurgie. Vol. IV., Art. Chirurgie. Geschichte desselben von Hecker. B. Surgery in General. De Vigo, J., Practica in Chirurgia. Lugd. 1516. 4to. Translated as "The most excellent Workes of Chirurgerye," by B. Traheron. London, 1543. fol. Abulcasem, De Chirurgia. Argent, 1544. De Cauliaco, Guido, Chirurgia Magna. Lugd. 1685. 4to. |----, Chirurgia Parva. Chirurgia Albucasis. Tractatus de Oculis Jes. Hale. Tractatus de Oculis Canamusali. Venet. 1500. fol. fCoPLAND, R., The Questionary of Cyrurgeans, with the Formulary of Lytell Guydo in Cyrurgie, with the Spectacles of Cyrurgeans. Translated out of the Frenssche. London, 1541. tGALE, Thomas, An Enchiridion of Chirurgerie, conteyning the exacte and perfect Cure of Wounds, Fractures, and Dislocations. London, 1563. 8vo. Clowes, William, Approved Practice for all young Chirurgians, concerning Burn- ings with Gunpowder, and Wounds made with Gun-shot, Sword, &c. Hereto is adjoyned a Treatise of the French or Spanish Pockes, written by J. Almenai. Also a commodious Collection of Aphorisms. London, 1588. 4to. j-----, A profitable and necessarie Booke of Observations, for all that are burned with the flame of Gunpowder, &c; with a Short Treatise for the Cure of Lues Venerea. London, 1596. 4to. Pare, Ambrose, QSuvres. 10th Edit. Lyon, 1641. fol. 22 LITERATURE. t---, The Works of the famous Chirurgeon, translated by Thos. Johnson. Lon- don, 1649. fol. Hildani, G. Fabricii, Opera. Francof. 1646. fol. Severini, M. A., De Efficaci Medicin^. Lib. III. Francof. 1046. lo 1. Fabricius ab Aquapendente, Hieron., Opera Chirurgica. Franco!. 1<>~0. Hvo. Boerhaave, Herm., Lehrsatze von Erkenntniss und Heilung der chirurg. ^rank- heiten mit van Swieten's Commentar. 4 vols. 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Repertorio di Medicina. Antologia di Firenze. Giornale Critico di Medicina Analitica. Atti dell'Academia dei Gurgafili di Firenze. fAnnali Universali Medicina; da Annibale Omodei. Milano. 32 OF INFLAMMATION. FIRST DIVISION. OF INFLAMMATION. First Section.—Of Inflammation in General. Brambilla, G. A., Tratato Chirurgico-practico sopra il Flemone ed il suo esito, ed altri punti importanti di Chirurgia. Milano, 1777. 2 torn. 4to. Milano, Bosch, H., van der, Theoretisch-practischer Versuch uber Entzundung, ihre Endi- gungen und mancherlei andere Krankheiten des menschlichen Leibes, wobei die Muskelkraft der Haargef asse zum Grunde gelegt wird. Munster und Osna- briick, 1786. 8vo. Wedekind, G., Allgemeine Theorie der Entziindungen und ihrer Ausgiinge. Leip- zig, 1791. 8vo. Hunter, John, A Treatise on the Blood, Inflammation, and Gunshot Wounds. London, 1794. 4to. Meyer, J., tiber die Nature der Entzundung. Berlin, 1810. 8vo. Dzondi, C. H., Aphorismi de Inflammatione. Halae, 1814. 8vo. Gruithuisen, Frz. v. Paula, Theorie der Entziindung in Med.-chirurg. Zeitung. 1816. Vol. II. p. 129. Thomson, John, M. D., Lectures on Inflammation, exhibiting a view of the general Doctrines, pathological and practical, of Medical Surgery. Edinburgh, 1813. 8vo. Langenbeck, C. J. M., Nosologie und Therapie der chirurgischen Krankheiten en Verbindung mit der Beschreibung der chirurgischen Operationen, &c. Gotting., 1822—25. 3 Bde. 8vo. Travers, Benjamin, An Inquiry concerning that disturbed state of the Vital Func- tions usually denominated Constitutional Irritation. London, 1826. 8vo. Gendrin, A. N., Histoire Anatomique des Inflammations. Paris, 1826. 2 torn. 8vo. Scott, J., Surgical Observations on the Treatment of Chronic Inflammation in vari- ous structures, particularly as exemplified in Diseases of the Joints. London, 1828. 8vo. Somme, C. L., Etudes sur 1'Inflammation. Brux., 1830. 8vo. Travers, Benjamin, A further Inquiry concerning Constitutional Irritation and the Pathology of the Nervous System. London, 1835. 8vo. Earle, J. W., On the Nature of Inflammation, with an aceount of its Principal Phe- nomena; in Medical Gazette, vol. xvi. London, 1834—5. Vogel, J., Entzundung und ihre Ansgange; in Handworterbuch fiir Physiologie mit Riichsicht auf physiologische Pathologie von R. Wagner. Braunschweig, 1842. p. 311. Gerber, Fried., Handbuch der allgemeinen Anatomie des Menschen und der Haus- saugethiere. Bern, Thur, und Leipzig, 1840. 8vo. lb. translated as " Ele- ments of the general and minute Anatomy of Man and the Mammalia;" to which are added Notes and an Appendix, by George Gulliver. London, 1842. 8vo. Travers, Benjamin, The Physiology of Inflammation and the Healing Process. London, 1843. 8vo. Jones, Wharton, Report en the Present State of Knowledge of the Nature of In- flammation, in Forbes's Brit, and For. Med. Review, vol. xvii. p. 567. 1844. Bennett, J. H., M.D., On Inflammation as a process of Anormal Nutrition. Edin- burgh, 1844. 8vo. 1. Inflammation {Inflammatio Phlogosis, Lat.; Enhundung, Germ.; Inflammation, Fr.) is that condition of an organized part in which the vital process and plasticity of the blood are unnaturally raised, and which is manifested by pain, redness, increased temperature, and swelling INFLAMMATION. 33 The elevation of the vital process must be of a certain duration and intensity, that is, it must be actually diseased, when we apply to it the name Inflammation. There- by, alone, is inflammation distinguished from the temporary condition of active con- gestion and increased turgor vital!*. The proximate cause of these phenomena is in- deed the same as in inflammation, and may run into it. The same applies to the so-called inflammatory irritation. [The term "inflammation" has been objected to by Andral, (a), one of the most able French writers on pathology. He says:—" Created in the infancy of science, this expression, (inflammation,) completely metaphorical, was destined to represent a morbid condition, in which parts seemed to burn, to inflame, as if they had been subjected to the action of fire. Received into the language, without any precise idea having ever been attached to it, under the triple relation of symptoms which announce it, of lesions which characterize it, and of its actual nature, the expression "inflammation" has become so vague, and its interpretation so arbitrary, that it has really lost all value: it is like a piece of old money without the impress, which must be put out of circulation, as it causes only error and confusion. Inflamma- tion can only be considered as the expression of a complex phenomenon, compre- hending many other phenomena, the dependence of which is neither necessary nor con- stant." (vol. i. p. 9.) He has, therefore, chosen to set aside the term, "inflamma- tion" as generally characterizing the phenomena we are about to consider, and has employed that of " hyperaemy," restricting it, however, only to that condition of the vessels in which they are loaded or congested with blood, from whatever cause, healthy or unhealthy, such condition may arise. John Hunter (b) seems to have anticipated these objections; for, he observes:—"The term or idea of inflammation may be too general, yet it is probable that it may form a genus, in which there is a number of species, or it may.be more confined in its classification, and be reckoned a species containing several varieties. These are, however, so connected among themselves, that we cannot justly understand any one of the species or varieties without forming some idea of the whole, by which means, when treating of any one, we can better contrast it with the others, which gives us a clearer idea, both of the one we are treating of, and of the whole." (p. 265.) The difficulty, however, is to distin- guish the onset of the diseased action, inflammation, from the natural one, conges- tion or turgescence. Their close resemblance was first pointed out by Hunter, who observes:—" The very first act of the vessels when the stimulus which excites in- flammation is applied, is, I believe, exactly similar to a blush. It is, I believe, sim- ply an increase or distention beyond their natural (ordinary1?) size. This effect we see takes place on many occasions : gentle friction on the skin produces it; gently stimulating medicines have the same effect; a warm glow is the consequence simi- lar to that of the cheek in a blush: and, if either of these be increased or continued, real inflammation will be the consequence." (p. 279.) So Andral:—"Will ana- tomy establish any line of demarcation between physiological (healthy) and patho- logical congestion? No more than the latter can always be strictly separated from the complex phenomenon called " inflammation." Thus, under the influence of vio- lent emotion, vessels appear on the conjunctive coat of the eye, and the lids become red. The same effect follows a grain of sand falling on the front of the eye; insen- sibly does the congestion increase from that almost normal condition in which ves- sels appear on the conjunctive coat to that when the mucous membrane of the eye, becoming uniformly red and considerably swelled, presents that variety of opthalmy known as chemosis." (vol. i. p. 13.) The same language is held by Muller (c) :— "Inflammation begins, indeed, with phenomena which are similar to turgescence. The organs attract more blood than usual, in consequence of the altered affinity be- tween the blood and the tissue, and obstructs its efflux; but we must be very cau- tious in calling increased vital action that important change caused by inflammatory irritation which produces functional disturbance, and has consequent to it an effort of nature to compensate an injury which has interfered with the action of the organ. Had the vital action been increased, so would not the morbid processes of inflamma- tion have occurred," (vol. i. p. 218.) Hunter also observes:—"Though pure in- flammation is rather an effort of nature than a disease, yet it always implies disease or disturbance, inasmuch as there must be a previous morbid or disturbed state to make such effort necessary." (p. 260.) Again:—" Inflammation is to be considered (a) Precis d'Anatomie Pathologique. (c) Handbuch der Physiologio des Men- (b) On the Blood, Inflammation. &c. schen. 34 DISPOSITION TO only as a disturbed state of parts which require a new but sa utary."^ °^70£ restore them to that state wherein a natural mode of action alone is necessary^ iroa such a view of the subject, therefore, inflammation in itself 19 "°* ^olence or some as a disease, but as a salutary operation, consequent either to ^^^J6^'8.^6 disease." (p. 249.) "Inflammation is not only occasionally the causef diseases but it is often a mode of cure, since it frequently produces a resolu*»°" * ™™JJ* parts, by changing the diseased action into a salutary one, if c*Pab'e°*™*°™™?' (p. 250.) "Inflammation may first be divided into two kinds a firs J^f^l viz., the healthy and the unhealthy. The healthy probably consists only of one kind, not being divisible but into its different stages, and is that which will ahvaj s attend a healthy constitution or part, is rather to be considered as a restorative ac on than a diseased one, and would rather appear to be an effect of a stimulus than a, irri- tation. The unhealthy admits of vast variety, (diseases being almost numberless,) and is that which always attends an unhealthy constitution or part, but principally according to the constitution: however, many parts naturally have a tendency to run into inflammations of particular kinds.* * The simple act of inflammation cannot be called specific, for it is a uniform or simple aetion in itselt; but it may have peculiarities or specific actions superadded. Inflammation is either single or compound: it may be called single when it has only one mode of action in the part inflamed, as in its first stages; compound, when attended with another mode of ac- tion, or when it produces other effects." (p. 251.)] 2. All organs of the body may become inflamed except the cuticle, hair, and nails. The disposition to become inflamed depends on the number of nerves and capillary vessels in a part. The actual seat of in- flammation is always the capillary-vascular system, and the ganglionie- nervous system, accompanying the most delicate blanches of the vessels, which specially presides over vegetation in the organism. ["Inflammation," says Hunter, "mayarise from very different causes, and often without any apparent cause, and its operations are far more extensive than simply the act of producing union in parts divided by violence." (p. 248.) " Susceptibility for inflammation may be said to have two causes—the one original, the other acquired. The original constitutes a part of the animal economy, and is probably inexplicable. Of the acquired, it is probable that climate and modes of life may tend considerably either to diminish or increase the susceptibility for inflammation. The influence, however, of climate may not be so great as it commonly appears to be; for it is generally accompanied by modes of life that are not suited to others." (p. 226.) " Inflammation, when the constitution is strong, will be commonly the most manage- able, for strength lessens irritability; but in every kind of constitution inflammation will be the most manageable where the power and the action are pretty well propor- tioned; but, as every part of the body has not equal strength, these proportions can- not be the same in every part of the same constitution. According to this idea of strength, the following parts—viz., muscles, cellular membrane, and skin,—and more so, in proportion as they are nearer to the source of the circulation—will be most manageable in inflammation and its consequences, because they are stronger in their powers of action than the other parts of the body. The other parts, as bone, tendon, ligament, &c, fall into an inflammation, which is less in the power of art to manage, because, though the constitution is good, yet they have less powers within themselves, and therefore are attended with the feeling of their own weak- ness ; and I believe they affect the constitution more readily than the former, because the constitution is more affected by local disease, when the parts have less power within themselves of doing well; and the effects, if bad on the constitution, reflect a backwardness on the little powers they have. * * * The inflammation, if in vital parts, will be still less manageable; for, although the parts themselves may have pretty strong powers, yet the constitution and the natural operations of universal health become so much affected, that no salutary effect can so readily take place, and therefore the disease becomes less manageable. * * * In weak constitutions, although the inflammation be in parts which admit of the most salutary operations, in the time of the disease, and in situations the most favourable to restoration after disease, yet the operations of inflammation are proportionably more backward as to their salutary effects in such constitutions, and more or less, according to the nature of the parts affected." (pp. 228, 9.)] INFLAMMATION. 35 3. Inflammation always commences with a more or less intense pain; the sensibility of the part is increased, redness soon follows, and blood appears in vessels where previously it had not been observed; the tem- perature of the part is raised, its functions disturbed, secretion suppressed, (at least at first,) or changed, perspiration diminished, and the part swelled. These appearances are developed, in different proportions, to a higher degree, in which fever (Febris inflammatoria secunda) usually becomes connected with them. [I apprehend it would be more correct to say " that inflammation, from its very commencement, is always accompanied with a more or less intense pain," than to say, with our author, it "always commences with a more or less intense pain;" inasmuch as, though that by which the patient's attention is first excited, yet it is only an indication of a disturbance set up in the economy, and which, as it becomes greater, renders itself apparent to the eye, most commonly by redness.—J. F. S. Dr. Alison (a) observes:—"In order to give the requisite precision to the general notion of inflammation as a local change of the condition of any part of the body, it seems only necessary to include in it, besides the pain, swelling, heat, and redness, the tendency always observed, even when the changes in question are of short dura- tion, to effusion from the blood-vessels of some new products ;* speedily assuming in most instances the form either of coagulable lymph or of purulent matter." (vol. i. p. 53.)] 4. The pain depends on the increased activity of the nerves (1,) and this again produces the succeeding increased influx of the blood, and the vital expansion of the vessels (2;) afterwards the pain is increased by the decided expansion and tension which the part suffers. It differs according to the degree of inflammation and the sensibility of the affected part: often it consists only in the sensation of prickling, itching, tickling, and a troublesome stretching; often is it stabbing, tearing, burning, and, in structures largely supplied with nerves, it attains a most vehement degree (3.) The redness, heat, and swelling, depend on the increased action of the nerves and capillary vessels, and is in immediate relation with the rich- ness of their ramifications. Hence the various degrees of redness, heat, and swelling, according to the degree of inflammation and the organs therewith affected. At the onset of the inflammation the swelling always depends on an increase of blood. The reddening of the blood (4) and evolution of warmth are attributes of the living process: they must, therefore, be also increased by its greater activity. According, however, to experiments with the thermometer, the warmth in inflamed parts is not so considerable as to our touch it seems to be (5.) Where the most delicate branches of the capillary-vascular system anastomose to form the transition into the veins, several capillary vessels always open toge- ther into one single vein. By this disposition of the capillary-vascular system there is already in the healthy state a slower motion of the blood, which is in close relation to the functions of the capillary-vascular system. If, then, in inflammation there be an additional influx of blood, there must arise with the increased activity of the capillary-vascular system and vital expansion (6) an accumulation of it, (the blood,) as the veins are not in a condition to take up and carry away with equal readiness the blood which is brought to them in excess. The capillary vessels be- come therefore expanded, as if filled by artificial injection, and even (a) Library of Medicine. 36 CAUSES. distinct in those parts where we assume that in the natural state vessels carrying only the uncoloured part of the blood exist: in the subsequent course "of the inflammation new vascular branches are formed. Ihe cellular tissue is the most especial seat of the development of vessels. These occurrences are the cause why the inflammation, which at first was to be considered merely as a dynamic disease, brings about distinct changes in the structure of organs. The increased activity of the nerves and capillary-vascular system produces a more copious infiltration into the cellular tissue than in the natural state; a part of the serum—in some cases even of the red part of the blood—penetrates through the expanded walls of (he vessels, and empties itself into the cellular tissue. The walls of the cells are, therefore, in this case, found thickened, filled with a serous, albuminous, often bloody fluid, in which frequently albuminous flakes float or are connected with the walls of the cells. The changed condition and increased plasticity of the blood is shown by the crusta inflammatoria, which consists of the fibrin of the blood. According to the different degree of irritation, and the consequent reaction of the nervous system, so long as, excepting the pain, no other appearance of inflammation exists, (which condition many consider as the forerunner of inflammation,) there is produced a spasmodic contraction with accelerated motion of the blood in the small vessels, upon which first follow their vital expansion, the greater influx of blood, and the other phenomena of increased living actions (7.) A comparison may therefore be instituted between these local appearances and those coming in with inflammatory fever. As we have there contractions of the vessels and obstruction of the circula- tion, so we have here chilliness, contraction of the skin, small pulse, which are followed by the phenomena of vital expansion of the vascular system, increased warmth, and so on. In the commencement there is in a manner present an inflam- matory spasm—the vascular system is entirely controlled by the nervous system. With the increased influx of the blood, and its accumulation in the capillary vessels, is the previously quickened motion of the blood corpuscles retarded, the capillary vessels, by the consequent exudation of the serum, become completely filled with blood-corpuscles, and an actual stagnation, an inflammatory stasis ensues, but which is not to be considered as a passive over-filling. [(1) But what causes this increased action of the nerves? The squeezing and stretching of the minute nerves of the part, by the increased size of the capillary vessels, resulting from the obstruction of the current of blood through them, which occurs at the very onset, and which, indeed, is, as will be presently shown, the first step of the inflammatory process. Travers (a) considers "the pain of inflammation directly or indirectly connected with the state of the blood-vessels," and it is, proba- bly, the nerves of the blood-vessels that are first excited in the pain of inflammation." (pp. 46, 7.) This opinion is corroborated by referring to John Hunter's observa- tions on the passage of the adhesive to the suppurative inflammation, in which he says, "The pain is increased at the time of the dilating of the arteries, which gives the sensation called throbbing, in which every one can count his own pulse, from paying attention merely to the inflamed part; and perhaps this last symptom is one of the best characteristics of this species of inflammation." (p. 378.) And in a pre- vious passage he had, observed :—" Whether this pain arises from the distention of the artery by the force of the heart, or whether it arises from the action of dis- tention from the force of the artery itself, is not easily determined." (p. 287.) The throbbing, however, is not entirely confined to suppurative, but also accompanies acute, inflammation; and Travers has well observed:—"Throbbing, lancinating or pulsatile pain,—i. e. pain accompanied with a sense of motion of the fluids in the part,—is the most characteristic distinction of acute inflammation; and an obtuse, aching, or heavy pain belongs to a congested state of the local circulation." And he also points out that " the description of pain unattended with inflammation, differs from the pain of inflammation, although the former is subject also to varieties in kind, duration and intensity;" observing that " Neuralgia is generally attended more (a) Physiology of Inflammation. INFLAMMATION. 37 or less with muscular cramp or spasm, and such pain is either intermitting or periodi- cal;" and that such medicaments "as relieve pain in the absence of inflammation have little or no beneficial effect on the pain of inflammation. Blood-letting aggra- vates neuralgia and relieves inflammatory pain. Steel and arsenic aggravate inflam- matory pain, and cure neuralgia." (pp. 45, 6.) (2) According to his neuropathological theory, Henle(s only a small collection of pus, and the muscles were seemingly healthy. The hip-joint contained a small quantity of dirty purulent fluid; there were slight traces generally of synovial inflammation, specially at the notch, and where the acetabulum was devoid of cartilage. The right ilium was rough and carious on both external and internal surface, and the right sacro-iliac symphysis so extensively destroyed that slight force separated the bones, the surfaces of which' were carious. 60 LYMPH-ABSCESS. The left knee-joint: nearly all the articular surfaces deprived of their cartilage, small isolated patches alone remaining, and the exposed surface ot the Done Demg everywhere rough and carious. The crucial ligaments were only partially destroyed. Neither of the vertebral bodies were affected with disease.—J. t. >. My friend Dr. Rigby (a), in his account of contagious or adynamic puerperal lever, speaks of a peculiar kind of abscess following attacks of that disease, which we saw too-ether in several instances at the General Lying-in Hospital. "Where, says he, "the constitution has borne the brunt of the attack without immediate collapse, and the lodal mischief been controlled by appropriate means, we find that fresh efforts are made to rid the circulation of the morbid matter with which it is infected. The patient is suddenly seized with severe pain, with heat, redness, and swelling of one of the large joints, presenting all the appearance of arthritic or rheumatic inflamma- tion, and also of certain muscles especially, the supinatores of the arm, the glutaei and gastroenemic. The painful spot soon becomes hard, it is intensely tender, and in two or three days the feeling of fluctuation indicates tbe formation of an abscess, from which a large quantity of greenish coloured pus mixed With blood and serum, is discharged. The cellular tissue beneath the skin and between the muscles is equally affected, and, if examined when the abscess is just beginning to form, will be found of a dirty brown colour, softened, infiltrated, and here and there condensed with lymph or pus, precisely as in cases of gangrenous erysipelas: the muscular tissue has entirely lost its red colour, and closely resembles the appearance of boiled meat, its structure so softened as to tear easily under the fingers, and interspersed with deposits of immature lymph and purulent fluid, the commencement of what would have been an abscess. Like gangrenous erysipelas, the extent of the abscess does not seem to be limited by a surrounding wall of healthy lymph, as seen in a common phlegmon, but, if deep beneath the surface, it continues to spread in all directions, until nearly the whole limb appears to be implicated in one immense abscess: hence, in those patients who have recovered under these attacks, the limb has frequently been rendered useless, the muscles being atrophied and coherent." (p. 291.) The following observation of the same writer in reference to the contagious nature of these abscesses is extremely important. " That the discharges from a patient under puerperal fever are in the highest degree contagious, we have abundant evidence in the history of lying-in hospitals. The puerperal abscesses are also contagious, and may be communicated to healthy lying-in women, by washing with the same sponge; this fact has been repeatedly proved at the Vienna hospital; but they are equally communicable to women not pregnant: on more than one occasion the women engaged in washing the soiled bed linen of the General Lying-in Hospital, have been attacked with abscesses in the fingers or hands, attended with rapidly spread- ing inflammation of the cellular tissue." (p; 292.)] 17. Beinl, Rust, and others, consider the nature of the so-called lymph-swelling to be an extravasation of lymph, depending on a rupture of the lymph-vessels, or on an unnatural extention of their walls, and they explain the gradual sinking of the powers of the constitution and so on, which occur at the latter period of the disease, and after its burst- ing, by the continued loss of the lymph (b). The observations made on the fluid contained in these swellings (which Rust imagined to be only in the earlier period of the disease, transparent and colourless) have shown that it has more of the properties of pus than of actual lymph, and Walther has decidedly proved that the acceptation of the term lymph- swellings in the sense just mentioned is inadmissible ; that they must be considered only as abscesses (lymph-abscesses) preceded by a stealthy, if not a sensibly perceptible, inflammatory condition, which, however, on account of the too much depressed vital activity, could not produce a plastic consistent pus, but only a secretion of a thin more or less turbid (a) A System of Midwifery, Lond., 1844, forming part of Tweedie's Library of Medi- cine. J (b) J. A Schmidt, iiber den Grund der Todtlichkeit de Lymphgeschwulste; in Abhand- lungen der Medic. Chirurg. Jos. Akademie in Wien, vol. ii. ULCERATION. 61 lymphatic fluid. The opinion advanced by Beinl that the strongest and most healthy subjects are commonly more subject to this disease than the weakly, that men more than females, and that, without an external injury, a general diseased condition is incapable of producing a lymph-abscess, is incorrect, and has been disproved by Rust. How frequently, even by writers on lymph-swellings, cold abscesses and such collections of pus as have formed at distant parts (congestion-abscess), (a) in consequence of carious destruction of the bones of the vertebral column, have been taken for lymph-swellings, and treated as such, I myself have frequently observed. Nasse (b) describes a case in which a powerful healthy young man, in consequence of an external injury, had a swelling formed on the upper part of the thigh, the con- tents of which, after opening, perfectly resembled lymph. The pouring out of a clean transparent fluid could not be allayed by any treatment recommended for lymph-swellings, and the patient was exposed to the danger of hectic consumption. The local use of a solution of nitrate of mercury alone brought the lymph-vessels to close. This case (which I myself saw, although only once, in passing through Halle, and convinced myself of the continued outflowing of clear lymph which could be increased by pressure) proves that a collection of lymph in the cellular tissue is Siossible, as the consequence of an actual tearing of lymph-vessels by external vio- ence, the exudation from which ceases only by obliteration of the torn vessels. Cases of this kind are, however, undoubtedly very rare; to them alone can be applied the term lymph-swelling in its proper sense, and therefore the above advanced opinion, "that the cases commonly spoken of as lymph-swellings are merely modifica- tions of abscesses," is rather confirmed than contradicted. This opinion Langen- beck (c) has also advanced; although, he adds, that not unfrequently a swelling is observed on the elbow, which is formed sometimes from a local cause, and some- times also without, is situated immediately on the olechranon, and contains a clear lymphatic fluid enclosed in a cyst, which deserves the name of lymph-swelling, I must yet deny this assertion, as this swelling at the elbow joint is a dropsy of the mucous bag there situate, and may be compared to the Hygroma cysticum patellare. Just as little also can I agree with the opinion of Ekl (d), who considers the lymph- swelling as an expanded mucous bag in which there is a diseased secretion going on. Zemusch (e), according to Kluge, in order to accommodate the different opinions of writers, distinguishes, 1st, the acute and chronic lymph-swelling, as idiopathic and symptomatic disease; 2d, the false lymph-swelling or lymphatic abscess. [A case marked in my note-book, " Collection of synovial fluid within the femoral sheath," which occurred in St. Thomas's Hospital in 1839, seems to be more nearly allied to the lymph-abscess of this paragraph, of which I was then ignorant than to a collection of synovia, as I thought it perhaps might be. The patient was a healthy country lad, seventeen years old, who three years previously had received a blow on the upper outer part of his left thigh, but seemed to have recovered from its effects. Two months since he noticed a swelling on the outside of the same thigh, about a hand's breadth above the knee-cap, which gradually increased both downwards and upwards, so that at his admission it occupied the outer and fore part of the thigh, from a little above the knee to near the great trochanter, fluctuated distinctly, and was presumed to be an abscess in the outer chamber of the femoral sheath. Fifteen minims of tincture of muriate of iron in mucilage thrice a day were ordered, to excite absorption, which was continued for nearly three weeks without benefit. The thigh then having increased, and fluctuation and swelling having extended about the whole knee, I made, by the direction of my then colleague Travers, whose patient he was, an incision two inches long, about the middle of the outside of the thigh, expecting (a) A. Pauli, Bemerkungen Uber Conges- (c) As above, vol. ii. p. 197. tions abscesse; in Rust's Magazin, vol. vii. (d) Bericht Uber die Ergebnisse; in Chi- p. 383, vol. viii. p. 434. rurg. Klinikum zu Landshut. Landshut, (6) Archiv fur medicinische Erfahrung 1824. 4to. von Horn, Nasse, und Henke, vol. i. 1817, p. (e) Ueber du Lymphgeschwulst; in Rust's 377. Magazin, vol. xxvii. p. 1. Vol. i.—6 62 ULCERATION. to evacuate pus or open the femoral sheath; but neither pus nor any other fluid escaped, although I cut into the m. vastus externus an inch deep. A tent ot lint was left in the wound to keep it open, and hasten the escape of pus if any should make its way through the wound; but none appeared, and in the course of a fortnight the wound had entirely healed. The tincture of iron, which had been continued to this time, was now left off, and two grains of iodide of iron thrice a day, ordered in its stead. A week after the whole thigh was wrapped in mercurial ointment, and swathed in a roller. This treatment was continued for three weeks, but without any diminution in size, or apparent change; fluctuation was still very distinct, and the fingers of one hand being applied, whilst pressure was made with the other hand alternately above, a thrilling fluctuation was felt. It was therefore determined to intro- duce a grooved needle about the middle of the thigh, and some fluid very similar to synovia escaping by it, an abscess lancet was then, with my colleague's consent, thrust in, making an opening an inch long in the skin, and half its length in the sheath, from which escaped about twenty ounces of the seemingly synovial fluid, which nearly emptied the cavity, leaving a rather moveable lump about the middle of the fore part of the thigh, the character of which I could not make out. The edges of the wound were carefully brought together, the limb rolled, and in four days union had taken place. A week after another free puncture below the former voided a quart of the same fluid as before, and on applying heat it coagulated speedily and almost entirely. The wound was left open, and a roller applied above and below it; but in the course of a week it had again united, and fluid was again secreted, though in smaller quantity. A solid but moveable swelling had at this time also formed to some extent around the Wounds. The iodide of iron was then omitted, and, instead, was ordered decoction of sarsaparilla four ounces, with five grains of iodide of potash twice a day; the whole thigh to be enveloped in ointment of iodide of potash. Three weeks after the solidification had increased, and the fluctuation generally was less distinct, and soon after the ointment was given up, and mercurial plaster applied. Two months after, having begun to take the iodide of potash, the thigh had much diminished, there was less fluctuation, the middle outer skin was almost solid, and there is less effusion about the knee. The diminution of size and fluctuation con- tinued, and in about two months he was able to walk about. He continued with us about four months longer, and when he left the house, the swelling about his knee, although not completely subsided, had so considerably diminished as not to interfere with his walking.—J. F. S.] 18. Ulceration (Exulceratio, Lat.; Verschwdrung, Germ.; Ulceration, Fr.) is distinguished from suppuration, in being connected with an actual destruction of parts, (by ulcerative absorption,) and with the secretion of a thin, acrid, fetid, and variously coloured pus-like fluid. It arises either immediately from inflammation, or from a preceding abscess. Its causes are either local injury,—for instance, improper treatment of the abscess which has been opened,—or general disease, as scrofula, syphilis, and so on. [In considering the subject of ulceration, or " ulcerative inflammation," as he most properly calls it, Hunter first indicates the economy of the absorbent vessels, and speaks of them in two views: first, as they absorb matter, which is not any part of the machine; secondly, as they absorb the machine itself." The former of these functions is of two kinds, of which the one absorbs external matter, either applied to the skin or received into the alimentary canal; and the other takes up internal mat- ter, as many of the secreted juices, the fat and the earth of bones, &c.; both, how- ever, serve principally to the nourishment of the body as well as to other and even hurtful purposes. The second function, that of " removing parts of the body itself, * * * may be viewed in two lights." The one view presents them as causing "a wasting of the whole machine or part, * * * which I call interstitial ab- sorption, because it is removing parts of the body out of the interstices of that part which remains, leaving the part still as a perfect whole. But this mode is often carried farther than simply wasting of the part; it is often continued till not a ves- tige is left, such as the total decay of a testicle." The other view exhibits them as "removing whole parts of the body," and "may be divided into the natural and dis- ULCERATION. 63 eased." Under natural circumstances the absorbents "are to be considered as the modellers of the original construction of the body;" for " no alteration can take place in the original formation of many of the parts, either in the natural growth, or that forma- tion arising from disease, in which the absorbents are not in action, and take not a con- siderable part: this absorption, I shall call modelling absorption. * * * Absorption, in consequence of disease, is the power of removing complete parts of the body, and is in its operation somewhat similar to the first of this division or modelling process, but very different in the intention, and therefore in its ultimate effects. This process of removing whole parts in consequence of disease, in some cases, produces effects which are not similar to one another; one of these is a sore or ulcer, and I therefore call it (the absorption) ulcerative. In other cases no ulcer is produced, although whole parts are removed; and for this I have not been able to find a term; but both may be denominated progressive absorption. ***** It may be difficult at first to conceive how a part of the body can be removed by itself; but it is just as difficult to conceive how a body can form itself, which we see daily taking place; * * * but this I may assert, that wherever any solid part of our bodies under- goes a diminution, or is broken in upon, in consequence of any disease, it is the ab- sorbing system which does it. When it becomes necessary that some whole living part should be removed, it is evident that nature, in order to effect this, must not only confer a new activity on the absorbents, but must throw the part to be absorbed into such a state as to yield to this operation. This is the only animal power capa- ble of producing such effects, and, like all other operations of the machine, arises from a stimulus or an irritation; all other methods of destruction being either mechani- cal or chemical. The first by cutting instruments, as knives, saws, &c.; the second by caustics, metallic salts, &c. The process of ulceration is of the same general nature in all cases; but some of the causes and effects are very different from one another." (pp. 440, 2.) "This process of the removal of parts of the body, either by interstitial or progressive absorption, answers very material purposes in the machine, without which many local diseases could not be removed, and which, if allowed to remain, would destroy the person. It may be called in such cases the natural surgeon. It is by the progressive absorption that matter or pus, and extraneous bodies of all kinds, whether in consequence of or producing inflam- mation and suppuration, are brought to the external surface; it is by means of this that bones exfoliate; it is this operation which separate's slough ; it is the ab- sorbents which are removing old bones, while the arteries are supplying new ones; and, although in these last cases of bones it arises from disease, yet it is somewhat similar to the modelling process of the system in the natural formation of bone; it is this operation that removes useless parts, as the alveolar processes when the teeth drop out, or when they are removed by art; as also the fangs of the shedding teeth, which allows them to drop off; and it is by these means ulcers are formed. It be- comes a substitute in many cases for mortification, which is another mode for the loss of substance; and in such cases it seems to owe its taking place of mortifica- tion to a degree of strength or vigour superior to that where mortification takes place; for, although it arises often from weakness, yet it is an action, while mortifi- cation is the loss of all action. In many cases it finishes what mortification had be- gun, by separating the mortified part. These two modes of absorption—the inter- stitial and the progressive—are often wisely united, or perform their purposes often in the same part which is to be removed; and this may be called the mixed, which I believe takes place in most cases, as in that of extraneous bodies of all kinds coming to the skin; also in abscesses, when in soft parts. It is the second kind of interstitial absorption, the progressive and the mixed, that become mostly the object of surgery, although the first of the interstitial sometimes takes place so as to be worthy of attention. This operation of the absorption of whole parts, like many other processes in the animal economy, arising from disease, would often appear to be doing mischief, by destroying parts which are of service, and where no visible good appears to arise from it: * * * but in all cases it must still be referred to some necessary purpose; for, we may depend upon it that those parts have not the power of maintaining their ground, and it becomes a substitute for mortification; and, indeed, in many ulcers we shall see both ulceration and mortification going on; ulceration removing those parts that have power to resist death." (pp. 414, 5.) As regards " the absorption of whole parts from disease, it would appear," says Hunter, " that they are capable of being absorbed, from five causes: first, from parts 64 ULCERATION. being pressed; secondly, from parts being considerably irritated by irritating sub- stances; thirdly, from parts being weakened; fourthly, from parts being rendered useless; fifthly, from parts becoming dead." (p. 446.) ,.,,,, , "The dispositions of the two parts of the living body, which absorb and are ab- sorbed, must," says Hunter, "be of two kinds respecting the parts; one passive and the other active. The first of these is an irritated state of the part to be ab- sorbed, which renders it unfit to remain under such circumstances; the action ex- cited by this irritation being incompatible with the natural actions and the existence of the parts, whatever these are, therefore become ready for removal, or yield to it with ease. The second is, the absorbents being stimulated to action by such a state of parts, so that both conspire to the same end. When the part to be absorbed is a dead part, as nourishment or extraneous matter of all kinds, then the whole dispo- sition is i'n the absorbents, (p. 446.) Many parts of our solids are more susceptible of being absorbed, especially by ulceration, than others, even under the same or similar circumstances, while the same part shall vary its susceptibility according to circumstances." (p. 447.) " Progressive absorption is divisible into two kinds, one without suppuration, and the other with. * * The absorption which does not produce suppuration may take place, either from pressure made by sound parts upon diseased parts, or by diseased upon sound parts." (p. 454.) The absorption attended with suppuration, "which I call ulceration,'''' * * * is connected with the formation of pus, being either a consequence of it or producing it, and is that which in all cases constitutes an ulcer. It is this which principally constitutes the progressive absorption. This differs from the foregoing in some circumstances of its operations. It either takes place in conse- quence of suppuration already begun, and then the pus acts as an extraneous body, capa- ble of producing pressure ; or absorption attacks external surfaces from particular irri- tations or weakness, in which case suppuration, forming an ulcer, must follow, let the cause of that breach or loss of substance be what it may." (p. 456.) " This process of ulceration or absorption with suppuration, is almost constantly attended by inflammation, but it cannot be called an original inflammation but a con- sequent, which gave rise to the term 'ulcerative inflammation.' It is always pre- ceded by the adhesive inflammation, and perhaps it is simply this inflammation, which attends it." (p. 457.) " The effect, then, of irritation, as above described, is to produce first the adhe- sive inflammation in such parts as will readily admit of it, and, if that has not the intended effect, the suppurative takes place, and then the ulceration comes on to lead the matter already formed to the skin if it is confined." (p. 458.) "Any irritation which is so great as to destroy suddenly the natural operations of any one part, and the effect of which is so long continued as to oblige the parts to act for their own relief, produces in some parts, first, the adhesive inflammation ; and, if the cause be in- creased or continue still longer, the suppurative state takes place, and all the other consequences, as ulceration; or, if in tbe other parts, as secreting surfaces, then the suppurative takes place immediately, and, if too violent, the adhesive will succeed; or, if parts are very much weakened, the ulcerative will immediately succeed the adhesive, and then suppuration will be the consequence. This species of ulceration in general gives considerable pain, which pain is commonly distinguished by the name of soreness; * * * but it does not attend all ulcerations, for there are some of a specific kind, which give little or no pain, such as the scrofula; but, even in this disease, when the ulceration proceeds pretty fast, it gives often considerable pain: therefore the pain may in some degree be proportioned to the quickness of its operation. The greatest pain which in general attends this operation arises from those ulcerations which are formed for the purpose of bringing the matter of an ab- scess to the skin, as also where ulceration begins upon a surface, or is increasing a sore: whether the increase of pain arises from the ulcerative inflammation singly, or from the adhesive and ulcerative going on together in the same point, is°not easily determined; but, in some cases, these three are pretty rapid in their progress, and it is more than probable that the pain arises from all these causes. In those cases where ulceration is employed in separating a dead part, such as sloughing, exfoliation, &c, it is seldom attended with pain: perhaps it may not be easy to as- sign a cause for this." (p. 459.) The following are some of Travers's observations on this important subject— " Ulceration, when it occurs, is consecutive to adhesion and suppuration, in almost HARDENING. 65 all cases; and, although suppuration may now and then pass without ulcerations, in the same manner as adhesion prevents suppuration, yet the frequent case of ulcera- tive inflammation succeeding to abscess, and the very rare existence of ulceration without pus, constitute the ulcerative, third in order, of the processes of inflamma- tion." (p. 187.) " Ulcerative absorption never occurs but as an inflammatory process, and the ac- tion of the absorbents in this process is therefore exclusively a morbid one, and gene- rally partakes of an increase proportionate and corresponding to the opposed action of morbid secretion." (p. 188.) "iThe ulcerative, being a purely vital action of the absorbents proper to the part affected, goes on progressively, either by perforation of the substance, or by an en- croachment on the surface, or by undermining and separating parts prepared by dis- organization or actual death from being cast off. The texture of the part determines which of these modes of .action is employed. The cornea, the cartilage, and bone present the penetrating and circumscribed, foveolous or fossulated ulcer, a pit or chink; the cellular membrane presents the hollowing and undermining process, as in the sinuses and pouches of abscess in cellulous parts and on the margin of indo- lent ulcers, also between the articular extremities of bones and their cartilages; the spreading or superficial ulceration is best exemplified in the skin. But it is always by the absorbents proper to the inflamed surface that this action is carried on." (p. 190.) "The ulcerative process stands between the life and death of parts subjected to its action, and administers to either, according to the circumstances of the case; being the instrument of reparation in the suppurative and adhesive inflammation, and of separation and removal of the waste and decayed, in the suppurative and gangre- nous. It is the agent of granulation in the former, of sloughing in the latter, case, suppuration being the common link by which these extreme processes are connected. Without granulation ulceration is a wasting process ; with it, a repairing one. In like manner, ulceration without suppuration is a devastation without means of con- trol or repair." (pp. 191, 2.) "An ulcer is a patent and familiar illustration of the pathology, not only of the ulcerative, but of all the processes of inflammation; and, as it is that vital action by which not only the dead are separated from the living, but the living are removed, which have undergone such organic changes, or lost so much of their vital power as to be incapable of resisting absorption, it may be regarded, as before observed, as an agent for life and death, and, if in one case the 'natural surgeon,' (Hunter,) in another the natural destroyer." (p. 196.)] 19. Hardening (Induratio, Lat.; Verhartung, Germ.; Induration, Ft.) occurs when during inflammation the fluids effused into the cellular tissue (par. 4) collect, thicken, and connect the walls of the cells together. Vessels pass into the connecting mass, which becomes organized, and the nutrition of the swelling depends on these vessels. If they are numerous or much expanded, the volume of the part is correspondingly increased, and permanent coagulable lymph is deposited, fatty or even bony masses are produced. If the walls of the cells become firmly united together without farther deposit in the swelling, the hardened part sometimes becomes smaller than in the healthy state. The hard- ness of the indurated part varies according to the quantity of lymph effussed in the cellular tissue, according to the structure of the part, according to the course of the previous inflammation, and the duration of the hardening. The skin upon the swelling is commonly not changed : the vessels, however, may be varicose, or the skin itself may be inti- mately united with the swelling. In this manner are formed, consequent on inflammation, various degenerations, enlargement of parts by hyper- trophy, sarcomatous, steatomatous degenerations, and so on. 20. In the hardened parts, if no peculiar irritation exist, the sensibility is lessened, the circulation seems to proceed but imperfectly, because 6* 66 MORTIFICATION. the nerves are completely enveloped in the plastic mass which connects the several parts, and the more minute vessels are closed : hence tbe temperature is lower, often sensibly so to the patient himself. Some- times not the least inconvenience arises from the hardening ; but it may run into inflammation, ulceration, and cancer (a). In every part inflammation may run into hardening ; but especially in 'long continued insidious inflammations ; in organs which possess a low degree of vitality, in glands, and those organs in which the very numer- ous ramifications of vessels are surrounded with dense cellular tissue, in persons of atrabiliary constitution, who have had much mental anxiety, have been subject to scrofula or other diseases which depend upon unnatural mingling of the juices. 21. The transition of inflammation into Softening (Erweichung, Germ.) produces changes directly contrary to those caused by hardening, viz., diminished cohesion and consistence—liquiescence. It occurs only in long continued dyscratic and cachectic inflammations ; it is always con- nected at the onset with collections of serous, not plastic matter in the parenchyma of the part, which is therefore sometimes loosened up and thickened ; or it consists in actual deliquescence and dissolution of the parts, probably consequent on diminished or changed nervous in- fluence. It may, to a certain extent, be considered as the intermediate condition between ulceration and mortification. The softer and looser the texture of an organ, so much the more readily does softening take place, though it also occurs in hard organs ; for example, in the bones: childhood is most subject to it. In many swellings softening precedes and accompanies their giving way. 22. Mortification (Gangrcena, Sphacelus, Lat.; Brand, Germ.; Gan- grene, Sphacele, Ft.) is the passage of inflammation into partial death, and the mortified part is subject to the general chemical laws. We usually distinguish with the name of mortification two conditions, viz., the hot Mortification, (Gangrcena, heissen Brand, Germ.; Gangrene ckaude ou Asphyxie des parties, Fr.,) in which the living power is not perfectly extinguished, and in which it may be restored to its natural action, (here there is but a certain degree of inflammation,) and the cold Mortification, (Sphacelus, kalten Brand, Germ.; Gangrene froide, ou Sphacele, Fr.,) in which the part is actually dead. [The division here employed by Chelius is that proposed by Dr. John Thomson. Travers objects to the terms mortification and sphacelus on the following ground: —" I do not," says he, " employ the term ' mortification' because it is not techni- cally explicit, and has been vaguely and indiscriminately used. Nor shall I use the term 'sphacelus,' because gangrene is a sufficient synonyme, if the term gangre- nous inflammation be accepted, which presents the stages of recoverable and irrecover- able, threatened and devitalized texture. A gangrened part is never restored. By the arrest of gangrenous inflammation, the gangrene may be circumscribed, and, by the supervention of other processes, the dead may be cast off, and the living part repaired with more or less loss of substance. The special use of the term sphacelus has been to designate a state of utter death, in which the part becomes subject to chemical changes, as if severed from the body, and such meaning I affix to the substantive term 'gangrene.'" (p. 208.) Hence it will be observed that Travers's gangrenous in- flammation, and his gangrene, are synonymous with Chelius's hot mortification, and with his cold mortification.—J. F. S.] (a) Wentzel Leber die Induration und das Geschwiir indurirten Theilen. 8vo. Mainz, 1815. MORTIFICATION. 67 23. Mortification truly consists in the extinction of vascular and ner- vous activity, in consequence of which partial death ensues. This transition is to be feared in unusually severe and quickly developed inflammations with well marked general symptoms in young powerful subjects, and after the operation of severe injuries ; in persons with the general appearance of weakness, if the redness of the inflamed part be bluish, of a dirty yellow, the pain slight, and if it be accompanied with typhus. If the pain quickly increase to a great degree, the inflammatory swelling be hard, dry, and very tense, the heat intolerable, the skin dark red, often brownish, the fever extraordinarily severe, and no ap- pearances ensue which lead to the hope of the inflammation terminating in suppuration, then the signs of incipient exhaustion become manifest. The acute pain becomes dull, aching, stretching; there is still indeed circulation, but its current gets slower and slower, and at last stops altogether. The redness therefore becomes deeper, more dusky, and farther extended ; the warmth diminishes, the swelling at first hard and tense, becomes soft, doughy, cedematous, the cuticle rises in blisters, containing a dark-coloured brownish fluid. In this condition the part has not yet lost all its sensibility and warmth ; the vital activity may therefore be reawakened and reparation effected. The pulse is small, quick, and loses all fulness and hardness; the patient is depressed, is uneasy, has a languid countenance, cold sweats, dry, dirty tongue, un- quenchable thirst, frequently burning hot skin ; the features at the same time become pinched, and the urine is thick. When exhaustion of the living activity and fully developed mortification takes place, then the pain ceases entirely, the colour of the part becomes blue, ash gray, or even black, the bone assumes a light white dirty yellowish, or even black spotted appearance. By the decomposition of the parts still covered with skin, and the evolution of the gases of mortification an emphysematous swelling is produced, the part becomes quite cold, and the general appearances of exhaustion are present in a higher degree, the mortification either spreads farther and death ensues from exhaustion, or on the confines of the slough is produced a bright redness, suppura- tion, and by the operation of the absorbing vessels a groove, becoming deeper and deeper, by which the slough is thrown off. [This is Travers'sacute gangrene. He observes also, that "if the inflammation occupies a circumscribed space, it is generally consecutive upon, and defined by, the adhesive inflammation; if it appears in several contiguous spots or patches, the whole of the intervening surface, and more or less of the subjacent and surrounding part, partakes of the inflammation and is marked for destruction; if, as often hap- pens, it is of irregular size and shape and the surrounding margin darkly disco- loured, tumid and painful to the touch, it is spreading, and rapidly travels along a continuous surface without check, to the destruction of texture, and generally of life. * * * In some rare instances, gangrenous inflammation takes possession of an entire structure, as, for example, hand or foot, or even a limb up to its con- nexion with the trunk, and beyond it, and the indication is the sudden subsidence of agonizing pain, change of colour to a pale bluish hue, loss of temperature and of sensation, so that the limb looks and feels like gray or clouded marble. I have seen in two cases the upper and lower extremities of the same side so affected in the same patient. The rapid dissolution of the vital principle in such instances, anticipates the march of disorganization; such cases are generally depending on nervous prostration from injury or operation, attended by peculiar circumstances of aggravation, or, yet more frequently, peculiar temperament." (pp. 209, 10.) 68 MORTIFICATION. 24. The decomposition of the mortified part is accompanied by a peculiar exhalation, different in smell from that occurring in the decom- position of dead bodies, the cause of which seems to depend on the higher temperature to which the mortified part is exposed, lne de- struction of the mortified part occurs in different ways: 1st, the slough shrivels up, the cuticle does not separate, the fetid exhalation is less, the pain is sometimes very severe (Dry Gangrene; Trochxer Brand, Germ.; Gangrene seche, Fr.;) 2d, the mortified part increases in bulk, the cuticle rises in blisters, which burst and discharge a quantity of stinking ichorous fluid (Moist Gangrene ; Feuchter Brand, Germ.; Gan- grene humide, Fr.;) 3d, all the organic structures without distinction are changed into a glutinous grayish white or ulcerous mass (Hospital Gangrene; Hospital-Brand, Germ. ; Pourriture dhbpital, Fr.) [In severe bruises, and occasionally when, after the swelling of a limb conse- quent on a fracture, the bandages confining splints have become tight and caused much pressure, vesications filled with bluish or bluish-black fluid occur. This often excites alarm, and is mistaken for mortification; but it is of little consequence. It is only requisite to puncture the blisters with a needle, evacuate the fluid, and apply lead wash for a few days, when all soon becomes sound. If the vesications are left unemptied, they often produce inconvenient superficial sores, which heal with the use of zinc ointment.—J. F. S.] 25. Mortification may be produced by all hurts which cause a too high degree of inflammation, obstruction of the circulation, weakness, oppression of the nervous activity, and thereby loss of life of a part; for instance, too irritating treatment of inflammation, checking of the circu- lation by ligature, too tight bandaging, pressure kept up by unyielding aponeuroses ; violent operation of heat and cold, malignant character of the inflammation where in seeming mildness of the symptoms mortifica- tion often occurs, of which the cause is generally unknown, but some- times depends on hurtful matter in the bowels; farther, from a great degree of weakness, degeneration of the juices, scurvy, and so on, malignant, putrid fevers, great age, severe bruises and concussions, by which the part is filled with stagnant juices ; ligature and ossification of the vessels, (which may without inflammation give rise to mortification,) certain fluids extravasated from their cavities, as urine, bile, feculent matter; bad foul air and contagious influences. [Brodie (a) enumerates sudden loss of blood as sometimes causing mortification, and in proof mentions the case of a man who, whilst very tipsy, one evenino-, was bled to the extent of three„pints, when he became very ill, and the next morning his toes and feet up to the insteps were mortified. They sloughed off, however, and he did well. (p. 635.) Travers mentions among the causes of mortification "such deep and extensive effusions as compress and annihilate the internal circulation of the part. Thus, I have seen," says he, "a subfascial effusion, following a severe strain of the fore arm, producing a spreading gangrenous inflammation of the extremity to within a hand's breadth of the axilla; and similar cases, of suppuration, between the deep- seated muscles of the thigh, I have known terminate suddenly in gangrenous in- flammation of the entire limb to the groin. Injuries of nerves, particularly, are lia- ble to be followed by gangrenous inflammation: of this I have also seen some marked examples. Baron Larrey found reason to attribute the gangrene of the foot following the operation for popliteal aneurism to the nerve having been injured or in- cluded m the ligature." (p. 214.) J I recollect many years ago seeing a case of mortification of the whole lower ex- (a) Lectures on Mortification; in London Medical Gazette, 1840—41, vol. i. MORTIFICATION. 69 tremity, consequent on a bayonet wound of the femoral artery, in which the death of the limb seemed to result from the slow effusion of blood and gradual distention first of the fasciae, and subsequently of the skin, which occupied many months. The man was a sailor, and during a homeward voyage from the East Indies dropped a bayonet point into bis thigh. The ship being without any surgeon, the captain bandaged the thigh tightly up, and effectually prevented external haemorrhage for five or six weeks. When he reached home, he was brought to St. Thomas's Hos- pital, and, on removing the bandage, the wound was found united. The limb was much swollen up to the pelvis; but his health had not suffered much. It was thought advisable to wait and see what might be the result. The limb increased in size, the skin gradually became more and more discoloured, and gangrenous in patches; indistinct fluctuation was perceived: he was slowly worn out, and died. On examination, the whole limb was found distended with blood, some of which was coagulated, some fluid, and other mixed with pus. On removing the clots, which were principally about the femoral artery, a spurious aneurism was found, the sac formed by the clot being as large as a hen's egg around the wound made by the bayonet in the artery, which had not closed, and was rather bigger than a crow-quill. On one side of the sac, close to the vessel, was a small aperture, by which blood had continued escaping probably up to his death, into the surrounding soft parts. Mortification of a limb, or at least of that part of it in the neighbourhood of an aneurismal sac (which is not uncommon if from any cause the vessel have not been tied at the proper time) in general depends simply on the distention from effusion, which at last bursts the skin. Mortification occasionally happens in simple fracture, from slow but continued effusion, and without wound of the principal artery or arteries of the limb. I have seen this once in a flour-porter, whose leg was broken by being jammed with a cart-wheel; hie constitution speedily took the alarm, and, though incisions were made through the skin to relieve the tension, he gradually became worse, and sunk into hectic, in which state his limb was removed; but he died a few hours after. Although from the first no pulsation could be felt in the tibial arteries, yet the ex- amination after death showed them uninjured and undiminished in size. Mortification I have also seen in one or two instances occurring from splints having been applied previous to the substance of the swelling after fracture, and not pro- portionally loosened as the swelling increased. The two following are cases of mortification, resulting, the first from simple con- tinued fever, and the second probably after scarlet fever:— Case 1.—J. J., forty-eight years of age, a hatter by occupation, of intemperate habits, is now— Aug. 1. Slowly recovering from an attack of fever which commenced seven weeks since. A sore on the inner ankle of the left leg, which he has had for eighteen months, about five weeks since became sloughy, and the surrounding skin was at- tacked with gangrene, which continued spreading till it has attained its present size, that of the hand. As yet there is not any line of demarcation, and the wound is very painful though cleaning. He is much emaciated, very weak, without appetite, cannot rest, his pulse extremely quick and almost imperceptible, (this may perhaps arise from exhaustion in bringing him to the hospital,) the countenance sunk and palHd, surface warm, but occasionally bathed in profuse sweats, tongue clean. I ordered for him five grains of carbonate of ammonia, with ten minims of tincture of hyoscyamus every six hours, six ounces of brandy and a pint of beef tea, with ar- row-root daily. To the wound, chlorate of soda lotion and linseed-meal poultice. Aug. 2. Better, but without sleep. Twenty minims of tincture of opium at night. Aug. 4. Is improving; the wound is free from pain, and two or three granula- tions are seen in its centre; the slough has rather increased. An abscess which has formed on the outside of the knee was opened, and a teaspoonful of thin but other- wise healthy pus discharged; pulse improved; he complains of sore throat, with difficulty in swallowing, and disposition to retch, but he takes plenty of fluid though he cannot manage solid food. As he wished for some porter, a pint daily was ordered. The mixture discontinued; but twenty minims of tincture opium in cam- phor mixture directed to be taken at night. Aug. 9. Is improving, and yesterday began taking a mutton chop. The slough has cleaned from the wound, leaving a sore surface which, occupying nearly two- thirds of the back and inner part of the leg, is now beginning to granulate. As the 70 SIMPLE MORTIFICATION. pus seemed disposed to bag on the outside of the instep, in consequence of the limb lying on its outside, the skin was cut through to prevent this, and a small abscess below the tubercle of the shin-bone opened. Aug. 15. Improving, and desiring more nourishment. Two pints ol beet tea daily. , . „ Aug. 22. The wound almost completely cleaned, but the granulations are flabby and pale. An abscess which has formed at the upper part of the thigh was opened, and about an ounce of good pus evacuated. He wished to have more porter, which was therefore increased to two pints, and the brandy diminished to four ounces. Nitric acid wash to be applied to the wound. Sept. 2. During the last two or three days the granulations have been receding,and have now exposed a large portion of the shin-bone, which is apparently dead; a con- siderable part of the Achilles' tendon has become gangrenous. The drain upon his constitution has lately been much increased, and it is now a question whether ampu- tation be not necessary, and also whether he is in a condition to bear it. Sept. 6. The wound is more healthy, and the gangrene seems to have stopped. Another abscess, merely superficial, which had formed about the middle of the thigh, burst yesterday. Sept. 11. Sleeps well and feeds well, but does not get flesh; there has been a slight increase of sloughing on the instep, but it is now cleaning. The discharge from all the wounds is very free, and the granulations rather more florid. Sept. 13. Appetite failing. An abscess on the inside of the calf, which seems to extend among the muscles, opened, and about three ounces of pus discharged. Sept. 20. Still declining, and during the last two or three days sloughing has re- curred. Amputation was therefore proposed, but he would not consent. Sept. 24, 9 a. m. Much exhausted; pulse quick and scarcely perceptible; counte- nance pallid; voice weak; the sore quite bleached. I ordered him brandy and egg, as much as he could be induced to take, which somewhat revived him, and after- wards he took some wine. At 1 a. m. bleeding occurred, probably from the saphe- nous vein, as it traversed the wound; it was, however, easily checked, and did not recur. He continued gradually sinking, and, on Sept. 25, 2 p. m. He died. Case 2.—E. U., Twenty-seven months' old, of scrofulous habit, has been weaned about thirteen months, and, like the children of the poor generally, since fed on bread and butter, with tea. She has been always healthy till about sixteen days since, when the whole surface of the body became so scarlet that it was supposed to have scarlet fever. Two days after she was observed to point continually to the left side of her chest, and on examination there was found on the axillary margin of the pec- toral muscle a dark-coloured swelling, in circumference about the size of a small tea-cup. Soon after the redness of the body subsided; but her belly was enlarged and the legs swollen. It would, therefore, seem probable that the previous disease was scarlet fever. At the present time (Sept. 8) there is a well-formed brown slough, surrounded with a dusky-red elevated edge of skin with similar inflammation extending about half-way down the left arm, also upon the neck and back, reaching as far as the right shoulder. The cellular tissue of the right arm-pit hard, inelastic, and painful, as if another slough were likely to take place. A layer of the slough was removed, and strong nitric acid applied with a feather; after which it was covered with nitric acid lotion and linseed-meal poultice. To the back of the neck a linseed poultice with acetate of lead wash was applied. Five grains of extract of bark every four hours, an ounce of gin every six hours, were given in arrow-root. Sept. 10. The sloughy sore is cleaning; but the hardness on the right shoulder has increased; the inflammatory blush has spread considerably, and now covers all the chest and the belly as far as the navel, extending down on either side towards the flanks. On the left arm it reaches below the elbow, and on the right half down the upper arm. The cellular tissue on the loins is ojdematous. As the gin is re- jected, a couple of teaspoonfuls of port wine with syrup was ordered frequently during the day, but not to exceed four ounces. Two grains of mercury with chalk, and four grains of rhubarb with as much carbonate of soda, nightly, were prescribed. ^ Sept. 11. Has had three dark-coloured stools, but her appearance not improved. She continued sinking, and about 4 p. m. died. No opportunity of examining her body occurred.—J. F. S.] DRY OR MUMMYLIKE. 71 26. The mortification dependent on very low vita] activity which generally attacks the feet and more rarely the hands of old people (Senile Gangrene, Gangrcena senilis, Lat.) must be considered as peculiar. Under this name, however, conditions have been classed together which, at least in reference to their origin, must be distinguished from each other. 27. In persons who in every respect have lived irregularly, and whose living powers are in a great degree exhausted, who have suffered much trouble, and had irregular gout, specially in the feet and erysipe- latous inflammation with dusky redness and severe pain arises after any injury, viz., after the violent action of frost, contusion or wound of the toes in cutting the nails or corns. This redness spreads more or less, forms blackish bladders on one or more toes; the cuticle separates, and the exposed true skin exhibits a deep dusky redness. The inflammation usually spreads still farther, but slowly; attacks one after another all the toes; and usually in its progress the part next to be attacked swells, and is excoriated. Sometimes it is circumscribed, in which case the toes dry like mummies and fall off. Most commonly the mortification spreads over the ankle-joint, and in its farther extension death ensues from ex- haustion : it may, however, be confined to different parts, and nature may bring about a separation of the mortified part. The pain is usually severe, and is soon accompanied with fever. 28. In this kind of mortification the depressed condition of the vas- cular and nervous activity must be considered as the actual cause why in the operation of the above-mentioned hurts, the inflammation quickly passes into mortification and drying up, mostly of the parts farthest dis- tant from the centre of circulation. This mortification exhibits some similarity to the dry mortification of frostbite. 29. The other form of this mortification happens without any previous local injury, but after general indisposition of more or less duration, such as depression of spirits, listlessness, unquiet sleep, debility, sparing, high- coloured urine, laborious breathing, palpitations of the heart, anxiety, pain at the pit of the stomach, small, weak, irregular, or intermitting pulse, shiverings, or constant internal cold. In the part in which subsequently the gangrenous drying appears, pains of varying severity come on, sometimes accompanied with cramps in the extremities : these go on for weeks, and even for many months, before the local destruction is observed. Or the patient has a sensation of cold in his extremities, a recurring sensation of being asleep for a longer or shorter time, insen- sibility to external irritation of fingers and toes, entire loss of motion. Without any local case the patient observes on his toe or on his finger a black blackish-brown or brownish (never dusky-red according to Bal- ling) colour, without any tense swelling. The part dries, the cuticle loosens itself, the part becomes quite black and lifeless. The prognosis of the disease varies : often is only one toe or one joint thrown off', or it attacks all the toes, confines itself to the foot, or spreads up to the knee. The process of separation is connected, as in common mortification, with a bounding red line and light suppuration. This kind of mortification may occur on various parts at the same time. The same appearances take place in children: the extremity becomes black-blue, its tempera- 72 MORTIFICATION. ture diminishes, and it seems to be completely atrophied. In one case Balling observed a blackish-yellow colour and dried skin. Sometimes a lower degree occurs, and then from the first the extremities are livid and cedematous. [This form of mortification is Travers's chronic gangrene, which he says "is generally an idiopathic affection, i. e. independent of injury, and which he has never known to be traumatic. * * * The main distinction between this and acute gan- grene is, that from the first the part thus affected losing its temperature and colour be- comes dry, tough, and shrunken, instead of moist, soft, and swollen, and takes on a yellow or blackish-brown appearance, nearly resembling that of a mummy." (p. 2110] 30. This form of mortification or mummy-like drying up is always the consequence of an exhaustion in the peripheral parts of the vascular and nervous systems. This condition occurs most commonly in old decrepid persons living anxiously and in want of food ; more frequently in men than in women ; in persons who have prematurely exhausted themselves by excessive debauchery ; in those subject to the gout, in whom, perhaps, the ossification of the arteries, so often observed in this kind of mortification, seems to be connected : this disease, however, may occur in every age if the above conditions are present. This kind of mortification may arise suddenly, and without any previous inflam- matory symptoms, by metastasis during the course of malignant fever. (1). In children born with blue, cold atrophied extremities, in whom the circulation does not proceed properly it is often noticed. The closing up of the blood vessels is, according to Balling (a), constantly ob- served (2) Organic changes in the heart and aorta are also invariably present (3). (1) I have seen one case in a man thirty-five years old, in whom during the pro- gress of abdominal typhus, the right foot up to the middle of the leg, became sud- denly pale, icy cold, senseless and motionless, shrivelled, subsequently quite black, and the dry gangrene reached to the upper third of the leg, where it stopped. (2) The closing up of the arteries is always present in dry gangrene, as was ob- served in former times; it may be also in certain cases the special cause of the mor- tification, and consequence of the inflammation of the arteries, (arteritis,) or of the capillary vessels, first described by Dupuytren (b). It cannot, however, be consi- dered as the general and constant cause; for, in many cases, there is not a single previous appearance indicating inflammation of the arteries, and their closure is caused by the mortification, and consequent to it. Compare also Hecker (c). (3) I have observed a case of dry gangrene in a man about forty years old, which extended up to the middle of the leg, where it stopped, and the part separated. There had existed for a long time undoubted symptoms of organic disease of the heart. [Brooie (d) mentions a case of mortification of the leg up to the middle of the thigh, whicb commenced with a sense of pricking numbness and weight, and on the following day the limb had mortified; "no vesications formed on the foot; it was not swollen, and no part became putrid except just a little in the middle of the thigh, where was a great mass of soft parts. The limb dried, the skin assuming a brownish colour, being at the same time hard and semi-transparent, so that the white tendons could be seen shining through it. It was in fact what has been called a case of dry gangrene." The patient's powers failed, and he died at the end of six weeks. Upon examination, Brodie "found marks of inflammation everywhere around the principal artery and vein of the limb. From the bifurcation of the large trunk down to the middle (a) Ueber die Gangrana senilis in Journal ungen fiber die brandige Zerstorung durch vonv.GRAEFEundv.WALTHER,vol.xiv.p.42. Behinderung der Circulation des Blutes. (b) Transactions Medicales, May, 1833. Stuttg., 1841. (c) Nosologisch-therapeutischeTJntersuch- (d) As above. MORTIFICATION. 73 of the thigh, the artery was obliterated, being completely filled with coagulated lymph, evidently effused from inflammation; closely adhering to the inner surface, but with some admixture of red coagulum. The vein was filled with lymph and obliterated in the same manner as the artery. There had been inflammation of the sheath of the vessels, in consequence of which the artery and the vein adhered closely to each other and to the surrounding parts. I suppose that the nature of the case is plain enough: there had been inflammation of the artery and the vein, and the obli- teration of the artery was to so great an extent as to cut off the supply of blood, not only through the trunk, but through the anastomosing branches." (p. 635.) Brooie also points out the cause of the distinction between dry and moist gangrene:—" If mortification be the result of inflammation or of venous obstruction, there is always an effusion of serum before the parts completely dry, in the form of vesication of the skin and oedema of the cellular membrane; and tben, when the parts die, being infiltrated with serum, they readily become putrid. But here (in inflammation of the arteries) the blood is prevented from entering the limb, so that there can be neither vesication nor effusion of serum into the cellular membrane, and the dead parts dry readily from the absence of moisture." * * * Gangrene from arterial inflammation is comparatively a rare disease, and may occur at any period of life; whereas the gangrene of old age arises, as repeated dissections have enabled me to determine, entirely from other causes." (p. 636.) From this latter observation it will be perceived that Brodie does not agree either with Cruvelhier (a), who says, that " coagulation of the blood is, after his observations, the essential character of incipient arteritis," (p. 394;) or with Dupuytren (b), who says that, in such cases, " Pathological anatomy always shows the existence of inflammation of the arterial tunics. This phlogosis may doubtless occur in arteries which are unhealthy, indurated, ossified, as often met with in old persons; but it appears also in the arteries of young people without trace of these disorders. In a word, it may coin- cide with the calcareous incrustation of the vessels and with age, or it may be inde- pendent of both conditions." (p. 484.) I have seen but a single case of arteritis, which happened in a young man of twenty years. It differed from Brooie's case in not having exhibited the slightest appearance of gangrene, and, on dissection, the brachial artery was found partially obliterated, and shrivelled to a narrow cord, precisely as if a ligature had been applied upon the subclavian artery. Although, in this case, the pulse at the wrist ceased suddenly, yet the circulation was undoubtedly carried on by the collateral circulation, and thus gangrene prevented. I shall refer to this case again when considering inflammation of the coats of arteries, (p. 74.)—J. F. S. A most remarkable case is given by Solly (c) of gangrene, which commenced in a boy about three years old, and, gradually spreading from limb to limb, destroyed him when four years old. In four months from its commencement the disease had amputated the left foot above the ankle, as also two toes of the right foot, and upon the right calf and knee were hard gangrenous spots. The right fore arm was cut off through the middle of the ulna, and the radius had dislocated itself from the elbow joint; the whole of the left fore arm and part of the upper arm were gangrenous. There was a dusky spot on the nose upon the scar left by a gangrenous spot which had formed previously, and separated. In the sixth month the left leg, which had become quite gangrenous, was thrown off below the knee, and the toes of the right foot had also sloughed off. The right ulna had come off at the elbow-joint, and the left arm had amputated itself through the middle of the upper arm. The gan- grene on the nose had reappeared, but been checked. For a short time there seemed a little rest in the gangrenous process; but it was again set up, and by the twelfth month the left leg had become gangrenous to the middle of the thigh, and all the soft parts separated, leaving the bone bare. The right leg had mortified to the mid- dle of the calf, and the right foot separated above the ankle. The stumps of both arms had become gangrenous up to the shoulders. In the beginning of the following month the child died. Careful examination of the body did not show any organic disease; but the child had become much emaciated. The stumps of the arms had (a) Maladies des Arteres; in Dictionnaire (b) Lecons Orales de Clinique Chirurgicale, de Medecine et de Chirurgie Pratiques, vol. vol. iv. iii D 394 (c) Med. Chir. Trans., vol. xxii. p. 253, 'v' ' 1839; vol. xxiii. p. 237, 1840. Vol. i.—7 74 FROM COCKSPURRED RYE. nearly hfealed; but in the lower limbs the bones protruded, and the cure was less perfect.] 31. Mortification from continued pressure, or from constant lying upon one part (gangrcena ex decubitu) occurs more readily, the weaker the patient, and the less cleanly and smooth the bed is. On those places where the pressure acts, most commonly, therefore, on the sacrum and Coccyx, the great trochanters, the shoulder-blades, elbows, heels, and so on, a limited redness appears, with pain more or less severe, the skin is destroyed by ulcerative absorption, and a dry slough is formed, which is dissolved in the suppuration set up around it. Should the pressure continue, and the general weakness be great, (for example, in typhus fever,) the destruction spreads very extensively, and in many cases death is thereby accelerated or even caused. 32. A special mention is required of that mortification which, in cer- tain localities, in very wet and humid years, when the rye is infected with the blight, called " cockspur," occurs in the lower extremities, with a constant sensation of itching, great burning, and a darting pain, some- times with redness and swelling, consequent on which the parts become cold, senseless, black, mummy-like, and shrivelled up. In rare cases this disease has been also observed in the upper extremities. During the course of the disease general symptoms, fever, delirium, and so on, frequently arise. Oftentimes the mortification becomes defined and the part is thrown off, and often it spreads up to the hip-joint. [A very interesting account of mortification from the use of rye-bread affected with cockspur (secale cornutum, Lat.; Mutterkorn, Germ.; ergot, Fr.) has been given by Thomson. "This is," says he, "a species of mortification which has not been ob- served in this country; but it is well known and has been frequently observed in different parts of the continent of Europe, particularly in France, where it has been repeatedly known to prevail in some districts as an endemial disease." (p. 538.) Pereira (a) supposes this disease is referred to in a passage he quotes from Sige- bert. "1089, a pestilent year, especially in the western parts of Lorraine, where many persons became putrid, in consequence of their inward parts being consumed by St. Anthony's fire. Their limbs were rotten and became black coal. They either perished miserably or, deprived of their hands and feet, were reserved for a more miserable life." He also refers to a similar passage in Bayle, with the addition, that "the bread which was eaten at this period was remarkable for its deep violet colour." (part ii. p. 595.) Thomson says, the disease was first noticed by Dodard in 1676; then by Saviard (b), in 1694; and by Noel (c), in 1710, in the Hotel Dieu at Orleans, of which they were both surgeons; in 1709 and 1716 it appeared in Switzerland, and was described by Langius (d); Quassoud, and also Bossau, de- scribed it on its appearance in Dauphiny in 1709. Duhamel (e) mentions that in 1748 not more than four or five persons out of a hundred and twenty who had been attacked escaped with life. Elliotson some years since had, in St. Thomas's Hos- pital, a case of gangrene of the leg after using ergot; but he informs me that on examination after death the arteries of the limb were found ossified: it might, how- ever, have been the immediate exciting cause of the disease. Although there was no doubt that in man the cockspur would produce gangrene, Model (/) a Russian, made experiments which led him to conclude that rye, damaged with cockspur, had not the power of exciting gangrene in brutes. This remarkable statement induced the Royal Society of Medicine at Paris to employ (a) Elements of Materia Medica, part ii. (d) Descriptio Morborum ex esu Clavorum London, 1840. 8vo. Secalinorum. (b) Journal de Savans, 1676, p 76; (e) Memoires de l'Academie Royale de (c) Memoires de l'Academie Royale des Paris, 1748 p, 528 Sciences de Paris, 1710, p. 61. (/, Boma're, Dictionnaire d'Histoire Na- turelle, vol. xix. NOMA. 75 Tessier (a) to visit those countries where the disease was prevalent, and to insti- tute experiments to determine the fact, and the result showed that brutes eating it were destroyed by gangrene; but, in all the animals upon which it was tried a cer- tain quantity, varying according to circumstances, of the cockspur was required to be taken, in order to produce the effect; and, as Thomson says, "this afforded also a simple explanation of the fact, that persons might live for a considerable time upon rye affected with cockspur without suffering any sensible injury from its use." (p. 547.) Pereira states, however, that " there are not wanting cases apparently showing that spurred rye bas no injurious action on animals. The most remarkable and striking are those related by Block. In 1811 twenty sheep ate together nine pounds of it daily for four weeks without any ill effects. In another instance twenty sheep consumed thirteen pounds and a half daily for two months without injury. Thirty cows took together twenty-seven pounds daily for three months with impunity, and two fat cows took, in addition, nine pounds of ergot daily, with no other obvious effect than that their milk gave a bad caseous cream, which did not yield good butter. These statements furnish another proof to the toxicologist that the ruminants suffer less from vegetable poisons than other mammals." (p. 600.) A very curious history of a mother and five children, some of whom lost one and others both legs, as related by Dr. C. Woolaston (b), seems to have originated in the use of discoloured clog-wheat. Ergotism, as the disease produced by the cockspurred wheat or rye is called by the French, is of two kinds, the convulsive and the gangrenous,- with the latter only have we to do here; it sets in with formication, or the feeling of insects creeping over the skin, voracious appetite, coldness and insensibility of the extremities, fol- lowed with gangrene.] [32.* Here must also be mentioned that mortification of the cheek which has been called Noma by Vogel. It is fortunately not frequent, as it is a horrible and generally fatal disease. With a single exception, of the half dozen cases I have seen, all were children under four or three years old; some idiopathic, and others originating in a sloughing of the mucous membrane of the mouth, under the careless use of mercurials ; and, though generally in unhealthy subjects, yet the disease also occurred in robust, well-fed children. In its idiopathic form it has been well de- scribed, by Drs. Evanson and Maunsell (c), as follows:—" A parti- cular form of gangrene of the mouth without any preceding inflammation occasionally attacks infants, especially such as are feeble at birth or broken down by disease. An oedematous circumscribed swelling appears on the cheek, with a central point, more or less hard, over which oc- curs a dark-red spot. This spot may appear on the inside or outside of the cheek ; and the skin over the oedematous part is characterized by an oily appearance. An eschar forms from within outwards on the central point, and the soft parts mortify, often extensively, down to the bone, so that the parietes of the cheeks and gums are destroyed, falling off in shreds, mixed with a dark sanguineous fluid, and accompanied by a very fetid odour." (p. 214.) In neither of rny cases, excepting the adult, did I witness the beginning of the disease ; but gangrene to a greater or less extent of one cheek, involving generally the corresponding half of the upper lip, existed when the children were brought to me ; the sur- rounding parts were tumid, hard, and of dull yellow-white hue, very si- milar to the characteristic colour of the countenance of patients under malignant disease. I have little doubt that the mortification of the mouth and fauces after measles, mentioned by Huxham (d), as well as those (a) Memoires de la Societe Royale de Me- (c) A Practical Treatise on the Manage, decine 1776, p. 254, 1777-8, p. 587. ment and Diseases of Children. 2d Edit. (b) Philos. Trans. 1762, p. 523. Dublin, 1838. 8vo. (d) Reports, July, 1745. 76 NOMA. referred to by Marshall Hall (a), and by him stated to have happened after previous disorder of the digestive organs, typhus fever, or some in- flammatory disease, are of precisely the same character as those resulting from mercurial influence. The little patient, if not already in a typhoid state, soon falls into it, rapidly sinks as the gangrene spreads, and quick- ly dies ; often, indeed, before the least attempt at separation of the slough has been made. Usually three or four days are sufficient to destroy life; but, in one instance, I recollect a child of two years old having lived for a fortnight, and the greater part of the gangrenous cheek had sepa- rated, leaving one side of the cavity of the mouth completely exposed. I fully agree with Evanson and Maunsell, that " no disease can be more frightful or formidable than sloughing of the mouth in children. Recovery seems impossible, when once the disease has set severely in, the child sinking beneath the constitutional disturbance, independent of the local ravages of the disorder, which, however, are often such as to render recovery not. to be desired, so frightful is the deformity necessa- rily entailed," (p. 215.) The term Cancrum oris has been loosely applied both to the disease just mentioned, and also to another form of mortification commencing with ulceration, generally first in the gums, and thence spreading to the lips and cheeks. This second form alone is considered by Dr. Cumming(6) to be cancrum. He describes it as being either acute or chronic, and, if the former, more liable to be accompanied with sloughing, but the ul- cerative process predominates, and by it, principally, the destruction is effected. It does not, according to this writer, attack children at the breast, nor under eighteen months, but occurs between twenty months and seven years. The following is a short account of the case of noma in the adult alluded to above:— R. L, a gunmaker by trade, was admitted under my care— August 1, 1844. Having two superficial sores on the glans penis and a superficial sore on the back of the pharynx, sloughy and painful, so much so as to prevent him sleeping at night. He is much out of health; quick, irritable pulse; hot, dry skin, and foul tongue. He has also a very small sore, scarcely perceptible, and covered with a dry scab, on the face near the nostril. He was not seen till August 2. Probably from not having come in, and then ordered pulv. rhei. c. hydr. E>j. stat; sod.' carb. gr. xv. acid, citr.gr. x. tinct. hyoscyam. 3ss. aq. distill. gjss. 6th horis; garg. acid, nitr. August 6. The mixture omitted, and in its stead ordered acid. nitr. fy iij- inf. rosar. 3Jss. ter die. pulv. ipec. c. gr. x. On August 9. Very restless, scarcely sleeps at all; and is so feeble that he can hardly answer the questions put to him. Ordered a glass of wine and a pint of porter daily, and morph. mur. gr. %. On August 15. Has slept better since taking the morphia. The crust under the right nostril has increased in size and is accompanied with swelling of the surrounding parts which are of a purplish colour. August 17. Is much worse; the lip immensely swollen and livid, but not giving any discharge; face so much disfigured that he can scarcely be recognised. The sore in the throat much worse; bowels confined. & pulv. rhei. c. hydr.gr. xv. stat ,• vtn. rubr. 3yj. quotid. y ° August 20. Is very feeble and unable to speak. The slough has now extended around the mouth from the nose to the chin, including the* lipsaj pTrt ^both rn(a) °u-\pefflllar*.Sp^ieS ?f GangrenouB Edinburgh Medical and Surgical Journal Ulcer which affects the Face in Children; in vol. xv. p. 547. »uigiuu Journaa, (b) Dublin Hospital Reports, vol. iv.'p. 18. MALIGNANT PUSTULE. 77 cheeks. The sore in the throat has become very sloughy. Four ounces of brandy, three eggs and some arrow-root were ordered; but he was not able to take much, and gradually sunk till, 11. p. m. When he died. No discharge at all had occurred from the lip. No examination of the body was made.—J. F. S.] [The attention of the profession in America, was first particularly di- rected to that peculiar affection of the mouths of children, terminating rapidly in extensive sloughing of the gums and cheeks, by Dr. Benja- min H. Coates, and his excellent essay on the subject, published in the second volume of the North American Medical and Surgical Journal, may be consulted with profit by the practitioner. He found a solution of blue vitriol, grs. xxx to the ounce of water, applied as a wash, to be more efficacious than any other medicine which he tried. See also a paper by Dr. S. Jackson, on the Gangroenopsis, or Gangrenous erosion of the cheek, in the Medical Recorder, vol. 12.—g. w. n.] 33. Mortification occurs as a consequence of contagious influence, either by the contagious matter producing at first an inflammation which terminates in mortification, (malignant pustule,) or by coming in contact with the surface of a wound or sore, whereby the destruction of it is brought about (hospital gangrene.) 34. The Malignant Pustule (Pustula maligna, Lat.; bbsartige Pustel, Germ.; Pustule maligne, Fr.) is always consequent on local contagion. On the place which the contagious matter has touched, there appears in a short time prickling and a red point, which is scarcely raised above the skin. The cuticle rises in a blackish vesicle, which is soon con- verted into a slough surrounded by a whitish or violet edge and oede- matous swelling, and spreads quickly in all directions. From the very onset there is perceived in the pustule a hard nucleus, which enlarges both inwards and outwards, or only spreads laterally. Notwithstanding the decided swelling, the patient complains rather of tension than of actual pain. Sooner or later it is accompanied with fever, pain in the region of the stomach, nausea, vomiting, high delirium, fainting, and so on. The pulse is small, irregular, and, if left to itself, the disease generally runs on to death, which in malignant cases follows very speedily. It is rarely that the slough comes away, and that the cure is effected by the mere powers of nature, or that in the course of this disease the general symptoms already mentioned do not appear. If several pustules are formed at the same time, especially on the neck or face, the disease is more dangerous. The swelling is often here so great that symptoms of suffocation and congestion of the brain are produced. In women the disease proceeds more quickly than in men. At the onset a stop may usually be put to this disease ; the danger increases in its subsequent course. It differs from carbuncle (par. 118.) The contagion develops itself in beasts which are affected with con- tagious carbuncle (Mihbrand;) it may be communicated whilst the animal is alive, or it may take place during the preparation of wool, hides, and so on. The malignant pustule is therefore most commonly observed in butchers, tanners, woolbeaters, shepherds, and especially on those parts of the body usually uncovered. In wet districts, in moist autumns, the disease is most common. The contagion preserves its power for a long period. Actual contact is not always necessary to 78 MALIGNANT PUSTULE. produce infection. The use of the flesh of such beasts sometimes does not produce any, but at other times very dangerous, symptoms, lnis disease seems not to be communicable from one man to another, at least the facts relating thereto are not perfectly indisputable ; it is also doubtful whether the general symptoms can be produced by the assumption of this contagion into the body, without the malignant pustule on the skin. Precisely similar phenomena have been observed in reference to the transference of the poison of glanders from horses; upon which see the article entitled Ansteckung, Uebertrao-ung des Ansteckungstoffes von Thieren auf Menschen, in Hufeland's Journal, vol. iv. part iii. p. 57, which contains the following three notices:— Remer, W., Ein Beitrag zu den bisherigen Beobaetungen von Krankheiten der Thiere, welche sich dem Menschen mitgetheilt haben. Schilling, Merkwiirdige Krankheits-und sections-Geschichte einer wahrscheinlich durch Uebertragung eines thierischen Giftes erzeugten schwarzen Blatter. (This notice is also in Rust's Magazin, vol. ii. p. 480.) Meier, Todtliche Uebertragung des Milzbrandes auf Menschen. See also, Tarozzi, Tommaso, Casi di Malattia Pestiforme nata in diverse persone che con- venivano in una stalla in cui era un cavallo moccioso; in Omodei's Annali Universali di Medicina, 1822, vol. xxiii. p. 220. Seidler, Geschichte einer muthmasslieh durch Uebertragung eines thierischen Krankheitsstoffes erzeugten merkwilrdigen, in todtlichen Brand ubergegangenen Gesichtrose, in Rust's Magazin, vol. xvii. p. 161. Eck, Beitrag zu den Erfahrungen fiber die schadlichen Einwirkungen des Rotz- giftes des Pferde; in Medinischer Vereinszeitung fiir Preussen. 1837. 3d May. Elliotson, John, M.D., On the Glanders in the Human Subject, in Med-Chir. Trans., vol. xvi. p. 171. Additional Facts respecting Glanders in the Human Subject, ib., voL xviii. p. 201. [Elliotson has given a very excellent account of " The Glanders in the Human Subject," in which the communication of the disease from the horse to the patient is distinctly made out. He mentions six cases; the first three he considers acute, two of which occurred in St. Thomas's Hospital, and both died very speedily after having been attacked; the third occurred in a dragoon regiment in Ireland : the fourth was a veterinary surgeon at Clapham: both died. Two cases, which he calls chronic, extracted from Travers's book "On Constitutional Irritation," one of which died, and the other long suffered from a broken-up constitution. He also refers to the cases mentioned in Rust and Omooei's Journals. In a subsequent paper he gives " Additional Facts respecting Glanders in the Human Subject," in which he men- tions another case that occurred in St. Thomas's Hospital, which also died. I have to thank my friend Lawrence for the following observations of the cases of malignant pustule which have come under his care, and which, on account of their rarity, I gladly avail myself of the opportunity to introduce on the present occasions, He says:— "I have had under my care, in St. Bartholomew's Hospital, three cases of malig- nant pustule, in neither of which, however, did I see either pustule or vesicle,- of the first and most remarkable, the following is the report from the Lancet of 1825-6, p. 127, in which it is described as "A singular case of Erysipelatous Inflammation of the lower Eyelid, terminating in gangrene in the short space of six hours." __3pital. Feb. 18, 1826. He stated, that the day before yesterday, whilst at his usual em- ployment, he struck his right eye with a skin of leather, which at the time caused him great pam and uneasiness. At this time there is an erysipelatous inflammation extending around the organ, but more especially on the lower lid and adjacent por- tion of the check, m the centre of which there is a hard and indurated lump, more prominent than the rest, feeling like carbuncle. It has a very livid hue, and may be said to have gone into a state of gangrene. Since his admission into the hospital, he has not complained of any particular pain in the part, nor is the constitution appa- rently much affected; the tongue is but slightly loaded; the pulse feeble Mr. MALIGNANT PUSTULE. 79 Lawrence made an incision through this hard and indurated portion, when a little dark blood escaped. The globe of the eye not in the least affected. Two grains of sulphate of quinine to be taken every six hours, and six ounces of port wine, daily. Feb. 22. The pulse having been quickened last night, the wine has been in conse- quence discontinued; and a dose of house medicine given this morning. The tumefaction above the lid still continues, and there is now a distinct line of de- marcation around the gangrenous spot before alluded to. The whole of the inflamed skin, has a peculiar, hard, brawny feel, very similar to carbuncular inflammation. Mr. Lawrence stated, that when the man came to the infirmary, there was no unusual vascularity of the eye; a slight serous effusion only had taken place beneath the conjunctiva palpebrae. A slight puffiness is observable about the under lid of the corresponding eye, but there is no redness. Pulse soft and compressible; bowels open and tongue moist. The quinine to be continued; the wine resumed, but omitted at night if necessary. Feb. 25. Has passed a good night and the condition of the parts is improved. The wine and bark, being too stimulating, are both discontinued. A more scarlet or what may be termed phlegmonous inflammation now surrounds the dark gangrenous portion of skin, which is about the size of a half crown in extent; and the contiguous parts have a less brawny feel. Pulse 90, soft, and the patient free from any particular pain. Wears a poultice to the part and takes saline mixture. March 1. But little constitutional derangement is manifest. The eye examined to-day, but presented no unnatural appearance. Neither of the tarsi are implicated, although the swelling commences immediately below the lower one. To continue as before. Mr. Lawrence observed, that Beer only mentions two cases wherein such a sudden change had taken place, and those resulting from the sting of bees, whereas, in the present instance, the mere contact of the leather had produced it. He also remarked that the only author who had mentioned any case like the present was M. Delpech of Montpelier, who has described two ojfthree cases as occurring in butchers and tanners, where the parts went into a state of mortification in the space of a day or two after the occurrence of the accident, although there was no severe contusion of the parts. He ascribes it to some peculiarity in the skin with which they were struck. March 1. The process of separation goes on favourably; that portion of the slough which is nearest the eyelid has become detached, and is found to extend to some depth. The bowels are kept open by medicine, and a poultice is applied to the part. March 10. A portion of the slough was removed to-day. For the last two days, as he has had a feeble pulse and complained of great weakness, six ounces of wine, daily, have been allowed. March 13. The whole of the slough has now been detached, and, as was suspected, the tarsus is quite undermined along its central part, which has caused its dropping, and, consequently, a degree of ectropium. The surface of the sore discharges pretty freely, but has a healthy aspect. Continue as before. March 16. Every thing to be omitted but the wine. March 19. The edges of the sore have already considerably approximated, and the granulations have nearly rendered it a mere superficial ulceration. Continue as before. Mr. Lawrence says, that he shall be obliged, at a future period, to remove the everted portion of the conjunctiva palpebrae. March 23. The ectropium is lessened, and cicatrization of the sore only now remains to complete the cure. The man was permitted to leave the hospital, and to continue his visits to the Eye Infirmary if he found neeessary. In reference to this case Lawrence observes, in his note, "the essential circum- stances of this case were a reddened and thickened state of the skin on the cheek, just below the eye-lid, presenting, at the first view, the aspect of incipient erysipelas; speedy mortification of the reddened part, and its slow separation, the mortification including the subjacent textures, so tbat the cicatrix was fixed to the bone, and the lower lid partially drawn down; absence of constitutional disturbance. "In the other instances," he continues, "both of which were persons employed in a horsehair manufactory, the skin had sloughed before they came to the hospital. The affected portions were circular, the size of a shilling in one, on the front of the chest; that of a sixpence in the other, on the fore arm. There were no other local symptoms, nor the slightest constitutional disturbance." 80 MALIGNANT PUSTULE. Turchetti (a) has given, under the name of Anthrax, an account of some cases of malignant pustule, which occurred in 1841, after eating diseased flesh of cattle which had died of an epidemic anthrax of the tongue, and had been sold in the market of Fucecchio. In some persons, small, and very painful tubercles, with a red areola, or small whitish pustules, encircled with purple or violet, appeared on the face, lips, neck, or arms, gradually increasing in size until in the space of from one to three days they presented the genuine characters of anthrax. In the greatest number of these cases the slough separated in the course of a week, leaving a more or less healthy ulcer, which cicatrized speedily. In the more severe cases the pustules ran together, the inflammation spread like erysipelas, with extensive livid swelling and obstinate disorder of the alimentary canal. The sloughs did not separate for a fortnight, and left very foul ulcers, which healed with great difficulty. Two elderly persons died of this disease. A young man, eighteen years old, was attacked twenty-eight hours after taking this food with an anthrax on the left upper eye-lid, whence followed mortification of the whole of that side of the face and neck, and part of the chest. At the end of a fortnight the slough cleared off, leaving an enormous ulcer, which sup- purated freely and healed slowly. Dr. Wagner (b) relates several cases of malignant pustule produced in man and beasts, both by contact and by eating the flesh of diseased animals, which happened at the village of Striesa in Saxony. On the 13th of July, 1834, a herd of cattle having been brought from the pastures to the village, the bull fell to the ground, and was incapable of getting up again. Supposing that it had met with some injury in the loins which would render it useless, it was destroyed by shooting through the head, as happened to be most convenient, and then, having been dressed and cut up by two labourers, the meat was distributed among the villagers. A few days after, some more cattle on the same farm died, and were skinned by the same persons; but the meat was not used as food, as almost all the persons who had eaten of the first beast had felt more or less unwell, mostly, however, complaining only of weight at the pit of the stomach, and pain in the^fcelly, without fever: but, several, espe- cially the two persons who had both dressed the animal and also eaten its flesh, complained severely of soreness of the limbs, dizziness and debility. Between the 15th and 18th of the month several more beasts dropped and died without any pre- vious illness. On examining their bodies the spleen was found completely gangre- nous and in so broken up a state, that, when cut into, it presented a black paste-like mass, which readily flowed out: there were also other inflammatory marks in the belly, and hydatids here and there beneath the skin, especially about the neck. One of the flayers, notwithstanding his uncomfortable feelings, proceeded to a village three leagues off, which he accomplished; but, on attempting to return, was attacked with colic and vomiting, and some hours after was found on the ground suffering severe pain, and passing black blood by stool; his limbs were cold, and soon became attacked with cramp ; the whole body like ice; the eyes sunken; and he died vomit- ing, passing bloody stools, and under great anxiety. One widow woman, of thirty years, who had eaten the flesh, but otherwise not touched the animal, complained of oppression at the heart, and weight of the limbs, had a black pustule on the thigh, felt herself very ill in the evening, went to bed, and early in the morning was found dead. Other persons had pustules on different parts of the body. Two very remarkable cases occurred eight days after any beast had been affected with diseased spleen; both were women, one of twenty-six, and the other of fifty years, and in them the pustules were well marked, and the general symptoms similar to the other cases. The latter patient said she had been bitten by a fly upon the back of the neck, at which part the carbuncle appeared; and the former, that she also had been bitten on the right upper arm, by a grTat. Upon inquiry, Wagner found that the skin of one of the infected beasts had been hung on a neighbouring wall, and thought it very possible that the insects might have been attracted to them by the smell, and had thence conveyed the poison. A very interesting paper upon malignant pustule has within the last two years (a) Sapra alcuni casi di Malattia Carbon- chiosa nata per ingestione delle carni di bue perito di glosso-anthrace; in Omodei's Annali Universal! di Medicina, vol. cii. p. 276. 1842. (b) Uebertragung des Milzbrandgiftes auf Menschen und Thicre sowohl durch Beruh- rung, als durch Genuss des Fleisches; in Hufeland's and Osann's Journal der practi- schen Heilkunde, October, 1834, p. 1. MALIGNANT PUSTULE. 81 been published by Dr. Bourgeois (a) illustrated with numerous cases. He states that the disease appears in from one to three days on the point where the virus char- bonneux has been deposited, as a little reddish spot almost always of a deep hue, sometimes accompanied with itching, at other times without. It resembles a gnat- bite, is very ephemeral, and soon followed by a little vesicle slightly puckered, of the same colour, containing a small drop of reddish serosity. Sometimes, instead of this mark, the vesicle is preceded by a solid pimple as big as a pin's head, more or less brown and rosy in some cases. The vesicle thus formed is accompanied with a sensation of great itching, and sometimes shivering, but is rarely painful. The patient scratches off the vesicle with his nail, and the itching generally ceases for a few hours, after which, around the scratched pimple, which is dry and yellowish, a regular circle of vesicles, similar to the first, but larger, are formed. In the centre of the circle, now only a few millimetres in diameter, a little brownish depression, deprived of its cuticle, and formed by the skin, on which rests the primitive ampulla, mortified, and forming a dry and very hard scar, and including the whole thickness of the skin. This continues enlarging, and fresh vesicles are formed around its margin. In from twenty-four to forty-eight hours the flesh on which the pustule rests swells, hardens, and forms a tumour more or less sensible, rarely deficient, and generally roundish, but sometimes oval, and of variable size; this he calls the tumeur charbonneuse, on the top of which, but rarely occupying its whole extent, is the pustule. That part not covered with vesicles is of a livid red, and spreading more or less on the neighbouring tegument. The middle part of the tumour is especially depressed, but the whole limb, head, trunk, or several of these parts, may simultaneously acquire an enormous size. As the pustule continues increasing, the redness spreads farther, and fresh vesicles are developed. At this time the parts, if touched, have, in many cases, a hardness equal to that of a schirrous breast, but gradually soften at a greater distance from the centre, become tremulous, and even oedematous. But Bourgeois says he has never noticed the emphysema mentioned by authors, and copied by one writer from another. The heat of the diseased part, at first very great, by degrees diminishes, till it becomes quite cold. On the limbs red tracks of inflamed superficial absorbents are constantly noticed. Before the parts in the neighbourhood of the tumour swell, there is most generally constitutional impregnation; the patient has lassitude, headach, the tongue is covered with a whitish coat more or less thick, the appetite diminisbes, the pulse is full, rather frequent and soft. More rarely these symptoms do not appear till the disease is accompanied with considerable swelling. If the disease be not arrested, the swelling extends more and more; the parts become enormously swollen, the phlyctaenae increase in number, and the scar in size, with scarcely any pain, but there is only weight and numbness of the affected parts. The general symptoms, however, become more formidable, the pulse small, quick, narrow, depressible and irregular; frequent vomiting of yellow or greenish bilious matter; violent thirst, faintings; singing in the ears; somnolence; urine scanty, red and brick-dusty; difficult motions, but at other times, and, very rarely, very fetid purging; the skin, at first hot and perspiring, becomes covered with cold clammy sweat; respiration more or less difficult; in tbe greater number of cases the intelli- gence remains undisturbed, but in some there is violent delirium. Subsequently the pulse ceases at the wrist, the body is covered with a cold sweat; the voice quenched; the skin becomes bluish; there is a sensation of burning heat within the body; unquenchable thirst; threatening suffocation; the patient cannot sit up; no urine; extreme anxiety, and finally death puts an end to this frightful condition, generally without pain. Bourgeois says, that he has never observed the dull delirium mentioned in books, and that, with the exception of one case in which the patient had evidently an affec- tion of the brain, all he saw were sensible to the last. Nor has he ever seen the enormous eschars attacking all the soft parts of a limb or spreading to a great extent, as mentioned by writers in general. Authors have usually divided the disease into four stages, without including that of the incubation of the disease: these, however, Bourgeois considers arbitrary, and thinks that there are only two distinct periods in the course of malignant pustule; (a) Memoire sur la Pustule Maligne, specialement sur celle qu'on observe dans la Beauce; in Archives Generates de Medecine, &c, Fourth Series, vol. i. pp. 172,334. 1843. 82 HOSPITAL GANGRENE. the first commences with the appearance of the primitive malignant spot, which he calls the local period or first period. The second, which he designates under the name of the period of impregnation or intoxication, commences with the nrst general symptoms and terminates only with death or cure." The course of the disease is very variable; it may terminate in two or three days or extend to the fourteenth. The first period is generally the shortest, but he has noticed it running on to the fifth day; the second varies from thirty-six hours to eight or nine days.] For the Literature of Malignant Pustule, see p. 112. 35. Hospital Gangrene (Gangrcena nosocomialis, Lat.; Hospitalbrand, Germ. ; Pourriture dVwpital, Fr.) consists of a peculiar decomposition of organic parts appearing under manifold forms. A wound or sore begins to be painful, the edges inflame, the suppuration becomes less and of a serous character. Some days after, on certain parts, or on the whole extent of the wound, appears a whitish, thin, semi-transparent membrane pretty firmly connected with its surface, which increases in thickness and extent, and gives the whole surface a grayish-white appearance. This mass cannot be removed, and, if it be attempted, only a part of the whole which is firmly connected with the wound, can be removed. The wound increases in all directions ; the edges become still more pain- ful, oedematous, and the oedema spreads. Sometimes hospital gangrene commences also with painfulness of the suppurating surface; but upon it are observed more or less deep cavities, the edges of which are dusky red, and covered with yellowish, white, consistent pus. These ulcerous spots increase and run together; a bloody ichorous fluid is secreted, and the surface of the sore increases in all directions. Lines of inflamed lymphatic vessels commonly stretch to the neighbouring glands. The destruction is often restricted to the cellular tissue ; but, in more decided cases, the muscles and all parts without distinction are destroyed. Bleeding often occurs from the destroyed vessels. The bones resist for a long while, but finally give way. With these local appearances there is always loss of appetite, pain in the region of the stomach, disposition to vomit, costiveness, loss of sleep, a quick and rather weak than strong pulse, hot skin, great anxiety, and restlessness. In the more severe form of the disease all the symptoms of typhus fever come on. These general symptoms often precede the local. The severity and course of this disease as well as its continuance vary in different persons. If it be long continued or often recur, hectic fever and exhausting purging at last set in. In some cases the hospital gangrene arises in form of a little inflamed pimple or vesicle, without any preceding injury to the part being perceptible (a). Hospital gangrene is quite different from the scrofulous complication of sores and wounds. [Liston (b) gives the following brief account of hospital gangrene, as it appeared in University College Hospital, in the year 1841. The case he mentions followed the removal of some metacarpal bones and fingers. " All at once, the stump, which had been healing kindly, assumed a carious appearance; it became enormously swollen within a few hours, and profuse haemorrhage took place, which there was considerable difficulty in stopping. This might have been, and was sure enough by some who saw it, taken for malignant disease; but it was exactly like what I had seen before in unhealthy seasons, and in badly-regulated hospitals. The season was a very severe one; there had been a great snow-storm, with very cold weather of (a) Thomson, as above, p. 460. (b) Lectures on the Operations of Surgery, &c, in Lancet (New Series,) vol. i. p. 57, HOSPITAL GANGRENE. 83 long duration. Not many days passed over before a number of wounds assumed the same appearance; the parts got puffy round about them, the discharge became slimy and tenacious, very putrid; and bloody fetid gas filled the cellular tissue around them. fThey extended rapidly, presenting a circular form. Many patients lost a considerable quantity of blood ; in fact, we were visited by a rather rare dis- ease, hospital gangrene, one which I trust I may never see again. Luckily, out of a good many patients who were so attacked, and in all parts of the hospital almost simultaneously, not one perished. Many of the wounds and ulcers were frightfully extended; but they speedily got clean, and healed soon afterwards very kindly. * * * After the separation of the sloughs, a circular clean granulating surface was left. We were at a loss to account for this invasion: there was nothing as regarded the hospital, its ventilation, or drainage, or management, the dressing of sores, &c, that could be blamed. The disease came upon us suddenly, and as suddenly dis- appeared; and I need not tell you that we have seen nothing of the kind since." My friend Arnott informs me that in January, 1835, in one of the female wards of Middlesex Hospital, three cases occurred which mightbe classed under the head of hospital gangrene, of which the following is a short account:— Case 1.—The disease attacked a common ulcer of the leg; the surface became black and pulpy, with a broad very red margin of integument, a raised edge, and great pain. From the size of half-a-crown, the disease extended and occupied, ere it was stopped, a space of a large wash-hand saucer, exposing the muscles and bone. It was arrested by the application of pure nitric acid, and the removal of the patient into another ward. Case 2.—The disease appeared on an ulcer by the side of the anus, presented the same character, but was arrested by balsam of Peru, locally, and a grain of opium every six hours, internally. The disease recurred, and the patient was removed from the hospital. Case 3.—A punctured wound of the chest did not heal, but that of the integument enlarged by the conversion of the tissue into a grayish pulpy substance, (not black, and without the fiery margin and intense pain of the other cases,) more like phage- dena. It was stopped by balsam of Peru. " I have never seen," he says, "a simi- lar case in the Middlesex Hospital before or since." I have mentioned the above cases of hospital gangrene, because they are, as far as I can ascertain, the only instances of the disease which have been seen in either of the London hospitals for many years. Cases occurred many years since in the old Westminster Hospital, and also in the York Hospital at Chelsea, which latter being a military establishment, the disease was believed to have been brought home by the sick and wounded soldiers from abroad. With these exceptions, I have the best grounds for stating that in no other hospital in London has it existed in the memory of either of the present surgeons; so that it is a disease entirely unknown to them, excepting to the few who have seen it elsewhere. Lawrence (a), speaking of sloughing phagedaena, observes "that these occur- rences generally take place in women of the town under the particular circumstances I have now stated; but it is by no means exclusively confined to cases in which the origin might be supposed to be venereal. I remember a very bad instance in this (St. Bartholomew's) hospital, in a case that was under the care of Dr. Latham, by whom I was requested to see it on account of the sloughing phagedaena. It was a young woman who had had the small-pox very badly. The disease had rendered her very weak, and diarrhoea came on. There was a considerable discharge from the vagina, and a constant moisture of the parts by a discharge from the rectum. Thus the skin of the nates became highly inflamed, and in fact a large excavation of sloughing phagedaena formed on each buttock, and she was reduced to a very low state by the disease. Dr. Latham asked me what I thought could be done; and, having examined her, I thought badly of the case, but that we might destroy the excavations in her buttocks, which were nearly as large as a good sized teacup, and possessing all the characters that I have mentioned. They were treated by nitric acid applied with lint wrapped round the end of a probe till the sore was saturated with it, and a brown eschar produced ; the surrounding parts having been previously well dried, to prevent the spreading of the acid beyond the sore. Port wine was liberally allowed her, and she got well. This was a cause of a common kind, in (a) Lectures, as above. 84 HOSPITAL GANGRENE. which you could not ascribe the effect to syphilitic disease. Now, as far as I can understand the affection called hospital gangrene, it is the same as the sloughing phagedaena I have now described." (p. 454.) I think there is little doubt that this was a case of hospital gangrene, and not of the so-called sloughing phagedaena. But it is difficult to make out whether Lawrence holds them as distinct or as the same disease; though probably the former, as, in speaking of " the treatment" of hospi- tal gangrene, specially, he says, it, " in other respects, is the same as I have men- tioned for sloughing phagedaena." (p. 455.) I cannot agree with Samuel Cooper, that the sloughing phagedaena, of which an account, founded on the cases to which Lawrence refers in his Lectures, is given by Welbank (a), "certainly resembles hospital gangrene," as described in books. The sloughing phagedaena was certainly an endemic supervening on venereal exco- riations or sores, and not hospital gangrene. I shall advert to it hereafter, in speak- ing of chancre, or venereal ulcers. The only cases that I have seen, with the slightest resemblance to hospital gan- grene, were the sloughy stumps now and then occurring, perhaps more frequently during those years, formerly, when our wards were much troubled with erysipelas. The operation would either seem to be going on favourably for two or three days, the patient comfortable, and adhesion in progress, when a sudden change would set in, the stump become painful, swollen, hard, and red, the un-united part become sloughy, and the united part falling asunder, and soon also becoming sloughy; or, the stump never making any attempt at union, but soon becoming painful, swollen, and sloughy. In either case, the patient himself hot, dry, flushed, with brown tongue, and foul alvine discharges, the pulse quick, irritable, delirium and death supervening. I said such cases occurred, perhaps, more frequently when erysipelas was rife; but they really do happen when no erysipelas is in the ward at the time, nor has been for many months, and they occur not unfrequently in primary amputa- tions in stout persons who have been accustomed to large quantities of beer or spirits, or of both, and from which they are not unfrequently entirely at once (and, as I con- sider, improperly) debarred; and hence, with a greater call than usual upon the powers of the constitution, are left to meet it with diminished means. Such cases are to be considered merely as resulting from want of power; but they are never epidemic or contagious, and must not be confounded with, hospital gangrene, which, however frequent it may be elsewhere, is, in London, at the present time, and has been for years, unknown by personal experience to most hospital surgeons.— 36. The characteristic of hospital gangrene is its quick extension and the decomposition of the tissues without any special residue ; if the gray- ish-white mass in certain cases be not so considered. Hospital gangrene is an extension of a wound or of a sore intermediate between ulceration and mortification. 37. The cause of hospital gangrene is the operation of a peculiar con- tagious matter, either upon wounds and the ulcerated parts or upon the whole body. The contagion develops itself usually in hospitals, where the air is deteriorated, many patients huddled together, and the bandages not kept clean ; specially in unhealthy places, as jails and so on. We know not how long the contagious matter may retain its activity. Pro- bably the constitution of the atmosphere, the weather and climate influ- ence the development and character of hospital gangrene. The suscep- tibility to contagion is not diminished by its having once been acted upon; on the contrary, it seems to have increased. The contact of the conta- gious matter with the wound is either the consequence of want of care in dressing it, its long exposure to the action of the air infected with con- tagion, or its having been covered with bandages in which the poison is retained. The contagion may happen to every person, and in every kind of wound and ulcer: it rarely, however, alters specific ulcers, (a) Medico Chirurg. Trans., vol. xi. 1821. DIVISION OF INFLAMMATION. 85 whilst, on the contrary, a bilious constitution, mental affections, great feebleness, typhus fever, appear to be most favourable to it. The cha- racter of the disease itself may be changed by the constitution of the pa- tient, and by the state of the weather; it may even become inflammatory, in which case the wound is encircled with a red ring, the pain is severe and throbbing, the pulse quick and hard, and the bleeding which occurs produces relief. Hospital gangrene is always a very dangerous compli- cation of wounds and sores. Accidental circumstances may render the danger still greater; for instance, if it be impossible to give the patient attacked with the disease better air and better nursing, and so on. Left alone, hospital gangrene is usually fatal. If it have proceeded to a cer- tain extent, art is rarely of any avail. For the Literature of Hospital Gangrene, see p. 114. 38. After the appearances and terminations of inflammation, which have been described in general terms, we now come to those variations which inflammation may offer to our notice. The existence of inflammation depends always on unnaturally raised vital processes : manifold circumstances, however, may change the ap- pearances and course of inflammation, and these changes are only to be considered as modifications of simple inflammation : and the more so, the less they correspond to what we understand by increased vital action. The inflammation may be classed, 1st, according to its appearances and course; 2d, according to its causes; 3d, according to the structure of the parts attacked. 39. If the inflammation make its appearance with a certain intensity of its symptoms, and proceed rapidly, it is called acute; but, contrari- wise, chronic, when the intensity of the symptoms is slight and their duration protracted, which condition may be either primitive or conse- cutive, depending on the constitutional condition. In regard to its cha- racter, inflammation is farther divided into simple, erethitic, torpid, malig- nant, and obscure. In simple inflammation all the symptoms of inflam- mation are present in a corresponding degree ; it runs a speedy and most commonly satisfactory course ; it is almost peculiar to strong persons, who have good health ; its termination, if not resolution, is generally suppuration. The erethitic and torpid character of inflammation are merely modifications according to the constitution of the patient and the degree of the inflammation. In the erethitic inflammation the symptoms have not the same degree of severity as in simple inflammation; the sensibility is, however, distinctly increased, and it therefore especially appears in persons of delicate constitution. The torpid inflammation has a remarkably tedious course, and its symptoms seem to depend rather upon a local obstruction of the circulation in the capillary-vascular system than upon an accelerated vital activity ; all the signs of active congestion are wanting, the part is not bright red, but dusky and biownish. It occurs specially in weak, reduced, cachectic subjects. Simple inflam- mation may also, under improper treatment, assume a torpid character. Malignant inflammation (Infiammatio maligna, gangrcenosa) is often pain- less, or accompanied by an obtuse, heavy pain and dusky redness : its cause is sometimes manifest as the effect of deleterious or contagious matter ; at other times, it is unknown : it supervenes on typhus and pu- Vol. i.—8 86 INFLAMMATION OF SKIN, CELLULAR TISSUE, GLANDS. trid fevers, and usually runs into gangrene. Obscure inflammation (In- flammatio occulta, clandestina) is that which is little or not at all indicated by symptoms. 40. Inflammation is divided, according to its different causes, into idiopathic, symptomatic, specific, and sympathetic. Idiopathic inflamma- tion is the consequence of external violence ; it exists as a local disease, and its severity is regulated by the degree of the injury and the condi- tion of the subject*. Symptomatic inflammation, at least the definite form under which it first appears, depends on internal causes, and the inflam- mation itself is to be considered only as a reflection of the general disease. If this be of a specific nature, as syphilis and so on, the inflammation is said to be specific. Sympathetic inflammation is the consequence of a consensual change in the mutual relations which one part holds to another by which their diseased affections become shared by both. The metas- tatic inflammation which passes from one organ to another is in close con- nexion with the sympathetic. Symptomatic inflammation is either the original symptom of general disease, or an originally idiopathic inflammation acquires, through the general disease, a defi- nite character. 41. In whatever part inflammation may occur, its peculiar seat is always in the capillary-vascular system. But its symptoms vary accord- ing to the different conditions of the affected part. Inflammation of the Skin, if not severe, terminates in resolution with scaling of the cuticle, and not unfrequently also with dropsical swelling. In a more active inflammation a fluid is poured out beneath the cuticle, producing vesications and pustules. If the inflammation be tedious with- out being active, the cuticle is destroyed; the fluid poured out by the exposed vascular net thickens into crusts. If the inflammation extend to the subjacent cellular tissue, it is generally severe and runs into sup- puration. Inflammation of the Cellular tissue is usually accompanied with much ill-defined redness, with firm elastic swelling, much tension and throb- bing pain ; it does not resolve except it be in a mild form ; its usual ter- mination is suppuration, not unfrequently gangrenous destruction of the cellular tissue. [This important affection of the cellular tissue, which has only within the last twenty years been particularly noticed, though commonly spoken of under the com- mon title of erysipelas, is described more at length by our author, at page 103, "as a metastatic deposit in the cellular tissue, and one of the causes of his Erythema symptomaticum seu consensuale. Doubtless, it may be, and occasionally is, metas- tatic ; but, generally it is idiopathic. It has of late years become common, and is a very rapid and dangerous disease, unless early and properly treated. Its impor- tance is so great, that it is as fully entitled to a proper chapter as erysipelas, from which it most decidedly differs. But it will be, perhaps, more convenient to insert what I have to add where the subject comes under consideration in our author's arrange- ment, rather than to remove and drag his paragraphs into places for which he had not intended them, under pretence of making his meaning more clear, as if the au- thor did not best understand his own view of the subject he discusses; a proceeding which has been occasionally practised in English translations, which I think cannot be too much deprecated, and the least inconvenience of which is, that it is not un- frequently impossible to refer from the original to the translation, or from the translation to the original.—J. F. S.] Inflammation of the Glands mostly exhibits not very acute but father MUCOUS AND SEROUS MEMBRANES. 87 dull pain, no great heat, very solid circumscribed swelling, which also extends itself into the surrounding parts. Its termination is similar to that of inflammation in the cellular tissue, except that glandular inflam- mation most commonly assumes a chronic character, and then easily passes into hardening. In inflammation of the Mucous Membranes, their secretion is stopped at the onset; at the same time, increased warmth and sensibility, heavy pain and great redness make their appearance, a secretion of thin some- what acrid fluid, the thickness of which increases, becomes creamy, and of perfectly mild character. No tissue so readily as the mucous mem- brane acquires a morbid disposition to inflammation. When affected with long-continued inflammation their spongy cellular tissue becomes loosened, swelled, thickened, and the vegetation on it often is so changed that new formations, polypous excrescences, are developed. In active inflammation, or in long-continued flow of mucus, ulceration and destruc- tion of the underlying parts frequently occur. Very rarely do inflamed mucous membranes become adherent. [In reference to the kind of inflammation which occurs in mucous membranes, Hunter says :—"In internal canals, (I make a difference between an internal cavity and a canal; they are very different in their construction, their uses, and also their mode of action in disease are very different,) where adhesions in most cases would prove hurtful, the parts run immediately into the suppurative inflammation, the ad- hesive inflammation in common being excluded; such parts are the internal surface of the eyelids, nose, mouth, trachea, air-cells of the lungs, oesophagus, stomach, intestines, pelvis of the kidneys, ureters, bladder, urethra, uterus, vagina, and in- deed all tbe ducts and outlets of the organs of secretion, which all these parts men- tioned may be in some degree reckoned, and which are commonly called mucous mem- branes. In such parts, if the inflammation is but slight, the suppurative in common takes place, which is almost immediate, as it is not retarded by the adhesive stage, which accounts for the quickness of suppuration of these parts in many cases. * * * Since those surfaces are, in general, secreting surfaces, suppuration would appear to be only a change in the secretion; and I think I have visibly seen, or could visi- bly trace, the one change gradually leading into the other; the different parts, there- fore, of which the pus is composed, will not always be in the same proportion, so that the matter will seem to vary from true matter towards that of the common secre- tion of the part, and vice versa ,- but this does not alter the position, for it is common to matter from a sore, and even common to our ordinary secretions. If this inflam- mation which produced suppuration on these surfaces becomes more violent, or has something of the erysipelatous disposition, we find that it moves from the suppura- tive to the adhesive, and throws out the coagulating lymph." (p. 241, 2.)] The Serous Membranes have great disposition to inflame; the inflam- mation is very painful, usually appears suddenly, spreads quickly, and easily passes into resolution, adhesion, transudation, and mortification, but rarely into ulceration. Serous membranes often thicken, either by the cellular tissue upon their external surface or by plastic membranes, or evem in their own proper substance. Chronic inflammation of serous membranes appears mostly in the form of dropsical affections. [Serous membranes are the circumscribed cavities which, with "the cellular membrane or the body in general," belong to the first order of parts into which the body is divided by Hunter, and in relation to which he observes:—"When in- flammation takes place in the first order of parts, it is commonly the adhesive; but it will be according to circumstances whether the suppurative or the ulcerative follows first." (p. 253.) " The adhesive inflammation serves as a check to the sup- purative, by making parts which otherwise must infallibly fall into that state, pre- viously unite, in order to prevent its access, as was described in the adhesive inflam- mation being limited; and, where it cannot produce this effect so as altogether to 88 INFLAMMATION OF FIBROUS TISSUES, ARTERIES. hinder the suppurative inflammation itself from taking place, it becomes, in most cases, a check upon the extent of it" (p. 365;) of which inflammations of the pleura, or surface of the lungs, presents a good example; " the adhesive inflammation takes place, and the surfaces are united, which union going before the suppurative confines it to certain limits, so that distinct abscesses are formed in this union ol the parts; and the whole cavity of the thorax is not involved in a general suppuration, (p. 36G0 f AV. The peculiar disposition of serous membranes to assume in preference adhesive inflammation is remarkably contrasted with the equally special preference of mucous membranes for the suppurative inflammation. The construction of closed cavities by the serous, and of canals by the mucous membranes, afford the ready explanation of these peculiarities. Any opening, therefore, in a serous membrane puts it in an unnatural condition, and, consequently, if it were attacked with suppurative inflam- mation, the pus produced requiring an aperture for its escape, such unnatural state would be induced, and the functions of the membrane interfered with or destroyed: therefore, most commonly, adhesive is the kind of inflammation occurring, which only diminishes the cavity (the lesser evil) without opening it; and when, more rarely, suppurative inflammation ensues, it is most usually shut off from the general cavity by adhesive inflammation, as in spurious empyema; and only in few cases existing without such adhesion. Whilst, on the contrary, were mucous canals at- tacked with adhesive inflammation, they would be at once blocked up and the most dangerous consequences ensue, as occasionally observed in croup, and so on; but they prefer suppurative inflammation, and no such danger accrues.—J. F. S. The inflammation of serous membranes sometimes runs on to suppuration. This was noticed by Hunter, who observes:—"In spontaneous suppurations, one, two, three, or more parts of the inflammation lose the power of resolution, and assume exactly the same disposition with those of an exposed surface, or a surface in con- tact with an extraneous body. If it is in the cellular membrane that this disposi- tion takes place, or in the investing membranes of circumscribed cavities, their ves- sels now begin to alter their disposition and mode of action, and continue changing till they gradually form themselves to that state which fits them to form pus. * * * From hence it must appear that suppuration takes place upon those surfaces without a breach of solids or dissolution of parts, a circumstance not commonly allowed; and, when got beyond the adhesive state, they become similar in their suppuration to tbe inner surfaces of internal canals." (p. 378.)] In inflammation of the Fibrous Tissues the pain is sometimes very severe, sometimes changeable,deep-seated, increased less by pressure than by the motions of the part, the warmth is much increased, the swelling, according to the difference in structure of the neighbouring parts, some- times hard, sometimes soft, the redness slight, often scarcely discernible, but often far outspread. Its terminations are resolution, metathesis, gouty concretions, gangrene, and suppuration, which is confined to the cellular tissue connecting the fibres together, whereby a laminated arrangement is produced. Inflammation of the coats of Arteries (1) is either generally diffused, with violent pulsation of the heart and arteries and high fever ; or it is confined to one spot, when the symptoms are commonly obscure. The acute partial inflammation of arteries commonly runs into adhesion ; the chronic, which mostly depends on diseases with little power, into1 thick- ening, loosening, ulceration, deposition of calcareous masses, whence (2) commonly results the origin of aneurisms. [(1) Arteritis, as it is now generally called, is, probably, if idiopathic, an inflam- mation of the internal only, and not of all the coats of an artery, but, if traumatic, arising either from wound, from ligature, or more extensive pressure and the like, or it the inflammation have been communicated to the artery from neighbouring dis- eased parts then all the coats of the vessel become affected, and may pass through the various forms of inflammation. "The active and violent pulsations," says ARTERITIS. 89 BoUlLLAUD (a), which the arteries in the neighbourhood of a very acute whitlow perform are the type of those which characterize general arterial irritation. And he also observes, that there is besides the increased force of the arterial pulsations, a sensation of heat and uneasiness in the region which the inflamed artery occupies." (p. 411.) Redness, thickening and friability are the appearances described as presented by the internal coat of an artery under acute inflammation; the redness and thickening from swelling of the membrane occurring simultaneously. Hodgson (b) describes four cases, in the first of which the internal coat of the aorta was of deep red colour; a great effusion of lymph had taken place into its . cavity, and become very intimately connected with the internal coat, and a plug of the lymph extending into the left subclavian artery nearly obliterated its cavity: these appearances accompanied a violent pneumonia. In three cases, viz. of carditis, pneumonia and bronchitis, he also saw it, but the effusion of lymph was less; in one case the aorta was throughout of a deep scarlet colour, and a little above the semilunar valves the coats of the aorta were distended with lymph, (p. 5.) He also quotes from Portal (c) a case of sudden subsidence of measles, in which "the aorta was throughout nearly its whole extent very red, and its walls swollen and soft, especially in the thoracic region, near the diaphragm, where it was covexad with varicose vessels ; the internal coat was swollen and softened." (p. 127.) ft. mist, cujus capiantur each. magn. bis. terve indies; or, should that fail, Jfc pulv. lytt. gr.}, tereb. chise gr. v. pro pil. bis terve quotid. sumend. As to local treatment, he employed bougies, either simply smeared with oil, or with ung. hydr. mitius, or ung. hydr. nitr. oxyd. The latter first in proportion of a scruple of the salt to an ounce, and gradually increased in strength; using at the same time injections, "from which there would be no danger of stricture, as the bougie would prevent it." The injection he preferred was hydrarg. bichlorid.. gr.lA, aq. 3 i ij -, and gradu- ally increased up to half a grain to an ounce, (p. 27-2.) A generous diet is necessary in cases where the gleet continues, and not unfre- quently it is found advantageous for the patient to take wine. Balsam of copaiva, either in mixture or in capsules, is often very serviceable in addition to injections, of which I prefer that of nitrate of silver. When the gleet continues very obsti- nate, there is reason to suppose, as stated by Hunter, that stricture exists, and it is then necessary to use the bougie. Ricord mentions that " inoculation of a new gonorrhoea has been advised, and is still perpetrated by many practitioners, either to cure a chronic discharge, or to com- bat, by revulsion, symptoms which gonorrhoea may produce, such as epididymitis, ophthalmia, &c. Some, in this case, are content with advising a new infecting coition; others make a kind of inoculation with the muco-pus of gonorrhoea, carried on a probe into the urethra, or applied to the mucous membrane it is wished to infect, by means of a bit of lint which is impregnated with it. * * * However, were I not convinced that the cases in which it is useful to recall an old discharge, (a) Clinical Lecture on Gleet; in Lancet, 1821, vol. ii. 196 TREATMENT OF GONORRHOEA J or develop a new one, are as rare as some persons think them frequent, and that they have either aggravated the disease they wish to combat, or given it a new complica- tion, I would not apply the muco-pus of a gonorrhoea of one individual to another before having ascertained, upon the one from whom it is taken, that it produces nothino-when inoculated with the lancet; otherwise, without this precaution, a patienf with gonorrhceal symptoms might be affected with masked chancres, (chan- cres larves) and communicate to an individual, who till then had only a simple catarrhal affection, without further consequences, all the formidable chances of syphilis." (p. 89; Fr. edit., pp. 188, 9.) I have noticed these proposals for the cure of obstinate gleet, or other conse- quence of gonorrhoea, merely to point out their absurdity; as I presume no one, excepting those whose treatment of disease is founded on the similia similibus, eadern iisdem principle, could seriously think of adopting them. The moral con- duct involved in the attempt to acquire a new gonorrhoea to put an end to an old one, is about on a par with that of commerce with an uninfected person for the same purpose, (a vulgar notion which was formerly held,) and the benefit from either alike.—J. F. S.] 167. The mode of treating gonorrhoea already mentioned is founded upon the various degrees and nature of this complaint. Of late cubebs have been recommended by many practitioners as the most effectual re- medy against it, and, according to my own experience, I must accede ' to the good report of it given by others, and especially by Delpech.— This remedy operates upon the gonorrhoea not merely, as many suppose, when the inflammatory period has passed over, but it performs its good offices in every stage of the disease. The principal point in the use of cubebs is, that they should be genuine, and given in sufficiently strong doses. With small doses of cubebs the gonorrhoea is commonly in- creased. At the onset, at least half an ounce a-day should be given, which should be much increased if no special symptoms ensue. In many cases Delpech gave four doses daily of two or three drachms each with- out producing any peculiar symptoms; it is, however, better to divide the doses and give them more frequently. If required to act briskly and for some time, it is most advisable to give a dose every three or four hours, and meal times should be regulated accordingly, or a dose taken even during the night. The usual consequence of this remedy is a gentle warmth in the belly, not always accompanied by an increase of thirst, which generally ceases in a few days, even when the dose of cubebs is increased. If therefore this symptom pass by, it is not neces- sary to discontinue the remedy ; but, if it continue, and pain in the belly be produced, the doses must be diminished to two or three ; it may then do good, bnt its operation on the disease is more tedious. In many cases the remedy produces frequent, thin stools with or without pain in the belly, very rarely accompanied with tenesmus, but never with discharge of bloody mucus. In such cases the remedy must be withheld, solid food forbidden for some days, mucilaginous drinks taken, and then the medicine resumed in the same doses as before, or in smaller ones. Fre- quently this symptom is the consequence of gastric irritation, which may be relieved by an emetic, and then the earlier or stronger doses may be used. Some persons bear this remedy only when given at meal-time; or when food is taken with it. In many cases where it cannot be endured, balsam of copaiva, according to Delpech's experience, is useful; but, when that causes purging, cubebs must be employed. Frequently do the cubebs produce no satisfactory alteration ; but in no instance is the WITH CUBEBS. 197 disease thereby rendered worse. In recent gonorrhoea the burning, the heat, the not very severe pain, and the discharge soon diminish, the lat- ter become serous, and in two or three days the whole has passed off.— The same occurs with the slighter claps, even when they are of longer standing. Three doses daily of two drachms each are sufficient in these cases. More severe gonorrhoea in the second or third week, with severe pain, chordee, and so on, yield less easily and only to larger doses. Improvement also takes place very rapidly ; the chordee frequently con- tinues longest, but often subsides after a blister, when every thing else fails. Also in those cases in which the inflammation has extended to the neck of the bladder accompanied with discharge mixed with blood, with severe inflammation, with swelling of the prostate glands, if the pain was exceedingly severe, and in swelling of the testicle, this re- medy was very efficient. Old and painless swellings of the testicle re- maining after acute affection, which were connected with symptoms of general infection,and had even withstood antisyphilitic treatment, yielded to the use of the cubebs, even although general syphilitic disease conti- nued. The same occurred in the swellings of the vaginal glands, if depending on gonorrhoea. During the use of cubebs a mild diet and rest must be observed. The remedies must be continued for at least eight days after all symptoms have disappeared. Delpech has disproved by numerous observations that cubebs can produce in- flammation of the testicles, as by some supposed. Previous to using cubebs Del- pech had given balsam of copaiva in large doses in all stages of gonorrhoea with good effect. Both remedies, according to recent observations, contain an analogous substance. Perhaps the inefficiency of cubebs, when properly administered, may prove the peculiar syphilitic nature of the gonorrhoea. In order to prevent the gene- ral infection, Delpech, when the gonorrhceal inflammation is not too great, uses at the same time twelve to fifteen rubbings-in of half a drachm of mercurial ointment night and morning on both sides of the penis. Velpeau (a) employs cubebs and balsam of copaiva in clysters; two, four, six, or eight drachms rubbed down with yolk of egg or with decoction of marsh- mallows. Michaelis (6) has tried cubebs on many patients who were suffering from gonor- rhoea, and only in one single case, in which gleet had existed for a short time, did he observe a cure. Just as inefficient did he find it in the whites and in chronic catarrh of the lungs. Richon and De Salle have given, as they assert, with great effect, thirty drops of tincture of iodine night and morning in gonorrhoea. In some cases, leeches were first applied to the urethra, and an antiphlogistic diet coupled with it. [Astley Cooper was a great advocate for the use of cubebs. He said it "ap- pears to produce a specific, inflammation of its own on the urethra, which has the effect of superseding the gonorrhceal inflammation. * * * In the very early stages of gonorrhoea, when the inflammation is just beginning, it often succeeds in removing the disease in a very short space of time." But he observes :—" I do not say that it would be advisable to employ this remedy at once for a first gonor- rhoea, where the symptoms of inflammation run very high in a young and irritable person; it is better not to begin with the use of it until a week or ten days have elapsed, and the inflammation is considerably reduced." He thinks it "a most useful remedy also for the cure of gleet, as it is called, where gonorrhoea has con- tinued for a length of time." And also that" the greatest advantage may be derived from combining its use with that of copaiba, when the balsam alone is beginning to lose its effect," and he gives it as a mixture, viz., "An ounce of the balsam of copaiba, an ounce of the mucilage of acacia, two drachms of cubebs, in four ounces of camphor mixture." (pp. 146, 7.) (a) Archives Generates de Medicine, Jan. 1827, (b) Journal of Graefe und Walther, vol. v. p. 70. 17* 193 OF EXTERNAL For my own part, I may state that I have used cubebs very freely in all stages of clap and gleet, but not with the advantage attributed to it. I do not think it supe- rior to other of the usual treatments, and it often produces much annoyance from loading the stomach. If used, I think it is better to employ it in the shape of ex- tract, as pills, in which form, also, copaiba is prepared, and may be used in like manner. But the more common mode now of exhibiting copaiba in private prac- tice is in little capsul es of caoutchouc. Some years ago, we were in the habit of using at St. Thomas's Hospital, the following copaiba mixture, which was very efficacious, and had the advantage of rarely disagreeing with the stomach, a matter of much consequence if the medicine be long persisted in:—fy bals. copaib. spir. aether, nitr. aa irjjxl., Und. hyoscyum., liq. potass, aa rrjjxx., ex. aqua ter die sumend. If necessary to increase the quantity of the balsam, a proportionate quantity of mucilage is added.—J. F. S.] On the use of cubebs, or Java pepper, see Crawford, J., on the Effects of the Piper Cubeba in curing Gonorrhoea; in Edinb. Med. and Surg. Journal, Jan., 1818, p. 32. Adams, J., A short Account of Cubebs as a Remedy for Gonorrhoea. lb., Jan., 1819, p. 61. Jeffreys, Henry, Practical Observations on the Use of Cubebs, or Java Pepper, in the Cure of Gonorrhoea. London, 1821. 8vo. Makly, M., in London Medical and Physical Journal. 1821, June. Brqughton, S. D., in Medico-Chirurg. Trans., vol. xii. p. 100. Delpech, Memoire sur l'Emploi du Piper Cubeba dans le Traitement de la Gonorrhee ; en Revue Medicale, May, 1822, p. 1 ; June, 1822, p. 129. Heyfelder, fiber die Anwendung des Bals. Copaivae und des Piper Cubeba; in Heidelberg. Med. Annalen, vol. iii. part iv. Hacker, fiber der Copaiva-Balsam beim Tripper; in Summarium der Med., vol. viii. part i. 1839. 168. External Gonorrhoea (Gonorrhoea Glandis, Balanitis, Posthitis, Lat.; Eicheltripper, Germ.; Blennorrhagie externe, Fr.) is either a mere consequence of want of cleanliness, in which case the sebaceous matter secreted by the odoriferous glands collects and becomes acrid ; hence it particularly occurs with a lengthened narrow prepuce, or is consequent on syphilitic infection. The latter may always be guessed at when it follows suspicious connexion, is connected with excoriation, and is ob- stinate. [Hunter believes, that, "when the disease attacks the glans and other external parts, as the prepuce, it is principally in those persons whose glans is commonly covered with the prepuce, and it is principally about the root of that body and at the beginning of the prepuce, the parts where the cuticle is thinnest, and of course where the poison gets most readily to the cutis ; but, sometimes, it extends over all the glans and also the whole external surface of the prepuce. It produces there a soreness or tenderness, with a secretion of thin matter commonly without either excoriation or ulceration. I am not certain, however, that it does not sometimes excoriate those parts ; for I once saw a case where the whole cuticle came off the glans." (p. 44.) I have seen this condition not at all unfrequently; it is quite distinet from any syphilitic affection. Excoriation with little or no discharge often happens to young persons, even children, simply from the acridity of the secretion of the odoriferous glands ; and I have seen it produce violent inflammation and swelling of the prepuce, and threatening mortification. It frequently recurs and is very troublesome.—J. F. S.] In Gonorrhoea of the Glans which is not syphilitic the observation of great cleanliness,'frequent washing of the glans with tepid milk, lead wash, and so on, are sufficient for the cure. In the syphilitic form, mer- cury must be used both externally and internally. [The simple treatment recommended by Chelius is generally quite sufficient; mercury is never needed. " When the glans can be uncovered and the inflammation is not excessive," Ricord says, the method he has " found best succeed, is passing INFLAMMATION OF THE TESTICLE. 199 the pencil of nitrate of silver gently over the diseased surfaces, so as to cauterize them superficially, after which it is sufficient to put a bit of dry lint round the glans and draw the prepuce over again. Lotions of lead wash or cold water are to be ap- plied over," p. 331;—Fr. ed., p. 669.) This is very good practice, but I commonly use only a little black wash.—J. F. S.] [169*. Gonorrhoea of the nose sometimes occurs during gonorrhoea of the urethra, or whilst there is an enlargement of the testicle from the same cause. The Schneiderian membrane is tender over its whole surface, but not painful; is of a deep red colour, but not ulcerated ; and there is a free discharge similar to that of clap. This disease was first noticed by Benjamin Bell, and he mentions two cases of it: in the first, " the discharge from the urethra lessened before the testes became inflamed, and on this taking place from the nose, itceased entirely." It was treated with an astringent lotion and the insertion of sponge moistened in it up the nose, and cured in a few days. In the second case, " the discharge took place during the continuance, and had existed many years, and, although it had frequently become less, it never disappeared entirely." Various attempts at its cure were made with- out success, " and, though no other symptom appeared, he was advised to undergo a course of mercury; but no advantage ensued." (pp. 29, 30.)—J. F. S.] 169. In the treatment of Gonorrhoea, of which the ground is a gouty or herpetic disease, and so on, that given for the non-syphilitic gonor- rhoea is suitable; but in these cases the inflammation is usually long- continued, even when the disease has run into a chronic form. Then especially must be employed purging, warm bathing, preparations of sulphur, antimony, and so on. V.—OF INFLAMMATION OF THE TESTICLE. 170. Inflammation of the Testicle (Inflammatio Testiculi, Orchitis, Hernia humoralis, Lat.: Hodenentzwidung, Germ.) may be produced by different causes. [" In some instances," as observed by Benjamin Bell, and it might be added, specially during or after gonorrhoea, "both testicles swell. They seldom, however, swell both at once ; but the swelling, on leaving one testicle, is very apt to go to the other; and when both have, in this manner, been affected, they sometimes swell alternately for a considerable time together. I have known this happen for the space of a year and upwards, where the patient, during the whole period, was never com- pletely free of the disease." (p. 337.)] First. It occurs most frequently in gonorrhoea, either with a very high degree of inflammation, with dragging pains in the belly and pelvis if the patient move about much, and the testicles be supported ; in which case, the inflammation extending to the testicles, first attacks the epi- didymis, and next the whole gland; or it confines itself merely to the former (Epididymitis;) or it may be produced when the inflammatory symptoms have declined, by any irritation of the testicle, violent ex- ercise, for instance. [Hunter remarks very justly, of the singularity of swelling of the testicle not coming on " when the inflammation of the urethra is at its height; he thinks it happens when the irritation is going off, and sometimes even after it has entirely ceased, and when the patient conceives himself to be quite well." (p. 60.)] Second. It may be a symptom of general syphilis. [Even Hunter says :—" I believe the swelling of the testicle, like the affection 200 INFLAMMATION OF THE TESTICLE. of the bladder, and many of the symptoms mentioned before, is only sympathetical, and not to be reckoned venereal; because the same symptoms follow every kind of irritation on the urethra, whether produced by strictures, injections, or bougies. It may be observed here, that those symptoms are not similar to the actions arising from the application of the true venereal matter, whether by absorption or otherwise; for they seldom or ever suppurate, and when suppuration happens, the matter pro- duced is not venereal." (p. 57.) Astley Cooper holds with Chelius's opinion. He says :—" I have seen this organ, (the testicle) so frequently enlarged during the existence of secondary symp- toms of syphilis, more especially in combination with a cutaneous and periosteal venereal affection—and have observed it additionally swollen and painful in the evening, although relieved by the recumbent posture in bed—and known it yield so easily and readily to the influence of mercury, and just in proportion to the dis- appearance of the venereal symptoms, that I think it quite unreasonable to doubt its liability to be affected by the venereal poison. * * * The testicle and epididymis become four or five times their natural size. The pain which accompanies the disease is not severe, but it is increased towards evening. When one testicle is enlarged, the other is apt to become affected; and I think, in the majority of cases, that the disease exists in both testicles. * * * It is rarely a concomitant of the syphilitic sore throat only ; but it frequently accompanies the venereal eruption and periosteal inflammation. The distinguishing mark of this disease from the simple chronic enlargement of the testicle, will be found in its succeeding syphilitic symp- toms, and often in its being combined with those I have mentioned, as well as in its obeying the law of syphilis, viz., of its being liable to an evening exacerbation. (pp. 102-4.) I am sure I have seen such enlargements of the testicle combined with syphilis, and that their best mode of treatment is similar to that for iritis. * * * I feel assured that the testicle becomes affected during the progress and in- fluence of the syphilitic poison upon the body, in some persons; and that mercury, Whilst it subdues the other symptoms, is also the only cure for this disease." (p. 110.) Eight cases are given by Cooper in support of his opinion of the syphilitic character of this enlargement. Ricord also agrees with Cooper: he says:— " Syphilitic sarcocele must not be confounded with gonorrhceal epididymis; * * * it is seldom found as a sole sign of a secondary affection, but is commonly preceded or accompanied by other symptoms of general infection; it frequently attacks only one testicle at a time. * * * The disease is frequently accompanied or preceded by nocturnal pains in the loins. The induration may have its seat in the epididymis or the cord ; but it is the substance of the testicle which is almost invariably affected. Syphilitic sarcocele may often be complicated, which renders the diagnosis very obscure." (p. 303; Fr. edit., p. 640.) Notwithstanding these high authorities, I must confess I have great doubt as to the swelling of the testicle depending on a syphilitic cause.—J. F. S.] Third. It may be produced from external injury. Fourth. From cold especially in persons who sweat much, on the perinaeum, and on the insides of the thighs. Fifth. Violent exertions may produce increased congestion of blood to the testicle and, its return being impeded, may excite inflammation. [Hunter says he has "known the gout produce a swelling in the testicle, of the inflammatory kind, and therefore similar to the sympathetic swelling from a venereal (gonorrhceal—j. f. s.) cause, having many of its characteristics." p. 60. Astley Cooper mentions enlargement of the prostate gland in old age, as occa- sionally accompanied with swelling of the testicle; also inflammation of the neck of the bladder; a stone passing through the ureter, or pressing upon the commence- ment of the urethra from the bladder. This latter circumstance I have seen two or three times. Another cause of mild, but sometimes severe, though easily manageable, inflam- mation of the testicle, is that arising from congestion of semen in the seminal tubes; which is of very frequent occurrence in lads soon after puberty. First one testicle is attacked with swelling, tenderness, and pain, which speedily subsides on taking a purge, and keeping quiet for a few days; but, in the course of four or five weeks, the other testicle is, in like manner, attacked. And when it gets well, the first CONSEQUENCES. 201 affected is again attacked. This will go on for three or four years, to the patient's great inconvenience; but no danger is to be apprehended from it.—J. F. S.] 171. The inflammation of the testicle generally soon becomes acute. The testicle swells considerably, and the swelling is further increased by exudation into the cavity of the vaginal tunic ; the skin of the purse is ex- panded, reddened, and very painful, not unfrequently accompanied with fever, pain in the belly, disposition to vomit, with great weariness (1). The usual termination of this inflammation is resolution (2). Dropsy of the vaginal tunic often remains if the inflammation be improperly treated, or if it continue in a less degree for a long time (3). Suppuration is to be feared if in active inflammation the pain be throb- bing. The skin then rises and thins at different parts ; it bursts, the pus is discharged, and oftentimes the convoluted vessels of the testicle pro- ject from the opening of the abscess, like grayish-white flocculent bodies, which draw out when pulled, so that in the end the albugineous tunic remains empty (4). Hardening is, on account of the peculiar condition of the testicle, no uncommon termination, specially if the treatment have not been exactly suitable, and scrofulous or gouty disposition be superadded. The bulk of the testicle is often distinctly increased by the hardening. Sometimes it confines itself merely to the epididymis, sometimes ihe whole testicle, and even a large or small part of the spermatic cord, is hardened (5). Gangrene is a very rare termination, and only from improper treat- ment. [(1) Astley Cooper observes:—"The first symptom of this disease, when it arises from sympathy with the urethra, is an irritation of the membranous or pros- tatic portion of their canal, as if some drops of urine still remained in the beginning of the urethra, and this is succeeded by a tenderness in the spermatic cord at the abdominal ring, and by swelling and pain in the epididymis. The testicle next swells. * * * The pain is obtuse, and more difficult to bear than that which is more acute, and it resembles the suffering which is produced by squeezing the testicle; and, indeed arises from the same cause, for the glandular structure of the testis swells, whilst the tunica albuginea, being tendinous and consequently inelastic, does not yield to the swelling from within, but resists its increase and presses upon the sensitive internal structure of the testicle, producing the dull, heavy, and aching pain of which the patient complains. The pain and swelling extend along the spermatic cord into the inguinal canal, producing great uneasiness in the groin and in the spinous process of the ilium, the hip, and the inner part of the thigh on the affected side, and at length fixes itself more particularly in the loin; and this arises from the renal and lumbar spermatic nerves having their principal origin from the renal and lumbar nerves. * * * The epididymis swells more in proportion than the testis, owing to its covering being less compact, and it remains longer swollen. Its two extremities, i. e. the globus major and minor are more affected than its body, and the swelling of the former is generally very perceptible before the spermatic cord." (pp. H-10.) Sometimes, though not very frequently, for I have never observed it,) inflamma- tion of the testicle, consequent on gonorrhoea, is immediately preceded by great irritation of the brain, which subsides on, or soon after, the appearance of the swell- ing. I am indebted to my intelligent friend Sams, of Lee, for the following. Case.—A. B., a«jed 19 years, of strumous constitution, had gonorrhoea for six weeks, and, after the usual treatment with purgatives, nitrous aether, and copaiba, the discharge had nearly ceased for two or three days, when he was attacked with violent febrile excitement, very quick pulse, and delirium, which continued forty- eight hours, towards the latter part of which the testicle began to swell, and, as the size increased, the head symptoms diminished and subsided. Leeches and other suitable treatment having been employed, the swelling of the testicle declined, and 202 TREATMENT OF INFLAMMATION the gonorrhoea returned, but gradually diminished, till there was not more than six or eight drops of discharge a-day. He then left the house, and took a walk, but soon°had a recurrence of the febrile attack and head symptoms, which, however, went off again as the testicle again swelled, and that also subsided on the reappear- ance of the discharge from the urethra.—j. f. s. (2) In general, as the inflammation of the testicle subsides, if the gonorrhoea had stopped, it reappears. Hence some surgeons have proposed its restoration, to cure orchitis. (3) Adhesion and thickening of the tunica vaginalis is also a consequence of inflammation, and Astley Cooper observes that, " on examining the testicles which have felt harder than usual, that one surface of the tunica vaginalis was glued to the other, in some cases partially, and in others entirely." (p. 21.) (4) Suppuration is but rare when the inflammation of the testicle is sympathetic; thus forming one of the instances of the law on this point, recognised by John Hunter, and already adverted to in speaking of sympathetic bubo (par. 1G0, note.) And, indeed, generally suppuration following inflammation of the testicle, from any cause, is not frequent. In these cases " the tunica albuginea," says Astley Cooper, "like other tendinous structures possessing few absorbent vessels, does not readily give way to the pressure of the abscess; and it is a long time before it discharges itself, even after the matter can be distinguished by fluctuation.. It generally breaks at several apertures, and sinuses follow, which are very difficult to heal, for they issue a seminal as well as a purulent discharge." (p. 12.) Not unfrequently, after the bursting of an abscess in the testicle, a fungus shoots up, which often exceeds the size of the testicle. It is not painful and but little sensible; neither is it malignant, nor likely to become so, but it often grows very pertinaciously, and requires removal to get rid of its inconvenience. The constitutional excitement is often very great, setting in with nausea, and fol- lowed by hot skin, furred tongue, quick pulse, and constipated bowels, and some- times even with severe rigors. It is scarcely possible to confuse orchitis with any other disease, on account of its ordinarily slow progress, and from the epididymis and the body of the testicle being, in general, readily discernible from each other, although much swollen. But Sa- muel Cooper has mentioned a case in which on the fifth day there was so much pain in the belly, accompanied with incessant vomiting, great constipation, and high constitutional disturbance, that it led to a presumption of a rupture, from which, however, it was distinguished by the want of particular protrusion at the ring, by absence of tension of the belly, to one side of which alone the pain was confined. When swelling of the testicle arises from blows, it comes on very quickly, and doubtless depends on the bursting of some vessel or vessels in the testicle ; and it may be complicated with haematocele or effusion of blood into the vaginal tunic. " Wasting of the testicles," says Astley Cooper, " is another effect of inflam- mation in this organ ; and this absorption takes place more frequently at the age of puberty than at any other time;" generally follows inflammation from a blow; sometimes, when it arises spontaneously, and rarely after gonorrhoea, " it begins to be absorbed as the swelling subsides; but the absorption does not stop at the na- tural size of the part, but proceeds until the whole of the glandular structure of the organ is absorbed, leaving the tunica vaginalis adhering to the tunica albuginea and the septa within the latter; but the whole substance which remains is not larger than the extremity of the finger, and it feels a firm and very solid body." (pp. 23, 24.) Probably the tube of the vas deferens is obliterated, as its functions cease;.for, in a preparation we have in St. Thomas's Museum, of a wasted testicle, the quick- silver would not descend to within an inch of the testicle.—j. f. s. (5) Astley Cooper says, that the globus major "is more frequently diseased than any other part of the testis or epididymis," an observation the correctness of which experience fully proves ; and he might have added, that it is also of longer endurance, and more difficult to get rid of. " But," he observes, " the result is less important here than in other parts, because some of the vasa efferentia and coni vas- culosi still carry the semen from the testicle to the epididymis. When the harden- ing is in the upper part of the epididymis, adhesive matter is effused into the cellular membrane, between the coni vasculosi, at their termination in the epididymis; and sometimes a sac, containing a mucilaginous fluid, is found at that part. Th<' OF TESTICLE, AND ITS CONSEQUENCES. 203 coni vusculost, under this state of disease, are thickened, hardened, and of a dark brown colour." (p. 22.)] 172. The Cure of inflammation of the testicle is directed by its cause and degree. If consequent on gonorrhoea, still in its commencement, and connected with no great swelling, the patient must keep quiet, sup- port the testicle, apply cold lotions of lead wash, lay softening bread- poultices upon the penis, and take a cooling purge. Cold applications, however, which are only to be used at the beginning when the swelling is small, frequently cannot be borne, in which case soothing fomentations and poultices are to be preferred. In greater inflammation, in robust per- sons, blood must be taken away or leeches applied in sufficient quantity on the perinaeum and inside of the thigh, and warm softening bread poul- tice applied on the swelling. If, after this treatment, although the inflam- mation is reduced, great pain still continue, opium with nitre or calomel must be given, opium clysters administered, and narcotic poultices ap- plied. When the tension has diminished, lead wash may be added to poultices. After the resolution of the inflammation, if the swelling of the testicle still remain for a long time, it must be supported by a suspensory bandage, and mercury with camphor rubbed in. According to Del- pech's experience, the above-mentioned treatment of gonorrhoea, com- bined with cubebs, is sufficient to get rid of the inflammation of the tes- ticle accompanying it. [The general practice in swelling of the testicle is to adopt the antiphlogistic treatment, which practice I formerly pursued, giving, after a dose of rhubarb and calomel, either a drachm of sulphate of magnesia three or four times a-day, or tartarized antimony sufficient to produce nausea; and sometimes giving mercury internally, and using friction of mercurial ointment and camphor on the testicle till the mouth became affected. If the inflammation were very severe, cupping on the loins was employed, or local bleeding by leeches, or by opening two or three veins in the purse; and withdrawing three or four ounces of blood, and afterwards a warm bread poultice was applied. When the inflammation was subdued by these means, if the testicle still remained hard, as generally happened when no mercury had been used, then either mercurial friction or binding the testicle up in mercurial plaster was re- sorted to. Cold washes I never employed, nor have I any experience in the use of cubebs, as recommended by Delpech. I rarely now follow either of these plans, but prefer the use of compressing straps of adhesive or soap plaster, on Fricke's principle, (pars. 116, 1.)—J. F. S.] 173. If the inflammation run on to the suppuration and an abscess be formed, this must be opened and treated in the usual manner. The whitish-gray flocculi, which lie in the opening of the abscess, must be left alone; they often become covered with granulations and are united with the opening. If the suppuration cannot be restrained and the tes- ticle pass into disorganization, its removal is called for. [When a fungus has sprouted from the aperture by which the pus has been dis- charged, it should be treated at first by brushing over with nitrate of silver or solu- tion of sulphate of copper, and then compressing it with circular straps of adhesive plaster. But, if this practice do not succeed, it may be cut off with a knife to the level of the skin, and the edges of the wound having been pared, to set the skin loose, it may be brought together, and treated as a simple incised wound, which usually effects the cure. Occasionally, however, though rarely, little abscesses are cut through in removing the fungus: as these descend more or less deeply into the body of the testicle, it is better to remove the entire gland at once; a case of which kind I have lately operated on. But under ordinary circumstances castration is neither required nor to be practised.—J. F. S.] 174. Hardening is for the most part confined to the epididymis, gene- 204 FRICKE'S TREATMENT WITH COMPRESSION. rally gives scarcely any pain, and may continue throughout life. In dis- eased dispositions and dyscracy, or from injuries which set up inflamma- tion afresh, swelling of the spermatic cord, collections of water in the vaginal tunic, sarcomatous and cancerous hardenings are produced.— The dispersion of the hardening may with proper care be attempted by the general remedies (par. 68) already mentioned, during which the tes- ticles must be supported in a suspender. If the pain in the testicle become more severe and shooting, if the swelling be uneven and knobby, its extirpation is the only mode of preventing its passage into cancerous destruction. Not unfrequently, as a symptom of general venereal disease, a hard swelling of the testicle is slowly produced, which may generally be dispersed by a regular mercurial treatment or by the proper exhibi- tion of cubebs (par. 167.) The hardening of the testicle from one gonor- rhoea is not unfrequently dispersed by a fresh gonorrhoea ; hence the pro- position of passing bougies smeared with red precipitate ointment, (not with gonorrhceal mucus,) to excite fresh inflammation of the urethra. 175. Inflammation of the testicle following mechanical violence or catching cold, is to be treated as above prescribed, (par. 172,) without reference to the inflammation of the urethra. 176. As in diffuse inflammation of the cellular tissue, its resolution has been attempted by continued pressure, (par. 21,) so Fricke (a) has recommended compression as the most effectual remedy in all cases of inflammatory swelling of the testicle, from whatever cause. The degree and duration of the inflammation are here of no consequence; but, if gene- ral illness, (for instance, actual gastric disease, be connected with it,) this treatment must be given up. Vascular reaction does not contra-indicate compression, nor yet buboes nor sores. After compression the pain is at first frequently increased, and, if the pressure be too great, it is very severe; it does not, however, continue long, and, speedily, often within a quarter of an hour, the patient is free from pain. Frequently after com- pression gastric symptoms, as disposition to vomit, bitter taste and so on, occur, the compression must then be removed and a vomit given. If the pain continue after the compression, there must be some general dis- ease causing this want of success. In severe traumatic orchitis, leeches first, and poultices for two or three days must be used. [I have, for some time past, adopted Fricke's practice of compression with the greatest success, and rarely now use any other. I have occasionally heard it ob- jected, that it produces so much pain, the patient cannot bear it, and that its removal is absolutely required. My experience is directly contrary to this assertion. I have had but two cases in which the compression was unbearable ; whilst on the other hand, all pain generally subsides in a quarter or half an hour. I feel, therefore, pretty certain, that the fault must rest with the mode in which the compression is applied, and not on the remedy itself. I think it far preferable to the old method of purging, or of making the mouth sore, which I, in common with many others, here- tofore generally adopted, and therefore strongly recommend its employment as an easy and speedy cure. Very often under this treatment, as under the antiphlogistic, when the inflamma- tion subsides, the discharge from the urethra returns. Sometimes, but not always, hardness of the epididymis remains for a long while; but I do not think it of ma- terial consequence.—J. F. S.] (a) Ueber die Behandlung der Hodenentziindung durch compression; in Hamburger Zejtschrift fttr die gesammte Medicin, vol. i. part i. FRICKE'S TREATMENT WITH COMPRESSION. 205 177. For compressing the testicle, strips of new linen or sheeting, cut in the direction of the threads, should be used, a full thumb broad and an ell long, and spread by a machine with good sticking but not too irri- tating adhesive plaster. The patient, in slight cases, may place himself before his medical attendant, leaning against the wall, in other cases he must lie on the edge of the bed or sofa that the purse may freely hang down. If the hair on the pubes be too long, it must be shaved. The practitioner takes the testicle in one hand, separating it from the sound one, while with the other he somewhat stretches the skin of the scrotum. The spermatic cord is also in like manner to be separated. If the testicle be very much swollen an assistant must hold it, otherwise it is sufficient for the patient himself to separate the healthy from the diseased testicle. The first strip of sticking plaster is to be applied upon the isolated sper- matic cord an inch above the testicle, the end of the strip is to be held with the thumb whilst a circular band is applied round the cord. In the same manner a second strip is to be put on, which should partially cover the first. This act of compression must be carefully made, the sticking plaster must closely envelop the cord, so that the testicle, espe- cially if compressed at its lower end, cannot slip up through the loop which has been made towards the abdominal ring. The application of the stick- ing plaster is to be continued downwards to the bottom of the testicle in such way that each new turn overlaps one-third of the breadth of the prece- ding one. Having reached the part of the swelling which has the largest girth, and where it gradually diminishes towards the base, the sticking plaster must no longer be applied circularly ; the left hand must now grasp the part where the first strip was applied, and apply other strips, that, beginning from the upper part, they may be stretched in the long diame- ter of the testicle over the bottom and the other end attached behind.— So many strips are to applied in this direction that every part of the purse is covered, and the testicle enclosed and compressed in every di- rection. The application over the testicle must not be too tight. If both testicles are swollen, the compression must be applied as above de- scribed on one; there will not, however, be sufficient room for the cir- cular straps to be applied separately on the other; they must, there- fore, be so arranged that the previously compressed testicle should be enclosed with the other, and that thus strips of plaster shoujd be carried around both testicles, the former serving as the point of support for the other. The strips from before to behind should be applied as already- stated. [I do not either approve or practise this mode of applying the plaster, but always commence from the bottom of the testicle, and pass upwards. It is rather more difficult; but if the skin of the purse be made tight over the testicle, as in operating for hydrocele, there is little awkwardness in applying the first few strips of plaster. and the rest follow with ease, Also as regards binding up the second testicle, if swollen, against that first compressed, I have not found much need to do so. The plasters will not fit very well at the first application; but, generally at the second, the pressure yields quite sufficiently for the perfect adjustment of the compression on each single testicle.—J. F. S.] 178. The patient can generally leave his bed immediately after the plaster has been put on ; if the inflammation be not very severe, or, if just commencing, he may even go about. The re-application of the ban- Vol. 1.—18 206 METASTASIS OF GONORRHOEA, &C, TO THE BRAIN. dage, if once be insufficient, should only be made when the sticking plaster has become so loose that the scissors can be introduced under it to divide it. If in patients with irritable skin the plaster causes excoria- tions, little notches must be made, and Goulard's wash applied over it- [I have not found once nor twice sufficient for the reapplication of the compress- ing straps, but they need putting on afresh for several days. The diminution of the bulk of the testicle at each visit, till it reverts to its natural size, is often very remarkable.—J. F. S.] [Metastasis of Gonorrhoea and Inflamed Testicle to the Brain. In speaking of Mumps it was mentioned that metastasis of that disorder some- times occurred to the testicle or breast: and, I think, I am able to show that from gonorrhoea, and swelled testicle consequent on it, a metastasis may also take place to the brain, as in the following Case.—G. C, aged 31 years, a gardener, of healthy appearance, with a slight drawing up of the left corner of his mouth, was admitted into St. Thomas's, under my care. Oct. 22, 1844. He states, that during infancy he was subject to fits, whence ensued the drawing up of his mouth, as at present existing; but his health has been good up to two years since, when, whilst walking, he suddenly became giddy and insen- sible, and was told he was convulsed. He remembers he had then violent head- ach, and that he was cupped, blistered, and bled repeatedly, and under medical treatment for two months or more. Last June he had another attack of severe head- ach, and was relieved by cupping and purging; but he has since been subject to swimming in the head, with dread of falling. About six weeks since he was attacked with a thick glutinous discharge from the urethra, which he cannot ascribe to a recent < ause, not having had any connexion for a long while. The discharge continued pretty copious till within the last three days, when it diminished considerably, and the left testicle began to swell: it is now twice as large as natural, flattened, and very painful. I ordered him a dose of rhubarb and calomel, and the testicle to be strapped. Oct. 26. The size of the testicle much reduced, and the strapping therefore to be reapplied. The discharge has rather increased. Oct. 29. In consequence of the continued increase of the discharge, an injection of nitrate of silver, three grains to a pint of water, was ordered, by the use of which, in the course of a few days, the discharge was lessened. Nov. 9. The testicle has returned to its natural size. He is complaining of head- ach, and feels swimming and giddiness. Nov. 12. Ha^ violent pain across the temples; pupils dilated and fixed, and vision dimmed ; hearing very acute, and he is much disturbed by the slightest noise; pulse 80, full and very incompressible ; tongue white; bowels soluble; urethral discharge lessened. Tfr pil. col. c. cal. gr. x. stat., c. c. ad 3xij. nuchae et empl. lytt. poiteu adhib. Nov. 14. Has not slept for the last two nights ; mouth more drawn up since yesterday than heretofore; hearing very acute; vision more dim. The shooting pain across the forehead is more severe, and conies on every ten minutes in parox- ysms; is perfectly sensible, and answers without hesitation; bowels confined. Discharge from the urethra entirely stopped. & pulv. rhei, c. hydr. 9j.; hirud. xij. temp. Nov. 15. Mouth more drawn; head symptoms as last reported; pulse 108, softer; bowels open; complains of nausea. Jfc hydr. chlorid. gr. ij., ant. potass, tart, gr.i 6tis; hirud. xij. temp. Nov. 17. This afternoon he had an attack of violent pain in the belly, with ten- derness on pressure, pulse 108 and feeble. He was put in the hot bath, and a mustard poultice applied to his belly, by which he was relieved. But in the even- ing he had violent spasmodic pain, and it was found his bowels had not been relieved for the last three days. & oh ricini. 33s., tinct. opii r#xx. stat. This INFLAMMATION OF THE LUMBAR MUSCLES. 207 relieved him of the pain in the belly in the course of an hour or two. The head symptoms still continuing, a blister was applied to the nape of the neck. Nov. 18. Had no sleep last night, but was quiet; and has had this morning about half an hour's sleep, the first he has had (according to his own account) since the 12th ult. Pain in the head violent as ever; pupils fixed and eyes vacant; pulse 108, feeble, sharp, but soft; tongue'brownish; bowels open. Nov. 19. Still most violent headach, and complains of pain in the belly. Put into a slipper bath immediately, which much relieved him; his head to be shaved, and cold lotions to be applied. I* tinct. rhei 3iv., tinct. op. tn>xx. ex aqua mentha; piper. Nov. 20. His head aches much less: the pupils contract sluggishly on the appli- cation of light; pulse 108, feeble; bowels freely opened. Nov. 21. Slept well last night; has less headach, but the pupils still continue sluggish ; the countenance is less anxious; pulse 84, softer. Nov. 22. His mouth having now began to be affected with the mercury, and his symptoms being improved, the pill was directed to be taken at night only. Nov. 29. Has continued mending; the headach has ceased, and his mouth has now reverted to its usual drawing up, the medicine was therefore left off. A gleety discharge from the urethra has re-appeared. Dec. Left the house quite well. The discharge has gradually subsided without any treatment.—J. F. S.] 179. The proper application of the plaster requires great care; I have observed injurious effects from compression, in the practice abroad, by inattention to this circumstance. The advantages of this mode of treat- ment are, according to Fricke's numerous observations, quick subsi- dence of the pain, a more rapid cure of the disease, simplicity, cheap^ ness, and little want of attendance. VI.—OF INFLAMMATION OF THE LUMBAR MUSCLES, Ludwig, Diss, de Abscessu Latente. Lipsiae, 1758. Pott, Percivall, On the Palsy of the Lower Limbs; in his Chirurgical Works, vol. iii. London, 1783, 8vo. Pearson, John, Principle of Surgery, &c. London, 1788. 8vo, Meckel, Diss, de Psoitide. Hallae, 1796. Kirkland, Thomas, M. D., An Enquiry into the present state of Medical Sur- gery, vol. ii. London, 1783. 2 vols. 8vo. And Appendix to the same. London, 1813. 8vo. Abernethv, J., Surgical Observations on Chronic and Lumbar Abscesses; in his Surgical Works, 2d Edit., London, 1815, vol. ii. p. 137. Cooper, Astlev, On Psoas and Lumbar Abscess Surgical Lectures; in Lancet, 1824, vol. ii. Lawrence, William, On Chronic Abscess; in Surgical Lectures in Lancet, 1830, vol. i. Dupuytren, Article De la Carie de la Colonne Vertebrate; in his Lecons Orales, vol. i. 180. Inflammation of the Lumbar Muscles (Lumbago, Psoitis, Lat.; Entzundung der Lendenmuskeln, Germ. ; Inflammation des Muscles Lorn- haires, Fr.) is situated in the musculuspsoas and m. quadratus lumborumy and in the surrounding cellular tissue (1). It sometimes occurs suddenly ; the patient feels pain in the loins ; walking becomes troublesome ; the thighs can be neither raised nor completely extended without pain. Sometimes it commences gradually, with pricking pain, which, becoming more severe, spreads into the hip and thigh to the knee-joint. Not unfrequently the course of the inflam- 20S CAUSE OF PSOAS AND mation is so insidious that it is scarcely noticed, and the disease is first shown by the collection of pus. According to the degree of the inflam- mation does suppuration occur early or late. The pus collects in the cel- lular tissue surrounding the psoas muscle, descends in its course, and a swelling is produced beneath Poupart's ligament, in the neighbourhood of the rectum, upon the spine, and so on. During these collections of matter, the patient suffers pain in the loins ; walking is troublesome, a movement of the pus contained in the swelling is felt on coughing; the swelling is smaller when in the recumbent posture; at first the skin is un- changed. The general symptoms of suppuration, as emaciation, night sweats, hectic fever, and so on, rarely occur wlren the extent of the ab- scess is not large. But if, during its increase, the skin covering it inflame and break, pus is discharged at first without smell, but subsequently stinking and the powers of the patient are quickly exhausted, or the aper- ture draws together and remains fistulous for a long time. [(1) It must be distinctly understood that the disease now under consideration, is not that we usually call " Lumbago," which consists of a rheumatic inflammation of the lumbar fascia, but the complaint which we know as " Psoas or Lumbar Ab- scess ;" and, as will be presently seen, it is almost always a secondary disease, a disease in the part, and not of the part, as Hunter calls such, resulting from affec- tion of the vertebra?, and would be more in place if considered with diseases of joints, under the head "Inflammation of the Vertebral Joints." (par. 257 and fol- lowing.)—j. f. s. Astley Cooper says of this disease:—"You may know this abscess by the following marks:—in the first place, when you ask the patient whether he has for a long time had continued pains in the loins; if he has psoas abscess, he will reply ' yes; four, five, or six months;' you will find that he has a difficulty in extending the thigh if he puts his legs together, he feels pain and tightness in the groin, and has increased pain in attempting to exert the limb, in consequence of the psoas muscle being then on the stretch." (p. 460.) Pearson remarks, that " during the progress of suppuration, as there is a remis- sion of the more severe, symptoms, the patient often imagines that he is recovering his health; some degree of pain, however, and an inability of duly performing the motion of the parts always remain. He is, sooner or later, alarmed by the appear- ance of a soft tumour, which arises in one or more of the parts enumerated above. At the first it is rarely accompanied with any discoloration of the integuments or pain, unless it be compressed. When the person stands erect the tumour becomes more prominent; but its contents recede, either in whole or in part, when he assumes a horizontal posture." He also notices, " that if the contents of the abscess be included in a firm cyst, the long-continued pressure of so large a body upon the lumbar vertebra? will sometimes induce a paralysis of the lower extremities." (pp. 97-9.)] 181. The causes of this inflammation may be external violence, severe strains, catching cold, rheumatism, gout, dyscratic affections of all kinds. Caries of the lumbar vertebrae very frequently accompanies lumbar ab- scess, of which it may be cause or consequence. [The cause of this disease is held by English surgeons in general to be disease of the vertebrae. This seems to have been first noticed by Pott, who, in speaking of the cornplaint which arises from what is commonly called " strumous or scro- fulous indisposition affecting the parts composing the spine," says, that. " sometimes it is found in the form of bags or cysts, containing a quantity of stuff of very un- equal consistence, partly purulent, partly sanious, and partly a curd-like kind of substance; and not unfrequently entirely of the last. Sometimes, under these bags or cysts, even while they remain whole, the subjacent bones are found to be dis- tempered, that is, deprived of periosteum, and tending to become carious." And then he comes to the disease now considered:—" Sometimes these collections erode the containing membranes, and make their way down by the side of the psoas LUMBAR ABSCESS. 209 muscle towards the groin, or the side of the pelvis behind the great trochanter, or, in some cases, to the outside of the upper part of the thigh." (pp. 467,8.) Astley Cooper describes it as " very often nothing more than an abscess, from the disease of the intervertebral substance which I have just spoken of, having its origin in inflammation of the spine and the intervertebral substance. The matter spreads till it reaches the origin of the psoas muscle, which passes into ulceration, and forms a bag, surrounded by a complete ring. The abscess proceeds as far as the tendon of the muscle, by Poupart's ligament, and its further progress is re- strained by the tendon; when it passes under Poupart's ligament, between the femoral vein and the symphysis pubis, it has generally attained considerable mag- nitude, and has the appearance of femoral hernia. * * * If the abscess form on the side of the vertebrae, instead of the fore part, it is termed lumbar abscess instead of psoas." (p. 460.) Abernethy says :—" Lumbar abscesses in general descend along the psoas muscle, under Poupart's ligament;" they " also, in general, are not simple dis- eases ; they arise from and communicate with carious vertebrae; which circumstance is, I believe, the cause of their frequent fatality. The first eight cases that I at- tended, after I had adopted a new mode of opening them, were simple abscesses, and not arising from disease of the bone, which led me to believe that they were more fre- quently unconnected with diseased bone than later experience has taught me. The general opinion of surgeons, in which I entirely concur, is, that lumbar abscesses most frequently arise in consequence of disease of the vertebrae, and they should certainly all be treated as if such was their origin;" (p. 143,) "as," he afterwards observes, "we cannot know whether the bone be diseased or not." (p. 159.) Lawrence speaks of" the chronic abscess termed psoas or lumbar abscess, where, in consequence of the disease of the vertebra? of the lower portion of the back or loins, matter forms around that diseased part, and then descends through the loose cellular membrane covering the muscles along the side of the pelvis into the thigh; it may take a course towards the back, or may go in various directions either within or on the outside of the pelvis." (p. 396.), Dupuytren says :—" Caries having been once established, the pus remains for a longer or shorter time in the carious spot, in the parts surrounding it, and especially in the cellular tissue. It forms at first a cyst where the pus collects. As the quantity of pus increases the cyst descends; lengthens as it inclines to one or other side of the spinal column, or to both sides at once; the pus makes its way, pushing before it the lower end of the cyst; if it meet with any obstacle it spreads out, but contracts when pressed on by the neighbouring parts, and dilates again when re- lieved from the pressure. Having arrived beneath the skin, after a more or less lengthy course, the pus projects, and causes a swelling which terminates by forming an abscess. This purulent collection, known by the name of congestive abscess, but more properly called symptomatic abscess, is a very serious disease, and generally considered fatal." (pp.* 136,7.) The disease may and frequently does arise from external violence, blows, strains, or the like; but its commencement is in the spine, whence it is propagated to the muscles, which, however, are in fact only absorbed to form a route for the matter produced by the diseased vertebrae to escape. Inflammation and suppuration in the psoas muscle, or in the lumbar mass of muscles, without disease of the spine, is rare, and more especially in the former. Of the nineteen cases given by Abernethy, only two are mentioned in which there was no actual disease of spine.—J. F. S.] 181*. Psoas abscess, when protruding below Poupart's ligament, may, on account of having the same seat as femoral hernia, be mistaken for that disease, especially as it dilates on coughing, and to a certain degree returns into the belly when the patient lies down. But it is gene- rally of larger size, of greater breadth than femoral rupture, and the fingers cannot be at all thrust behind it, as they can be partially behind the hernial sac. The principal distinction, however, is the long contin- nuance of pain in the loins previous to its appearance, and which, indeed> still continues: and the pain produced by attempting to extend the thigh 18* 210 TREATMENT OF backwards upon the pelvis, and which can only be effected to a limited extent. When the abscess appears in the loins there is no difficulty in determining its character by its history and by its dilatation on coughing. Pulsation may sometimes be communicated to it from the neighbouring large vessels, and under such circumstances it has been mistaken for aneurism.—J. f. s. John Pearson well observes:—"The situation of the external abscess is not uniform; most commonly it is at some distance from the original seat of the disease; nor is the point at which it projects forward to be considered as forminga portion of the abscess. The fluctuation of the matter may therefore be most palpable about the loins, or at the hip, in the groin, or near the rectum, and sometimes it points towards the lower part of the thigh, in the direction of the large blood-vessels.'' (pp. 96, 7.) " As the purulent matter is situated behind the peritoneum, and the erect position of the body is favourable to its progression downwards, we do not often meet with instances where it is effused into the cavity of the abdomen.'" (pp. 98, 9.) Samuel Cooper (a) mentions a remarkable case of lumbar abscess, under the care of Ramsden, in which " the tumour extended, from the ilium and sacrum below, as high as the ribs ; its diameter, from behind forwards, might be about six or eight inches; it was attended with so strong a pulsation, corresponding with that of the arteries, that it was considered to be a case of aneurism of the aorta. After some weeks, as the tnmour increased in size, the throbbing of the whole swelling gradually became fainter and fainter, and at length could not be felt at all. The tumour was nearly on the point of bursting, and Ramshen, suspecting that it was an abscess, determined to make a small puncture in it; and a large quantity of pus was evacuated at intervals." (p. 944.) 182. The dispersion of the inflammation of the lumbar muscles would be in most instances possible, were not the symptoms often at first so slight as to be usually neglected. The Cure is directed by the degree of the inflammation and its causes. In severe inflammation the antiphlo- gistic treatment is properly adopted, blood-letting, the application of leeches or cupping-glasses. As the inflammation diminishes, the resolu- tion is to be encouraged by volatile ointments and perpetual blisters.— If the cause be rheumatism or gout, and the inflammation be insidious, solution of acetate of ammonia in infusion of elder flowers, antimonial wine in small doses, Dover's powder, camphor and the like, may be given ; but especially warm baths, rubbing in volatile ointments, blisters, and issues, are to be used. [The reason assigned by Chelius for the neglect of the primary symptoms of this disease is hardly carried far enough, as, in reality, the attack comes on so slowly and insidiously that the patient is scarcely aware of having any thing more than slight rheumatic or " growing pains," as young people call them, till some trifling occurrence brings him to a stand-still, and the serious character of his disorder is almost accidentally discovered, often, indeed, not before it has proceeded to suppura- tion.—J. F. S.] 183- When the inflammation terminates in suppuration, and swellings are formed by the descent of the pus, such absceses, even when they have obtained a considerable size, may, in some cases, although rarely, be dispersed, by perpetual blisters or issues on the loins, by general treatment which puts the abdominal functions in order and strengthens the patient's powers (1). But if, under this treatment, the abscess in- crease, it must be opened "fee with a lancet, which should introduced ob- (o) Surgical Dictionary.—Article Lumbar Abscess. PSOAS AND LUMBAR ABSCESS. 211 liquely (2). The pus must be discharged, as far as possible, in an un- broken stream. The wound is to be carefully closed with sticking plas- ter, a compress is to be laid over it, the patient kept quiet, and the above- mentioned treatment employed. The wound usually closes in a few days; but the pus most commonly re-collects, though in less quantity than at first. If the swelling again rise sufficiently high, it must be again emptied as before, and this must be repeated as often as the abscess is re-formed. If the abscess be originally of no great size, or diminished by repeated punctures, it is often best to treat it as a common abscess, to open it freely, and simply apply a poultice ; at the same time, however, supporting the powers by tonic remedies, and by a proper dietetic regi- men. [(1) Dupuytren observes, that " these abscesses remain sometimes in the same state for years, and without causing any symptoms ; the pus is gradually absorbed and no trace of them remains. At other times, after a greater or less interval, the skin covering them inflames, bursts, and gives issue to the pus, wThich drains away and is not reproduced. In other circumstances, the pus having remained for a longer or shorter time, is converted into an adipocerous matter : chemical experi- ments have proved, indeed, that such is the nature of the substance sometimes met with in abscesses of this kind." (p. 138.) Astley Cooper has made the following observation in regard to the treatment of this disease :—" You must allow the abscess to take its course ; very little can be done in this disease until it has acquired considerable magnitude." (p. 460.) This recommendation is very unsatisfactory ; for the treatment should be commenced so soon as the existence of the disease can be ascertained with any certainty, so far, at least, as the use of counter irritants is concerned; for I cannot agree wTith Cooper that " little can be done to prevent its progress when once formed, and I do not know that any advantage is to be derived from counter irritation." (p. 461.) I feel sure, on the contrary, that much may be done, and, believing that caries of the ver- tebrae is always the origin of the disease, the treatment which it requires is that which at the onset is necessary for lumbar or psoas abscess, and which indeed must be persevered in even after the abscess has either burst or been punctured ; I mean the use of issues.—j. f. s. Various expedients have been proposed for exciting the absorbents to take up the pus. "The elder Cline (a) once gave digitalis to a very considerable extent to a boy of fourteen or fifteen years old ; the abscess diminished for a little time, but when the digitalis was given up, in consequence of its influence on the general health, the disease returned." (p. 461.) Abernethy has recommended the applica- tion of repeated blisters or of open blisters upon the swelling, and has given two cases under this treatment in which the pus was absorbed. I have not had any per- sonal experience on this point, and cannot, therefore, say any "thing about it. The same distinguished surgeon has also advocated the use of electricity ; but, as in all the cases in which he employed it, other remedies were also used, it is not possible to determine what benefit was attained by it. The exhibition of emetics, to which he also resorted, was under the same circumstances, and, therefore much cannot be decidedly attributed to them. Issues are most important aids in the successful treatment of psoas or lumbar ab- scess, either whilst the abscess remains unopen, or after an aperture in it has been self-formed or made artificially, by which the pus has escaped, and from which it long continues to be discharged. I do not know any circumstance under which their employment should be withheld. The issue should not be made on the same side of the spine as that where the abscess is, if presenting in the loins, but on the other side, and opposite the outer margin of the m. quadratus lumborum. And, if there be abscess in both lumbar regions, the issues should be put in above and below them. But, if the swelling present in the top of the thigh, as in the psoas abscess specially so called, it may then be made on the same side, or indeed, on both sides issues may be introduced. The issue should never be made upon the ridge of the (a) As stated by Astlev Coofer. 212 TREATMENT OF spine, as, on account of the nearness of the spinous process to the skin, the perios- teum and ligaments covering their tips may be involved in the slough, and the processes themselves become necrotic. Neither should it be made over or upon the abscess itself, as the separation of the slough will open its cavity. Large issues I do not think advisable: a slough as large as a sixpence, made with caustic potash, will, when thrown off, leave'a wound as big as a shilling, which is large enough to hold three or four glass beads, and amply sufficient, as with but little attention the issues can be kept open for a considerable time, and when they seem disposed to heal, their surface must be smeared with the caustic potash sufficiently to produce a fresh slough, and on its separation, the peas are to be again introduced. The intention of the issues is to divert the diseased action going on in the vertebral column, which is generally the cause of psoas or lumbar abscess, as already mentioned, and is a practice which I have found eminently successful.—j. f. s. (2) Much difference of opinion still exists among surgeons as to the propriety of waiting the self-evacuation of these abscesses, or of puncturing and emptying them either entirely or partially. Abernethy asks, when the abscess " protrudes the integuments, that they, from distention, become irritated ; that their temperature is slightly augmented ; what are we then to do1? Are we to wait till evident signs of inflammation appear] I think not. I would relieve them from distention, by emptying the abscess through a wound made by an abscess lancet. I would open the abscess for a reason which appears paradoxical on its first proposal, which is that it maybe kept closed. We can empty a cavity, and by healing tbe wound keep it afterwards shut, and no inflam- mation ensues. If nature opens the cavity by ulceration, the opening is permanent and the inflammation consequent must be endured." (p. 153.) The practice of puncturing large abscesses with a trocar, seems to have been first advised by Deckers, in 1696; he left the canula in the cavity stopped with a cork, and let out the matter at intervals. The same proceeding was also adopted by Benjamin Bell. Tapping these abscesses with a small trocar was also recom- mended by Crowther, who always introduced it at the same spot. He thought that the aperture so made did not ulcerate, nor allow the matter to escape after being dressed. In addition to drawing off the pus with a trocar, Latta (a) advises, that after this is effected, the end of the canula, wrhich had been introduced at the bottom, should be pressed gently up to the top of the abscess, the trocar introduced into it and thrust through the skin, and then, being withdrawn, a skein of silk to be passed through the canula, which is also to be removed, and thus a seton formed, (p. 36.) The introduction of the seton is, I should consider, a very dangerous experiment, as likely to excite inflammation, always too much to be dreaded, in a part too prone to run into that condition. I have never pursued this practice, nor, for the reason just mentioned, should I be disposed to do so. And, as to puncturing with the trocar, I do not see any advantage to be obtained from it, and certainly cannot believe the wound would heal more speedily than a simple puncture with a lancet.—j. f. s. Abernethy's peculiar treatment consisted in puncturing with " an abscess lancet introduced with very little obliquity so far that the wound of the cyst of the abscess should be half an inch in length, and that of the integuments, of course, a little longer. A wound of that size is generally sufficient to give discharge to the solid flakes which will occasionally block up the opening without much poking. It is necessary that the flow of matter should be uninterrupted, so that no air should gain admittance; it is, therefore, right to make pressure on the abscess, in proportion as it is emptied. The abscess where it presents itself as emptied before that part of it in the loins is completely so. The surgeon should then press the sides of the wound together with his finger and thumb, so as to prevent the ingress of air, and desire the patient to cough repeatedly, which will impel the matter from the internal part of the abscess into that which is punctured. When the abscess is emptied as much as possible, the wound should be attentively wiped, and the edges placed in exact contact, and retained in that state by strips of plaster." (p. 154.) A compress is then put on, but no bandage; the patient is to lie perfectly quiet, and the wound, being dressed every second day, " generally united by adhesion, though sometimes otherwise, for it may discharge a little, and yet unite firmly. The abscess thus treated is as free from inflammation as it was before it was punctured. The abscess (a) Practical System of Surgery, vol. i. PSOAS AND LUMBAR ABSCESS. 213 will, however, fill again, and that sometimes even rapidly. In the first cases which I attended, I punctured pretty regularly after the expiration of a fortnight, and I found in general that the abscess contained about one-third less of fluid. * * * After having discharged the contents of the abscess three or four times, I found that it was not necessary, nor, indeed, easily practicable to puncture it at the end of the fortnight, because it was so little filled and prominent." (pp. 155, 6.) Astley Cooper supports Abernethy's mode of treatment. He says :—" Let the abscess proceed until you observe a redness or blush of the skin, and then adopt Mr. Abernethy's plan of making a valvular opening into the part, so as to dis- charge the matter, and close the wound almost immediately. The danger does not arise from the quantity of matter accumulated, but from the irritation produced by the attempts of nature to close the abscess and fill the cavity by the process of ad- hesion. Four days after the abscess is opened violent symptoms of constitutional irritation are apt to come on, such as great depression of strength, loss of appetite, and the patient is soon reduced to the lowest extremity. It is extremely desirable to prevent the occurrence of these symptoms, and the plan of Mr. Abernethy is the best that has ever been suggested by any Surgeon with a view of preventing them." (p. 461.) Lawrence also advocates Abernethy's practice, as it "gets rid of the conti- nuance of an abscess of this kind without incurring the risk of the inconvenience" which arises when, " as in opening a phlegmonous abscess, an incision is made and the matter let run out, and then applying a poultice over it, the access of air into the abscess produces decomposition of the pus which it contains, the matter becomes fetid, the surface of the abscess is inflamed, and the secretion from its sides becomes exceedingly altered, thin, and stinking, extremely irritating to the portion which is in contact with it. The inflamed surface of the abscess is a source of sympathetic disturbance in other parts in the alimentary canal or in the vascular system, and thus arises fever of a different kind." (p. 396.) Other writers, as Kirkland, prefer " the tumour being suffered to break of itself, and its contents to drain gently off, through a very small aperture, which prevents the free ingress of air and violent symptoms; for, when a large tumour of this sort forms on the inside of the thigh, and breaks in a large opening, in such a manner that the air has already passage, we frequently see a violent colliquative fever succeed, that closes the scene in a very short time. But, though small openings should be obtained if possible, they too seldom secure the patient." (p. 199.) John Pearson observes on this point:—"Some of the older Surgeons, and the French Surgeons (of his time) in general, advise a free opening to be made, or the introduction of a seton. It hath been thought more advisable, by other practitioners, to permit the abscess to burst spontaneously. Several of the modern Surgeons re- commend a very small aperture to be made, and the ulcer to be treated in a very gentle manner. My own experience is in favour of the last mode of treatment, and I have been so happy as to see it followed by a perfect cure of the disease." (p. 103.) Dupuytren " considers it dangerous to open symptomatic abscesses, resulting from caries of the spine, which has yielded to treatment. So to proceed is to re- excite the principal malady, and to lose all the benefit of long and active treatment. He, therefore, recommends giving up these abscesses to the mere efforts of nature; and he follows the same practice even when all remedies have been unavailing to cure the caries." (p. 139.) The practice I have pursued, which has been for many years past commonly followed at St. Thomas's Hospital, has been either to permit the abscess to break of itself, or only to puncture it when the skin has so reddened and thinned at one point that there is no chance of its bursting being avoided. The puncture should not be a large one, nor do I think making it valvular is of any consequence, as 1 make no effort to produce its union. It should be of sufficient size to permit the escape of the pus, which should flow out, if it may be so said, at the pleasure of the abscess, which should, on no account, be squeezed or kneaded, to empty its cavity. If thus left to itself the pus flows slowly and the sides of the abscess gradually fall together, though without at once uniting, and accommodate themselves to their new condition, so that ultimately the original abscess becomes only a more or less capacious sinuous cavity, which, if the disease originate in the spine, gives vent to the pus there formed, and may itself also, for a longer or shorter time, furnish the 214 TREATMENT OF PSOAS AND LUMBAR ABSCESS. discharge. I have not generally observed the hectic symptoms which by some surgeons are described as almost certainly occurring when large abscesses, bursting or being opened, at once empty themselves; and I apprehend that when the sac inflames and hectic fever comes on, the cause is rather in the irritable state of the constitution than in the emptying of the abscess. I am not prepared to say, nor would I advise a large puncture and the immediate emptying of the abscess; but, from repeated observation of the practice of others, corresponding to my own above described, viz., the gradual evacuation, either by bursting or by a moderately large puncture, I am convinced that this plan of proceeding is the best.—j. f. s. The issues are to be still kept up, even after the puncture has been made, for the purpose of diverting the original disease, as already mentioned; and this practice is in accordance with Abernethy's recommendation, that "an issue should be made in the loins, which is likely to be beneficial by its counter-irritation, even when the abscess is not connected with diseased bone ; but, when it is, then an issue will be more serviceable and necessary." (p. 151.) As regards injecting the sinuous cavities into which, after a time, these abscesses are converted, Pearson states, that " some of the older writers forbid the use of in- jections in the lumbar abscess; but their reasons seem to be founded upon mistaken ideas of the true situation of the disease. Solutions of copper, vitriol, or even tepid sea water may sometimes be applied in this way with considerable advantage." (pp. 103,4.) Astley Cooper also says, he "has seen benefit from injecting the abscess, (I presume when it has become fistulous,—j. f. s.:) the injection usually employed is the sulphate of zinc or alumen ; it promotes the adhesive process in the interior of the abscess, glues its sides together, and lessens the purulent secretion." (p. 461.) Dupuytren states "that cauterization may be employed advantageously; but the actual cautery must be straight and exactly run through the canal. In other cases it may be convenient to have recourse to injections of nitrate of silver, or of nitric acid, largely diluted with water, taking care that these liquids do not escape in their course. For these injections he employs twenty or thirty grains, or a drachm of nitrate of silver to a pint of distilled water, and injects it with a siphonous syringe." (p. 148.) 184. There is danger when the cavity of the abscess inflames after the discharge of the pus; and attempts must be made to diminish the inflammation by quiet, by suitable antiphlogistic treatment, and by dis- charge of the pus. If symptoms of hectic fever are indicated, or the opening of the abscess becomes fistulous, (the cause of which may be some internal process still going on, such as caries of the lumbar vertebras or thickening of the walls of the abscess,) the powers of the patient must be supported as much as possible, and, if a general cause can be found out, we must endeavour to counteract it. [When the cavity of the abscess is inflamed it is known by the great pain caused by slight pressure on the surface, and by the escape of a thin, fetid, frothy matter from the aperture, whether made by ulceration or artificially. It is generally ac- companied by the hectic symptoms ; but, sometimes, Abernethy observes, " both the local and constitutional diseases are of a more purely inflammatory kind;" under which circumstance, the above-mentioned discharge and the hectie symptoms are deficient. Sometimes "the fever is at first inflammatory, then hectical, and, when the local complaint becomes indolent, the general state of the patient's health is no longer affected." And Abernethy says, he has " known a considerable space of time elapse between the first bursting of a lumbar abscess and its assuming that morbid state which is so peculiar to those diseases, and which produces a corre- sponding affection of the system in general." (pp. 221, 2.) In conclusion, it is right to mention the important observation made by Pearson, that, "although the larger arteries have been known to be surrounded with'purulent matter for a considerable length of time without suffering any injury, yet this is not universally the case; there have occurred may instances where erosion has taken place, and the person has been suddenly destroyed with hemorrhage." (pp. M, 100.) M'Dowell (a), however, mentions a case in which "ulceration took place in a portion of the ilium adhering to the cyst of the abscess : and the contents of the (a) In Dublin Journal of Medical Science, vol. iv. KINDS OF WHITLOW. 2L5 bowel, after having passed into the abscess, escaped through a fistulous opening near tbe spine of the ileum. Ulceration also of the external iliac artery followed about an inch and a half above Poupart's ligament, and sudden death resulted from the blood escaping in large quantities into the cavity of the abscess." (pp. 912.)] VII.—OF INFLAMMATION OF THE NAIL-JOINT, OR WHITLOW. Garengeot, Traite des Operations de Chirurgie. Paris, 1720, 8vo. Vol. III.— Translated as, A Treatise of Chirurgical Operations, according to the Mechanism of the Parts of the Human Body. London, 1723, 8vo. Le Dran, Hen. Fr., Traite des Operation de Chirurgie. Paris, 1742. 8vo.— Translated as, the Operations in Surgery of Monsieur Le Dran, by Mr. Gataker. 3d Edit. London, 1757. 8vo. Focke, Diss.de Panaritio. Gotting., 1786. Melchior, Diss, de Panaritio. Duisb., 1789. Flajani, Osservazioni Pratiche sopra il Panereccio. Roma, 1791. 8vo. Vogt, Diss, de Paronychia. Viteb., 1803. Sue, P., Reflexions et Observations, Pratiques sur le Panaris; in Recueil des Memoires de la Societe Medicale d'Emulation de Paris, vol. ii. Wardrop, J., An Account of some Diseases of the Toes and Fingers; with Ob- servations on their Treatment; in Med-Chir. Trans., vol. v. p. 129. Duteil, Dissertation sur la Panaris. Paris, 1815. Craigie, D., Pathological and Practical Observations on Whitlow, in the Edin- burgh Med. and Surg. Journal, April, 1828, p. 255. 185. Whitlow, or Inflammation of the Mail-Joint of the Fingers and Toes, (Panaritium, Onychia, Paronychia, Lat. ; Umlauf Wurm, Germ.; lnjlamiiialion des Doigts, Panaris, Ft.,) according to its seat and the con- sequent variations of its severity, usually presents itself in the following four degrees :— [The following mode of deriving the term whitlow, as given by Becket (a), is interesting :—" The old English word hawe signifies a swelling of any part. Thus, for instance, a little swelling on the cornea, was anciently called the hawe in the eye; and the swelling that frequently happens on the finger, on one side the nail, was called whitehawe, and afterwards whitflaw or whitlow." (p. 52.) The division of whitlows employed by Chelius was first proposed by Garengeot, and is generally followed; but, excepting the first species, which is well marked, I am rather disposed to agree with Gibson (b), that "these varieties, however, are in a great measure arbitrary; for it is not always in the power of any surgeon to declare from examination of the part, what particular texture is affected." (p. 186.) -J. F. S.] First. If the inflammation be entirely superficial at the root or side of the nail, the pain is not great; the swelling does not spread beyond the first joint of the finger, but quickly passes to the outpouring of a puru- lent matter which lies immediately beneath the skin, and assumes a bluish colour; the pain only becomes severe when pus has collected beneath the nail, which generally falls off, and a new one soon grows. [This whitlow is Abernethy's Paronychia ungualis. It begins with slight in- flammation, accompanied with a throbbing, and by degrees raises up a small white semi-transparent bladder, the whiteness of which depends on the thickness and opacity of the cuticle. It seems, as Le Dran says, to be "only a disease of the skin, which, being slightly excoriated or irritated from some external cause, in- flames, and is followed by a collection of purulent serum between the cuticle and true skin." (p. 413; Fr. edit., p. 539.)] If the whitlow be left without puncture, it continues increasing, stripping the cuticle of the true skin, and distending it more and more, till at last, finding a crack (a) Phil. Trans., 1720, vol. xxxi. (b) Institutes and Practice of Surgery, vol. i. 216 KINDS OF WHITLOW. or a thin part, it bursts, and the pus is discharged. But the continued pressure has ulcerated the cutis and then, as John Hunter observes, "the soft parts underneath push out through the opening in the cuticle, like a fungus, which when irritated from any accident, give a greater idea of soreness, perhaps, than any other morbid part of the machine ever does. This is owing to the surrounding belts of cuticle not having given way to the increase of the parts underneath, by which means they are squeezed out of this small opening, like paint out of a bladder." (p. 470.) Hunter gives the following reasons (the correctness of whicb must be readily admitted) why the abscesses " about the nails commonly called whitlows, more especially in working people, give so much pain in the time of inflammation, and are so long in breaking, even after the matter has got through the cutis to the cuticle; the thickness of the cuticle, as also the rigidity of the nail, acting in those cases like a tight bandage, which does not allow them to swell or give way to the extravasation ; for in the cuticle there is not the relaxing power, which adds con- siderably to the pain arising from the inflammation ; but when the abscess has reached to this thick cuticle it has not the powrer of irritation, and therefore acts only by distention : and this is, in most cases, so considerable as to produce a separation of the cuticle from the cutis for a considerable way round the abscess." (p. 469.) # * # "All of which circumstances taken together make these complaints much more painful than a similar-sized abscess in any of the soft parts." (p. 469.)] Second. When the inflammation is situated in the cellular tissue be- neath, the skin and commonly at the bulbous end of the finger, the pain is very severe on account of the tension of the thickened skin. If the inflammation pass into suppuration, fluctuation cannot readily be per- ceived, and the pus makes itself an outlet with difficulty. [This form might not inaptly be called Paronychia cellulosa, as in the inflamed cellular tissue of other parts, the inflammation is disposed to spread ; the whole finger often becomes affected, and the disease occasionally extends into the hand itself. The severity of the pain is great, because, as Le Dran observes, " the skin of the finger is of very close texture, and therefore cannot yield to the increased size of the inflamed parts which it encloses, consequently the tension, pain, and fever are more violent." (p. 414 ; Fr. edit. p. 542.)] Third. If the inflammation be situated in the sheaths of the tendons, the pain, which is specially situated on the front of the finger, is very severe, and strikes up through the whole arm to the shoulder; upon the finger only a slight swelling is to be observed, but it spreads so much the more over the greater part of the hand to the wrist, and even to the fore-arm. Severe fever usually accompanies it. If the thumb, fore, or middle finger be attacked, the pain ascends outwards upon the front of the hand ; but, if the ring or little finger be attacked, then the pain is con- tinued along the ulnar surface to the elbow-joint and up to the arm-pit. When suppuration occurs, fluctuation is not distinguishable on account of the deep situation of the pus. The inflammation readily spreads to the periosteum, and destruction of the phalanges often ensues. [This form is Abernethy's Paronychia tendinosa. Travers (a) observes that " this, the case of acute paronychia," as he calls it, " is frequently accompanied with absorbent inflammation, but not invariably; nor is it on this account more serious. Matter is secreted by the inflamed synovial surface of the tendinous sheath, or the particular fascia investing the tendinous extremity of a muscle of the arm or leg; or beneath a ligamentous expansion, as the palmar or plantar aponeurosis." Sometimes the symptoms supervene in a few hours after the injury, sometimes not for days, so that the patient scarcely recognises the injury, usually a small penetrating wound. If the wounded thumb or finger is disfigured by excessive cedema, the symptoms of disturbance are less severe than when, with great tension, the swelling Is inconsiderable and void of fluctuation, so as to make (a) On Constitutional Irritation, part i. WHITLOW. 217 the existence of matter doubtful. The quantity of pus is so small, and the relief of discharging it so great, as to demonstrate that its situation alone had given rise to the intense pain. Is it owing to the partial escape of matter into the cellular sub- stance, or to the inflammation having originally attacked this texture, exterior to the theca or fascia, and affected the interior only by sympathetic connexion, that the symptoms are less urgent when the cedema is present!" (pp. 216, 17.) Le Dran considers this form of whitlow to differ from the preceding in'not being consequent on phlegmonous but erysipelatous inflammation : and he does " not think that an erysipelas affecting these parts, and forming a whitlow can proceed from an internal cause, as other tendons are not found subject to this disorder; but it may be owing to a puncture which has affected the tendon, together with the sheath, or even the sheath alone. These two parts, we know, are blended together at the third joint where the tendon is inserted into the bone : it is therefore no wonder if inflammation of the one should extend to the other. The inflammation spreads afterwards all over the hand and along the muscle from which the tendon arises, as far as to the fore-arm, sometimes even to the whole arm, forming an erysipelatous inflation, wiiich terminates under the arm-pit, and swells the axillary glands. The pain and fever are then very violent, attended sometimes with delirium and convul- sions." (p. 419; Fr. edit., p. 547.) This tendinous and the cellular whitlow just described are continually running one into the other from continuous sympathy; and, under one or other form, or a compound of both, often appears the result of punctured wounds, (which will be hereafter considered, par. 328,) especially those most dangerous and often fatal re- ceived during dissection. The inflammation set up in the tendon or its sheath, and propagated from the one to the other, as described by Le Dran, is always accom- panied with inflammation of the neighbouring cellular tissue, and, as Chelius ob- serves, often spreads to the periosteum, which, separating from the bone in conse- quence of the effusion of matter beneath it, and often participating in the slough of the theca and tendon, which not unfrequently, though not so constantly, happens in this disease, that we can agree in Le Dran's definition, that it is " not a phlegmo- nous abscess, like the second kind, but a putrefaction either of the sheath alone or the tendon with it." Under these circumstances, the bone is destroyed and exfo- liates, which is commonly a very tedious though not dangerous process.—J. F. S.] Fourth. On the inflammation taking place in the periosteum ; the pain is excessively severe, though not spreading over the hand and fore-arm ; the affected finger at the beginning is not at all swollen ; it soon suppu- rates, and the bone is attacked. The severe kinds of whitlow may be connected with each other, inas- much as a less may pass into a more severe form. In the spreading of the inflammation over the hand, painful swellings may occur in various parts. A painful state, near the nail of the little finger, without any previously apparent inflainmation, has been observed, which Richter calls the dry whitlow, in which the pain continues for minutes or hours, and then disappears for days or weeks. On amputation of the finger all the soft parts are found natural, but tbe bone converted into a mass resembling fat (a). [Abernethy calls this Paronychia osseosa. Le Dran asserts " that this species of whitlow proceeds from a disease of the bone, in consequence of which the periosteum soon putrefies, or is attacked with an ery- sipelas which degenerates into a putrefaction: from whence it happens that when making an opening, the bone is found bare and frequently carious." He observes that "the inflammation seldom extends over the fore-arm, as described in the pre- ceding kind." (p. 420 ; Fr. edit., p. 550.) I do not recollect to have distinguished this disease, and doubt much whether the indications mentioned are sufficient for that purpose.—j. f. s. Abernethy speaks of " an ulceration with great thickening at the end of the fingers and toes, and pain particularly at night, which has been described under the (a) Acrill, Chirurgische Vorfalle, Got., 1777, vol. p. 210. VOL. I.—19 213 CAUSES OF WHITLOW. name of Epinychia. It goes on producing disease of the skin, and no nail will grow, or perhaps the disease extends and leaves a little island of nail, and this I have seen plucked out as the cause of the disease, though, it was really the only sound part. I have seen it go on for three years and not get well. It is the produce of an ill state of health." (a.) I presume under this name Abernethy refers to the dis- ease called by Sauvages (b) Epinydis ,- he describes it, however, as a pustule risino-in the night, resembling a boil, of a blackish red colour, crowding together three"or four lines in diameter, affecting chiefly the legs, and very frequently pain- ful, especially at night. He describes two species,—E. vulgaris, and E. pru- riginosa. John Pearson speaks of a Venereal Paronychia, which he describes as appearing in the form of a smooth, soft, unresisting tumour, of a dark red colour, and situated in the cellular membrane, about the root of the nail. It is attended with an incon- siderable degree of pain in the incipient state ; but, as suppuration advances, the pain increases in severity; its progress towards maturation is generally slow, and seldom completed. When the sordid matter it contains is evacuated, the nail is gene- rally found to be loose, and a very foul, but exquisitely sensible ulcer is exposed ; Considerable sloughs of cellular membrane, &c.,are frequently exfoliated, so that the cavity of the sore is often very deep. The discoloured and tumid state of the skin commonly extends along the finger, considerably beyond the margin of the ulcer; in such cases, the integuments that envelop the finger become remarkably thickened, and the cellular membrane so firmly condensed as not to permit the skin to glide over the subjacent parts. The bone is not usually found in a carious state. This species of paronychia is more frequently seen among the lower class of people, when they labour under lues venerea, than in the higher ranks of life. It does not appear to be connected with any particular state of the disease, nor is it confined to one sex more than the other. In the Lock Hospital it occurs in the proportion of about one patient in five hundred." (pp. 85-7.) It is evident, however, that Pearson is not quite satisfied as to the actual nature of this disease, which seems more to resemble onychia maligna than any other form of whitlow ; for he proceeds :—" When I adopt the name of venereal paronychia, it is not with the design of implying that this is a true venereal abscess, containing a fluid wThich is capable of communicating syphilis to a sound person. Its progress and cure seem to be unconnected with the increased or diminished action of the venereal poison in the constitution, and to be also uninfluenced by the operation of mercury. I consider the venereal disease as a re- mote cause which gives occasion to the appearance of this, as well as several other diseases, that are widely different from its own specific nature." (p. 88.)] 186. The causes of whitlow are in many cases unknown ; it is often, however, very common at certain periods. Sometimes a general cause, as gout, and rheumatism, seems to give rise to it; but, in most cases, the cause is local, as contusion, sudden warming of the fingers after they have been chilled, injury with fine puncturing instruments, from splinters, and so on. To these causes Garengeot adds " the excrescences (or rather little shreds) which form about the nails, and are commonly known as hagnails.'''' And he observes, " that wcrk-women using the needle are most subject to whitlow; though, on the other hand, they protect themselves by immediately sucking their finger, thus imita- ting the suckers of wounds, or certain irregular practitioners; because, by this pro- ceeding they abstract the blood which escapes from the little vessels opened by the sharp instrument, and thus prevent any deposit, and consequently also abscess." (pp. 2S7, 8.) Another very common cause of whitlow is the impure soda often used by laundresses in washing linen, which often either irritates any small scratch or crack there may be in the skin of the finger, or even first produces a cleft which presents the appearance of a knife having been drawn through the cuticle down to the cutis, and then, irritating the latter, sets up considerable inflammation in the shape of whitlow.—j. f. s. Hunter takes the whitlow as an example of " the ulcerative process having n° (a) MS. Lectures on Surgery. (b) Nosologia Methodica. Amsterdam, 1768. 4to. vol. i. TREATMENT OF WHITLOW. 219 power over the cuticle, so that when the matter has got to that part it stops, and cannot make its way through till the cuticle bursts by distention." (p. 469.)] 187. The treatment of whitlow varies according to its different forms. In the first form, it may often be at the very onset dispersed by cold applications. If pus be formed, it must be soon evacuated, that it may not spread beneath the nail. If the nail, however, be loosened, it must be partially removed with the scissors, and a piece of linen spread with cerate must be laid between the edge of the nail and the soft parts, in order to prevent the irritation of the latter. If pus be collected beneath the nail, the latter must be scraped thin, so that it may be pierced with the bistoury, and the pus allowed to escape ; or, if the nail be somewhat loose, it may be torn off. Generally, as it separates, a new nail grows ; it should be covered with wax, to give it a good shape. [Gibson says " venesection, both general and topical, may be required in the early stages of whitlow; leeches especially prove very serviceable in all cases, by abating pain and reducing the inflammation. These remedies, however, are seldom sufficient to procure resolution; but this has often been accomplished by the early and repeated applications of a blister. On the other hand, it must be stated that many patients derive no advantage whatever from the blister." He further, and very justly, notices :—" The same applications, I have observed, produce very oppo- site effects on different patients : thus I have known common linseed oil spread over a whitlow afford instantaneous relief in some cases, and, in others, so far from proving beneficial, aggravate all the symptoms. Soft soap or common brown soap, warmed and applied to the affected part occasionally acts in a wonderful manner, assuaging the pain and subduing the swelling in a very short time. Poultices some- times give relief, and are useful always in softening the skin and removing tension; but, when the swelling is very great, the pain intense, and matter evidently formed, the most effectual mode of easing the patient is to lay the part open freely with the knife." (p. 188.) Hunter observes, that " the application of poultices in these cases is of more benefit than in any other, because here they can act mechanically, viz. the moisture being imbibed by the cuticle as in a sponge, and thereby softening the cuticle, by which means it becomes larger in its dimensions, and less durable in its texture." He advocates of course the early opening of these abscesses; and, speaking of the fungus which almost invariably protrudes through, as also when the skin gives way of itself, he says :—"it is a common practice to eat this down by escharotics, as if it was a diseased fungus; but this additional pain is very unnecessary, as the de- stroying a part which has only escaped from pressure cannot, in the least, affect that which is within; and, by simply poulticing till the inflammation and, of course, the tumefaction subsides, these protruded parts are gradually drawn into their original situations." (p. 470.) With the practice of freely opening the whitlow I fully concur, and the sooner it is done after suppuration has taken place, and the cuticle is raised like a blister from the true skin, the better. The suppuration takes place usually in twenty-four or forty-eight hours from the onset of the disease, and should be carefully watched that it may be punctured immediately the pus has been poured out. The longer cutting through the skin is delayed after this event, so much the worse; for, beside the separation of a larger extent of cuticle and even of the nail, and the continuance of violent pain from the pressure which the pent-up matter makes on the sensitive extremities of the nerves at the tips of the fingers, the pus presses also on the cutis and causes it to ulcerate, thereby rendering the cure at best tardy; and often pro- ducing a very ugly and tiresome sore. After the pus has been discharged by punc- turing or cuttinn- through the cuticle, it is best to notch out a little bitof the skin, to ensure a free and constant escape for the matter, otherwise the cut edges often be- come glued trio-ether by the drying of the pus between them, and then it again collects, and sometimes needs a fresh cut. If the pus, be confined beneath the nail, as is sometimes the case, the nail having been scraped, it should then have a little hole carefully cut through it to let the matter out. It rarely happens that the whole nail at once separates from the true and highly sensible skin beneath, but is held 220 TREATMENT OF WHITLOW. sometimes at the root, side, or end according to the part at which the pus has been poured out. I do not think it advisable to thrust in lint to save the soft parts be- neath, as scraping the centre of the nail, from root to tip, till it will bear scraping no longer without bleeding, or, in other words, till it is almost completely scraped through, allows the edge of the nail so to alter its place that little or no irritation is pro- duced by it. All that is necessary is to give free vent to any matter which may exist, to keep the parts clear from any dirty or irritating substances, and to prevent the loosened part of the nail (the movement of which causes much pain) being disturbed, which is best done by wrapping in a poultice, or covering with wax and oil dress- ing, for I am not disposed to remove any part of it so long as the cutis beneath con- tinues suppurating, as the nail protects it best, just as the cuticle does a blister-sore, and, as the new nail forms, it gradually stretches beneath it, and then, but not till then, may portions of the old separating nail be cut off. If, however, as is sometimes the case, the loosened nail digs in and irritates the sore; if the cutis have ulcerated in consequence of the pus not having been evacuated sufficiently early, or, if it twist up, as it will occasionally do, and continually catch in the dressing, then it may be cut off. I am no advocate for tearing off the nail, nor any part of it, and I can scarcely imagine that in this form of the disease it is ever necessary.—j. f. s. Higginbotham advises brushing over the whitlow with nitrate of silver, and con- siders it very good practice. I have not, however, had any experience of it. Gibson mentions that Perkins of Philadelphia is said to have frequently removed whitlows in a very short time by an admixture of corrosive sublimate and white vitriol, applied to the part on lint steeped in tincture of myrrh, and suffered to remain for several days. Gibson has tried the remedy in several instances, but cannot say it has answered his expectations in any one case. (p. 189.)] 188. The second form of whitlow requires, in consequence of the severity of the inflammation, bleeding or leeches to the affected finger, cold applications, and rubbing in mercurial ointment. If the cause of whitlow be a puncture, it must be ascertained whether any splinter remain; and, if so, it must be removed; also, if any noxious matter have penetrated into a wound, it must be carefully washed out with warm water. If resolution do not occur in the first three days, the affected part must be cut into. The patient is always thereby relieved, either by the escape of the pus, or, if the pus be not perfectly formed, by the division of the tough and tight skin, and by the bleeding. The cut should always be pretty free. Soothing poultices should be applied till the pain and swelling have subsided. If the skin be thinned to a great extent, and raised like a bladder, it must be removed as soon as the pus is discharged. [The treatment of this is precisely similar to that directed for the previous form of the disease, excepting that, in the present case, it is always necessary to cut through the cutis as well as the cuticle, and relieve the tension of both at once; the pus, if the incision be made at the proper time, not having yet ulcerated through to the cutis, and poured itself beneath the cuticle.—J. F. S.J 180. The treatment of the third form of whitlow is the same as in the second, except that the incision must not be deferred beyond the third day; for, otherwise, the tendon will be destroyed. The cut must pene- trate into the tendon sheath. The pain is usually quickly diminished by the application of soothing remedies. As the inflammation often spreads over the whole hand, if in any particular part pain, swelling, and fluctuation occur, it must be opened : and as, when the tendons are destroyed, the motions of the finger are lost, care must always be taken to keep it in a proper position. [The incision, when the sheath of the tendon is concerned, should always be made deeply and freely, and in the course of the tendon, as if that be divided longitudi- nally, no inconvenience accrues to the movement of the finger or toe, as would were IN-GROWING OF THE NAIL. 221 it cut transversely. It must not be expected always to find pus flow in openino- the tendon-sheath ; very frequently but a drop or two escapes, and sometimes none, the secretion not having been established. The anticipation of such occurrence is not, however, to be any bar to making the incision, as the immediate relief it affords, by getting rid of the tension, and emptying the vessels of the inflamed part, and check- ing the high constitutional disturbance almost always attending inflamed tendinous structures, is most remarkable. If the inflammation and suppuration be propagated to the palmar or plantar fascia, or further on the arm or leg, incisions through the fascia must be made, for the voidance of the pus. As this subject will be again treated of, in considering punctured wounds, it need not at present be further pursued. As regards the sloughing of the tendons of the fingers or toes, the extent to which they are destroyed is very great: indeed, I have known an instance of slough of the entire tendon, up to its junction with the muscular fibres, of one of the flexor muscles of a finger, of which the top had sloughed off. The straight position is best for the finder, when either flexor or extensor tendons has sloughed ; but very commonly, for working persons, its immobility is so inconvenient, that it is necessary to amputate it at the knuckle.—J. F. S.] 190. The fourth form of whitlow must be treated the same as the previous forms; and, if the severe pain and tightness do not diminish, an early cut through the whole must be made, to prevent the destruc- tion of the bone. This must be made where the pain is most severe, and must be carried down to the bone. The finger must be put in decoction of chamomile if the suppuration be sluggish; it must be bathed in lye (a,) and soothing applications employed. The bone of the last finger-joint often separates, or may be removed frequently without pain, the finger retaining its form, though rather shorter. If the bone of the second or first joint be affected, the removal of the finger is necessary. However, under the preceding treatment of soothing poultices and bathing with chamomile, the most severe cases of this kind are often cured. [For the cure of Epinychia Abernethy recommends the use of " a combination of arsenic and sulphur, which, together with some herbs, formed the principal part of a quack medicine called Plunket's Epithema; that composition, bowever, was horribly painful, and produced the most horrible sloughs, not by decomposing the parts, but by exciting vehement action ; I have, therefore, followed it so as to render it only a corrigent, and, in many cases, it will relieve without producing pain." For the same purpose he used also successfully the Aqua Arsenicalis of St. Bartho- lomew's Hospital, consisting of arseniate of potash, spirit, and mint water, which he considered to have an excellent corrigent effect on local diseased action. It is also well to use it mixed with basilicon; but care must be taken in its employment, for if the constitution become affected, as sometimes happens, it will make the patient very ill, and even cause temporary blindness.] 191. It is here proper to mention two diseased conditions which depend on changed form a,nd direction or unnatural structure of the nail, or are therewith connected : growing of the nail into the flesh, and inflammation and suppuration of the surf ace producing the nail. 192. The In-growing of the Nail into the flesh depends less on an increase of the breadth of the nail, than on the pressing upwards of the soft parts. It is ordinarily consequent on squeezing together of the toes by tight shoes, especially if the nails be cut too short, and is almost confined to the great toe, specially to that side of it next the second toe. The irritation of the edge of the nail causes inflammation ; at first, the secretion of a serous fluid which dries to a callous mass; subsequentlv suppuration and fungous excrescences spring up, which spread over the (a) Common mixture of crude potash and water. 19* 222 TREATMENT OF nail; the disease may even assume a carcinomatous character, or the inflammation may extend to the bone. The nail itself grows thicker, and is frequently softened at the ulcerated part. The pain in the severe form of this disease is always very great, and walking often becomes quite impossible. [The commencement of this disease has been well described by YVardrop, who says:—" This affection is chiefly confined to the great toe. It frequently happens, when the foot is kept in a tight shoe, that the soft parts situated on the edge of the nail thicken, are pressed over it, and become more or less inflamed and painful. If the inflammation and thickening of the soft parts increase, the edge of the nail becomes at last completely imbedded in them, and its sharp edge, from the pressure of the body when resting on the foot, increases the inflammation, and produces suppuration of the contiguous soft parts. Thus the hard and sharp nail, by pressing on the surface which has become ulcerated, causes great pain and lameness, and in many cases, prevents the person from walking. The ulceration generally extends round a considerable part of the nail, and a fungus arises from this surface, accom- panied by excessive irritability." (p. 130.) This, "the first variety," says Dupuytren, "consists of the ulceration sometimes of one, sometimes of both the lateral edges of the nail at once. It almost always happens on the outer edge. If the conformation of the nail be remembered, if the flatness of its body, the direction of its corners, its situation in the thickness of the skin wrhich surrounds and covers it, we may easily conceive how a tight or ill made shoe, producing a constant pressure on the hail, will forcibly thrust its corners upon those parts of the skin where it rests. By degrees these corners, always more or less sharp and cutting, bury themselves .into the skin, with the greater facility as the skin itself pushes upwards and outwards, and endeavours to cover them ; finally, the irritation increases by walking, and produces a very painful inflammation. Such is really the most common cause of the incarnation of the outer edge of the great toe. The affection almost alwrays commences at the point of union of the front with the side edge of the nail, and appears to be occasioned by the fold that forms in the flesh; as this interrupts the action of the scissors while cutting the nail, they are almost invariably checked before they can cut away the whole of its front edge, especially at that point where an angle is formed by union of the nail with its cor- responding lateral edge. This allows the remaining nail to grow, which soon forms a sharp point, punctures, and cuts into the flesh, and gives a sort of signal of ulcera- tion which soon spreads along the corresponding edge of the nail. So sure is it that this point is constantly found on the nails which have been torn off. Scarcely has the nail cut itself into the skin it covers, than the pain becomes very severe; walking, and even standing, are unbearable; a serous or sero-purulent oozing establishes itself in the part affected, and, if the patient take exercise, the whole foot swells. The pain, however, continues increasing, the oozing becomes more abun- dant, and the sanious pus which escapes has a smell more fetid from mixing with the perspiratory humour of the feet. The patient, tormented with pain, is driven to raise the nail and cut it back; but this proceeding, though sometimes causing momentary relief, far from curing increases the difficulty of the treatment. Finally, if the disease be left alone, the ulcer produced sometimes runs into a cancerous state, sometimes is covered with enormous vegetations, sometimes even the inflammation is propagated to the periosteum, and soon gives rise to caries and necrosis of one or more phalanges." (p. 46.) Dupuytren also mentions that the disease is liable to be confused with some others, and instances a case which, for eight years, had been treated as if depending on gout. Colles (a) observes, that "the colour of the fungus is rather florid; surface is smooth; the discharge is purulent, in small quantity, and tolerably healthy, unless the part have been irritated by too much exercise of the limbs, or by some external inflammation or local injury: there is little or no surrounding inflammation, no en- largement of the toe, and the pain is in general trifling, unless during exercise, when the weight of the body on the limb causes the nail to press into the soft sub- («) Observations on some Morbid Affections of the Nail of the Great Toe; in Dublin Journal of Medical Science, vol. xxiii. 1843. IN-GROWING NAIL. 223 stance of the fungus, which thus often induces considerable uneasiness and lame- ness. This disease does not appear to me to have any tendency to spread to, or to involve, the adjoining parts, as I have seen cases in which it has remained stationary for some months, and in one for two years; at the end of which period the symptoms were in no way more severe than at the commencement, although most writers assert that it generally passes into malignant onychia. The origin of this trouble- some affection is usually attributed to the effects of a tight boot or shoe, or to some accident in cutting or of breaking off the end of the nail; in many instances, how- ever, no cause can be recollected or assigned for its occurrence." (p. 241.) Collks, however, speaks of the form of disease liable to be mistaken for gout as quite distinct from that just described. He says:—"There is another morbid affection which occasionally engages the anterior and inner angle of the great toe nail, and which causes considerable lameness and uneasiness, particularly on pres- sure ; this affection is often mistaken for an attack of gout, especially in those per- sons where such an attack may be expected or even desired. In this disease there is no swelling or redness ; but pain, on pressure, at the anterior and internal angle of the nail. On close examination of this spot, we find that this angle rests on a hard white mass of laminated, horny cuticle, which we can easily remove in bran-like scales, when we shall see a small cup-like cavity, without any ulceration or disease. The ungual angle appears thick and bulbous opposite this point, and the pain is caused by its pressing against this mass. * * * I may remark I have never seen this disease engage the outer angle, neither have I seen that last described engage the inner angle of the toe-nail." (p. 244, 5.) VS-k In the slighter forms of this disease, it may always be easily re- lieved by inserting a slip of lead under the edge of the nail which is to be fixed there, by twisting round it a piece of sticking plaster; by which means the nail is raised and the flesh depressed. If there be fungous excrescences, these must be first removed with lunar caustic, or cut off with the knife. It would be too painful at once to insert the plate of lead beneath the edge of the nail; but it is also unnecessary, as its insertion under the front edge, if the nail be allowed to grow, gradually raises the hind part, and then the lead may be further intro- duced. When the nail has recovered its proper direction, it must not be cut too short nor rounded at the sides, but only shortened trans- versely. With these precautions, this treatment, recommended by Desault and Richerand, has, in almost all cases, answered my wishes. Introduction of charpie or wax beneath the edge of the nail is useless. Biessey (a) scrapes the whole free surface of the nail till nearly its entire thick- ness is destroyed, particularly in the centre. Then he touches the scraped part five or six times, more or less severely, with lunar caustic until the nail contracts com- pletely, and draws out of the flesh. He then lays pads of charpie under the edge of the nail, till by its growth it stretches over the bulbous part of the toe. Zeis (b) especially recommends the introduction of charpie under the edge of the nail, and the use of foot-baths. [The treatment recommended by Meigs (c) is very simple:—"Let a small pledget of lint, just large enough to cover all the granulations, and of sufficient thickness to act as a compress, be neatly adjusted, over which a roller of linen, three-quarters of an inch wide and eight or ten inches long, is to be applied, having one end previously spread with adhesive plaster. By this method we are enabled, with great ease, to make it not only act on the compress, which will destroy the gra- nulations very rapidly, but, by confining the toe and nail, to prevent even the small degree of sliding motion or friction of the latter over the wounded part, thus doing away one principal cause of the disease. By pursuing this treatment, the patient will"generally recover, even while walking about." (p. 266.) (a) Revue Mediosilc, April, 1830. (c) Cursory Remarks on Inverted Toe- (6) In Danzig, Ess ii sur l'Oiijrle Incarne; Nail; in Philadephia Journal of the Med. suivi dc la description d'un nouveau Procede and Phys. Sciences, vol. ii. 1821. 0]>:';rutoirc. Strasbourg, 1836. 224 TREATMENT OF IN-GROWING NAIL. Astley Cooper says, that "the application of a blister will bring away the cuticle, and often the nail along with it." (p. 193.) I have tried this plan several times, but have rarely succeeded in inducing the separation of the nail.—J. F. S.] 194. It is not possible, however, in many cases to render assistance by this treatment, partly because the nail has gone in too deeply, and is too much covered with fungous growths, partly because it is too painful. Here the treatment proposed by Dupuytren is applicable. When the inflammation of the toe is diminished by poulticing, rest, and so on, a pair of straight sharp scissors, of which one branch is very pointed, must be thrust by a sudden motion from before backwards, from the front edge to the middle of the root of the nail, to at least three lines behind its hinder edge, thus dividing the nail into two halves. The diseased halves are then to be taken hold of and twisted round, all connexion destroyed, and the nail itself removed ; the same must be done with the other half, if necessary. If the fungous excrescences are high, they must be destroyed with caustic, by which the skin beneath the nail dries, the sore surface disappears, and in from twenty-four to forty-eight hours is cicatrized. In old persons the nail is generally not replaced ; in young persons it sometimes reappears; a recurrence of the disease is, however, rarely to be feared. [According to Scoutteten (a), if it is determined to destroy the matrix of the nail, the point of a straight bistoury should be placed upon the middle of the dis- eased phalanx, about four lines from the edge of the nail, and the skin divided down to the nail. The cut should not penetrate deeper than the matrix, as this only is to be exposed. The edges of the wound are then to be raised from the nail and kept asunder by the introduction of charpie. On the day following, the little wound must be filled with a caustic paste, (five parts of caustic potash, and six of quick- lime, moistened with alcohol immediately before use,) and the dry phalanx, covered with sticking plaster, the excrescences must be destroyed by the gradual application of the caustic; and, after the falling off of the slough, until the healing is complete, which takes place usually in twenty-four days, there is nothing to do except merely to cut away the exposed edges of the nail with scissors. The following are Pare's and Faye's treatment. The former consists in thrust- ing in a straight bistoury at the base of the soft parts which cover the nail, and dividing this part from before backwards to the edge of the nail, then the bistoury is to be turned to the other side, and the flap perfectly removed. Cauterization is to follow. In Faye's method a V-shaped piece of the nail (first scraped thin) must be removed out of the front edge, and through the two edges a metal wire is drawn and twisted together, by which the edges of the cut are approximated, and the in- growing edge of the nail raised up. Of the various modes of treatment which have been recommended for the cure of the in-growing of the nail, compare Michaelis (b) Sachs (c) Zeis (d). Astley Cooper first proposed the operation of, "with a pair of scissors, slitting up the nail on that side where the disease exists, and then with a pair of forceps turning back and completely removing the divided portion. This is a very painful operation certainly; but I have known persons get well by this treatment in ten days, where the complaint had for months resisted every other. The applications to be used after the operation are of little importance ; poultices are the best, and these will be required but for a very limited period, for the irritating cause having been removed, the fungus will soon disappear." (pp. 192, 3.) Nearly the same plan was followed by Dupuytren, as above described. I entirely concur, however, with the observations made by Colles on this point. He says:—"This operation inflicts a great degree of suffering, because in this dis- ease the nail is not, as in onychia, seperated from the vascular and highly sensitive (a) Remarques sur le Cours d'Operations de Chirurgie de M. Dionis. 8vo. 1736. (6) In Journal von Graeee und von Walther, vol. xiv. p. 284. (c) Ibid. Vol. xxii. p. 108. (d) Above cited. INFLAMMATION, &C, OF NAIL MATRIX. 225 matrix, except only through a small extent of space, not more than a quarter of an inch at its external angle, and, therefore, the scissors pushed upwards between the nail and the adherent matrix, and the forcible evulsion of the former by the forceps, must cause exquisite pain, which though of short duration, can be regarded as no- thing short of actual torture. * * * I am by no means an advocate for this peculiarly painful and distressing operation, but on the contrary, I believe we may be relieved from the necessity of performing it, and that we can in all instances, effect a perma- nent cure by a very simple operation, and one comparatively free from suffering; namely, by confining the excision of the nail to so much only as is already detached from the matrix; all of this portion, as well as that imbedded in the fungus, must be removed." His operation consists in having the fungus pressed down with aspatula, and the edge of the portion of nail to be removed seized with strong flat-blade for- ceps; the flat end of a probe is then thrust beneath the nail as far as it will go, di- recting it towards the outer edge, and upon the pointed edge of a pair of stout crooked scissors is to be carried, with one stroke of which the detached portion of nail is cut off, and then drawn away by the forceps with moderate force. But, if this be insuf- ficient, the probe is to be passed still higher, the scissors introduced again, and a second cut frees the nail: sometimes a sharp momentary pain occurs from the point of the scissors penetrating the sensitive matrix. The only dressing required is " a small bit of dry lint, to be pressed firmly between the fungus and the edge of the nail." 'In a few hours the toe is free from pain, and the patient can walk without any lameness or uneasiness in three or four days after the operation. The dressing continues per- fectly dry, and need not be changed till the fourth day. At this time the fungus will be found much reduced in size, perfectly dry, and of a firmer consistence. * * * In the course of ten or fifteen days the fungus will have entirely disappeared, and the parts be restored to a healthy state. * * * The result of the operation is not in all cases so successful; in some instances, four or five days after the operation, the pa- tient will complain of some uneasiness in the toe, when we shall find on examination that the dressing is moistened with a little discharge, and that a small portion of a whitish substance, like soft and swollen leather, is rising up through the fungus.— This substance may be regarded as a sort of accessory ungual filament, arising close to the original nail, from the anterior and outer border of its matrix, and which is now altered in texture and direction ; this filament is so soft that it breaks and tears, if caught by the common dissecting forceps." (pp. 243, 4.)] 195. The Inflammation and Suppuration of the Surface which pro- duces the nail, (Dupuytren's matrix of the nail,) which Wardrop has pointed out as a peculiar kind of whitlow, (Onychia maligna,) begins with dusky redness and swelling of the soft parts in the neighborhood of the nail; an ichorous fluid oozes between the nail and soft parts ; ulcera- tion takes place at the root of the nail; the neighbouring parts become swollen, dusky red, and the pus which the sore secretes is ill-conditioned and stinking. The nail loses its colour, becomes gray or black, and does not grow, so that it shortens and loses half its width ; sometimes it entirely disappears, and only a few streaks of horn are seen here and there ; sometimes part is concealed under the fungating flesh ; in many cases it is completely separated. This state may continue for many years, and the toe or finger become converted into a shapeless mass. This dis- ease is frequently very painful, especially when touched ; the fungations (which do not, as in simple in-growing of the nail, arise on the side, but are seated at the root of the nail) bleed on walking and standing. [As Dupuytren observes, " the formation of this second species will be better un- derstood after saying a few words on the anatomical structure of the nail. Its adhe- rent extremity, the only part at present,needing study, is implanted in the skin in a pe- culiar manner; the latter, having passed on the dorsal surface of the nail, is reflected, and, having reached the hind end, divides, into two portions, the epidermis which covers the whole superficial layer, and the cutis which passes beneath the nail, and is con- tinuous with the skin covering the free extremity of the finger. The cul de sac, in which this part of the nail is received, is called the matrix. It is, then, very impor- 226 TREATMENT OF tant to be acquainted with this disposition of the organ, as fully explaining why the nail received into the flesh is, in many cases, only produced by the ramming in (re- foulement) of its free extremity into the cul de sac. This alteration may take place in consequence of the running over, or fall of heavy weight upon the great toe. What- ever may be the cause, the patient at first complains when walking of a pain which gradually increases ; the kind of cul de sac, lodging the base of the nail, reddens and inflames, as well as the bottom of the fold which receives its lateral edges; ulceration is soon observed, which makes rapid progress; its form becomes semilunar, its edges elevated and hard, its base red, violet, and livid. The nail shortens and diminishes to half its size, sometimes even entirely disappears, and in its stead are observed, here and there, pencils of horny substance; often, also, part of the nail is hidden under fun- gous flesh. These fungosities serve to distinguish this disease, resulting from primi- tive alteration of the skin, from that consequent on the nail digging into the flesh.— When the disease is caused by the nail, the fungosities originating from the inflam- mation occur on the front and sides of the nail; but when, on the contrary, it depends on the affection of the skin, the fungosities are always observed at the root of the nail. The colour of the nail in these cases is gray and black; sometimes it does not retain its ordinary connexions; the sore is generally bathed in a saniousor sanguinblent sup- puration, and spreads far and wide a fetid smell. If the patient walk, or even remain standing upright, the fungosities bleed : every kind of shoe is unbearable, and the least rubbing is extremely painful. In general it is impossible to' remain in the same place with persons who have this disease, as the stench which circulates around them, and clings to their clothes, is infectious and penetrating, being produced by the union of the ichorous pus oozing from the bottom of the ulcer, and the copious sweat which the feet of these patients secrete." (p. 61-4.) Colles mentions:—"When the original nail has been cast off, we usually see projecting from the sides, and tarsal border of the ulcer, a narrow plate of a white sub- stance, not unlike white leather soaked in water; this sometimes forms one conti- nuous shelf all around the ulcerated border, projecting in a peculiarly prominent man- ner, that is, rather at an angle to, instead of being a plane parallel with, the dorsal sur- face of the phalanx. In some cases this white substance (which is the result of an abortive attempt to produce a true nail) appears only in detached spots or flakes, the intermediate parts of the ulcerated margin being devoid of any such growths; they are most frequently seen at the posterior and anterior angles of the nail, but occasion- ally in other parts of the circumference. The surrounding integument is discoloured, being often of a livid or purplish tint; it is also indurated, and exudes a copious per- spiration, of a peculiar heavy odour. This ulceration sometimes induces caries of the bone, and even extends to the phalangeal articulation." (p. 246.) Wardrop says :—" In this state I have seen the disease continue for several years, so, that the toe or finger became a deformed bulbous mass. The pain is sometimes very acute, but the disease is more commonly indolent, and accompanied with little uneasiness. It affects both the toes and the fingers. I have only observed it on the great toe, and more frequently on the thumb than any of the fingers. It occurs, too, chiefly in young people ; but I have also seen adults affected with it." (p. 136.) " When the disease, more especially, attacks that part of the skin immediately beneath the nail, then," says Dupuytren, " is it observed to be raised by the develop- ment of little tumours, the presence of which cause pain in proportion as the pressure is more considerable. They are of different kinds, fibrous, cartilaginous, bony or vas- cular ; and the proof of their development, simply depending on alteration of the cutis covering the nail, is, that if they are removed, without, also, taking away the skin from whence they spring, the skin generally, again becomes diseased, ulcerates, and sooner or later requires complete removal." (p. 64.)—J. F. S.] 196. The causes of this disease are either local, mechanical, or che- mical, for instance in persons having much to do with alkalies ; or general, herpetic, but especially syphilitic, dyscracy. Several fingers and toes of both hands and feet are then attacked at the same time; the disease com- mences sometimes with little sores in the clefts between the fingers or toes, which extend around the origin of the nails ; these separate from their root. The disease ordinarily resists murcurials. 19/. In the treatment of this disease internal remedies are to be em- INFLAMED NAIL MATRIX. 227 ployed, according to its different causes, and local, according to the degree of irritation; leeches, soothing applications, baths, and so on, and the foot kept quiet. Astley Cooper recommended a grain of calomel and opium night and morning with decoction of sarsaparilla, and the application of lint steeped in lime water and calomel, (black wash,) covered with oiled silk. If this treatment be ineffectual, the nail with its secreting surface should, according to the opinion of both Dupuytren and Cooper, be removed. According to Dupuy- tren, the foot is to be steadied, and the diseased toe held with the left hand ; a deep semicircular cut is then to be made with a straight bis- toury three lines behind the skin in which the nail is supported, and parallel to its fold. An assistant then holds the toe, whilst the operator raises the flaps from behind forwards with a pair of forceps, and dissects away the skin which produces the nail ; if any shreds of nail remain, they must be gradually destroyed. This operation is very painful, but of short duration. The toe must be enveloped in pieces of linen perfo- rated and spread- with cerate, and a thin bundle of charpie with a com- press put upon it; the patient put to bed, and the foot half bent laid on a pillow. The pain subsides some hours after the operation, and on the third or fourth day, when the bandage is removed, the wound is found covered with good pus, and is then to be simply dressed. The granu- lations are to be touched from time to time with lunar caustic; if new shreds of horn are formed, they must be pulled out, and the part pro- ducing them be cut away. Usually in from fourteen to eighteen days the patient can return again to his business. The scar is a smooth thick nailless skin, which sometimes acquires a horny consistence. If the disease depends on syphilis, Dupuytren treats it with liq. hydr. nitr. I must deny the assertion that in this disease the tearing out the nail and the employment of caustic are of no effect. I have in several instances torn out the nail and merely employed soothing poultices and bathing, and have effected permanent cure. I, therefore, only have recourse to extirpation when the above treatment has not any permanent result. [In regard to the treatment of this disease, Wardrop says:—"The only local treatment I have ever seen relieve this complaint has been the evulsion of the nail, and afterwards the occasional application of escharotics to the ulcerated surface. But even this painful operation in some cases does not succeed, and will seldom be submitted to by the patient; he must therefore, either continue lame or submit to the removal of the member. Other surgeons have cut out the soft parts at the root of the nail, an operation equally severe." In preference, therefore, Wardrop recom- mends the internal exhibition of mercury, which he has found beneficial, "in small doses at first, and gradually increased, so as in twelve or fourteen days sensibly to affect the gums. The sores, in general, soon assumed a healing appearance after the system was in this state, and the bulbous swelling of the joint gradually sub- sided. The ulcers were dressed with wax ointment, so that the effects of the mer- cury might be watched ; and, after the sore began to heal, a weak solution of the muriate of mercury and escharotics were occasionally used to clean the wound. The mercury was continued till the ulcers were perfectly healed, and, as is generally advisable under such circumstances, it was taken in smaller quantities for some time after the patients were apparently cured." (p. 138.) Colles, admitting that " the complete removal of the entire of this diseased matrix does effect the cure in a very short space of time, provided the bone or joint is not diseased, (in which case amputation is inevitable,) and that subsequently rest and simple dressing will alone accomplish the healing process, the place of the nail being supplied by adverse hard skin," objects to the operation, not only for its 228 TREATMENT OF INFLAMED NAIL MATRIX. severity, but because " it also too frequently happens, that the disease returns in some one spot or. other, owing to the matrix not having been wholly eradicated, which, indeed, it is often extremely difficult to do, for the shape of the toe is so bulbous, and so deformed, the texture so changed and so condensed by chronic inflammation, and the edges of the ulcer are so raised over the part to be removed, that even an anatomist cannot easily recognise the relations of the several tissues involved in the disease, or ascertain the exact extent of the substance to be excised." Hence " some days after the operation the patient becomes alarmed, by feeling a slight return of his former uneasiness, on any exercise of the limb, or any pressure on some particular spot, generally on one of the angles of the original ulcer; and on careful examination there is found still a little ulceration, and a fresh production of that ungual growth already described, and indicating the persistence of some of the diseased matrix." (pp. 246, 7.) This causes a repetition of all the suffering, and requires removal a second, or even a third time. Colles, therefore, prefers the following plan, which in a few days will induce a considerable amendment, and even a perfect cure in the course of three or four wreeks :— * * * " I confine the patient to bed, and direct a poultice to the toe for two or three days. I then cleanse the ulcer carefully, by directing on it, from some height, a small stream of tepid water, from a sponge. 1 next cut away as much of the loose nail as I can, without paining or irritating the sensitive surface around, and then I fumigate the part by means of the mercurial candle, containing hydr. sulph. rubr. 3j., ad cerae%\). This fumigation is to be applied night and morning, and, after each, the toe should be gently enveloped in lint or linen, lightly spread with ung. spermac. In four or five days the patient will express himself considerably relieved : the discharge from the ulcer will be found of a healthy, purulent character, and the appearance of the whole part much more favourable. The fumigation is to be still persevered in, and all projecting portions of nail to be closely cut. I consider this latter direction as very essential, as thereby the mercurial fumes can have more free access to the surface of the ulcer. In proportion as the ulcer improves it is interesting to observe, so does the condition of the growing nail; it acquires not only its natural firm and horny consistence, but also assumes its proper horizontal direction. For some time after the general surface of the ulcer has been healed, there still remain small spots of ulceration, generally at the angles around some white germs of new nail; against these points the full force of the mercurial vapour should be directed. This can be effected by adding a small conical wavy tube to the funnel. I attribute much of the success of this treatment to the use of the mercurial candle in preference to fumigation in the ordinary way. During this treatment the patient must absolutely abstain from walking or even standing on the affected limb ; exercise but for a single day will counterbalance all the amendment produced by a week's rest and fumigation." (pp. 348, 9.) Colles did not employ any constitutional treatment in his cases, but he thinks it may sometimes be required. I have never employed this mercurial treatment, and, therefore, only mention it on Wardrop's authority. Neither have I ever torn out the nail, nor dissected away the nail gland, although I admit that either is very efficient, because I believe they are horribly painful, and not absolutely called-for operations, and may, therefore, be avoided. The only advantage, as seems to me, resulting from their preference is, that the disease is cured rather more quickly. My own observation convinces me that cauterizing the nail gland with nitric acid is equally efficient, though not quite so speedy. It should be run quickly round the gland with a bit of stick in sufficient quantity to destroy it, otherwise a second application will certainly be needed ; and, as soon as it has dried, a poultice should be applied. If successful, the nail in a day or two curls up out of the matrix, and gradually separates from the rest of its attachments; but if it do not, the acid must be applied again, and if properly done, will not generally call for repetition.—J. F. S.] For the further literature of Paronychia Maligna, see Dupuytren, De l'Ongle rentre dans les chairs; in Lecons Orales, vol. iii. F.Lebut. Etudes Anatomiques et Pathologiques sur l'Onglade; in Repertoire Generate d'Anatomie et de Physiologie Pathologique et de Clinique Chirurgicale, Pans, vol. iv. 1827, p, 225. 15 Cooper, Astley ; in London Medical and Physical Journal, April, 1827, p. 189. Froriep, Chirurg. Kupfertafeln, Plate cxcvi. cxcviii. Rynd, Fr., A. B., Observations on some of the Affections of the Finrrers and INFLAMMATION OF THE JOINTS. 229 Toes attended with Fungous growths; in Medico-Chirurgical Review and Journal of Practical Medicine, vol. xiv., 1831. VIII.—OF THE INFLAMMATION OF JOINTS. Pott, P., Chirurgical Works, vol. iii.—Article, On that kind of Palsy of the Lower Limbs frequently accompanying a Curvature of the Spine, <^c. Reimarus, Diss, de Tumore Ligamentorum circa Articulos, Fungo Articulorum dicto. Leyden, 1757. Russell, James, A Treatise on the Morbid Affections of the Knee-Joint. Edinb. 1802. 8vo. Verbeck, F. A., De Morbo Coxaico seu de Tumore Albo Articuli Coxofemoralis. Paris, 1806. 4to. Cooper, Samuel, A Treatise on the Diseases of Joints. London, 1807. 8vo. Ficker, Worin besteht dasEigentliche Uebel, das unter dem freiwilligenHinken der Kinder bekannt ist. Wien, 1807. Albers, The same question considered by Schreger in Horne's Archiv., 1810, vol. i. part ii. p. 269. Ford, E., Observations on Diseases of the Hip-Joint; with Notes by Thomas Copeland. London, 1810. 8vo. Moffait, L., Sur la Phlegmasie des Membranes Sereuses des Articulations. Paris, 1810. 4to. Copeland, Thomas, Observations on the Symptoms and Treatment of the Diseased Spine, more particularly relating to the incipient stages ; with some Remarks on the consequent Palsy. London, 1815. 8vo. Volpi, T., Saggio di Osservazioni e di Esperienze medico-chirurgiche fatte nello Spedale Civico de Pavia. 3 vols. Milano e Pavia, 1814-16. 8vo. Schupke, De Luxatione Spontanea. Atlantis et Epistrophei. Berol., 1816. 4to. Schrag, Diss, de Luxatione Vertebrarum Spontanea Observatio quasdam, cum Tab. aeneis. Lips. 1817. 4to. Rust, N., Arthrokakologie, oder fiber die Verenkungen durch innere Bedingungen; mit 8 Kupfertafeln. Wien. 1817. 4to. Brodie, B. C, Pathological and Surgical Observations on Diseases of the Joints. London, 2d Edit., 1822. 8vo. Reisich, J. M., Theoretisch-praktischer Versuch fiber die Coxalgie; oder das sogenannte freiwillige Hinken. Prague, 1824. 8vo. Wenzel, C, uber die Kranheiten am Riickgrathe; mit 8 Kupfertafeln. Bamberg, 1824. Margot, Memoire sur les Tumeurs Blanches des Articulations recueilli a l'Hopital de la Pitie dans les Salles de M. Lisfranc ; in Archives Generates de Medecine, May, 1826. Scott, J., Surgical Observations on the Treatment of Chronic Inflammation in various structures, particularly as exemplified in the Diseases of Joints. London, 1828. JjEGEr, M., die Entzundung der Wirbelbeine, ihre Arten und ihr Ausgang in Knockenfrass und Congestions abscess. Erlang, 1831. 8vo. Wickham, Will. J., A practical Treatise on Diseases of the Joints. Winchester, 1833. Mayo Herbert, Outlines of Human Pathology. London, 1836. 8vo. Coulson, W., On the Diseases of the Hip-Joint; with plain and coloured Plates. London, 1837, 4to. 2d Edit. 1841, 8vo. 198. The various parts of which the joints consist, stand in the most intimate relation with each other; therefore, in disease of any one, all the other parts are gradually drawn into participation. We speak of the ligaments and synovial membrane, the cartilages, and the spongy ends of bones. In each of these structures inflammation may be set up as the primary disease, which may be communicated to the others, and various organic changes be produced, which are described as Articular Vol. i.—20 230 INFLAMMATION OF Fungus (Fungus Articulorum, Lat.; Gliedschwamm, Germ.; Fongus Articulaires, Fr.,) White Swelling of the Joints, (Tumor Albus Articulo- rum, Lat. ; Weisse Glenkgeschwulst, Germ. ; Tumeurs Blanches, Fr.,) Arthrocace, Dislocations from their original place, (Luxationes Spontanece, Lat.; Verrenkungen aus inneren Bedingungen, Germ.; Luxations Sponta- nees, Fr.) In reference to joints, Hunter (a) observes :■—" They being circumscribed cavities, are subject to the same diseases as other circumscribed cavities, as inflam- mation, &c.; but their peculiar structure sometimes renders their consequences different. Nature is very little disposed to take on the adhesive inflammation, because the necessary consequence would be a loss of motion in a part originally intended for motion. This makes inflammation in joints so much worse than many other circumscribed cavities; for, as before observed, if adhesive inflammation does not come on, the inflammation and consequent suppuration must spread through the whole cavity. * * * Inflammation in joints is generally of more serious consequence than in other parts ; even when resolved it is disagreeable; yet this is always to be wished for." pp. 519, 20.) 199. Inflammation of Joints (Arthrophlogosis, Lat.; Gelenkentziindung, Germ.; Inflammation des Articulations, Fr.) is either idiopathic or symptomatic, and its course acute, subacute, or chronic. The causes are external injury, cold, and general diseases, which either of them- selves or after the previous operation of local mischief produce disease of the joint, as scrofulous, gouty, rheumatic affections, syphilis, diseases of the skin, metastasis, suppression of the ordinary secretions, and so on. The reason of their beginningisometimes in the soft, sometimes in the hard parts, depends perhaps on the different relations in which the general and local causes stand to the production of the disease. A.—OF THE INFLAMMATION OF THE LIGAMENTS. 200. When inflammation takes place in the fibrous structure of a joint, (Inflainmation Ligamentorum, Lat.; Entzundung Gelenkbdnder, Germ.*; Inflammation des Ligaments, Fr.,) it is only in certain stages confined to that alone; but, in its further progress, it spreads to the cellular tissue surrounding the capsule of the joint without, and the synovial membrane within. Its course is more or less acute or chronic. [In regard to the rarity of affections of the ligaments independent of other parts of a joint, Brodie observes :—" The ligaments cannot be regarded as more exempt from disease than the fibrous membranes, which they very nearly resemble in their texture. It is not improbable that some of the pains which take place in the joints, in syphilitic affections, may depend oh a diseased action occurring in the ligaments; and there can be no doubt that the long continued symptoms which occasionally follow a severe sprain, depend on these same parts being in a state of slow inflam- mation, in consequence of some of their fibres having been ruptured or overstretched. I cannot say that I have never seen a case where disease, independently of these causes, has originated in the ligaments; but I certainly have never met with a case where it has been proved to have done so, by dissection, and it may be safely asserted that this is a rare occurrence, and not what happens in the ordinary diseases to which joints are liable." (p. 7.)] Among the " variety of cases," mentioned by Mayo, u in which the ligaments appear to be the parts exclusively or principally affected," is one arising from a blow («) Lectures on Surgery ; in Palmer's Edition of his Works, vol. i. THE LIGAMENTS. 231 on the knee, in which, " after many weeks' confinement to the bed or sofa, the least exertion was followed by heat and pain in the knee. The joint was, in a slight degree, larger than the sound knee; but it contained no fluid; and pressure of the articular surfaces against each other, produced no pain. It caused no pain to rest his weight upon the extended knee; but when he stood on the other leg, and allowed the diseased knee to hang or swing, he felt uneasiness in it, which was greatly increased by twisting the knee. When he remained perfectly still, he would experience no uneasy feeling in the joint for several days together; and tben, without any visible cause, the joint became a little heated and the skin slightly reddened. The same effects followed any deviation from the strictest rest." (p. 79, 80.) Now, if the injuring cause here mentioned as "a blow," be "a twist or wrench," from the foot slipping, or by falling on the hand, the symptoms are precisely simi- lar in their immediate appearance, and their long continuance. Whether, in such cases, the ligamentous fibres are simply stretched beyond what they can bear with comfort, or whether they are actually torn, in however slight degree, is very difficult to determine; but that they at once become as painful before any inflammation can have been set up, as they afterwards are when they are said to be inflamed there is no doubt. Still, however, this seems the very utmost we know, and little enough it is, of inflammation of ligaments, and I fully concur in the following observations of Wickham of Winchester, who says:—We have no reason, a priori, to suppose that the ligaments are not liable to primary disease, or that a lesion of these structures may not originate complaint, and propagate it to the other component parts of the joint. The result of my observation, however, has been, that the ligaments are the last of all the different parts diseased, and that it is very common, on dissection, to find the ligaments perfect and uninfluenced by disease, even when every other texture is either altered or destroyed. The intimate connexion of the capsular liga- ment with the cellular tissue which invests it, and the synovial membrane which lines it, renders it difficult to distinguish inflammation begun in the ligaments, from diseased action commencing in those other parts; and, in its first stages, I should think it impossible to detect it; in the latter stages it has so blended itself with disorganizing effects of disease in other parts as not easily to be selected as giving rise to primary affections." (p. 98.)] 201. In Acute Inflainmation of the Ligaments there is more or less severe pain, increased by pressure and motion, and accompanied with a feeling of heat and warmth ; sometimes there is also an elastic, tense, not hard, shining swelling, which in very severe inflammations, is red and extremely painful, and most prominent at those parts where the joint capsule is merely covered by skin and cellular tissue. The limb is bent. The pain is not simply confined to the joint; it spreads in the course of the tendons, and by the periosteum, over part of the limb, which frequently becomes oedematous. Fever is always connected with a high degree of this inflammation ; frequently the fever precedes, and the inflainmation follows it. If the inflammation do not subside, it spreads upon the synovial membrane, and then produces the changes hereafter to be mentioned ; or it runs into a chronic condition, in which the pain subsides, but the swelling increases. If this inflammation come on less actively, i. e., in a subacute form, it may continue a very long time. [I do not know in what respect simple acute inflammation of ligaments differs from acute rheumatism ; nor how they are to !be discriminated primarily except by refe- rence to the constitutional disturbance which, in this condition, is a very uncertain sign. But that they are different I think there cannot be a doubt; as in the one case, the disease is propagated to the other parts of the joint, and the ordinary results of inflammation attacking mucous surfaces, viz., suppuration and ulceration, ensue in the cavity of the joint itself; whilst, in rheumatism, the affection is confined to the ligaments and the parts exterior to, or enveloping them, and consists only in the effusion of serum or adhesive matter into the cellular tissue, thereby increasing the bulk and interfering with the motions of the joint. I must confess that I am igno- rant of the signs which indicate simple inflammation of ligament, independent of rbeu- 232 INFLAMMATION OF THE LIGAMENTS. matism or of injury, and that I do not know the peculiar symptoms which point out the extension of inflammation to the ligaments, from the synovial membrane or proper tissue of joints. As seems to me, all our knowledge of inflamed ligaments is merely negative, except, perhaps, so far as concerns the injuries to ligaments known as sprains. I say perhaps, because in sprains the pain, on motion, which is held to be one principal sign of inflammation, occurs immediately after the ac- cident, and before it is possible that inflammation can have occurred, however early that condition may, under these circumstances, be setup; and, if the part be care- fully preserved in a state of repose, pain does not exist, nor is any other sign of in- flammation present, although the slightest movement will produce excruciating pain; to explain the production of which, some other cause than inflammation must be sought for.—J. F. S.] 202. Chronic inflammation of the Ligaments either begins with acute pain, or comes on gradually with a less degree of pain, observable only on pressure and motion, and entirely subsiding when the patient is at rest; with a soft, doughy-elastic, colourless swelling, which frequently, like the pain, is but partial; usually, however, the whole joint is affected; it becomes shiny as the swelling goes on, penetrated with varicose veins, and is mostly somewhat warmer than the healthy parts, in which it is gradually lost. As the swelling increases, the limb wastes, becomes bent at the joint, and all extension is impossible, on account of the thickening of the ligaments and cellular tissue ; the patient has the sen- sation of weight, weakness, heat in the whole limb, and is frequently, from time to time, attacked with severe pain. 203. Acute inflammation of the ligaments may be resolved under pro- per treatment, in which case simultaneous critical symptoms of fever appear, the inflammation subsides, and there remains only for a long time slight swelling and stiffness of the joint. Rarely, and only in rheu- matic and gouty subjects, does metastasis take place to other parts. Very severe inflammation runs either into suppuration and abscess on the external surface of the capsular ligament, or, when continued, upon the interior parts, into suppuration of the joint, and carious destruction, in which case the local and general symptoms hereafter to be described occur. In chronic inflammation the thickening of the ligaments, and the cellular tissue, surrounding them, may be very considerable without the deep parts of the joint being attacked. This swelling is rarely dis- persed entirely; generally, there remains thickening of the ligaments, with impeded motion of the joint, and a greater or less degree of bend- ing of the limb ; just as in gouty inflammation, swellings, and knots arise from early deposits. If the chronic inflammation attack the synovial mem- brane, earlier or later suppuration of the joint is produced, and the happiest result is anchylosis; but generally hectic consumption is pro- duced. 204. Examination of the joint presents various changes in the struc- tures affected, according to the degree and duration of the inflammation. In the more trifling form, the ligaments, and their investing cellular tis- sue, are thickened ; subsequently they are changed into a brawny or fatty, grayish white, yellowish or brownish mass. The synovial mem- brane often remains unchanged for a considerable time, or, at the utmost, has a wrinkled appearance. In the further progress of the disease, how- ever, it is drawn into this fat-like degeneration ; so that the whole of the joint presents a homogeneous mass, in which are dispersed white mem- branous shreds, vessels, and tendons, and not unfrequently abscesses TREATMENT. 233 from the size of a pea to that of a hazel nut (a.) This mass gradually involves the healthy cellular tissue, and even extends to the muscles. If further destruction occur in the joint, all those changes take place which are alluded to in other forms of inflammation of the joints. [Key (b) says, that, " in ligamentous fibre, the process of ulceration appears to be accompanied with some peculiar circumstances. The ligament, instead of pre- serving its usual form and size, becomes distended, and feels pulpy. When cut into, the fibres are found to be separated from each other by a vascular structure, which, upon being injected, has a villous appearance. This interstitial vascular mass is the reticular membrane, that in the healthy structure unites the ligamentous fibres; under inflammation it becomes highly vascular, and assumes the appearance alluded to, while the fibres of the ligament retain their natural glistening appearance, until, in the progress of the disease, they at length become softened and pulpy pre- viously to their undergoing absorption. It is not improbable that the ligamen- tous fibres themselves are passive in the ulcerative process which, there is some reason for believing, is performed entirely by the vascular tissue that sur- rounds them." (p. 215.) Sometimes, young people, from being compelled by their occupation to bear heavy weights, and especially from wheeling heavy barrows, have the plantar liga- ments of the foot, or the inner lateral ligament of the knee, very considerably length- ened ; and, as regards the lateral, that very common condition of the joint in labour- ing persons called knock-knees or in-knees, a very remarkable instance of which is mentioned by Wickham, in which " the left leg was so affected by this lateral in- clination that the leg was nearly at right angles with the thigh." (p. 100.) Not unfrequently, also, are the ligaments of a joint generally relaxed, and thereby the strength of the joint greatly diminished, when large quantities of synovial fluid pro- duced by inflammation and long continuing, have at last been absorbed. In neither case, however, is there any actual disease of the ligament, but simply are they re- laxed.—J. F. S.] 205. The causes of inflammation of the ligaments may be all the general causes already mentioned, (par. 199,) especially the traumatic and rheumatic in scrofulous and lymphatic persons, in whom particularly the chronic form of this inflammation is most common. It may occur in all joints, but it is most common in that of the knee and elbow. 206. The treatment must be guided by both the degree of the inflamma- tion and its cause. In severe traumatic inflammation, general, but espe- cially repeated and free local blood-letting by leeches, cold applications, and a corresponding general treatment must be employed. Perfect rest in this, as in all other forms of inflammation of the joints, is absolutely necessary. In rheumatic and gouty inflammation in the slighter stages, warmth is to be applied, by rolling in flannel, woollen, and the like, and the internal use of diaphoretics, as hydrochlorate of ammonia, anti- monial wine in small doses, or wine of colchicum seeds; in more severe inflammation, more active antiphlogistic treatment is called for, always, however, with caution and proper restriction. In the chronic course of inflammation, repeated blood-letting by a small number of leeches or by- cupping-glasses must be employed. If rheumatism or scrofula be the ground of the disease, the internal use especially of vinum colchici and cod-liver oil is requisite. As the inflammation subsides, mercurial friction and repeated blisters are very advantageous. 207. If without further inflammation thickening and swelling of the ligaments and cellular tissue occur, their dispersion must be attempted (a) J.*:ger : in his Handworterbuch der gesammten Chirurgie und Augenheilkunde, Leipzig, 1836, vol. i. p. 537. (b) On the Ulcerative Process in Joints ; in Med. Chir. Trans., vol. xviii. 1833. 20* 234 SUPPURATION IN CELLULAR TISSUE OF JOINTS. by encouraging absorption, for which purpose various infrictions, fomen- tations, and plasters are recommended. The most efficient remedies, according to my experience, are, repeated cupping or dry cupping, rub- bing in mercurial ointment either alone or with caustic ammonia and camphor, iodine ointment, proper pressure with a bandage ; in suppuration, continued blisters ; corresponding general treatment of the internal cause. I have not seen any particular benefit from moxas, or from the slight scoring with the actual cautery, which has been recommended. 208. If the inflammation run into suppuration on the external surface of the capsular ligament, it must, when fluctuation is distinct, be properly opened ; care must be taken for the free flow of the pus, and poultices applied (1.) If the suppuration attack the joint itself, and, if the sim- ple local use of poultices and corresponding general treatment do not lead us to hope that anchylosis can be effected ; if the symptoms become worse, and hectic consumption be feared, amputation, or under favour- able circumstances, removal of the carious joint ends of the bones, is the only remedy. During the treatment of the inflammation of joints, care must be taken that the limb should be as much as possible in such position that, if stiffness and anchylosis should happen, it may be the least inconvenient; in the knee-joint, for instance, in a straight posture, but at the elbow-joint half-bent (2.) [(1) The suppuration which Chelius here mentions, has certainly nothing to do with the ligaments, but is that " Disease of the cellular membrane of joints " spoken of by Wickham, which has resemblance, in some respects to the white swelling described by Russell and Nicolai, but seems to me, on the whole, very different. " Inflammation," says he, " having its seat in the cellular substance, existing as a primary affection of that tissue, and continuing to occupy that part only of the joint, gives birth to a succes- sion of symptoms wholly distinct from those which are the effect of disease, in any other part." It is first indicated by " swelling more or less, according to the si- tuation and extent of the inflammation. If the cellular substance within the joint be affected, and the inflammation be of a chronic character, the swelling is but slight, but if that structure which invests the capsule be attacked, the swelling is very considerable, and the inflammation generally more active in its progress. The first stages of the disease, under all circumstances, are nearly the same, differing only in degree. The swelling of the joint is equable and firm, and, as the skin becomes placed on the stretch, grows shining and white : this stage, which may be called the adhesive, will last sometimes for many months, and produce very great irritation on the general system." As the skin stretches more, the sensibility is much quickened, and the patient's sufferings much aggravated, so that " at times he cannot bear the weight of the bed-clothes. * * * The pain, until the arrival of this symptom, is more obtuse and oftentimes but very slight. The duration of this stage varies very much; but the approach of that which is attended by the suppurative process, is, for the most part, marked by the usual constitutional symptoms indicating the formation cf matter, such as rigors and succeeding heat, and general febrile paroxysms, which assume, if the suppuration be large, a hectic character. It sometimes happens that the constitutional disturbance is so great as to require the removal of the limb, and that before any other structure is implicated ; but it is more common for inflamma- tion to propagate itself by contiguity to the synovial membrane, and afterwards to the articulating cartilages, when it becomes confused with the peculiar symptoms attendant on disease of those parts." The disease of the cellular membrane ap- pears in two forms: " the one in which a single, or more spots may have been the seat of the inflammation, having its origin from some injury which the part may have received, and pursuing a chronic course to the formation of small sacs of pus in those situations, which, perhaps, ulcerate through the synovial membrane; the second case is that in which the whole of the cellular membrane, surrounding the articulation, becomes inflamed, and ultimately envelops the joint in one large ab- STRUCTURE OF SYNOVIAL MEMBRANE. 235 scess. The first case is the more common of the two; the latter the effect of a sud- den attack of inflammation, and more active in its course." (p. 84-6.) In 1839, I amputated the knee of a man, aged twenty-seven years, for disease of the former kind, which had resulted from slipping down stairs and bending his knee under him sixteen months before. The examination of the joint presented a large abscess on the inner condyle of the thigh-bone, which it had flattened and some- what roughened without laying it bare ; another long abscess extending from the knee upwards behind the hamstring, and downward, about three inches, below the head of the fibula; the skin over both abscesses very thin, but neither communicating with the other, nor with an open wound upon the outer condyle, the remains of an abscess which had burst five weeks before tbe operation. Behind the knee, in the popliteal space, was a fourth abscess, large and deep. Neither of the four bad any commu- nication with the cavity of the knee-joint, which did not contain any pus, but the synovial membrane, around the knee-cap, was thickened, soft, and jelly-like. Earlier in the same year I saw a case of the latter kind in a woman who, about a month previous, had received a blow on the inside of the knee ; a fortnight after she was attacked with severe shivering, which was followed by much swelling and puffiness about the joint, especially on the inside. A puncture was made just below the knee-cap, and twelve ounces of good pus discharged, but it was requisite to make a second opening two days after, and eight ounces more passed out. She did well. In a second case, where 1 had been attending a lady for many months, with what seemed to me chronic inflammation of the synovial membrane, with large effusion in the cavity of the joint; suppuration occurred some time after, whilst she was in Barbadoes ; the abscess was opened, and she did well. Both these cases I, at the time, considered connected with the joint; but the result proved that such could not have been the case.—j. f. s. (2) Chelius's direction to keep the knee-joint straight, as the most convenient position, when there is a probability of stiffness resulting from the disease with which it is affected, is not at all satisfactory, nor should it be followed, as, thus fixed, it causes considerable halting in the gait, and, preventing the play of the ankle-joint, puts the patient in nearly the same condition as if he wore a wooden leg. And also when he sits down, the limb is obliged to be thrust out before him, very incon- veniently both to himself and others. The knee should, indeed, from the first of the treatment, be half bent and supported beneath by pillows, as the tendons passing over the joint, and the tendinous expansions connected with its capsule are thereby relaxed; and, if permanent stiffness take place, the bent position is most convenient for sitting; and, in walking, the play of the ankle-joint is so increased that the halting is comparatively trifling, and the patient's movements much more free than if straight. The bent position is obviously best for persons accustomed to ride on horseback. For these reasons, therefore, the bent is preferable to the straight posi- tion of the knee and leg.—J. F. S.] B.—OF INFLAMMATION OF THE SYNOVIAL MEMBRANE. 209. Inflammation of the Synovial Membrane (Inflammatio Membrance Synomnlis, Lat.; Entzundung der Synonalhaut, Germ.; Inflammation de la Membrane Synoviale, Fr.) may arise either as a primary disease, or may- have extended from other tissues. The synovial membrane is frequently attacked with inflammation on account of its vital relations ; it has gene- rally a tedious course, and the functions of the joint are not at the onset entirely destroyed. [The importance of every circumstance connected with the diseases of joints, and the difference of opinion in regard to the special structure in which one or other of them commences, and by which they are sustained, is sufficient warrant for giving some account, of their natural structure and condition. And for this reason I shall here notice The Structure of Synovial Membrane.—The first satisfactory mention of it is that 336 STRUCTURE OF SYNOVIAL MEMBRANE. of William Hunter (a); a careful perusal of which will show that very little has been really added by modern writers to his observations. "We are told by anatomists," says this able teacher (b), "that cartilages are covered with a membrane named perichondrium. If they mean the cartilages of the ribs, larynx, ear, &c, there, indeed, such a membrane is very conspicuous; but the perichondrium of the smooth articulating cartilages is so fine and firmly traced upon the surface that there is room to doubt whether it has been often demonstrated or rightly understood. This membrane, however, I have raised in pretty large pieces, after macerating, and find it to be a continuation of that fine smooth mem- brane (the synovial membrane) that lines the capsular ligament, folded over the end of the bone, from where that ligament is inserted. On the neck of the bone, or be- tween the insertion of the ligament and border of the cartilage it is very conspicu- ous, and may be pulled up with a pair of pincers; but where it covers the cartilage it coheres to it so closely that it is not to be traced in the recent subject without great care and delicacy. In this particular it resembles that membrane which is common to the eyelids and the fore part of the eyeball, and which is loosely con- nected with the albuginea, but strongly attached to the cornea." (p. 516.) This observation of William Hunter's in regard to the continuity of the synovial membrane over the cartilage of joints, has been confirmed by Henle (c), who says:—"The epithelial layer on the inner surface of the synovial membrane attains a thickness of 0,006"—0,008". Many layers of cells are here observed piled on each other, and the outermost, viz. those next the free surface, are like those in the epidermis of the cutis and mucosa, broad, flat, and of irregular form; their nucleus is not always distinct. The round cells of the synovial membrane have, in the mean, a diameter of 0,004'"—0,005 ", and the oblong cells measure as much in their smallest diameter. The ligaments and cartilages which pass through the cavity of a joint, have a covering of epithelium which is continued in a thin layer upon the joint surfaces of the cartilages, but separated from the cartilage corpuscles by a thin layer of cellular tissue." (p. 116.) Toynree (d) also states that, " in a foetal calf, towards the latter part of uterine ex- istence, he had removed the synovial membrane from nearly the entire surface of the articular cartilage of the condyle of the femur, to which it was attached by a con- siderable layer of cellular tissue in which the blood-vessels are seen to ramify." (p. 167.) These are not, however, as he supposes, the branches of William Hun- ter's circulus articuli vascuhsus, which, as we shall hereafter see, are described by him "as creeping around the cartilaginous brim, or under the cartilage," for especial reasons; butToYNBEE himself properly describes them as "the vessels of the syno- vial membrane which cover the articular cartilage," and says that "during foetal and infantile life, previous to the period when the articular cartilages are subject to pressure, the synovial vessels extend over certain portions of them, from which, in childhood and during adult age, owing to the functions of the joints, they are neces- sarily absent. At the period when the child begins to use the various joints, and (a) I am not aware it is generally known of Physicians in London, in the year 17f>6; that William Hunter was not only a sur- but at the time of his writing thie, as well geon, but also a member of the Court of As as other valuable papers, he was a surgeon; sistants of the Corporation of surgeons of and it is too honourable a distinction for the London. I became accidentally acquainted Corporation of surgeons to have included with this fact last year, in looking over the amongst its members two such celebrated Court Books of the Corporation, where is the men as William and John Hunter, as to following entry:—"1st July, 1756. It hav- pass over without its being distinctly re- ing been reported to the" Court that Dr. corded.—J. F. S. William Hunter, a member of this Court, (b) Of the Structure and Diseases of Ar was desirous of being disfranchised on such ticulating Cartilages; in Philos. Trans, vol. terms as the Court would agree on, it was xlii. 1743. Ordered that the clerk do deliver him the (c) Ueber die Ausbreitung des Epitheli- instrument of disfranchisement, under the um im Menselilichen Korper; in Mulleb'8 seal of this Corporation, on his paying down Archiv. 1838. forty guineas for the same, being the same (d) Researches tending to prove the non- terms on which it was granted to Dr. Wa- vascularity and the peculiar uniform mode then, on the 6th Dec. 1753."—William of organization and nutrition of certain ani- Hunter took the degree of M. D. in the mal tissues, viz. Articular Cartilage and the University of Glasgow, 24th October, 1750, Cartilage of the different classes of Fibro- and he became a Licentiate of the College Cartilage, &c, &c; in Phil. Trans., 1841. STRUCTURE OF SYNOVIAL MEMBRANE. 237 subjects them to pressure, these vessels recede, and in adult life they are only found on that margin of articular cartilage which is exempt from the influence of external forces. The arteries which pass between the articular cartilage and the synovial membrane, like those of the foetus, may be considered as the termination of the articular arteries. At the point where the reflexed become continuous with the ar- ticular synovial membrane, it contains large vessels subjacent to it which are nu- merous and plexiform. Immediately, however, that they enter the cellular web, between the articular cartilage and synovial membrane, they become enlarged and straight, and pass to a greater or less distance over the border of the articular carti- lage, forming loops, frequently with considerable dilatations, and becoming finally continuous with the veins. The free surface of adult cartilage appears to be nourished by the liquor sanguinis which exudes from these looped and dilated ves- sels." (pp. 172,3.) I doubt the correctness of Toynbee's statement of the recession of the vessels when the child begins to use his joints, and consider that the analogy with the conjunctive coat of the eyeball here also holds good, and, as there, under ordinary circumstances, its vessels are not seen, as they then carry only colourless blood, yet under inflammation they appear numerous and loaded with red blood; so also the same condition is that of the vessels of synovial membrane. Before con- cluding this short notice regarding the synovial membrane, I would mention Clop- ton Havers' (a) opinion, that the "soft parts, found in the sinuses of the bones within the joint, which to the touch seemed vesicular and spongious, and the mem- brane not only lax, but also unequal, with protuberances of a different figure and magnitude," were, the latter, " truly glandulous, and those soft bodies, glands." He applied to them the name of " glandulae mucilaginosae, or the mucilaginous glands." (pp. 188, 89.) After giving an account of their structure and vascularity, he speaks of their form as " various, and accommodated to the sinus or cavity in which they are seated. Some are not only long but broad at their top, and grow narrow towards the top, so as to terminate in an edge ; some have a broad basis, and rise into a sort of cone; some are like 1 ittle ridges, some like a fimbria, some are broad and pretty flat;" and then observes on their situation, that "in general they are so seated that they cannot be injured by a compression from the bones." (pp. 193, 4.) Goodsir (b), in referring to them, says:—" I have been in the habit of considering the highly vascular fringes and processes of the synovial membranes as more active in the formation of epithelium, and therefore more closely allied to the secreting organs than other portions of these membranes. If this be the case, Clopton Havers was not mistaken in his ideas regarding the functions of these vascular fringes. They are situated where they cannot interfere with the motions of the joint. They hang in those parts of the cavity best fitted for containing and acting as reservoirs of synovia; and their high vascularity, and the pulpy nature of their serous covering tend to strengthen this opinion." (pp. 42, 3.) That Havers' opinion is correct as to the function of these vascular fringes, I think there is not a doubt, having had to-day (May 2, 1845) the pleasure of being shown, by my laborious friend Rainey, our microscopist at St. Thomas's museum, their minute structure on the synovial membrane of joints and in tendon sheaths, which, he tells me, he made out and showed to our mutual friend Grainger, at least eighteen months since, although till the present time, it has not been made public. lie demonstrates the vessels contained in the fringes as having a very different dis- position from those secreting fat, and, being surrounded by an investment of epithe- lium, from which it is evident that the old idea of their being the synovial glands is correct, and that the modern notion of their being fat-vessels, held by some physi- ologists, is incorrect. Moreover, that when the sheath, at least of an adult tendon, is injected, these organs are the only parts which readily receive the injection, and appear like vascular lobules on a whitish ground, the other parts of the sheath scarcely exhibiting any injection.—j. f. s. " No part of the body," says Brodie, "is much more frequently diseased than the synovial membranes. This is what their anatomical structure and functions might lead us to expect, since we find that living organs are more subject to have their natural functions deranged, in proportion as they are more vascular, and as they are employed in a greater degree in the process of secretion." (p. 8.)] (a) Ostelogia Nova; or some New Ob- (b) On the Structure of the Serous Mem- servations of the Bones, &c. London, 1691. branes ; in his Anatomical and Patliological 8vo. Observations. Edinburgh, 1845. 8vo. 233 INFLAMMATION OF THE SYNOVIAL MEMBRANE. At the beginning the pain was trifling, and, although affecting the whole joint, is more severe at one part. Frequently, however, it is very violent, motion of the joint is impossible, and fever occurs. After some time swelling comes on, which fluctuates differently, according to the form of the joint, and is more evident at those points where the soft parts afford least resistance. If the inflammation be long continued, or recur frequently, the swelling becomes gradually larger and harder, depending on the loosening and hardening of the synovial membrane and liga- ments ; severe pain, sleeplessness, and hectic fever come on; the swelling bursts at different parts, and the powers of the patient are ex- hausted. In the most favourable cases anchylosis takes place. If the inflainmation be very insidious, and do not go on to loosening of the synovial membrane, it may terminate in dropsy of the joint and weak- ening of the ligaments ; so, when the inflammation specially affects the ligaments, thickening of them, with impeded motion and greater or less bending of the joint, swellings, and knots from deposition of earthy matter, (especially in gouty inflammation,) may occur. [Chelius here considers as one, the two forms of diseased synovial membrane which have been distinguished by Brodie ; the one as " consisting simply in a morbid action," and the other, or " others, in which the morbid action produces a morbid change of anatomical structure." (p. 76.) The former, arising simply from common inflammation, which may be resolved entirely, or terminate in one or other of the usual consequences of inflammation, or which may degenerate into the second form, in which a specific change of structure takes place. It will, therefore, be necessary to point out these different forms.—j. f. s. Common inflammation of the synovial membrane may be either acute or chronic, or it may assume the sub-acute form, which is by far the most frequent, and gene- rally passes by the name of chronic inflammation. As to the comparative occurrence of synovial inflammation, Brodie observes;— "Although no period of life is altogether exempt from this disease, it does not occur equally in persons of all ages. It very seldom attacks young children, becomes less rare as they approach the age of puberty, and is very frequent 'in adult persons. This is the reverse of what happens with respect to some of the other diseases to which the joints are liable, and a knowledge of these circumstances will be found of some importance to the surgeon, in assisting him to form a ready diagnosis." (p. 20.) Acute synovial inflammation may arise spontaneously, but mostly it results from injury as either blows or wounds. When it occurs, Brodie observes, that, "the swelling takes place immediately after, or at the same instant, with the first attack of pain; there is redness of the skin; the pain is more severe, and it is so much aggravated by the motion of the parts, that the patient keeps the joint constantly in the same position, and usually in an intermediate state between that of flexion and extension. In addition to these symptoms, there is more or less of symptomatic fever of the inflammatory kind. In a few days, the disease, if left to itself, assumes the chronic form, or, perhaps, under proper treatment, it subsides altogether. It must be observed, however, that the boundaries of acute and chronic inflammation do not admit of being very well defined. These terms accurately enough express the two extremes; but there are numerous intermediate degrees of inflammation, of which it is difficult to determine whether they should be considered as being of the acute or chronic kind." (pp. 31, 2.) Sometimes the inflammation runs on to suppuration, and the constitutional excite- ment is more or less severe till the pus have either found its way out by ulcerating through the whole wall of the joint, or till it have been discharged by puncture: but in either case it sometimes proves fatal from the disturbance produced. The following are examples: Case 1 is mentioned by Brodie :—" A young lady, nine years of age, being at play on the first of January, 1808, fell and wrenched her hip; she experienced so little uneasiness that she walked out on that day as usual. In the evening she went ACUTE INFLAMMATION OF SYNOVIAL MEMBRANE. 239 to a dance, but while there, was seized with a rigor, was carried home, and put to bed. Next morning she was much indisposed, and complained of pain in the thigh and knee; on the following day she had pain in the hip, and was very feverish. These symptoms continued; she became delirous, and she died just a week from the time of the accident. On inspecting the body on the following day, the viscera of the thorax and abdomen were found in a perfectly healthy state. The hip-joint on the side of the injury contained about half an ounce of dark coloured pus ; and the synovial membrane, where it was reflected over the neck of the former, was destroyed by ulceration for about the extent of a shilling." (pp. 73, 4.) Brodie mentions this as a case of "ulceration of the synovial membrane, as a primary affec- tion;" but it seems to me rather the result of the pressure of the pus in attempting to produce an outlet, And I think that his other case, in which there was "about half an ounce of thin pus found in the shoulder-joint; and the synovial membrane bore marks of general inflammation, and in one spot where it was reflected over the neck of the os brachii was destroyed by ulceration for about the extent of a sixpence," (p. 75,) was under similar, though less urgent circumstances.—j. f. s. Case 2 is related by Wickham, in which the pus was discharged by ulceration, but the girl died. M. C, aged fifteen years, applied to him, "on account of pain which she had for several days experienced in her left knee-joint; at that time it had not been severe, but was confined to one spot below the patella, and she de- scribed it as of a dull aching kind." Leeches, saturnine lotion, and aperient medi- cine were ordered. Three days after she was " suffering very greatly; the pain was general over the joint, of the tensive character, and the part swollen to nearly double its natural size. The skin over it was hot and shining; the febrile symp- toms were very high, and delirium had come on. Six days after, suppuration had established itself; and, after the lapse of eleven days more, " she died without any mitigation of the constitutional disturbance ; the sensorium continuing to be affected to the last." (pp. 68, 9.) Case 3.—In this instance the abscess was opened, and ultimately did well. In 1836, E. A., a girl of twenty-two years of age, slipped down stairs, and wrenched her knee, but so slightly, that she took no notice of it till a week after, when she had pain at the top of the knee, which increased so much during a single night, that on the following day she was unable to put her foot to the ground, on account of the severity of the pain. She continued suffering severely for three weeks, and then came to the hospital, the girth of her knee being twenty-two inches : fluctuation was very distinct all round the knee-cap; she was free from pain when at rest, but if moved, pain came on, and was increased if the leg hung down. Leeches, blisters, and an issue were employed, but without benefit. The tumefaction increased, and the neighbouring cellular tissue on the thigh became oedematous. She continued during five weeks getting worse, and, the skin thinning, a lancet was passed in, which evacuated eight ounces of pus, and the wound, having been carefully closed, healed up. But the matter continued to form, and the pain increasing, and the joint having acquired its former size, another puncture was made, and half a pint more pus escaped. The wound was left unclosed, the discharge continued, but in the course of a fortnight, pain even on motion ceased, and she slowly recovered. When the synovialmembrane suppurates after wound of the joint, very commonly the whole of its interior is destroyed, and the patient is worn out, unless the limb be amputated ; or under favourable circumstances the patient recovers with a stiffjoint. If the acute stage be checked, it sometimes subsides entirely, but at other times the inflammation becomes chronic, or terminates in the effusion of a large quantity of fluid in the cavity. In the much more frequent subacute or chronic form, when "inflammation of the synovial membrane takes place, as a symptom of constitutional affection, where the system is under the influence of gout, or rheumatism, &c," Brodie says, "in these cases, the disease, for the most part, is not very severe; it occasions a preternatural secretion of synovia, but does not, in general, terminate in the effusion of coagulable lymph, or in thickening of the inflamed membrane. Sometimes it attacks the greater number of the joints at the same instant, and even extends to the synovial membranes, which constitute the bursas mucosae and sheaths of the tendons. At other times, it leaves one part to attack another, and several joints are affected in suc- cession. In other cases, the disease is entirely local, produced by a sprain, or other injury, or the application of cold, and sometimes arising from no evident cause. 240 SUBACUTE INFLAMMATION OF SYNOVIAL MEMBRANE. * * * "Where the inflammation is thus confined to a single joint, it is more proba- ble that it will assume a severe character, and that it may be of long duration. It leaves the joint with its functions more or less impaired, and occasionally termi- nates in its total destruction. In itself it is a serious disease ; but it is often con- founded under the alarming name of white swelling, with other diseases, which are still more serious." (pp. 21, 2.) " The pain," Brodie observes, " usually continues to increase during the first week or ten days, when it is at its height. Sometimes even at this period the pain is trifling, so that the patient experiences but little inconvenience from it: at other times it is considerable, and every motion of the joint is distressing and difficult. In the course of one or two days after the commencement of the pain, the joint may be observed to be swollen. At first the swelling arises entirely from a preternatural collection of fluid in its cavity. In the superficial joints, the fluid may be dis- tinctly felt to undulate when pressure is made alternately by the two hands placed one on each side. When the inflammation has existed for some time, the fluid is less perceptible than before, in consequence of the synovial membrane having be- come thickened, or from the effusion of lymph on its inner or outer surface; and, in many cases, where the disease has been of long standing, although the joint is much swollen, and symptoms of inflammation still exist, the fluid in its cavity is scarcely to be felt. As the swelling consists more of solid substance, so the na- tural mobility of the joint is, in a great degree, impaired." (p. 23-5.) " Inflammation may attack the synovial membranes in different, degrees of in- tensity; but for the most part, it has the form of a chronic or slow inflammation, which, while it impairs, does not altogether destroy the functions of the joint; and which, if not relieved, in the first instance, by active and judicious treatment, may. like a chronic ophthalmia, continue for weeks or months, and, with occasional recoveries and relapses, may even harass and torment the patient during several successive years." (p. 23.) " The form of the swelling deserves notice. It is not that of the articulating ends of the bones, and, therefore, it differs from the natural form of the joint. The swelling arises chiefly from the distended state of the synovial membrane, and hence its figure depends, in a great measure, on the situation of the ligaments and tendons, which resist it in certain directions, and allow it to take place in others. Thus, when the knee is affected, the swelling is principally observable on the ante- rior and lower part of the thigh, under the extensor muscles, where there is only a yielding cellular structure between those muscles and the bone. It is also often considerable in the spaces between the ligament of the patella and the lateral liga- ments; the fluid collected in the cavity causing the fatty substance to protrude in this situation, where the resistance of the external parts is less than elsewhere. In the elbow, the swelling is principally observable in the posterior part of the arm, above the olechranon, and under the extensor muscles of the fore arm. And in the ankle, it shows itself on each side, in the space between the lateral ligaments and the tendons, which are situated on the anterior part." (pp. 25, 6.) "After inflammation of the synovial membrane has subsided, the fluid is absorbed, and, in some instances, the joint regains its natural figure and mobility; but, in other cases stiffness and swelling remain. Sometimes the swelling has the same peculiar form which it possessed while the inflammation still existed, and while fluid was contained in the joint; and we may suppose that it depends principally on the inner surface of the synovial membrane having a thick lining of coagulable lymph ; at other times, the swelling has the form of the articulating extremities of the bones, that is, nearly the natural form of the joint, and it probably arises from the thickened state of the synovial membrane. * * * In those cases where the synovial membrane is thickened, although the fluid which had been effused is ab- sorbed, and the principal swelling has disappeared, it occasionally happens, not only that a certain degree of inflammation still lingers in the part, but that it con- tinues until the morbid action extends to the other textures, and ultimately ulcera- tion takes place in the cartilages, suppuration is established, and there is complete destruction of the articulating surfaces." (p. 28, 9.) " With respect to the fluctuation," Lawrence (a) says, "that cases of this kind differ materially. In some instances the tumefaction of the joint is quite soft, and (a) Lectures in Lancet, 1829-30, vol. ii. FIBROUS AND SYNOVIAL RHEUMATISM. 241 we can very easily detect the fluid : we can move it from one part to another: by pressing on the tumour above, we elevate the patella from its situation, actually lift it up from the trochlea of the os femoris, and then, by pressure upon it, can push it down again into a sort of cavity. In some cases the swelling feels much harder; and there are cases, where the inflammation is violent and has proceeded rapidly, in which the swelling is so firm as to afford but a slight sensation of tumefaction to the hand. I have seen cases which, from the tension produced by the large quan- tity of fluid, have quite deceived me, and have presented all the characters of a solid tumour. However, on cautiously examining those cases, more particularly if the knee is put as much as possible into the extended state, so as to relax the extensor muscles, you will be able to detect the nature of the tumour, although at first it may give you the impression that it is solid." (p. 480.) Not very unfrequently, I think, though Brodie says "not often * * * a joint is swollen from a preternatural quantity of fluid collected in its cavity, without pain or inflammation. This may be supposed to arise, either from a diminished action of the absorbents, or an increased action of the secreting vessels. The disease may be compared to the dropsy of the peritoneum or pleura, or, more properly, to the hydrocele; and it has been not improperly designated by the terms Hydrarthrus and Hydrops Articuli.'''' (p. 10.) Here would seem to be the most convenient place to mention the alleged diffe- rences between inflammation of the ligaments, and that of the synovial membrane; and, though the form specially mentioned is that of rheumatic inflammation, and it might be more strictly considered to belong to the physician's department, yet, as it is the only attempt made to distinguish between the inflammatory conditions of the two tissues, I shall make no apology for the following long extract from Wat- son^):—"There are two varieties of acute rheumatism, a circumstance first noticed by Dr. Chambers at St. George's Hospital, and afterwards made public by Dr. Francis Hawkins in his Gulstonian Lectures. The varieties are spoken of under the names of fibrous or diffused rheumatism, and synovial rheumatism. I apprehend, however, that in both of them the inflammation has its starting point in some fibrous texture ; but, that in one a considerable extent of that texture is implicated, while the inflammation does not involve the neighbouring synovial or serous tissue; and in the other the extent of fibrous tissue affected in the onset is comparatively small, while the local symptoms are more expressive of the secondary synovial disease. I will briefly state the distinctive characters of these two varieties of what is pri- marily and essentially the same malady. In the one, then, the inflammation com- mences in the immediate neighbourhood of one of the larger joints; not in the joint; but near it. It attacks the tendons, fasciae, ligaments, and possibly also the muscles. There is not, at first, much redness or swelling; but after the pain has been of some duration, there is a puffiness around the parts affected, caused appa- rently by turgescence of the blood-vessels, and at length slight pitting or oedema may supervene, from effusion into the surrounding cellular tissue, and what redness is present is disposed in streaks, following the course of the tendons. On the other hand, in the synovial variety, which shows itself more frequently and more plainly in the knee than any where else, the pain, which marks the onset of the complaint, does not last long before some degree of swelling is perceptible, together, in most instances, with slight redness of the skin; and this swelling is not due so much to turgescence of vessels or to cedema of the cellular tissue, as to fluid poured into the cavity of the joint. And the form and character of the swelling indicate that it is the result of the fulness and distention of the synovial membrane; it is tight and elastic, and protrudes, as it were, through the spaces that intervene between the tendons and the ligaments, by which it is in other parts bound down and restrained; and fluctuation is often distinctly perceptible in the superficial joints, when both hands are applied to them. These are the local differences between the two forms of the disease. And there are differences equally well-marked between the consti- tutional symptoms that attend them. It is in that form which (jut s*:jw) is called fibrous rheumatism, that the inflammatory fever runs so high, that the tongue is so thickly furred, that the round full-bounding pulse occurs, that the profuse sponta- neous acid perspirations break out, which exhaust the patient's strength without alleviating his sufferings, that the urine is high-coloured, and deposits a copious (a) Lectures on Physic, vol. ii. VOL. I.—21 242 PULPY DEGENERATION OF SYNOVIAL MEMBRANE. sediment like brick-dust. In the synovial form, the fever is either less intense from the beginning, or soon moderates, after the joipts begin to swell; the tongue is less foul; the patient sweats much less. It is to this form that the term rheumatic gout is often applied." (pp. 621,2.) Of the chronic rheumatism Watson also mentions two kinds:—"One attendant with local heat and swelling, although the constitution at large sympathizes very little, or not at all, with the topical inflammation; the other characterized rather by coldness and stiffness of the painful joints. In the former of these, the pains are increased by pressure, and by movements of the limbs, and by external warmth, the warmth of a bed for example; and there may be even some slight degree of pyrexia at night. In truth, this form of chronic rheumatism claims a near relationship with the acute, into which it sometimes passes, and of which it is frequently the sequel." (pp. 628, 9.) Gonorrhceal Bheumatism and Gonorrheal Ophthalmia were, I believe, first men- tioned publicly by Astley Cooper, and " the first of these affections," he considers, " is not an unfrequent disease ;" but it appears to have been previously observed by the elder Cline ; for, in reply to the question put to him by Cooper, Whether he had ever seen rheumatism produced from gonorrhoea 1 he said :—" Several times." Cooper's account of the disease is described in his usual homely but graphic man- ner, in the following, his first Case.—"An American gentleman came to me with a gonorrhoea, and, after he had told his story, I smiled and said, ' Do so and so,' particularizing the treatment, and that he would soon be better, but he stopped me and said, 'Not so fast, sir; a gonorrhoea with me is not to be made so light of; it is no trifle; for in a short time you will find me with inflammation in the eyes, and in a few days after I shall have rheumatism in the joints. I do not say this from the experience of one gonorrhoea only but from that of two, and on each occasion I was afflicted in this manner.' I begged him to be careful to prevent any gonorrhceal matter coming in contact with the eye, which he said he would. Three days after this 1 called on him, and he said, ' Now you may observe what I told you a day or two ago is true.' He had a green shade on, and there was ophthalmia of each eye. * * * In three days more he sent for me rather earlier than usual, for a pain in his left knee; it was stiff and inflamed. \ ordered some applications and soon after the right knee became affected in a similar manner. The ophthalmia was with great difficulty cured, and the rheumatism continued many weeks afterwards. * * * Whether it is by absorption of the poison or the constant irritation produced by the inflammation of the urethra, I do not know; but certain it is that gonorrhoea produces ophthalmia and rheumatism, and when not a single drop of matter has been applied to the eye. The inflamma- tion generally attacks both eyes and is of long duration." (pp. 273, 4.) Brodie also speaks of cases of inflamed synovial membrane after gonorrhoea; these were in every instance accompanied with purulent ophthalmia, which, in most, but not in all, preceded the affection of the joints, which recurred often, again and ajain; and in one case the joint was affected nine times. For our knowledge of that form of diseased synovial membrane, which may be called pulpy degeneration, we are indebted to Brodie, who describes it as consisting "in a morbid alteration of structure, which takes place in the synovial membranes of joints, and which, as far as I have seen, is peculiar to these parts. I have never known an instance of the same disease in the serous membranes, which so nearly resemble the former in their nature and functions; nor even in the synovial mem- branes that constitute the bursa; mucosas and sheaths of the tendons." (p. 77.) The disease seems to commence in the reflected portions of the synovial membrane, con- verting them into a light brown pulpy substance, varying from a quarter to a half, or even a whole inch in thickness, intersected with white membranous lines and red spots, formed by small vessels injected with their own blood. It then attacks the synovial membrane, which over-spreads the cartilaginous covering of the ends of the bones, beginning at their edge and extending gradually over them, ulceration in those cartilages going on correspondent^, till the carious or ulcerating surfaces of the bone are exposed. The cavity of the joint sometimes contains pale yellow fluid in the floating flakes of lymph, or pus, which is discharged externally by ulceration; but sometimes neither. Or abscesses may exist in the altered synovial membrane itself, without communication in the joint. Lawrence says, that " the ligaments, perhaps, are free from disease, and so, perhaps, are the cartilages; at all events, if either are affected, it will be the cartilages :" (p. 482 :) on this point, therefore, he PULPY DEGENERATION OF SYNOVIAL MEMBRANE. 243 does not agree with Brodie. The latter author considers that this disease " belongs to the same order with tubercles of the lungs, scirrhus of the breast, the medullary sarcoma or fungus haematodes of the testicle, and numerous other diseases, in which the natural structure of the affected organ is destroyed, and a new and different structure is added in its place. To these also it bears a near resemblance in its progress. Thus tubercles of the lungs, in the first instance, occupy the vesicular and interlobular substance; but ultimately they inflame and ulcerate, abscesses form in them, and the pleura, the bronchia, and other contiguous parts become af- fected. * * * In every case in which I have had it in my power to watch its pro- fress, the complaint has advanced slowly, and sometimes has remained in an in- olent state during a very long period, but ultimately it has always terminated in the destruction of the joint. It is a remarkable circumstance that this affection of the synovial membrane is rarely met with, except in the knee. I have never known an instance of it in the hip or shoulder. But Hodgson of Birmingham informs me he has met with one example in the ankle, and another in one of the joints of a finger." (p. 95-7.) If by placing this disease in "the same order with tubercles of the lungs, scirrhus of the breast," &c, Brodie means to infer that it is malignant in the usual accepta- tion of the term, I must differ from him, as I am not aware that it presents itself in any other organ of the body, and, indeed, he himself observes, " it is a remarkable circumstance that this affection of the synovial membrane is rarely met with except in the knee." It destroys life, indeed, if the limb be not removed; but only in the same way as other causes by which the surface of the joint is destroyed and either opened or not, by wearing out the powers of the constitution.—j. f. s. "This disease," according to Brodie, "generally takes place in persons who are not much above the age of puberty. I do not recollect," says he, "one instance of it having occurred after the middle period of life. In general it can be traced to no evident cause ; but occasionally it is the consequence of repeated attacks of inflam- mation. In this respect it resembles other diseases of the same order. Inflamma- tion of the lungs may lay the foundation of tubercles, and inflammation of the breast may occasion the growth of a scirrhous tumour. * * * In the origin of this disease there is a slight degree of stiffness and tumefaction, without pain, and producing only the most trifling inconvenience. These symptoms gradually increase. In the greater number of cases, the joint at last scarcely admits of the smallest motion; but, in a few cases, it always retains a certain degree of mobility. The form of the swelling bears some resemblance to that in cases of inflammation of the synovial membrane, but it is less regular. The swelling is soft and elastic, and gives to the hand a sensation as if it contained fluid. If only one hand be employed in making the examination, the deception may be complete, and the most experienced surgeon may be led to suppose that there is fluid in the joint when there is none; but, if both hands be employed, one on each side, the absence of the fluid is distinguished by the want of fluctuation. The patient experiences little or no pain until abscesses begin to form and the cartilages ulcerate ; and, even then, the pain is, in many in- stances, not so severe as where the ulceration of the cartilages occurs as a primary disease, and the abscesses heal more readily, and discharge a smaller quantity of pus, than in cases of this last description. At this period the patient becomes affected with hectic fever, loses his flesh, and gradually sinks, unless the limb be removed by an operation. * * * The gradual progress of the enlargement and stiffness of the joint without pain, and the soft elastic swelling without fluctuation, in the majority of cases, enables us to distinguish it readily from all the other morbid affections to which the joints are liable. The cases with which those of this disease are most liable to be confounded are those of chronic inflammation of the synovial membrane. Firstly. When the synovial membrane has undergone a morbid change of structure, it occasionally happens that a preternatural secretion of fluid takes place at the same time from its inner surface, and the joint becomes distended, not with synovia, but with a turbid serum, having flakes of coagulable lymph floating in it, which causes the tumour to present nearly the same external characters as where synovial membrane is inflamed." But Brodie distinguishes it by its not yielding to the ordinary treatment, and by the accurate previous history. " Secondly. When the synovial membrane, after inflammation has subsided, has been left in a thickened state, and coagulable lymph has been effused into the articular cavity, the tumour, in some instances, a good deal resembles the tumour which occurs in cases of this 244 TREATMENT OF INFLAMED SYNOVIAL MEMBRANE. disease; so much so, that it will be very difficult to give a correct opinion merely from observing the present appearance and condition of the joint. The surgeon must, in great measure, form his judgment from the account which he receives of the origin and early symptoms of the complaint, or, when an accurate statement cannot be procured, by waiting to observe its future progress." (pp. 101-6.)] 210. The examination of the joint after death shows, in a milder form of the disease, the synovial membrane inflamed, and the cavity of the joint filled with a thin, often reddish, fluid (1). In a more advanced staie, thickening of the ligaments, swelling of the synovial membrane into a fungous fleshy-like mass penetrated with white streaks, often with a mass beset with polypous or hydatid-like growths, a collection of yellowish lymph mixed with white flakes (2;) finally, destruction of the cartilages and caries of the joint ends of the bones (3). [(1) This is the result of simple inflammation. Brodie mentions one excellent example, in which, "throughout the whole of its internal surface, except where it covered the cartilages, the synovial membrane was of a dark-red colour; the vessels being as numerous and as much distended with blood as those of the tunica conjunc- tiva of the eye in a violent ophthalmia." (p. 12.) In another case—"the synovial membrane was increased in thickness about one-eighth of an inch, and was of a gristly texture." (p. 14.) The former patient had died of fever, independent of the disease in the knee-joint; and the limb of the latter was removed for some other complaint. These are highly important cases, as opportunities for examining in- flamed synovial membrane in this, its primary condition, are very rare. (2) This is the pulpy degeneration described by Brodie. (3) This appears to me the form of joint disease described by Key (a,) in which "the cartilage is not absorbed per se, but through the agency of a structure probably evolved for the special purpose of completing that process," (p. 134,) or, as he else- where (b) expresses it, a " highly vascular fringe of (synovial) membrane, which is a newly organized, and, in some parts, a superadded structure for the purpose of producing ulceration of the contiguous cartilage." (p. 224.) I fully concur with the correctness of Key's views upon this point, having seen the condition he describes again and again. But it will be more convenient to consider the subject in connexion with true ulceration of cartilage, a little further on.—j. f. s.] 211. The inflammation of the synovial membrane occurs very readily in superficial joints, especially in the knee-joint, from mechanical violence, cold, rheumatism, gout, gonorrhoea, syphilis, or improper use of mercury. It takes place frequently in several joints at once, or in one after another. When arising from some marked internal cause, the course of this inflammation is usually tedious. 212. The prognosis is more favourable when the disease is consequent to external than when it depends on internal causes. At first it can be dispersed by proper treatment; subsequently, when a collection of fluid has taken place, the resolution is only slowly brought about, and there remains for a long while, and often permanently, a swelling of the joint. If the synovial membrane and the ligaments be much thickened or ulcerated, the cartilages and bones affected, and openings of abscesses present, anchylosis must be considered the most favourable termination: in the majority of cases, however, the removal of the joint is the only remedy. 213. The treatment is guided by the causes and degree of the inflam- mation. If the affection of the joint be connected with general disease, the plan of cure must be directed towards it. In rheumatism and gout especially, vin. sem. colch.; in scrofula, cod-liver oil; in gonorrhoea and (a) Med.-Chir. Trans., vol. xix. (b) Med.-Chir. Trans., vol, xviii. \ TREATMENT OF SYNOVIAL EFFUSION, &C. 245 syphilis, Zittmann's decoction. In more severe degrees of inflamma- tion, general, but especially repeated local blood-letting with leeches, and cold fomentations with lead wash are required ; but warm fomenta- tions or soothing poultices when the swelling is considerable. When the course of the inflammation is slow, cupping at the commencement is sufficient. [As regards the local treatment of simple acute inflammation of the synovial mem- brane, Brodie says, " If the swelling has rapidly risen to such a height as to occa- sion considerable tension of the soft parts, the pain will be best relieved by means of warm fomentations and poultices; but otherwise cold evaporating lotions seem to produce a better effect." (p. 35.) I must confess in these cases I prefer warm poultices, either of bread or chamomile flowers, or hot flannels frequently reapplied: the warmth having appeared to me most soothing in the majority of cases. But, as sometimes cold, sometimes heat, affords ease to patients of different constitutions, their feelings must be attended to, and either treatment, found most agreeable, con- tinued. The subacute inflammation requires leeching more frequently, and some- times cupping; but I think leeches are preferable, as the wounds they make often excite a little erythematous inflammation on the skin, which acts as a gentle diver- sion. Warm applications here also seem to me preferable to cold. Blisters should not generally be employed till blood has been taken from the part twice or thrice, and the tenderness is either subsiding or has subsided. But sometimes they may be needed earlier if the constitution be weakly and the patient cannot bear the loss of blood. If the simple acute inflammation of the synovial membrane terminate, as it some- times does, in suppuration, the swelling should be punctured and the pus discharged as soon as it points, or, perhaps, even before, as the severity of the constitutional excitement will lead to a tolerably sure diagnosis of its existence. The longer it is retained the more does the constitution suffer, and the greater is the liability ot ulceration of the membrane and cartilages. There is but a choice of evils, and that of opening the joint seems, to me, less than that of the continued confinement of the pus. I do not think blisters in this case are of much use.—j. f. s.] 214. When the inflammatory stage has passed, but the swelling (from effusion of fluid into the joint) continues, the dispersion is to be encou- raged by blisters, repeated around the whole joint, or applied in the neighbourhood, or kept open for some sufficient time with savine cerate ; by rubbing in mercurial ointment with camphor and caustic ammonia, by application of solution of acetate of ammonia, by stimulating and dispersing plasters, as emp. amnion, c. acet. scill., and so on. The stiffness in the joint, which often is long continued, maybe removed by rubbings with volatile substances, by baths, douche, and careful motion. [For the removal of fluid in the joint I believe that blisters are the most efficient remedy we can employ; but I do not like blistering the whole joint at once, nor dressing blisters with savine ointment, as, in the one case, independent of strangury, which is sometimes excited, and is very annoying as well as painful, it is requisite to wait till the sore is healed before a second application can be made; and, as regards the savine ointment, the pain it causes, if properly applied, (i. e., immedi- ately to the cutis, the cuticle having been previously removed,) is extremely severe, and, as I think, not warrantable by the benefit obtained. I therefore prefer the employment of repeated blisters, two at a time, each about as large as a crown-piece, one above and the other below and on opposite sides of the joint, applied on the alternate parts every third day, by which time, generally, the first applied blisters are beginning to heal, if, immediately after they have risen, they be punctured, and either poulticed or dressed with simple ointment. In this way a constant diversion on the skin may be kept up to an almost unlimited period, with little actual incon- venience to the patient, but with remarkable benefit to his joint. Or, each side of the joint may be alternately blistered, and, the cuticle having been removed, may 21* 246 TREATMENT OF SYNOVIAL EFFUSION be dressed with the ointment of iodide of potass, a drachm to the ounce, which is often very efficacious.—j. f. s. In reference to friction, which was formerly more in vogue than at present, and, if properly employed, is very useful in cases of stiffness after the absorption of the fluid, Brodie very justly observes :—" It should be employed with caution, as, when used too freely, it sometimes occasions a return of the inflammation. Whenever there is the slightest indication of this being the case the friction should be omitted, blood should be taken from the part, and some time should elapse before the friction is resumed. It is sometimes productive of very essential benefit, but not unless it be employed to a considerable extent, as for two or three hours daily, and during a long period of time." He also mentions having " sometimes tried the effect of pumping hot water on a stiff joint, as recommended by Le Dran, and now practised at some watering-places. The blow of a column of water, falling from a height of several feet, produces considerable friction, even so as to excoriate the surface, with which are combined the relaxing powers of heat and moisture. This practice is certainly productive of benefit; but the observations just made apply to this as well as the other modes of producing friction." (p. 40-42.)] 215. If there be already thickened synovial membrane, and if the acute have passed into the chronic condition, leeches must be repeatedly applied, but in small numbers, waiting, however, each time till the erysipelas thereby excited has subsided. If the swelling be soft, light compression may be employed, mercurial or iodine ointment used ; con- tinued derivation by blisters and issues, and moxas or the actual cautery applied (1). When suppuration occurs in the joint, with destruction of the carti- lages and bones, care must be taken for the proper discharge of the pus (2 ;) the limb must be kept in the most perfect rest; the powers supported by the use of tonic remedies, and a proper attention to diet; and poul- ticing must be continued. If exhaustion be feared, the removal of the limb is indicated. [(1) When the inflammation has become actually chronic, especially if there be thicking, then irritating applications are particularly beneficial. In the milder form soap liniment, either alone, or rendered more stimulating by the addition of liquor ammoniac or tinctura lyttae, in proportion of a drachm to the ounce, the liniment of ammonia, with oil of turpentine, as recommended by Brodie, or mustard liniment, made by macerating an ounce of mustard flour in a pint of turpentine, are often suf- ficient. When more active excitement is necessary, friction with Croton oil, about a dozen or twenty drops every evening till it brings out little blisters, which soon run into suppuration, is very serviceable, and a very eleanly application. Brodie recommends a liniment consisting of ol. olivae ,?jss., ad acid, sulph. £ss.; but, if the patient's skin be delicate, or very tender, less acid must be used; it excites some degree of inflammation of the skin, and the cuticle browns, and is thrown off in thick broad scales. Some persons paint the whole joint over with tincture of iodine, which often acts like a blister. Mercurial ointment, with or without camphor, is frequently used, or ointment of iodide of lead ; these are best applied upon lint without rubbing, as the former, if rubbed, often causes ptyalism in delicate persons especially, and the latter soon irritates the skin so much, that its discontinuance is compelled. The use of pressure, with straps of soap plaster, is very often com- fortable and beneficial, and may be combined with stimulation of the skin, by using emp. thur. comp., emp. ammon. c. hydr., or emp. picis Burg. Tartarized antimo- mial liniment was a favourite remedy of Astley Cooper's; but it requires to be used w-ith great caution, as, in persons with delicate skin, it often very speedily excites violent inflammation, with a very large crop of pustules, which become extremely painful, and often degenerate into deep and tiresome sores. (2) The puncture of a joint when fluctuation is accompanied with other symptoms which lead to the presumption of pus being confined in its cavity is, though highly necessary if there be much constitutional excitement, and specially if the abscest AND SUPPURATION. 247 point, not always unattended with inconvenience or even danger, and not certainly beneficial to the patient, of which the following is an instance : Case.—J. P., aged twenty-five years, a baker, came under my care in the year 1843. Three months after having had typhus fever four years and a half since, his right knee became weak, and he began to limp; at this time there was not any swelling of the joint, but during the following six months the knee swelled, and he was under medical treatment; an abscess formed below the knee-cap, and burst subsequently by two wounds below and on the inside of the tubercle of the shin-bone. A discharge continued for four or five months, during which he followed his business, and walked about a good deal. The wounds at last healed, but soon after swelling occurred below and around the knee-cap, and thirteen months since it suppurated, and con- tinued discharging on the apex of the knee-cap till the beginning of April in this year. During nearly the whole of this time he has walked, though not without pain, but has been unable to follow his business. The discharge having ceased, general swelling of the whole knee commenced, and he began to feel weakness on the sides of the joint. Being thus again crippled he came into the hospital. May 2, and I presume (for I did not make any note of his case at the time) I then considered his case as chronic inflammation of the synovial membrane, as he was treated by repeatedly blisteringthe joint, but the disease has not been at all checked. It is only, however, within a fortnight from the present time (Aug. 19) that I have begun to think very seriously of his condition. During this time his sleep has been disturbed by shooting pain on the outside of the knee, the pain extending down the leg, always coming on as he falls asleep, and rousing him completely. Latterly he has lost flesh ; his pulse is small and quick; but he does not sweat much, and his appetite is good. . The joint is now a good deal swollen and fluctuating, especially above the base of the knee cap, and on the condyles of the thigh-bone, and less distinctly below the former bone. It is tender on pressure about the middle of the joint on the outside, and above the knee-cap on the inside. He has great pain on the slightest motion: pain on striking up the leg; and on pressing the articulating surfaces together, and twisting the leg upon the thigh causes severe pain ; but no grating of the bones can be felt, though perhaps it might be, were not the movement of tbe limb so painful as to forbid persisting in attempts to ascertain it. As Ifeltpretty^confident that the joint contained pus, I determined, although it did not point, to evacuate it, and try if it were possible to bring about anchylosis by keeping the parts perfectly quiet, and establishing issues to promote a diversion of the irritation of the joint. And tberefore in the afternoon of this day, Aug. 19. Made a puncture with an abscess lancet on the outside of the base of the knee-cap, where the skin was thinnest. Blood flowed rather freely (about two ounces) at first, but on introducing a director about an ounce of synovial fluid escaped. As no pus appeared, and as the director did not give the sensation of touch- ing any articular surface, I presumed I had only opened the bursa above the knee- cap, and thought it best to close the wound and obtain adhesion as soon as possible, by bringing the edges together with adhesive plaster ; for although blood continued flowing from between the lips of the wound, I expected the slight pressure would stop it. The tension was diminished, and the patient was relieved from pain on the inside of the knee immediately on the discharge. Shortly after the wounds had been brought together the knee began to swell again and feel distended, and in about a quarter of an hour or twenty minutes the oozing of blood which had been rather free, was con- verted into a stream which flowed freely, and was checked partially by pressure on the artery at the hip-joint, but still the bleeding continued for some time, and he lost twenty-six ounces of blood, when he became very faint. The swelling of the knee, which had been at first very hard, gradually diminished and softened as the blood flowed. A tourniquet was applied high up, and the bleeding completely arrested. But he had become so faint and his pulse so weak and fluttering, that it was neces- sary to give him five ounces of wine and four ounces of brandy before he could be brought round. Two hours after I saw him again; he had then rallied, but was still very pale, and his pulse small, weak, and quick. The swelling of the knee, however, being soft, and no haemorrhage having occurred, the tourniquet was removed, and an eva- porating lotion applied to the knee. I presumed that the bleeding depended entirely on the increased vascularity of the 248 STRUCTURE OF CARTILAGE. synovial membrane, and not from wound of either of the articular arteries, which, however, might have been the cause. The almost immediate recurrence of the swelling is accounted for by the closure of the wound preventing the external escape of the flowing blood, which was therefore retained in the synovial cavity. No further bleeding occurred; but as his health continued failing it was determined to amputate the knee, which I did, and he recovered. On examining the joint the whole of the 'synovial membrane lining the capsular and extending over the other ligaments of the joint was found covered with a vas- cular, thick, soft, and granular substance. The cartilage on the edge of the patella was partially absorbed, as also that on the left articular cavity of the head of the tibia in a semicircular form, and on both condyles of the thigh-bone it was par- tially removed, these corresponded to the granular substance on the synovial mem- brane ; and a groove on the cartilage of the internal condyle answered to a remark- able slip of the granular substance, which crossed between and connected the cap- sular and crucial ligaments. There was not any pus on the joint; but the wound by which the lancet had entered, as it proved to have done, was distinct.—j. f. s.] C—OF INFLAMMATION OF THE CARTILAGES. 216. The joint-cartilages may be the primary seat of inflammation (lnflammatio Cartilaginum Lat. ; Entzundung der Knorpel, Germ.: Inflammatio des Cartilages, Fr.) and ulceration, which may thence be propagated over the other structures of the joint. [Before considering the effects of inflammation, and its results on cartilage, it will be well to take a view of the opinions which have been, and are, held as re- gards its vascularity or non-vascularity, not only on account of the difference of opinion there is upon these points whilst cartilage is in a healthy state, and during its growth, but also, because upon one or other of these views are founded the dif- ferent opinions held in reference to their activity or passiveness in the production of the diseases with which they are affected. Structure of Cartilage.—William Hunter (a) examined articular cartilages pre- viously prepared by boiling, or long-continued maceration, and thus describes them :—" W'hen an articular cartilage is well prepared it feels soft, yields to the touch, but restores itself to its former equality of surface when the pressure is taken off. This surface, when viewed through a glass, appears like a piece of velvet. If we endeavour to peel the cartilage off in lamellae, we find it impracticable, but if we use a certain degree of force, it separates from the bone in small parcels, and we never find the edge of the remaining part oblique, but always perpendicular to the subjacent surface of the bone. If we view this edge through a glass, it appears like the edge of velvet, a mass of short and nearly parallel fibres rising from the bone, and terminating at the external surface of the cartilage ; and the bone itself is planned out into small circular dimples where the little bundles of the cartilaginous fibres were fixed. Thus we may compare the texture of cartilage to the pile of velvet, its fibres rising up from the bone, as the silky threads of that rise from the woven cloth or basis. In both substances the short threads sink and bend upon being compressed, but by the power of elasticity recover their perpendicular bearing as soon as they are no longer subjected to a compressing force. * * * Now these perpendicular fibres make the greatest part of the cartilaginous substance ; but, without doubt, there are, like- wise, transverse fibrils which connect them, and make the whole a solid body, though these last are not easily seen, because, being very tender, they are destroyed in pre- paring the cartilage. * * * The blood-vessels are so small that they do not admit the red globules of the blood ; so that they remained in a .great measure unknown till the art of filling the vascular system with a liquid wax brought them to light. Nor even by this method are we able, inadult subjects, to demonstrate the vessels of the true car- tilaginous substance; the fat-glands and ligaments shall be red with injected vessels, while not one coloured speck appears upon the cartilage itself. In very young sub- jects, after a subtle injection, they are very obvious; and I have found their course (a) Above cited. STRUCTURE OF CARTILAGE. 249 to be as follows : all round the neck of the bone there are a great number of arteries and veins which ramify into smaller branches, and communicate with one another by frequent anastomoses like those of the mesentery. This might be called the circulus articuli vascuhsus, the vascular border of the joint. The small branches divide into still smaller ones upon the adjoining surface in their progress towards the centre of the cartilage. We are very seldom able to trace them into its substance, because they terminate abruptly at the edge of the cartilage, like the vessels on the albuginea oculi when they come to the cornea. The larger vessels which compose the vascular circle, plunge in by a great number of small holes, and disperse themselves into branches between the cartilage and bone. From these again there arise a crop of small short twigs, that shoot towards the outer surface; and whether they serve for nourishing only, or if they pour out a dewy fluid, I shall not pretend to determine. However that be, I cannot help observing that the distribution of the blood-vessels to the articulating cartilages is very peculiar, and seems calculated for obviating great inconveniences. Had they run on the outer surface, the pressure and motion of the two cartilages must infallibly have occasioned frequent obstructions, inflammations, &c, which would soon have rendered our motions painful, and at last entirely de- prived us of them. But by creeping round the cartilaginous brim, where there is little friction, or under the cartilage, where there is none, they are perfectly well de- fended from such accidents. It were to be wished we could trace the nerves of car- tilages ; but, in relation to these organs, here, as in many other parts of the body, we are under a necessity, from the imperfections of our senses, of being satisfied with mere conjecture; and though, from the great insensibility of a cartilage, some have doubt of its being furnished with nerves ; yet, as it is generally allowed, that these are sine qua non in the growth and nourishment of animals, we have no sufficient reason to deny their existence in this particular part. With regard to the manner of their distribution, we may presume, from analogy, that they follow the same course with the blood-vessels." (p. 515-19.) Miescher (a) says there is not the least difference between permanent cartilage and thatwhich is to be converted into bone. (p. 15.) His observations in regard to arti- cular cartilages do not, however, agree with William Hunter's as regards their actual fibrous structure. He observes:—" When articular cartilages have been thrown for some time into acid, they can easily be separated from the other cartilage which was bony. They are more easily split transversely than in any other direction, their bro- ken surface presents a fibrous appearance, but when placed under the microscope forthwith lose it, and exhibit none other than a regular pellucid substance with ovate corpuscles. These are ranged in the manner of clusters; their longitudinal dia- meter is situated transversely, as is very distinctly perceived in the thick cartilage covering the joint surface of the knee-cap. On the corpuscles being thus arranged depends the fibrous appearance." (p. 25.) Todd and Bowman (6,) however, consider there is a difference between temporary and articular cartilage. In the latter "the cells are oval or roundish, often disposed in small sets of two, three, or four, irregularly disseminated through a nearly homo- geneous matrix which is more abundant than in the former." This, however, is in reality all the difference which even they point out, as although they say " in the inner part of the cartilages of incrustation (a term applied to articular cartilages by some anatomists) we usually find the cells assuming more or less of a linear direc- tion and pointing towards the surface, which arrangement is probably connected with a corresponding peculiarity of texture of the intercellular substance, but which it is more difficult to distinguish; for these specimens have a disposition to frac- ture in a regular manner along planes vertical to the surface, and the broken surface is striated in the same direction." Yet had they previously stated, in reference to temporary cartilage, " When ossification begins, the cells which hitherto were scattered without definite arrangement become disposed in clusters or rows, (Mies- cher's exact expression corpuscula racemorum in modum consita,) the ends of which are directed towards the ossifying part." (p. 90.) The fibrous structure of articular cartilage as described by William Hunter is explained in the following way by Henle (c) :—"I have sometimes observed," (a) De Inflammatione Ossium eorum- (c) Allgemeine Anatomy. Lehre von den que Anatome generali. Berolini, 1836. 4to. Mischungs und Formbestandtheilen des (6) Physiological Anatomy and Physiolo- menschlichen Korpers. Leipzig, 1841. gy of Man, chap. iv. London, 1843. 8vo. 8vo. 250 STRUCTURE OF CARTILAGE. says he, "the contour of the cavities projecting from one longitudinal row of cavi- ties (in the cartilage) to the next, and it appeared as if a part of the cavity together with the enclosed cells were separated by a cleft. It is, however, possible that these are the hollow parts of one system of long canals which twisted, or perhaps also in rare cases divided angularly, penetrate the cartilage from its lower towards its upper surface, and remain in the cleft partially in the one and partly in the other segment. By this formation is satisfactorily explained why the articular cartilage presents a fibrous fractured surface, and seemed to the old observers to consist of fibres which ran perpendicularly through its thickness. Next the free surface they are more lamellar and can be separated into delicate plates (Meckaiter.) The flat- tened cells of this layer have the closest resemblance with the epithelial cells of the synovial membrane and often subside imperceptibly into it; but usually a layer of connecting tissue forms the boundary between them." (p. 196.) "Most cartilages," says Henle, "are devoid of vessels. Tlie joint-cartilages at their adhering surface are in contact with the very vascular bones, at their free sur- face they are overspread with synovial membrane; in the connecting tissue of which. however, in the newly-born child, and sometimes even in the adult, vessels pass from the edge, and are rendered apparent by injection. Perhaps they originally cover the entire surface and subsequently are obliterated towards the edge from which they are reflected out of the synovial membrane upon the capsular ligament. But in the adult no branches either from the bone or from the synovial membrane penetrate into the cartilage." (pp. 802, 3.) " The cartilaginous covering of joints is not at first separate from that part of the bone cartilage which will be ossified. During the period of ossification there is a considerable layer of vessels between the cartilage and the already perfectly ossified parts, and it is easy to separate the two parts ; as already stated by Hunter.) " Both have irregular surfaces, elevations, and depressions, by which they hold together. In proportion as ossification extends towards the epiphysis, the vascular layer shrinks and the adhesion becomes more intimate. In newly-born children, however, pretty wide but only slightly branching canals with blood-vessels from without, and from the surface, covered with synovial membrane, penetrate the cartilage deep enough to reach the epiphysal cartilage. * * * When the formation of cartilage is completed, the vessels retract from it, and in the adult its nutrition seems derived only from the vessels of the adjacent bone and perichondrium, perhaps in the joint cartilages also mediately from the synovia which comes from the vessels of the synovial membrane, and the so-called Haverschian glands. The taking up of the plasma thus follows by saturation and thereto seems the special use of the cavi- ties of cartilage. * * * Macerated cartilage is often distinctly reddened by imbibi- tion of the red colour of the blood, and the reddening is greater, the more the cells proportionally exceed the basement; most distinctly therefore in foetal cartilage. If the blood in the living body carry unnatural colouring substances, as for instance the bile pigment, it penetrates the cartilage, which, therefore, in jaundice, becomes yellow, as noticed by Bichat." (pp. 808, 9.) Toynbee (a) observes, in reference to articular cartilages :—"Although they are properly considered as non-vascular tissues, they appear to be pervaded by blood- vessels at an early period of their development, or, perhaps, it would be more correct to say, that as growth proceeds, the cartilage increases, so as to occupy the space that had previously been permeated by vessels. I have been able," he con- tinues, "to demonstrate that vessels are never found within these cartilages when fully developed; but at that period vessels form convolutions in their immediate vicinity. These vessels are separated form articular cartilage, at adult age, by a layer of bone; and in fibro-cartilage, at the same period, they uniformly terminate within the boundary of its fibrous tissue. Over a certain portion of the free surface of both these tissues blood-vessels extend, but they do not penetrate into their sub- stance. The investigations which are about to be detailed lead, I think, to the cer- tain conclusion, that articular cartilage in the adult state is principally nourished by fluid derived from the vessels of the cancelli of the bone to which it is attached, which exudes through the coats of those vessels, and makes its way into the sub- stance of the cartilage through the intermediate lamella of bone. The cartilage of fibro-cartilage is nourished, in like manner, by liquor sanguinis, derived from vessels (a) Already cited. STRUCTURE OF CARTILAGE. 251 situated in the contiguous fibrous portion. These vessels ramifying in a certain extent of the free synovial surface of both these species of cartilage, contribute, doubtless, to their nutrition, but not to near the same extent as do the vessels of the opposite side. With respect to the actual process of nutrition, I shall only ob- serve here, that the cells of these structures must be regarded as having the function which has been ascribed to those of all non-vascular tissues, viz., that of promoting the circulation of and modifying the nutrient liquor. In connexion with this pro- cess, however, it will be seen that articular cartilage presents, in its adult state, very minute canals, which may be regarded as existing for the reception of the nutrient fluid, and for its circulation through the mass of cartilage; their presence is especially required in this particular form of cartilaginous structure, from the great degree of density which it possesses. * * * The portion of bone upon which arti- cular cartilage rests is, in some instances, formed by the ossification of a distinct cartilaginous epiphysis. In non-epiphysal bones, the extremity of the shaft of the bone performs the same functions with regard to the articular cartilage situated upon it as do the epiphyses in those bones which are provided with them. There is this difference in articular cartilage, with regard to its nutrition during and after its de- velopment, that in the former state there is no positive separation of it from the cartilage which is subsequently converted into bone, and in which its nourishing vessels are contained; wbilst, in the latter state, these vessels are separated from it by an osseous lamella. The free surface of articular cartilage during, as well as after, its development, is covered by synovial membrane, to which it is attached by cellular membrane." (pp. 162, 3.) Toynbee concludes, from examinations he has made, "that during the most early periods, the cartilage of the epiphysal extremities of bones does not contain any blood-vessels, and that, notwithstanding their absence, the cells of this cartilage are developed, and its growth carried on; and that, at the same time, the cells of the epiphysal and the articular cartilage are formed and developed without the presence of vessels;" and "that, at the more early period of foetal development, the synovial surface of cartilage does not contain blood-vessels." (pp. 164, 5.) According to tbe same observer, in the second stage of development the epiphysal cartilage " presents, except at its articular surface, numerous depressions of various depths. The deepest may be regarded as canals, some of which are single, others bifid ; they terminate in blind sacs. The direction of some of these canals is to- wards the centre of the. epiphysis, of others towards its point of attachment to the osseous shaft, and of others towards the articular cartilage. Some of these canals are of a large size, and are frequently considerably dilated at their blind extremities. They do not penetrate into the substance of the articular cartilage; they are for the reception of branches of sanguiferous vessels. When the epiphysis is minutely in- jected, the depressions upon its surface will be found to contain congeries of con- voluted vessels, which are more drawn out the deeper the depression, until at length, in the interior of the canals and their divisions, single and nearly straight vessels are found. These epiphysal vessels have a very peculiar disposition. They consist of an artery having a course more or less straight, which terminates in a dilatation, or in convoluted branches, from which the vein arises. From the fact of the presence of these vessels, which converge towards, and form convolutions inter- nal to the articular cartilage, it may be inferred that they supply the cells of the latter with a nutrient fluid. As the articular cartilage increases in thickness, and the ossific nucleus which is developed in the epiphysal cartilage becomes larger, these vessels gradually recede from between them, and leave a considerable mass of non-vascular cartilage between the osseous nucleus and the synovial membrane; all of this appears to be articular cartilage, which is now nourished by the vessels in the interior of the nucleus. The supply of blood-vessels in the cancelli of the osseous nucleus is remarkably abundant; they are large, and are separated from the surrounding cartilage by an extremely delicate lamina of bone, which is principally made up of osseous cells. I am induced to believe that at this stage of develop- ment, as in adult age, the fluid passes from the bone into the cartilage and nourishes it. * * * The articular cartilage, at this early period of life, is thicker than in the adult state. Although devoid of canals for the reception of blood-vessels, it presents numerous minute canals, which pervade that portion of it contiguous to the osseous nucleus, and the course from the latter toward the synovial membrane, which, however, they do not reach. * * * They are minute, and extremely nu- 252 ULCERATION OF CARTILAGE. merous; they divide, sub-divide, and communicate with each other, and form dilata- tions. The parietes of these canals present distinct rounded cells, which in some places are arranged in rows and groups. The substance between these tubes is transparent, and contains no corpuscles. The articular cartilage above described is gradually being converted into bone during the whole of life."(pp. 165-7.) . The nutrient vessels of articular cartilage during its development, which are si- tuated betwixt it and its synovial membrane," are contained and ramify in a consider- able layer of cellular tissue," by which tbat membrane is attached to the articular cartilage, and from which Toynbee detached nearly the whole. His statement, how- ever, that " these vessels have been alluded to by Dr. William Hunter under the name of 'circulus articuli vasculosus,' " is quite incorrect, as reference to the pas- sage already quoted will prove; in which Hunter says, they " plunge in by a great number of small holes, and disperse themselves into branches between the cartilage and the bone ;" and not " on the entire surface of the articular cartilage," as de- scribed by Toynbee. " It is difficult," says this latter writer, " to state generally at what period of foetal existence, these vessels, which have been spoken of in the first stage as forming convolutions around the joints, are prolonged upon its (the articular cartilage's) surface." But, after having studied with care these stages, he states, that " at between the third and fourth month of fcetal life these vesselsare simply a mass of delicate convolutions, situated between the synovial membrane; at the fifth month, these convolutions are somewhat unravelled, so as to extend over the surface of the cartilage to the distance of about half a line ; and at between the seventh and eighth months, they are drawn out and prolonged to the distance of a line and a half. At this stage these, vessels consist of arteries of considerable size, which radiate in a straight course from the attachment of ligamentum teres. They give off but few branches, and previous to terminating, divide and sub-divide, but do not much diminish in size. They terminate by turning and forming loops with the small veins. Subsequent to the eighth month these vessels begin to recede in their course; and at birth, and the periods subsequent to it, they are again found to be gathered immediately around the point of attachment of the ligamentum teres. After these vessels have receded, the position they occupied at the more early pe- riods may be for some time detected by the white aspect of the cellular tissue be- tween the cartilage and the synovial membrane." In the knee-joint there is a little difference: " The arteries which have run straight towards the centre of circulation, give off small branches, forming a delicate net-work communicating with the small veins, and terminate either by turning in their course, and forming broad loops with the venous radicles, or empty themselves into a single vessel from which the veins arise." (p. 168.) The canals in adult cartilage, already mentioned, Toynbee describes as "irregular in their distribution ; some are merely dilated cavities; frequently several of these cavities are elongated and arranged serially, running from the attached towards the free surfaces of the cartilage. At the free or synovial surface these canals do not exist; the cells of the texture at this part being elongated and flattened, and having their long diameters parallel to the free surface. These canals contain a transparent fluid, which is seen to ooze from them after a section. It is most probable that the uninjected vessels mentioned by Meckel, Bichat, and others, were these canals and sinuses." (pp. 169-70.) The observations just alluded to are the following : Meckel (a) says, " Cartilages do not receive vessels carrying red blood, although in cutting them distinct vessels are frequently observed in their substance." Bichat (6) observes that in cartilage " no blood-vessels are dis- tinguishable. The exhalant system carries only white juices; but as this system is continued to the arteries of the neighbouring parts, so that the organic sensibility is there elevated by weak irritants, and so brought into relation with the red globules of the blood, that they pass readily, whence arises the redness which cartilage as- sumes as seen in inflammation, wounds, &c. It is exactly the same as occurs in inflamed conjunctiva, &c. When the irritation ceases, the sensibility resumes its natural type, and the red globules at the same time become alien to the cartilage, which recovers its whiteness. We know not the nature of the white fluids ordi- narily circulating in the vascular system of cartilage. They are very susceptible of (a) Handbuch der Menschlichen Anatomie, vol. i. Halas et Berol., 1815-20. lb) Anatomie Generate, vol. iii. Edit. 1812. ULCERATION OF CARTILAGE. 253 becoming the vehicle of the bile, or, at least, of its colouring substance, when dif- fused throughout the animal economy in jaundice." (p. 129-30.) Muller (a) states that " in tendons, ligaments, and cartilage, there are blood-vessels, but few in num- ber." (p. 362.) In Brodie's opinion the cartilages are vascular, He says :—" Up to the period of growth being concluded, we must suppose the articular cartilages to be vascular, otherwise we cannot account for the changes of bulk and figure which mark their progress towards complete development. In the child, canals or sinuses may be seen ramifying through their substance, containing blood, and manifestly intended to answer the purposes, though not constructed with the distinct tunics of ordinary blood-vessels. In the adult person these canals for the distribution of blood are not perceptible. This proves that they are very minute, but not that they are altogether wanting." (p. 111.) He also supports his opinion by the analogy of" the transpa- rent cornea of the eye, in which no vascular structure can be detected under ordi- nary circumstances, but the existence of vessels in it is proved by the changes which it undergoes in disease; and when it is inflamed such vessels become distinctly visible, injected with red blood. So we meet with occasional though rare instances of vessels containing red blood extending from a diseased bone into the cartilage covering it." Also by the exposure of the joint cartilages to friction without being affected by it, which "cannot be explained unless we admit the cartilages to possess a power of reparation; and this must be supposed to depend, as in other textures, on the action of blood-vessels modified by that of the absorbents." And lastly, he brings forward the occasional conversion of an articular cartilage " into a number of ligamentous fibres, each of which is connected with one extremity to the bone, whilst the other is loose towards the cavity of the joint. Here is a morbid altera- tion of structure, the occurrence of which seems to indicate that there must be such a vascular apparatus entering into the formation of cartilage as enables new materials to be deposited and old materials to be absorbed, and without which morbid alterations of structure do not take place in other parts of the body." (p. 111-13.) Toynbee, however, asserts, that "into the substance of healthy cartilage he has never been able to trace blood-vessels, and his researches induce him to believe that they do not possess any. (p. 170.) Of the same opinion also is Beclard, (b) who says:—"These cartilages have no vessels : delicate injections and microsopie examinations exhibit the capillary vessels terminating at the circumference and ad- hering surface without ever penetrating their substance." (p. 466.) And Cruvel- hier (c) still more decidedly affirms, that the " diarthrodial cartilages donotpresent any trace of organization." (p. 162.) The importance of the subject will, I trust, be sufficient apology in regard to this long anatomical digression, in which it will be observed that William Hunter appears to have held generally very correct views on the structure of cartilage, ex- cepting as to its fibrous character. The reader will also be struck with the near resemblance of the opinions held by Toynbee and Henle. I have, indeed, men- tioned those of the latter author first, as in the course of the narrative it was conve- nient so to do. But the statements of both were published in the same year, and it is scarcely possible that either could have had knowledge of the views of the other.—j. f. s.] ■ At first the patient feels only little and passing pain, which is increased by the motions of the joint, but ceases when it is at rest. It gradually becomes continuous, and spreads from the joint over the bones. After several weeks or months, the swelling of the joint is af- fected with a slight external inflammation. This swelling is neither great nor fluctuating, and has pretty much the form of the joint. After a shorter or longer time, suppuration in the joint occurs : it breaks, and hectic fever destroys the patient. Although the course of this disease (a) Hanbuch der Physiologie, vol. i. Coblentz, 1834. (6) Anatomie Generate. (c) Observations sur les Cartilages Diarthrodiaux ; in Archives Generates de Medecine, vol. iv. VOL. I.—22 254 ULCERATION OF CARTILAGE. is nearly always insidious in its beginning, peculiar conditions may in- crease the symptoms, and the disease assume an acute form. Mayo (a) speaks of " three distinct forms of ulceration " of joint cartilages, which, although they may be occasionally combined, are oftener met with separately, (p. 49.) First. Rapid absorption of cartilage beginning on its synovial aspect; the new surface, if cartilaginous, being smooth and unaltered in structure; if of bone, healthy; the absorption of cartilage being attended with inflammation of the capsular synovial membrane, (p. 50.) This form is " of rare occurrence. The absorption of cartilage takes place rapidly. It is attended with severe pain, with inflammation of the capsular synovial ligament, and generally with suppuration in the cellular tissue adjacent to the joint. The only favourable termination of the disease, that 1 have witnessed, is anchylosis. Second. Chronic ulceration of cartilage beginning on its synovial aspect, producing an irregularly excavated surface with fibrous or brush- like projections of the cartilage and synovial membrane, attended with inflammation of the capsular synovial membrane, and sometimes of the same membrane where it is reflected over the cartilage, the bone and the surface of cartilage towards it being healthy, (p. 53.) Third. Absorption of cartilage beginning on the surface towards the bone, attended with inflammation of the adjacent surface of the bone, with in- flammation of the synovial membrane, and sometimes with sensible vascularity of the cartilage itself." (p. 59.) [As to the inflammation of cartilage, if such there be, Wilson (b) observes, " the active powers of life are possessed by articular cartilages in a very limited degree, so much so, that the ocular demonstration is wanting of their being capable of in- flammation. This affection is in other parts marked by a state of vessels easily dis- tinguished by the eye and by the touch ; but as vessels are not to be seen or felt in these cartilages, we have not sufficiently decisive proofs of inflammation ever taking place in them. I have never seen in articular cartilages, which were com- pletely formed, any vessels either filled with its own blood or having its cavity dis- tended by injection." (pp. 327, 28.) John Hunter (c) takes no notice of this point at all ; but, after speaking of the union of fractured cartilage by bone, proceeds:—" Sometimes the inflammation goes on to suppuration; but they (the cartilages) seem to have sufficient power to admit of ulceration, yet they may be absorbed by the absorbents of other parts, as in white swellings, when suppurated, the cartilaginous ends are removed by the absorbents on the surface of the ends of the bone that the cartilage covers. It may be ulcerated in this manner in other joints also : in the knee we find all the different stages of absorption of cartilage; granulations will shoot from under the cartilage, and some- times, when there is not much matter in the joint, these granulations will inosculate and form a bony union, (p. 535.) Wilson says that " the synovial membrane which lines the capsular ligament, and is reflected from it over part of the bone to the edge of the articular cartilage, will indeed sometimes pass a little way on the surface; it there becomes inseparably connected with the cartilage, and its appearance is then lost." But he continues: —" In a diseased state of joint, I certainly have seen the surfaces of the articular cartilages covered by a membrane, but this membrane I have no reason to believe to have been originally more than a coating of coagulable lymph; it is of different degrees of thickness, and at first easily peels from the surface it covers, but it soon becomes organized and very vascular. In a preparation, belonging to the Windmill- street museum, vessels seem to pass from this new-formed membrane into little in- equalities on the surface of the cartilage, and it is far from improbable but that ab- sorbent vessels may be among these, and which are employed, along with the ab- sorbents from the bone7 in removing the articular cartilage. * * * I do not mean to deny the possibility of the removal being attempted partially by vessels belonging to their own substance, so as to produce some of the appearances called ulceration of cartilages; but we are deficient in proofs of this, and, from what I have observed of the state and appearance of diseased joints, I am induced to abide by the opinion entertained by John Hunter, that the removal of articular cartilages is generally (a) On Ulceration of the Cartilages of Joints ;in Med. Chir. Trans, vol. xix. {b) Lectures on the S'ructure and Physiology of the parts composing the Skeleton, and on the Diseases of the Bones and Joints, &c. Lond., 1820. 8vo. (c) Lectures; Palmer's edition. ULCERATION OF CARTILAGE. 255 effected by the vessels of the neighbouring more vascular parts, viz., of the bones and synovial ligaments, and occasionally by the vessels of coagulated and organized lymph." (pp. 328, 29.) Brodie, however, holds there is "sufficient to prove that the articular cartilages may be absorbed or ulcerated from the action of their own vessels, and that the ulceration may begin and frequently does begin, on that surface which is towards the articular cavity. At the same time it is to be observed that in many instances the ulceration begins in another situation, and I have frequently seen the cartilage abraded where it had been in contact with the bone, while on the surface, towards the cavity of the joint, it remained smooth and perfect. Under these circumstances the space formed by the absorption of the cartilage becomes filled up by a vascular substance resembling granulations, and uniting the hone and cartilage to each other. In whatever way the ulceration of the articular cartilages is produced there is this remarkable difference between it and the ulceration of soft parts : suppuration seldom takes place while the ulcer of the cartilage is small, and often the disease proceeds so far as to cause caries of the bones to a great extent without matter beintr formed in the joint. This circumstance is deserving of notice. It has long been established, that suppuration may take place without ulceration, and it appears that, in this in- stance, ulceration occurs without the formation of pus." (pp. 116, 17.) Lawrence (a) also says, that " ulceration of cartilage," not only takes place from other causes, but "as an original affection of the joints. Without any disease of the synovial membrane, without the occurrence of any accident or injury, it may commence as a primary or original affection of the joint itself. The ulceration is attended with two circumstances which are very different from those we observe in ulceration of other structures. There is no formation of pus, nor do we ever find granulations produced from diseased cartilages—no attempt at reproduction of the cartilaginous structure. Although ulceration of the cartilages may be in the first instance limited to the cartilaginous structure itself, yet it soon involves other parts of the joint. It extends in tbe first place to the bony articular extremities, which become ulcerated, and are, in common language, rendered carious.- the synovial membrane and external soft parts about the joint become inflamed : small abscesses form and break externally ; a succession of these takes place in various parts of the joint, and a number of fistulous openings are established about the joint, o-ivin"- place to matter, and, in many cases, to carious portions of bone. The ulcerative process often extends to the ligaments that connect the articulations; the conse- quence of which is, that bones are no longer retained in their relative, positions, but are thrown into certain unnatural directions by the action of the strona muscles of the limb." (p. 483.) According to Key's views, the ulceration of cartilages, commonly so called, de- pends on four conditions, in three of which "the cartilage," he says (6,) "is not absorbed per se, but through the agency of a structure, probably evolved for the special purpose of completing that process," and the fourtb is " the result of disor- ganization of texture." The first two forms, viz., "the loss of articular cartilage that attends upon the chronic inflainmation of the synovial membrane, and the more active destruction of the articular cartilage that attends acute inflammation of the joint," appear to me simply modifications of the same process by the degree of the inflammatory action, and, therefore, to be considered as one form, either in its chroni; or acute stage, as may be, the result of which is the production of a vascular and absorbing membrane from the synovial membrane. The next is " the absorption of cartilage that accompanies strumous disease of the cancellated structure of bone," or that condition mentioned by Brodie, in which "the cancellous structure of the bones is the part primarily affected ; in consequence of which ulceration takes place in the cartilages covering their articulating surfaces." (p. 226.) The consideration of this form must be deferred to Inflammation of the Joint-ends of Bonos, (par. 221- 21.) The last condition, much less frequent, is that in which Key says, "that structure (cartilage) appears to undergo a change in its organization, independent of foreign agency. * * * An action altogether different from absorption, and analo- gous to the softening of the intervertebral substance." To which he applies the term " disintegration, in contradistinction to absorption, the one being a loss of (a) Lectures in Lnncet. (6) Further Remarks on the Ulcerative Process; in Med.-Chir. Trans., vol. xix. 256 ULCERATION OF CARTILAGE BY substance from an absorbing action, the other being the result of a disorganization of texture. It is the primary ulceration of cartilages described by authors." (pp. 134,35.) Of the absorption of cartilage by a new membrane produced by inflammation of the synovial membrane, Key (a) thus speaks :—" In a manner analogous, in many respects, to the process of removing dead bone, does nature achieve the task of absorbing the cartilaginous structure covering the articular extremities of bones. These structures possess but a low degree of organization; in their healthy condition they present very few of the characters of animal vitality: they exhibit scarcely any trace of red blood-vessels, and, for obvious reasons, their supply of nervous influence is not more than suffi- cient to connect them with the surrounding structures, as part of a whole. Under disease they exhibit that want of action which might be anticipated from the limited extent of their organization. In acute inflammation of a joint, while the synovial membrane and ligaments are much altered, the cartilage appears unchanged in colour or in texture, and apparently uninfluenced by the increased action going on in the surrounding (.arts. The cartilage becomes, under disease, softer somewhat in texture; but this change may be as well attributed to the absence of pressure as to the effect of inflammatory action ; for healthy joints when kept long at rest are found to undergo a similar change, on their cartilaginous surface, from the want of that pressure to which they have been accustomed, and which may be necessary to the preservation of their due consistence. There are, however, some forms of in- flammation under which the cartilage, very early in the disease, undergoes a change of structure: these instances are much less frequent, and may be looked on as ex- ceptions to the ordinary rule." (pp. 216, 17.) "The progress of ulceration in cartilage covering the ends of bone," continues Key, " is not uniform in its course. The means by which it is effected vary ac- cording to the cause that gives rise to it. It is sometimes the result of acute syno- vial inflammation, or of a chronic affection of that membrane: it is occasionally found as a primary affection, independent of the other textures of the joint. * * * I am inclined to believe that inflammation of this membrane is the most frequent cause of ulceration of the cartilage. This opinion I have been led to adopt from the examination of a considerable number of diseased joints, in which ulceration of car- tilage has been found to exist in different degrees of progress from its most ad- vanced stage, in which the bone has been entirely denuded, to the very incipient abrasion of its surface or margin. The history of some of these cases, together with the morbid appearances, has also satisfactorily proved the existence of a long con- tinued synovial affection, before any alteration of the cartilaginous surface could have taken place, as the cartilage in some has been quite sound, with the exception of a slight loss of substance at the edge of the bone, where the synovial membrane is reflected from it: while the symptoms of diseased joint have existed for many months, with pain over a large part of the synovial surface, and general swelling of the joint. * * * The inflammation of the synovial membrane that leads to ulcera- tion of cartilage in the ordinary strumous affection of joints in the adult, is not, as far as my observation goes, of the most acute kind. * * * The less acute forms of the disease, assuming various shades of activity between the chronic and the acute forms, rarely occur for any great length of time without the cartilage participating in the mischief. This may in some measure depend on the peculiarity of those consti- tutions in which sub-acute inflammation seems to have a spontaneous origin. The knee-joint is most frequently observed to suffer disorganization from this form of inflammation. * * * When the more acute symptoms are subdued (by treatment) the membrane sometimes fails to regain its normal condition, passing into a chronic form of action so slight as to attract but little attention, and often regarded as stiff- ness that will yield to exercise and passive motion. This slight degree of inflammation that remains often lays the foundation of future mischief, especially if the condition of the patient's health is not adverted to after the acute stage of inflammation had subsided. The nature of the remedies employed always leaves the patient in a state of weakness and irritability, under which the low degree of action that remains in the joint will be disposed to assume the ulcerative form. * * * This state of joint as the disease advances is usually attended with more pain, than when the {a) On the Ulcerative Process in Joints; in Med.-Chir. Trans., vol. xviii. ADVENTITIOUS MEMBRANE. 257 disease assumes from the commencement the chronic form; the intervals of ease become short and few; and the action goes on with but little interruption to the formation of abscess. In the chronic form of synovial inflammation that occurs in indolent habits of a strumous tendency, especially in persons below the age of pu- berty, years often elapse before the ulcerative process is completed. The symp- toms are proportionally mild in their course. The joint is not much swelled, the general and uniform fulness of the joint, so characteristic, as Brodie has observed, of the most acute forms of inflammation of the synovial membrane, is absent; the joint appears as if the bones themselves were enlarged, an appearance as much pro- duced by the shrinking of the limb above and below the joint as by the swelling of the joint itself. The swelling of the soft parts about the joint depends on the degree of inflammation presentinthe synovial membrane, and the consequent effusion in the soft parts. In the most chronic forms the bones can almost be felt through their liga- mentous investments; in the less chronic forms, when the disease runs its course in a shorter period, there is effusion of albumen in the soft structures surrounding the joint, which increases its volume, preventing the bones being distinctly felt, and in some measure altering the form of the joint, (pp. 218-22.) " The patella and the extremity of the femur are the parts on which the ulcerative process can be best traced, on account of the disease being in these less advanced. In the former bone, the first part that commonly gives way to ulceration is the margin of the cartilage, where the synovial membrane is reflected from it. At this point sulci of different depths are formed, which cannot be always distinguished until the thickened edge of the synovial membrane is raised. The ulcerated surface some- times exhibits parallel vascular lines, verging towards the centre, and having their origin from the synovial membrane. The synovial membrane at this part, if the vessels are well filled with fine injection, appears highly vascular and fringed, or villous, like a mucous membrane. This increased vascularity is particularly notice- able at the edge of the membrane and in those portions of the fringed margin that correspond to the ulcerated surface of the cartilage; the other parts of the synovial membrane have their vascularity but slightly increased. This highly vascular fringe of membrane is a newly organized, and will be found in some parts to be a super- added, structure, for the purpose of producing ulceration of the contiguous cartilage. It may, when recently formed, be raised in some parts from the synovial membrane, but is found to adhere very slightly to that part of the cartilage where ulceration is going on; this adhesion is not perceived unless the joint is opened with great care. * * * The process, therefore, by which the ulceration of cartilage is in this case effected, is analogous to that by which the sequestrum of the cylindrical bones under necrosis takes place. Indisposed to ulceration, from the low degree of its organiza- tion, it is acted upon by the newly organized synovial surface, which is rendered highly vascular, and by means of its villous processes forms a groove in the edge of the cartilage, thus commencing the work of destruction. The cartilage at the edge is sometimes entirely destroyed, so as to lay bare the bone, in which case vascular gra- nulations also arise from the surface of the exposed bone, and assist the membrane in the work of absorption. This, however, is more usually observed in the most acute form of inflammation. In the more chronic form, the vascular fringe of synovial membrane contracts adhesion to the surface of the cartilage in which ulceration is going on, and gives rise to the formation of a new membrane, which spreads gra- dually over the surface of the cartilage. A diseased joint is hardly ever examined without exhibiting one or more of the bones partly covered with this pulpy mem- brane. When injected, its vascularity is found to vary according to the activity of the inflammation in the joint; when first formed it exhibits considerable vascularity during the ulcerative process : when the cartilage has been wholly absorbed, and the ulcerative process has been checked by the inflainmation being arrested, this mem- brane then serves another purpose ; it becomes the rnedium of union between opposed surfaces of bone, or the means of anchylosis. Long after all inflammation has sub- sided, one of the condyles of the femur is often found adhering to the tibia by means of this membrane, which appears white and ligamentous; a layer of cartilage often remaining between the membrane and the bones, as if the process of ulceration were arrested." (p. 223-226.) Goonsiu (a) holds with Key in the deposit from the synovial membrane being (a) The process of Ulceration in Articular Cartilages; in his Anatomical and Pathologic cal Observations. Edinburgh, 1845. 8vo. 22* 253 ULCERATION OF CARTILAGE BY the cause of ulceration in cartilage; for, as "in the thin articular cartilages of the adult human subject, fewr or no vessels can be detected, it is evident that in the pro- cess of ulceration in cartilage, it cannot be the usual blood-vessels of the part which are the active agents, still less likely is it that lymphatics, the existence of which has never been asserted in this texture, are the absorbing instruments." He then proceeds:—" If a thin section, at right angles, be made through the articular carti- lages of a joint, at any part where it is covered by gelatinous membrane in scrofu- lous disease, or by false membrane in simple inflammatory condition of the joint, and if this section be examined, it will be found to present the following appear- ances. On one edge of the section is the cartilage unaltered, with its corpuscles natural in position and size. On the opposite edge, is the gelatinous, or false membrane, both consisting essentially of nucleated particles, intermixed, especially in the latter, with fibres and blood-vessels; and, in the former, with tubercular granular matter. In the immediate vicinity, and on both sides of the irregular edges of the section of cartilage, where it is connected on the membrane, certain remark- able appearances are seen. These consist, on the side of the cartilage, of a change in the shape and size of the cartilage corpuscles. Instead of being of their usual form, they are larger, rounded, or uniform; and, instead of two or three nucleated cells in their interior, contain a mass of them. At the very edge of the ulcerated cartilage, the cellular contents of the enlarged cartilage corpuscles communicate with the diseased membrane by openings more or less extended. Some of the ovoidal masses in the enlarged corpuscles may be seen half released from their cavities by the removal of the cartilage; and others of them may be observed on the Substance of the false membrane, close to the cartilage, where they have been left by the entire removal of the cartilage which originally surrounded them. If a por- tion of the false membrane be gradually torn off the cartilage, the latter will appear rough and honeycombed. Into each depression on its surface a nipple-like projec- tion of the false membrane penetrates. The cavities of the enlarged corpuscles of the cartilage open on the ulcerated surface by orifices of a size proportioned to the extent of absorption of the walls of the corpuscle, and of the free surface of the cartilage. The texture of the cartilage does not exhibit, during the progress of the ulceration, any trace of vascularity. The false membrane is vascular, and loops of capillary vessels dip into the substance of the nipple-like projections which fill the depressions on the ulcerated surface of the cartilage; but, with the exception of the enlargement of the corpuscles, and the peculiar development of their contents, no change has occurred in it. A layer of nucleated particles always exists between the loops of capillaries and the ulcerated surface. The cartilage, where it is not covered by the false membrane, is unchanged in structure. The membrane gene- rally adheres with some firmness to the ulcerating surface; in other instances it is loosely applied to it; but, in all, the latter is accurately moulded to the former. (p. 17-19.) The view given by Key, of the usual mode in which cartilage is absorbed, or as it is commonly called, ulcerates, is in the main similar to that held by Wilson, but more fully and more satisfactorily developed. Its correctness I cannot doubt, for I have seen it, I think more than once or twice, from the first commencement, in which, on carefully lifting up the new membrane, its perfect impress is perceived upon the cartilage, varying in depth and extent according to the thickness and size of the membrane, till the entire depth of the cartilage is removed and the membrane comes in contact with the bone, the articular surface of which is also destroyed either by it or by simultaneous inflammatory action set up in the cancellated struc- ture of the bone. The preparations to which I allude are in St. Thomas's museum, and some of the patients were under my own care.—j. f. s. "When suppuration,'''' Key continues, '■'■follows acute inflammation,from a wound of the synovial membrane, the latter undergoes that change which enables it to per- form its new function. The surface becomes highly vascular, and in most parts, covered with a new deposit of adhesive matter, which adheres firmly to the synovial membrane. The new surface is irregular, wanting the polish of the origi- nal membrane, and appears in many parts villous, or furnished with vascular fringed projections. In a joint thus far advanced in disease, the only mode of arresting the disease, or of repairing the mischief occasioned by the inflammation, consists in an- chylosis. To this end, the removal of the cartilage is an essential step; and it would appear that the office of removing it devolves on the inflamed synovial mem- ADVENTITIOUS MEMBRANE. 259 brane. The cartilage, under these circumstances, is not only eroded at the edge where the synovial membrane is reflected upon it, but grooves and indentations may be traced in various parts of it, having no connexion, as in the progressive strumous form of ulceration, with the edge of the synovial membrane, and not showing any indications of a new membrane forming on its surface. The means by which this ulceration is effected appear to be the newly organized surface of the synovial mem- brane in contact with the parts in which absorption is going on. To those who will carefully examine joints in this condition, the evidence of this will, I think, be sufficiently conclusive. The absence of all action in the cartilage, and total want of vascularity in those parts where ulceration appears to be most active, were the cir- cumstances that first led me to look for some agent in the work of ulceration. The ulceration evidently begins on the surface of the cartilage, and not on that side next to the bone. It presents merely an eroded surface; there is no disorganization of its texture in the parts where absorption is about to take place; there is no previous degeneration of the cartilage into its primary fibrous structure, as may be seen in other forms of ulceration; but the cartilage seems to have lost part of its surface, as if it had been dug out, the remaining part appearing healthy, and presenting no trace of increased vascularity. The grooves are found only in those parts of the cartilage that happen to be opposed to the fringed and vascular synovial membrane; and these highly organized portions of the membrane may be seen to be closely adapted, and even to fit into the grooves in the cartilage. Those parts of the carti- lage that happen to be in contact with another cartilaginous surface present no signs nor trace of ulceration, but appear to the eye perfectly healthy, and in texture firm. The process exhibits the closest analogy to that by which nature removes dead bones; the same inactivity or passive condition of the parts absorbed; the same suppurative action from the vascular granulation; and a similar degree of vascularity bestowed upon the newly organized structure which has to perform the office of ab- sorption. It is not, however, in every instance of suppuration in a joint, even where this villous membrane is found, that ulceration of the opposite cartilage is to be looked for as a uniform occurrence ; for strumous joints are occasionally examined, in which the synovial capsule has been for many months distended with purulent sections, and the synovial membrane covered with flocculi hanging into the joint, without a trace of ulceration in the opposite cartilaginous surface. This exception rather favours the view which I have advanced of the ulcerative process in the case of suppuration from wound. The condition essential to the act of absorption is here wanting. There is not a wound or opening by which the pus can escape as fast as it is secreted: it consequently collects in the cavity of the joint, and, by distention. prevents the membrane coming in contact with the cartilage; and the villous pro- jections from the membrane, even when the vessels are well filled with fine injection, do not exhibit that degree of vascularity which is so clearly developed when ulcera- tion of the cartilages takes place, (p. 234-37.) Nature, it seems, does not often adopt this mode of removing the cartilage. It is only in the acute form of inflam- mation, as in wounds of joints, that I have observed it. The process of removing the cartilage appears at all times, and under all circumstances of disease, an object that she endeavours to accomplish ; while the cartilage remains entire, anchylosis, the natural cure in some forms of diseased joint, cannot be effected; and, therefore, we may often observe ulceration of cartilage going on very early in those diseases that, forming some defect in the patient's constitution, cannot be arrested without anchylosis, (pp. 239, 40.) Brodie (a), however, still considers that "the explanation which Key has offered does not admit of a general application, and that the absorption of the cartilage, com- mencing on the surface towards the cavity of a joint, may take place under such circumstances, that it cannot be supposed to be the result of any other agency than that of the vessels of the cartilage itself, (p. 331.) In speaking of ulceration of the articular cartilages, as a consequence of inflammation of the synovial membrane, I have not endeavoured to explain the exact nature of the process by which such ulceration is effected, and simply for this reason,—that I have not been able com- pletely to satisfy my own mind on the subject. There can be no doubt that, in many instances, ulceration begins at the margin of the cartilage, where the synovial membrane is reflected over it from the neighbouring bone, or from the inter-articular (n) Additional Notes on Ulceration of Cartilage; in the Third Edition of his book on the Diseases of Joints, 1834. 260 ULCERATION OF CARTILAGE FROM, &C. ligaments, where such ligaments exist; but it may still admit of a question, in what manner the ulceration is accomplished; whether it be from the inflammation extending directly to the cartilage itself, or to the bone first, and the cartilage after- wards ; or whether, according to the views entertained by Mr. Key, the latter, being altogether in a passive state, becomes absorbed by the action of the vessels of the fringed process of the synovial membrane lying in contact with it. But there are other cases of inflammation of the synovial membrane, in which ulceration begins in the centre of the cartilage, so that none of these hypotheses afford any reasonable ex- planation of it. It seems not improbable that, in some of those cases which are usually regarded as examples of simple inflammation of the synovial membrane, the inflammation may not have been confined (even in the first instance) to this indi- vidual part, but may have begun simultaneously in all the textures of the joint. This is in conformity with what is observed to happen occasionally in the eye and other organs; and under such circumstances, it is no more than might be expected, that, as the inflammation subsides, the cartilage should ulcerate either in the centre or in some other part of its surface. Nor is this a merely speculative opinion; at least I am much mistaken if it be viewed in that light by any one who, after having perused the history of the following case, considers what would probably have happened if the patient had not died of another disease before there was time for the disease of the joint to have run its course. A gentleman, about twenty-five years of age, had laboured for several years under a disease of the brain, in consequence of which he had been in a state of complete helplessness and imbecility. In the sum- mer of 1820 he became indisposed otherwise: there was a cluster of enlarged glands in the left groin, and a purulent sediment was deposited by the urine. I was now desired to see him in consultation with Dr. Maton, who was his ordinary medical attendant. Soon afterwards, it was observed, that there was a general tumefaction of the left thigh and nates, and the patient complained of pain in certain motions of the limb. Under the treatment employed, the tumefaction subsided; but, imme- diately afterwards, a violent attack of diarrhaja took place, under which he sunk, and died on the 29th of July. On examining the body we discovered an abscess, which seemed to have had its origin in the. cellular membrane of the pelvis, near the neck of the bladder, which had burst into the neighbouring portion of the urethra, and which had also extended upwards on the left side, so that it could be traced as high as the mass of enlarged glands in the groin. The whole of the muscles surrounding the left hip-joint, were preternaturally soft and vascular, and so altered from their natural condition, that they could be lacerated by the slightest force. They also were to a considerable extent detached, or separated from each other, apparently in consequence of a serous fluid which had been effused between them, but of which nearly the whole had become absorbed. The capsular ligament and synovial mem- brane of the joint were of a red colour, and unusually vascular; and the cartilages covering the head of the femur and lining the acetabulum were also red and of a soft consistence, giving to the fingers a sensation somewhat resembling that which is produced by touching velvet." (pp. 336-39.) A very remarkable instance of ulceration of cartilage in an almost incredibly short space of time is mentioned by Lawrence (a). In a case of phlebitis, after bleeding, which came under his own care in St. Bartholomew's Hospital, the patient had pain in his knee, commencing on the fourth, and he died on the eighth day of the same month. " On examination after death I found the knee-joint filled with pus of a reddish colour, that is, with pus rendered red by the admixture of blood. The synovial membrane which had produced this pus was highly inflamed, but the arti- cular cartilage of the femur and the corresponding articular surface of the tibia were completely destroyed, and this high degree of ulceration had been produced within the short period mentioned." (pp. 482, 3.) He also mentions the following very curious circumstance :—" When necrosis attacks the shaft of a long bone, though it does not involve the ends, yet the morti- fication extends (or rather may extend'?—j. f. s.) sufficiently to the extremities to excite inflammation and absorption of the cartilages, although the synovial mem- brane does not become involved." And he speaks of a case in which "the whole shaft of the thigh-bone had perished, and the cartilages were as completely removed as if they had been cut out by the knife." (p. 483.) This appears to me the con- (a) Lectures on Surgery ; in Lancet, 1829-30, vol. ii. SELF-ULCERATION OF CARTILAGE. 261 dition, though much more advanced, to which Key refers, when having spoken of the vascular deposit on the synovial membrane that destroys cartilage, he proceeds: —"A membrane is sometimes seen in joints under different circumstances, and affords a contrast to the above, as well in structure as in office. I allude to that adventitious membrane that is formed from the edges of the synovial membrane, in consequence of inflammation of a joint, induced by a contiguous disease of bone, as necrosis. In this case the membrane is formed for the purpose of circumscribing the cavity of the joint, when the cartilage is destroyed by the extension of the disease. It possesses but little vascularity, is smooth on its surface, not being fur- nished with the villous texture necessary to the ulcerative function. The opposed cartilage, under these circumstances, appears entire, ulceration taking place only on the surface next to the bone, and the membrane has not any connexion with the surface of the cartilage." (pp. 226, 27.) Although it appears that, under inflammation, either chronic or acute, the less or greater deposit of coagulable lymph from the synovial membrane, which becomes organized, absorbs or eats up the cartilage with which it is in contact, as has been so ably described by Key just quoted, and often requires amputation of the limb to tranquillize the constitutional excitement of the patient, which, if continued, would wear out his powers and destroy him ; yet is it not to be considered as always a destructive, but rather, as Key (a) has very truly stated it to be, " a repairing pro- cess, established with a view to the ultimate anchylosis of the joint, and by an efficient provision to prevent an inflammatory process that would otherwise end in ulceration and suppuration. A membrane is gradually developed by the agency of which the cartilage is absorbed, and which afterwards becomes the medium of anchylosis; thus the destruction of the joint is often prevented." (p. 146.) Henle agrees with Key as to the absence of vessels in cartilage, but he explains its wasting or ulceration as dependent on want of nutriment. The following are his observations on the subject:—"As cartilage has not vessels, it is not subject to any disease which depends on unnatural movement of the blood, neither inflammation nor hypertrophy; for the same reasons, as it needs no vessels, it is not so easily wasted by pressure as bone. * * * Cartilage only wastes when the Current of blood into the tissue upon which its nutrition depends is interrupted ; the diseased cartilage, as for instance of inflamed joints, therefore is destroyed as if by maceration, rough, then as it were eaten, and finally dissolved." (p. 809.) Of Ulceration of Cartilage.—This, the more rare mode in which destruction of cartilage is effected, really occurs, in the cartilage itself, and is described by Key (b) as "an action altogether different from absorption, and analogous to the softening of the intervertebral substance," in other words, " the result of disorganization of texture." (p. 135.) But before stating his opinions on this subject it will be advi- sable to mention his views on ulcerations in general, for the better comprehension of their application to cartilage. " Ulceration is a process analogous to the softening attending suppuration ; it is a degeneration of tissue, a change in the affinities exist- ing between its component parts, by which it becomes changed from a solid texture to a fluid inorganic mass. It differs from gangrene in being a vital action; while gangrene, by at once producing death in a part prevents any such change taking place. In gangrene the supply of blood to the part altogether ceases, while the integrity of tissue is preserved ; under ulceration the circulation in the vessels con- tinues during the action, and the part still belongs to the living mass, and remains under the influence of vital action until its separation is completed." (pp. 137, 38.) " Ulceration of cartilage," says Key, " is effected in the same manner as an ulcer in soft parts ; it is a destructive action that sooner or later is followed by suppuration of the joint. It commences in the structure of the cartilage itself, which, no longer under the influence of those forces that unite its integral parts, breaks up, and be- comes converted into a purulent mass, which, mixing with the synovia of the joint, irritates the synovial membrane to inflammation, and ultimately to suppuration and ulceration. Ulceration of cartilage, however, as a primary disease, is a much less frequent occurrence than absorption through the intervention of membrane. I do not remember," says Key, "to have examined a joint, that had been the subject of ordinary chronic inflainmation, in which this membrane was not more or less de- veloped. Nor have I seen an instance of chronic inflammation, in the early stage of (a) Med.-Chir. Trans., vol. xix. (6) Ibid. 262 SELF-ULCERAT10N OF CARTILAGE. strumous disease, in which degeneration or ulceration of the cartilage existed as the primary action. Chronic inflammation, however, after existing for many months or years in strumous subjects, may, and often does become acute, and ulceration sometimes, in such cases, supersedes the absorbing process, and abscess rapidly forms. * * * Nature endeavours, so long as she can, to remove the cartilage by absorption, in order to prevent the necessity of suppuration ; for primary ulceration of cartilage leads to the formation of abscess. The breaking up of the tissue of the cartilage is equivalent to the suppurative process in softer tissues; it creates a pro- duct that must be got rid of; the synovial membrane is irritated, and ulceration with abscess is the result. In absorption of the cartilage through the intervention of the membrane, suppuration is not a necessary attendant, and we sometimes find the whole process completed without abscess. But where the membrane is wanting, the process is analogous to the degeneration of soft parts, and is sooner or later fol- lowed by suppuration. * * * The diseases in which the texture of the cartilage pri- marily undergoes ulceration are, for the most part, acute from their commencement. The inflammation that follows wounds of joints often leads to the rapid ulceration of the cartilage, and to burrowing abscess. In these cases, the cartilage is found often to be extensively destroyed, and the bone laid bare, without any appearance of a membrane for the purpose of absorption. The remaining cartilage sometimes exhi- bits different stages of approaching disorganization; in some parts retaining its natural form, consistence, and appearance; in others being soft and spongy, or even pulpy; and in those parts most advanced towards ulceration, the fibre of the cartilage can be seen to separate, and flakes here and there appeared to be almost detached. * * * The chronic inflammation of the synovial membrane, attended with absorp- tion of the cartilage, not unfrequently becomes acute from accidental causes, and, leading to ulceration, quickly disorganizes the joint. Both ulceration and absorp- tion may be seen to operate. In some parts may be seen the membrane adhering to the cartilage or to the denuded bone, in various degrees of activity or vascularity, according as its office is completed or in progress ; and in others a total loss of the cartilage may be observed, without the development of a membrane. It is not un- usual for one half of a knee-joint to be losing its cartilage by absorption, while, by a process of inflammation subsequently excited, the other is in a state of active ulceration. On one side the cartilage is furnished with the absorbing membrane, which sometimes spreads over the whole of that side of the cavity, and protects it from the devastating process of ulceration that is at work on the other side of the joint, which is filled with pus and the remains of the disorganized cartilage. In persons who have become extremely irritable and weak, the ulcerative process is so determined, that the membrane itself is sometimes found in a state of ulceration." (p. 146-50.)] 217. On examination of the joint after death, produced by other dis- eases, it has been found, if the disease were still in its commencement, that the cartilage, at one or more places, was loosened into a fibrous mass, and ulcerated ; at a later period there was great destruction of the cartilage, the joint was filled with ichor, the synovial membrane and other parts of the joint disorganized. Many will not allow the possibility of primary affections of the cartilage, as the cartilages of a moveable joint must be considered as lifeless parts, which cannot take on inflammation, do not feel the effects of irritants, and, in affections of the synovial membrane or of the bony tissue beneath it, only suffer destruction and ex- foliation. Schumer (a) has, in his experiments on animals, observed the same results as Dorner and others had previously, that the joint-cartilages, laid bare, in- jured, and even exposed to the air, never snowed any trace of inflammation, which appeared only in the bony epiphyses and synovial membrane. Gendrin (1A sup- ports this opinion especially on the ground of the cartilage not being covered with synovial membrane ; an assertion which, though also put forth by others, is con- tradicted by observation. J. B. Marc (c.) According to Brodie's and my own observations, I must consider the disease here (a) Diss, de Cartilaginurn Articulorum tions. Paris, 1836. 2 vols. 8vo. ex Morbis Mutatione. Groning, 1836. 8vo. (c) Essai sur les Synoviales, Paris, 1834, (b) Histoire Anatomique des Inflamma- p. 13. SELF-ULCERATION OF CARTILAGE. 263 described as different from common inflammation of the synovial membrane and of the spongy ends of bones, even although perhaps it does not always arise as a pri- mary affection of the cartilage, but is caused by partial inflammation of the synovial membrane, and of the spongy bony tissue beneath the cartilage. Meckel (a) also supposes that the cartilage in different diseases of the joints may redden, swell, soften, and loosen up, but with this peculiarity, that suppuration is not necessarily connected with their ulceration. [Sufficient has been already said in the last paragraph to prove, as seems to me, the truth of Wilson's and Key's notion of the deposit of a new and vascular sub- stance upon the synovial membrane being the usual cause of ulceration of cartilage, and that the cause is not in the cartilage itself. It will not, therefore require, again to be adverted to further than to observe that it is quite distinct from the " loosening of the cartilage into a fibrous mass," spoken of in the present paragraph. This form Brodie speaks of thus :—" We find occasionally some portion of the cartilage covering bone, altered from its natural organization, converted into a num- ber of ligamentous fibres, each of which is connected by one extremity to the bone, whuVthe other is towards the cavity of the joint" (p. 113 ;) and as he soon after mentions in the dissection of one such case, " having no lateral connexion with each other" (p. 119 ;) producing the " brush-like projections of the cartilage and synovial membrane," as Mayo calls them (b.) This " conversion of the cartilage into soft fibrous structure," Brodie says, "1 am disposed to believe is the frequent, though not constant, forerunner of ulceration. In a woman who died a week after a severe contusion of the hip, the cartilage of the hip was found in some parts entirely ab- sorbed, in others having a fibrous appearance, similar to what has been described. And I have noticed the same circumstances in other cases sometimes connected with, and sometimes independent of local injury." (p. 121.) Here, then, is a mor- bid alteration of structure, the occurrence of which seems to indicate that there must be such a vascular apparatus entering into the formation of cartilages as enables new materials to be deposited and old materials to be absorbed, and without which mor- bid alterations of structure do not take place in other parts of the body." (p. 113.) Brodie (c) further observes :—" The degeneration of the cartilage into a fibrous structure is no uncommon circumstance ; and I suspect that it is one cause of the crackling of the joints, which is not uncommonly met with in persons somewhat advanced in life. I have no doubt that it often exists where it is never followed by ulceration ; but I am also well assured that, in many other instances, it precedes, and, in fact, forms, the first stage of the disease." (p. 339.) In regard to this " dege- neration of the cartilage of a joint into a fibrous structure," which Key holds as a dis- tinct form, and describes as the third mode of ulceration of cartilage, he says :—" As far as my observations have enabled me to judge, it is a disease of a peculiar character, and differing in many respects from the ordinary affection of joints that end in the destruction ofthe cartilage. I have had but few opportunities of verifying by dissec- tion the existence of this disease. Brodie has described it, and appears to regard it as a not uncommon occurrence ; in one instance he found it combined with disease of the intervertebral substance. Of three cases that have come under my notice, two have occurred in subjects brought into the dissecting-room, and the history of which I was unacquainted with ; the other case was that of a gentleman who was labouring under stone in the bladder, and suddenly experienced a severe attack of pain about the head of the fibula and the bursae at the back part of the head of the tibia. The pain was accompanied with considerable fever, and slight swelling of the parts in which he complained of the pain. On the third day the pain shifted from the fibula to the knee-joint, which swelled, as if from an effusion of synovial fluid. The suffering now became excessive, and the fever assumed a typhoid character. At the end of ten days from the commencement of the attack he died. The bladder presented less evidence of the inflammatory action than might have been expected from the intensity of his sufferings. The knee-joint was distended with a thin opaque synovial secretion of a somewhat purulent character ; the surface ofthe synovial membrane presented here and there patches of more than ordinary vascularity. The cartilaginous surfaces ofthe bones wrere entire, with the exception of a small spot on the end of the femur which appeared ragged and irregularly broken up into a fibrous mass." (pp. 241, 2.)] (a) Above cited, par. 2. {b) Med.-Chir. Trans., vol. xix. p. 49. (c) Additional Notes. 264 INFLAMMATION OF THE JOINT-ENDS OF BONES. 218. This disease shows itself in every age, but especially in children; more frequently in the hip and shoulder than in other joints. Its causes are external injury, but especially dyscratic diseases. [" The ulceration of the articular cartilages may," according to Brodie, " occur at any period of life, but it is most frequent in those who have passed the age of puberty, and who are under thirty-five years of age. We meet with it, however, some times in young children, and at other times in old persons." (p. 151.)] 219. The prognosis is always unfavourable, as the disease is often mistaken at its commencement, and speedy destruction of the parts ofthe joint is produced. 220. In severe irritation of the joint, leeches, cupping, even blood- letting, warm baths, and so on, must be employed at the onset. If the inflammation be thereby diminished, or if the disease has originally taken an insidious course, derivative remedies, and, among these, issues espe- cially and the actual cautery are to be employed. The action of these reme- dies is often very rapid ; the suppuration must, however, be kept up from the surface for a long time, and the joint kept perfectly at rest. Some- times improvement quickly takes place ; but the attacks recur, in which case, probably suppuration has already taken place in the joint. When abscesses are formed, they must be treated as already directed, and espe- cially the general diseased condition of the body somehow connected with the disease ofthe joint, properly attended to. D.—OF THE INFLAMMATION OF THE JOINT-ENDS OF BONES. 221. The inflammation, in these cases, (Inflammatio Processum Ar- ticulorum, Lat.; Entzundung der Gelenk-Enden der Knocken, Germ.; In- flammation des Extremites Articulaires des Os, Fr.,) begins in the very vascular spongy part ofthe joint-end ofthe bone, and is at first accom- panied with little pain, which comes on imperceptibly. After a lapse of time of uncertain length, there appears an elastic, irregularly spreading swelling of the outermost parts of the joint, the form of which depends on the expanded joint processes ; the swelling is larger when the joint is in action, and smaller when it is at rest. The motions of the joint are a little interfered with. After a shorter or longer time, increased pain comes on, the external skin becomes dusky red, and finally breaks; ill- conditioned pus is discharged, and caries is felt on using a probe. So often as some wounds close, others break out, and hectic fever threatens to exhaust the patient. [" There is another malady," says Brodie, " which affects the joints, having all the character of scrofula, generally occurring in persons who have a scrofulous ap- pearance, and usually preceded by, or combined with, scrofulous symptoms. In this disease of the joints, the cancellous structure of the bone is the part primarily affected ; in consequence of which ulceration takes place in the cartilages covering their articulating surfaces. The cartilages being ulcerated, the subsequent progress of the disease is, in many respects, the same as where this ulceration takes place in the first instance." (p. 226.) The morbid affection appears to have its origin in the bones, which become preternaturally vascular, and containing a less than usual quantity of earthy matter; while at first a transparent fluid, and afterwards a yellow cheesy substance, is deposited in their cancelli. From the diseased bone we see, in some instances, vessels carrying red blood extend into the cartilage. The carti- lage afterwards ulcerates in spots, the ulceration beginning on that surface which is OF THE JOINT-ENDS OF BONES. 265 connected to the bone. The ulceration of the cartilage often proceeds very slowly. I have known a knee amputated on account of this disease, in which the cartilage was absorbed for not more than the extent of a sixpence. Occasionally a portion of the carious bone dies and exfoliates. As the caries of the bones advances inflamma- tion takes place of the cellular membrane, external to the joint. Serum, and after-* wards coagulable lymph, is effused, and hence arises a puffy and elastic swelling in the early, and an oedematous swelling in the advanced, stage of the disease. Abscess having formed in"the joint, makes its way by ulceration through the liga- ments and synovial membrane, and afterwrards bursts externally, having caused the formation of numerous and circuitous sinuses in the neighbouring soft parts. In one case, thin layers of cartilage were found lying on the ulcerated surface of bone, apparently unconnected with it. In some instances, in the advanced stages of this disease, we find nearly the whole of the cartilage forming an exfoliation instead of being ulcerated. This scrofulous affection attacks those bones, or portions of bones, which have a spongy texture, as the extremities of the cylindrical bones, and the bones of the carpus and tarsus, and hence the joints become affected from their contiguity to the parts which are the original seat of the disease. Sometimes, how- ever, we may trace the effects of these morbid changes even in the shaft of a cylindrical bone; so that we see the femur or tibia converted in its middle into a thin shell of earthy matter, enclosing a medullary canal of unusual magnitude. It has been remarked by a modern author (a,) that in the last stage of this disease the bones not only lose the preternatural vascularity which they possessed at an early period, but even become less vascular than healthy bone. I believe the observation to be correct; and this diminution of the number of vessels, and consequently, of the supply of blood, is probably (as this author has suggested) the proximate cause of those exfoliations which sometimes occur where the disease has existed for a con- siderable length of time, especially in the smaller bones." (p. 245-48.) Upon this condition, his "last form, in which ulceration (or rather absorption) of cartilage takes place," Key (b) observes :—" There are two forms of disease in bone under which this secondary absorption of cartilage takes place; the one is of a chronic nature; the other assumes an acute form; but in the process of ulceration the same passive condition of the cartilage may be observed as in that which com- mences within the cavity of the joint. The chronic form is that in which a strumous action takes place in the cancellated structure," (pp. 243, 44,) and is that just described. "I apprehend," says Key, " that most pathologists will concur in the probability of the loss of the cartilage being effected by means of the vascular granulations that spring up from the cancelli, and appear to form a continuous structure with the surface of the cartilage. In making a transverse section ofthe joint, under these circumstances, there is no trace to be seen of increased vascularity in the cartilage, nor in the synovial membrane, until the action is far advanced, that can lead us to suppose that the cartilage was ulcerated by any other agent than the vascular tissue of the bone. The acute form ofthe disease differs from the former in the comparative sudden- ness of the attack, as well as in the appearance which the bone presents. The former is, like all strumous affections, slow in its progress, and at first marked by little or no pain in the part. Months often elapse before the symptoms become severe, and the constitution much affected. But in the acute form of disease attack- ing the spongy extremities of bones, the pain is often severe in the beginning, the limb at that part tender when pressed, and the constitution a good deal disturbed. A few weeks only elapse before the joint exhibits symptoms of participating in the mischief. From this time the disease makes rapid progress : if suppuration takes place in the cavity of the joint, the synovial membrane ulcerates and allows the matter to burrow between the muscles of the limb : fistulous openings at length form, and tend in some measure to abate the patient's sufferings. The effect, however, on the constitution is such that amputation is usually resorted to for the preservation of life. Examination of the joint exhibits very different appearances from those which are observed in the chronic strumous disease of the bone; not in the cavity ofthe joint itself, for here the process of destruction is in some respects the same; but in the bone the affection is found to be altogether of a different character. The substance of the bone retains its firmness of texture; and when cut through shows (a) Lloyd on Scrofula, p. 123. (6) Med.-Chir. Trans., vol. xviii. Vol. i.—23 266 SCROFULOUS INFLAMMATION. no sio-ns of disease except at one part of the cancelli. There a cavity is found containing one or more portions of detached bone, surrounded with pus ; this cavity is found to communicate with the joint by a fistulous opening of small size, which may sometimes escape observation. The cancellated structure of the bone surround- ing the cavity usually appears natural and sending forth vascular granulations. The cartilage covering the end of the bone is extensively ulcerated in some parts, whilst in others it appears to have undergone no change. The process of ulceration evi- dently begins on the outside of the joint, for the cartilage, when closely examined, appears to be undermined, and the surface towards the joint where this undermining process is going on seems quite sound. The synovial membrane shows signs of acute inflammation, and its cavity is found to communicate with one or more exten- sive collections of pus above and below the joint. This form of disease is in its nature analogous to necrosis of the shafts of the cylindrical bones." (p. 245-47.) " In scrofulous disease of the cancellated texture of the heads of bone," says Goodsir, " or in cases where the joint only is affected, but to the extent of total de- struction ofthe cartilage over part or the whole of its extent, the latter is, during the progress of the ulceration* attacked from its attached surface. Nipple-shaped pro- cesses of vascular texture pass from the bone into the attached surface of the cartilage, the latter undergoing the change already described. The process from the two sur- faces may thus meet half way in the substance of the cartilage, or they may pass from the attached, and project through a sound portion of the surface of the cartilage, like little vascular nipples or granulations. The cartilage may thus be riddled, or it may be broken up into scales of various size and thickness, or it may be undermined for a greater or less extent, or be thrown into the fluid of the cavity of the joint in small detached portions, or it may entirely disappear." (p. 19.)] 222. According to the stage of the disease, the joint ends are found on dissection in different conditions. They are soft, broken up, dusky red ; their vessels much enlarged, and the cells of the bone are filled with reddish lymph. The cartilages are often still unchanged externally, but their inner surface is loosened from the destroyed bone. In the most advanced stage, both bone and cartilage are destroyed, the synovial membrane and ligaments disorganized, and the cavity of the joint filled with ichorous pus. 223. This disease is more rare in the hip and shoulder than in other joints, and most frequent in the spongy bones of the wrist and instep. It is more, frequent in children and young persons than in adults. Its occasional cause may be external violence, but there is always dyscratic disease, and especially scrofula, in casual connexion with it. [Brodie says :—"The scrofulous affection ofthe joints occurs frequently in chil- dren ; it is rare after thirty years of age. Examples of it occur in almost every joint of the body ; but the hip and shoulder appear less liable to it than many other articu- lations." (p. 248.) But Key states:—" The bones in which he has observed this (the chronic) form of disease are the small bones of the carpus and the extremity of the femur; and, more frequently, the head ofthe tibia and the bones of the tarsus. Persons of all ages appear to be liable to it: I have witnessed it," he says, " in pa- tients from the age of two years to fifty." (p. 244.) Brodie also further observes :—" As it depends on a certain morbid condition of the general system, it is not surprising that we should sometimes find it affecting several joints at the same time, nor that it shows itself in different joints in succes- sion, attacking a second joint after it has been cured in the first, or after the first has been removed by amputation. It is seldom met with, except in persons who have the marks of what is called a scrofulous diathesis; and in many cases it is either preceded, attended, or followed, by some other scrofulous symptoms, such as en- largement of the scrofulous glands of the neck, and mesentery; or tubercles of the lungs. I have often been led to believe that the occurrence of this disease in the joint has suspended the progress of some other j and perhaps more serious, disease else- where." (pp. 249, 50.) Brodie's last observation is, I am convinced j exceedingly correct, if, as I presume, CONSEQUENCES OF ULCERATION OF CARTILAGES. 267 he means some modification of scrofulous disease in other parts of the body. I am certain that I have, again and again, seen persons, whose appearance betokened inci- pient phthisis, recover, and become stout and healthy; as if the disease had proceeded to its crisis in the joint, and on the removal of which by amputation, all the consti- tutional disturbance ceased.—j. f. s. Brodie considers that " the scrofulous disease is more likely to be confounded with ulceration of the articular cartilages than with any other. There is, in many respects, a correspondence in their symptoms. There'are, however, certain points of difference, and I believe that this difference will be found in general sufficient to en- able the practitioner, who is careful and minute in his observations, to make a correct diagnosis ; at least, in those cases in which the local disease is not so far advanced, and in which it has not so much affected the general constitution as to make the diag- nosis of no importance, (p. 250.) The principal difference which is to be observed between the symptoms which have been just-described, and those which are met with, where ulceration of the cartilages occurs as a primary affection, is in the degree of pain which the patient endures, and which is much less in the cases of the former (the scrofulous disease) than in those of the latter description. It may, indeed, bo matter of surprise that, in cases of this scrofulous affection, the sufferings of the pa- tient should be so little as they are found to be in proportion to the quantity of local mischief. For the most part, the pain which he experiences is not a subject of seri- ous complaint, except at the time when an abscess is just presenting itself under- neath the skin, and then it is immediately relieved by the abscess bursting. There is never that severe pain which exhausts the powers and the spirits of the patient in cases of ulceration of the cartilage, except in a very few instances, and in the most advanced stage of the disease, when a portion of the ulcerated bone has died, and, having exfoliated so as to lie loose in the cavity of the joint, irritates the parts with which it is in contact, and thus becomes a source of constant torment. There are other circumstances, besides the less degree of pain, which, although not in them- selves sufficient, it is useful to take into the account in forming our diagnosis, such as the genera] aspect and constitution of the patient, and his having manifested a disposition to other scrofulous symptoms; the very tedious progress of the disease; and the circumstance of the suppuration not being in general confined to a single col- lection of matter, but producing a succession of abscesses." (pp. 255, 6.)] 224. The prognosis and treatment are the same, as already stated, in inflammation and ulceration of cartilage. [OF THE FAVOURABLE CONSEQUENCES OF ULCERATION OF CARTILAGES. 224.* The termination of ulceration of the articular cartilages from whatever cause, although generally destroying the patient by wearing out his constitutional powers, unless prevented by the removal of the limb, is neither always fatal, nor does the joint or its motions even seem to be always destroyed. When the destruction of cartilage has a favour- able issue it terminates in one of two ways. In the first, the cartilage is replaced by a layer of ivory-like bone, and the motions of the joint con- tinue ; this especially happens in disease of the hip-joint. In the second, the opposed ends of the bones are united either by a ligamento- fibrous structure, which permits a slightly yielding motion of the joint, or by bone which precludes any motion, and thus are produced the two forms of anchylosis, viz., the soft and the hard. Whether the one kind passes into the other, I cannot positively state, though I think I have seen, in more than one instance, part of the connecting medium ligamen- to-fibrous and part bony. 268 IVORY-LIKE COVERING.--ANCHYLOSIS. I. Of the ivory-like covering of the joint surfaces of bones. This condition has been by some anatomists thought to be merely a natural process, the common consequence of*age, by which the cartilage thick in youth is gradually thinned in adult age, and finally in advanced life completely removed, bone being stated to be constantly de- posited in its place till the whole surface ofthe joint is thus covered. I think, how- ever, I shall he able to show that this is an erroneous statement, as at the very onset it would appear unlikely that more earthy matter should be deposited, under natural cir- cumstances, upon the ends of bones, so as to give those parts an ivory-like charac- ter, whilst on every other part of the same organs less earth is deposited, and even the fibrous mould in which it is lodged becomes thinner and thinner in age. " The removal of the cartilage from the heads of bones in old people," observes Key, " proceeds so slowly that it is difficult to say, on the examination of a joint, whether the action has ceased, or is still in a state of progress. The form of dis- ease to which I allude is attended with a good deal of stiffening of the joint, accom- panied by what are termed rheumatic pains. The place of the cartilage is often supplied by a bony deposit, resembling ivory in texture as well as appearance." (p. 242.) Toynbee says :—" The articular cartilage is gradually being converted into bone during- the whole of life ; thus it is thicker in young than in adult subjects; and, as Sir B. Brodie informs me, it is much thinner in old age than in the adult: in fact, it is not very rare to find that the articular cartilage of the head of the os femoris in very old persons has completely disappeared, a change which is probably to be attributed to its entire ossification." (p. 167.) That this is merely a natural process as might be inferred from Toynbee's ob- servation cannot be admitted; were it so, the disappearance of the cartilage and the ivory-like covering of the joint-end ofthe bones would be much more frequent than it is. It is quite true that the cartilage of elderly people are much thinner than those of young persons; but this does not depend on their conversion into bone, for the shell of bone in the aged is commonly as much attenuated in comparison. It ought also to be commonly happening in all joints, which is far from the case, as it is but rarely found except in the hip-joint. For these reasons I think Brodie's opinion is correct, that " it is probable in these cases the original disease had been ulceration of the cartilages." And especially as he mentions what appears to me to be the two stages of this ivory-like appearance, the first being that which he speaks of as having "many times in (dissection observed a portion of cartilage of a joint wanting, and in its place a thin layer of hard, semi-transparent substance, of a gray colour, and presenting an irregular granulated substance;" and the second, that in which "no remains of cartilage were found on the bones of one hip; but, in its place, a crust of bony matter was formed, of a compact texture, of a white colour, smooth, and having an appearance, not very unlike that of marble." (pp. 204, 5.) The difference of the two appearances seems to me easily explained by the continual motions in the joint wearing down the irregular granulated surface till the white, smooth, marble-like condition is produced. That it is also a consequence of absorption of the cartilage I think is further proved by the expansion of the articular surface?, which is very often noticed in the hip-joint under this form of disease, both the head of the thigh-bone and its socket being also flattened, which flatten- ing and spreading ofthe ball and socket, or of hinge-joints, very frequently occurs with ulceration of cartilage without any ivory-like deposit, and as commonly when soft anchylosis exists. This then is the first and most favourable result of ulceration of cartilage, in which the motions of the joints are not materially im- paired. II. Of'Anchylosis.—"This is a union of bone with bone," says John Hunter (a,) " which ought not to be united, and is of two kinds, one by soft parts, the other by bone. In inflammations of joints we often have adhesions by a soft medium. Very considerable inflammation is necessary to produce anchylosis in joints, and much time is necessary for their perfection, as we see in white-swellings. The adhesions are sometimes partial, sometimes universal. The soft is from two modes, viz., ad- hesion and granulation. The soft only can take place where there is naturally no intermediate substance, and the joint is surrounded by capsular ligament. Bony anchylosis I shall divide into five kinds, four of which are in the surrounding parts by ossific inflammation, the other by an entirely new substance between the extre- mities of a bone." (p. 521.) With the first four kinds we have at present nothing to do, but the fifth kind is the immediate object of our attention, viz., (a) Lectures on Surgery, Palmer's Edition, SOFT OR FIBROUS ANCHYLOSIS. 269 Anchylosis effected " by the whole substance of the articulation.'''' This is of two kinds, and these are the only ones which can admit of the soft anchylosis. It is somewhat similar to the union which takes place in soft parts ; it arises from two causes, 1st, from inflammation of the parts themselves: 2dly, from the inflammation ofthe surrounding parts, the parts themselves partaking of it. From the first cause, or inflammation ofthe parts themselves, arises "suppuration in joints producing anchylosis. This is of two kinds," says Hunter, "viz., the truly inflammatory, and the scrofulous : the former we shall now treat of. "If the inflammation be carried on, an abscess is formed in the cavity as in any other part; and the suppuration is more universal in the cavity than in other parts, being diffused through the whole. This continues to approach nearer and nearer the external surface, and either breaks or may be opened. So far as they are con- nected with bone, they are similar to compound fractures, but the suppuration is slow, and takes place with difficulty, and then generally falls into the natural scro- fulous disposition, which renders it tedious. The suppuration is then imperfect, ap- pearing to partake of both the adhesive and suppurative. The ulcerative disposi- tion is slow in bringing the matter to the skin, which arises from the indolence of the prior suppurative disposition and inflammation. The ulcerative inflammation sometimes goes on, so as entirely to alter the joint, that is, the receiving cavity becomes larger and the received part less ; this is often the case in the hip-joint. These cases then become very tedious, and generally very uncertain in their cure. Before they are opened they are generally become so indolent that opening has very little effect, and often, when scrofulous, such a disagreeable inflammation comes on as to destroy the patient, and therefore amputation had better be performed at once, if this disagreeable inflammation does not take place immediately after opening; yet a fistulous opening is generally the consequence. " Soft anchylosis from granulations.—A joint so healed has no cavity left; the surfaces uniting. A joint coming to suppuration from not being resolved in the first mode, but forming granulations, is more tedious in the soft parts, and the powers of restoration in them are very weak. " Bony anchylosis takes place when the granulations ossify, so that the two bones are united into one, exactly similar to a compound fracture. But when the suppu- ration is healthy the joints sometimes recover; in such cases the matter is sooner discharged, and the parts are more disposed to return into their original state." (pp. 522, 23.) Such is John Hunter's account of this important process, to which, however, some exceptions must be made. He seems to wish it inferred, that anchylosis generally results from suppuration of joints, for he has elsewhere observed, that, " Nature is very little disposed to take on adhesive inflammation, because the neces- sary consequence would be loss of motion in a part originally intended for motion." (p. 519.) And that granulations as the consequence of suppuration produce anchy- losis either soft or bony. I am. not, however, disposed to assent generally to these statements, though I would not deny their occurrence as exceptions. In the first place, as regards the frequency of Soft Anchylosis from granulations following suppuration, I feel assured, from frequent observation, that soft anchylosis is produced by the adventitious membrane poured out during inflammation of the synovial membrane, which as KEy (a) says, " produces ulceration of the contiguous cartilage," (p. 224,) and, "when the cartilage has been wholly absorbed, and the ulcerative process has been checked by the inflammation being arrested, serves another purpose : it becomes the medium of union between opposed surfaces of bone, or the means of anchylosis. Long after all inflammation has subsided, one ofthe condyles ofthe femur is often found adhering to the tibia by means of this mem- brane, which appears white and ligamentous, a layer of cartilage often remaining between the membrane and the bones, as if the process of ulceration had been ar- rested." (p. 226.) And I believe most commonly, when the soft anchylosis so originating is completed, that no suppuration in the joint takes place, and that, when it does happen, it results from recent inflammatory action assuming the suppurative character, and set up by external violence', which, destroying the cartilage down to the surface of the bones, these also ulcerate; and then, if there be sufficient con- stitutional power, the bones produce the granulations, and these inosculating, uniou (a) Med.-Chir. Trans, vol. xviii. 23* 270 SOFT ANCHYLOSIS. ofthe opposed surfaces is produced, as seen in Mayo's case below, (p. 273.) and as in compound fracture, by deposit of earthy matter in the granulations, andtbus bony anchylosis is brought about. I think this will be shown to be a correct view ofthe subject on examination of the cases which will be presently mentioned. Hip dis- ease, which is also almost invariably attended with suppuration, and more or less complete destruction of the cartilage, and even of the head of the thigh-bone and its socket, seems to me a further proof of the opinion I have advanced, as at that joint soft anchylosis is very rare ; whilst, on the contrary, bony anchylosis, if the patient's strength enable him to battle out the disease, is almost the constant favourable issue of the contest. Key states, that " the formation of the vascular membrane frequently takes place without suppuration, as may be seen in strumous joints that have been the subject of chronic inflammation for years, without abscess having formed; and the inflam- mation is sometimes confined to one side of the joint. Such joints are sometimes seized with an acute attack of inflammation of that part which had been previously healthy ; suppuration rapidly ensues under which the failing of the patient's health and powers demand amputation of the limb for the preservation of life. The two sides of the joint present different appearances: one shows no recent signs of inflam- mation ; the ends ofthe bones are partially, perhaps wholly, deprived of their car- tilage, or the cartilaginous surface is ulcerated only to a certain depth; between the bones is seen the membrane adhering to the cartilage, white, possessing scarcely a trace of vascularity, and merely serving to connect the ends of the bones by means of what is termed ligamentous anchylosis. The other side ofthe joint is full of pus; every tissue in a state of active inflammation ; the cartilage removed by a rapid process of ulceration, in wrhich the bone is probably found to have taken an active part; and the ends ofthe bones are seen covered with vascular fungous granulations, from which pus is abundantly secreted." (pp. 227, 28.) With the correctness of these remarks I fully concur, and the following instances well support them, ex- cepting that, in the first, the pus had been discharged, and, in the second, ulceration had occurred without suppuration. Case 1.-—B. S., aged nine years, a fair-haired strumous boy, became my patient in June, 1840. Five years ago he was attacked with swelling and lameness ofthe left knee, withoat any known cause; he was put under medical treatment, and afterwards was admitted into the hospital, from which, about four years since, he was discharged ; and it may be presumed all active disease had ceased, as his mo- ther was told that the knee, which had become much bent, with the heel much raised from the ground, would be restored, as his health recovered. No such im- provement, however, has taken place, and he has since gone about constantly on a crutch. Being a very active boy, he has frequently got falls, and hurt his knee; which, however, in the course of a few days have been recovered from. Within the last two months he has fallen twice, but has not got well as previously; and though during the day his knee has been little painful, yet at night it has become so much so as to prevent his sleeping. The leg is now bent nearly at a right angle with the thigh; it can be bent a little more, but not straightened; the great toe only touches tbe ground, but he cannot bear upon it* The knee is rather larger than natural, especially the inner condyle; and both condyles project a little over the front of the head of the shin-bone. There is a little fulness above the knee-cap, as if the joint wTere distended; but there is little tenderness, and gentle motion does not cause pain. During a month nothing was done except keeping quiet; and it was observed that, if he did not move about during the day, he had not any pain at night. The joint then seeming to be perfectly free from irritation, I thought it advisable to at- tempt straightening the leg, sufficient to bring the foot down and render the limb useful. A hinge-splint, adapted to the bent state of the limb, was, therefore, ad- justed to the back ofthe leg and thigh, which it was purposed slowly to extend by a screw, the two ends of which were affixed to the two portions of the splint. This practice was continued for some weeks without benefit; but swelling coming on, attended with pain and tenderness, it was discontinued, and amputation successfully performed in the September following. On examination the wThole joint was found largely covered with fat; and imme- diately above the knee-cap an abscess, about the size of a shilling, communicating with the joint below the front ofthe outer condyle by a narrow passage an inch long, SOFT ANCHYLOSIS. 271 lined with adhesive matter, but not containing pus. There is not any dislocation, but mere bending ofthe leg upon the thigh-bone. The cavity of the joint was de- stroyed, and the opposed bony surfaces united with fibrous matter, but some ofthe cartilage still remained. Case 2.—J. P., aged nineteen years, a dark-haired scrofulous lad, came under my care in November, 1839. Eight years ago, whilst running, he felt a sudden snap in his left knee-joint, and almost immediately a swelling appeared above the base of the knee-cap, rather larger than a pigeon's egg, but unattended with pain. This on the following morning had subsided, but another swelling presented itself on the inside of the ham, which was at once blistered by his medical attendant. On the next day he was attacked with bilious fever, which confined him to bed fifteen weeks, and reduced him very much; but during this time he did not suffer any pain or inconvenience in his knee. Soon after getting about, the knee began to swell and to become stiff, but unaccompanied with pain, and not preventing his walk- ing. Leeches were once applied, and an evaporation lotion used, but nothing more done; and at the end of a twelvemonth the knee having become fixed in a straight position, he was told he had a white-swelling, and the removal of the limb advised, to which, however, he would not submit. His health continued improving, and he walked about with the aid of a stick, without pain, or further inconvenience than a little halting, as late as July last, when he took a walk of fourteen miles without annoyance. At the latter end of the following month (August) he slipped on a stone, and fell on his side, at the same time bending the previously fixed knee. At the moment he had little pain; but when he went to bed the pain came on, and has recurred nightly ever since. Little swelling followed, but he could no longer bear on the limb without pain, which was also excited when pressure was made on the knee-cap. On first getting up in the morning, the leg shakes very much, and causes great pain in the knee; but both subside in a few minutes, and he has not any more pain till he again goes to bed, when it recurs, and much disturbs his sleep. His general health is good. The knee-joint is now but little enlarged, and there does not appear to be any fulness from fluid in the joint. The leg is partially bent, the condyles of the thigh projecting much over the head of the shin-bone, and the knee-cap seems nearly fixed on the front of the outer condyle. The whole knee is generally tender, but especially upon the inner side. When the bones are pressed together he suffers pain, and a slight grating is felt. Amputation was performed and he recovered. Upon examination, the whole exterior of the joint was found eovered with much fat, especially in the ham,, and on the inside of the tip of the knee-cap was a small abscess, containing a tea-spoonful of thick greenish-yellow pus. Within the knee- cap was found adhering by bone to the outer condyle of the thigh-bone, and the latter was connected by fibrous tissue with the outer articular surface on the head of the shin-bone ; but the greater portion of the hind part of the condyle was absorbed. The cartilage upon the inner condyle was partially destroyed, and the surface of the bone exposed ; upon the corresponding part of the head of the shin-bone the carti- lage was almost entirely destroyed, and the bone itself ulcerating. \\ hether the fibrous anchylosis be the first step to bony anchylosis, I am not pre- pared to say; but the following instance in which the limb was amputated between thirty and forty years after the motion of the knee had been destroyed, for necrosis in the condyle, produced by a comparatively recent injury, would lead to the belief that the two diseases were distinct. Cask 1.—S. D., aged fifty years, a sickly woman, came under my care in Octo- ber, 1839. When ten years old she fell down an area on her right knee, which immediately swelled and became painful; suppuration ensued, and pus having been discharged on the outside of the thigh and knee, after a time she got comparatively well, being able to tread on the entire sole ofthe foot? but she has never since had free motion of her knee, though capable of bending it to some extent. Twenty- three years since suppuration of the joint again occurred shortly before one of her confinements, and from that time a sinus on the fore and upper part ofthe inner con- dyle has continued discharging. Three years ago she received a blow with a heavy boot, just above the knee-joint, which suppurated and burst, an inch or two above and on the outside of the base of the knee-cap. From this time her health failed, and, though after lying in bed for nine months she was able to go about her usual occupations, yet during the last year the pain in the knee again became so severe 272 MIXED ANCHYLOSIS. that she has been constantly confined to her bed. She has now one sinus near the outer hamstring, a little above the knee-joint, and other three about the inner con- dyle, from which there is a free discharge. The condyles project forwards, as if the ligaments of the knee had given way, and partial dislocation had taken place. Motion of the knee-joint does not cause much pain, but she has frequent dull aching pain just above the knee, both day and night, which occasionally extends up to the hip, and is brought on whenever attempts are made to put the foot to the ground. Her health is much broken ; her appetite bad, and she gets but little sleep. Under these circumstances, amputation above the knee was performed, and she did well. Upon examination, by making a vertical section of the bones, the recent disease was ascertained to consist in a sequestrum as large as the top of the thumb in the expanded part of the thigh-bone, which was enlarged just above its articular surface; the front ofthe shell of the bone was here absorbed, forming an aperture as big as a sixpence, which communicated with the wound above the knee-cap, and with the lower wound on the inner condyle; the sequestrum, which was quite loose in the cancellated structure of the bone, might have been easily removed by dilating the former wound. The popliteal space of the thigh-bone was quite bared of its peri- osteum, and communicated with the upper two wounds in the inner condyle. Of the primary disease there were the following traces:—The joint surfaces of the thigh and shin-bone connected by fibrous structure; the front of the head of the latter de- stroyed, and in its place a patch of fibrous matter; the bottom of the condyles destroyed, and in several parts the remaining articular surface deprived of its carti- lage ; both condyles weie partially dislocated forwards upon the head of the shin- bone. The semilunar cartilage remained on the outer, but not on the inner side. The knee-cap was not anchylosed. The following is a similar instance, but of much shorter duration, and strengthens my opinion of the long existence of the fibrous structure just mentioned. Case 2.—E. B., aged thirteen years, a fine boy, but of strumous appearance, be- came my patient in December, 1839. Five years since, but without any injury, he had some affection of his right knee-joint, accompanied with much pain and draw- ing'up of the heel, so that he could not put the whole sole of his foot upon the ground. He was not, however, put under medical treatment till the lapse of six months; but the knee became more and more bent, and about two years since the leg was so much drawn up that the foot would not reach the ground. About this time an abscess, doubt- less connected with the joint, burst just above the outer condyle, from which pus was freely discharged, and the pain he had previously suffered diminished. The wound became sinuous and has so continued to the present time. The leg is now bent upon the thigh at an acute angle, beyond which it cannot be straightened, though it may be bent up to the thigh with a little pain. The con- dyles, of the thigh-bone project in front of the head of the shin-bone, which rests entirely on the hind articular surfaces of the former. The knee-cap is sunk between the condyles and between it and the head of the shin-bone is a large fluid cushion, painful on pressure, and occupying the place of the ligament, which seems com- pletely destroyed. Upon the inside of the knee there is also tenderness. Amputation above the knee was performed, and he did well. On examination of the joint, a sinus was found extending around the outer con- dyle to the knee-cap, behind which was some scrofulous matter. All the articular surfaces were connected by fibrous structure, but some portions of cartilage still remained. Within the epiphysis of the head shin-bone was a small portion of dead bone, but not communicating with the joint. That soft or fibrous and bony anchylosis may occasionally, though rarely, happen at the same time I do not deny, as they are shown to do so by the following Case.—J. M., aged forty-two years, a stout healthy sailor, was put under my care in May, 1838. Two years ago he was attacked suddenly twice or thrice, with- out assignable cause, with numbness of the left leg and knee, and inability to stand upon it for four or five minutes, after which he moved about as freely as usual. In August of the same year he caught violent cold, was very sick, and his knee be- gan to ache constantly, accompanied with shooting pain. Soon after he was unable to bend the joint at all without excessive pain. In the following month, his leg having become perfectly straight and incapable of motion without great pain in the knee, the inside of which was very tender, he was admitted into the hospital. He was then freely leeched, cupped, blistered, and had his mouth kept sore for a long MIXED ANCHYLOSIS. 273 while. Under this treatment the active stage of the disease passed by, but the leg r-adually became half bent by his own effort to render his position more easy, and could not ascertain whether it could be then straightened. It was however deter- mined to attempt anchylosis in the bent posture, and the limb was therefore put on an Amesbury's apparatus, where it was kept for several months. In the May of the year following, anchylosis being presumed to have taken place, the apparatus was removed, and he walked on crutches, the toe touching the ground ; but he could not bear on it without having pain in the knee. As his home was at the sea-side it was thought advisable that he should go there; but after remaining about six weeks, he came up to another hospital where he continued for three months, during which time a screw apparatus was applied for the purpose of straightening the limb, but no benefit resulting, he went home in the following September. He has now come to me to have amputation performed, as, though the joint is quite fixed and but little larger than the other, he is still unable to walk without crutches, cannot bear upon the limb, and if he accidentally strike the toe, has severe pain in the knee. His general health good. On the second of June I amputated through the thigh, but he died three weeks after of peripneumony and ulceration of the mucous membrane of the bowels. On dissection of the joint it was found covered with fat, and the ligaments had degenerated into a sort of half-fatty, half-cartilaginous structure. A vertical section made on the inner edge of the knee-cap and from before to behind presented a firm anchylosis, which appeared bony on the sides, and specially on the inner side of the joint. The hinder half of the condyles being destroyed and the knee half bent, the thigh at its truncated part rested on the head of the shin-bone, but not immediately, as a quantity of dense fatty fibrous tissue was interposed between them. This new structure was about half an inch thick behind towards the ham, but in front it thinned and became sharp, so as to have a wedge-like shape. Where the articular surface remained there was a thin layer of cartilage. The knee-cap was anchylosed by bone to the outer condyle, but its edge, where unapplied, still exhibited a trace of cartilage. On clearing oft the half-fatty half-ligamentous structure into which the ligaments had been converted, the ends of the bone were found close together and not separated as within. There was a slight indication of cartilage between them on the exterior, but on the interior of the joint the union seemed to be bony. The posterior ligament was undistinguishable, being involved in the fibrous mass between the thigh and shin-bone. In front of the thigh-bone at top of the pulley for the knee-cap, there was a slight remnant of what was probably synovial membrane, but it was little vascular. Of the second cause or inflammation of the surrounding parts, in which the parts themselves partake of it, John Hunter gives the following Case.—A lady had an inflammation come on from the opening of a sacculas mu- cosas on her elbow, which inflammation was very violent and extended to the joint, soon after which she lay in and died of puerperal fever. On opening the joint, soft union was found to have taken place, which, if she had lived, would probably have become bony, and the joint would have been anchylosed, merely from adhesive inflammation." (p. 522.) The following very similar instance is given by Mayo (a):— Case.—" A young man had a lacerated wound of the ankle; ten days after erysi- pelas had supervened, and matter had formed about the joint; the integument slough- ing, an opening could be seen into the fore and outer part of the ankle-joint, the cartilage of which became rapidly absorbed. The patient suffered severe pain, which he described as gnawing, throbbing pain, with occasional violent shootings through the joint, and a distressing sense of grating when the limb was disturbed. The patient's strength declining rapidly, amputation was thought necessary. The limb was removed two months after the accident. " Upon a vertical section being made of the ankle, one common change was found to have taken place in both the joints, which the upper and under surfaces of the astragalus contribute to form. In each of these joints the cartilage had entirely disappeared ; and the denuded ends of the bones were joined together by a layer of semitransparent and organized lymph, from a sixth to a quarter of an inch in thick- (a) On Ulceration of the Cartilages of Joints, and on Anchylosis; in Med. Chir Trans., vol. xix. 274 BONY ANCHYLOSIS. ness. This union by lymph was a step towards union by bone. One circumstance appeared to me of peculiar interest. The interior of the bones was perfectly healthy, but the surfaces to which the lymph adhered, were for the depth of one or two lines, extremely vascular. They combined with tbat vascularity the roughness of surface and softness of texture described as found upon the articular aspect of bone in the third kind of ulceration of cartilage, specified above, (p. 253.) I conclude, from hence, that bony anchylosis may, under favourable circumstances, take place after that form of ulceration of cartilage, which depends upon inflammation of the adjacent surface of the bone." (pp. 68, 9.) Bony Anchylosis may occur in any joint, either by the conversion into bone ofthe cartilages forming symphyses, as in those connecting the pelvic bones together, which can scarcely be called disease,—1st, by the conversion of ligament and fibro- cartilage, as in the anterior and crucial ligaments, and the intervertebral substance of the spine, which scarcely at all differs from ossification of the symphyses just mentioned, instances of which are far from uncommon in elderly persons as regards all the vertebrae, except the two uppermost, which, however, in very rare cases, are also in like manner not only united by bone to each other, but also to the occipital bone, of both which conditions we have examples in St. Thomas's museum ; in these the articular surfaces have been deprived of their cartilages either by ulcera- tion or ossification, and the true joints destroyed by bony union : 2dly, by conver- sion of the ligamentous capsules alone into bone, the contained joints still existing ; this occurs in the capsules of the articular processes of the vertebrae, and is not to be confused with that just mentioned. I am not aware that it happens on any other joints. One or other, or all these forms together, are found in elderly persons. But the most important form of bony anchylosis is that which I have mentioned above, and produced, as I believe, from the granulations ofthe joint-ends of bones, the cartilaginous covering of which, as well as the articular surfaces, having been destroyed by suppuration, whether arising from acute or from scrofulous inflamma- tion; and thus circumstanced, "the two bones are," as John Hunter observes, " united into one exactly similar to compound fracture." This kind of anchylosis is undoubtedly most common in the hip-joint, where the inflammation seems to run more readily into suppuration than in any other joint; it is next frequent in the bones of the wrist and instep, but least usual in the elbow, knee, and shoulder; in- deed, as regards the latter, anchylosis is, under any circumstances, rare. Instances of anchylosis, even of the lower jaw to the temporal bone, have been mentioned by the older writers; and of late, Cruvelhier (a) mentions the case of an old woman who had anchylosis ofthe right condyle of tbis bone, the result of a blow received when a child. In these cases the greater part, if not the whole, of the articular surfaces are re- moved, and the cancellated structure seems continuous from the one to the other bone. Other kinds of anchylosis are mentioned, as where bones are fractured into joints; but, so far as my-observation has gone, I have not noticed this fact. It is quite true that often when a fracture extends into a joint, the motions of the latter are destroyed, but this generally depends on the displacement of the joint surfaces. Anchylosis is also said to occur wben, from any cause, a limb has been kept in one position for several years, and the attitudal penances of the Indian fakirs have been quoted as examples: I presume, however, that in these cases there is not union of the joint surfaces, and that the fixation of the joint simply depends on the rigidity which the muscles have acquired from being long retained in the same position, instances of which, though in minor degree, are of daily occurrence, in the stiffness of unin- jured joints which have been long kept in one posture during the cure of fracture, and to restore their perfect freedom of motion is often a very tedious process, and occasionally even not to be effected. As regards the treatment of anchylosis, if it be of the soft or ligamento-fibrous kind, attempts for its relief may be made either by passive motion or by the use of a hinge-splint, the hinge of which is to be placed in the bend of the joint, and its two parts bandaged to the corresponding members ofthe limb, which is very slowly to be moved, two or three-eighths of an inch daily, as the patient can bear it, by means of an iron rod, each end of which is provided with a male screw acting in a (a) Anatomie Pathologique, livr. ix. TREATMENT OF ANCHYLOSIS. 275 female screw, sunk in a movable but shorter rod attached to each portion of the splint; or passive flexion may be performed frequently during the day with the hand alone. In employing either method, however, special care must be taken to relieve the stress on the joint by taking off the apparatus, or to leave off passive motion, whenever pain occurs in the joint, as that indicates at least a disposition to inflam- mation, which, if increased, may be productive of very serious consequences. As adjuncts to these immediate remedies, covering the joint with warm brewer's grains, or friction, may be employed to promote relaxation; but, if pain be excited by either, it must not be persisted in.—j. f. s. Velpeau (a) has considered ably, and at great length, the treatment of complete anchylosis in reference to the three modes proposed for its relief, viz., 1st, the cutting out a wedge-shaped piece of bone; 2dly, the establishment of a false joint; 3dly, the violent and sudden rupture of tbe anchylosis. The first operation was proposed by Barton (b,) one of the surgeons to the Penn- sylvania Hospital, Philadelphia, U.S., who performed a bold and successful operation for the relief of an anchylosed hip, in a young sailor who had fallen down a ship's hold, and had not any surgical assistance for seven months. The injured thigh, which was the right, was bent, with the knee drawn across the left femur; the outer edge of the foot was placed forwards, and the sole turned outwards, which circumstances led to the presumption of dislocation; but there was so much swell- ing, and so great pain on making any attempt to discover it, that it was left alone. After these symptoms had subsided the limb was put in an apparatus for some weeks, but no relief was obtained, and anchylosis took place. After the lapse of a year Barton determined to attempt an artificial joint, for which purpose he made in the upper part of the thigh an incision six or seven inches long, with its middle corresponding to the great trochanter. A second incision was made across the centre of the former at right angles, and four or five inches in length. The cuts were continued down to the bone, so as to expose its front and hind part between the great and little trochanter, after which the bone was sawn through between the great trochanter and the neck. The limb was then readily restored to its natural posi- tion, and found to be only half an inch shorter than the other. The case did extremely well, and, at the end of four months, the patientcould walk aconsiderable distance, and he could by that time carry the foot twenty-four inches forwards, twenty-six backwards, twenty laterally, and rotated it six inches inwards or outwards. The same operation was performed a second time (c,) with success, by Barton, on a young physician, but on the lower part ofthe thigh, for anchylosis ofthe knee ; and subsequently by Gibson of Philadelphia, also in anchylosis of the knee. The second operation consists "in laying bare the bone, and sawingit in such a way as to interrupt its continuity ; and for the purpose of preventing union, it must be slightly moved from time to time, and all other means used likely to produce a false joint; by degrees the two ends of the bone grind against each other, and the movable end rounds and becomes blunted, whilst the other hollows slightly. The muscles soon adapt themselves to this new joint, and in the end permit the patient to use the limb as previously." Velpeau is favourable to this operation, from the motions occurring in false joints caused by ununited fractures. "As to the danger of the operation," says he, " it is much less than those of amputation or resection of the bone." (pp. 200, 201.) Two operations of this kind have been performed with success upon the thigh ; the first by Barton, in 1826, who cut tbrough and de- tached all the soft parts about the great trochanter, and then divided the bone with a small saw ; after which the limb was placed on Dessault's extending splint. The second was performed by Rodgers of New York, in 1830, and also did well. The third operation, viz., that of breaking through the anchylosis, was practised and recommended by the older surgeons; but Velpeau does not favour it, and men- tions a case, referred to by Amussat (d,) of anchylosis of the knee-joint, in which "an attempt was made to restore motion by bending the leg suddenly upon the thigh. A painful cracking was immediately heard in the knee, and very soon alarming abdominal and thoracic symptoms occurred, which in a few days destroyed the pa- tient." Velpeau thinks that " if the union be but slight, or so dispersed that some little motion is permitted, prudence allows the anchylosis to be broken either (a) Leeons Orales de Clinique Chirurgicale, vol. ii. {b) North American Med. and Surgical Journal, April, 1827. (c) Archiv. Gen. de Med., 1838, p. 357. (d) Revue Medicale, vol. ii. 1831. 276 TREATMENT OF ANCHYLOSIS. suddenly or gradually; if the deformity be so great as to render walking or standinor impossible without assistance, but not if the contrary be the case; * * * the rup- ture of the anchylosis being then, really difficult to effect, dangerous, and success by no means certain, as there is always a tendency to the reproduction of union. * * * Attempts only are justifiable when the limb is in such a state of flexion or deviation that its use is prevented. And if the patient earnestly require it, the ope- ration may be performed, but never if the knee-cap adhere to the thigh-bone." And he well observes that " the adherence of the knee-cap to the front of the condyles ofthe thigh, when existing alone, does not appear to have sufficiently attracted the attention of practitioners. The action of the extensor muscles of the leg is de- stroyed thereby, and thus the flexors, deprived of their antagonists, gradually drag the head of the shin-bone into the ham, and bend the leg. It matters little that the mobility of the rest of the joint remains, or that it is by any means restored, the anchylosis of the knee-cap continues an insurmountable obstacle to the restoration of the functions of the knee-joint, (p. 229-30.) When the knee-cap is movable, and there is simply false anchylosis, the subcutaneous division of the ligaments or tendons is preferable to the sudden rupture ofthe anchylosis, because it is infinitely less dangerous and painful, and has at least as favourable a result. * * * If it be a true anchylosis, it would be better in the great number of cases, to do nothingatall. It may, however, be necessary, for some reason or other, to choose between the vio- lent and sudden rupture, the wedge-shaped section of the bone, and the establish- ment of a false joint. Of the latter two operations I have already spoken. As to the rupture, if the soldering of the knee-cap is such as to render dislocation of the shin-bone backwards very probable, we should only operate at the urgent entreaty ofthe patient,'and after having laid before him or his friends the chances of what may happen. This operation is indicated if the flexion be not directly at a right angle, if the knee-cap be not so fixed as to leave little hope of its being detached, or if even it be so situated that, notwithstanding its union, the shin-bone can be brought back beneath the thigh-bone. (pp. 260, 61.) The apparatus (a) by which the rupture of anchylosis is effected was invented by Louvrier, and is thus employed :—"The patient seated on a padded table, is con- fined in that position by a laced thigh-bandage, fastened to the front of the table by a strong strap, and to the thigh by the lace and some straps and buckles, the thigh being protected from pressure by wadded pads, and a roller lightly applied. The foot is then enclosed in a half boot, laced in front, the sole of which, near the heel, has a metal mortise of two inches, to receive the middle of a metal bar, seven or eight inches long, having at each end a little copper wheel, by which, during the extension, the leg can be directed on a double inclined ascending plane. In the groove of the mortise is attached and fixed one of the pulleys of the winch upon which the extending cord is wound. The thigh and leg are then to be confined in a sort of leather gutter, which is closed in front by straps and buckles, and has on each side, long stout steel splints, those on the outer side jointed together at the top of the knee, and taking at first the same angle as the anchylosis, the one corres- ponding to the thigh and the other to the leg; the inner splints are also similarly connected. To render his apparatus most effective, Louvrier thinks it necessary to make upon the thigh, at the knee, direct pressure from before backwards, and to push it in that direction, whilst the leg is extended. This is effected by means of two uprights fixed on each side of the knee, by their lower ends upon the splints, the four upper ends of which are connected by a rectangular parallelogram, in which they are enclosed and retained by copper nuts. A thick pad is placed on the knee, and be- tween the metallic rectangle and this compress, a cushion formed of a plate of metal, and padded towards the thigh. The limb thus fixed is placed in a rectangular wooden gutter, at the end of which is a winch; within these planes is a chase, on which the foot, supported laterally by the bar attached to the sole, travels. A set of cords attached to these parts connects them with the winch, and with a few turns of its handle, the leg is straightened always in less than a minute, and most commonly, when the anchylosis is angular, with one or two distinct and successive cracks." (p. 396.) Velpeau evidently is no favourer of this apparatus; and he enumerates among the objections to its employment, the severe pain, but as this is very short it may be borne with; and the violent purulent inflammation of the joint which may ensue, (b) Dictionnaire des Dictlonnaires de Medecine, vol. i. 8vo. Paris, 1810. HYSTERICAL AFFECTION OF JOINTS. 277 the danger of this, however, is exaggerated. But the more serious accidents are laceration of the integuments of the great arterial or venous trunks; of the nerves and ligaments; and the more or less severe bruising of the soft parts, in consequence of which sloughing occurs. "If, however," says he, " we observe the cases (about twenty) on which Louvrier has operated, there are but few in which symptoms, more or less serious, occur immediately. I know,however, that these facts are still too few; at present we may presume that this plan of treatment is not so dangerous as one might be led to suppose." (pp. 208-15.) To the question, " What benefit is the patient to derive from this treatment V Velpeau replies, as regards the re- establishment of the motions of* the joint, that neither theory nor Louvrier's facts are favourable. To prevent the reunion of the bone frequent motion must be resorted to, which is dangerous; but if not employed the bones become resoldered, and the leg either becomes straight, with the sole of the foot flat on the ground, (which is the most favourable result,) or the limb continues more or less bent, and the foot cannot be put flat, so that the patient needs crutches. Another result is, that the head of the shin-bone is thrown behind the condyles, and dislocation is produced, as, if the knee-cap be soldered to the fore and lower part of the condyles, which is often the case, it prevents the head of the shin-bone resuming its natural place, and, serving as a wedge, pitches the latter into the ham, so that a dislocation being pro- duced the patient is not benefited by the operation, (p. 215-17.) HYSTERICAL AFFECTIONS OF THE JOINTS. Hysterical females are often subject to affections of the joints, especially ofthe hip and knee, which, without any actual disease in the part, produce excessive suf- fering, and are liable to be mistaken for dangerous ailments. Brodie, in reference to this point, says:—"At first there is a pain referred to the hip, knee, or some other joint, without any evident tumefaction; the pain soon becomes very severe, and by degrees a puffy swelling takes place, in consequence of some degree of serous effu- sion into the cells of the cellular texture. The swelling is diffused, and in most instances trifling; but it varies in degree; and I have known, where the pain has been referred to the hip, the whole of the limb to be visibly enlarged from the crista ofthe ilium to the knee. There is always exceeding tenderness, connected with which, however, we may observe this remarkable circumstance, that gently touching the integuments in such a way as that the pressure cannot affect the deep-seated parts, will often be productive of much more pain than the handling of the limb in a more rude and careless manner. In one instance where there was this nervous affection of the knee, immediately below the joint there was an actual loss of the natural sensibility; the numbness occupying the space of two or three inches in the middle of the leg. Persons who labour under this disease are generally liable to other complaints, and in all cases the symptoms appear to be aggravated, and kept up by being made the subject of constant anxiety and attention." (pp. 339,40.) In an affection of this kind in the knee, Tyrrell (a), observes :—" The point which convinced me that the affection was not one of actual inflammation of the ligaments ofthe knee, but a sympathetic disease depending on the peculiar condition of the constitution, is this, that if she had inflammation merely of the internal lateral liga- ment and the posterior ligament, the pain would be confined to those parts, particu- larly when the limb was at rest, and she would complain of pain particularly on pressure on those parts; but when you examined the surface of the joint, it mattered little where you pressed, it was all the same, she complained of pain." (p. 316.) Bell (b) mentions a very remarkable case of hysterical affection, " in which there was great difficulty of discovering whether there was actual disease or not, in which the pelvis was pitched obliquely, as if there were disease in the hip. But there arose a class of symptoms which pointed to the right source, a singular contraction and retraction of the leg, so that the knee was bent almost to the bursting ofthe ligaments, and the foot turned in so extraordinary a manner, that the great toe lay dose to the anus. The retraction was so powerful that we naturally apprehended that the ligaments of the joint must be destroyed. It proved to be a case of hysteria, and, what was extraordinary, was the resemblance it had in every feature to the (a) St. Thomas's Hospital Reports. (b) Medical Gazette, vol. xiv. 1833,34. Vol. i.—24 278 HYSTERICAL AFFECTION OF JOINTS. disease of the hip-joint." (p. 297.) Coulson also mentions a case which he saw in St. Bartholomew's Hospital, in which " the patient was twenty-eight years of age, and had suffered from hysterical affections for ten years. The right heel was doubled under the thigh, the heel rested against the tuberosity of the ischium, and the great toe, as in the case just related, was close to the anus." (p. 117.) Coulson observes that, in this affection, "the affected limb is liable to remarkable alternations of heat and cold; at one part of the day the limb feels cold, and assumes a purple aspect; at another, hot flushes, followed by perspiration, break out over the extremity ; again, the limb does not merely feel hot to the patient, but is actually so to the touch of another, and the whole capillaries of the affected part become turgid with excess of blood." (p. 117.) Goodlad (a) objects to the term hysterical being applied to these affections, and says :—" If after a careful examination of the hip, or any other joint, and of the muscles connected with it, no adequate cause of pain can be discovered there, it surely becomes an imperative duty, and it is the only one remaining to ascertain whether any and what cause exists in the course of the nerves, and if there be no such cause discoverable, the practitioner may safely rely upon finding it where it very frequently, nay, by much the most frequently exists, viz., at the point of con- nexion which those nerves possess with larger masses of the nervous system; it matters not whether in the brain or in the spinal marrow, the same effects follow. The tenderness of the skin both here and on the spine may alike be disregarded; it is sometimes permanent, at others fugitive ; but in either case it is an indication only where disorder maybe found by tracing the nerves distributed on these parts to their origin." (p. 93.) In these cases menstruation is generally either irregular or defective, and the bowels are torpid; the most important point, therefore, towards the cure consists, in putting these matters to rights by constitutional remedies. Local applications, I do not think, are of much service; but Brodie says :—"The parts may be bathed with a cold evaporating lotion, or they may be enveloped in a plaster composed of equal parts of the extract of belladonna and soap plaster, an application which will be found of singular utility, not only in these, but in a great number of other painful nervous affections." (p. 340.) Goodlad thinks that, in addition to whatever may be deemed necessary for the general state of the system, local measures must be had recourse to, not applied to the part where the pain is experienced, but to the origin of the nerves distributed to it; and the greatest caution seems necessary that nothing applied there can give local activity to vessels already too active.— j. f. s.] 225. As we shall now consider these diseased conditions of the various joints, under the several names already mentioned, (par. 198,) we shall be able to show, by the difference of their course and the re- sult of pathological anatomy, in what structure the disease has primarily developed itself. Thus the various opinions which have been advanced with great partiality, as to the nature of these diseases, will be known to be well founded in particular instances, although their universal cor- rectness is denied. I.—IN THE HIP-JOINT. (Coxalgia, Morbus Coxarum, Luxatio spontanea Femoris, Coxarthrocace.) 226. The symptoms of this disease exhibit three well-defined stages, according as the inflammation has an acute or chronic character. 227. In the Acute Inflammation ofthe Hip-Joint, after any occasional cause, there arises sharp pain in the hip-joint, which extends on the inside ofthe thigh to the knee-joint, not increased by touching the knee if the thigh be undisturbed at the hip-joint, but increased by any pressure and (a) A letter to Sir B. Brodie, containing a Critical Inquiry into his Lectures illustrative of certain local Nervous Affections. London. 8vo. INFLAMMATION OF THE HIP-JOINT. 279 motion of the hip-joint itself. The region of the hip, especially the buttock, is more or less swollen, consequently its wrinkles are mostly somewhat deeper; the thigh is drawn up towards the belly, because outstretching it is very painful; the foot is turned somewhat outwards, and cannot be removed inwards without pain. If the length of both extremities be compared, they are either alike or the diseased extremity is seemingly shortened or seemingly lengthened ; both, however, only in a slight degree. Fever exists in proportion to the severity of the symp- toms. Standing and walking are very difficult, or even quite impossible ; the patient, therefore, throws the whole weight of the body upon the sound limb, draws up considerably the hip of the ailing side, bends the knee, and merely touches the ground with the tip of his foot. [Key (a) says:—"The hip-joint is less frequently the subject of acute than of chronic inflammation, probably from being well protected from the influence of atmospheric changes, to which the knee and most other joints are exposed. In the adult, acute disease of this joint is occasionally seen, in which the whole structure ofthe joint, cartilage as well as ligament, undergoes complete disorganization in the space of a few weeks." (p. 230.)] 228. If the inflammation do not subside, it passes into suppuration, with an increase of all the general and local symptoms; collections of pus are formed within the joint as well as on its exterior; the fever assumes a hectic character, the powers sink, the patient wastes con- siderably, the muscles ofthe hip and thigh become flabby, and a careful measurement of both extremities shows that the diseased one is really lengthened. The abscesses become superficial around the joint, either in its immediate neighbourhood or at a distance from it; and during this time or subsequently, when the abscesses have burst, the head of the thigh-bone escapes from the hip-socket, and is dislocated commonly upon the back of the hip-bone (b,) so that the diseased extremity becomes considerably shortened, is rolled inwards, and appears somewhat bent at the knee-joint. The patient now either sinks under long continued hectic consumption, or, what is more rarely the case, the suppuration diminishes, portions of bone come away, and the apertures of the ab- scesses close. 229. In the Chronic Progress of Inflammation ofthe hip-joint, the three stages are, on account of the gradual development of the symptoms, more distinctly and determinately marked (1.) In the beginning, the patient complains of slight pain in the hip-joint, of some weariness in the thigh and stiffness of the joint, especially in the morning, which subsides during the day, but is always increased by much exertion. The pain is not continuous ; it often increases towards evening, with slight febrile excitement, and specially resembles rheumatic pain moving slowly about the thigh (2.) At the hip-joint itself no disease is discoverable, except an increase of pain on pressure behind the great trochanter, or on the front of the joint where the femoral vessels pass beneath Poupart's ligament. These symptoms may continue, better or worse, for months (a) Med.-Chir. Trans., vol. xviii. English names wherever parts of the body (b) I have presumed to use the ordinary possess them. I know no reason why we English terms, hip-bone, haunch-bone, share- should be more ashamed of using our mother bone, and hip-socket, in preference to the tongue than the Germans or the French, and Latin names, ilium, ischium, pubes, and I see no particular advantage in using the acetabulum, and I purpose always employing figurative Latin ofthe Schools.—J. F. S. 280 HIP-DISEASE,—SECOND STAGE. or years, under a lingering course of this disease. The gait is merely trailing, and the foot commonly somewhat turned outwards. [(1) Brodie says:—"I believe, in the greater number of those cases to which the name of Diseased Hip has been usually applied, the ulceration of the cartilage is the primary affection, and the other parts in and near the joint become affected only in a secondary manner." (p. 137.) Key (a,) however, holds a different opinion, and observes:—"The Hip Disease, emphatically so called, is a chronic affection, uniformly attended with ulceration of the cartilage;" and, from the cases which he has examined, he is induced to believe "that the ulceration is preceded by inflam- mation of the ligamentum teres," (p. 230.) (2) It is somewhat remarkable that Chelius does not enumerate, among the symptoms of the first stage of hip-disease, the pain more particularly about the inside of the knee, which almost invariably exists, and being often the only pain noticed by the patient, has frequently led to mistake of the actual seat of the disease, and to the treatment of the knee, as if that were the part affected. It indeed presents an example of John Hunter's (b) "remote sympathy," in which "there appears no visible connexion of parts that can account for such effects. In these cases there is commonly a sensation in the sympathizer which appears to be delusive, and pro- duces a wrong reference of the mind to the seat of the disease." (p. 7.) This sympathetic pain in the knee is by some held to depend on irritation of the anterior crural plexus of nerves as it passes over the hip-joint; but Sir Charles Bell thinks the obturator nerve is the communicant. " The obturator nerve," he says (c,) "passes through the thyroid foramen, down to the hip-joint, and, after supplying the muscles, is distributed upon the inner part ofthe knee. The nerve in its course is thus involved in the inflammation which affects the hip-joint, and the pain is referred to its extreme cutaneous branches, at a part distant from the seat of the disease." (p. 77.) Coulson does not agree with this explanation, as "very com- monly we find the pain extending along the middle, and even outer part ofthe thigh, whilst the obturator nerve is distributed to the muscles of the inner side of the limb." He therefore suggests, that "from the intimate connexion ofthe longhead ofthe m, rectus femoris with the outer edge of the acetabulum and with the capsular ligaments, the fascia of this muscle may take on the inflammatory action, and the pain in this way be conveyed down the limb to the thigh." (p. 3.) I prefer Bell's explanation, however; as certainly in the majority of the cases of diseased hip which I have seen, the pain is usually on the inside ofthe knee.—j. f. s.] 230. The second stage is characterized by a lengthening of the dis- eased extremity; the buttock of the affected side is flatter, its fold becomes deeper, the whole thigh is wasted and flabby, the great tro- chanter stands more upwards and outwards; every movement by which the surfaces ofthe joint are brought into contact is in the highest degree painful; the gait ofthe palient is very limping; the weight of the body rests entirely on the outstretched sound leg ; the lengthened limb is bent at the knee, approached to the sound one, and the foot most commonly much everted. A peculiar sharp pain now comes on in the knee, which however, usually retains its natural condition, only now and then being changed in its form, according to the observations of Albers and Rust. Although the pain in the knee is nearly always more severe than that in the hip-joint, yet the latter only is increased by direct pressure. [Astley Cooper observes:—" The motions of the joint are impeded; extension is performed with difficulty; the child's knee is bent; and the heel, on the diseased side, scarcely touches the ground. Besides this incapacity for extension, great difficulty is experienced in the flexion of the joint. Thus if you attempt to bend the knee towards the abdomen, the child shrinks from the touch and complains of pain. If you throw something on the floor, and desire the child to pick it up, you will observe, that, in attempting to get possession of it, it bends only the sound knee. (a) Med. Chir. Trans., vol. xviii. (b) On the Blood, &c. (c) London Medical Gazette, vol. i. HIP-DISEASE,—THIRD STAGE. 281 If you say, ' Let me see you put your foot on the chair,' the child does this readily enough with the sound leg, but is incapable of doing it with the other, in conse- quence of the confined state of the flexions of the joint. The rotation of the joint is also impeded, more especially the rotation inwards, which cannot be attempted without great pain and uneasiness. If the patient be laid down on his face, to examine whether the nates are lower on one side than the other, there is generally a difference of an inch or more on the diseased side." (pp. 454, 55.) As to the mode of determining the special part of the joint which is diseased, Key (a) observes "the motions ofthe joint, that give the patient most pain, are strongly indicative of the seat of the affection. In the earliest stage, before the soft parts could well be affected, if the disease commenced in the cartilage, eversion of the thigh and abduction of the limb from the other produce the greatest degree of suffering to the patient, while he can bear the joint to be flexed, and to be slightly in- verted, without complaining. A similar indication of the ligamentum teres being- inflamed, is the pain sometimes expressed on pressing the head of the femur against the acetabulum ; in its healthy state the ligament being lodged in the hollow of the acetabulum, receives but little pressure, but when it is swelled by inflammation, the cavity of the joint affords it less protection; and, when pressure is made by forcing the head of the femur upwards, the ligament is compressed, and usually produces some degree of pain. The circumstance, too, of the ligamentum teres being destroyed by ulceration, when the head of the bone and acetabulum are only partially ulcerated, may be considered as presumptive proof of it being-very early engaged in the disease. There are few cases of post-mortem inspection of the hip-joint in an advanced stage of disease in which the ligamentum teres is not found destroyed, (pp. 232, 33.)] 231. The disease gradually runs on to its third stage; the diseased extremity becomes shortened, either as a consequence of displacement ofthe head ofthe thigh-bone, or, if that and the hip-socket have been destroyed by caries, by the diminished head of the bone being drawn into the much expanded socket. Oftentimes the disease here termi- nates, the pain diminishes, and on the spot where the displaced head ofthe thigh-bone lies a hollow is formed, or the head ofthe bone being retracted into the socket is anchylosed to it, and the patient consequently recovers with an incurable lameness. Most frequently, however, in this stage a painful fluctuating swelling occurs about the whole hip-joint, which ultimately breaks, and a quantity of pus is discharged ; the sup- puration becomes bad ; the probe introduced into the abscess openings indicates carious destruction, and the powers of the patient are worri out by hectic fever. But rarely do these apertures close ; the suppura- tion then diminishes, pieces of bone are thrown off', &c. &c. In order to measure accurately the length of the extremity during the progress of this disease, we examine it most satisfactorily, according to Fricke's method (b,) in the following manner :—The patient being laid on a table covered with a woollen rug, an assistant fixes the pelvis, and places the thumb beneath the anterior supe- rior iliac spine, for the purpose of steadying the skin. A painted tape, or a wooden measure furnished with two moveable pointed transverse pieces, and a Paris mea- suring scale, is now to be applied above the thumb ofthe assistant upon the spine, and being there fixed the other part of the measuringinstrument is to be carried down to, and immediately beneath the outer ankle. The same measurement is repeated on the sound side. In the same manner then is the thigh measured, the measure being- stretched to the upper end of the splint-bone ; and then the leg alone, which is especially necessary if the patient be unable to straighten the leg. [Abscesses ofthe hip-joint do not always burst externally. " Sometimes the ab- scess," says Astley Coopet (c) " breaks into the pelvis, at other times into the (a) Med.-Chir. Trans., vol. xviii. (6) Ueber Coxalgie und Coxarthrocace; in Annalen der chirurg. Abtbcilung des allge- meinen Krunkenhauses zu Hamburgh, vol. ii. p. 21. (c) MS. Lectures on Surgery. 24* 282 DISTINCTION BETWEEN THE rectum, and a large quantity of pus is voided with the stools, which was the case with a young gentleman I attended ; in another case it opened into the vagina; the lady was lame, but ultimately recovered." We have also a preparation at St. Thomas's museum, of which, however, I do not know the history, excepting that Astley Cooper used to mention it as a case in which abscess ofthe hip-joint, in making its escape, had ulcerated a small hole in the femoral artery, as that vessel passed over the front of the joint. Besides these, Coulson mentions a case in which matter had made its escape from the affected joint into the pelvis, so as to press on the neck of the bladder, and had caused paralysis of that organ. (I presume he means retention of urine.—j. f. s.) On examination after death, I discovered," says he, " that the matter had escaped through the acetabulum to the posterior part of the bladder, and had made a lodgement close to its neck." (p. 23.) Samuel Cooper quotes a case under Dr. Mackenzie, of Glasgow, of a lad of sixteen, who died of enormously enlarged liver; but, on dissection a communication was found through the bottom "of the acetabulum, between the cavity of the hip-joint and the colon, smooth, as if of long standing, (p. 869.) Scott also mentions a case of this disease affecting both hips, and the abscesses communicated with the cavity of the pelvis on each side, through the acetabulum, (p. 106.) ' So great is the importance of Diseases of the Hip-Joint, that I think it advanta- geous to give at length Brodie's account Of the difference between the Hip-disease arising from Ulceration of the Cartilage, and that from Scrofulous deposit in the cancellous structure of the Bones. As already stated, Brodie considers that ulceration ofthe cartilages is the primary affection in the disease to which the term Diseased Hip is usually applied, and that the scrofulous affection of the cancellous structure is less common in the hip and shoulder than in many other joints, and that these two diseases have many circum- stances in common, but have certain points of difference which, in their early stages, admit of their being distinguished from each other by careful and minute obser- vation, it will be advisable to give his account of the symptoms presented by each. The occurrence of ulceration ofthe cartilages at any period of life, though most. frequently between the age of puberty and thirty-five years, has been already no- ticed, (p. 262,) as has tbat of scrofulous affecticn occurring frequently in children, though rarely after thirty years of age. (p. 2(34.) " When the cartilages of the hip are ulcerated, the only symptoms met with for some time are pain, and a slight degree of lameness in the lower limb. The pain at first is trifling and only occasional ; afterwards becoming severe and con- stant. It resembles a good deal the pain < f rheumatism, since it often has no certain seat, but is referred to different parts of the limb in different individuals, and even in the s?ime individual, at different periods. As the disease ad- vances the pain becomes exceedingly severe, particularly at night, when the patient is continually roused from his sleep by painful startings of the limb. Sometimes he experiences sorie degree of relief from pain in a particular position of the joint, and in no other. A patient in St. George's Hospital never obtained any rest except when he had plaeed himself on the edge of the bedstead, with his feet on the ground and resting on a pillow. As the pain in- creases in intensity, it is more confined in iis situation. In the greater number of instances it is referred to the hip and knee, also, and the pain in the knee is generally the most severe of the two. At other times there is pain in the knee and none in the hip. Sometimes there is pain referred to the inside of the thigh, sometimes even to the foot. Wherever the pain is situated, it is aggravated by the motion of the joint; but it is aggravated in a still greater degree by what- ever occasions pressure of the ulcerative cartilaginous surfaces against each other. Hence the patient is unable to support the weight of the body on the affected limb ; and if he be placed on an even surface, in a horizontal position, and the hand of the surgeon applied to the heel, so as to press the head of the femur against the concavity of the acetabulum, violent pain is the consequence, although this be done in so careful a manner that not the smallest degree of motion is given to the hip-joint. This circumstance is well deserving of attention; and no one should attempt to give an opinion as to the nature of a disease connected with the hip, without having made an examination in the manner which has been just KINDS OF HIP-DISEASE. 283 described. Soon after the commencement of the complaint the hip-joint is found to be tender, whenever pressure is made on it either before or behind. The ab- sorbent glands in the groin become enlarged, and sometimes suppurate. Occasion- ally there is a slight degree of general tumefaction in the groin. In this there is nothing remarkable, since we must suppose that a disease going on within the articula- tion must ultimately occasion inflammation in the neighbouring parts. But it is a curious circumstance, that in some cases there is tenderness of those parts, to which, though not diseased themselves, the pain is referred from sympathy with the disease in the hip. I have observed this in the knee several times, and I have also seen a slight degree of puffy swelling of this joint, where pain was referred to it in consequence of disease in the hip. * * * When the disease has existed for some time the nates undergo a remarkable alteration in their form. They become wasted and less prominent, so that, instead of their usual convexity, they present the appearance of a flattened surface; they are flaccid to the touch, and hang more loosely towards the lower edge, and they have the appearance of being wider than those of the other side. In a very few cases, in the advanced stage of the disease, the nates are really wider, in consequence of the acetabulum being filled with coagu- lable lymph and matter, and the head of the femur being pushed out of its natural situation. But in general the increased breadth ofthe nates is only apparent, and on an accurate measurement no difference will be found between the nates on one side and those on the other. The alteration in the figure of the parts, in those cases may- arise partly from the position in which the patient usually places himself when he stands erect; but the principal cause to which it is to be attributed, is the wasting of the large fleshy bellies of tbe glutaei muscles, from want of use ; and this has been ascertained by repeated and accurate examinations of the living and nnmerous dis- sections ofthe dead body." (pp. 153-57.) "While the disease is going on in the cancellous structure of the bone, before it has extended to the other textures, and while there is still no evident swelling, the patient experiences some degree of pain, which, however, is never so severe as to occasion serious distress, and often is so slight, and takes place so gradually, that it is scarcely noticed. After a time (which may vary from a few weeks to several months) the parts external to the joint begin to sympathise with those within it, and, serum and coagulable lymph being effused into the cellular membrane, the joint appears swollen. The swelling is puffy and elastic, and though usually more in degree than it is, at the same period, in those cases in which the ulceration of the cartilages occurs as a primary disease, it is not greater in appearance, because the muscles ofthe limb are not equally wasted from want of exercise. 1 have observed that in children the swelling is, in the first instance, usually less diffused and some- what firmer to the' touch than in the adult. If a suspicion of some disease of the joint has not existed previously, it is always awakened as soon as the swelling has taken place. Should the patient be a child, it not uncommonly happens that the swelling is the first thing which the nurse or the parents discover. This leads to a more accurate inquiry, and the child is observed to limp in walking, if the disease be in the lower limb, and to complain of pain on certain occasions. * * * The swelling increases, but not uniformly, and it is greater after the limb has been much exercised than when it has been allowred to remain for some time in a state of quietude. As the cartilages continue to ulcerate the pain becomes somewhat, but not materially, aggravated. It is not severe until abscess has formed, and the parts over the abscess have become distended and inflamed. The skin, under these cir- cumstances, assumes a dark-red or purple colour. The abscess is slow in its pro- gress; when it bursts, or is opened, it discharges a thin pus, with portions of eurdly substance floating in it. Afterwards the discharge becomes smaller in quantity, and thicker in consistence; and, at last, it nearly resembles the cheesy matter which is found in scrofulous absorbent glands. In most instances several abscesses take place in succession, but at various intervals; some of which heal, while others remain open, in the form of fistulous sinuses, at the bottom of which carious bone may be distinguished by means of a probe, (p. 250-53.) The progress of the malady in both these forms of hip-disease are very nearly alike; in both is there the same reference of the pain to the knee rather than to the joint affected, the same alteration in the appearance of the nates, the same shorten- ing ofthe limb from destruction of the head of the thigh-bone, or its dislocation, and the same production of abscesses. But the principal distinction is in the less 284 SHORTENING AND LENGTHENING degree of pain which accompanies the scrofulous disease, " except in a very few instances, and in the most advanced stage of the disease, when a portion of the ulcerated bone has died, and having exfoliated, so as to be loose in the cavity ofthe joint, irritates the parts with which it is in contact, and thus becomes a source of con- stant torment." (p. 256.)] 232. Among the phenomena which appear in the course of the coxalgia, the shortening and lengthening of the diseased limb have specially attracted the attention of physicians, and have given rise to various explanations, which must be particularly considered. [" In most cases of lameness or wasting of the lower extremities the affected limb," says John Hunter (a,) "appears longer than the other, in consequence of the patient pressing most on the sound limb, and putting the diseased one further out from the pelvis so as to raise the ilium. This is particularly the case in dis- eases of the hip, although the leg is not found to be longer than the other, if the patient is laid on the back. It arises from the centre of motion in the pelvis being rather altered by habit, which is removed if the patient is laid on the back. But sometimes, when the muscles are much wasted, the limb is shorter, which I cannot account for, nor why the limb is sometimes drawn up more, and sometimes put out further than the other. Mr. Cline says the limb is actually longer and shorter in different stages of the disease, and accounts for it thus:—In the first instance, in- flammation takes place in the ligaments of the joints, occasioning the parts to swell, and a larger quantity of synovia to be accumulated in the joint, which displaces and pushes out the head of the femur, thus occasioning a lengthening of the limb; but as the disease advances absorption takes place, not only of the accumulated syno- via, but also ofthe bone itself, with the surrounding ligaments; and the head of the bone being drawn into the new-enlarged cavity by the action of the gluteal and other muscles, occasions a shortening of the limb; and this lengthening and shortening of the limb is peculiarly evident on laying the patient on the belly." (p. 595.) " In order to form a correct judgment" upon the actual state of the limb, Law- rence (6) says, " you must strip the patient, and make the examination on a straight horizontal surface. You will then immediately observe the position of the pelvis and discover the cause of the apparent elongation or shortening of the affected limb. At all events, you may remove every doubt as to the apparent or manifest shorten- ing or elongation, by measuring on each side from the anterior superior spine of the ilium to the patella ; this will enable you to ascertain whether there is a real, or only a seeming alteration in the length. The change, however, in the subsequent period of the affection is quite a different matter. The disease, as it proceeds, is attended with destruction ofthe ligamentum teres, with ulcerative destruction ofthe orbicular ligament of the hip-joint, with destruction and ulceration of the head of the thigh-bone, and of parts of the acetabulum. Thus all the causes which would prevent the muscles from retracting the limb are removed ; the muscles, therefore, draw the extremity upwards and outwards, and a real shortening to the extent of some inches, is the consequence." (p. 485.)] 233. The shortening ofthe extremity which, commonly, occurs in the first period of acute inflammation of the hip-joint, is always a seeming shortening dependent on a shifting upwards of the pelvis on the diseased side., All other explanations given of this shortening are incorrect, and incompatible with the true situation of the hip-joint; such as Rust's, and specially Fkicke's, explanation, that, by violent muscujlar contrac- tion, which occurs in this acute inflammation of the joint, the head is pressed deeper into the socket, and thereby the shortening ofthe limb is produced. Fricke (c) seeks to ground his opinion on the circumstance, that the leg in its healthy condition may be shortened by voluntary effort ofthe muscles ofthe thigh, —as every one may prove on himself. But this assumption is quite incorrect, and (a) Lectures, Palmer's Edition. (b) Lectures in Lancet. (c) Above cited. OF THE LEG. 285 whoever makes the experiment on himself or on some other person, will, if, at the same moment when the thigh is retracted, the hands are placed on both bip-bones, easily and decidedly be convinced that the retraction of the extremity depends only on the elevation of the hip-bone. It is perfectly inadmissible to explain the shorten- ing by the compressibility of the cartilaginous overspreading of the head of the thigh-bone and its socket. In the severe painfulness of the acute inflammation of the hip joint, the thigh is always more or less bent and drawn up towards the belly ; the muscles are no doubt contracted, but at the same time the patient draws up the pelvis, especially if, as usual, he lies bent towards the sound side, and the extent of this drawing up ofthe pelvis is in close dependence upon the degree of painful- ness, and upon the position which the patient constantly assumes. We tberefore observe the same in bruises of the parts about the hip-joint, and in every painful affection of the thigh and hip. An unprejudiced observation and attentive measuring, will convince every one of the truth of the statement here advanced. I have ob- served two cases of traumatic inflammation of the hip-joint, in which this seeming shortening of the extremity had led the medical attendants into the belief of a luxa- tion, and to the employment of very improper means for its reduction. 234. The lengthening of the extremity which occurs in chronic, and in the latter course of the acute coxalgia, when morbid changes have been set up in the joint, may be either seeming or real. The seeming lengthening is here again dependent on the shifting of the pelvis, because the patient in the tedious course of this disease still limps about, and in doing so throws the weight of the whole body upon the sound extremity, and, by this means and by the position he keeps in bed, the pelvis is so twisted that the hip-bone on the sound side is raised, and that on the diseased side depressed. In the subsequent course of the coxalgy, when the morbid changes in the joint have proceeded still further, there is real lengthening of the diseased extremity, which does not depend on mechanical disproportion between the head of the thigh-bone and its socket, and the expulsion of the head of the bone on account of its in- creased bulk, but upon the extension of the capsular ligament, on the collection of fluid, on the relaxation of the capsular ligament, and on flaccidity of the muscles. The most different reasons have been assigned for the lengthening of the extre- mity consequent on the supposed expulsion of the head of the thigh-bone from its socket; for instance, accumulation of synovia (Petit, Camper, and others;) swell- ing and degeneration of the mass of fat, improperly called the synovial gland, in the hip-socket, (Valsalva, Monro, van der Haar, deHaen, Vermandois, Schwencke, Callisen, Plenck, Portal, Ficker, &c.;) inflammation and swelling ofthe joint- capsule (Duverney, Clossius ;) swelling of the cartilage, round ligament, and mass of fat (Boyer;) swelling ofthe cartilage and periosteum of the head of the thigh- bone and its socket (Falconer;) swelling of the head of the bone from caries cen- tralis (Rust;) destruction of the lower edge of the hip-socket Langenbeck;—in destruction ofthe upper edge shortening is said to occur;) relaxation and unnatural extension of the ligaments and muscles (Richter, Schreger, Larrey, Chelius;) relaxation of the muscles (Fricke.) Brodie first accurately explained the seeming lengthening ofthe limb as dependent on the twisting ofthe pelvis, produced by the position of the patient, and connected with a lateral twisting of the vertebral column. This opinion, however, was not particularly regarded, and considered to have been only incidentally noticed in single cases (Falconer, Crowther, Rust;) while on the other hand, the explanation given by Rust of the enlargement ofthe head of the bone by caries centralis was most commonly received, which opinion, however, is groundless, and was formerly disproved by me by the results of morbid anatomy, ana more recently by Fricke's (a) experiments on the dead body. Weber's interestino- experiments show that the head of the thigh-bone is chiefly retained in its socket by atmospheric pressure,- since, if all the muscles and liga- (a) Above cited. 286 LENGTHENING OF THE LEG. ments surrounding the hip-joint and even the capsular ligament itself be cut through, the head of the bone is not withdrawn from its socket by the weight of the depend- ing extremity; whilst, with perfect integrity ofthe ligaments and muscles, the head of the bone drops from three to four lines out of the socket so soon as, by boring through the latter from the pelvis, the atmospheric pressure is permitted to operate on the surface of the head of the bone (a.) These experiments are of great impor- tance in reference to diseases of the hip-joint, as GjEdechens has shown in a very perspicuous manner(J.) Hence it is most completely proved that, as we have al- ready observed, a shortening ofthe extremity from violent pressing of the head of the bone into its socket is perfectly inadmissible; and, on the other hand, that by mere relaxation of the muscles (as Fricke supposes) no lengthening of the extre- mity can be produced : since neither, as already mentioned, does there exist any space between the socket and the head of the thigh-bone which can be changed bv any muscular action, or can be increased by their relaxation, as the most perfect and intimate contact exists. It further follows that, when an actual lengthening of the extremity takes place, the stated relations between the head of the thigh-bone and its socket must have been first destroyed by diseased changes, and the ground ofthe actual lengthening we can only seek in the simultaneous relaxation and distention of the capsular ligament by increase of its fluid contents, and in the relaxation of the mus- cles. Fricke's observation, that in the seeming lengthening of the extremity, (by dropping of the pelvis,) measurement shows the shortening of the thigh to be, as GjEdechens correctly observes, and as every one can prove to himself by voluntary dropping of one or other side of the pelvis, and placing one finger on the crest of the hip-bone and another on the great trochanter, dependent on the whole hip-bone of the sunken side being approached nearer to the great trochanter, whilst on the opposite side the hip-bone is proportionally separated from the trochanter; in consequence of which, in the one instance a shortening, and in the other a lengthen- ing, of the space between the great trochanter and the iliac spine, and consequently ofthe whole bone must be produced. [As regards the lengthening of the limb, Astley Cooper says:—"It is possible that an effusion into the joint may push the limb a little, but I doubt whether this has any influence in producing an elongated appearance of the limb. The length of the limb is not really increased, but an appearance of elongation is produced by the parietes being depressed on the diseased side." (p. 454.) Lawrence gives a very good description of the lengthening of the limb. He says :—" In the earlier period of the disease we sometimes find the limb longer than that on the sound side, and sometimes shorter. This is only apparent. It depends on the position of the pelvis; hence, when the lower extremity of the affected side appears to be longer than that of the other, we shall find that the anterior superior spine ofthe ilium on that side is so much lower than its fellow; if the extremity of the sound side appear to be the longest, we shall find that the anterior superior spine of the ilium of that side is lower down than that of the affected side. When a patient has this disease of the hip-joint, the weight of the body is not supported on both hips, but by that of the sound side; so that when the patient stands erect, the sound thigh sustains the weight of the trunk, and the diseased lower extremity is placed in front of the sound leg, the knee being a little bent, and the anterior part only of the foot brought to the ground. Under these circumstances, the pelvis, generally speaking, sinks a little towards the diseased limb, and this is compensated by the limb being bent a little towards the opposite side ; a degree of curvature of the spine is thus not unusual in affections of the hip-joint. In other instances, how- ever, the patient bends the knee slightly on the affected side, and rests the foot on the ground; this will be attended with an apparent shortening of the extremity. In order, then, to form a correct judgment, you must strip the patient, and make the examination on a straight horizontal surface. You will then immediately observe the position of the pelvis, and discover the cause of the apparent elongation or shortening ofthe affected limb." (pp. 484, 85.)] (a) MOller's Archiv. fur Anatomie, 1836, (b) Die Physiologie des Hilftgelenkes in part i. p. 54; Muller's Handbuch der Phy- ihrer Beziehung zur Lehre von den Coxar- siologie, vol. ii. p. 124; Lauer in Hamburger throcace; in Hamburger Zeitschr., vol. vi. Zeitschrift fur die. Med., vol. ii. part iii. p. part i, 283. DISLOCATION IN HIP DISEASE. 287 235. Dislocation of the head of the thigh-bone is not a necessary phenomenon in the third stage of coxalgy, it is rather accidental, and depends on the position of the diseased extremity, on the motions of the patient, and other influences during the relaxation of the muscles, and on the relaxation and destruction of the ligaments, specially ofthe round ligament. Hence the dislocation may occur in various directions ; most commonly, indeed, backwards and upwards; but also downwards and inwards, (Nester, Van der Haar, Berdot, Schreger, Trextor,) in which case the direction and length of the extremity are differently cir- cumstanced. In rare cases the head of the bone superficially de- stroyed by caries may remain, and become anchylosed with the socket, which has also been deprived of its cartilaginous overspreading by similar caries ; of this termination of coxalgy I have two specimens. Spontaneous separation, and throwing off the head ofthe bone through the enlarged apertures ofthe abscess, may also ensue (a). Coulson quotes from Hoffman two cases in which the detached head of the femur made its way through the abscess and was removed by the assistance of the surgeon, (p. 23.) If the patient's constitution be sufficiently strong to carry him through the stages of this disease which have been mentioned, the hip-joint will be found on examina- tion after death, in one of three or four different conditions ; two of these I have already noticed, viz., the overspreading of the head of the thigh-bone and its socket with an ivory-like deposit, and anchylosis of the ball and socket, almost invariably by bone. But sometimes the capsular ligament having given way, the head ofthe thigh-bone slips through and is dislocated, and the most common direction it takes is upwards on the back of the hip-bone (dorsum ilii.) But it may be displaced, though more rarely, into either of the other localities of dislocation; thus the younger Earle mentions a dislocation into the ischiatic notch; in the Museum ofthe Royal College of Surgeons of England there is a dislocation into the foramen ovale; Boyer also mentions a case of this kind, Brodie another, and Coulson another in a boy nine years old, in which " the limb was much elongated, the knee and foot turned outwards, and the head of the femur near or in the foramen ovale," (p. lil); Ducros the younger (b) speaks of a dislocation forwards on the horizontal branch ofthe share-bone (os pubis) in a female twenty-seven years old, who had in- flammation ofthe hip-joint. When dislocation has taken place the new socket is formed on that part of the pelvis on which the head ofthe thigh-bone rests, and according as the head is nearer or farther from the hip-socket, does the latter participate in the formation ofthe new joint, the unoccupied part ofthe socket, being filled up with a structure which in one case Samuel Cooper (c) describes as consisting " partly of a fungoid (granulating, I presume, j. f. s.) mass, and partly of firm coagulating lymph. The brim of the acetabulum was rough and gritty, and the os ilium above the acetabulum destitute of periosteum." (p. 255.) The same writer also mentions a most remarkable in- stance which is in University College (London) museum, in which "the articular cavity is formed in the upper portion of the femur and a new ball on the ilium. The old acetabulum is nearly obliterated, and near it within the pelvis the remains of the cyst of an abscess." (p. 868.) At other times, however, no dislocation takes place, but the hip-socket expands, perhaps in part from the pressure of the pus contained in the capsular ligament or within the walls of the. abscess which form about it, and part from the continual pressure of the head ofthe thigh-bone against the edge ofthe socket, softened by its spongy tissue, which has lost its cartilaginous and bony articular covering, soaking (a) Cases of this kind, in which the cure nus de Exstirpatione Femoris, p. 65: Klinge ; was always followed by the use ofthe joint, in J.kger's HandwOrterb. der Chir. u. Au- are to be found in Schlichtixg ; in Philos. genhcilk, vol. i. p. 585. Trans. 1742 : A. F. Vogel, Obs. quicd. chi- (b) Gazette des Hopitaux, June 30, 1835. rurg. Kilisp, 1771, No. 2: Hoffman, vom (c) Surgical Dictionary,—article, Diseases Scharbrocke, Munster, 1782, §283: Hede- of Joints. 288 DISEASES DISTINGUISHABLE FROM HIP-DISEASE. constantly in pus, in consequence of which the socket loses its deep cup-like shape, and often resembles a shallow saucer with a much-everted lip. Upon this the wasted head of the bone moves, and were it not for the adhesive deposit which has taken place in the surrounding soft parts and rendered them unyielding, so that they really act as a mould to keep the parts of the joint together, the thigh would dangle, and never permit the weight of the body to be borne on it, which is contrary to what frequently happens.—j. f. s.] 236. Characteristic, however, as are the phenomena of coxalgy, yet may they be confounded with other diseases ; for instance, with the conge- nital luxation ofthe thigh, with a shortening of the extremity from a reces- sion and twisting of the hip-bone, nervous sciatica, and malum coxa se- nile. In Congenital Lameness, the cause of which lies in dislocation of the hip-joint, the thigh is shortened from the very beginning: if, whilst the child lies in the horizontal position, the pelvis be fixed with the hand by slight drawing down, the thigh can be, without pain, somewhat length- ened, but again shortens when the extension is withheld. The buttock is either natural or flatter, the motion of the thigh is free, and the sole of the foot can be placed completely on the ground. If the congenital dis- location exist, as it usually does, on both sides at once, the diagnosis is thereby assisted ; but, if it exist only on one side, a mistake in the diag- nosis can only arise from superficial examination. I have, however, seen two cases of congenital dislocation of the thigh on one side, which were really treated as coxalgy. In Twisting ofthe Hip-bone, which depends on weakness and loose- ness of the ligaments, the patient suffers least pain in the morning, but most in the evening: the one hip is higher than the other; the extremity is from the first shortened, and can be lengthened by a slight pull. In Sciatica the pain follows the course of the ischiatic or crural nerves; there is a sense of lameness in the whole thigh ; no change is observed in the position of the great trochanters or in the length of the two extre- mities (1). In the malum coxce senile, which depends on interstitial absorption and wasting of the head and neck of the thigh-bone, pain and stiffness first appear in the hip-joint; the former does not continue with equal se- verity, and the latter is diminished or lost in walking, but generally towards evening becomes worse, which is also invariably noticed in cold moist weather, and in oppressive heat. The extremity gradually begins to shorten ; the patient begins to limp, but can set the sole of the foot flat upon the ground ; the toes are turned outwards ; the lumbar vertebrae acquire a great degree of mobility ; the buttock on the affected side is less pro- minent : a careful measuring ofthe limb in the mode directed shows ac- tual shortening. The patient frequently complains of pain in the region of the knee, which has its seat, however, rather in the knee-cap, and which he describes as if it were dependent on the contraction of the flexing muscles. I have never observed increase of pain in pressing on the hip-joint (2). Coxalgy cannot be well confounded with white leg, (phlegmasia alba dolens,) with psoas abscess (3), nor with primitive dislocation ofthe thigh; but it may be confounded with fracture of the neck of the thigh-bone, if the shortening be slight, the patient still walking, the upper fractured DISEASES DISTINGUISHABLE FROM HIP-DISEASE. 289 portion thrust into the shaft of the lower, and if inflammatory symptoms have taken place (Jjeger). [(1) In regard to the pain in hip-disease, Sir Charles Bell (a) observes, " that pain arising from disease of the greatsciatic nerve, as itpasses near the hip-joint, may be mistaken for inflammation of the hip involving the same nerve ; so that when you find a patient with pain in the hip, the very first thing you have to inquire is, whether this be not symptomatic of internal disease 1 and I would remind you that it is not the more formidable disease of the viscera which produces this affection of the nerve, but rather disordered function. The next thing you have to consider is the lesser degree of pain in the hip, which still proceeds from disorder in the lower part of the canal; for example, accumulation in the colon will produce pain in the hip, which may be mistaken for disease in the hip-joint." (p. 297.) I remember a very good example ofthe pain produced as just mentioned by Bell, though the accumulation was very slight, but recurred continually a few hours after eating even a small quantity of hard biscuit, which as soon as it reached the synovial flexure of the colon, produced a dull heavy pain in the iliac pit, and thence extending down the inner and fore part of the thigh to the knee, increased on walking. This would continue, although the bowels acted freely and as usual, for two, three, or four days, till either castor oil were taken, or an injection thrown up for its special relief; soon after which all the pain ceased.—j. f. s.] (2) This disease, my own personal observations of which entirely agree with those of Smith (b) and of Wernherr (c) cannot, if attention is paid to the symptoms above mentioned, be readily mistaken for coxalgy. I have, however, seen such mistake twice. The disease occurs generally in elderly persons, rarely before fifty years of age. I have most frequently seen it after concussion and contusion of the hip-joint, specially in women, but occurring, also, without any previous cause. In some cases the gout seemed to me connected with it. This disease never runs into suppuration, and, above all, excites no symptoms dangerous to life. On examination of such a joint, the capsular ligament is found thickened, the cotyloid ligament bony or ab- sorbed, the round ligament destroyed, the mass of fat in the hip-socket wasted, the cartilage ofthe socket, absorbed, and in its stead a hard enamel, and the hip-socket materially changed in form and extent. The cartilage on the head of the bone is absorbed, and the surface ofthe head is porous. I have, however, found, in advancd disease, the cartilage on the head ofthe bone unchanged. In cases of long continu- ance, a hard glossy enamel is generally deposited on the surface of the bone; the round shape of the head is changed, at first it is flattened from above downwards, but, subsequently, it assumes the shape of the socket. The neck ofthe thigh-bone is subject to a partial or complete absorption, and the head sinks together with the shaft at a right angle, and appears to stand out directly from it. If the head and neck of the bone be sawn vertically, it has completely the appearance of a fracture of the neck of the thigh-bone, externally to the capsule, which has united: the bony mass is remarkably light, and the shaft of the thigh-bone con- sists merely of a thin bony shell, and the medullary canal is much widened. Astle V Cooper and Charles Bell have made remarks on these changes of the head and neck ofthe thigh-bone; and Smith has also observed them in the shoulder-joint. [(3) Coulson says:—-'The disease of the hip in this (third) stage may be mis- taken for psoas abscess ; attention, however, to the following points will materially assist us in our diagnosis. First, in psoas abscess, the patient complains of violent or dull pain in the region ofthe loins, which is very much increased in the upright posture of the body, and by every motion of the limb, particularly on extending it; in the diseased hip there is no fixed pain in the loins; it is felt more in the neigh- bourhood ofthe hip, and especially in the knee. Secondly, in psoas abscess, during the whole course of the complaint, there is no deviation to be perceived in the natural situation of the trochanter, and no difference in the length of both limbs; in diseased hip, on the contrary, this is always the case. Thirdly, in affection of the psoas muscle, the patient cannot turn the foot ofthe affected side outwards, without increasing the pain; in diseased hip, on the contrary, the foot is generally turned outwards. Fourthly, on taking a deep inspiration, on coughing or crying, and in (a) Medical Gazette, 1838-39- (4) Dublin Journal of Medical Seience, vol. vi. Sept. 1834. (c) Schmidt's Jahrbucher, Vol. i.—25 290 APPEARANCES ON DISSECTION. the erect posture of the body, the fluctuating swelling, either on the nates, or in front of the thigh, increases, and the exit of matter, if the abscess burst or be opened. will be facilitated ; in abscess of the hip-joint from disease, neither is the case. In this stage, also, the disease of the hip may be confounded with deep-seated forma- tion of matter in the region of the groin, either connected or unconnected with a carious state of the bones of the pelvis. In these cases there is very acute pain in the anterior region of the hip, with shiverings, and inability to rest the limb on the ground, but the great diagnostic mark is the absence of pain on rotating the head of the femur. There is no pain over the posterior part of the joint, or at the knee. (pp. 34, 5.)] 237. Examination of the joint after death presents different results, ac- cording to the degree ofthe disease and its original seat. In the earlier stage, the cartilaginous covering of the head ofthe thigh-bone is mostly inflamed, ulcerated, often the spongy substance itself is inflamed and more rarely the synovial membrane, the capsular ligament is swollen, the round ligament still maintaining the connexion between the bone and its socket; at a later period of the disease the cartilaginous covering of both the head and socket is destroyed ; the former is carious, often en- tirely separated from its neck; the carious destruction penetrates even into the cavity of the pelvis, the synovial membrane and capsular ligament are entirely changed, swelled up and destroyed ; pus is collected in the joint and between the muscles. If the head of the bone be displaced, the socket also is entirely filled with a steatomatous mass, or with brown pus. [It has been already stated, that Brodie holds ulceration of the cartilages to be a primary form of disease of joints; his reasons for which opinion are quoted pre- viously (p. 254); and his statement of the symptoms which peculiarly characterize it in the bip-joint are also subsequently mentioned, (p. 282.) Key, however, does not entirely, at least, agree with Brodie on this point, and the following are his views:—"The opportunities," says he, "which present themselves to any indi- vidual of observing this disease in its early stage by dissection, must necessarily be few. The cases which it has fallen to my lot to examine, have induced me to be- lieve that the ulceration ofthe cartilage is preceded by inflammation ofthe ligamen- turn teres.'''' He found in "a young female who, for six months prior to her death, had laboured under the usual symptoms of chronic inflammation of the hip-joint," and in whom " the symptoms had partially yielded to the treatment employed, when she was attacked by another disease, of which she died, the ligamentum teres much thicker and more pulpy than usual, from interstitial effusion, the vessels upon its investing synovial membrane distinct and large, without being filled with injection. At the root of the ligament, where it is attached to the head of the femur, a spot of ulceration in the cartilage was seen commencing, as in other joints, by an extension ofthe vessels, in form of a membrane, from the root ofthe vascular ligament. The same process was also taking place on the acetabulum, where the ligamentum teres is attached. I cannot undertake to say, that the hip-disease shall, in every instance, present these morbid appearances, or that cases do not occur in which ulceration exists as a primary disease, without any affection of the ligament or synovial mem- brane. Mr. Brodie's assertion, that it does exist as a primary disease, coming from so excellent a pathologist, is sufficient to substantiate the fact. But obser- vation of this disease in its different stages, and of the mode in which the disease is brought into action, together with the post-mortem appearances, afford strong proof that, at least in many instances, the action is propagated from the ligament to the cartilage, and that ulceration of the latter is consequent upon inflammation of the former." (pp. 230, 31.) In confirmation of Key's opinion, I mention the following account of the exami- nation of a hip-joint by my friend William Adams, in a case with which I was most deeply and painfully interested. The child, ten years of age, had been lame in the right hip for five or six months, but had no other symptom of hip-disease, no pain on motion nor on pressure, nor any restriction to the motion of the limb, till within a fortnight of his death, (which was caused by tubercles and effusion into the ventricles of the brain,) when he complained of violent pain, if the thigh were TREATMENT OF ACUTE AND CHRONIC HIP-DISEASE. 291 only slightly moved in lifting him from or to the bed. A small abscess, of the size of a nut, was found close to the origin of the upper head of the m. rectus femoris. On laying open the capsular ligament, a small quantity of dirty brown-coloured fluid escaped. The synovial capsule had become thickened, tender, in the sense of being readily torn, granular on the surface, and yellowish in colour. The round ligament and contiguous synovial membrane in the portion of the acetabulum uncovered by cartilage had been the seat of inflammation, the vessels were injected, the membrane was thickened, and a small quantity of lymph adhered to its surface. The state of the synovial membrane of tbe round ligament, just described, appears to me pre- cisely the same as that described in Key's case, but less advanced.—j. f. s.] 238. The general observations already made apply to the etiology.— Inflainmation appears to arise in the hip-joint, more frequently in the car- tilage and bone than in the soft parts. Fricke (a) makes a distinction between coxalgy and coxarthrocacy. In the former, at the onset, there is not, he says, any inflammatory affection in the hip- joint, but only relaxation of the muscles, whereby, in time an inflammatory affection ofthe hip-joint is secondarily produced. The latter is always from the beginning connected with distinct inflammatory symptoms ofthe hip-joint. We cannot, how- ever, agree to the admission of a coxalgy in this sense, after what has been said of the lengthening of the extremities, and after the results of our experience. 239. The prognosis is always unfavourable, least so, however, if dis- ease have arisen in the ligaments, or in the synovial membrane. In the first period of the disease only is the cure of the disease possible ; sub- sequently, even if healing should follow, there still remains a more or less halting gait. In actual dislocation, or in anchylosis, the lameness is very decided. It is generally less dangerous in children than in grown per- sons. In robust people, and where external violence has caused the dis- ease, the prognosis is more favourable than in general dyscratic subjects. If it have already proceded to carious destruction, to the formation of ab- scess in the hip-joint, there is but rarely any cure possible. 240. The treatment of coxalgy is guided by the rules laid down, and must vary according to the activity of the inflammation, the stage of the disease, and the general causes connected with it. 241. In trie first stage of acute coxalgy, the treatment corresponding to it must be strictly antiphlogistic, and the diseased extremity kept in the most perfect quiet. In traumatic inflammation, if very severe and in robust persons, blood-letting, repeated application of a great number of leeches, and continued cold applications, with corresponding attention to food, and cooling medicine given internally are required. If the in- flammation be less active, especially when it springs from rheumatic causes, or in scrofulous persons, repeated application of leeches or cup- ping will always be found sufficient. If the pain and inflammation dimi- nish, which is shown by the natural direction and length of the limb being restored, rubbing in mercurial ointment and repeated blisters must be by turns employed around the whole joint. Care must be taken in warm bathing, which is recommended by many, as the motion connected with it, and the cold so easily taken after it, frequently operate prejudicially. If the inflammation continue for a long time in a less degree, especially in strumous subjects, a continued and powerful derivation must be kept up by a pea-issue behind the trochanter. If all pain cease, and the mo- tions of the hip-joint become free, only gradual and careful use ofthe limb (a) Above cited, 292 TREATMENT OF may be permitted, so that no cause may be given for a relapse, or a pas- sage of the disease into the chronic form, which so easily happens in neg- ligent and too early motion. [With regard to salt-water bathing Coulson observes :—" In no class of patients. and in no stage of this particular disease, are sea air and warm salt-water bathing so beneficial as here. Warm or tepid bathing agrees with nearly every patient. * * * The sea-side, however, is not beneficial in cold weather. The best time is from the beginning of May to the end of October; but, if the autumn sets in cold earlier than usual, the patient should return before this. * * * The period at which patients affected with diseases of the hip-joint derive most benefit from going to the sea-side is, either at the commencement of the disease, before much inflammatory action has begun, or towards the end of the third stage, when the abscesses are discharging, and the health is impaired by the long continuance of the complaint. On the contrary, during the formation of matter, and before the abscess begins to discharge, the patient will not derive much benefit from the change. The plan adopted at the Margate Infirmary is as follows :—For the first two or three days after the patient's admission, warm bathing only is employed, in order that the constitution may re- cover the effect of the journey, and adapt itself to the atmospheric change. The patient commences with the warm salt-water bath about three times a-week, at a temperature of 96 degrees, and is directed to remain in it from fifteen to twenty mi- nutes each time. Afterwards the tepid bath is used ; and then, dependent on the state of the weather, and the health of the patient, the cold bath is employed ; one dip only in the sea being allowed each time. The time selected for bathing is in the morning. The cold or warm douche bath is often used in this stage with very good effect, (p. 79-82.)] 242. If the coxalgy have from the beginning assumed a chronic- course, the most perfect rest, which can be produced by securing the diseased limb in a suitable apparatus, is essential, and is often alone sufficient in slight form of the disease, to produce a cure, in a space of time varying from eight to ten weeks. According to the degree of pain in the hip-joint and the inflammatory symptoms, leeching or cupping, rubbing in mercurial ointment with caustic ammonia, repeated blisters, or an issue behind the great trochanter, are here especially indicated. Xicolai (a,) Klein (b) and others have recommended, (and employed with ad- vantage,) for keeping up the continued rest of the diseased limb, the apparatus for fractured neck ofthe thigh-bone. Physick (c) has proposed a treatment of coxalgy, of which the fixing of the limb in apparatus is the principal part. If the joint be swollen and inflamed, he applies leeches ; then gives his patient for some weeks a laxative of cream of tartar, and jalap every other day, so as to produce copious stools. During the employment of the purgatives, the patient must be kept lying horizon- tally in bed upon a horse hair-mattress, and not leave that posture till he is perfectly cured. When the patient, during the use ofthe purgatives, has become accustomed to lying, a padded splint, reaching from the middle ofthe chest to the outer ankle, fitting closely, and surrounding nearly half of the parts, is to be applied. If the leg be bent, the splint must be accommodated to the curve of the limb. When the patient has worn the angular splint for some time the limb may be brought to a straight position and a straight splint applied. In most cases only two splints are necessary. The splint should be attached by one bandage around the breast, and by a second from tbe ankle to the hip. The shortest time for the cure is six months, the longest two years, and the middle and usual time a year. During this time the splint sbould be continually on the limb, and never removed till the symptoms ofthe disease are manifestly diminished ; in which case the limb may be moved very gradually. This treatment is, however, admissible only when the head of the thigh- bone is neither destroyed by caries, nor has become displaced; when no abscess has yet formed, and the patient has not apparently a scrofulous constitution. (a) Journal von Graefe und Walther, (c) American Journal of Medical Science, vol. iii. part. ii. Feb., 1831. (b) lb., vol. iv. p. 25. CHRONIC HIP-DISEASE. 293 The following is the plan of treatment recommended by the Scotts (a,) which is often very efficient, and may be employed on any joint. " In the first place, the surface of the joint, suppose the knee, is to be carefully cleansed by a sponge, soft brown soap and warm water, and then thoroughly dried ; next, this surface is to be rubbed by a sponge soaked in camphorated spirit of wine, and this is continued a minute or two, until it begins to feel warm, smarts some- what, and looks red. It is now covered with a soft cerate made with equal parts of the ceralum saponis and the unguentum hydrargyri fortius cum camphora. This is thickly spread on large square pieces of lint, and applied entirely around the joint, extending for at least six inches above and below the point at which the condyles of the femur are opposed to the head of the tibia ; over this, to the same extent, the limb is to be uniformly supported by strips of calico, spread with emplastrumplumbi of the London Pharmacopoeia. These strips are about an inch and a half broad, and vary in length; some are fifteen inches, others a foot, others half these two lengths, and the shorter or longer are selected according to the size of the part round which they are to be applied. This is the only difficult part ofthe process. This adhesive bandage ought to be so applied as to preclude the motion of the joint, prevent the feeble coats of the blood-vessels from being distended by the gravitation of their contents in the erect posture, and thereby promote their contraction. Over this adhesive bandage, thus applied, comes an additional covering of emplastrum saponis, spread on thick leather, and cut into four broad pieces, one for the front, the other for the back, the two others for the sides of the joint. Lastly, the whole is secured by means of a calico bandage, which is put on very gently, and rather for the purpose of securing theplaster and giving greater thickness and security to the whole, than for the purpose of compressing the joint. This is an important point, as otherwise an application which almost invariably affords security and ease, may occasion pain, with all its attendant mischief. " In some cases in which the skin is thick and indolent, sufficient irritation will scarcely be excited by the above application, and this may be promoted by rubbing on a small quantity of tartar emetic ointment previously to the application of the cerate. This, however, is rarely necessary. "In some cases, also, it is desirable more effectually to prevent the motion of the limb, particularly in children. This may be done by applying on each side of the joint, externally to the plasters, a piece of pasteboard, softened by soaking in water, and cut into the length, breadth, and form of splints. These being soft will accom- modate themselves to the figure ofthe joint, and when dry, effectually preclude all motion. " I think this form of splint is infinitety preferable to those that are made of wood. It affords a very firm support to the limb, and at the same time counteracts the contracting effort of the muscles in as great a degree as can be effected without exciting inflammation. I have met with cases in which the diseased surfaces have been so forcibly compressed, by means of wooden splints, as to excite inflammation, and thereby cause a more violent contracting effect of the muscles, the resistance of which has aggravated the disease." (p. 133-37.) Upon this plan of treatment, Lawrence justly observes:—" A question naturally arises, whether this free application of mercurial ointment to a large portion ofthe limb is of use in all the various diseases to which joints are liable; for it is recom- mended by the Scotts, without any distinction as to the nature of the affection, whether originating in the synovial membrane, or in the articular surfaces, or from scrofulous disease of bones. This is a point that must be solved by ex- perience, and I cannot say that I am possessed of such as will enable me to answer the question. I think we should be rather inclined to ask another question on the subject, and that is, whether this free application of mercurial ointment to so large a surface of the body, and that too to a surface which not uncom- monly includes some portion of ulceration, can be considered as perfectly safe. That is, whether there may not be an absorption of the mercury capable of pro- ducing certain effects upon the constitution." Lawrence says he has seen this treatment adopted in a few instances, and in one " that the life of the child was nearly lost by the effect produced from the absorption of the mercury oi; the system. It caused a serious affection of the bowels. wrhich, in the first (a) Cited above. 25* 294 TREATMENT OF CHRONIC HIP-DISEASE. place, showed itself by pain, griping, and purging, and which then put on the appearance of a dysenteric affection, the child lost its appetite, became extremely thin, got a white tongue, and in fact, seemed to be sinking as fast as it could. The dressings were, therefore, removed, and the child sent into the country, where it quickly recovered." (pp. 515, 16.) These observations are sufficient to prove that this treatment must be pursued with some caution, as some persons are more readily affected by mercurial applications than others, and in such serious mis- chief may accrue. Fricke (a) has seen good results from this treatment. 243. In the second stage, thickening and loosening up of the liga- ments having already occurred, exudation existing, and the affection of the bone having begun, the actual cautery and issues must be employed, after the proper subduing ofthe inflammatory symptoms, for the purpose of restraining, by external derivation, the deep-seated disease, and en- couraging the absorption of the unnaturally secreted fluid. Three or four streaks are to be made with Ihe prismatic cautery heated to white- ness, extending from the middle ofthe buttock over the joint, avoiding the skin upon the trochanter; and upon the skin behind the trochanter the flat ofthe iron is to be firmly pressed, for the purpose of making an issue. The burnt part is to be covered with soft linen, and, in severe pain, with anodyne bread poultices. When the slough has separated, the discharge is to be kept up with irritating ointments, of which, ung. sabin. is best. For the purpose of making an issue, a tolerably large patch behind the great trochanter is to be rubbed with caustic potash, slightly moistened, until the skin is brown (1.) After some days the crust falls off, and a sufficient quantity of peas are to be introduced to keep up the suppuration. The suppurating part must be frequently touched with caustic. Repeated and perpetual blisters, rubbing in tartarized antimony oint- ment, as also the application (2) of hot steam (b) and the introduction of a seton through the skin (3,) especially in the region ofthe groin, if the pain more attack this part, and extend along the crural nerve, (Form, Brodie, Larrey, and others,) may reasonably be regarded as inferior to the more powerful means before mentioned. The result ofthe burning is often remarkably quick. Rust objects to the use of caustic, that by its destructive operation on organic matter it does not produce suffi- cient excitement to effect an alteration ofthe soft and hard parts of the joint; nume- rous observations, however, prove the efficiency of issues. In the comparison of these two remedies, the momentary and severe operation ofthe hot iron is not merely to be considered, but the continued derivation, which is better supported by> the issues than by the actual cautery. I therefore give the preference, in the second stage, to issues, if there be not great lengthening of the foot; but I prefer the actual cautery, or the burning cylinders, (recommended by Albers, Larrey, and others,) in all cases where the limb is much lengthened, the muscles relaxed, and where there is great swelling from collection of fluid. Volpi (c) has not observed any effect from the application of the actual cautery, when the signs or precursors of coxalgy were first manifested not at the hip but at the knee-joint. [(1) Brodie's observation, that "the good derived from the issue does not seem to be in proportion to the quantity of pus discharged from its surface," will, I am sure, be admitted by every one who is frequently in the habit of using them; and I fully agree with the opinion, " that sometimes more abatement of the symptoms is produced in the first few days after the caustic is applied, and before the slough has (a) Above cited. 7U artzlichen Zwekken; in Dzondi's jEscu- (ft) Die Dampfmaschine, ein neues Heil- Up., vol. i. p. 87; pi. i. 11. Leipzig, 1821. mit el, oder Uber die Anwendungdes Strahls (c) Above cited, p. 30. der heissen Dlmpfe des sicdenden Wassers scotts' treatment. 295 separated, than in several weeks afterwards," which, I presume, depends upon the fresh irritation produced by the new issue upon the skin: whilst, on the contrary, when an old issue is long kept up in one spot, the parts accommodate themselves to the intrusion, and after a certain period the issue is, as it were, naturalized, and causes no further inconvenience, and, consequently, no more benefit, as it fails to keep up the irritation required to create a diversion from the disease in the hip-joint. "This circumstance," says Brodie, "first led me, instead of employing beans for this purpose, to keep the issue open simply by rubbing the surface occasionally with the caustic potash, or with the sulphate of copper; and, after an extensive trial of both methods, the latter has appeared to be decidedly preferable to the former. The pain produced by the caustic is very considerable, but the relief of the symptoms is such, that I have known patients to be in the habit of making the application them- selves, saying, that, "they knew they should be better by the next morning.' Be- sides, the issue managed in this way is more easily dressed than where beans are used; and the inconvenience arising from the beans slippiftg out under the adhesive plaster, and from any accidental pressure of them against the sore surface, is avoided." (pp. 148, 49.) I have not any practical experience of this plan, being always in the habit of using glass beads, which quietly rest in the cavities they soon form for themselves, and when the wounds are disposed to heal, I brush them over slightly with caustic potash, which I have not found to give very much inconvenience; but 1 think Brodie's plan is likely to be preferable.—j. f. s. (2) A very clever but simple apparatus for local steam-bathing invented by Duval (a,) has been used in some of our hospitals for the last few years, and well deserves being more extensively adopted, on account of the facility witb which it can be employed and the great benefit attained by it, especially in chronic diseases of the joints. " It consists of a reservoir for the water, capable of containing a little more than a pint, supported upon three metallic rods, and having a coverlet, which is furnished with two openings, one at the centre and one towards the side. From that in the centre arises a tube, terminating in a hollow globe, having attached to it and communicating with its interior three short branches, furnished with movable lids. A similar branch is connected with the opening at the upper edge of the re- servoir. Beneath in a pan, supporting the parts already described, is placed a spirit- lamp, having four burners, and these, when lighted, quickly vaporize the water 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 with any one or all its branches at pleasure, to the part of the body required. The force and the quantity of vapour 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 stop-cock, while its escape upwards is entirely and instantly prevented by exposing the opening at the edge of the reservoir. The way in which it is used for joints is as follows: the patient covers the wrist, for instance, with a piece of flannel large enough for its edges to fall on a pillow, which is placed to support the forearm. The nozzle of one of the tubes is then placed beneath the funnel, and the steam allowed to escape. The joint thus enveloped in steam has usually been allowed to remain for about half an hour; the application being made once a-day or oftener •as the circumstances require. It may be also used as a vapour-bath, thus : the pa- tient lies supine in bed, and three or four arches of wood or other convenient mate- rials are placed across the body, so as effectually to raise the blanket from any contact with it. The apparatus is supported on a stool at the foot of the bed, and one of the pipes allowed to project into the arched cavity, which soonbecomes filled with vapour. In this way all the inconveniences attending a removal to and from the bed are of course got rid of." (p. 205.) (3) " The objections which may be urged," says Brodie, " against the application of caustic to the skin of the groin do not hold good with respect to a seton in this situation. I was led to adopt this treatment some years ago, partly from observing that the skin ofthe groin is nearer to the hip-joint than the skin elsewhere; partly from an expectation (though not a very confident one) that the making a seton over the trunk of the anterior crural nerve might be particularly calculated to relieve the pain referred to those parts to which the branches of that nerve are distributed. The results of this practice more than realized whatever hopes I had entertained of its (a) Provincial Med. and Surg. Journ., Dec. 1840. 296 GENERAL TREATMENT. success. In many cases the seton occasioned very speedily a complete relief of the pain. In other cases, indeed, it failed in producing the like good effects; but these cases have borne only a small proportion to those in which it has succeeded. On the whole, I am led to conclude, that wThere the pain is very severe, the seton in the groin is more calculated to afford immediate relief than the caustic issue; but that it is not so efficacious in checking the progress ofthe disease, as it is in lessen- ing the violence of its symptoms; and that the caustic issue can be better depended on for the production of a cure." (pp. 150, 51.)] 244. The good effects of this treatment are shown by the diminished pain, and by the gradual return of the foot to its natural length. Its effects are to be assisted by rubbing in, at the same time, mercurial or iodine ointment. The observance of complete rest is here also indis- pensable. If, from this improvement there should be again a relapse without any decided cause, the prognosis is very unfavourable. The repeated application of the actual cautery is sometimes effectual. When all symptoms of the disease have subsided, the patient must still be kept quiet for a long while, and the suppurating parts must not quickly be checked. During convalescence sulphur baths may be advantage- ously used, and issues inserted in the arm to keep up.continual deriva- tion. In this stage, also, I do not consider the use of warm bathing proper, (Rust, Brodie, and others,) on account of the motion therewith connected. The use of mercurial ointment has been prescribed in various ways : Fritz (a) employs Lou- vrier's treatment, but not so as to produce salivation; Rust rubs in daily one or two drachms ; JjEger justly considers this as too strong a dose, inasmuch asi t frequently produces too" speedy salivation, which, in scrofulous subjects especially, is always to be avoided ; he therefore rubs in mercurial ointment, in increasing doses from ten to sixty grains, to which he adds about five grains every three or four days, so that altogether from one to three ounces are used; and, when salivation has com- menced, he changes it for iodine or white precipitate ointment. [Brodie very justly lays great stress not only on rest but also on the patient's position. He says (b :)—" When the cartilages of the hip are ulcerated, the patient should be confined to his bed or couch, being never allowed to move from it on any occasion. If left to himself, he is generally inclined to lie on the side opposite that of the disease. There are, however, good reasons why this position should be avoided, if possible. It necessarily distorts the pelvis and increases the disposition to a lateral curvature of the spine. It also, in those cases in which the round ligament of the joint is destroyed, facilitates the escape of the head of the femur from the aceta- bulum and the production of dislocation. Somethingmay be done towards preventing this last by interposing a pillow or thick-cushion between the knees ; and it is difficult to do more than this, after the patient has already been lying on his side for a con- siderable time : otherwise he should be placed on one of the bedsteads invented by Mr. Earle, lying on his back with the shoulders and thighs somewhat elevated and the latter as nearly as possible parallel-to each other. On some occasions, however, it is convenient to fix the pelvis by a strap or bandage, passing over it, from one side of the. bedstead to the other; and even the thigh may be fixed in the same manner. At a later period when, in consequence ofthe extensive destruction of the articulation, the muscles begin to cause a shortening or retraction of the limb, I have found great advantage to arise from the constant application of a moderate extending force, operating in such a manner as to counteract the action of the muscles. For this purpose an upright piece of wood may be fixed to the foot of the bedstead, opposite the diseased limb, having a pulley at the upper part. A bandage maybe placed round the thigh above the condyle, with a cord attached to it passing over the pulley and supporting a small weight at its other extremity. I will not say that the effect of such a continuance is to prevent the shortening of the limb altogether ; but I am satisfied that it will, in a number of instances, render it less than it would have been otherwise, at the same time preventing, or very much diminishing, that ex- (a) Salzb. Med. Chir. Zeitung, 1828, No. 37. (b) Third Edition. TREATMENT OF ABSCESS OF THE HIP-JOINT. 297 cessive aggravation of the patient's sufferings with which the shortening of the limb is usually accompanied." (pp. 145, 6.)] 245. The general treatment in the first two stages of coxalgy is di- rected by the degree of the inflammation, and the nature of its cause. In severe acute inflammation, whether the origin be traumatic or other- wise, more than proper antiphlogistic treatment and attention to diet, is superfluous. If the inflammation be chronic, the choice of internal remedies is to be directed according to the cause. In rheumatic and scrofulous patients, I have always found cod-liver oil in increasing doses, and, in torpid scrofulous subjects, the internal use of iodine, (after Lugol's plan,) the most efficient. We may consider that both these causes are combated by the various remedies which have been recommended, in coxalgy. Jaeger recommends tartar emetic in large or small doses, Zittmann's decoction in divided doses; Rust, Dieffenbach, and others, use cod-liver oil; also the de- coct, balhtac lanatae, the extract, pampinoram vitis viniferae 3j. to oij. daily, or a satu- rated decoction, or the recently expressed juice. (Frank, Rust, and others,) calo- mel, kermes mineral, sulphur, aurat., turpentine, and so on. Fricke recommends, in coxalgy, (in the above given sense,) rest and fixing of the limb by an apparatus. If the thigh remain longer, this passive treatment is not sufficient, and a two-fold condition must be distinguished; 1st, an irritable state of the nervous system, in which the patient complains of this and that, has disturbed digestion, chylification and assimilation, and stoppage of the bowels, for which mild purgative remedies of various kinds, warm baths, and, locally, warm poultices must be used ; 2d, muscular weakness,—for which there should be advised, as most efficient, rubbing in volatile ointments, blisters, plasters of tartar emetic, dry cup- ping, stimulating baths, and steam of hot water, moxas, and actual cautery applied superficially only. 246. If the head ofthe thigh-bone become displaced, and the disease arrested, an artificial joint may be produced by continued rest; and when the patient begins to walk, he must support the foot as much as possible, at first with crutches, and afterwards with a high shoe corre- sponding to the shortening ofthe extremity. The great degree of lame- ness, and, in children especially, the frequent contraction of the thigh, have led some to attempt the reduction of the luxation ; and the results which have thereby been obtained are well suited to determine on careful attempt at reduction, and then to keep the limb in a straight po- sition, which is best done with Hagedorn's apparatus for fracture ofthe neck of the thigh-bone. If the reduction cannot be effected, we may attempt to keep the limb in its proper place, and the head of the bone in the neighbourhood ofthe socket, by gentle, gradually increased, and continued extension, by means of the apparatus just mentioned, or of some other kind, and so decidedly improve the direction and length of the limb in the course ofthe cure. Owing to the nature of the circumstances under which the reduction is here at- tempted, it frequently does not succeed; and, indeed, when not employed with the greatest circumspection, very serious consequences may ensue. But, upon these grounds to reject these experiments, and to consider their success impossible, (Pe- tit, Callisen, and others,) or to imagine that if they actually succeed, the head of the thigh-bone cannot be fixed in the hip-socket, is opposed, according to Jaeger (a,) to all the under-mentioned observations. Berdot (b\ reduced, by pressure, the head of the thigh-bone, dislocated upwards; Hagen (c,) by means of Ravaton's (a) As above, p. 597. (b) Act. Helvet., vol. iv. p. 236. (c) Wahrnehmungen Mietau, 1772. 298 EXFOLIATION FROM THE HIP-JOINT. reductor. Ficher (a) and Thilenius (b) relate similar cases, Mozilewsky (c) undertook the replacement thrice with success; in the first case he succeeded in a luxation of several inches, and of several weeks' standing, without difficulty, but it was necessary to maintain it by constant pressure; in the second, it was not until after nine months', and, in the third, after five weeks', continued extension. Schnei- der (d) replaced the head ofthe thigh-bone, but it was always again dislocated, in spite of the splint which he applied. B. Heine (e) employed continued and gradu- ally increased extension for a year, in a girl eleven years old, who had a sponta- neous luxation of eight years' standing, with a shortening of three inches, and con- siderable lateral curvature ofthe spine; the head ofthe thigh-bone not only retained its place in the joint, but the thigh moved as perfectly as the other, so that the girl could dance. F. Humbert and M. N. Jacquier (/) profess, by means of a proper apparatus, to give to the short limb similar length with the healthy one, to restore the head ofthe bone to the socket, and to confine it there till, by increased muscular energy, the necessary connexion and firmness are attained. Textor's observation of a case of long standing dislocation of the head of the bone, being driven back into the joint by a fall upon the rump, is extremely interesting; this he himself related to me. Volpi, Schreger, von Winter, Harless (g,) and Fricke (h,) have recommended gentle and continued extension, with proper fixing of the limb. There would be always decided advantage if, in cases where replacement does not succeed, the head ofthe thigh-bone were brought down from the back of the hip-bone into the ischiatic pit, and there fixed. J. Heine (i) has communicated most interesting and successful observations upon four cases in which he happily effected the reduc- tion with permanent success. In one case he had the opportunity, after the subse- quent death ofthe patient, to examine, by dissection, the reduction and condition of the joint. 247. If collections of pus take place, which are often very far spread, and accompanied with much pain and increased hectic consumption, they must be opened with a sufficiently large cut, and care taken in the application of warm poultices for the proper escape of the pus; and the powers of the patient are to be kept up by tonic remedies and good diet. In scrofulous persons, the cod-liver oil is particularly advantageous. It collections of pus take place after acute coxalgy, a speedy cure often takes place under the preceding mode of treatment. The same course must be pursued with fistulous passages. Different opinions are held as to the treatment of these abscesses, in reference to their dispersion by the application of caustic (Ford,) of seton (Wend, van der Haar,) of actual cautery (Rust.) Brodie and Jaeger have never seen any result from the actual cautery, and my experience is the same. The greatest number of surgeons leave the opening of these abscesses to nature, in which case the pus flows out more slowly, and the hectic consumption does not increase in the same degree as in the artificial opening: they advise only, in great and continued tension, and constant uncontrollable pain, a simple puncture ; whilst others recommend an early opening. The aperture itself is advised to be made by caustic, (Sabatier, Ficher,) by the red-hot trocar, (Larrey,) and by the actual cautery (Rust.) The latter further recommends drawing a seton through the whole joint, by means of a trocar and an edged probe, in order that, after remaining there a few .days, it may produce a severe inflammatory process in the deep-seated parts, a mode of proceeding which is certainly more likely to hasten death than improvement. Larger incisions, as («) Salzb. Med.-Chir. Zeitung, 1807, vol. syniptomatiqucs de l'Artieulation Ilio-femo- iv. p. 381. rale, methode applicable aux Luxations an- (b) Hufeland's Journal, 1816, May, p. cienncs par cause cxteme. Paris, 1835. 102. Atlas folio. (c) Schreger; in Horn's Archiv., 1817, (g) Jahrb. der deutschen Medicin, vol. iii. vol, i. p. 316. parti. (d) Chirurgische Geschichtcn, Chemnitz, {h) Funfter Bericht Uber die Verwaltung 1764, vol. ii. p. 77. des allg. Krankenhausscs zu Hamburg. (e) J,eger, above cited. (i) Ueber spontane und congenitale Lux- (/) Essai et Observations sur la maniere ationen, u. s. w. Stuttgart. 1842. de Teduires les Luxations spontanees ou EXFOLIATION FROM THE HIP-JOINT. 299 recommended specially by Brodie, J^ger, and others, have certainly the preference over the above-described mode of treatment, and more simply and satisfactorily support nature in throwing off the diseased bone, and so on. Injections of decoc- tion of bark, of oak bark, or of walnut leaves, with tincture of myrrh, turpentine, and so on, are useless, and nearly always injurious. [As regards the opening of abscesses at the hip, Brodie notices, that " an abscess connected with any joint, but particularly one connected with the hip, does not form a regular cavity, but usually makes numerous and circuitous sinuses in the interstices ofthe muscles, tendons, and fasciae, before it presents itself under the integuments. It is, therefore, less easy to evacuate its contents, than those of an ordinary lumbar abscess ; and, indeed, it can seldom be emptied without handling and compressing the limb, in order to press the matter out of the sinuses in which it lodges. But this is often attended with very ill consequences. Inflammation takes place of the cyst of the abscess, and pus is again very rapidly accumulated. Small blood-vessels give way on its inner surface, the bloody discharge of which, mixed with the newly secreted pus, goes into putrefaction, and exceedingly irritates the general system." (p. 160.) He, therefore, states:—"The practice which has appeared to me to be, on the whole, the best, is the following:—An opening having been made with an abscess lancet, the limb may be wrapped up in a flannel wrung out of hot water, and this may be continued as long as the matter continues to flow of itself. In general, when a certain quantity has escaped, the discharge ceases ; the orifice heals, and the puncture may then be repeated some time afterwards; but where the puncture has not become closed, I have seldom found any ill consequences to arise from its remaining open." (p. 161.) On the whole, I think it preferable not to meddle with abscesses ofthe hip-joint, unless they excite much constitutional irritation, until the skin is on the point of ulcerating; then they may be punctured, and rarely untoward symptoms follow.— j. f. s.] 248. If, under this treatment, the general and local condition improve, if separate pieces of bone are thrown off, which are removed in the usual way, one or other opening, however, generally remains fistulous, and may so continue, without detriment, for years; often closing after repeated separations of bone, or, in younger persons, they close on the approach of puberty. If the carious destruction, however, continue, and the hectic consumption be in no way checked, examination must be made with the finger merely, ofthe caries ofthe head of the thigh-bone, and if the soft parts are not too much undermined and destroyed, the cutting off the head ofthe thigh-bone ; and, in greater destruction of the soft parts by the burrowing ofthe pus, provided the powers are not too much ex- hausted, the exarticulation of the thigh-bone is the only, although very doubtful, means for the possible recovery of the patient. The circum- stance of the hip-socket being usually affected in carious destruction is principally against this operation. The amputation of the head of the thigh-bone (as recommended by Jaeger) has been proposed by Kirkland, Richter, and Vermandois, instead of the more dangerous exarticulation, was successfully performed by White, and, without benefit, by Hewson. Kerr and Baffos performed the exarticulation of the thigh- bone without advantage. In both cases the hip-bone was affected; in Baffos's case, however, death occurred three months after, and when the wound was perfectly healed. Charles Bell's proposition (a) to saw through the neck of the thigh-bone, in order to produce anchylosis by the quietude of the head of the thigh-bone (!) is decidedly less suitable. [Coulson mentions, as an instance of spontaneous reduction of a thigh-bone dis- located by hip-disease, the following case, communicated to him by Barry of Richmond. It will be seen, however, from the account, that the replacement was not effected spontaneously, but rather by the nurse lifting the head of the bone (a) London Medical Gazette, 1828, Jan. 300 SHOULDER DISEASE. over the edge of the socket into its proper place. It is, however, a very in- teresting— Case.—I. S., aged forty years, who had been for a number of years employed in carrying the produce of a market-garden to town, and generally by night, and had of late years suffered from rheumatism and occasional hepatic derangement, was, in February, 1826, labouring under the most aggravated form of ulceration of the car- tilages of the hip-joint, induced by a fall from a cart on the frozen ground about a month before. In the following month luxation had taken place on the dorsum ilii ,- the head of the femur can be felt, and the limb is shorter by about three inches and a half, with a slight inversion of the foot." Suitable treatment was adopted, and in the May following extension was made for a few days, " to relieve the pain caused by the unusual aetion of the m. glutazi, and for about four days the intention was fully answered by these means; but the extension becoming a source of irrita- tion, was discontinued two days after, being 2d of June; and about seven weeks from the time of extension, while the female attendant was helping him to turn in bed, with her right hand on the inside of the thigh, and her left between the aceta- bulum and the new position of the head of the femur, the bone was felt by her hand rushing past this intermediate space. Next day," says Barry, " I found the limb restored to within half an inch of its proper length, with neither inversion nor ever- sion of the foot, and pain gone. The patient says he heard the sudden 'snap,' and exclaimed, at the same time, that mischief had been done ! It was, as has been seen, unlooked for reduction. In November following, the man walked about on crutches, and had not any pain." (pp. 103, 4.) Ducros's case already mentioned appears to have been cured by continued exten- sion for fifty days.] IL—INFLAMMATION OF THE SHOULDER-JOINT. (Omalgia, Omarthrocace.) 249. This disease runs through the same three stages as coxalgy. The pain, at the onset a more constant symptom than in coxalgy, is tearing, darting at one part or other and descending to the elbow. It is felt when pressure is made with the finger in the arm-pit directed for- wards. The arm wearies with but slight motion, and the pain is increased every time it is moved, especially when raised. No disease is distinguishable on the shoulder. The pain increases after some time, especially at night. The sensibility and weakness of the arm become very great. 250. Gradually the arm becomes bent at the elbow-joint, and sticks out from the body; every movement of it becomes painful: it grows flabby and wastes. The shoulder sinks in, and loses its rounded form ; the folds ofthe arm-pit also grow deeper; between them the head ofthe bone is felt, and the arm-pit is more filled. The diseased arm seems longer when compared with the healthy one. Often also, Ihe shoulder swells, becomes more rounded, and the skin itself reddened and hotter. Febrile symptoms accompany the exacerbations which occur at various periods. 251. If the head ofthe bone escape from the socket, the curved form of the shoulder is entirely lost; the acromion juts out; in the arm-pit, the sunken head of the bone is felt, which gradually softens above towards the collar-bone, so that the arm is somewhat shortened and directed backwards, and its motion hindered: or, the swelling of the shoulder increases, becomes harder and more painful on pressure, and on every motion of the arm. DISTINCTION OF KNEE-DISEASES. 301 Here, as in coxalgy, collections of pus take place, which, in the end, burst, and form fistulous passages. Carious destruction of the head ofthe upper arm-bone, ofthe socket, of the ribs, and so on, occur, and profuse suppuration, which destroys the powers of the patient. In favourable cases, a new socket is formed for the head of the upper arm- bone, or it anchyloses with the shoulder-blade. 252. On examination of the joint after death, the cartilaginous cover- ing of the head of the bone, and of the socket of the blade-bone, is found either partially or entirely destroyed ; carious destruction of the bone, which generally does not reach far down the shaft of the upper arm-bone ; frequently the head of the bone is swollen up, covered with fungous growths, its cells enlarged and filled with blood or yellowish red exuda- tion; the capsular ligament and surrounding tissue thickened and loosened up, the synovial membrane degenerated ; pus poured out into the cavity of the joint, and into the various muscular interspaces. 253. The etiology, prognosis, and treatment, correspond with those laid down in coxalgy. III.—INFLAMMATION OF THE KNEE-JOINT. (Weisse Kniegeschwulst, Tumor Albus Genu, Gonalgia, Gonarthrocace.) 254. The pain is at first generally very trifling ; the patient feels rather a stiffness of the knee-joint, and the pain only comes on with active motion. Sometimes it is confined to one spot, sometimes spread over the whole joint. This state may often continue for a long while, with alternate improvement and relapse ; the pain at last increases, and the joint begins to swell. Frequently the pain is severe from the first, and the swelling soon appears. In many cases it is elastic and fluctuating, but has not the form of the joint; in others it yields but little to pressure, and is often so hard that it might be taken for bone. In proportion as the swelling of the knee increases, the leg becomes more bent; walking becomes very painful, or quite impossible; the skin over the swelling is shining white, exceedingly stretched, and at last bluish through the swelling of the veins. The pain now increases to a great degree; the swelling becomes at some parts distinctly fluctuating; the skin grows red and thin: it bursts, and discharges thin pus, mixed with cheese-like flakes. The openings often close and break out afresh. In general, the powers of the patient sink very rapidly; a probe passed into the joint shows carious destruction; hectic fever, with colliquative diarrhoea, comes on with more severe pain in the knee-joint, and death ensues, if the limb be not removed in proper time. The duration of the disease is uncertain. 255. What has been already said as to etiology applies here. The difference in the course of the disease depends on whether it has com* menced as inflammation of the ligaments and synovial membrane, or as ulceration ofthe cartilages ofthe bones. Hence arises the earlier division of white swelling of the knee-joint into rheumatic and scrofulous. In the former, the disease of the knee is more general, and the swelling occurs more quickly after the setting in of the pain; the synovial membrane, vol. i.—26 302 DISTINCTION OF and the soft parts of the knee, are primarily attacked: in the latter, the pain is fixed to one particular spot, and the swelling, which retains the form ofthe knee, takes place later, and is more hard. This difference in the swellings ofthe knee is confirmed by examina- tion of the diseased joint after death. The soft and hard parts of the joint are often completely changed, and so connected together by a tough thick lymph, that they form a perfectly fungous mass. The synovial membrane is often inflamed and ulcerated, and the cartilage at the same time degenerated into a red spongy mass. All the soft parts of the joint are often thickened, as is also the cellular tissue on the ex- ternal surface ofthe capsular ligament. The cavity of the joint is filled with brownish flocculent fluid. The cartilaginous surfaces are often partially or entirely destroyed, and the bones are carious. The head of the shin-bone is more usually affected with caries than the joint-end of the thigh-bone. The soft parts of the joint may be completely destroyed, and the carious ends ofthe bones exposed. [The following is a brief account of the symptoms by which diseases of the knee may be distinguished :— In synovial inflammation of the knee-joint, the swelling, which at first depends only on the increased quantity of fluid contained within, is readily and " distinctly felt to undulate when pressure is made alternately by the two hands placed, one on each side. When the inflammation has existed for some time the fluid is less perceptible than before, in consequence of the synovial membrane having become thickened, or from the effusion of lymph on its inner or outer surface; and, in many cases, where the disease has been of long standing, although the joint is much swollen, and symptoms of inflammation still exist, the fluid in its cavity is scarcely to be felt. As the swelling consists more of solid substance, so the natural mobility of the joint is in a greater degree impaired. * * * The swelling is not that of the articulating ends of the bones, and therefore it differs from the natural form of the joint;" * * * depending " in great measure on the situation of the ligaments and tendons which resist the distention of the synovial membrane, in certain directions, and allow it to take place in others;" thus, " the swelling," says Brodie, " is ob- servable on the anterior and lower part of the thigh, under the extensor muscles, where there is only a yielding cellular structure between those muscles and the bone. It is also often considerable in the space between the ligament ofthe patelja and the lateral ligaments; the fluid collected in the cavity causing the fatty substance to protrude in this situation, where the resistance of the external parts is less than elsewhere." (pp. 24, 5.) The swelling from synovial effusion is easily distinguishable from the large fluid swellings of the bursa of the knee-cap by the latter being always in front and of a rounded form, whilst the former is on the sides of the knee-cap. It may, however, be confused with collections of fluid in the hamstring tendons, which sometimes occur, as those tendons pass on the sides of the joint to their insertion in the leg; but the nature of the latter is shown by their more circumscribed extent, and by not undulating through the joint.—j. f. s. The pain in this complaint, though increased by motion, and by pressure with the fingers, is not, at least in the early stage, increased by pressing the cartilages together; but when adhesive matter is effused, and the cartilage is ulcerating or absorbing, there is pain more or less severe according to the mischief going on. In the pulpy disorganization of Brodie, as already mentioned, (p. 242.) the disease begins with a slight degree of stiffness and swelling without pain, and the symp- toms gradually increase. The form of the swelling is "less regular, is soft and elastic, and gives the sensation as if it contained fluid; * * * but if both hands be employed, one on each side, the absence of fluid is distinguished by the want of fluctuation." (p. 103.) There is not generally much pain till abscesses begin to form, and the cartilages ulcerate. The progress ofthe disease is slow. " Wlien the cartilages of the knee are ulcerated," says Brodie, "there is pain in the affected joint; at first slight, and only occasional, and, in the early stages ofthe disease, it is completely relieved by remaining in a state of rest for a few days, but KNEE-DISEASES. 303 it returns as soon as the patient resumes the exercise of the limb. By degrees the pain becomes constant, and very severe, particularly at night, when it disturbs the patient by continually rousing him from sleep. The pain is referred principally to the inside of the head ofthe tibia, but sometimes a slighter degree of pain extends down the whole of that bone. The pain is aggravated by motion, so that the patient keeps the limb constantly in one position, and generally half bent; and he never attempts to support the weight of the body on the foot of this side." It is distinguished from inflammation of the synovial "membrane in this, that the pain in the former is slight in the beginning and gradually becomes very intense, which is the very reverse of what happens in the latter." From most other diseases of this joint it differs, in that " the pain in the first instance is unattended by any evident swelling, which comes on never in less than four or five weeks, and often not until several months have elapsed from the commencement of the disease." (pp. 167, 68.) The swelling Brodie describes to "arise from a slight degree of inflammation having taken place in the cellular membrane external to the joint, in consequence of the disease within it. The swelling is usually trifling, appearing greater than it really is, in consequence of the wasting of the muscles ofthe limb. °It has the form of the articulating ends of the bones, that is, the natural form of the joint. No fluctuation is perceptible, as where the synovial membrane is inflamed, nor is there the peculiar elasticity which exists where the synovial membrane has undergone a morbid alteration of structure." (p. 170.) When ulceration of the cartilages has taken place, striking the heel so as to jar the knee, or rubbing the ends of the bones together, though but slightly, causes severe pain, and if there be much destruction of cartilage, a grating sensation is conveyed along the leg to the surgeon's hand. "The progress of the ulceration of the cartilages," Brodie observes, "varies, with respect to time, in different cases; but it is generally tedious. In one case, where violent pain had existed in the knee, with little or no swelling, for two years and a half previous to amputation, I had," says he, "an opportunity cf examining the dis- eased joint, and found the cartilages destroyed for only a small extent; a drachm and a-half of pus in the articular cavity, and no morbid appearances of the soft parts, with the exception of a very slight inflammation which had been induced in the synovial membrane, and the effusion of a minute quantity of coagulable lymph into the cellular texture on its external surface." (pp. 171, 75.) Since the observations referring to ulceration of c milage, from pressure of adven- titious membrane, have passed through the press, I have had the opportunity of examining with the microscope, both the adventitious membrane and cartilage, in the case of a boy aged ten years, whose knee having been affected with disease for four years, was removed by the wish of his friends on the 17th of this month, (May, 1H 45.) In this case I saw distinctly the vascular loops in the adventitious membrane, already quoted (p. 258) from Goodsir's papers; and also the peculiar degeneration in the cartilage which my friend Rainey has described as follows :— " A vertical section through the joint on one side of the patella exposed adventi- tious membraneous structures, extending from the synovial membrane towards the interior of the joint, and lying against the articular cartilage, wrhich was excavated in such a manner as to have the exact form of the membrane in contact with it. These structures were of different forms and degrees of thickness in different parts of the joint, and always continuous with the synovial membrane. "In some parts of the joint, the articular cartilage of the femur, and that ofthe opposite part of the tibia, were completely destroyed, and the denuded osseous sur- faces of these bones, connected by a newly formed fibrous structure, which was sufficiently long to allow of considerable motion. The free surface of the articular cartilage was, in some parts, covered by a thin layer of membrane, which admitted easily of being detached, in other parts excavated, as before observed ; the opposite surface was either completely detached, or only loosely connected with the bone. Some abscesses communicated with the joint. "The microscopic examination of the membranous productions showed that they were vascular, the vessels forming loops towards the cartilage, which I have ob- served in other cases that have been better injected. But what seems most interest- ing is, that the absorption of the cartilage is preceded by its fatty degeneracy, diminishing in degree from its free surface to the one connected with the bone. " This degeneracy is first perceptible by the division of the nuclei of the cartilage cells into several minute spherical particles of oil. These particles increase as the 304 WHITE SWELLING. nuclei lose their natural appearance, and at length the cartilage cells become entirely filled with oily matter. Although the microscopic characters are sufficient to show the real nature of this matter, I acted upon it with aether, which took up a consider- able portion, and after evaporating, left it on the glass, thus confirming the informa- tion derived from the microscopic examination. The intercellular matter, some- times called hyaline, like the nuclei of the cells, becomes also converted into oil, the minute particles of which are arranged in irregular lines running in all direc- tions, and thus grooving and excavating the cartilage, they produce its gradual removal. " I am disposed to think that this mode of degeneracy of cartilage, by its recon- version into a substance more absorbable than itself, and less nitrogenized,—a kind of process exactly the reverse or counterpart of nutrition,—has not been observed by those who have written upon these diseases."—Geo. Rainey. In the scrofulous disease of the cancellated structure of the bones, Brodie says:— " Before it has extended to the other textures, and while there is still not evident swelling, the patient experiences some degree of pain, which, however, is not so severe as to occasion serious distress, and often is so slight, and takes place so gradually, that it is scarcely noticed." The patient is able to go about often for a long while, hence " the swelling, though usually more in degree than it is, at the same period, in those cases in which the ulceration of the cartilages occurs as a primary disease, is not greater in appearance, because the muscles of the limb are not equally wasted from want of exercise. In children the swelling is, in the first instance, usually less diffused, and somewhat firmer to the touch, than in the adult. * # * The swelling increases, but not uniformly, and it is greater after the limb has been much exercised, than when it has been allowed to be in a state of quietude." (pp. 251, 52.) " As the caries of the bones advances, inflammation takes place of the cellular membrane external to the joint. Serum, and afterwards coagulable lymph, is effused, and hence arises a puffy and elastic swelling in the early, and an oedema- tous swelling in the advanced stage of the disease. Abscess having formed in the joint, makes its way by ulceration through the ligaments and synovial membrane, and afterwards bursts externally, having caused the formation of numerous and circuitous sinuses in the neighbouring soft parts, (p. 246.) As the cartilages con- tinue to ulcerate, the pain becomes somewhat, but not materially aggravated. It i9 not severe till abscess has formed. * * * Tbe dirsease not unfrequently remains in this state for several months, or even for a much longer period, without the consti- tution being materially disturbed, (p. 252-54.) " When the disease occurs in those joints which are more superficially situated, as the knee and ankle," Brodie (a) says, "we may be further assisted in our dia- gnosis by observing the character of the swelling by which it is accompanied, and which is somewhat peculiar, especially in children, previous to the formation of abscess. It is then limited to the immediate vicinity of the affected part, and has a pretty well-defined margin. When the disease is in the knee, the child usually keeps the leg a good deal bent, and the condyles of the femur are seen projecting, of a somewhat globular form, and appearing as if they were actually enlarged, although we know them not enlarged in reality." (p. 202.) The principal dis- tinction between this form of disease and primary ulceration is the less degree of pain. In considering diseases of the knee-joint, it would seem improper to pass ovei without notice that which has been called White Swelling.—This term has been so long, and so generally, applied to s< vtral different diseases of the joints, that its real meaning has been almost entirely lost sight of, and it is now only applied, by unprofessional persons in this country, to swellings ofthe knee-joint, of long endurance and great obstinacy; and even by some continental writers, as, for instance, Velpeau, it has been made to include the whole class of disorders affecting both the soft and hard parts of joints, though he has chosen to designate them with the classical title Arthropathie, (diseases of joints,) which has been coined for the purpose, in preference to the other equally mystic name, Arthrite, (inflammation of joints.) Yet the term White Swelling, had a special signification, and designated an important and dangerous, though not malig- (a) Third Edition. WHITE SWELLING. 305 nant, disease, and, within a few years, its right to be distinguished as a peculiar form, has been asserted and proved by Nicolai of Berlin, who published, in Paris, a very clever thesis, entitled Memoire sur les Tumeurs blanches des Articulations; which he reprinted, in 1832, with little alteration, in Rust's Handbuch der Chirur- gie, in the article. Fungus Articulorum. I rather suspect he must have been well acquainted with Russell's Treatise on the Morbid System of the Knee-Joint, in which a very excellent account of white swelling is given; but he has gone more care- fully and extensively into the subject, as will be presently seen. '• There is, indeed, no country," says Russell, " in which white swelling more frequently occurs than in the island of Great Britain," (p. 53 :) a remark previously made by Gotz, who speaks of it as " ligamenta articulationis genu praesertim affi- oiens morbus Britannis prae caeteros communis." (p. 15.) Morgagni mentions its unfroquency in Italy; and it would seem rare at Vienna, and in many other parts of Germany, where scrofula is much less prevalent than in the colder climates of the north. Russell says it is called a White Swelling, " on account of the appearance of the complaint in its advanced stages, as the skin, in general, remains of its natural colour, however large the size may be which the swelling attains." Or it is named an In-come, in consequence of the slow and insidious approach of the attack, as the complaint often arises from insensible beginnings, and without any known cause. Russell's description of this disease is well worthy perusal, and if it be not a dis- tinct disease, which, at the onset, it seems to me to be, it more resembles the disease of the cellular membrane of joints above mentioned, (p. 234,) as de- scribed by Wickham, than any other; whilst at its termination it has more close connexion with the results of synovial inflammation. I shall first give Russell's ac- count of the appearances which the disease presents on dissection ; and, though his account ofthe symptoms are deserving attention, yet, on the whole, I think it rather preferable to give Nicolai's statement on the latter points, as being rather in accord- ance with the present notions of disease. The appearances on dissection " are," says Russell, " in general, sufficiently characteristic of the complaint. The great mass of the swelling appears to arise from an affection ofthe parts exterior to the cavity of the joint, and which, besides an enlargement of size, seems also to have undergone a material change of structure. There is a larger than natural proportion of a viscid fluid, intermixed with the cel- lular substance. And the cellular substance itself has become thicker, softer, and of a less firm consistence than in a state of health. Thus it approaches somewhat to the nature of a uniform pulpy mass, and by this means undulates when struck, so as to resemble the obscure fluctuation of a fluid, and, when gently and regularly pressed, applies accurately to all the little inequalities of the bone, presenting the appearance of a solid, permanent enlargement. The consistence of the swelling, indeed, varies considerably according to the duration of the complaint. When tbe swelling is recent, and has increased rapidly, the glutinous fluid is more liquid, and the cells which contain it more distinctly separated, so that the distinction between the fluid and solid parts is quite evident. But when the swelling is of an old date, and has grown by slow degrees, the whole of its substance becomes of a more homo- geneous consistence, very much resembling a mass of soft cartilage, in which no diversity of parts is easily discernible. In this state the substance is too solid to communicate to the touch any sensation similar to the fluctuation of a fluid. Ano- ther circumstance which prevents the perception of any such symptom in those old cases, is the change which the skin undergoes, as it becomes thicker, firmer, and more insensible, approaching somewhat to the appearance which the skin assumes in cases of elephantiasis. The capsular ligament would appear to undergo a material alteration in its structure very soon after the commencement ofthe attack. It loses the firmness of its texture, and, as the texture becomes looser, the thickness of sub- stance increases." Gotz says :—" Ipsa circa articulos ligamenta turgent ac tela quoque proxima ambiens infacta ostenditur, sic ut simul in densam, fungosam, quasi substantiam, mutentur." (p. 16.) "The external surface, too, in place of present- ing a bluish colour, with somewhat of a shining lustre, is more of a dead opaque white. But, in general, the most essential change is to be observed upon the inside ofthe ligament, which becomes covered with a layer of a soft substance, of a pale yellowish colour, and semi-transparent. This substance is often nearly one-eighth of an inch in thickness; it is commonly very soft on the inner concave surface, and 2G* 306 WHITE SWELLING. firmer on the outer convex part, where it adheres to the inside of the capsular liga- ment with a considerable degree of firmness. In many places there is a very beau- tiful plexus of vessels, and at the interstice, between the surfaces of the femur and tibia, an appendage full of blood-vessels, particularly at its edges, frequently in- sinuates itself to the distance of nearly half an inch. This layer of adventitious matter seems to be composed of a lymphatic exudation, and, in this respect, may not so far differ from the nature of the effusion which forms the external swelling. The greater number of vessels proves the existence of a certain state of inflamma- tion." (p. 30-3.) The following is Nicolai's account of Tumor Albus, as he calls this disease :— " The disease has three stages, and runs sometimes a chronic, and sometimes an acute course. In the first stage of the chronic form, pain is observed from the very commencement, increasing on every movement of the limb, and a sensation of wearisomeness, the joint, and these sensations wander from one place to another. Pressure does not increase, but rather diminishes, the pain, and, therefore, the pa- tient swathes the limb with a bandage. Motion of the diseased joint is difficult, and increases the pain and sensation of fatigue. The eolour of the skin is un- changed, nor is there any swelling, but the temperature is somewhat increased, and motion ofthe limb produces crepitation in the joint. The pain and sensation of weariness increases when the patient warms in bed, and destroys his sleep. After these symptoms have continued some weeks, and the girth of the joint has increased, the second stage sets in. The swelling ofthe joint is at first pale, free from pain, and most so where, at first, the pain was most severe ; it is soft, fungous, elastic, and somewhat hotter than the other parts. When pressed no pitting is produced, but merely a paleness on the skin. The swelling involves the greater part of the joint, and at last engages it completely; the skin appears shiny; the pain be- comes more severe; the movement of the limb difficult and painful (a) on account of the pain the patient bends the knee, and in this continued position the tendons becomes rigid, so that in the end both flexion and extension become impossible. The pain and tension are specially situated in the knee-cap ; therefore, in motion of the limb, the patient fixes it with his hands. The veins glimmer through the shining skin, the whole of which is bluish and reddish. If thejoint swell, the limb shrivels below it, so that at last it seems to consist only of skin and bone, and the skin is exceedingly loose. In the third stage some spots of skin become redder and projecting, the veins show more distinctly through, the skin here becomes thinner and softer, and fluctuation beneath is felt; the wasted lower part of the limb be- comes oedematous, and every part discharges, when opened by nature or art, a bloody, puriform, ichorous fluid. If the probe he introduced, the bone is felt carious, or deprived of periosteum, or the tendons and ligaments, and maybe moved in all directions. And now, under continued suppuration of the joint, the well- known general symptoms occur with fatal result. In the acute form a rheumatic fever not unfrequently precedes the swelling, with wandering pain in all the joints, and after a day or two, tbe pain and swelling fixes very decidedly in one joint, forming the commencement ofthe Tumor albus. The joint is red, swollen, and extremely painful, so that it cannot bear the least touch or movement; the skin is shining and burning; pressure diminishes the redness, but leaves no pit; fluctuation is some- times felt, which depends on much synovia. The pain becomes especially severe when the person is warm in bed. The swelling occupies the whole joint, and stretches to the neighbouring parts of the limb. After some days it acquires its greatest extent, and is often quite extraordinary; but the circumference of the bone is unchanged, and the pain is not deep-seated. When the fever has con- tinued some days, the fever diminishes, or entirely subsides; the swelling loses its rosy colour, does not diminish, but rather increases; is usually soft, pale, (and flabby, so timt the finger, when pressed on it, causes a pit. The heat and pain subside, and the swelling now becomes chronic, as if from acute rheumatism; such is the so-called acute rheumatic species of Tumor albus. The joints, rich in cellular tissue and aponeurotic parts, and the articular parts are especially attacked by this disease, which, in its subsequent eourse, becomes chronic. (a) Rust observes on this point: " The patient complains ofthe sinews being shortened, which is explicable by the ligaments and tendons in the neighbourhood of the joint having their motions interfered with, and being compressed by an immoderate deposit in the sellular tissue surrounding them."— Handbuch, p. 556. SPINE-DISEASE. 307 Anatomy of Tumor albus.—In the first stage of the disease, the soft parts of the joint, the cellular tissue which surrounds the tendons and ligaments are very full of blood, which is specially collected in the small vessels of the cellular tissue. The latter appears to be in large quantity; at least there is formed a yellowish white substance which coagulates, resembles lymph mixed with jelly, and is in largest quantity near the tendons and ligaments. (At the knee-joint, it appears first on the lateral and posterior, then on the anterior part; at the elbow, on the sides and behind; on the foot, at the sides ofthe ankle.) The deep parts of the joint seem little changed, only the periosteum and synovial membrane are redder, and have reddish dots and points; at some parts the synovial membrane is thicker, softer, and closely connected with the above-mentioned gelatinous mass. In the second stage, the Tumor albus contains, in the cellular tissue and around the tendons, a fibrous, thick, tough substance, not unlike lard, in which run white threads, con- necting the skin to the deep parts. The blood-vessels are less numerous than in the first stage; but injection shows that every white thread is only a large vessel, which on account of the thinness of its walls, rather resembles a vein; the arteries also may be distinguished, although, for the most part, they are obliterated. The lardaceous mass is softer than the integument and tendons, which parts, although covered with this substance, are perfectly healthy; a proof that the Tumor albus is situated only in the cellular tissue surrounding it. In some parts of this substance, especially in the neighbourhood of large vessels, blackish-red spots are found, which contain a softer, cheesy, livid matter. In the third stage, there is always found, beneath the skin, in the cellular tissue, a red bloody ichorous fluid ; the soft parts, skin and cellular tissue, easily melt, and are like jelly ; bones, tendons and ligaments are found covered with a white cheesy substance. The capsular membrane is soft, thickened, and grayish-red; in the cavity of the synovial membrane there is also found a cheesy gray matter, which sticks tightly to its walls. If there be ulcers, the bones are stripped of periosteum, rough, and covered with an ichorous pus-like matter. The ulcers form fistulas which pass in all directions, backwards and for- wards through the lardy mass to the bones and cartilages, are lined with a soft membrane, to and upon, which at different parts, large vessels proceed and ramify. The mass of vessels is in this stage less than the two former; the large veins and almost all the arteries are obliterated." (pp. 149-153.) 256. The prognosis and treatment are. determined by the different seat of the disease, according to the foregoing rules. IV.—1NFLAMMATION IN THE JOINTS OF THE VERTEBRAE. (Potfs Disease, Spondylarthrocace.) 257. This disease may take place in all parts of the spinal column, and its symptoms vary accordingly. Sometimes without any cause, sometimes after a fall or contusion, after catching cold, or after debility from masturbation, pain occurs in the spinal column, which is variable and indistinctly marked, and which increases and diminishes, without entirely subsiding. The spine does not present, upon examination, the least change. Pressure does not increase the pain. After a time, projection of one or more spinous processes is noticed ; the motions of the body are unsteady; the patient can still walk, but he soon tires; the pain increases, and fixes itself at the projecting part; movement of the feet becomes more difficult; they at last lose their sensibility, and become quite paralyzed ; at the same time there are symptoms of palsy of the bladder and rectum (1.) Ac- cording to the different seat of the disease on the lumbar or dorsal vertebra, the patient has distention of the belly, weight at the stomach, pain along the ribs, pain in the lower limbs, shortness of breath, attacks 308 SPINE-DISEASE — of suffocation, and symptoms of phthisis: finally, collections of pus appear under the crural arch, in the inguinal canal, in the neighbour- hood of the rectum, on the sides of the spine, and so on (2.) In such cases hectic fever soon destroys the powers of the patient. In rare cases, the collected pus makes its way inwards, into the belly, into a bowel, into the cavity ofthe chest, or into the lungs, as I have once seen. This disease is often, at first, unaccompanied by pain (3;) the spinous processes jut out, without the patient suspecting any disease at this place ; subsequently he complains of weight in the legs; they soon get tired, and suffer spasmodic contractions ; collections of pus form more rapidly. Often the spinous processes do not jut out, especially if the ulceration be spread over a large extent of the spine. In the dorsal and lumbar vertebrae, the curving ofthe spinal column usually occurs as an angular projection backwards; sometimes it also projects sideways, sometimes in that direction only, and in the most rare cases the projection is forwards (4.) [(1) Pott says :—" To this distemper both sexes and all ages are equally liable. # * * When it attacks an infant of only a year or two old, or under, the true cause of it is seldom discovered until some time after the effect has taken place, at least not by parents and nurses, who know not where to look for it. The child is said to be uncommonly backward in the use of his legs, or it is thought to have received some hurt in the birth. When it affects a child who is old enough to have already walked, and who has been able to walk, the loss of the use of his legs is gradual, though in general not very slow. He at first complains of being very soon tired, is languid, listless, and unwilling to move much, or at all briskly ; in no great length of time after this he may be observed frequently to trip and stumble, although there be no impediment in his way; and whenever he attempts to move briskly, be finds that his legs involuntarily cross each other, by which he is frequently thrown down, and that without stumbling: upon endeavouring to stand still and erect without support, even for a few minutes, his knees give way and bend forward. When the distemper is a little further advanced, it will be found that he cannot, without much difficulty and deliberation, direct either of his feet precisely to any exact point; and very soon after this both thighs and legs lose a good deal of their natural sensibility, and become perfectly useless for all the purposes of locomotion. When an adult is the patient, the progress of the distemper is much the same, but rather quicker, (p. 397-99.) * * * Without this erosive destruction of the bodies of the vertebrx there can be no curvature of the kind I am speaking of (curve forward;) or, in other words, that erosion is the sine qua non of this disease; and although there can be no true curve without caries, yet there is, and that not unfrequently, caries without curve. Also that the caries with curvature and useless limbs is most frequently of the cervical and dorsal vertebrae; the caries without curve, ofthe lumbal, though this is by no means constant or necessary. And that in the case of carious spine without curvature, it most frequently happens that internal abscess and collections of matter are formed, which matter makes its way outward, and appears in the hip, groin, or thigh; or being detained within the body, destroys the patient: the real and imme- diate cause of whose death is seldom known or even rightly guessed at, unless the dead body be examined. Further, that what are commonly called lumbal and psoas abscess, are not unfrequently produced in this, manner, and therefore, when we use these terms, we should be understood to mean only a description of the course which such matter has pursued in its way outward, or the place where it makes its ap- pearance externally. * * * And contrary to the general opinion, a caries of the spine is more frequently a cause than an effect of these abscesses." (pp. 472-74.) " After ulceration has gone to a certain extent," says Lawrence, " the spine bends forwards and becomes crooked; but the curvature which is thus produced essentially differs in its nature and direction from that of rickety affection of the spine; the curvature, in the present case, is always in the anterior direction, while in rachitis it is to one side." (p. 561.) Brodie, however, observes, " this rule must not be admitted without some exceptions. A slight degree of lateral curvature is, in som« SYMPTOMS. 309 instances, the consequence of caries, * * * by the bodies of the vertebrae having been destroyed on one side to a greater extent than on the other." (p. 311.) With regard to the so-called palsy of the limbs in this disorder, Pott remarks:— "I have, in compliance with custom, called the disease a palsy; but it should be observed that, notwithstanding the lower limbs be rendered almost or totally useless, yet there are some essential circumstances in which this affection differs from a common nervous palsy; the legs and thighs are rendered unfit for all purposes of locomotion, and do also lose much of their natural sensibility: but, notwithstanding this, they have neither the flabby feel, nor have they that seeming looseness at the joints, nor that total incapacity of resistance, which allows the latter to be twisted in almost all directions ; on tbe contrary, the joints have frequently a considerable degree of stiffness, particularly the ankles, by which stiffness the feet of children are generally pointed downwards, and they are prevented from setting them flat upon the ground." (p. 400.) (2) Brodie says:—" There is reason to believe that suppuration takes place at an earlier period in those cases in which the disease has its origin in the cancellous structure of the bones, than where it begins in the intervertebral cartilages. It is remarkable in some cases of this last description, to how great an extent ulceration will sometimes spread without the formation of abscess. I have known as many as three bodies of vertebrae completely destroyed, and the disease to have lasted many years, without matter having been formed. * * * We must not however conclude, because no abscess has shown itself, that therefore no abscess exists. Frequently, in examinations after death, we find an abscess in connexion with carious vertebrae, which had never presented itself externally, but which evidently had existed for a considerable length of time. It is not uncommon to find caries of the vertebrae going on for two or three years before there are any certain indications of the existence of abscess. In one case in which the disease was in the vertebrae of the loins, an abscess presented itself in the groin at the end of eight years; and in another case, in which the disease was situated in the dorsal vertebra;, the interval was still longer, not less than sixteen years." (pp. 253-54.) Brodie makes the following interesting observation on the disappearance and reappearance elsewhere of abscess, connected with carious spine: " I have known an abscess to have descended from the loins, and presented itself as a tumour in the groin. Suddenly the tumour disappeared, and the patient has been led to entertain hopes of a speedy recovery. But these have been soon disappointed, in consequence of the discovery of a large collection of matter in the posterior part of the limb, behind the little trochanter of the thigh. In a case of this kind, in which I had the opportunity of examining the morbid appearances after death, I found that the abscess had taken the course of the common tendon of the m. psoas magnus and iliacus intemus, to their insertion into the little trochanter, afterwards extending further backward, over the inferior edges of the m. quadratus femoris.'''' (pp. 260, 61.) (3) " The pain," says Brodie, " at first trifling, but afterwards more severe, is aggravated by any sudden motion of the spine; by percussion, or by a jar commu- nicated to it in any other way ; as by stamping on the ground, striking the foot accidentally against a stone, sneezing or coughing. In the advanced stage of the disease the pain is sometimes so severe, and so easily induced that the patient cannot bear the slightest movement. Yet in other cases there is sometimes no pain what- ever in the spine, from the first access of the disease to its termination;" of which he mentions one remarkable case, "in which, judging from the degree of distortion, I was," says he, " satisfied that the bodies of not fewer than four or five of the dorsal vertebrae must have been destroyed, and that the disease had been going on for several years; yet he had never been known to complain of pain; and the first cir- cumstance which attracted the attention of the parents was the angular projection of the spinous processes. This patient ultimately died ; and, on examining the body after death, a large abscess was discovered lying on the surface of the carious vertebrae. In another case, in which the disease was supposed to have been cured, and the patient had not experienced pain for the two or three preceding years, on examining the appearances after death, I found the bodies of the vertebrae still in a state of caries, and an abscess, containing not less than half-a-pint of matter, connected with them." (p. 250.) (4) "When the spine is incurvated forwards," observes Brodie, "in conse- 310 SPINE-DISEASE—PATHOLOGY, quence ofthe destruction ofthe bodies ofthe dorsal vertebrae, the angular projection behind is more distinct than it ever is where the disease has attacked the vertebra; of the neck or loins. This is to be attributed to the greater length of the spinous processes in this part of the spine, and to the circumstance of their being, in the ordinary position of the parts, inclined more or less downwards. When the curva- ture is considerable the thorax becomes at the same time altered in figure. The diameter of the thorax, from above downwards, is rendered shorter, while the other diameters are increased ; so that, while the figure of the chest is altered, there is but little difference in its actual capacity." (p. 257.)] 258. On examination after death, one or several of the bodies of the vertebrae are found destroyed by caries; the neighbouring vertebra are eaten away and crushed together in front, so that tbe spinous pro- cesses project. A sac is formed of the apparatus ligamentorum anticus, cellular tissue, and so on, at the part where the vertebra are destroyed, which contains a purulent cheesy mass, and from which openings lead into the external abscesses; in these sacs loose pieces of bone often lie. The bones are often converted into a spongy mass, which yields to the knife. Sometimes the inter-articular cartilages especially are attacked, loosened up, and destroyed. Circumscribed deep holes are often found in the bodies of the vertebrae, filled with cheesy matter, and which I hold, with Delpech and others, to be tubercles (1). The area of the spinal canal is generally undiminished; sometimes, however, it is so, and there are traces of chronic inflammation, redness, thickening or softening of the spinal marrow, of its membranes, and of the nerves passing through them. These examinations show that the disease occurs sometimes as a primary affection of the cartilages and ligamenls, sometimes as a primary affection of the spongy substance of the bones themselves. (1) Nichet (a) has endeavoured to prove this view of the disease by numerous examinations. On the other hand, J.eger (b) believes that these supposed tubercles are merely the modification of pus in the bony cells and beneath the periosteum, or inflamed and suppurating lymphatic glands on the spinal column. [The pathological history of caries of the spine is thus briefly recapitulated by Brodie: (c)—"In some instances it has its origin in that peculiar, softened, and otherwise altered condition of the bodies of the vertebrae, the appearance of which, in the bones belonging to other joints, and which seems to be connected with what is called a scrofulous state of constitution. In these cases ulceration may begin on any part of the surface, or even in the centre of the bone; but, in general, the first effects of it are perceptible when the intervertebral cartilage is connected with it, and in the intervertebral cartilage itself. In other cases, the vertebras retain their natural texture and hardness, and the first indication of the disease is ulceration of one or more of the intervertebral cartilages, and of the surfaces of bone with which they are connected." (p. 243.) In reference to this point Key (d) observes:—" In scrofulous ulceration, the intervertebral substance is not unfrequently the part in which the degeneration begins; large masses of the fibro-cartilaginous structure de- generate and disappear, cavities containing pus are found in its substance, and the broken down fibres surrounding the walls of the abscess sufficiently attest the nature and progress ofthe action." (p. 140.) On the other hand, according to Lawrence, " this disease attacks only the bodies of the vertebrae, that is, it attacks that part of the bony structure of the spinal column which is its most frequent seat in other parts of the skeleton, the cancellous or spongy part. The processes of the vertebra:, which are composed of firm or compact bony tissue, it does not attack." (p. 561.) " There is still another order of cases," says Brodie ; " but these are of more rare occurrence, in which the bodies of the vertebrae are affected with chronic inflamma- tion, of which ulceration of the intervertebral cartilages is the consequence. In (a) Gazette Medicale, 1835, Nos. 34, 35. (b) Handworterbuch, vol. i. p. 572. (c) Third edition. (d) Med.-Chir. Trans., vol. xix. TREATMENT. 311 which ever of these ways the disease begins, if not checked in its progress, it pro- ceeds to the destruction of the bodies of the vertebrae and intervertebral cartilages, leaving the posterior parts of the vertebrae unaffected by it; the necessary conse- quence of which is an incurvation of the spine forwards, and a projection of the spinous processes posteriorly. At this period of the disease, the membranes ofthe spinal cord sometimes become affected with a chronic inflammation, which may extend even to the spinal cord itself; and when there is much incurvation, the latter not only becomes incurvated with it, but actually compressed in such a manner as cannot fail to interfere with the due performance of its functions. "Suppuration sometimes takes place at a very early period; at other times, not until the disease has made considerable progress. The soft parts in the neighbour- hood ofthe abscess become thickened and consolidated, forming a thick capsule, in which the abscess is sometimes retained for several successive years, but from which it ultimately makes its way to the surface, presenting itself in one or another situa- tion, according to circumstances. "In the advanced stage of the disease, new bone is often deposited in irregular masses on the surface of the bodies of the neighbouring vertebrae; and when recovery takes place, the carious surface of the vertebrae above coming in contact with that of the vertebrae below, they become united with each other, at first by soft substance, afterwards by bony anchylosis. The disposition to anchylosis is not the same under all circumstances ; it is much less where the bones are affected by scrofula, than where they retain their natural texture and hardness; and this explains wherefore, in the former class of cases, a cure is effected with more difficulty than in the latter. "Occasionally portions of the ulcerated or carious bone lose their vitality, and, having become detached, are found lying loose in the cavity of the abscess. It is scarcely necessary to add, that the existence of such exfoliations is, of itself, almost sufficient to preclude all chance ofthe patient's recovery." (pp. 243-45.)] 259. The causes of this disease are scrofula, masturbation, rheuma- tism, gout, external violence. Where the complaint arises more from scrofula, it seems to originate as a primary disease of the bone; if, on the contrary, from gout, external injury, and so on, the cartilages and ligaments rather are attacked. 260. The stealthy progress of the disease must render the medical attendant very cautious in his diagnosis. Every thing depends upon attacking the disease at the onset. If once displacement have happened, the most fortunate result is that the swelling of the parts should diminish, and the pressure on the nerves springing from the spinal marrow be removed. If abscesses have already taken place, the prognosis is always very unfavourable; if left alone, symptoms of hectic consump- tion come on, when they burst, and the patient quickly sinks; or they contract to fistulous openings, discharge but little serous or purulent fluid, and the patient lives a long time in a miserable condition. Very commonly no treatment can prevent this melancholy result. The practitioner must be exceedingly careful with little children who do not yet walk, because in them the most important diagnostic character is deficient. To determine more precisely the seat of the disease, various distin- guishing signs have been given. According to Copeland, great sensi- bility ofthe diseased vertebrae on external pressure, and on rubbing down with a sponge dipped in hot water. According to Wenzel, the pain should be increased by pressure with both hands upon the shoulders acting on the parts beneath, or on the application of volatile irritants, especially caustic ammonia. According to Stiebel, the situation of the disease is more distinctly shown in a warm-bath with potash. But 312 SPINE-DISEASE all these methods of proof give no decided result; and I have observed, on the contrary, many cases in which, as the result proved, no spondy- larthrocace was present, although it had been indicated by these tests. (Melker) (a.) I consider especially important in the diagnosis of this disease, the peculiar carriage of the body which often precedes, but always accompanies, weakness of the lower limbs. The knees of the patient in standing are somewhat bent, and the head inclined backwards, so that the neck sinks between the shoulders; in walking, the arms are bent at the elbow-joint and hold to the trunk; the patient always seeks after a resting place with his hands, places them upon the hips, and in stooping, upon the thighs; in bed he can turn only with difficulty, and very commonly sweats at night. This disease is clearly distinguished from the curvature depending on rickets or improper action of the mus- cles, though it may be connected with them. In adults the disease is more dangerous than in children. In children whose head and the upper part of whose body are very heavy, there often appears, when they first begin to walk, a bending ofthe spine and a weakness of the legs, so that they draw them back at every attempt to place themselves erect. This condition, which depends on weakness of the muscles of the back and the weight of the head, may be, as I have frequently seen, mistaken for spondylarthro- cace. Careful observation ofthe condition ofthe body, examination ofthe spine in the prone position, and the projecting curve which the spine forms in sitting and standing, easily determine the diagnosis. [The distinction between curvature of the spine from caries,and that from rickets, is very well marked, and the two can rarely be mistaken. In caries, the spine is always bent forwards, and, having usually a sharp abrupt form, is called the angu- lar curvature, or- from its direction, the anterior curvature ; and there is rarely, if ever more than one curvature of this kind. But in rickets, as Lawrence well ob- serves, "you never find a single turn, only in the vertebral column. If the vertebrae were weakened in the loins, so that the column would bend towards the right side, that must necessarily be followed by a bending of the spine higher up towards the left side, in order to preserve the line of gravity of the body. If the vertebral column wrere to bend altogether towards the right side, the weight of the head and upper parts of the body could not be supported at all. Thus one curvature in the bones of the spine necessarily induces a deviation in'another part. You sometimes find that you have two, three, or more of these curves ; the effect of one compensates for the other; so that, however great the curvatures may be, the weight of the upper part of the body still falls upon the pelvis and lower extremities. The curvature, which takes place in consequence of this condition of the spinal column, is on one side, and is commonly called the lateral curvature of the spine, from the circumstance that the incurvations are all of them towards the side; so that sometimes the spine exhibits, under these circumstances, very much the form of the letter S, instead ofthe natural upright appearance. This is an affection which takes place in young persons. It occurs during the period that the body is growing, and at the time of puberty; when the frame acquires its full strength and solidity, the bones become firm and strong, they lose their softened or rickety state; they, however, are not natural in their i'orm, and consequently the figure remains permanently deformed." (pp. 533, 34.) In rare cases, however, curvature forwards ofthe spine also occurs from "a weak con- dition of the muscles, or a rickety affection of the bones," and upon such examples Brodie observes:—"In general, in such cases, the curvature occupies the whole spine, which assumes the form of the segment of a circle. At other times, how- ever, it occupies only a portion of the spine, usually that which is formed by the superior and inferior dorsal vertebrae; as I have ascertained, not only by examina- tions during life, but by dissection after death. Here the curvature is always gra- dual ; never angular, and thus it may be distinguished from the curvature as arising from caries. Nevertheless, I am satisfied that these different kinds of curvature, arising from different causes, have frequently been confounded with each other; and (a) Diss, de Medullce Spinalis Erethismo. Francof., 1838. TREATMENT OF THE SPINE DISEASE. 313 that some of the cases which have been published as examples of caries in the spine, and in which it may, at first, be a matter of surprise that so complete and so speedy a cure has been effected, have in reality been cases of an entirely different malady." (p. 253.) Brodie refers to some excellent observations of Henry Earle (a) on this subject. Brodie states that, " as the disease advances the patient, in some instances, com- plains of pains, which are referred to one groin and hip, such as may lead to the suspicion that there is disease in the hip-joint; and, in fact, a very common error (and one into which even surgeons of great experience are liable to fall) is to regard the symptoms of caries of the middle and inferior dorsal vertebrae as indicating in- cipient caries ofthe hip." (p* 285.)] 261. The treatment must be conducted in reference to the previous rules. At the onset, according to the constitution of the patient, leeches, cupping, and internal remedies adapted to the general cause of the disease must be employed. In traumatic inflammation of the spine, cold applications, with suitable antiphlogistic treatment, must be used from the beginning. When the inflammatory symptoms have been, in this.way, diminished, rubbing in mercurial ointment and (in scrofulous persons) iodine ointment, are exceedingly serviceable ; but the most important are continual derivations, most conveniently made by several issues of caustic placed on both sides of the diseased part of the spine (1,) or by several suitable long streaks with the actual cautery. If im- provement take place, and the weakness of the lower limbs cease, the issues must nevertheless be kept open for a long time. In sluggishness of the bowels, attention must be paid to regulating the motions; in failing ofthe powers, they must be supported by bark and proper diete- tic treatment; and in retention of urine from weakness ofthe bladder, care must be taken to empty it with the catheter. An attempt to remove the deformity of the spine by machinery, and the like, shows an entire misunderstanding of the disease, but is necessary, both on account of resting the diseased part, as well as to prevent further sinking down of the spinal column, to preserve strictly the horizontal position on the back or belly during the whole treatment (2.) When abscesses are formed, they must, if not very large, be left alone ; if the caries of the vertebrae be brought to heal by the application of powerful derivatives, these abscesses often disperse of themselves by the pus in them being ab- sorbed and their walls contracting to a cord ; in rare cases, the pus con- tained in them may be changed into a mass like adipocere. (Dupuy- treiv) (b). If these abscesses be very large and threaten to break, they must be opened by a single thrust of a lancet, emptied of the pus by equable pressure without permitting the entrance of the air, and the opening carefully closed with sticking-plaster. The edges of the open- ing soon unite, and the emptying of the swelling, if the re-collection of the pus should make it necessary, is to be repeated in the same way (3.) Compare B. St. Hilaire (c) upon the symptomatic abscesses which accompany caries of the vertebrae, and upon the possibility of being able to determine anatomi- cally, from the external seat of these depositions of pus, the diseased vertebras. [(1) In regard to the fact "some cases occur in which the caustic issues seem to be productive of little or no benefit." Brodie observes, " probably it is with diseases ofthe vertebral as it is with those ofthe other joints, and issues may be of little or (a) Edinburgh Medical Journal, Jan. 1815. (b) Lecons Orales de Clinique Chirurgicale, Paris, 183?, p. 138. (c) Journal Hebdomadaire, 1834, Decembre. Vol. i.—27 314 SPINE-DISEASE. ao efficacy where the ulceration of the cartilages is preceded by a scrofulous dis- ease of the cancellous structure of the bones; and they may be productive of real benefit where it takes place under other circumstances. Nor, if my observations on the subject be well founded, is this to be regarded as a merely theoretical opinion. I have repeatedly known the greatest relief to follow the establishment of issues where the patient has suffered severe pain in the situation of the carious vertebrae, presenting, at the same time, no distinct indications of a scrofulous diathesis; while in young persons, with fair complexion and dilated pupils, in whom the disease ha9 proceeded with little or no pain, they have appeared to be either inefficacious or actually injurious. It appears to me, also, that, in caries of the spine, as well as in that of other joints, issues are to be employed only in the early stages of the disease with a view to prevent suppuration, and that they are of no service after abscess has actually formed." (p. 268.) With great deference to so high authority as Brodie, I cannot agree to the opinon last mentioned, a9 I am quite sure that I have several times seen issues extremely useful after suppuration has taken place, so that, under their employment, the irritation which has given rise to the abscess has subsided, and the disease cured. (2) "The mode in which the disease becomes cured is," says Astley Cooper, "by the upper portions of the vertebrae falling on the lower, and, in this way, anchy- losing. This must be your object in the treatment of this disease. You should keep the spine of the child as much as possible at rest; with this view he should be constantly in the recumbent posture, so that the vertebrae may be suffered to fall into contact, and, by coalescing, effect anchylosis. If you attempt to keep the spine straight, you will defeat the object of nature; do not keep the patient in a direct straight line, but rather assist nature in producing the union of the vertebrae. * * * If the child cannot be kept at rest, if the parents are unable or refuse to observe these instructions, the next best treatment will be to apply one of Callow's backs, which is worn upon the spine, and fixed round the pelvis and shoulders. As to avoiding deformity, that is out of the question; in all these cases deformity is in- evitable : whatever you do, this cannot be prevented." (p. 459.) "The incurvation forwards," says Lawrence, "is necessary to fill up the de- ficiency produced by the ulcerative absorption. The bodies of those vertebras which have been partially destroyed cannot be restored, for, as the spine bends forwards, the upper part comes in contact with the inferior, and an imperfect kind of anchy- losis ensues; some additional bony matter is thrown out, which attaches the two ends of the chasm, consolidates them together, as we might say, gives a sufficient degree of solidity to the parts, and enables them to sustain the weight of the body above, and to admit of the ordinary motions of the spine. The curvature, therefore, here, is really only a necessary part of the curative process. The disease cannot be brought to an end with preservation of the straight figure of the spine where it has gone to a certain extent; nor when the curvature has once taken place, will any attempt to restore it succeed." (p. 562.) " From the first moment," says Brodie, " in which the nature of the case is clearly indicated, the patient should abandon his usual habits and be confined altogether to his bed or couch. In some instances in which severe pain in the ver- tebrae is among the early symptoms of the disease, the patient will submit to the privations which are thus imposed upon him with sufficient willingness, while in others nothing but a candid exposition ofthe ill consequences which may otherwise arise will overcome his reluctance to do so. The invalid bedstead, contrived by Mr. Earle, will, in ordinary cases, afford the most convenient means of eonducting this part ofthe treatment. The use of it is attended with this great advantage, that the patient may be laid on his back, and the trunk and thighs may be, from time to time, and within moderate limits, elevated or depressed, so that their relative posi- tion maybe varied without the smallest movement being communicated to the carious vertebras. Where, however, the disease has been going on for a long time, and there exists already a considerable angular curvature of the spine, it is desirable that the patient should recline on his side rather than on his back; or if he finds this in any way inconvenient or disagreeable, he should lie, not on an absolutely flat surface, but supported by cushions and pillows, so that the position in which he is placed may have no tendency to restore the spine to its original figure. In the manage- ment of these cases it is important that we should always hear in mind, that with- out undue interference on the part of the surgeon, the carious or ulcerated surface IN THE NECK. 315 of the vertebrae above will come in contact with that of the vertebrae below; and that it is to the union which takes place between them under these circumstances, at first by soft substance and afterwards by bony anchylosis, that we are to look for the patient's recovery. In artificial straightening or elongating the incurvated spine, we necessarily disturb this curative process, and therefore all attempts to do so, whether by machinery or by laying the patient in the supine posture on a horizontal board, are to be scrupulously avoided." (pp. 265, 66.) (3) |Abscesses connected with disease of the spine so commonly terminate in psoas or lumbar abscess, that what has been already mentioned in relation to those disorders sufficiently applies here, and, therefore, does not need repetition.— j. f. s.] 262. In a similar way to that in the dorsal and lumbar vertebrae does the diseased condition come on in the cervical vertebrae, and most com- monly between the head and the first, or the first and second vertebra, and in the synchondrosis sacro-iliaca. In the former case the disease commences with a painful affection of the neck, which is increased at night, in damp weather, in swallowing large morsels, and even on deep inspiration (1), but may be diminished, or often apparently removed, by volatile rubbing and blistering. The uneasiness, however, soon returns; bending the head towards the shoulders is painful, and a drawing pain extends from the larynx into the nape, and even to the shoulder-blade. No change is to be perceived in the nape ; but pres- sure with the finger at the union of the first and second vertebrae pro- duces severe pain. Swallowing and breathing are painful, the voice is hoarse, the pain is concentrated at the back of the head, and on every one of its movements is intolerable. The head at last drops on the shoulder opposite the disease, in which position the patient keeps it fixed. Symptoms of general illness in different degrees are present. After a short seeming improvement the pain returns more severely, and the patient has the sensation ofthe head being enclosed with a cord. It sinks at last in the opposite direction, and the patient endeavours to keep in the same posture on account of the severe pain. Noise in the ears, deafness, giddiness, convulsions, partial paralysis, especially of the upper limbs, loss of voice, all the symptoms of hectic fever occur, and death often suddenly takes place. Fistulous openings in the neck are rare (2). Generally there is not any external diseased indication in the neck, except that the patient cannot bear the least pressure. [(1) Brodie says this pain "is not unfrequently mistaken for the muscular pains and stiffness connected with what is commonly called a stiffness from cold. The pain gradually increases; and, according to my experience, is more liable to be severe than when the seat of the disease is in the lower part of the spine. * * * At an early period the patient frequently complains of pains in the arms and shoulders. After some time these pains subside, but they are followed by complete paralysis of the upper extremities; while the muscles which derive their nervous influence from the spinal cord below the neck, remain subject to the will. In a still more advanced stage ofthe disease, the paralysis extends to the muscles of the trunk, and of the lower extremities. Then there are pains in the abdomen, which becomes distended and tympanitic; the bowels being, at the same time, obstinately costive. In all cases there is pain in the occiput and temples; which is, however, most severe, when the disease is situated in the two or three superior vertebrae.'''' (p. 255.) Astley Cooper says, that " when the disease is in the neck, the head is the only part ofthe body, except the vital organs, which retains its power; volition is lost in all the parts of the body below the seat of the disease, and the patient is reduced to the most abject state of helplessness." (p. 458.) (2) Abscess connected with diseased cervical vertebrae,'1'' Brodie observes, " usually 316 SPINE-DISEASE. presents itself among the muscles on the side of the neck. Occasionally it makes its way forward, forming a tumour, and afterwards breaking, in the pharynx. I have seen one instance," says he, " in which the abscess penetrated into the theca vertebralis and the whole spinal cord, from its origin to its termination, was bathed in pus." (p, 355.)] 263. Dissection shows the periosteum and joint-ligaments ofthe atlas and axis destroyed, carious destruction on the occipital condyles on the atlas, and on the odontoid process of the axis ; suppuration among the neighbouring soft parts; sometimes blood poured out from the diseased vertebral artery ; pus in the cavity of the chest, or diseased changes of the membranes and substance of the spinal marrow and brain. 264. In the spondylarthrocace sacralis, if the disease first appear as inflammation and ulceration of the synchondrosis sacro-iliaca, occurring after mechanical violence on the rump-bone, after raising a heavy weight, after difficult delivery, or after previous rheumatic affection, there is a fixed pain near the rump-bone which is very severe on standing up- right : the patient, therefore, usually lies, or sits as little as possible ; his walk is very difficult, limping, painful; the position of the back stiff, which is lessened in moving ; the pain frequently extends through the buttock, in the course ofthe ischiatic nerve or the foot towards the groin. Pressure upon the synchondrosis sacra-itiaca, and upon the rump bone, is painful; frequently the region ofthe affected joint is swollen. The ex- tremity of the diseased side is often stiffened, and cannot be moved without the most severe pain- The inflammation is often great, espe^ cially after child-birth and severe injury, and is accompanied with con- siderable fever. I have observed this condition in both joints of the rump-bone at the same time, after difficult labour, in which walking was in the highest degree painful, and resembled an alternate dropping from one foot to the other. Palsy ofthe lower limbs and ofthe rectum is rarely observed. Abscesses may appear either externally on the synchondrosis, or in the neighbourhood of the rectum. 265. As to the etiology and treatment of this disease, all applies which has been hitherto mentioned. The same conditions which have been here described in various joints, may also arise, in a similar manner, in all the other joints,—-those of the foot, hand, and elbow,, and require the same treatment. [ 317 ] SECOND DIVISION DISEASES WHICH RESULT FROM THE DISTURBANCE OF PHYSICAL CONTINUITY. I.—SOLUTION OF CONTINUITY. A.—RECENT SOLUTION OF CONTINUITY. a.—Of Wounds. First Chapter.—OF WOUNDS IN GENERAL. Bell, John, A Discourse on the Nature and Cure of Wounds. 3d Edit Edinburgh, 1812. van Gesscher, Abhandlung von den Wunden. Translated from the Dutch bv Loffler. 2d Edit. Leipz., 1802. 8vo. Ecker, A., Beantwortung der Priesfrage : Welche Ursachen konnen eine geringe, durch scharfe und stumpfe Werkzenge verusachte Wunde gefahrlich oder todtlich machen. Wien, 1794. Lombard, C. A. Clinique Chirurgicale des Plaies faites par Armes a feu. Lvon an xii. 1804. 8vo. Zang, C. B., Wurdigung der KERN'schen Methode, Wunden zu behandeln. Wien, 1810. 8vo. Roux, Memoire sur la Reunion Immediate. Paris, 1814. 8vo. Pauli, F., Commentatio Physiologico-Chirurgica de Vulneribus sanandis Goetting., 1825. 4to.; cum tab. sen. ii. Serre, De la Reunion Immediate et de son influence sur les Progres recens de la Chirurgie dans toutes les Operations. Paris, 1830. Dupuytren, Traite theorique et pratique des Blessures par armes de guerre; publie sous ses yeux par Manx et Vaillard. Paris, 1834. Sanson, L. J., De la Reunion Immediate des plaies. Paris, 1834. Travers, Benj., The Physiology of Inflammation and the Healing- Process. London, 1841. 8vo. Jones, Wharton, Report on the changes in the Blood in Inflammation, and on the nature of the Healing Process; in British and Foreign Medical Review, vol xviii. July, 1844. 266. Every sudden division of organic parts produced by mechanical violence, and at first accompanied with more or less bleeding, is called a Wound (Vulnus, Lat. ; Wunde, Germ. ; Plaie, Fr.) 267. Wounds are differently divided, according to the instruments by which they have been produced, according to the condition of the wounded part, according to their form and direction, and according to their seat. 268. Wounds are distinguished according to the instruments by which they are caused; thus Incised and Punctured Wounds (Schnitt, Hied (1,) und Stichwunden Germ. ; Plaies par instrumens tranchans, contondans, et piquans, Fr.:) when the division is made by sharp, cutting, or penetrating instruments. Contused or Lacerated Wounds (gequetschte und gerissme 27* 318 DIVISION OF WOUNDS. Wunden, Germ.; Plaies contuses et dechirees, Fr.) when the parts are di- vided by blunt instruments, or when they have suffered severe tearing and stretching before giving way. Every division by cut or stab is accompanied with some contusion of the part; but the finer the edge and, point of the wounding instrument are, and the more they have acted by being drawn along, the less is the amount of contusion ; therefore cut and thrust wounds are at the same time contused, if the instrument producing them have not the proper degree of thinness and sharpness. [(1) German surgeons make a distinction of incised wounds which we do not commonly use. The Schaittwunde is made by drawing a cutting instrument along the part, which is thus divided ; our ordinary expression, a cut, or the phrase, the part has been cut, is equivalent to it. The term Hiebwunde implies a wound made by an axe or sabre struck into or through a part, and answers to our word, a chop, or the part has been chopped. The cut (Schnittwunde) implies the division of a part with the least possible injury. The cbop (Hiebwunde) may, on the one hand, be effected with as little injury as. the cut; but on the other, it may be aeeompanied with slight bruising, but sufficient, strictly, to put it among the most simple kind of contused wounds.—j. f. s.] 269. According to the condition of the divided parts, wounds are distinguished as simple and complicated.. Simple wounds are those in which the parts suffer no other injury beyond their division, and require only the junction of the. edges for their union. Complicated wounds, are those in which there is something wrong in the wounded parts, or in the constitution, which requires modifications ofthe treatment of simple wounds. The complications are very various, as depending on many accidental circumstances ; viz., bruising, bad form of wound, bleeding, discharge, or effusion of various fluids, loss of substance, the presence of foreign bodies in the wound, which act either merely mechanically, or have a special deleterious, influence on the whole organism, poisoned wounds. Wounds may, in their course, be accompanied with active fever, nervous symptoms, and so on. 270. According to the various direction and depth ofthe division, they are distinguished into longitudinal, transverse, oblique, superficial, deep, penetrating, and flapped wounds. According to the difference of the wounded parts, wounds are gene- rally divided into those of the skin and cellular tissue, of the muscles, of the tendons, of the vessels, of the nerves, of the viscera contained in cavities, ofthe bones ; and, according to situation, wounds ofthe head, neck, breast, belly, limbs, and so on. 271. The symptoms of wounds are pain, bleeding, separation, or gaping of the edges of the wound, inflammation, fever, and nervous symptoms. The pain at first depends upon the injury of the nerves, and afterwards on inflammation. It varies according to the kind of division, and the sensibility of the part and person. The bleeding is more or less abundant according to the size and num- b.er of the divided vessels, and is always greater in cut than in bruised or torn wounds. The gaping ofthe edges ofthe wound at the very first depends on the entrance of the wounding instrument, but especially on the elasticity and eontractility of the parts, and is greater the more the parts were stretched at the moment when the wound was made, or the more they were irri- tated during, or after the wound. MODE OF CURE. 319 The division itself, and the admission of the air to the exposed parts, excite a general reaction, and increased flow of blood,—inflammation, hence swelling, redness, dryness of the wound, and increased pain. According to the severity of the wound, the constitution of the patient, and the sensibility of the wounded part, is the reaction more or less great; and in proportion to these circumstances does the Sympathetic Fever (Febris traumatica, Febris inflammatoria secundaria, Lat.; Wand* fieber, Germ.) come on in direct relation to the inflammation of the wound. The inflammation either only attains the degree of adhesive inflammation, and passes on, if the wounded parts be kept in close con- tact, to resolution and adhesion ; or, if the inflammation be greater, or if the parts cannot be united, it proceeds to suppuration and, under par- ticular circumstances, even to mortification. The inflammation may have either a simple, erethetic, or torpid character, according to the difference of constitution and other circumstances. Just so does the nature of the fever differ according to the constitution of the patient, according to the prevailing character of the disease, and so on ; and it may even show an intermitting type. The nervous symptoms accompanying wounds are, severe pain, which is not proportioned to the inflammation in the wound, restlessness, loss of sleep, delirium, convulsions, trismus, tetanus, and so on. The causes of these symptoms are morbidly increased sensibility ofthe whole body or ofthe wounded part, wounds of nerves, aponeuroses, and tendinous parts, tying of nerves with vessels, foreign bodies or accumulated and bad pus in the wound, foul, damp, and cold air, sudden chills, great loss of blood, sympathetic irritation, especially in the bowels and so on. 272. The cure of wounds is effected in two ways :— Hunter, Meckel (a,) and others speak of three kinds of union of divided parts; viz., by the quick union, by adhesion, and by granulation. In the quick union blood is poured out between the two divided surfaces; this coagulates, separates into its constituent parts, applies itself to the divided surfaces, and from this moment the union commences. The blood dries on the surface, forming a scab which covers the surface of the wound ; and from the blood remaining beneath it the new parts are formed, the red parts being absorbed, and the coagulable lymph, from which the organs are formed, remaining. This union by coagulable fluid is effected without any increased activity of the blood-vessels, as the connecting medium is here poured out with the blood. If this, however, do not take place in consequence of the blood, by contact with the external air, having either lost its vitality, or at least its capability of becoming organized, and, if the separation have existed so long that the open mouths of the divided vessels are closed, then inflammation takes place; coagulable lymph oozes either from the half-open mouths ofthe divided vessels or out of the cellular tissue, coagulates, and in it are developed the connecting vessels. The quick union takes place even when the parts, on account of the blood poured out between them, do not directly touch; in which case the superfluous blood is absorbed, the swelling diminishes, and the new vessels spread from the coagulable lymph and surrounding parts into the unabsorbed blood", of which the red part at last dis- appears. In every cure by the first union there is always, at first, a layer of coagu- lated lymph upon each divided surface, and between these two sometimes a layer of blood, forming a middle layer. The union of bone, according to Meckel, takes place in the same manner; the out-poured blood being, in this case also, the base of the union, the red part is absorbed, and the remainder converted into gelatin. Meckel, however, adds, that the vessels also themselves seem to pour out the di- rect material of union and reparation, their tonicity being altered. This view of the process of quick union does not, however, agree with experience, (a) Handbuch der pathologischen Anatomie, vol. ii. part ii. p. 4 natural. It is a property in flexi- ble bodies to have their diameters contracted as they are lengthened ; in arteries this might be carried to a great degree when permanent effects are to be produced. It is necessary that they should be lengthened so much as to destroy the contractile power; for this is the way Nature takes to stop the bleeding of ruptured vessels. [a) Galkn (Meth. Medic, lib. v. cap. iii. (d) Hecker's Annalen. vol. xv. p. 185— p. 318. Edit. KOhn) says on this point: 196. Fob. 1830, Kti 3-cti§< ?a?4i " a5T*f* **■ f**TdL &l T*wrtt (e) Schrader-, Dissert, de Torsione Arte- l-i-Trxifi-t ayKtvpu xytttumait* k*i Tri^vT^tQiTm riarum. Berol., 1830. 8vo.—Velpeau, Me- pttttot. moire sur la Cessation spontanee des He- (o) Archives Generates de Medecine, vol. morrhagies traumatiqnes et les moyens, qui «. Aug. 1829. p. 606. dans quelques cas pourraient servir des (c) Dc la Torsion des Aiteres. Paris, succedanes a la ligature des arreres; in the 1829. Gazette Medicale, vol. i. No. 48. Nov. 1830 . (/) Lectures ; Palmer's Edition. 29* 342 TORSION OF ARTERIES. Thus we see that arteries which are lacerated will more readily stop bleeding than if cut with a sharp instrument, as was proved in the case of the miller related by Cheselden, and this is the way nature takes to stop the bleeding ofthe navel string in beasts. Surgeons do not take advantage of this ; but farriers and gelders do, as their practice of tearing the artery through, in gelding animals, shows." Upon this Palmer observes (a):—The principle of torsion, as practised by several of the French surgeons, is precisely the same as that which is here laid down in respect of lacerated arteries; that is, the extremity of the artery is drawn to a point, and does not return to its original calibre, in consequence of the destruction of its elasticity. We may also further add, that the rupture of the internal and middle tunics, which generally happens on these occasions, will tend to occlude the mouths of the vessels still more completely by entangling the blood among the lacerated fibres, and promoting its coagulation. But how far the first of these effects, or the obliteration of the calibre of the vessel, depends on the destruction of any vital pro- perty, as of muscular contractility, may well be questioned, since the same effect takes place on dead arteries when similarly treated." (pp. 539, 40.)] 296. Various methods of using torsion have been proposed. According to Amussat, the artery should be taken hold of, and drawn out five or six lines above the surface ofthe wound, by forceps of suita- ble breadth, and furnished with an apparatus for closing them ; the ves- sel is then to be separated from the surrounding parts with another pair of forceps which have rounded and rough points, or with a small knife, so that it may be entirely isolated. At the point where the artery still re- mains in contact with the soft parts, it is to be seized and fixed with the second pair of forceps, or with the fingers of the left hand. The artery is then to be turned round upon its axis until the end is torn off', when the bleeding is certainly stopped. Below the fixed part no blood is found in the canal of the artery. If no forceps be at hand, the artery, in pressing cases, may (as was proposed by Galen) be pierced with a needle or with a nail, and so twisted round. Thierry seizes the artery with a pair of broad forceps which shut close, but neither fixes the vessel nor draws it out. In small arteries four, in larger six, and in the largest ten turns may be made, without going so far as to tear the vessel through. According to Fricke, the artery should be gently drawn out six or seven lines, but not fixed, so that twisting may not extend to the part where the artery is still connected with the other parts. The artery thus held should be separated by another pair of forceps from the surround- ing parts. For holding the vessel Fricke employs a pair of simple forceps, the fine teeth of which do not lock into, but only meet, each other, and furnished with a stud at the upper part of one limb, which, on pressing the forceps, fits into a hole in the other limb, to prevent its slipping; sideways. In twisting, the fingers of the left hand must be so placed en the limbs- of the forceps that they move as if in a ring. The twisting should be continued till a> piece of the artery is torn off", for which, usually, eight or nine twists are necessary ; we may then be sure that the external valve is formed, though not so if we only give a certain number of turns, after Thierry's mode of proceeding. In the smaller arteries, a certain number of turns may be made, according to their size, or the turning continued till the artery is torn off. Dieffenbach uses the same kind' of forceps as- Rust, except that they are rather broader. Kluge has proposed a peculiar apparatus, by which the twisting of the (a) Lectures; Palmer's edition. TORSION OF ARTERIES. 343 artery upon its axis is effected, by means of a spiraVfeather attached to a pair of forceps (a.) 297. Experience has, up to the present time, sufficiently proved that by torsion, bleeding may be with certainty stanched, even from the largest vessels. The advantages derived from torsion, in comparison with the ligature of arteries, are, that, as in torsion, no foreign body re- mains in the wound, the quick union ensues more certainly than in liga- ture, in which the remaining threads, whether cut off or drawn over the edge of the wound, act as foreign bodies retarding that process; and that in sudden accidents the surgeon can effect the torsion of arteries alone, and without assistance. These circumstances do not, however, seem to me sufficient to decide the question upon the absolute preference of torsion over ligature. In reference to quick union, Dieffenbach (b) has raised a doubt, whether the knot made in the artery should not also, to a certain extent, be considered as a foreign body, in a wound to be healed by prima intentio; whether it may not produce suppuration in its immediate neighbourhood, although, as shown by experiment, it unites immediately with the neighbouring parts; and whether, on ac- count of the quick union of the torn and twisted trunk, it may not the more easily suppurate, and after-bleeding take place. In cases of tor- sion of arteries which have come under my notice, in simple wounds especially disposed to quick union, namely, in those ofthe face, the re- sult was not tin favour of torsion, inasmuch as suppuration followed it more commonly than after ligature of the vessels. Pulling out the artery, to the extent of six or eight lines, disturbs, in the large arteries, their connexion with their sheath, up to the next collateral branch, and produces injurious consequences. This is not, however, to be feared in the smaller arteries. By the tearing and bruising of the arterial coats in torsion, separate fragments ofthe coats die off, and suppurate. In an artery wounded near a large collateral branch, torsion is always less to be depended on, because here the necessary space for the formation of the blood-clot is diminished by the knotting of the artery (c.) The second advantage, namely, that torsion can be performed without assis- tance, is still important: however, here it is also to be borne in mind, that, with the close-shutting forceps, the ligature may usually be applied without the aid of assistants with little difficulty. On the other hand, it is not to be overlooked, that, whatever dexterity a person may possess, it is commonly very difficult to take hold of arteries which run in thick cellular tissue, to draw them out, and to isolate them from surrounding parts; and that deep-lying arteries, which can be taken hold of only with great trouble, may, in general, be more easily secured by ligature than by torsion. The pain is usually about the same in both proceed- ings; but in those cases where it is difficult to draw out and isolate the arteries, torsion must always be the more painful operation. Dupuytren (d) asserts that, according to the experience of distinguished practi- tioners, the consequences of torsion are inflammation and suppuration along the sheath of the vessels: that it is often insufficient; frequently, from many cireum- (a) Compare Rust's Handbuch der Chirurgie, vol. ii. p 291. Koch's Forceps; in vox Graefe and Walther's Journal, vol. xxvi. part iii. p. 496. (b) In Rust, just cited, p. 287. (c) Above cited, p. 30. (d) Lecons Orales, vol. iii. p. 161. 344 WEAVING OF ARTERIES. stances impracticable; and that after fruitless trials, the ligature must be made. Lorch (a) denies the bad results which torsion effected in various cases of Del- pech's, and does not believe that suppuration in the sheath of the artery can be ascribed to it. Just so does Textor (b,) but especially Fricke (c,) who, by nume- rous experiments, sufficiently proved the importance of torsion, and has set aside many groundless objections to it. Compare also, Elster (d,) Bramberger (e.) [I have never employed torsion, and, not being convinced of its having any pre- ference over ligatures, do not think it probable I shall resort to it; but the objections made to it by Dieffenbach, Dupuytren, and Chelius, are not to me very satisfac- tory. The safety of torsion can scarcely be denied, even if reference only be made to Ferne's remarkable case, in 1737, mentioned by Cheselden (/) in which " the arm of a miller, together with the scapula, was torn off from his body by a rope winding round it, the other end being fastened to the cogs of a mill. The vessels, being thus stretched, bled very little; the arteries and nerves were drawn out of the arm ; and the surgeons first called placed them within the wound, and dressed it superficially. Next day he was taken to St. Thomas's Hospital, but the dress- ings were not removed for some days. The patient had no severe symptoms, and the wound was cured by superficial dressings only, the natural skin being left almost sufficient to cover it." (p. 321.) We have also in St. Thomas's Museum an example of torsion ofthe femoral artery, accidentally effected by the coil of a cable, into which a sailor had stepped, being unwound by lowering the anchor, and tearing off the limb through the middle of the thigh; in this case, as probably in Ferne's, the cellular tissue is dragged beyond the torn end of the vessel for an inch at least, and twisted round, so that the vessel and tissue together resemble a long narrow cone. No hemorrhage followed, and the man was brought to Guy's Hospital, where amputation above the injured part was performed by Astley Cooper, who was accustomed to mention the case in his lectures.—j. f. s.] 298. After this review of the advantages and disadvantages of the torsion of arteries, an- absolute preference can only be given to it in those cases in which it is very important that no foreign body should be left in the wound, as in injury to the epiploic, mesenteric arteries, and the like. In inflamed, bony, or otherwise degenerated arterial coats, tor- sion has a satisfactory result as rarely as ligature, although Kohler (g) asserts that even bony vessels may be twisted with good effect, which Fricke (h) has confirmed by experiments. Of the various modes of applying torsion, that proposed by Fricke is to be preferred. 299. As a means of stanching bleeding from wounded vessels, the interweaving of vessels, recently proposed by Stilling (i,) is yet to be mentioned, in which the divided end of an artery is passed through a cleft formed in its own walls, and is so closed that no blood can flow out. The vessel is to be somewhat drawn out with forceps, the sur- rounding cellular tissue divided or thrust back, and compressing forceps applied at a distance from the edge of the artery, which is more than twice the diameter of its area. The vessel is to be laid hold of trans- versely close to its edge, is to be a little flattened, and the point of a lancet-shaped knife is to be thrust (according to the size of the vessel) at a distance of half or a whole line from the lateral edge of the flat- tened artery, and at a distance from its aperture equal to its breadth, (a) Rust's Magazin, vol. xxxvii. (c) Ueber die Torsion der Arterien; in (6) Froriep's Notizen, No. 723, May, Horn's Archiv., 1835, part i. and ii. 1831. (/) Anatomy ofthe Human Body, 11th (c) Annalen der Chirurg. Abetheilung des Edit., 1778. allg. Krankenhausen in Hamburg, vol. ii. p. (g) Hecker's Annalen, vol. xv. p. i. 150. (X) Above quoted, p. 164. (d) Comment, de Arteriarum Torsione, (i) Die Gefitss durch schlinung, eine Got. 1832. neue Methode, Bluntungen aus grosseren Gefltssen zu 6tillen. Marburg, 1834. STYPTICS. 345 parallel to the axis ofthe vessel through its upper wall, and pushed through it and under the wall, so that a bridge is formed, the length of which is equal to the diameter of the artery. In withdrawing the knife, the cleft in the lower Avail, which, on account of the converging edge of the knife, is somewhat shorter than that in the upper wall, is to be carefully lengthened ; a pair of close interweaving forceps,answering to the size ofthe cleft, is to be carried from the under wall through both clefts, so that, according to the size of the artery, the instrument projects from one to three lines out of the upper cleft. The other forceps may now be withdrawn. The interweaving forceps are next to be somewhat opened, and, by means of a probe-sbaped instrument which enters one or two lines deep into the tube ofthe artery, an attempt is made to bring a fold ofthe cut edge ofthe end ofthe artery backwards over their upper sur- face, and, at the same time, thrusting between them the end ofthe vessel. As the probe-shaped instrument is withdrawn, the forceps are closed, and the end of the artery which they hold is drawn into the double cleft. The compressing forceps may be now laid aside,the end of the vessel held by the interweaving forceps drawn backwards, and, if no bleeding follows, these also may be removed. The processes after interweaving agree with those which follow after ligature and torsion. The vessel, besides, must be more than a line in diameter, and easily accessible to the eye and hands. Stilling has also proposed interweaving for the veins: his experiments have, however, been only made on beasts and on the dead human body. 300. The astringent styptic remedies, turpentine, kreosote, tannin, em- ployed to stanch bleeding, produce more rapid contraction of the extre- mity of the artery, and, perhaps, a quicker coagulation of the blood. To these belong cold water, brandy, Theden's arquebusade, alum, blue vitriol, and so on. The colder these remedies are applied, the more powerfully do they act. They may also be employed in the form of pow- der, in which case they seem to close the mouth of the vessels mechani- cally, as gum kino, gum Arabic, colophonium, and so on. Their action, especially as they are most commonly accompanied with pressure on the wound, is always injurious to the healing: they increase the inflam- mation, prevent the quick union, and are not preservative against after- bleeding. Their use, therefore, is confined to bleeding from small vessels, from mucous membranes, and to so-called parenchymatous bleedings. According to the experiments made upon beasts and men by von Graefe (a) with Binelli's water, a wad of linen soaked in it, and pressed against the wounded surface for five or ten minutes, will quickly and permanently stanch bleeding from both small and large ves- sels, (even from the femoral artery in amputation of the thigh, and from the carotid in a horse,) without any other assistance, without the least pain in the wound, without discoloration of its surface, without the pro- duction of a slough, and without any local or general inconvenience. Examination of the vessel, the bleeding from which has been thus stanched, presented its mouth completely closed by a clot, which (a) Journal fur Chirurgie und Augen- de Aquee Binelli et Kreosoti virtute styp- hcilkunde.vol. xviii. p. 2, vol. xvii. p. 650, vol. tica, Berol., 1833, assigns to it, from experi- xxvi. part iii. p. 505. Maurocord.vto uber ments, scarcely more influence than cold die dynamische Wirkung des Bi.NELLi'schen water. Wasscrs. Wurzburg, ]830.—Simon, diss. 346 CAUTERIZATION. extended up to a considerable distance. The chemical examination of this water has hitherto discovered, besides a slight empyreuma, no very- active substance, viz., neither alkalis, acids, salts nor metals; and there is no doubt that the active principle is kreosote, and thatkreosote water acts in the same manner. Unfortunately, neither the experiments of other persons nor my own with Binelli's or with kreosote water, have had any satisfactory results. 301. Cauterization, that is, the application of a hot iron upon the mouth of a wounded vessel, produces a slough, which closes the open- ing in the vessel; a clot forms in its cavity, and plastic exudation is the result of the inflammatory process by which the coats of the artery are united. As the slough may separate too quickly, and the bleeding recur, (for, after the application ofthe heated iron, profuse suppuration always occurs) its use must be restricted to those cases in which the blood flows from many small vessels which cannot be tied, or where styptic remedies and compression are insufficient ; for instance, in severe bleedings, after operations in the mouth. The other remedies formerly employed for stanching bleeding are to be entirely rejected. 302. When the bleeding is stanched, the surgeon must be particularly careful to prevent its recurrence (after-bleeding.) The patient must be kept very quiet; he must, in important cases, be watched by intelligent assistants, especially if the sympathetic fever should be very severe. If after-bleeding take place, it must come either from vessels which had not been tied, or on which the ligatures have become loose, or from the whole surface of the wound where no vessel can be perceived. It de- pends upon the extent of the after-bleeding whether the stanching is to be attempted by the application ofthe tourniquet, the compression ofthe wound, the use of cold water, or by loosening the dressings and tying the vessels. In severe inflammatory fever, the bleeding often ceases after a large blood-letting, and the use of cold applications to the wound. Bleeding in the subsequent course of the wound occurs either from the too early loosening of the ligatures, from ulceration of the arteries, or from a debilitated condition ofthe vessels, and a disposition to fluidity in the blood. In the former case, it depends on the more or less ad- vanced state of healing of the wound, and the size and situation of the vessels, whether they are to be tied in the wound, whether pressure and styptic remedies are to be applied, or whether, the principal trunk of the artery is to be secured above the wound. In the latter case, local styptic remedies, pressure, even the use ofthe actual cautery (1,) or tying the trunk of the vessel above the wound, are proper; and a strengthening treatment, combined with acids, suitable to the general state of the constitution (a.) After-bleeding readily occurs, if the ligature be placed closebeneath alarge collateral branch, as also in morbidly changed arterial coats, in which ulceration readily takes place. If the arteries have become bony, the safest way to guard against bleeding is to insert a linen cylinder into the mouth of the artery, and to apply (not too tight- ly) a broad ligature around it (2,) as mentioned below, (p. 352,) or to use torsion (par. 298.) [(1) Tbe subject of after or secondary bleeding is of so great interest to surgeons, and of so serious consequence to patients,—not whose limbs only, but even whose life depends upon its proper and prompt treatment,—that I feel no need of apolo- (a) Heidelberger klinischen Annalen, vol. iii. p. 337. HENRY CLINE ON ACTUAL CAUTERY, &C. 347 gizing for the introduction of the following clinical observations made many years since, by the younger Cline, on two cases which were under his care. These have never been published, and as I have the good fortune to possess notes, I avail my- self of the opportunity to insert them here, believing them interesting and valuable, as having been treated with a different view of the operation of the actual cautery to that generally held. I wish, also, to put forward the just claim of my esteemed and skilful master (whose early death removed him from a course of professional use- fulness to the great establishment of which he was one ofthe surgeons, and to the students by whom he was attended, and deprived the profession of one of its most able and upright members) to the re-employment, at least in England, of, in many cases, that invaluable remedy, the actual cautery; which, like numerous other reme- dies of Ancient Surgery, had been thrown aside in consequence of its abuse, and of the fondness for new remedies, which, in our profession, is by no means uncommon. CASES OF AFTER-BLEEDING IN WHICH THE ACTUAL CAUTERY WAS EMPLOYED, AND CLINICAL OBSERVATIONS THEREON, By HENRY CLINE THE YOUNGER. Case 1.—G. G., aged twenty-eight years, a post-boy, was admitted into St. Thomas's Hospital, Jan. 24, 1815, with a compound fracture ofthe left leg, caused by the wheel of his carriage passing over it, he having slipped whilst getting on the bar, and fallen beneath. Both bones were broken, but did not protrude through the wound, although they evidently communicated with it. The edges were brought together with adhesive plaster, and, the limb having been placed in splints, an evaporating lotion was applied. On the 21th, as his bowels had not been relieved since his admission, and, as febrile symptoms had appeared, he was ordered a dose of infusion of senna and sulphate of magnesia immediately; and fever mixture with three drops of laudanum every six hours. Up to this time the case was going on well, but the medicine produced seven or eight stools next day, and at the visit on the 29/A he had passed eight or nine more. The result of the necessary frequent movements appeared this morning in the violent inflammation with which the limb had become attacked, accompanied with gangrenous vesication. Chalk mixture, with aromatic confection, was ordered ; the purging continued, however, through the night, but on the following day, Feb. 1, it was checked. He had a quick pulse, white but not furred tongue, and good appetite. The leg was now extensively in- flamed, and suppuration having commenced, a poultice was applied. Early on the following day his bowels were again disturbed ten or twelve times ; sloughy ulce- ration had occurred above the outer ankle, and on the ith Feb. another slough upon the instep; and a piece ofthe shin-bone being loose, was removed. The discharge was very great and offensive, The fever mixture was continued, a grain of opium given nightly, and rhubarb bolus twice a week. The limb, which to this time had been on the side, was now placed on the heel with the knee bent, in a thigh frac- ture box, and the poultice continued. This position, however, was not comfortable, and next day the limb was taken from the box, and on the day following put in a leg-fracture box, which suited well. On the 9th Feb. it was thought advisable to improve his living by giving some porter, but, as in the course ofthe day there was a little bleeding from the wound, it was not continued. He, however, went on well till the 15th, when a patient falling over the bed jarred his leg, and bleeding from the wound ensued to the amount of six or eight ounces. On the 2lsta sympathetic abscess in the groin was opened. His constitution continued fighting with the ailment, but another piece of bone was discharged, and the lower end of the shin- bone protruded considerably through the wound. His powers at last began to fail, and amputation, which could no longer be avoided, was performed, on 9th April, above the knee, by my friend Travers, whose patient he had become by the death ofthe surgeon under whom he had been admitted. Three ligatures were applied, and he went on exceedingly well, improving in health daily, till the evening ofthe 2'JI/i, when a severe arterial bleeding, to the amount of a pint and a half occurred; the ligatures had come away on the 16th, but that on the femoral artery still re- mained. The bleeding continued through the following day, and although the tour- niquet had been applied, he lost three pints of blood within the twenty-four hours. A solution of sulphate of copper was applied to the surface ofthe stump, and cold wet cloths over it, and the bowels cleared with castor oil. May 1, 1 p. m. Free bleeding to the amount of a pint took place; at half-past two 348 HENRY CLINE ON THE another pint, and smaller quantities continued to flow till 11 a.m., when eight ounces more escaped. Six grains of powdered digitalis were given in divided doses before 8 a. m., which reduced the pulse considerably, but without arresting the bleeding, though he had become very weak and covered with clammy sweat. Ten drops of laudanum every six hours Were then ordered, but he continued in a very unsatisfactory condition, and vomited twice in the course of the morning (a.) At 4 p. m., his surgeon being ill, I was requested to see him. On removing the coagulum, a ligature was found and withdiawn; the blood flowed from a sinus which would admit the finger, and up this a piece of sponge was introduced, the tourniquet taken off, and the stump kept cool with Goulard's wash. A grain of superacetate of lead was-ordered at 5 p. m., and to be repeated at 6 p. m. The vomiting soon after returned, and continued during the evening; but he got a little sleep. May 2, 1 a. m. The sponge having slipped out, was replaced; but bleeding did not return, and at noon it was removed. A small quantity of sulphate of magnesia was given to produce a stool, and a drachm of powdered sarsaparilla ordered twice a day. In the course of the afternoon he had a little wandering, but it soon went off. Under this treatment he continued improving till May 23, when another profuse bleeding (the dresser says to three pints) took place. Finding the end of the stump much swollen from the pressure of the tour- niquet, which had been put on to check the bleeding, I removed it, and adjusted the pad of a small truss upon the inner side of the thigh near the end of the stump, with a view to compress the sides of the artery, and at the same time permit the blood to pass through the small arteries, and allow its return by the veins, as well as that of the lymph by the absorbents. This plan succeeded, till May 26, 11 p. m., when the pad probably having slipped, another severe bleed- ing ensued, to the amountof two pints. The tourniquet was used, but without effect. and the bleeding could only be restrained by great pressure of the dresser's thumb, as the arterial action was very strong. An injection of strong solution of alum was thrown up, but without benefit, and gave much pain. He was much exhausted; and his pulse 120, and irritable. A grain of acetate of lead was given, with twenty drops of laudanum, at midnight, and May 27, 1 a. m., it was repeated; but the arterial action and bleeding continued. 5 a. m, I was called to him; and the means hitherto employed having failed, I determined to apply the actual cautery, by passing a hot iron up the bleeding vessel. With this view, the sinus from whence the blood flowed, together with a part of the end of the stump, were slit up; and it then appeared that the sinus was the end of the artery in a diseased state, resembling the structure of an aneurismal sac, when the whole cylinder of the vessel is enlarged. This aneurismal condition extended from the face of the stump upwards about two inches, and was large enough to admit the thumb ; above this the vessel was sound. A canula was then passed up to the distance of three inches, so as to enter the healthy part of the artery, and into it a hot iron was introduced, with which the coats of the artery were burnt, in hope of producing inflammation and consequent adhesion. The cauterization gave great pain, but immediately arrested the bleeding. The canula was left in the vessel, which, shrivelling up, had become adherent to it. He began speedily to improve, and, with the exception of one slight bleeding, did well; and was discharged. Aug. 10. Perfectly well. Case 2.—G. M., aged about twenty-five years, was admitted, Feb. 11, 1819, with an affection ofthe left knee, of long continuance, from which his health has suffered much. A fortnight ago an abscess of considerable size had formed on the inside of the knee, and burst. He was advised at once to submit to the loss of his limb, on account of the exhausting effect of the disease on his constitution. Feb. 19. The leg was amputated above the knee in the usual manner, and three ligatures applied. Two hours after, his pulse was quick and throbbing, and slight bleeding occurred from the stump, which was then covered with cold lotion, but without advantage, as the bleeding increased ; and in three hours' time had become so profuse, that it was necessary to remove the dressing, open the wound, and clear (a) Thus far is from the dresser's and my own notes, but the remainder ofthe case is from my master's narrative.—j. f s. ACTUAL CAUTERY IN AFTER-BLEEDING. 349 away the clot, which being done, a small artery was found and secured, and the bleeding ceased. Feb. 24. Has gone on well: part of the dressings were taken off, and replaced; there is a slight discharge, but no appearance of adhesion. On the following day the rest of the wound was dressed, and the ligature last applied came away. Feb. 28. Was requested to visit him on account of a return of the haemorrhage, and ordered the stump to be kept cool: pulse 140, and full; he has a troublesome cough. The wound has begun to granulate. At 5 p. m. As the bleeding was still free the dressings were removed, and attempts made to secure the artery, but in vain, as it had retracted very much. The patient soon became faint, and the bleeding then ceased. March 1. He appeared weak from the loss of blood, but haemorrhage had not re*- curred. His cough still remains troublesome. March 3. This evening a fresh bleeding having come on, Astley Cooper endea- voured to secure the vessel with a needle and ligature, but as the bleeding ceased before this could be affected he did not persist. March 5. Again very profuse bleeding, which was stopped by the application of some styptic. March 9. As fresh haemorrhage had taken place, the bleeding vessel was sought for, found near the sciatic nerve, and the actual cautery then applied by Cline, which immediately stopped the flow of blood. In its application he did not com- plain of any pain. Since that time he had no repetition of the bleeding, continued to improve in health, and during the course of the month was able to sit up, and ultimately re- covered. Clinical Observations. In order that my intention in applying the actual cautery, in the cases just men- tioned, may be understood, I shall make some remarks on after-haemorrhage, com- monly so called, and on the use of the actual cautery in cases of haemorrhage after operations or other injuries. By after-haemorrhage is meant a bleeding that takes place when the wound has been closed up and dressed, and the patient put to bed ; and it may happen at various periods after the operation. Such occurrence is particularly painful and alarming to the patient, as parts require to be disturbed which are in a state of inflammation, and if the bleeding be some hours after the operation, the inflammation is consider- able, and the pain greater than when the parts are uninflamed. These cases are, also very anxious and harassing to the surgeon; for, as he is unaware ofthe time of the occurrence of the haemorrhage, the patient may die in his absence. I do not purpose entering into all cases of after-haemorrhage, nor into these which, coming on two or three hours after the operation, are generally stopped by removing the coagulum and all extraneous and irritating matter except the ligatures, and exposing the face of the stump to the air, applying cooling lotions, and paying attention to the state of the bowels, but only to those cases which occur during the healing process, are obstinate, and very much reduce the patient. Eight or nine years since, this subject passing through my mind, and reflecting upon it, it seemed to me that those bleedings arose in consequence of the want of adhesive inflammation; that instead of an effusion of coagulable lymph, an ulcerative process commenced, and perhaps I might say that the ulcerative inflammation suc- ceeded the application of the ligature instead of the adhesive. Now, from what one observes to follow the application of a high temperature to living animal bodies, it seemed to me that the actual cautery would be most likely to bring on quickly the adhesive inflammation, just as in a scald or burn, though serum is thrown out so as to resemble a bladder of water, yet flakes of coagulable lymph are seen floating about in it. I therefore at that time applied the actual cautery to the carotid artery of a dog. As regards the case of J. G., it may be asked what effect could sarsaparilla have in checking haemorrhage ] to which I reply, I gave it from having observed that it has considerable power in tranquillizing the arterial system; and hence conclude that if it relieve the thrilling and throbbing of the pulse, the irritability of the arteries, and produce in their extremities a healthy action, independent of its improving the vol. i.—30 350 HENRY CLINE ON THE general health, we may consider it an auxiliary in stopping the haemorrhage. But I do not mean to say that when taken into the circulation it has any chemical opera- tion in producing this effect. When I saw the patient on the 27th of May, I found the dressers alternately relieving each other in compressing the artery, and with which they had been occupied during the whole night, as nothing could be done with the tourniquet. I thought it extraordinary that the tourniquet would not stop the bleeding, and therefore myself put it on, carefully placing the pad upon the artery, and then screwed it up, using as much force as I thought safe, taking care to avoid such as would crush the muscles, which might be easily done with so powerful an instrument, but the bleeding continued, and I therefore determined to use the actual cautery. Having first cauterized the aneurismal part, as I have called it, of the artery, which caused no pain, I then passed the canula up into the sound part ofthe vessel, and as soon as the red heat had to the eye subsided, the cautery iron was run up the canula, which caused extreme pain along the artery and its accompanying nerve, as much it seemed as the circular incision in amputation. The object of using the canula wTas to conduct the hot iron up to the spot to be cauterized; otherwise, as soon as it touches the vessel, it is stuck fast, and you cannot pass it further up. Besides, if this did not happen, few have so good an eye and so accurate a hand as not to miss so small an orifice as that of the artery ; which, however, does not occur if the canula be used. During the progress of the case I was asked why I did not slit up the sinus, and tie the artery again. But if it did not heal when one ligature was applied, it was highly probable it would not if a second were put on. I was also asked whether I would not tie it as in tying the artery above for aneurism. But then we should have still been in the neighbourhood of the diseased part: the same accident would have recurred, and probably the vessel would have bled again by anastomosis. To prevent this bleeding it was that I cauterized the aneurismal structure, for the pur- pose of producing a change in the action ofthe vessels. This case presented to me a new view of the subject, haemorrhage. It appeared the cause of the bleeding originated in a new structure being built up, whilst the artery was enlarged by absorption, so that a sort of aneurism was found at its ex- tremity. I do not mean that sort of aneurism in which one side only of the vessel becomes diseased, but where a general circular dilatation takes place. This ex- plains my reason for not applying a ligature upon the vessel, for had it been put on it would have given way: just as would an aneurism, if a ligature could be passed around it. The enlargement of the extremity of the artery is similar to what occa- sionally happens after bleeding from the temporal artery; you puncture the vessel, take as much blood as you wish : but, expecting to require more in a day or two, you do not divide it, but apply a compress. A spurious aneurism soon follows, and is occasion- ally accompanied with a sinus, from which repeated and obstinate haemorrhages occur. Four or five years ago I saw a man in Guy's Hospital bleeding from a sinus, with which the dressers had been harassed night and day, making pressure with the thumb on the vessel, which seemed to be the commencement of such a case as I have de- scribed. It appears to me, therefore, that the advantage of using the actual cautery consists in changing the action of the part, and rapidly inducing the adhesive in- flammation. After the employment of the actual cautery in after-haemorrhage, pressure should be made on the artery with a tourniquet, with the finger, or with the pad of a truss, which is better than a tourniquet, as it touches only two points and does not prevent the blood circulating to the stump for its support; and this pressure should be con- tinued till there has been sufficient time for the effusion of lymph. In the second case the patient did not feel pain when the hot iron was applied to tbe artery, which was a remarkable circumstance. But although it should give pain, yet it ought not on that account to be disused. It is a case of life and death. The pain is supportable, and soon goes off. It is remarkable in cases of haemorrhage, that when something efficient is done, Wore there is time for any change to take place, the system becomes tranquil, there seems to be a sympathy between the arterial system and the diseased extremity of the vessel; and so long is the patient in a state of uneasiness as this something effi- cient remains undone. This is what Mr. Hunter called a "consciousness of ACTUAL CAUTERY IN AFTER-BLEEDING. 351 wrong," the body being unable to be at rest, wanting to do a something which nature is incapable of accomplishing. In the two cases above mentioned, I feel certain that the haemorrhage ceased from the use of the actual cautery. I am not an advocate for using this remedy instead of ligatures ; it is not so convenient nor so certain as ligatures, in recent cases. It is only when you can do nothing else that I recommend its use. It must be applied up the canal of the artery, or else the end only is shrivelled, and no union produced. I find that the mere burning or searing the extremity of an artery is not to be depended on even in quadrupeds ; the vessel will still bleed : I am certain, therefore, it would not do in the human subject. And I conceive that by the old method of applying the actual cautery, the bleeding was stopped by burning all the parts which constringed and pressed upon the vessels. I have ascertained that this method is sufficient in the dead subject to prevent injection being forced out; but by simply cauterizing the arteries in the old way, without touching the surrounding parts this cannot be effected. The instruments required for this operation are a straight wire of corresponding size to the vessel to be cauterized, fitted with a canula, closed at its extremity to prevent the blood flowing into it and cooling the hot iron. The artery having been slit up, as already mentioned, the canula is to be passed up into its sound part, having been first smeared with grease, which renders its in- troduction and removal easier, and also when heated burns the vessel with the hot grease, and assists in exciting the inflammation. The cautery iron having been heated, is then to be introduced into the canula at a black heat. The object is not to destroy the parts, nor to bring on sloughing, but only to produce a higher degree of inflam- mation, so that an effusion of lymph may soon take place and seal up the vessel; and for this purpose the black heat is sufficient. After the cauterization is effected, the canula may be withdrawn; but if it will not come away, it is not of consequence, and may be left, as in the first case, to come away of itself; for the process of closing the vessel goes on without inconvenience. The following are some experiments which I made in reference to this subject:— Exp. 1, which was performed with a view to the treatment of those aneurisms in which a ligature cannot be applied upon that part ofthe artery next the heart, shows that a wooden plug may be passed into a vessel, and the natural process as regards its closure be accomplished. I divided the carotid artery of a dog, thrust a wooden plug an inch down that portion of the vessel next the heart, and tied it in. No haemorrhage ensued, and the artery healed. Exp. 2. On the 6th Jan., 1818, two ligatures were put upon the carotid artery of a sheep, and the vessel divided between them. A hot iron was applied to the end next the heart, till about half-an-inch of it from the ligature towards that organ shrivelled and turned white. At noon of the following day the sheep was killed. A portion of the artery immediately below that which had been cauterized was one- sixteenth of an inch less than the corresponding vessel on the other side of the neck, and contained a coagulum an inch long; but in the uncauterized part the coagulum measured three-eighths of an inch. In other respects the two portions were similar. Exp. 3. On the 12th Jan., 4 p. m., two ligatures were applied on the carotid of a sheep, which was divided between them. The ligature on that part of the vessel next the head was then untied, and the actual cautery passed up it; after which the liga- ture was retied to prevent haemorrhage. Twenty-one hours after, the sheep was killed, and there was found in the cauterized end a very firm coagulum, two and a half inches long, completely filling the cylinder of the artery, to the extent of one inch from the ligature. The uncauterized end contained a slender filament of coa- gulum, one inch long. Exp. 4. On the 19th Jan., 3 p. m., I cauterized the lower end of a sheep's carotid by passing in a tube closed at one end, and introducing the hot iron into it. The ends of the artery were tied as before. At noon of the following day the animal was killed; the ligatures were covered in with lymph, so that the cavity containing them and the ends of the artery were excluded from the air. The lower portion of the carotid contained a very firm coagulum, an inch and a quarter long, adhering strongly to the internal coat of the vessel. The coats of the artery and the surround- ing cellular membrane were much inflamed, and a mass of matter having the ap- pearance of coagulated blood, but which had probably been effused by the inflam- mation, surrounded the artery about half an inch from the ligature. 352 BLEEDING FROM VEINS. Exp. 5, made on Jan. 25th, was the reverse of the former. The lower portion of the vessel contained a clot of blood three quarters of an inch long, and as thick as a probe. The upper portion had nearly the same appearance as the lower in the last experiment, except that the coagulum was about an inch longer, and that there was less coagulum around the outside of the artery. In both experiments the iron was passed only once, and as the red heat went off. (2) Although in Cline's experiment a wooden plug was introduced into the carotid artery of a dog, and the vessel, having been tied upon it, did well, it does not render any support to the plan proposed by Chelius for treating bleeding ossified arteries. In the former case the vessel was healthy, in the latter diseased, and not very likely to adhere. I should certainly prefer amputation wTith the hope of finding the artery healthy above ; but if that were not done, I think it would be better to trust either simply to pressure or to use the actual cautery for the purpose of shrivelling the vessel up, and inducing the formation of a clot, to form a natural plug, and rely upon the accompanying increased inflammation to do the best for the patient. Such cases, however, must always be considered very doubtful as to their successful termination.—j. f. s.] 303. Bleeding from wounded veins, although less thought of, may produce dangerous consequences. It is characterized by the above-de- scribed symptoms (par. 276 ;) differences may, however, occur, which, for the moment, render the diagnosis difficult. If there be no preven- tion to the return of the blood, it flows in an unbroken current; but, if there be any obstacle, the blood spirts in a stream, or even in jets, as if from a wounded artery. This latter circumstance depends either on contraction ofthe muscles surrounding the vein, and is in direct propor- tion to the strength and frequency of the contractions ; or it is conse- quent on the motion propagated from the artery accompanying the vein, and, in this case, the manner in which the blood spirts out may easily deceive at the first moment, but compression above and below the wound will always determine the diagnosis. 304. Bleeding from the smaller veins usually stops of itself, if the patient be kept quiet, the edges ofthe wound brought together, and the circulation of the blood not disturbed. The clot which forms in the mouth of the wounded vessel prevents the escape of the blood, and, with the healing of the outer wound, that of the vein also takes place. But the bleeding is more severe, and requires the assistance of art, according to the condition of the wound, the size of the vein, and the existing obstacles to the return of the blood, such as the depending position of the wounded part, pressure upon the vein between the wound and the heart, exertion of the patient, by which either the muscles ofthe wounded part or those of the chest are contracted, and interruption to the return of the blood ensues; injuries of the large veins, as the internal jugular, the subclavian, the femoral, are soon fatal. 305. Compression is the usual remedy in venous bleeding; the ligature is seldom employed. The pressure must be made on the wounded part itself, and not to such extent as completely to flatten the walls of the vein, which would entirely check the return of blood, but only in a slight degree to support them. Especial attention must always be paid, at the same time, to the due freedom of respiration. The ligature must be applied, first on the lower, and then on the upper end, if the blood flow from the latter by regurgitation. It has the disadvantage of putting a complete stop to the return ofthe blood, and may also give rise to inflammation ofthe vein; it should, therefore, only be used when HISTORY OF THE RESUMPTION OF THE LIGATURE. 353 compression is not posible. Wounds which comprise the half or two- thirds of a vein, produce severe, and even fatal, bleeding, especially if the position ofthe part draw the wounded edges asunder. In this case, a better position and slight pressure often stop the bleeding ; but fre- quently it will not cease till tbe vein has been completely divided. Venous bleeding, in extirpating tumours, or in amputations, usually stops when the patient ceases to scream, or by letting him frequently take a deep breath. If, however, bleeding from a large vein should continue, it is necessary to tie it; in such cases, for instance in amputations, in which I have frequently tied large veins, I have never observed any symptoms of phlebitis. Compare Dupuytren (a). [Venous bleeding in operations is sometimes very severe, especially in the removal of diseased breasts. Usually it is stopped by pressure on the divided veins, but sometimes this is insufficient, if the vessels be very large, and the cellular tissue have become brawny, so that the apertures will not come together, but remain open like holes in a sieve. A case of this kind happened to me some years ago, in which the venous bleeding was so sudden and severe, and the number of bleeding veins so great, that the woman, who was advanced in life, died under the operation. Some thought that air might have entered the veins and caused death; but I feel sure that the sudden loss of a large quantity of blood destroyed her. Should I ever meet with another case in which venous bleeding from the breast were so free, I am quite determined I would tie every vein, however tedious the operation might be rendered. With regard to venous bleeding in amputation of the limbs, I never hesitate to tie the femoral vein, if it will not fall together and close ; and I have never found incon- venience from it but in a single case. The extension of inflammation along the vein is, I think, from my own experience, scarcely to be expected. In the case of axillary aneurism mentioned at p. 307, my friend Green put two ligatures upon the external jugular vein, and divided it between them, to obtain more room to get at the artery, and no inflammation ensued.—j. f. s. Before dismissing the subject of bleeding from wounds, it will be neither unin- teresting nor unprofitable to give a slight account. of the introduction, or rather resumption of the ligature of vessels, As now employed, in the practice of Surgery. There is no doubt that the ligature was used by the ancient surgeons; but Celsus appears to be the first who relied much upon it. To stop the flow of blood' from a wound, he recommends that it should be filled with dry lint, over which a sponge dipped in cold water is to be applied, and pressure made with the hand. These applications are to be frequently renewed ; and if the lint alone be unavailing, then vinegar is to be applied, as being very efficient in suppressing haemorrhage, on which account some pour it into the wound. And he then proceeds, "quod si illaquoque profluvio vincuntur venae, quae sanguinem fundunt, apprehendendae, ciroaque id, quod ictum est, duobus locis deli- gandae, intercidendasque sunt, ut et in se ipsae coeant, et nihilominus ora praeclusa habeant." (lib. v. c. xxi.) And he also directs, in treating of castration, "in quibus cum multae venae discurrant, tenuiores quidem praecidi protinus possunt: majores vero ante longiore lino deligandas sunt,- ne periculose sanguinem fundat." (lib. vii. c. xix.) After some time, but when is uncertain, the use of the ligature gave way to the practice of searing the wound with a hot iron, or of applying various caustic remedies, and no more is heard of it till Thomas Gale, Minister in Chirurgerie, again brings it forward in describing the various kinds of stitches required in the treatment of wounds (b,) as follows:— (a) As above. (6) An Enchiridion of Chirurgcrie, conteyning the exacte and perfect Cure of wounds, fractures, and dislocations; newly compiled and published. London, 1563. 30* 354 HISTORY OF THE RESUMPTION OF THE LIGATURE. " The fourth maner of stitching is when as a vayne or arterie is cut, and we use to stay the flux of blood, especially when as vene iugulares is cut. Thenwethurst the needle through that vaine or arlerye and then knit the same with the thried, then draw out the needle and let a portion of the threed hange out so longe untyll it falleth awaye." (p. 3.) Subsequently, also, in speaking specially " of woundes in vaynes and arteries," he says :—" If they be the smalle vaynes it shall suffyce to stiche the wound and use the pouder desiccatiue mencioned in the chapter goyng before, with twoe and the whighte of an egge. But if any of the great vaines be wounded, then the cure aforesaid is not sufficient. Wherefore you may attempt to stay the fluxe of blood with bending the contrary side to the place wounded; or with letting of blood in another place, whereby there is made diuersion ofthe fluxe. Also wyth frictions and rubbing the contrary parts. Yf these suffice not, then you must applye caustieke pouders as arsenicum sublimatum, vitriall burnt, unsleked lime, or such like; or ells make cauterization with an yron, or stiche the ende of the vninc. And lay some desiccatiue pouder on it, and so dresse the wounde, lettying it so remayne foure daies.. And if there be any asker, (escar,) you must apply to it the whighte of an egge and oil of roses well beaten together. And the cure that is heare spoken of vaines, is also to be understand of arteries; and the way to know whether a vaine or arterie is wounded: is by the yssuing oute of the blood. For in an arterie cut, the blood commeth leping and springing out with sume staye, accordinge to the dilatation and compressyon of the arterye." (p. 4.) From the notes which Malgaigne has added to his recent edition of Pare's works, it appears that when Pare published his Surgery, in 1552, he still employed the actual cautery, and made no mention of tying vessels till the following edition in 1564, published at Paris, and bearing the title Dix livres de Chirurgie avec Le Magasin des Instrument necessaires a icelle, in the seventh book of which, speaking of the treatment of gangrene and mortification which requires amputation, he first recom- mends tying the vessels to suppress bleeding after that operation in the following terms:— " Des moiens pour arrester leflux de sa7ig quand le membre est coupe. " Lorsque l'amputation du membre est faitte: il est necessaire que quelque qnan- tite du sangs' escoule, a fin qu'u la partie deschargee y suruiennent aiur'fe|a^ei*flii 8vo. Swan, J., A Treatise on Diseases and Injuries of the Nerves. 2d Edit. Lon- don, 1834. 8vo. Bell,- G.; in the Edinburgh Journal of Medical Science. October, 1826. 329. The enlargement of a punctured wound, which was formerly made in every case for the purpose of converting it into an open wound, the cutting through half-divided parts, and so on, must only be undertaken (as it is evident from what has been said)'for the removal of foreign bodies, or to effect the stanching of blood; or, in parts of an unyielding texture, to prevent the strangulation of deep-seated structures. And, in like manner, the introduction of a seton, which was formerly so common, is now restricted to those cases where the walls of the fistu- lous passage are become callous. Compare, sec. 66. III.—OF TORN OR LACERATED, AND BRUISED OR CONTUSED WOUNDS. (Vulnera lacerata et conlusa, Lat.: Gerissene und Gequetschte Wunden, Germ.; Plaies contuses et dechirees, Fr.) 330. Torn Wounds are those in which parts are subjected to the greatest degree of stretching before they actually separate; Bruised Wounds such as are produced by blunt instruments. 331. These wounds agree with each other in the disturbance effected 368 LACERATED AND CONTUSED WOUNDS. in the vitality of the divided parts, by severe bruising, stretching, and tearing. Their form and surface is always irregular ; their edges are uneven and hang down in flaps; whole pieces may be torn off the body. In consequence of the bruising and stretching the parts lose their sensi- bility and irritability; therefore, at first these wounds smart little, and their edges do not retract. They are accompanied with little and fre- quently with no bleeding, even when large vessels are injured ; but much swelling, pain, inflammation and fever soon take place after these inju- ries. Very frequently they are accompanied with severe shock, which will be presently considered in Gun-shot Wounds. The inflammation may quickly run into gangrene, which spreads the more speedily in pro- portion as the surrounding parts have suffered more severely from the shock. Nervous symptoms commonly take place in these wounds, but especially in those which are torn. The suppuration may become ex- hausting, 332. Only in wounds without much bruising or tearing can union be attempted; the edges of the wound are then to be brought together with sticking plaster, but without using any force for that purpose. Generally only the bottom of the wound will partially hold together, and the rest unites by suppuration and granulation. Severely bruised and torn wounds, which heal only by suppuration, must be lightly covered with charpie, confined with strips of sticking plaster, or with a loosely ap- plied bandage. The other treatment, both general and local, must be strictly antiphlo- gistic. From the first, cold fomentations must be constantly employed; and general bleeding, with the repeated application of leeches, if the inflammation be great. If much swelling and tension occur, warm, softening poultices should be employed, and when suppuration comes on, the wound must be treated according to the previous rules. The removal of foreign bodies, with whicb these wounds are frequently complicated, requires especial attention. As to the needfulness of enlarging the wound, as to its complication with broken bones, and the necessity for amputation, what is said in reference to these points in gun-shot wounds will apply here. [When, as occasionally happens, large pieces of skin are torn or stripped down from the parts beneath, it becomes an anxious point with the surgeon to satisfy himself as to what may be the expected result. From frequent observation I think I may say that torn wounds of the scalp more often do well than those of other parts. I have several times seen large flaps torn down, and in more than two or three instances nearly half the scalp torn down, which have united without difficulty, with or without any abscess forming here and there during the progress of the cure, even in cases where the cellular tissue has been so daubed with mud or sand that it has been sponged off with the greatest difficulty. Such cases are, however, to be much dreaded from cellular inflammation and sloughs, which commonly ensue, and from the participation of the membranes of the brain with the external injury. When large portions of skin are stripped down from the limbs, there is the great- est danger of the whole piece sloughing, for the vessels of the parts beneath being all torn through are incapable of effecting adhesive union, and the skin itself is not suf- ficiently vascular for its own support, except close to its remaining attachments.— The result of this is a large destruction of the skin and a large sloughy surface beneath, for the throwing off of which greater calls are made upon the constitution than it can answer to ; and the patient either dies in a few hours of the shock, or is cut off after a few days with typhoid symptoms. In such cases, in adult persons, GUN-SHOT WOUNDS. 369 my observation, both in my own practice and that of others, induces me to recom- mend amputation as a general rule. Only in very young persons does it seem to me to admitof a moment's hesitation; but as regards them, everypossible chance of their being able to struggle through the consequences of the injury should be well considered, for daily experience shows how great are the powers of Nature in youth to repairing injuries which would assuredly destroy adults.—j. f. s.] 333. Bruises without producing separation of the skin may injure underlying parts severely, and tear the cellular tissue and blood-vessels, by which outpouring of blood into the cellular tissue may ensue. Such extravasation of blood, even if accompanied with fluctuation and pulsa- tion, is often quickly resolved: but if not, the swelling bursts, blood mixed with pus is discharged, and healing by granulation ensues. These bruises are at first to be treated antiphlogistically, and cold ap- plications used. When the inflammation and swelling diminish, vola- tile lotions of camphorated spirit, soap spirit, aqua vulneraria, water and sal volatile, or poultices of aromatic herbs, may be used. If a large artery be wounded, it may be necessary to expose and take it up. If the swelling do not disperse, but goes on to suppuration, it must be treated as an abscess. [The effusion of blood from severe bruising is frequently great, and so rapid as to lead often to the supposition of an artery being torn. The patient's condition, how- ever, is the best means of solving the difficulty; if the swelling be large, but afteT the first shock the pulse continue little disturbed, and the countenance not pallid, and after a few hours the swelling cease to increase, it may be presumed that the ex- travasation is merely from the small arterial branches and veins. The quantity of serum in these cases generally far exceeds the mass of the clot, and the consequence is that very distinct fluctuation, like water in a bladder, often pervades the greater part ofthe swelling, and continues for some days in proportion to its size. Suppuration occasionally happens in these cases, but it is not of frequent occurrence. If an artery of any material size be torn, the swelling continues gradually increasing, and is generally much more firm, and little fluctuating, except in the immediate neigh- bourhood of the injured vessel; the effusion in this case being entirely blood, and coagulating soon after it has been poured out. If left alone, the continued distention will cause gangrene. In the ordinary run of severe bruises, even with much effusion, I prefer a warm linseed-meal poultice, or hot moist flannel, to cold applications, as the warmth and moisture are generally most agreeable to the patient's feelings, by supplying the skin and exciting perspiration on the surface. If the tension be very great, leeches should be applied freely, and repeated if necessary. If a large artery be injured, it must either be tied or the limb amputated ; but, in either case, the patient is in some jeopardy of gangrene, from the distention of the soft parts, which has oc- curred.—j. f. s.] IV.—OF GUN-SHOT WOUNDS. (Vulnera sclopetaria, Lat.; Schusswunden, Germ.; Plaies par armes a feu, Fr.) Pare, A., Maniere de traitor les Plaies faitespar arquebuses, fleches, etc. Paris, 1551. 8vo. Gale, Thomas, An excellent Treatise of Wounds made with Gun-shot, in which is confuted both the grose error of Jerome of Brunswick, &c, in that they make the wound venomous, which cometh through the common powder and shotte. And also, there is set out a perfect and true Methode of Curinge those Woundes. London, 1563. 8vo. Clowes, William, Approved Practice for all young Chirurgions concerning Burnings with Gunpowderand Woundes made with Gunshot, Sword, &c. London, 1588. 4to. Wiseman, Richard, A Treatise of Gunshot Wounds; in his Eight Chirurgical Treatises. London, 1676. Folio. 4th Edit., 1705, here used. 370 GUN-SHOT WOUNDS. Brown, John, A Complete Discourse of Wounds, both in general and particular. As also a Treatise of Gunshot Wounds in general. London, 167^. 4to. Le Dran, Traite, ou Reflexions tirees de la pratique sur les Plaies d'Armes a. feu. Paris, 1740. 4to. Louis, A., Cours de Chirurgie pratique sur les Plaies d'Armes a feu. Paris, 1746. 4to. Ravaton, Chirurgien d'armee, ou Traite des Plaies d'Armes k feu et d'Armes blanches. Paris, 1768. 8vo. Amsterdam, 1748. 8vo., here used. Schmidt, Preissschrift von der Behandlung der Schusswunden. Wien, 17S8. Percy, Manuel de Chirurgien d'armee, ou Instruction de Chirurgie Militaire sur le Traitment de Plaies, et specialement de cellus d'Armes a feu: avec la methode d'extraire de ces plaies les corps etrangers, et la description d'un nouvel instrument propre a cet usage. Paris, 1792. Hunter, John, A Treatise on the Blood, Inflammation, and Gun-shot Wounds, Edited by E. Home. London, 1794. 4to. Defauart, Analyse des Blessures d'Armes & feu, et de leur Traitement. Paris, 1801. 8vo. Lombard, Clinique Chirurgicale des Plaies faites par Armes a feu. Strasbourg, 1804. 8vo. Guthrie, G. J., On Gun-shot Wounds of the Extremities requiring the different Operations of Amputation; with their After-treatment. London, 1815. 8vo. 3d Edit. 1827. Thomson, Dr. John, Report of Observations made in the British Ministry Hospi- tals in Belgium, after the battle of Waterloo, with some Remarks on Amputation. 8vo. Edinburgh, 1816. Hennen, John, Observations on some important points in the Practice of Military Surgery, and the arrangement and police of Hospitals. Edinburgh, 1818. 8vo. 2d Edit. 1820. Dupuytren, Des Blessures par Armes -k feu ; in his Lecons orales de Clinique Chirurgicale, vol. ii. p. 417. Beside these the treatises of Boucher, Bordenave, De La Martiniere and Faure, in the Memoires de l'Academie de Chirurgie, and the greater number of the writers on Wounds in general, already quoted. 334. Gun-shot Wounds are those produced by hard, usually me- tallic bodies, as balk of various size, pieces of lead and so on, projected by the explosion of gunpowder. They are, therefore, in the highest de- gree bruised wounds. The violence with which the body causing the division of organic parts acts, is so great that, as a consequence of the immense bruising and tearing, it is always accompanied with disorga- nization, that is, with a slough. [" Wounds of this kind," says Hunter^ " vary from one another, which will happen, according to circumstances. These variations will be in general according to the kind of body projected, the velocity of the body, with the nature and pecu- liarities ofthe parts injured. The kind of body projected, I have observed, is prin- cipally musket-balls, sometimes cannon-balls, sometimes pieces of broken shells, and very often, on board of ship, splinters of wood. Indeed, the effects of cannon- balls on different parts of the ship, either the containing parts, as the hull of the ship itself, or the contained, are the principal causes of wounds in the sailor; for a cannon-ball must go through the timbers of the ship before it can do more execu- tion than simply as a ball, (which makes it a spent ball,) and which splinters the inside of the ship very considerably, and moves other bodies in the ship, neither of which it would do if moving with sufficient velocity: musket or cannon-balls seldom do any immediate injury to those of that profession." (p. 523.) Dupuytren observes :—" The effects of gun-shot depend on two principal cir- cumstances ; the manner in which the gun has been charged, and the distance at whieh it has been fired. If a gun be loaded with powder only, without being rammed down, its discharge makes little noise, but is quite sufficient to bruise the skin severely, if its contents be received at a short distance. If the gun, though loaded only with powder, have been more or less tightly rammed, its effects vary GUN-SHOT WOUNDS. 371 according to the degree of resistance, and the distance of the body struck: of which I witnessed the following example :—Two persons quarrelled, one of the two, ex- cited by rage, discharged a gun loaded with powder only into the belly of the other, who dropped dead on the spot; the distance between them being only one or two feet. On examining to ascertain the cause of death, we found the clothes torn, the wall of the belly pierced with a hole about an inch in diameter, and the intestine opened; the gun-wadding was in the middle of the belly, and there was not any other opening: it was ascertained that the gun contained only powder. I have known many other similar instances. Very often suicides, in the trouble and agitation by which they are possessed, forget to put the bullet into the pistol. The different parts ofthe walls ofthe mouth are violently distended by the rarefaction ofthe air. Sometimes the wadding passes through the palate. If the shot pass backwards, the vertebral column is certainly not damaged, but the soft palate is torn, and some- times even the lower jaw is broken. * * * Small shot of different sizes act in two ways, either as they strike en masse, and, it is said, make a bullet, which depends on the quality of the gun and the little distance of its aperture, or whether the shot spread and fall singly. In the former case its effect is very violent, and produces upon the livingbodyresultsmoreseriouseventhan abullet. In this way the son of Marshal Moncey was accidentally killed ; and every sporting season adds fresh victims, either of imprudence or awkwardness. Very frequently a single bullet will pass through the lung without producing death, whilst a charge of shot tears the organ to pieces, and infallibly destroys the party. In the second case, that is if the shot are received at a distance, it is very rare that any serious consequences ensue, unless the part hit be of great importance. An eye, struck by a single shot is almost always lost without remedy. If the heart, stomach, or intestine, be struck, serious mischief may ensue; but these projectiles rarely penetrate further than the sub- cutaneous cellular tissue." (p. 419-422.) I have had two cases under my own care, in which the former kind of accident occurred. In the one, a man received the whole charge of common small shot from a fowling piece, at the distance of a very few yards, on the upper outer part ofthe thigh, near the great trochanter, by which a single round hole, about an inch in diameter, was produced, with but little bruising. The accident had occurred about two hours before he came to the hospital, having been brought from a distance of three miles. He was in a state of collapse when he arrived, and died very shortly after his admission. On examination, the upper part of the thigh-bone was found broken to pieces, and the muscles in shreds; the femoral vessels (if I recollect, for I cannot find any note of the case) were torn asunder. The hemorrhage had been free. The second case was under my care last year :—A lad, in whose pocket a pistol discharged and shot him in the fore and inner part of the thigh, about the middle, producing a wound about the size of a halfpenny. The pistol was loaded with shot, and he said he had a sixpence in his pocket, which it was thought might have entered the wound. Suppuration commenced on the third day, the slough separated on the eighth, and suppuration was free. On the ninth day two shots were discharged, and on the day following a large piece of wadding, which left open a long sinus extending nearly to the knee. On the eleventh day another piece of wadding was discharged ; and on the twentieth, after some pain along the thigh up to the groin, a second large mass of w-ad came away. By the thirty-second day the discharge of pus had ceased, and the wound had healed to the size of a six- pence ; but a week after it became irritable, and 'pain extended up the thigh. The sore became more irritable and spread to the size of a crown-piece, and he seemed running fast into a hectic state ; but on the forty-third day two more shot were dis- charged. Immediately he began to improve, and in the course of five weeks he was perfectly well. I have several times seen persons peppered with shot, as it is called, from a fowling-piece discharged at a distance, which, as Dupuytren states, lodged in the subcutaneous tissue, and were of little consequence; some being dis- charged by suppuration, or removed by hand, whilst others remained quiet where they were lodged.—j. f. s.] 335. Gun shot wounds, like bruised and torn -wounds, are at first accompanied with slight pain (1.) They bleed little, or not all; but the bleeding differs according to the way in which the artery is divided. If a large artery be very quickly divided by a bullet, the bleeding is severe ; 372 SHOCK. but, on the contrary, scanty, if the artery be more bruised and torn by the diminished speed ofthe bullet (2.) From the same circumstances the form ofthe shot-wound varies : with a quick ball it often rather resem- bles a cut or stab; but a weak ball causes greater bruising, tearing, ecchymosis, and so on. Most commonly a greater or less degree of shock of the wounded part, or of the whole body, is connected with gun- shot wounds, especially if the ball strike above, or if the injury be in the neighbourhood of any important viscus. The shock consists in a diminished sensibility, or complete numbness ofthe injured part, or of the whole body; in faintness, trembling, cold sweats, vomiting, giddi- ness, small pulse, and so on (3.) The symptoms which come on at a later period in shot wounds are active inflammation and swelling, fever, gangrene, nervous symptoms, and copious suppuration (4.) [(1) "It has been supposed," says Guthrie, "that gun-shot wounds are not painful at the moment of infliction. This, as a general principle, is erroneous, although in many the pain is but trifling, whilst in others it is severe, and in some few rare instances the patient has been unconscious ofthe injury, (p. 3.) I am induced to conclude, from many considerations, that the greater the velocity with which the projectile is impelled, the rounder and smaller the size, and the less the re- sistance opposed, the less will be the sensation of pain produced in the sufferer. But even this opinion must be received with considerable latitude; and a cannon-ball will sometimes completely destroy the internal texture and life of a part, withou t tearing the skin or causing much pain, and yet the shot causing such injury have usually lost the greater part of the velocity with which it was originally propelled. A musket-ball merely impinging against a soft part, without rupturing the skin, inva- riably causes much more inability, than if it had actually entered or passed through it." (p. 5.) (2) " According to theory," says Guthrie, " a gun-shot wound being a contused wound, ought not to bleed, in the first instance, because the parts are dead or dead- ened ; and, if it should bleed, some great blood-vessel must be injured ; whilst, ac- cording to the same authority, secondary haemorrhage was to be expected and dreaded at the moment of the separation of the sloughs. * * * Facts are often opposed to theory, and in nothing more than on this point; for although some gun-shot wounds bleed but little at the moment of infliction, there is in the greater number more or less loss of blood, and occasionally in considerable quantity, although there be no vessels of importance injured. In wounds of the face and neck, the quantity lost is often considerable, and the clothes are generally covered with it. If the ball in- flicting the injury should have come in contact with any solid substance, previously to its touching the human body, it may have become of an angular, irregular, and even flattened form : the wound will be, in consequence of this change in the ball, more lacerated than contused, and the loss of blood in all probability greater. * * * The bleeding from a simple flesh wound soon ceases, and does not return except some violence be done to the part; whilst, in a case of a wounded artery, it sometimes continues until the patient dies, which is frequently the case when a large artery is partially divided. If the artery be completely divided, a considerable quantity of blood is quickly lost, and the patient may also die; but, in general, syncope or a state nearly allied to it supervenes, and the haemorrhage ceases spontaneously. The same' thing occurs when a limb is carried away by a cannon-shot, and proves the safe-guard of the patient's life ; for serious and destructive bleeding has ceased, in most cases, before a tourniquet can be applied : and, indeed, in the greater num- ber of cases they are of no use whatever, for after the haemorrhage has been spon- taneously suppressed, it does not in general return; and whenever it does return, the patient's life will certainly be lost, unless proper and effective assistance be at hand." (pp. 6, 7.) (3) With regard to the shock, Guthrie makes the following very interesting obser- vations :—"When an organ of importance has been injured, and the blow severe, as by a cannon or grape-shot, or shell, or from the fracture of a bone, and even from the attention being directed to the receipt of an injury from the situation in which the soldier may be placed, a peculiar constitutional alarm ensues, in a much greater SHOCK. 373 degree than would follow an injury of equal magnitude precisely in the same spot from any other cause. It affects alike, although not in an equal manner, the coward and the brave, the man of learning and the unlettered soldier. * * * On the re- ceipt of a wound which has the appearance of being fatal, or if circumstances of situation can give rise to such an idea in the patient's mind, the constitutional af- fection is often as manifest at first as when some vital organ has been injured ; but it subsides much sooner, and offers us, in doubtful cases, a diagnostic symptom of the greatest value and certainty. * * * The continuance of the constitutional alarm or shock ought to excite great suspicion of serious injury; and when wounds have been received in such situations, or bear such appearances as render it doubtful whether any parts of vital importance have been injured or not, the surgeon may sometimes make up his mind as to the fact from it alone, when other symptoms more indicative of the injury are wanting; and under all such circumstances he ought to be particularly guarded in the prognosis or opinion given to the patient or his friends, although every other appearance should even lead him to suppose the injury to be less serious." (pp. 10, 11.) Hennen remarks, that " some men Will have a limb carried off or shattered to pieces by a cannon-ball, without exhibiting the slightest symptoms of mental or corporeal agitation; nay, even without being con- scious of the occurrence; and when they are, they will cooly argue on the probable result of the injury; while a deadly paleness, constant vomiting, profuse perspira- tion, and universal tremor will seize on another on the receipt of a slight flesh-wound. This tremor, which has been so much talked of, and which to an inexperienced eye, is really terrifying, is soon relieved by a mouthful of wine or spirits, or by an opiate, but above all by the tenderness and sympathizing manner of the surgeon, and his assurances of his patient's safety." (p. 33.) (4) " Gun-shot wounds, from whatever cause," observes Hunter, " are in gene- ral contused wounds, from which contusion there is most commonly a part of the solids surrounding tbe wound deadened, as* the projecting body forced its way through these solids, which is afterwards thrown off in form of a slough, and which prevents such wounds from healing by the first intention or by means of the ad- hesive inflammation, from which circumstance most of them must be allowed to suppurate. This does not always take place equally in every gun-shot wound, nor in every part of the same wound; and the difference commonly arises from the variety in the velocity of the body projected ; for we find in many cases where the ball has passed with little velocity, which is often the case with balls even at their en- trance, but most commonly at the part last wounded by the ball, that the wounds are often healed by the first intention. Gun-shot wounds, from the circumstance of commonly having a part killed, in general do not inflame so readily as those from other accidents ; this backwardness to inflame will be in the proportion that the quantity of deadened parts bear to the extent of the wound; from whicti circumstance the inflammation is later in coming on, more especially when a ball passes through a fleshy part with great velocity, because there will be a great deal deadened in proportion to the size of the wound. * * * On the other hand, where the ball has fractured some bone, which fracture in the bone has done considerable mischief to the soft parts independent of the ball, then there will be nearly as quick inflamma- tion as in a compound fracture of the same bone, because the deadened parts bear no proportion to the laceration or wound in general." (pp. 523, 24.) Instances, however, do now and then occur, in which the wounds made by gun- shot are perfectly regular, and, more or less, like those made by a cutting instrument. Several such have been mentioned by H. Larrey; (a) and, in one case, a fragment of shell carried away a piece of the skin of the chest leaving a regular elliptical wound, resembling that produced by amputation of the breast. The edges were brought together without sutures, and was quickly cured, (p. 138.)] 336. The direction of the shot-wound varies extraordinarily, and depends on the speed of the ball, on the different thickness and resist- ance of the part which the ball strikes. Its course is usually indicated externally by a dark streak, or a certain emphysematous crackling may be observed by feeling along the shot track. Experience has proved that balls can travel not merely round the convex surface of the walls of (a) Hist. Chir. du Si6ge de la Citadelle d'Anvers. 8vo Vol. i.—32 374 VARIETIES OF GUN-SHOT INJURIES. the different cavities of our body, but even completely around their concave surface. 337. The following general kinds of injury from shot wounds may be distinguished:— 1. The ball may not penetrate, but injure deep-lying parts in various ways, so that muscles and other soft parts may be bruised, and bones even crushed, without the skin being injured. (Wounds by wind of the ball, or by rebound of shot.) This occurs, either because the ball has not sufficient power to penetrate, or because it strikes the body very ob- liquely (1.) 2. The ball penetrates, but remains lodged, and the shot passage has but one opening (2.) 3. The ball passes through : the shot passage has two apertures, the one by wdiich the ball has entered, pressed in, as large or even smaller than the ball, and the circumference of the other larger, outspreading, irregularly torn, and little bruised (3.) 4. The ball has taken off the greater part or the whole ofthe limb. Shot-wounds are also further distinguished into simple and complicated, according as merely soft parts of minor importance, or vessels, nerves, and bone, are injured. (1) The opinion that the so-called wounds from the wind of balls is produced by the compression of the air, by the electric condition of the ball during its passage through the cannon or through the air, has been long known as incorrect. Recently Rust (a) and Busch (b) have again taken up wounds by the wind of balls, but have not ascribed their operation to the pressure of the air, but to the vacuum mo- mentarily produced by the passage of a ball of large calibre, by which a turgescence in the part takes place externally towards the vacuum. This opinion, however, does not seem to me agreeable to the laws of physics. ["It very often happens," says Hennen, "that while all is smooth and sound to the eye, or there is perhaps only a slight erosion of the skin, a very serious injury has been done to the subjacent soft parts." If the vitality of the part be entirely destroyed, "a circumscribed tumour, soft and pulpy to the feel, forms on the spot; the skin, at first of a natural colour, gradually assumes a dusky shining hue, and either sloughs off, leaving beneath a dark glossy, flabby, muscular mass, discharging tenacious bloody sanies, or else a chain of ill-conditioned abscesses forms, which soon run into one another, and burrow deep beneath the disorganized mass of skin and muscle, if not prevented by timely evacuation." (pp. 91, 2.) (2) "These appearances," according to Guthrie, "are by no means constant, or so strongly marked. If the ball impinge with violence against a surface capable of offering considerable resistance, the entrance will be well-marked. If the resistance offered be nearly equal to the momentum, the ball will lodge or pass through with a well-marked exit; but if the velocity and impulse be greatly superior to the re- sistance, the exit, although not a depression, will often partake in the appearances of the entrance, the velocity with which the ball passes through the part overcoming so instantaneously the resistance, that the laceration, which would otherwise take place in the passage of the ball from the dense medium of the body to the rarer one of the air, does not occur." (p. 18.) Dr. Thomson says :—" It is no uncommon thing for a ball in striking against the sharp edge of a bone to be split into two pieces, each of which takes a different direction, Sometimes it happens that one of the pieces remains in the place which it struck, while the other continues its course through the body. Of a ball split by the edge of the patella, I have known one-half pass through at the moment of the injury, and the other remain in the joint for months without its presence there being suspected. In the same manner I have known a ball divided by striking against the spine of the scapula, and one portion of it pass directly through the chest, from the point of impulse, whilst the other moved along the integuments, till it reached the elbow." (p. 37.) Similar to this is the case, mentioned by Dupuytren, of "a (a) Rust's Magazin, vol. vii. part iii. p. 344. (b) Ibid, vol. x.part iii. p. 37?. TREATMENT OF GUN-SHOT WOUNDS. 375 man who received a shot, and the ball entering the lower part of the right leg was split into two upon the sharp edge of the shin-bone. Both halves passed the calf of'the leg a little apart, and lodged in the thickness of the other leg, which was behind. Such cases are not rare." (p. 429.) (3) Upon this point Guthrie observes:—" If there be but one opening to be seen, it is usual to suppose the ball has lodged'; but this does not always follow, although the finger may pass into the wound for some distance. * * * It sometimes happens in injuries of the head, that the ball drives a piece of bone nearly of its own size into the substance of the brain, although it does not actually penetrate with it, but falls to the ground. A ball will often be turned, as is well known, by a slight resist- ance which is not directly opposed to it; but if the resistance be greater than the mo- mentum, and offered by an elastic body, the ball may retrace the passage it has made; as for instance, when opposed by the cartilages of the ribs, or any strong tendon." (p. 19.) 338. Shot-wounds are most generally complicated with the presence of foreign bodies in the cavity of the wound. These may be, the ball itself, the wadding, pieces of clothes, splinters of bone, and so on. Slow balls usually drive a larger piece of the clothes into the canal of the wound, than balls which still move quickly, and where usually but a single tear, corresponding to the size of the ball, is found. 339. The prognosis of gun-shot wounds is the more serious as the wound is less simple; the greater the destruction, which the ball has produced by its size and swiftness, the more sensitive the wounded person is, and the more important is the injured part. The degree of the shock, the severity ofthe inflammatory symptoms, mortification, and copious suppuration, are in shot-wounds generally to be dreaded; and these evils are increased by the condition in which the wounded are commonly found, their crowding together in hospitals, the prevalence of contagious disease, the danger of hospital gangrene, of tetanus, and so on, 340. If the injury in shot-wound be not such as at once to require the amputation of the limb, or the stanching of a severe bleeding, the first indication is to examine the wound carefully, in order to ascertain its course and the presence of any foreign body: all which has been mentioned (pars. 275 and 306) in regard to the examination of wounds and the extraction of foreign bodies applies here. The enlargement of the shot-wound, in former times generally prac- tised, may, besides in the cases where the discovery and extraction of if. foreign bodies render it feasible, be necessary for the following rea- sons :—-1. In shot-wounds of parts covered with a tough aponeurosis ; for instance, on the back of the neck and spine, on the shoulder, fore-arm, hand, on the upper and outer part of the thigh, on the leg, and on the sole of the foot. In these eases the aponeurosis must be always more extensively cut into than the underlying parts, whereby the dreaded strangulation of the parts, in the ensuing swelling can, simply and alone be prevented. 2. In shot-wounds in very yielding parts, where a great outpouring of blood always takes place, as in the scrotum. 3. Wruen fibrous parts and nerves are only half divided, and much bruised. 4. In bleedings for the purpose of laying bare and tying the vessel. 5. When a bullet is lodged in a joint, and the wounded person resists amputation. 6. In wounds penetrating cavities, for the purpose of emptying the extravasated blood. Enlargement of the wound may also be necessary at a subsequent 376 TREATMENT OF period, in order to furnish a proper outlet for pus, or for the removal of loose splinters of bone or other foreign bodies. In making the en- largement a button-ended bistoury is to be introduced upon the fore- finger of the left hand, or upon a hollow director, and the wound en- larged in such direction and extent as the position of the part and the individual case may require. When it has been ascertained, by examining the wound, that no large vessel is injured, the most certain remedy to stanch the bleeding is suitable compression. When it is impossible, by enlarging the wound, to take up a large vessel in the wound itself, the artery must be laid bare and tied above the wounded part. [" If the ball has passed through the fleshy part of the arm, thigh, or buttock, we do no more," says Hennen, " than sponge the part clean, place a small bit of folded lint on each orifice, which we retain by two cross slips of adhesive plaster, and lay over two or three turns of a roller. The ball will frequently have passed nearly through the limb, and be retained only by the elasticity of the common integuments; these we cut upon and extract it at once; and we should lay it down as a rule not to be deviated from, to extract on the spot every extraneous body that we possibly can, either by the forceps alone or with a bistoury." (pp. 33, 4.) 341. The remaining treatment of gun-shot wounds does not differ from that of bruised wounds. The orifice is to be covered with a mass of soft charpie, which is to be slightly fastened with a bandage, resolving applications of cold water, solutions of muriate of ammonia, and so on, are to be laid over the neigbourhood ofthe wound. The general treat- ment must be strictly antiphlogistic, according to the state of the con- stitution and the inflammatory symptoms present. But when the shock is severe, stimulating and reviving remedies must be employed in the first instance. 342. If active inflammation and swelling exist, instead of cold appli- cations, warm, softening poultices should be employed to further sup- puration. When this takes place, the slough in the shot-passage sepa- rates, and the vessels, which had been closed in many instances begin to bleed. The direction of the shot-passage must draw the attention of the surgeon to the possibility of this occurrence. The patient should at this time be surrounded with clever assistants, and, if bleeding take place, it must be stopped by pressure, or by tying the vessel. If the bleeding be connected with inflammatory congestion, cold applications and blood-letting must be employed. [Guthrie says :—" On the separation of the sloughs a little blood may occasion- ally be lost, but it is generally caused by the impatience of the surgeon, or the irregularity ofthe patient, and seldom requires attention. Sometimes at this period, that is, from the eighth to the twentieth day, a large artery will give way from sloughing or ulceration; but the proportion of cases requiring the ligature of arteries will not be greater than three or four in a thousand taken indiscriminately, exclusive of haemorrhage caused by hospital gangrene, &c, which, as they may almost always be avoided by proper care and management, cannot with propriety be considered as legitimate causes." (p. 8.) Samuel Cooper's statement, in regard to bleeding from arteries on the separation of sloughs, differs materially from that of Guthrie. He says (a):—"In the beginning there may even be little haemorrhage, though a con- siderable artery be so hurt that it afterwards sloughs, and a dangerous ox fatal bleeding arise. Thus, in one of my own patients, who had received a musket-ball through the ham, the popliteal artery gave way about ten days after the injury and compelled me to take up the femoral artery; and, in the Elizabeth Hospital at Brussels, amongst the patients under the care of my friend Mr. Collier and myself, (a) Surgical Dictionary. Seventh Edition. GUN-SHOT WOUNDS. 377 about a week after the battle of Waterloo, the cases of haemorrhage, on the loosening ofthe sloughs, were numerous." (p. 632.) Dupuytren states, that consecutive haemorrhage " occurs under two different cir- cumstances, either the artery has been completely or in part only divided. In the first case, the scar produced by the shot and the clot of blood which forms its cavity, up to the first collateral branch, obliterates and suspends the circulation throughout its whole extent. But it often happens that, under the influence of certain causes, the circulation speedily resumes considerable activity, the clot is pushed off, the scar overcome and haemorrhage takes place. In the other case, the obstacles which prevent the bleeding resist till the very moment when the whole internal surface of the wound, and consequently the torn and disorganized parts of the artery are detached and thrown off by the suppuration. But at "this time, if the end of the artery be obliterated only to a short distance, if its adhesions be not sufficiently firm, if the careless movements of the patient destroy this union and so on, the artery is opened and the patient exposed to more or less imminent danger. These consecutive bleedings usually occur about the tenth, fifteenth, and even twentieth day, without any premonitory symptoms, except sometimes a serosanguinolent oozing from the wound." (pp. 465, 66.)] 343. The local and general treatment during suppuration must be always proportioned to the vital disposition and the powers of the wound. Particular care must be had for pure air, and for the function ofthe bowels. Often during suppuration inflammation recurs, the sup- puration is bad, or perfectly suppressed; the wound, when almost en- tirely closed, breaks out again repeatedly. In such cases foreign bodies, especially splinters of bone, are usually retained, which must be removed as soon as possible. If this cannot be effected in the usual way, the introduction of a seton is the most preferable means to obtain a proper outlet for the pus, and to promote the escape ofthe splinters of bone. [" In cases where the separated pieces (of bone) lie loose, and cannot easily be got at by the forceps, setons have been employed with some advantage, for the purpose of bringing them away; and when judiciously applied, and not carried to such a length as to affect sound pieces of bone with caries, and thus produce what they meant to remove, they may often be usefully had recourse to. Staff- Surgeon Boggie showed me," says Hennen, " some cases at Brussels in which he had employed the seton with success, and an account of a case in which he adopted the plan is published in the 7th volume of the Medico-Chirurgical Transactions. Dr. Arthur, Surgeon to the forces, has also sucessfully used them in some old cases at the General Hospital, Chatham. But to the indiscriminate introduction of . setons in gun-shot injuries, either ofthe bones or soft parts, I cannot help entertain- ing strong objections. They are the best but a clumsy and unmanageable substitute for the knife, and in numerous instances much more painful and irritating." (pp. 131, 32.)] 341. If the shot-wound be connected with fracture of bones, and im- mediate amputation be not indicated, the treatment is always very tedious and difficult. When the wound is enlarged, according to cir- cumstances, for the extraction of loose pieces of bone, and the arrange- ment in their place of the pieces still attached, we may proceed to put up the fracture, and the application of a contentive bandage by means of Scultetus's bandage and a large wooden splint, if there be not any great swelling by contraction of the muscles; but, if this be the case, or if the wounded person have yet to be moved, in which case this bandage cannot prevent the displacement of the ends of the bone, the limb should be put in the half-bent position, in which the muscles are for the most part relaxed ; it must be wrapped up in Scultetus's 32* 378 CASES REQUIRING AMPUTATION. oandage, and the ends of the bone protected against much displacement. As soon as the inflammatory symptoms are diminished by the general and local treatment, attention must be paid to the management of the fracture. Actual extension ofthe limb with Dessault's splint, with the machines of Boyer, Sauter, and others, may be employed with much advantage; but must be used with great caution. The causes which here especially delay the union of the ends of the bone are, too copious suppuration, improper arrangement ofthe fracture, foreign bodies, death ofthe bone (1.) If the suppuration be so great that the powers of the patient fail, amputation must be prescribed at the proper time. ["The disposition to necrosis in gun-shot injuries of the bones, a circumstance of daily occurrence in military hospitals, is," says Hennen, "always tedious, highly troublesome, and frequently dangerous. The precise time of its commencement is not easily ascertained: I have detected it on the twenty-first day from an injury; but it is more frequently a disease of the advanced periods. It is most frequent in bones covered by their soft parts, while caries takes place more readily when they are exposed to the air. Where the periosteum is removed for any extent by a gun- shot or lacerated wound, or suffers disorganization afterwards from any cause, whether inflammation, ulceration or erosion; or where the medulla is injured or de- stroyed, it becomes a never failing occasion ofthe death of that part of the bone in the immediate vicinity ofthe injury." (pp. 124, 25.)] 345. In long-continued suppuration, bleeding often occurs from the whole surface of the wound, which commonly retards and very much weakens the patient. These bleedings depend on a weakness of the vessels, and upon a state of thinness of the blood. Local, and general strengthening remedies must be employed; decoction of bark with the mineral acids; care must be taken for pure air and good food ; and the wound filled with charpie soaked in a vinous decoction of elm bark with alum and so on. If these means be not beneficial, and sinking be feared, the application ofthe actual cautery, or tying the principal arterial trunk of the limb, is the only remedy which can be tried, previous to amputa- tion. 346. The decision upon those circumstances in wounds, especially those from gun-shot, which render amputation necessary, belongs to the most difficult part of surgery. Not only must the importance of the injury itself be well considered; but also, as these cases for the most part occur in war, in so far as the transport of the wounded, the want of proper care and nursing, overfilled hospitals, and the danger connected with a long sojourn in the hospital, render possible or not the preserva- tion of the wounded limb and whether perhaps the limb can be pre- served only in such a crippled state that it is more inconvenient than useful, and the life of the wounded person is put in the greatest danger by the attempt to preserve the limb. 347. When the condition of the wound is favourable for amputation, it should be performed as soon as possible, at least in the first twelve or twenty-four hours before the secondary symptoms have come on. Ex- perience is against putting off amputation to a later period, as practised by the earlier surgeons. 348. The following are those cases which require amputation on the spot: 1. When a limb is entirely torn off by a ball; as in such an injury, especially when the ball has lost its power, the splitting of the bone CASES REQUIRING AMPUTATION. 379 commonly extends into the neighbouring joint, the limb must be removed high above the place of injury, or above the next joint (1.) 2. If both the soft and hard parts of a limb are so bruised and smashed that gangrene will certainly occur. 3. If, without injury of the bone, the soft parts of a limb, the largest vessels and nerves are mostly destroyed. 4. When the soft parts and bones of a limb, wfth the largest nerves, are smashed and torn although the principal arterial trunk is not injured. 5. Splitting of the large bones, with tearing of the vessels and bruising ofthe deep-lying parts, without injury of the external skin (2.) Before proceeding to amputation, we must cut down to ascertain the extent of the destruction of the parts. 6. Smashing of joints, especially of the knee and foot-joints, when the capsular ligament is very much torn and the bone split, or when the ball is lodged in the joint and cannot be removed. If the head of the bone be completely separated from its body in the shoulder-joint, the head of that bone may be removed. [(1) Hennen says:—"If, however, the bone is splintered to the very joint, or so close as to excite our fears as to future consequences, we operate beyond it on the upper part of the limb. If the head of the humerus itself is injured, or the shaft splintered, with much destruction of the soft parts, or if the head of the bone alone is left in the glenoid cavity, the rest being carried off, we forthwith take it out of the socket; an operation as simple, if properly planned, as any in surgery ; and one which, on all occasions where the bone is injured, is infinitely preferable to ampu- tation lower down. It not unfrequently occurs, tbat the arm is carried completely out of the socket; and, in this case, very little more remains for the surgeon than to pass a ligature round the arteries, even though they do not bleed, as often happens, and to cut short the leash of nerves, which in this case usually hangs far out of the wound, to bring the lips towards each other by adhesive straps, and to support them by proper compress and bandage." (pp. 38, 9.) (2) Hennen mentions "a species of the comminuted compound Gun-shot Fracture, which, although at first of but little consequence in appearance, is of most serious importance in its results. This occurs where a musket-ball has perforated a cylindrical bone without totally destroying its continuity, and consequently without producing any distortion of the limb, or other symptoms which characterize a frac- ture. The foundation of infinite mischief is, however, laid; for not only is the shaft of the bone injured, but fragments are carried into and lodged in the medullary canal; and if the limb has been in an oblique position, or the ball has taken an oblique course, these fragments are often driven in to a great distance, and fairly impacted in its cavity, there keeping up a constant and un- controllable irritation, and destroying both the medulla and its membrane, toge- ther with the cancelli, which naturally support it. I have repeatedly seen this separated portion of bone lying in the medullary canal, at the distance of from four lines to an inch and a half from the circular hole formed by the passage of the ball, retaining its shape, its colour, its solidity, while all the surrounding osseous parts were diseased, and formed a spongy discoloured mass of bony granulations around it, the periosteum, for some way, both above and below the wound, being entirely separated from the bone. To attempt to save such a limb is imposing a task upon the powers of nature, which, nineteen times in twenty, she is unable to effect, even under the most favourable circumstances. If a ball has passed through without carrying in any fragments of bone, a case which sometimes happens in the thigh, when the man is standing erect, and the ball has struck the bone fairly and directly, the case is more favourable, than when the wound is oblique as in the arm, which is so often thrown into a variety of postures; and consequently, where there is a greater chance that the channel of the ball should be formed obliquely, and the spicular fragments forced up into the medullary cavity. But even of this favour- able variety I have seen only two cases cured, both of persons struck on the centre 380 CASES REQUIRING AMPUTATION. of the femur, the wound admitting a finger to be passed into the bony ring or perforation, and there to find a clear, unembarrassed, and comparatively simple loss of parts. By far the most frequent result is the loss of the limb sooner or later, after a very tedious and distressing train of symptoms, exhausting to the patient and baffling every endeavour of his attendants." (pp. 133, 34.) (3) " Balls often pass through or along the bones of the hand or foot, and, except in .very severe cases attended with great loss of substance, amputation," says Hennen "is not immediately necessary. The strength of the fasciae covering those parts, and the number of minute bones composing them, will, however, render ex- tensive openings peculiarly requisite. These bones never suffer from necrosis, nor do they ever become regenerated as far as my experience goes; but if the aid of an appropriate supporting splint, assisted by proper bandages, is had recourse to, their loss is soon supplied by a new formation of soft parts, approaching to a cartilaginous nature; and by the approximation of the sound bones to each other. However desirable it may be to save a hand or foot, yet, in severe lacerations, the frequency of tetanic affections should at once lead us to adopt immediate amputation. Gun- shot injuries of the joint of the great toe are always extremely troublesome, and accompanied with excruciating pain, often giving rise to severe nervous affections, and often terminating in tetanus. Amputation of the toe will therefore be the safest mode of treatment, and it should be a general rule to amputate all lacerated toes and fingers, in preference to attempting their preservation." (pp. 154, 55.)] 349. The earlier in these cases amputation is had recourse to, the more successful is the result; but in very severe general shock, or in complete numbing from cold, the wounded person must be first revived with stimulants. When the secondary symptoms have once set in, before amputation is performed, it must be delayed, till afcer proper treatment the patient is in a quiet condition at the period of suppuration, at which time amputation should be immediately performed. [Immediate amputation after severe gun-shot injuries has long been the practice of English army and navy Surgeons, for it would seem in the way it is spoken of by Wiseman that even in his time it was a settled proceeding. He says :—" Ex- perience judge th it commendable, if it be necessary; and in such shattered limbs where there is no hope of preserving the patient's life otherwise. And then it must be done in its proper time, that is to say, suddenly upon the receipt of the wound, before the patient's spirits be overheated, either with pain, fever, &c. * * * But amongst us aboard, in that (the naval) service, it was counted a great shame to the chirurgeon if that operation was left to be done the next day, when symptoms were upon the patient and he spent with watchings, &c. Therefore you are to consider well the members, and if you have no probable hope of sanation, cut it off quickly, while the soldier is heated and in mettle. But if there be hopes of cure, proceed rationally to a right and methodical healing of such wound; it being more for your credit to save one member than to cutoff many." (p. 396.) The celebrated French surgeon, Le Dran, who published on gun-shot wounds a few years after WisEMAN, also advocated the early amputation, and lays it down as a rule, " that when the amputation of a limb is indispensably necessary, in the case of a gun-shot wound, it ought to be done without delay." (p. 163.) Ranby, (a) who was sergeant-surgeon to George the Second, and whom he accompanied in the wars in Flanders, adhered to Wiseman's practice, and says :— " If a wound be of such a desperate nature as to require amputation, (which is always the case when it happens in any principal joint,) it would certainly be of consequence could the operation be performed on the spot, even in the field of battle; lest, by deferring it, an inflammation may come on, which one may very reasonably expect should obstruct a work that ought rarely to be entered upon during the con- tinuance of so calamitous a circumstance. The neglecting this critical juncture of (a) The Method of treating Gun-shot their connexion with the barbers, and eata- Wounds. 8vo. London, 1774. To Ranby Wished as a distinct corporation, of which the profession of Surgery in this country is he was the first master, although not a much indebted, as it is believed that mainly member of the old court, and probably not by his interest and exertions the Surgeons even a member of the Company of Barbers were in 1745 (18 Geo II.) separated from and Surgeons. PROPER TIME FOR AMPUTATION. 381 taking off a limb, frequently reduces the patient to so low a state, and subjects the blood and juices to such an alteration, as must unavoidably render the subsequent operation, if not entirely unsuccessful, at least exceedingly dubious." (p. 29.) It is probable that about this time some dispute had occurred as to the propriety of this practice; for, in 1756, the French Academy of Surgery proposed it as the subject for the prize essay in that year, and in consequence of the paper of Faure, an army Surgeon, to which they assigned the reward, they decided in favour of delaying the operation wherever practicable, although from the first it were abso- lutely necessary. Soon after, this, Bilguer, Surgeon-general to the Prussian army, wrote against amputation in general, and permitted no amputation in that service. But although his statements were " much applauded, and in some countries held up as doctrines to be followed," yet, from carefnlly sifting them, and from his own practical experience, Guthrie says, that " Bilguer on this subject ought never to be quoted as an authority for modern times." (p. 205.) But neither the recommendation ofthe French Academy nor Bilguer's anathema seem to have had much influence on the medical officers of the British service, for Hunter says :—" In general, surgeons have not endeavoured to delay it (amputation) till the patient has been housed and put in the way of cure; and therefore it has been a common practice to amputate on the field of battle." But to primary amputation Hunter was decidedly averse, for he proceeds;— " Nothing can be more improper than this practice, for the following reasons. In such a situation it is almost impossible for a surgeon, in many instances to make himself sufficiently master of the case, so as to perform so capital an operation with propriety; and it admits of dispute, whether at any time and in any place amputa- tion should be performed before the first inflammation is over. When a case is so violent as not to admit of a cure in any situation, it is a chance if the patient will be able to bear the consequent inflammation, therefore in such a case it might appear, at first sight, that the best practice would be to amputate at the very first; but if the patient is not able to support the inflammation arising from the accident, it is more than probable that he would not be able to support the amputation and its conse- quences; on the other hand, if the case is such as will admit of its being brought through the first inflammation, although not curable, we should certainly allow of it, for we may be assured that the patient will be better able to bear the second. If the chances are so even, where common circumstances in life favour the amputation, how must it be where they do not? how must it be with a man whose mind is in the height of agitation, arising from fatigue, fear, distress, &c. 1 These circum- stances must add greatly to the consequent mischief, and cast the balance much in favour of forbearance. If it should he said that, agreeable to my argument, the same circumstances of agitation will render the accident itself more dangerous, I answer that the amputation is a violence superadded to injury; therefore heightens the danger, and when the injury alone proves fatal, it is by slower means. In the first case it is only inflammation; in the second, it is inflammation, loss of substance, and most probably loss of more blood, as it is to be supposed that a good deal has been lost from the accident, not to mention the awkward manner in which it must be done. The only thing that can be said in favour of amputation on the field of battle is, that the patient may be moved with more ease without a limb than with a shattered one." Hunter, however, doubts any advantage being obtained even on that point. He admits, "it is of less consequence whichsoever way it is treated if the part to be amputated is an upper extremity." And he even goes on to say, " If the parts are very much torn, so that the limb only hangs by a small connexion, then the circumstance of the loss of so much substance to the constitution cannot be an objection, as it takes place from the accident, and indeed every thing that can possibly attend an amputation; therefore, in many cases, it may be more convenient to remove the whole. In many cases it may be necessary to perform the operation to get at blood vessels, which may be bleeding too freely; for the searching after them may do more mischief than the operation." (pp. 561, 63.) Hunter's objections to primary amputation do not, however, appear to have had much weight, at least with the army surgeons of his own or the immediately sub- sequent period, for Hennen states, on the authority of Dr. Pitcairn, who served in the expedition to Egypt, " that wbenever the surgeons could operate on the field in that country they did so; and for himself, he only lamented that he could not remove more limbs in that situation, having never had a doubt upon the point, and being 382 WOUNDS RECEIVED IN still more confirmed in the justice of his opinion by the results of the deferred operations." To this Hennen adds:—"On the first landing of our troops in Portugal, the propriety of the practice was impressed upon the surgeons, as I have been informed, by Mr. Gunning, then senior Surgeon upon the staff, and subsequently Surgeon-in-chief of the Peninsular army; the practice was constantly followed, and the precept orally delivered from surgeon to surgeon, during the whole period that I served in that country." (p. 43.) . , Guthrie has ably advocated the practice of early amputation after gun-shot injuries, and makes the following judicious observations, which equally apply to this operation when required by any other accident, and which should never be lost sight of. "The anxiety (shown by the soldiers) to have these operations executed with as little delay as possible, has sometimes been prejudicial; for as much atten- tion must be paid, in my opinion, to avoid operating too soon as too late, and perhaps for a reason quite contrary to that usually received as ligitimate for not operating, viz., that the sufferer may have time to recover from the shock of the injury, and approach as near as possible to a state of health; and the further he is from this state, the greater the chance of a fatal termination. If a soldier at the end of two, four, or six hours after the injury, has recovered from the general constitu- tional alarm occasioned by the blow, his pulse becomes regular and good, his stomach easy, he is less agitated, his countenance revives, and he begins to feel pain, stiffness, and uneasiness in the part; he will now undergo the operation with the greatest advantage; and if he bears it well, of which there will be but little doubt, he will recover in the proportion of nine cases out of ten in any operation on the upper extremity, or below the handle of the thigh, without any of the bad con- sequences usually mentioned by authors as following such amputation. If, on the contrary, the operation be performed before the constitution has recovered itself, to a certain degree, from the alarm it has sustained, the additional injury will most probably be more than he can bear, and he will gradually sink under it and die. Upon the same point Hennen also observes :—" The propriety of amputation on the field being admitted, the question naturally suggests itself, what is the proper period] instantly on the receipt of the wound, or consecutively 1 The practical reply is, with as little delay as possible." But when "an army surgeon finds a patient with a feebleness and concentration ofthe pulse, fainting, mortal agony, loss of reason, convulsions, hiccup, vomiting, irregular chills, stiffening of the whole body, universal feeling of cold and numbness, sense of weight, change of colour, and other symptoms of collapse, so well described by Le CoNTE,he waits patiently for a return towards life : he administers wine, warmth, volatiles ; he soothes and he encourages; and when due reaction is established, he performs that humane op- eration, the utility and necessity of which are now confirmed beyond the possibility of doubt or the influence of cavil." (pp. 45, 6.) "Inflammation in the seat of the injury," Guthrie further observes, "comes on at an indeterminate period, varying in different people. When the injury is high in the thigh, it commences sooner than in the leg or arm, and the symptomatic fever accompanying it is proportionally severe. If, then, after an injury where the alarm has been very great, and the powers of life considerably diminished, so as to have prevented an operation shortly after the accident, some little reaction should take place, the patient should become restless, the pulse quickened, the parts injured painful, the operation should be no longer delayed; for the removal of the diseased parts can only moderate this nervous commotion and prevent delirium and death. * * * If the operation be delayed beyond the first twenty-four hours in some persons, and in others thirty-six hours, pain, heat, tumefaction, and the other constituents ot inflammation, come on rapidly, attended by increased arterial action, severe nervous twitchings, thirst, heat of skin, general restlessness, delirium, and the patient is soon carried off if the injury has been extensive. Many very severe wounds do not terminate so quickly; the symptoms exist in a less degree, and may be moderated by the antiphlogistic treatment until suppuration is established, and the primary high excitement reduced within the limits of hectic fever depending upon the irri- tation of incurable parts. _ . . "In any period from the time inflammation has commenced in the seat of injury, and symptomatic fever is established, amputation is performed under very dirlerent circumstances than when it has been done prior to their supervention; the parts to AMPUTATION. 383 be divided are no longer in a healthy state; they have taken on inflammatory action tending to suppuration, and will not unite by adhesive inflammation, as they would have done if they had been divided forty-eight hours sooner. The operation, instead of relieving the symptomatic fever, greatly increases it. It is now really a violence superadded to the injury; and the patient dies, unless very active means are em- ployed for his relief, and even under the most vigorous and attentive treatment it frequently proves fatal, although his life may be prolonged for some days."- (pp. 219, 20.)] 350. If amputation be not indicated by the nature ofthe wound, it is impossible to determine whether and by what consecutive symptoms it may be at a later period required. These symptoms may be: 1. Mor- tification ofthe limb.—2. Nervous symptoms, convulsions of the stump, tetanus, when the cause remains in the wound, and cannot in any way be removed.—3. Exhausting suppuration.—4. Bleeding from the whole surface ofthe wound which cannot be stanched. As to the indications for amputation after shot-wounds, and the time at which it should be performed, the following writers are to be especially compared :— Bilguer, Dissert, de membrorum amputatione rarissime administranda aut quasi abroganda. Hallae, 1761. 4to, The Treatises of Faure, Leconte and Grillion upon the question, L'amputation etant absolument necessaire dans les plaies compliquees de fracas des os, et princi- palement celles qui sont faites par armes a. feu, determiner le cas ou il faut faire l'amputation sur le champ, et ceux ou il convient de le differer, et en donner les raisons; in the Prix de l'Academie de, Chirurgie. Larrey, Memoire sur les Amputations; in Mem. de Chirurg. Milit, vol. ii. p. 451. ScHNEinER, Ueber die Amputation grosser Gleider nach Schusswunden. Leipz., 1807. 8vo. Wagner, Versuch einer nabern Bestimmung der Indicationem zur Amputation der grosseren Gliedmassen, besonders nach Schusswunden, in von Graefe und Walther's Journal fiir Chirurgie und Augenheilkunde, vol. i. p. 139. Hutchison, Copeland, Some further Observations on the subject of the proper period of amputating in Gun-shot Wounds. London, 1818. Ibid. Practical Observations in Surgery. 2d Edit. London, 1826. Rust, Ueber die Amputation grosserer Gliedmassen; in his Magazin, vol. vii. p. Guthrie, G. J., A Treatise on Gun-shot Wounds, etc., quoted at head of Article. V._ON POISONED WOUNDS. Ranby, John, The Anatomy of the Poisonous Apparatus of the Rattlesnake; together with an account of the quick Effects of its Poisons. Phil. Trans., vol. xxxv. p. 377. 1726. Hall, Captain, Experiments on the effects ofthe Poison ofthe Rattlesnake ; in Phil. Trans., vol. xxxv. p. 309. 1727. Portal, le Baron A., Observations sur la Nature et le Traitement de la Rage; suivics d'un Precis historique et critique des divers remedies qui ont ete employes jusqu'ici contre cette Maladie. Paris, 1779. 8vo. Leroux, L. C. P., Observations sur la Rage suiviesde Reflexions sur les Speci- flqucs decette Maladie, couronnees par l'Academie de Dijon. 1780. 8vo. Pontana, F., Traite sur le Venin de la Vipere, sur les Poisons Americains, sur la Laurier-Cerise, et sur quelques autres Poisons vegetaux. On y a joint des Ob- servations sur la Structure primitive du Corps animal differents Experiences sur la Reproduction des Nerfs, et la Description d'un nouveau Canal de 1'CEil. 2 vols. Florence. 1781. Ito. Fothergill, John, M. D., A case of Hydrophobia, and additional Directions for the Treatment of Persons bit by Mad Dogs; in the Complete Collection of his Me- dical and Philosophical Works by John Elliot, M. D. London, 1781. 384 WOUNDS RECEIVED IN Mederer, Syntagma de rabie canina. Friburg, 1783. 8vo. Kruse, W., (Rougemont,) Dissert, de Vulneribus quae virus habent. Bonnae, 1784. 8vo. Eneaux, Methode de traitor les Morsures des Animaux Enrages et de la Vipere; suivie d'un precis sur la Pustule Maligne. Dijon, 1785. 8vo. Hamilton, Robert, M. D., Remarks on the means of obviating the fatal effects ofthe Bite of a Mad Dog or other rabid animal, and on the mode of cure when Hy- drophophia occurs, etc. Ipswich, 1785. 8vo. Mosely, Benj., Dr., Treatise on Tropical Diseases, and on the Climate of the West Indies: in which are included the Treatment ofthe Stings of Scorpions, and of the Stings and Bites of other Poisonous Insects; of the Bites of deadly Veno- mous Serpents; of the Bites of Mad Dogs; of the Dysentery; of the Yellow Fever; of the Tetanus or Lock-jaw, &c. London, 1788. 8vo. Barton Benj. Smith, M. D., An Account ofthe most effectual means of prevent- ing the deleterious consequences of the Bite of the Crotalus horridus, or Rattlesnake; in the Transactions of the American Philosophical Society, vol. iii. p. 100. 1793. Anorey, C L. F., Recherches sur la Rage. Paris, 1779. 8vo. [Mease, On the bite of a Mad Dog. Philadelphia, 1801.—g. w. n.] Barosley, S. A., M. D., An Enquiry into the Origin of Canine Madness, &c; in Memoirs of the Literary and Philosophical Society of Manchester, vol. iv. 1793; and also in Medical Reports. London, 1807. 8vo. Beneoict, Ideen zur Begriindung einer rationalen Heilmethode der Hundswuth; nebst einer Vorrede von Rosenmuller. Leipzig, 1808. 8vo. Home, Everard, The case of a man who died in consequence of the Bite of a Rattlesnake; with an acconnt of the effects produced by the Poison; in Phil. Trans. vol. c.p. 75. 1810. Trolliet, Nouveau Traite de la Rage; observations cliniques, recherches d'anato- mie pathologique et doctrine de cette maladie. Lyons et Paris, 1820. 8vo. [Pennock, C. W. Operations and Experiments on the efficacy of Cup- ping Glasses in Poisoned Wounds; in the American Journal ofthe Me- dical Sciences, vol. ii. 1828.—g. w. n.] Bardsley, J. L., M. D., article Hydrophobia,- in Cyclopedia of Practical Medi- cine. London. Royal 8vo. 1833. von Lemiossek, M., die Wuthkrankheit, nach bisherigen Beobachtungen und neueren Erfahrungen dargestellt. Pesth und Leipzig, 1837. Youatt, William, On Rabies; in his work, The Dog. London, 1845. 8vo. Rust, Aufsatze und Abhandlungen aus dem Gebiete der Medicen, Chirurgie, und Staatsarzneikunde, vol. ii. p. 805. 351. In poisoned wounds not merely is the connexion ofthe part di- vided, but at the same time a peculiar matter is introduced into it, which gives rise to special symptoms. Here belong the stings of bees and wasps, the bite ofthe viper, and of rabid beasts. The poisoning of wounds re- ceived in dissection by putrid matter may be also here included. 352. Wounds in dissection do not always cause the same symptoms; much in this respect depends on the constitution of the wounded person, on the constitution of the atmosphere, and on the condition of the sub- ject. Cuts are not so dangerous as punctures, and the latter are less dangerous on the front than on the back of the hand. Often merely an active inflammation takes place at the wounded part, with severe pain and swelling of the lymphatic vessels. With these local symptoms (which mostly occur after from ten to sixteen hours) symptoms of nervous fever are often connected. In these injuries the wound must be carefully cleansed, allowed to bleed sufficiently, washed with water, sucked, covered with sticking plaster, and protected, so that it cannot come anew into contact with putrid matter. I have constantly found it very advantageous to wrap up the finger from its tip onward with a closely DISSECTION. 385 applied bandage. If severe inflammation take place, leeches must be applied, warm narcotic remedies used, and when abscesses have formed they are to be opened early. When the symptoms of nervous fever come on, the usual mode of treatment is to be employed. Many believe that the symptoms after injuries in dissection do not depend on the absorption of putrid matter, but on the constitution of the injured person, wherefore they reject all escharotics. Whether this opinion be well founded or not, I however agree with them in regard to the application of caustic; as thereby irritation and inflammation ofthe wound, with its consequences, which otherwise would not have happened, would be only too easily produced, (a) Shaw, J. (b), distinguishes those which occur in dissection, into such as arise from the examination, a short time after death, of subjects which have died from in- flammation of the serous membranes, and those from bodies already putrid; the latter of which are least dangerous. He recommends, after sufficient bleeding from the wound, fomentations of GouLARD-water and laudanum, then a smart dose of calomel and antimony, and two hours after a large dose of opium. If the pain still continue the whole arm is to be bathed with lukewarm GouLARo-water, and opium ; some ammonia to be given and hot drinks allowed. He considers leeches and vene- section improper. Baseoow (c) considers that the wounds produced by poisoning in dissection agree with Malignant Pustule. A careful collection of the various opinions on the nature and treatment of these injuries is given by M. Leo-Wolf (d). [The question of absorption of poisonous matter into wounds, received in dissec- tion, has been much disputed. But I must confess, that, after nearly twenty years' constant employment in the dissecting-room, I almost entirely agree with the opinions held by Lawrence on this subject. "It seems to be very doubtful," says he, "in those cases, whether any thing actually venomous or virulent is introduced, or whether the results of these injuries must be said to arise from such wounds, considered merely as mechanical wounds. If these be poisonous wounds, the poison certainly follows other laws than those we observe in cases in which we are more intimately acquainted with the poison. * * * If they arise from a poison, then it is one of a very uncertain, and, almost you might say, capricious kind. In the first place, in the great majority of instances of wounds received in dissection, no injurious effect is produced. There are hundreds and hundreds of such wounds always occurring without any injurious consequences. It is really only in a very small proportion out of the whole number of wounds that are received, that any pre- judicial effects are produced in the human frame. We can perhaps quite as well explain the occurrence of these effects when they do take place, by a reference to the particular state of health of the individual in whom they occur, as by any par- ticular virulent property that might be applied to the wound. Now it happened to myself, when I was employed'in dissection, to cut myself hundreds of times in dis- secting bodies that have died under every variety of disease, and I never experi- enced any ill effect but once, and then I was not in very good health. I had an inflammation of the finger, with swelling up the hand and arm, and subsequently swelling of the glands in the axilla, witb suppuration. There are cases, however, in which important local effects are produced, and in which very serious and even dangerous symptoms occur. * * * We cannot point out any particular state of a dead body, nor any condition of previous disease, that will certainly give rise to any set of symptoms in these cases : indeed, we shall observe, an individual receive a prick or a cut in dissection of a certain subject, and suffer certain inconveniences from it; while others, who have dissected the same subjeet, suffer no injurious con- sequences at all from a similar injury. In the majority of instances the effects that (a)CoorER, Astley, Leclurcs on the Prin- (c) Ueber die Schwarze Blatter; in von ciples and Practice of Surgery ; with addi- Graefe und Waltiier's Journal, vol. xii. p, tional notes and cases, by F. Tyrrell. Lon- 18.5. don, 1821, vol. i. p. 19--'1. (d) Diss, de morbo qui lesione; in cada- (b) On tbe Treatment of Wounds received veribus dissecandis haud rara sequi so!et. during Dissection; in London Med. and Heid., 1832. Phys. Journal, vol. liii. p. 369. 1825. Vol. i.—33 386 STINGS OF BEES, are produced seem to be nearly such as would arise from the infliction of the wounds considered in themselves, without any reference to the state of decomposition of the dissected bodies in which they occur." (pp. 651, 2.) "There are some other cases," continues the same writer, " in which the local and general symptoms have been rather different, and it is in those particularly that the agency of poison has been regarded as the true cause." And he then mentions the case of Dr. Pett («). who pricked himself at eight o'clock in the morning of the 28th of December without being aware of it, in sewing up the body of a female who had died of puerperal peri- tonitis. On the evening of the same day, feeling some heat and uneasiness, he care- fully examined his fingers, and at the tip of one observed a blush, with a very minute opening in it. This he touched with nitrate of silver and nitric acid, without, how- ever, causing pain; but as the uneasiness continued he again applied the nitrate of silver later in the evening, till he felt it sensibly, and then the pain became ago- nizing. On the morning of the 29th, after having passed a very restless night and had shiverings, the eschar was noticed as large as a split pea, and at I. p. m., the finger had become swollen, had a livid appearance, and was very painful. An in- cision was then made down the bone, which gave no pain, nor did any blood flow, and the last two joints were gangrenous; red lines extended along the fore arm to the elbow, and pain up to the axilla; complete prostration of strength; irregularity of breathing and considerable torpor came on; and, during the rest of the day, he had much heavy sleep, occasionally disturbed by severe attacks of pain: the pulse soft and between 90 and 100. The hand and arm continued swelling, the absorbents inflamed, as also the axillary glands, acccompanied with an erysipelatous blush, which extended over the side ofthe chest, and the torpor and difficulty of breathing increased. Punctures were made, but without giving vent to any pus, and he died at 6 a. M., on the 1st of January. The most certainly dangerous punctures, as far as my observation gees, are those which have happened in the examination of cases of peritonitis, either of the common or puerperal form; which certainly would lead to the presumption that, in such instances, there is an absorption of poison. But, on the other hand, I am sure that almost if not quite as severe symptoms have occurred when the wound has been received in examining a body recently dead and quite fresh. With regard to putrid subjects, or those just beginning to be so, my experience proves that wounds from them are almost invariably the least formidable kind. How these facts are to be explained other than by the assumption of a peculiarity in the constitution at the time of receiving the wound, I do not presume to say; but certainly, as regards the affections from peritoneal disease, there does not appear to be a very strong presump- tion of poisonous matter having been absorbed. In wounds received in dissecting I believe the mischief is often very considerably increased, if indeed it be not excited, by the very improper application of escharotics, either nitrate of silver, nitric acid, or caustic potash. All that I ever thought of doing for myself, or recommending to be done, was to wash the hand carefully, and then suck the wound for ten minutes or so, and afterwards to apply a poultice. If the matter did not rest there, but inflammation with swelling and great pain came on, leading to the belief of the sheath of one or other tendon, or of the palmar fascia, (according to the situation of the puncture,) or of the cellular tissue having inflamed, then free leeching was resorted to, and more or less deep incisions to relieve the ten- sion and permit the escape of any pus that might have formed, which, in an irritable constitution, will happen in a few hours. As a general rule, whenever pus in these cases is found, it must be evacuated immediately, as the longer it is left the more it increases the constitutional excitement. It not unfrequently happens after wounds received in dissection have passed through the more aggravated symptoms, that the scar remains red, angry, tender, swollen, elevated and spread, so that, that which was primarily a mere pin-hole wound becomes as large or larger than a sixpence, and is covered with a soft scaly cuticle, beneath which an ichorous exudation is continually produced, and has some- what the appearance of an inflamed soft wart. This often continues for months, and resists all binds of treatment, till change of air is made, soon after which it commonly subsides without any further assistance. Another consequence, after (a) For full particulars of this case, see Travers On Constitutional Ir.iti.tion, p. 292-306. WASPS, SCORPIONS, ETC. 3S7 every other symptom has subsided and all trace of the original injury has disap- peared, is, a creeping erythema, first beginning about the injured part, and then travelling about the hand and arm. I have frequently seen it run up one side of the finger to its tip, and down%gain to the knuckle, then pass to the next finger, up and down it and on again to the next, and having made the circuit of all the fingers, repeat its course. Positive pain in these cases there is none, but itching is plentiful and the annoyance scarcely creditable. Simple spirit wash, or camphorated spirit wash, or lead wash, or grease of any kind, are alike useless. And the only remedy I have seen at all efficacious is change of air, but even this often for a long while fails of getting rid of this troublesome companion.—j. f. s.] 353. The stings of bees and wasps are the slightest kind of poisoned wounds. An acrid fluid is introduced with the sting into the wound, which usually produces very severe pain, and speedily much swelling. The early application of cold water, or camphorated vinegar, averts or diminishes these symptoms. If the pain continue, bathing with warm oil and narcotics may be employed. If the sting be in the wound, it must be withdrawn. [The stings of bees and wasps sometimes produce very serious consequences. Dr. Gibson, mentions (a) a lady sixty-nine years of age, who died in fifteen minutes after receiving the sting of a yellow wasp, whilst engaged in drying apples. And he also states, that " occasionally death has followed from swallowing- a wasp or bee, in consequence ofthe gullet being wounded by the sting of the animal, while passing to the stomach. In this way a young woman in Jersey, U. S., lost her life, a bee having been enclosed in a piece of honeycomb which she swallowed. Lawrence refers (6) to the case "of a gentleman in France, who was walking in his garden, in his morning-gown, with his breast open. A large bee-hive was upset, and he ran to put it right again; the bees fixed upon him and stung him about the throat and chest: he immediately ran into the house, and the persons around him endeavoured to liberate him from the insects as soon as they could, but he said he felt himself sinking or dying. The action of the heart became very much enfeebled, the pulse sunk, the breathing interrupted, anxiety, agitation, and alarm arose, and he died very speedily, in fact in about ten minutes." (p. G22.) Scorpion Sting.—The following is the account of one of these accidents given by Dr. Mosely : (c)—Mrs. P. at Kingston in Jamaica, in January, 1781, was stung by a scorpion in the foot, above the little toe. The part became instantly red and pain- ful, and soon after livid. The pain increased to great severity. Some rum was ap- plied to the wound, on which the pain immediately left the foot, and passed up to the groin with great agony. The pain still passed upwards, a"nd diffused itself about the pit of the stomach, neck and throat, attended with tremors, cold sweats, and languors. As the pain passed the abdomen it occasioned a violent purgingand faintino-, which ceased on its advancing higher. I was called to her and gave her the following medicine :—fy sal. succin. 9ij. camph. gr. xij. cinnab. antim. gr. x. conf. card. q. s. utfiant boli sex, omni hard sumend. cumcochl. quat.mist. seq. viz. aq. menth. ^vij., elix. purcg. £>ij., syr. croci 3iv. misce; a few doses of which removed every symptom. She had been extremely ill for thirty-six hours." (p. 28.) Allan (d) says that "the wound caused by the scorpion was alwrays followed by a violent and extensive inflammation, considerable swelling, and great pain; but I never observed any violent constitutional symptoms succeed to the local." (p. 370.) A few years ago a man stung by a scorpion was admitted into the London Hospital: some in- flammation and swelling of the hand and arm ensued, with a good deal of nervous depression; but my friend Curling tells me it soon subsided and he did well. Kirby and Spence (e,) however, say that "the sting of certain kinds common in South America, causes fevers, numbness in various parts of the body, tumours in the tongue and dimness of sight, which symptoms last from twenty-four to forty- fa) Institutes and Practice of Surgery, (d) System of Pathological and Operative vol i. Philadelphia, 2d Edit., 1827. 8vo. Surgery, vol. i. (6) Lectures on Surgery. (e) Introduction to Entomology, vol. i. (c) A Treatise on Tropical Diseases, &c. 3d Edition. London, 1818. 8vo. 3d Edit. London, 1795. 3S3 BITES OF INSECTS eight hours. The only means of saving the lives of our soldiers who were stung by them in Egypt was amputation. One species is said to occasion madness ; and the black scorpion both of South America and Ceylon frequently inflicts a mortal wound." (p. 125.) 4 Our common gnat and the mosquito (Culex pipiens) are among those insects which, though unprovided with a special sting, yet, according to Kirby and Spence, "instil into the wound, made with their mouth, a poison, the principal use of which is to render the blood more fluid and fitter for suction." (p. 113.) Every one is unfortu- nately too well acquainted with the smarting pain and swelling produced by the gnat, and Mosely says of the bites of the mosquito, that they are " sometimes scratched into painful acrid ulcers, particularly in the legs." (p. 24.) Fleas and bugs are also very irritating, and the bites of the latter especially will often produce considerable swelling of an oedematous character, when they have been made on the eyelids or cheeks of delicate children.. The harvest bug (Acarus autumnalis, Shaw,) annoys us considerably. It is "a hexapod so minute," says Kirby and Spence, " that were it not for the uncommon brilliancy of its colour, which is the most vivid crimson that can be conceived, it would be quite invisible., * * * It attacks the legs of labourers employed in the harvest, in the flesh of which it buries itself at the root ofthe hairs, producing in- tolerable itching, attended by inflammation and considerable tumours, and some- times even occasioning fevers." (p. 105.) Of this abominable plague I had per- sonal experience many years ago whilst in Sussex, during harvest time. Both legs were attacked, and the itching was so intense that I could not refrain from constant clawing (scratching will not express what I mean;) the irritation continued for between a week and a fortnight, and the result was many troublesome and some not shallow sores which did not become quiet and heal for many weeks. The writers just quoted mention other acari, whose operations are very trouble- some, and, among tbem, one "common in Martinique, and called there bite rouge. When our soldiers in camp were attacked by this animal, dangerous ulcers succeed- ed the symptoms just mentioned, which in several cases became so bad, that the limb affected was obliged to be taken off." *■■ * * But the worst of all the tick tribe is the American, (A. Americanus, Lin.,) described by Professor Kalm. This insect, which is related to the dog-tick, is found in the woods of North America, and is equally an enemy to man and beast. They are there so infinitely numerous, that if you sit down upon the ground, or upon the trunk of a tree, or walk with naked legs, they will cover you, and plunge their serrated rostrum into the bare places of the body, begin to suck yourblood, going deeper and deeper till they are half buried in the flesh, though at first they occasion no uneasiness. When they have thus made good their settlement, they produce an intolerable itching, followed by acute pain and large tumours. It is now extremely difficult to extract them, the animal rather suffering itself to be pulled to pieces than let go its hold; so that the rostrum and head being left in the wound produce an inflammation and suppuration which ren- der it deep and dangerous. These ticks are at first very small, sometimes scarcely visible, hut by suction will swell themselves out till they are as big as the end of one's finger, when they often fall to the ground of themselves." (p. 106.) Other insects become sources of annoyance, not from the irritation of any poison, but simply by burying themselves beneath the skin to deposit their eggs. Of this kind is the great West Indian plague, the chigoe (Pulex penetrans.) Mosely in speaking of them says :—" Another tropical insect frequently attacks the feet and toes of new comers, and surprises them with an unusual sensation of itching. * * * They are about the size of a cheese-mite ; they lance the skin imperceptibly in the soles of the feet, or about the toe-nails, and insinuate themselves, where they deposit their eggs, including their eggs and themselves in a little round vesicle, which increases to the size of a small pea, sometimes before it is noticed. It then acquires a bluish appearance, from the colour of the chigoe itself, which is in the midst of an innumerable quantity of animalcula, each of which is capable of creating a new disturbance, if, in taking out the bag it be broken and any remain behind in the flesh. Some people have had great inflammations from them, and some have had their toes mortified. The negroes often let them collect and remain in their feet until their toes rot off. The common method of taking out the bag is with the point of a needle, without piercing it by separating it, from the skin quite round and draw- AND VIPERS. 389 ing it out; then filling up the hole, and rubbing the part with tobacco ashes." (pp. 25, 6.)] 354. The severity of the symptoms after the bite of a viper depends on various circumstances ; for example, whether more or less fluid has been poured from the poison bag into the wound ; whether the viper was excited or not at the moment when it bit. In winter the poison is less active than in summer ; but very rarely is the bite fatal. Imme- diately after the bite a severe burning in the wound occurs, the bitten part inflames and swells, and the inflammation spreads over the whole limb ; the lymphatic vessels are red and swollen to the next glands; the glands themselves swell; high fever comes on, delirium, small pulse, vomiting, pain in the region of the heart, and often in that of the throat; not unfrequently convulsions, jaundice, anxiety of mind, fainting, also are noticed. The best mode of destroying the poison in the wound, and for pre- venting its absorption is, after cutting upon it, to cauterize it with strong liquor ammonice, or with butter of antimony; the compression of the limb above the bitten part by means of a cord, and the application of a cupping-glass (a.) The neighbourhood of the wound is to be rubbed with oil; the part may be touched with oil in which caustic ammonia has been mixed. Fluid volatile alkalies are to be given internally, and the patient kept in bed, in order to keep up properly the accompanying per- spiration. Cupping-glasses and ligatures have only momentary effect if all of the poison be not removed from, the wound(5.) It appears from Pennock's observations (c) that the application of the cupping-glass operates partially by the pressure of its edge numb ng the nerves of the part, partly by the removal of the atmospheric pressure preventing the absorption of the poison. It is therefore always necessary before removing the cupping-glass to lay the wound open. Rodrigue (d) is of the same opinion, but he still advises the application ofthe ligature by whicb the absorption is also diminished. [Fontana did not consider that the bite of a common viper would be fatal to an adult, and observes that of a dozen cases he had known, and of fifty more he had heard of, only two terminated fatally. He could not obtain any history of one of these cases, but in the other gangrene commenced three days after the accident, although the wound had been freely cut into, almost immediately after the bite had been received, and the person died in twenty days. A case is, however, men- tioned, (e) of a woman, aged sixty-four, who died In thirty-seven hours after having been bitten on the thigh by a viper, notwithstanding the wound had been en- larged and cauterized with liquor ammonias, which was also administered'internally. An instance of death after a viper-bite occurred some years ago at St. Bartholo- mew's Hospital, in a young man about eighteen years of age, who was under my friend Vincent's care. He was very weakly, had considerable pain and swelling of the arm and side bitten, followed by extensive erysipelas and sloughing; no generous diet, &c, could keep up his powers, and after several weeks he sunk. I have seen a few cases of viper-bites in spring and summer, at which periods the animal is in strong health and proportionally virulent, but I have never seen the severe symptoms above described, nor has it been necessary to employ any other than very simple treatment, the means for which may in general be immediately pro- cured. The pain is always very severe, and swelling in the immediate neighbour- hood at once commences, which spreads rapidly up the limb, without the least resem- (a) Piorry,Considerations physiologiques (c) American Journal of the Medical Sci- sur la Morsure d'une Vipere, traite avec ences, May, 1828. succ6s par l'application de Ventouscs ; in (d) Ibid, August, 18281. Revue Medicale. Oct., 1826, p. 63. (e) Annales du Cercle Medicale, vol. i. p. (6) Annales des Sciences d'Observations. 44. 1820. Paris, 1829, April, p. 123. 399 TREATMENT OF blance of inflammation, but like an cedema of long continuance, and the skin is stretched almost to bursting in the course of three or four hours. An extreme sen- sation of depression, bordering upon faintness, soon sets in. accompanied with frequent vomiting; but I have never seen the constitutional affection proceeding further. The wound has sometimes assumed a gangrenous appearance, but gene- rally has been scarcely distinguishable. The treatment I have employed is exceed- ingly simple,—continued smearing for two or three hours of the whole limb, so far as it was swollen, with olive oil, and the administration of brandy again and again till the symptoms of depression have disappeared. The oiling is to be repeated less frequently afterwards, but sufficiently to keep the parts well soaked in oil. The pain soon subsides after the application ofthe oil, but the swelling and uneasi- ness from the distention ofthe skin is more enduring, and does not begin to subside till eighteen or twenty hours have elapsed, but then both disappear gradually, and after four or five days no traces of the injury remain, excepting that the patient is a little languid. In the cases under my own care I have never applied any caustic, and in those where nitrate of silver has been applied, I do not believe it has been of any real use; for, unless a wound be very large, it will rarely penetrate much below the surface. I do not, therefore, think it useful. How oiling the part acts I do not pretend to explain; but although Dr. Meaoe and the French Academy deny its efficacy, it is a fact beyond doubt that grease does not very speedily relieve the pain and remove all the symptoms... Hence the vulgar practice of killing the viper, if it can be caught, and rubbing its fat over the bitten and swollen part, of which Meade was well aware, for he says ; (a)—"Though they (the viper-catcbers) keep it as a great secret, I have, however, upon strict inquiry found it out to be no other than the Axungia viperina presently rubbed into the wound. And to convince myself of its good effects I enraged, a viper to bite a young dog in the nose : both the teeth were struck deep in; he howled bitterly, and the part began to swell. I diligently applied some of the axungia I had read)' at hand, and he was very well the next day." (pp.45, 6.) The practice of applying a ligature above the wound from a venomous bite is at least as old and probably much older than Celsus, who says :—" Igitur in primis supra vulnus id membrum deligandum est; non tamen nimium vehementer, ne tor- peat."—lib. v. cap. xxvii.. Astley Cooper recommended this practice, and, indeed, himself had recourse to it when bitten by a viper, which recovered itself after having been frozen, as he carelessly held it in his hand whilst lecturing. Home also says :—" Tbe only rational local treatment, to, prevent the secondary mischief, is applying ligatures above the tumefied part, to compress the cellular membrane, and set bounds to the swelling, which only spreads in the loose parts under the skin, and scarifying freely the parts already swollen, that the effused serum may escape, and the matter be discharged as soon as it is formed. The practice of sucking venomous bites was well known to the ancients. A people of Africa, called Psylli, were celebrated for their cure of serpent-bites, which they effected by applying their mouth to the wound, and sucking out the poison. The Italian Marsi also pretended to the same power. Celsus observes, with regard to this practice :—" Neque hercule scientiam praecipuam habent hi, qui Psylli nomi- nantur, sed audaciam usu ipso confirmatam. Nam venenum serpentis, ut quffidam etiam venatoria venena, quibus Gallis precipue utuntur, non gustu, sed in vulnere no- cent. Ergo quisquis exemplum Psylli secutus, id vulnus exsuxerit, et ipse tutus erit, et tutum hominem praestabit."—lib. v. cap. xxvii. The truth of the observa- tion, that the poison is not hurtful in the mouth but in the wound, has since been fully proved by Russel. But it may be presumed from Celsus's concluding ob- servation, that practice was not very general even in his time, though he vouched for its safety. Meade thought this mode of cure ought to be revived, the following remarkable case having occurred a few years before he wrote, which confirmed his opinion :—" A man was bit on one of his fingers by a rattlesnake just then brought over from Virginia. He immediately put his finger into his mouth and sucked the wound. His underlip and tongue were presently swelled to a great degree; he faltered in his speech, and in some measure lost his senses. He then drank a large quantity of oil, and warm water upon it, by which he vomited plentifully. A live (a) A Mechanical Account of Poisons. London. 8vo. First Edit., 1702. Fourth Edit. 1747. VIPER-BITES. 391 pigeon was cut in two and applied to the finger. Two hours after this, the flesh about the wound was cut out, and the part burnt with a hot iron, and the arm embro- cated with warm oil. He then recovered his speech and his senses. His arm con- tinued swelled the next day; but by common applications soon grew easy, and the patient suffered no further mischief. As the poison of this snake is more quick and deadly than any other that we know, a remedy for this will most certainly prove effectual against that of small vipers, and all other creatures of this kind." (pp. 40, 41.) The Doctor does not think that, excepting the vomit, any ofthe other applica- tions were of use, and " embrocating the arm with oil only abated the swelling;" which view of the case he held confirmed by the physicians of the Academy of Paris, who, after making experiments with oil, " pronounced it ineffectual." He, therefore, recommends that "the first thing to be done upon the bite of a viper of any kind is that the patient should immediately suck the wound if he can come at it; if he cannot, another person should do this good office for him. Whoever does it, ought (to prevent any inflammation of the lips and tongue from the heat of the poison) to wash his mouth well beforehand with warm oil, and hold some of this in the mouth while the suction is performing. After this is over, it will be proper to give a vomit. A dose of rad, ipecac, encouraged in the working with oil and warm water, may be sufficient. The good effect of this is [risum tenealis?'] owing to the shake, which the action of vomiting gives to the nerves, whereby the irregular spasms, into which their whole system might be drawn, is prevented." (pp. 42, 43.) I suspect that the sucker in the case mentioned by the Doctor not only neglected this precau- tion, but probably had some abrasion of the lining membrane of his mouth, or he would have escaped the swelling of his underlip and tongue. As a modification of the sucking practice, Sir David Barry (a) proposed the use ofthe cupping-glass over the snake-bite, and made numerous experiments on brutes, from whence he inferred first, that neither sound nor wounded parts of the surface of a living animal can absorb when placed under a vacuum; secondly, that the appli- cation of the vacuum, by means of a piston cupping-glass placed over the points of contact of the absorbing surface and the poison which is in the act of being absorbed, arrests or mitigates the symptoms caused by the poison ; thirdly, that the application of a cupping-glass for half-an-hour deprives the vessels of the part, over which it is applied, of their absorbent faculty, for an hour or two, after the removal of the glass; fourthly, that the pressure of the air forces into the vacuum, even through the skin, a portion of matter introduced into the cellular tissue by injection, that is, if the skin ofthe animal be not too dense, as in the dog. He objects to scarifications, because if beyond the cupping-glass, the contents of the divided vessels will cease to be influenced by it. But he does not object to excision, if the cupping-glass be ap- plied previously for an hour, by which he supposes the contents of all the vessels will have acquired a retrograde direction, and, after excision, the cupping is to be again resorted to. Meade took some pains to ascertain the nature of viper-poison. Having obtained some by irritating the animal, till it bit upon something solid, so as to void its poison, he put it under a microscope, and at first " could discover nothing but a parcel of small salts nimbly floating in the liquor; but, in a very short time, the appearance changed, and these saline particles were now shot out as it were into crystals of an incredible tenacity and sharpness, with something like knots here and there, from which they seemed to proceed, so that the whole texture did in a man- ner represent a spider's web, though infinitely finer and more minute." (p. 15.) On the application of chemical tests the poison did not exhibit either acid or alkaline properties. After sundry other experiments, "we resolved," says the doctor, "to end our poison inquiries by tasting the venomous liquor. Accordingly, having diluted a quantity of it with a very little warm water, several of us ventured to put some of it upon the tip of our tongues. We all agreed that it tasted very sharp and fiery, as if the tongue had been struck through with something scalding or burning. This sensation went not off in two or three hours; and one gentleman, who would not be satisfied without trying a large drop undiluted, found his tongue swelled with a little inflammation, and the soreness lasted two days. But neither his nor our boldness was attended with any ill consequence." (p. 22.) (a) Researches on the Influence of Atmospheric Pressure upon the Blood in the Veins. London, 1826. 8vo. 392 SYMPTOMS AND EFFECTS 355. The bite of snakes in hot countries produces the same symptoms as those from the viper, but so quickly and so violently that death soon follows, especially if any considerable blood-vessel be injured. The remedies recommended in these wounds, besides the cutting out or de- struction of the bitten part with the simultaneous application of the cup- ping-glass and ligature, are, senega root, fluid alkalies, and especially arsenic in large doses, (a) The poison of the more venomous snakes does not always act alike, as will be presently seen by comparing the symptoms enumerated by Dr. B. S. Barton as produced by the rattlesnake, with those resulting from the cobra de capello mentioned by Dr. Patrick Russell. But, though rarely, they are sometimes fatal either im- mediately, within a few hours, or by the more remotely consequent sloughing of the cellular tissue of the limb which the constitution cannot overcome. Barton (b) observes, that "in those cases where the poison is applied near to the orifice of an absorbing vessel, we have reason to suppose that it will be conveyed into the mass of blood with great celerity." (p. 106.) "But, unfortunately, cases sometimes occur in which this active matter is thrown immediately into a vein or artery. When this happens, the effects of the poison will be more readily propagated to the remotest parts of the system." (p. 107.) And subsequently he asks, "Does not this very sudden appearance of the nausea and vomiting seem to render it pro- bable that the poison of the rattlesnake exerts considerable effects on the nervous matter of animals'?" (note, p. 110.) That it does sometimes so act upon the nervous system cannot be doubted, for in some of these cases mentioned by Russell the bitten person died in a few minutes, and in one almost instantaneously, so that there could not have been time either for the absorption of the poison into the blood or its diffusion through the body by the blood-vessels. The following are the symptoms given by Barton as following a rattlesnake's bite. " When the poison of the rattlesnake has actually been introduced into the general mass of blood it begins to exert its most alarming and characteristic effects. A considerable degree of nausea is a very early symptom. (Note. It is remarkable that a nausea, and sometimes a vomiting, is induced in many cases in a few minutes after the poison has been thrown into a muscular part, and long before it can possibly have entered the blood-vessels, through the medium of the absorbent lymphatics; or, admitting that it has been introduced directly into a blood-vessel, before this active poison can have effected in the general mass any change whatever. Does not this sudden appearance of the nausea and vomiting seem to render it probable that the poison of the rattlesnake exerts considerable effects on the nervous matter of animals'?) We now discover an evident alteration in the pulse; it becomes full, strong, and greatly agitated. The whole body begins to swell: the eyes become so entirely suffused, that it is difficult to discover the smallest portion of the adnata that is not painted with blood. In many instances there is a hemorrhagy of blood from the eyes, and likewise from the nose and ears; and so great is the change in- duced in the mass of blood, that large quantities of it are sometimes thrown out on the surface ofthe body in the form of sweat; the teeth vacillate in their sockets, whilst the pain and groans of the unhappy sufferer too plainly inform us that the extinction of life is at hand. In this stage of its action, and even before it has induced the most alarming ofthe symptoms which I have mentioned, the powers of medicine can do little to check the rapid and violent progress of this poison." (p. 110.) Professor Owen informs me, that in 1840 he saw in the military hospital near Plymouth, a soldier, who having in a piece of bravado put a viper's head in his mouth, was, as might have been expected, bitten in the tongue, which soon swelled so much that respiration was almost entirely prevented, and also the introduction of any medicine into the stomach by the mouth. He did not see the termination of the case, nor is he aware of the treatment; but he believes the man recovered. This is the only instance of rattlesnake-bite in this country with which I am acquainted, (a) Ireland, Some Account ofthe Effects Means of Preventing the Deleterious Conse- of Arsenic in counteracting the Poison of quences of tbe Bite of the Crotalus horridus; Serpents; in Med.-Chir. Trans., vol. ii. p. in Trans, of tbe American Philosophical 398. Society, vol. iii. Philadelphia, 1793. (b) An Account of the most Effectual OF THE RATTLE-SNAKE'S BITE. 393 except the following case which came under Home's care Some years since in St. George's Hospital, and is an instance of death resulting from slough of the cellular tissue of the limb (a.) A spare man, aged twenty-six years, in attempting to take his rule from a rattle- snake's cage, into which he had dropped it whilst attempting to irritate the animal, was bitten twice, Oct. 17, 1829, half past 2 p. m., receiving two wounds on the back of the first joint of the thumb, and two on the second joint of the fore finger. He went to a chemist in the neighbourhood, who, considering him in a state of intoxication, (which, however, did not appear to have been the case,) gave him a dose of jalap and applied some slight remedy to the bites. No swelling in the hand had then appeared; but it speedily commenced, and when he reached St. George's Hospital, half-an-hour after, the swelling had extended half way up the fore arm; the skin on the back of the hand was very tense, and the part very painful. In an hour after the swelling had reached half way up the arm, and the pain had extended to the arm-pit. The skin was cold; pulse, 100; and he complained of sickness. Aq. ammon. pur. rrj^xx. spir. aether, vitriol, rrjjxxx. mist, camph. §j. were given but re- jected. The wounds were bathed with aq. ammon. pur., and the whole limb with camphorated spirit. At 5 p. m., he took spir. ammon. camph. 3ij. aether, trjjxxx. mist, camph. 3j., which was retained. An hour and a half after, his pulse having become very feeble, aether, et aq. ammon. pur. aa. tn> xxx. ex aqua were given and re- peated at the next hour. At 9 p. m., he felt greatly depressed, his skin was cold, pulse 80, and weak; the dose of both medicines was increased to fifty drops, and repeated. In rather more than an hour after, the pain had become very violent in the arm ; and, though his pulse was stronger, he was attacked with fainting every fifteen minutes, but the pulse was not visibly depressed. At half past 11 the swell- ing involved the whole arm up to the arm-pit; the arm was quite cold, and the sur- face generally unusually cold, and no pulse could be felt in any part of it. He was then perfectly collected; but, an hour and a half after, talked indistinctly. Oct. 18, 8 a. m. Pulse 132, and very feeble. ° The swelling had not extended; but there was a fulness down the side, and blood extravasated under the skin, as low as the loins, producing a mottled appearance. The arm and hand cold, painful when pressed, very tense vesications near the elbow, and under each of these a red spot in the cutis as large as a crown-piece. The general surface had become warm ; but he was low and depressed; the faintings had continued recurring every quarter of an hour, and there was a tremulous motion of the limbs. The medicine had been continued during the night, but the last dose was rejected ; some warm wine, how- ever, was retained. Fomentations were applied to the arm. Noon. Some broth which he had taken was rejected ; and, in addition to the previous symptoms, there was starting of the limbs. " The skin of the whole arm had a livid appearance, similar to what is met with in a dead body, when putrefaction has begun to take place, unlike any thing which I (Home) had ever seen in so large a portion of the living body. An obscure fluctuation was felt under the skin of the outside of the wrist and fore-arm, which induced me to make a puncture with a lancet, but only a small portion of a serous fluid was discharged." The internal use of the volatile alkali was continued, to rouse the action of the stomach, not as a specific; but as neither it nor small quantities of brandy were retained, it was omitted. At 11 p.m., two grains of opium were given, and repeated every four hours. The vesications and red spots had increased in size. Oct. 19, 3 p. m. Was drowsy, probably from the opium and brandy taken; was more depressed, and spoke only in whispers, but the faintings were less frequent. The vesications had increased, but the arm had diminished in size, and he had sensation down to the fingers. At 11 p. m. The pulse 130, and low. The opium was left oil'; a motion obtained by clyster; and he was ordered camphor mixture, wine, and brandy, as often as he would take them. Oct. 20. Had dozed during the night; his spirits were better, and his extremities were warmer; he had taken some coffee at breakfast, but rejected fish at dinner; brandy and coffee a table-spoonful occasionally were given, as more could not be retained. Oct. 21. Had slept at intervals during the night, and was occasionally delirious; (a) The Case of a Man who died in consequence of the Bite of a Rattlesnake ; with an Account ofthe Effects produced by tbe Poison; in Phil. Trans. 1830, p. 75. 394 SYMPTOMS AND EFFECTS pulse 120. The size of the arm was diminished, but the skin was extremely tender. Brandy and jelly only staid on his stomach. Oct. 22. The right side of the back down to the loins was inflamed, painful, and had a very mottled appearance from the extravasated blood under the skin. As this evening his pulse had become full, he was ordered wine instead of brandy. Oct. 23. The vesications had burst, and the exposed cutis was dressed with white ointment; but the arm was still very painful, though reduced in size. Porter was ordered instead of wine; and both yesterday and to-day he has had veal for dinner. A saline draught with antimonial wine was ordered in the evening. Oct. 27. The swelling and inflammation of the arm have increased ; he attempted to sit up, but the weight and pain forbade it. The arm was bathed with spir. vin. red. et liq. ammon. acet. aa part. acq. The pulse is now very frequent, and the tongue furred. Oct. 28. Had a rigor last night; a slough has begun to separate on the inside of the arm below the axilla. Purging having come on, chalk mixture w7ith laudanum was ordered. Oct. 29. The purging is abated ; but the pulse is 100, and feeble. A large abscess on the outside of the elbow was opened, and half a pint of reddish brown matter with some cellular sloughs discharged ; but the upper part of the arm was still tense. A poultice to it; and the fore arm strapped with soap cerate. Ordered wine and porter and bark. Oct. 30. The purging having returned, the bark was left off; chalk mixture and laudanum given, and an opiate clyster administered. Oct. 31. The purging continued ; pulse 120 ; and at night he had a rigor. Nov. 1. Delirious at intervals; voice feeble; no appetite. Nov. 2. Pulse very weak; countenance depressed ; tongue brown; the stomach rejects everything but porter; delirium last night; mortification extending more towards the axilla. Nov. 3. The purging continues; #the mortification has spread considerably; the fore finger, which had become gangrenous, was removed at the second joint. And on the following afternoon at four o'clock he died. Autopsy sixteen hours after death.—The fang wounds were healed, but the puncture on the back of the wrist was still open. The whole of the cellular tissue of the arm was sloughy, the skin separated from the muscles, and dark-coloured offensively smelling fluid between them. The other morbid appearances detailed are of no consequence. The symptoms which follow the bite of the cobra di capello, (Naja,) as mentioned by Dr. Patrick Russell (a,) differ from those produced by the rattlesnake. In one case, " a Malabar woman who had been bitten in the small of the leg, after ten hours had lost her senses of seeing and feeling, and deglutition was so much impeded that hardly any thing could be got to pass into the stomach. No other parts were visibly affected by spasms; but a torpor and listlessness pervaded the whole system, and from the moment of the bite had continually increased." She recovered in the course of ten days, after dilating the wound, and dressing it with mercurial ointment, under the use of the Tanjore pill. (p. 78.) In another case, "a Dubash was bitten in the toe; a few drops of blood issued from the part, and he was immediately sensible of pain. In half-an-hour the pain had extended up to the knee; and ten minutes after up to the top of the thigh, and much more severe. He then complained of severe pain in the belly, which was tense, and much swollen. A sense of tight- ness spread towards the chest, and respiration became very laborious. Soon after deglutition became impeded, and the stricture in the oesophagus increased so much that nothing could be forced down his throat; he foamed at the mouth; his eyes stood staring and fixed; his pulse and respiration became hardly perceptible, and, in short, every vital motion seemed at a stand." He recovered from the immediate effects of the poison, with the use of Madeira wine and the Tanjore pills, in the course of a few hours, but was weakly for some days. (p. 79.) The following case is remarkable on account of the sloughing which ensued, as in Home's case, but the man recovered. "A Gentoo man, about forty years of age, was bitten in the fleshy part between the thumb and fore-finger; he instantly felt a sharp pain in the part (a) Account of Indian Serpents collected Experiments and Remarks on their several on the Coromandel Coast, &c, together with Poisons. London, 1796. Fol. OF POISONOUS SNAKE-BITES. 395 bitten, which soon spread on the palm and upwards on the arm. He was sensible also of sickness at the stomach, but did not vomit. In less than an hour the hand and wrist were considerably swelled, the pain extending nearer the shoulder; he was sensible of a confusion in his head, and had a strong disposition to doze. He at times showed much inquietude, without making any specific complaint; at other times he lay moaning and dozing. Towards midnight his disorder increased, startings about his throat were observed, his breathing became laborious, he could not speak articulately, and seemed not to perceive objects though his eyes were open. A poultice of herbs was applied, and a secret internal antidote administered. When seen next morning by the surgeon, his hand and arm were monstrously swollen, and the punctures were presumed to be livid, although this might have been from the stain of the poultice which could not be got off. He had recovered his senses, was free from fever, and complained only of confusion in the head, of languor, and of pain in the arm. Bark was ordered, but a few doses only were taken. The parts about the puncture mortified first; the gangrene then spread over the back and palm of the hand, and part of the wrist, laying the tendons bare, and forming an ulcer of considerable extent, which, however, healed favourably under the usual treatment. He recovered his health in eight or ten days; but it was several months before he recovered the use of his hand." (p. 82.) Russell also mentions three fatal cases of snake-bites, but without stating what kind of snake. The first was that of " a Havildar, who was bitten at one o'clock in the morning, in the little toe of the right foot. He was not at the moment sensible of much more pain than that occasioned by the bite of a large ant, and lay down to sleep. At day-light he was found almost stiff, yet still retained the power of speech, and declared he should inevitably die in consequence of the bite. He complained very little of pain, but seemed to suffer a general stupor; he had totally lost his sight, and expired before seven in the morning. * * * The second was a Gentoo boy, who, thrusting his hand into a hole in the wall, was bitten in the hand. He exclaimed loudly, and his master, running to know what had happened, found the boy hardly able to give an account of what had befallen him, and in not more than ten minutes after crying out, he expired. * * * The third was a very stout Arab porter, who was bitten by a small snake, and expired almost instantaneously. The snake was that called by the Portuguese cobra de morte, from six to nine inches long, as thick as a tobacco-pipe; the head black, with white marks, bearing some resemblance to a skull and two cross bones; the body alternately black and^white, in joints, tbe whole length." The first case, which expired within six hours after the bite, Russell observes, "agreed nearly, as to time, with the few fatal accidents he heard of while in India." (p. 73-81.) Barton, speaking of the mode in which rattlesnake bites were treated in Pennsyl- vania in his time, says:—In general, the first thing that was attended to, after a person had been bitten by the rattlesnake, was to throw a tight ligature above the part into which the poison had been introduced; at least this was the practice wherever the situation of the wounded part admitted of such an application. The wound was next scarified, and a mixture of salt and gun-powder, sometimes either of these articles separately, was laid upon the part. Over the whole was applied a piece of the bark of the white walnut. At the same time some one, frequently more than one, of the vegetables which were mentioned to me, were given internally, either in decoction or infusion, along with large quantities of milk." (p. 102.) The treatment of these cases in India, during Russell's time, was the celebrated Tanjore pill, of which the following is the composition, as given byDuFFix:— White arsenic, roots of vellinavi, kernels of hervalam, pepper, quicksilver, of each an equal part; the quicksilver is to be rubbed with the juice of the wild cotton (Asc/cpias gigantea) till the globules become invisible. The arsenic being first levigated, and tbe other ingredients reduced to a powder, are then added, and the whole is beaten up together, with the juice of the wild cotton, to a consistence fit to be divided into pills. If a person is bit by a cobra de capello, mix one of the pills with a little warm water and give it to the patient. After waiting a quarter of an hour, should the symptoms of infection increase, give two pills more; should these not sufficiently counteract the poison, another pill must be given an hour after. This is generally found sufficient. The wound should be dilated, and the warm liver of a fowl applied to the part. * * * For the bite of less poisonous snakes, one pill every morning for three days is sufficient. The patient ought to keep a regimen 396 SYMPTOMS OF for six days, eating only congee (rice water) and rice, or milk and rice. He should abstain from salt, and his drink may be warm water. Sleep is to be prevented for the first twenty-four hours. The pills generally occasion a nausea and purging, but seldom in a violent degree." (pp. 74, 5.) The favourable report on tbe use of the Tanjore pill, of which arsenic is the principal remedy, led Ireland (a) to employ Fowler's solution, which contains half a grain of arsenic in a drachm ofthe solution, in cases which had been bitten by the great lance-headed viper of Martinique, (Trigonocephaly lanceolatus, Oppel.) Persons previously bitten had died, without using this medicine, between six and twelve hours after receiving the wound. This practice was successful in four or five cases. Russell says, that " the poisons of all the venomous serpents he has examined are in colour and consistence very much alike at the moment of emission through the fangs. They differ somewhat in colour from each other, but not more than the poison of each individual is found occasionally to differ from itself. The poison is somewhat mueilaginous when first emitted, but becomes quickly more so when exposed to the air; while its colour, from pale yellowish white, changes to yellow- ish ; and when dry, it resembles a yellow flaky resin. This resin, when long kept, grows much darker in colour, and is not easily soluble; but when recent or in the intermediate degrees of hardening, it mixes readily enough with water or with spirits." Russell applied less than one drop of the poison of the cobra de capello (Naja tripudians, Merr.) to his tongue, but after remaining ten minutes, it was insipid and inert like pure water. He was neither sensible at first of any saline taste, nor, though strictly attentive, could he perceive any subsequent effect what- ever on the tongue. This experiment was repeated more than once, at different times, invariably with the same result. The poison of the katuka retula poda (Vipera elegans, Merr.) was tried, with precisely the same success. Of a quantity which was emitted through the fangs, he rubbed almost two drops, perfectly recent, on his tongue and palate; but was neither sensible of pungency, nor of any conse- quence from it, more than from the poison of the cobra de capello." The recent poison of snakes applied to the eyes of chickens caused no visible irritation, nor was it followed by inflammation. The recent poisons of the cobra de capello and katuka retula poda, under the usual trials, gave no indication of possessing either an acid or alkaline quality." (pp. 86, 7.) Barton mentions the following very curious observation, which is well worthy remembrance :—" It often happens that the poison of the rattlesnake, like that of the mad dog, being merely thrown into muscular, tendinous, ligamentous, or cellular parts, is deposited there some time without being absorbed into the mass of blood. In these cases the success of the plan which I have described will, probably, be very great. Whatever preference may be given to the use of the knife or of the caustic over that of scarification, the application of the blister, &c, I think there can be very little doubt of the propriety of employing the ligature. I am convinced, indeed, that on the use of this simple application the success of our cure, or to speak more properly, of our prevention, will in a great measure depend." (p. 107.) Upon the bite of the rattlesnake, compare Revue Medicale, May, 1827, p. 298-321. 356. (The bite of a rabid beast, specially of a dog, wolf, fox, cnf, so-rietimeseven of some others, poisons the wound with a peculiar con- tagion, which, by its operation on the organism, produces hydrophobia, Lat.: die Wasscrscheue, Germ; Hydrophobic, Fr.; and dog-madness (Rabies canina, Lat.; die Wulh, Germ.; la Rage, Fr.) From numerous and careful observations, it cannot be doubted that the bite of beasts much excited, or when disturbed during copulation, may produce canine mad- ness. [Neither ourselves nor the French have any vernacular title for this dreadful dis- ease in the human subject, both therefore use the Greek compound, the French, how- ever, giving it their national terminal; whilst the Germans have translated it. On the other hand, as regards the disease in the dog, there is a special title for it both in (a) Above quoted. DOG-MADNESS. 397 German and French ; but we have none, and therefore indiscriminately apply the term hydrophobia to the disease in the dog, of which, as will be presently shown, neither the dread of water, nor incapability of swallowing it are to be properly considered as symptoms, whilst in man they are the most marked and characteristic. The Greeks had a special term for dog-madness, Kutro-x or kutth, which is used by Homer, in the 9th book, 239th line ofthe Iliad ; and Dr. Good has, in his Nosology, proposed the reintroduction of this title, calling the disease in the human subject Entasia lyssa.—- As, however, the disease is well known and understood by the term in common ac- ceptation, it is better to leave it alone, than to produce confusion by idle pedantry.— J. F. S.] 357. Dog-madness develops itself, either of its own accord, (sponta- neous madness,) or from the transference of the poison. A high degree of heat, sudden changes of heat and cold, bad food, want of water, and unsatisfied sexual desires, are assumed as causes of the spontaneous de- velopment of this madness. The spontaneous occurrence of hydra- phobia in man is denied by many, as the principal symptom, to wit, the fear of water, belongs also to several other diseases. Some obser- vations have, however, put the possibility of the spontaneous deve- lopment of canine madness in man beyond doubt (or). Ziegler (b) fixes the origin of madness in the want of the instinctive degree of nourishment from blood and flesh, and therefore calls the disease Blood durst (Blood- thirstiness or Fleischgier (Flesh-craving.) 358. The signs of incipient madness in the dog are generally very doubtful, and are the more to be noticed, as numerous and careful ob- servations have proved that the dread of water is by no means a de- cided sign of madness in the dog, as generally stated (c). According to Hertwig's \d) frequent observations, the most important symptoms of the raving madness in dogs are, change of their usual manner, uneasi- ness, and prevailing disposition to be continually changing and running away from their place of residence and bed (1); great disposition to lick cold subslances; loss of appetite, especially for firm solid food, (some few dogs, however, make an exception to this, taking from time to time some mouthfuls of better food,) and great disposition to use those things which cannot assist in their nourishment, as wood, leather, straw, wool, and so on ; they lick up not only their own and other dogs' urine, but sometimes also eat their own dung. Obstinate costiveness, disposition to bite, especially when they are excited by anger, or if the dog be of a biting and passionate temper, with many snaps in the air, asjf they would catch flies or other insects (2). And, most especially, a peculiar change in the voice and in the kind of bark, the former is harsh, hoarse, peevish, and uneasy-sounding, and the bark is always accom- panied with a short peculiar howl (3). In no dog does consciousness cease till shortly before death. All mad dogs can look at, lick up, and drink water and other fluids (4); generally they do not exhibit any increased disposition to sexual congress (5). Their external appearance at the very beginning of the disease is little or not at all changed ; about the se. cond or third day the eyes usually become reddened, and in most in_ (a) Mangor ; in Act. Soc. Reg. Hafn., vol. (c) Rust, loc. cit., p. 328. ii. obs. xxxii. p. 408. New York Medical (d) In Hiteland's Journal, supplementary Repository of Original Essays, by Mitchell, volume, 1828.—Bietrage zur naberen Kennt- Pascalis, and Akerlv, vol. v. niss der Wuthkrankheit oder Tollheit der (6) Salzb. Med. Chir. Zeit., 1821, vol. iii. Hunde. Berlin, 1829. p. 190. vol. i.—34 398 SYMPTOMS OF stances are occasionally closed for a few seconds; at the same time the skin on the forehead and above the eyes is drawn into little folds or wrin- kles in consequence of which the animal has a sleepy, surly, fretful appear- ance. Subsequently the eyes become dull and languid, but never fiery and lively, as at first; most have a rough, rugged appearance, and all in a short time become remarkably wasted. The mouth is in most cases rather dry than moist, and therefore generally without foam or spittle; but when the pharynx is decidedly affected, and the descent of the spit- tle probably hindered by its swelling, then is there an exception (6).— So long as the dog has power, and so long as it is not pursued, it carries its tail as usual, wagging it cheerfully, as it may fancy; but as weak- ness comes on the tail hangs down loosely, though never more drawn beneath the body than usual. The gait is not altered at the beginning of the disease; they do not proceed, as commonly believed, only straight forward and in the same course, but if undisturbed run about in various directions and wanderings, trot very actively along the road, and only when a paroxysm seizes them spring aside, in order to bite (7). Many dogs, however, which run away in a bewildered state, and the greater number at a later period of the disease, when they have become con- fused, run straight forward in one direction, till they drop down worn out, or are driven to change their course from some accidental circum- stance. In dumb madness the animal also changes its manner, becomes les3 lively and watchful, more quiet, restful, and melancholy; the lower jaw drops, as if paralyzed ; the spittle flows down to the ground, and every thing, even fluid, which the animal wishes to swallow, drops from its mouth (8); it can, therefore, bite but little, as the inclination to bite, to run, and even to restlessness, is diminished. All the other symptoms re- semble those of raving madness. The course ofthe disease is in both forms very various and entirely indefinite. In all cases it runs on to death, and generally by gradual, but daily, visible wasting ofthe living powers, in from six to eight days after the first attack; sometimes death occurs earlier, and the animal dies suddenly, as if from apo- plexy (9). [The following important additions are from Youatt's recent and very excellent work, The Dog:— (1) "The early symptoms of rabies in the dog are occasionally very obscure. In the greater number of cases, these are sullenness, fidgetiness, and continual shifting of posture. Where I have had opportunity, I have generally found these circumstances in regular succession. For several consecutive hours, perhaps, he retreats to his basket or his bed. He shows no disposition to bite, and he answers the call upon him laggardly. He is curled up, and his face is buried between his paws and his breast. At length he begins to be fidgety; he searches out new resting places, but he very soon changes them for others. He takes again to his own bed, but he is continually shifting his posture. He begins to gaze strangely about him as he lies on his bed. His countenance is clouded and suspicions. He comes to one and another ofthe family, and he fixes on them a steadfast gaze, as if he would read their very thoughts. ' I feel strangely ill,' he seems to say, ' have you any thing to do with it! or you? or you V Has not a dog mind enough for this? If we have observed a rabid dog at the commencement of the disease, we have seen this to the very life. * * * A peculiar delirium is an early symptom, and one that will never deceive. A young man had been bitten by one of his dogs, I was requested to meet a medical gentleman on the subject. I was a little behind my time. As I entered the room I found the dog eagerly devouring a pan of sopped bread. ' There is no madness here,' said the gentleman. He had scarcely spoke, when in a moment the dog quitted the sop, and with a furious bark sprung against DOG-MADNESS. 399 the wall, as if he would seize some imaginary object that he fancied was there. " Did you see that V was my reply ; ' What do you think of it V 'I see nothing in it,' was his retort; ' the dog heard some noise on the other side of the wall.' At my serious urging, however, he consented to excise the part. I procured a poor worthless cur, and got him bitten by this dog, and carried the disease from this dog to the third victim. They all became rabid the one after the other, and there my ex- periment ended. * * * I have again and again seen the rabid dog start up after a momentary quietude, with unmingled ferocity depicted on his countenance, and plunge with a savage howl to the end of his chain. At other times he would stop and watch the nails in the partition of the stable in which he was confined, and fancying them to move, he would dart at them, and occasionally sadly bruise and injure himself, from being no longer able to measure the distance of the object." From this state, however, " one word recalls him in a moment. Dispersed by the magic influence of his master's voice, every object of terror disappears, and he crawls towards him with the same peculiar expression of attachment that used to charac- terize him. Then comes a moment's pause—a moment of actual vacuity; the eye slowly closes, the head droops, and he seems as if his forefeet were giving way and he would fall; but he springs up again, every object of terror once more surrounds him, he gazes wildly around, he snaps, he barks, and he rushes to the extent of his chain prepared to meet his imaginary foe." (pp. 131, 2.) (2) " It is not every dog that, in the most aggravated state ofthe disease, shows a disposition to bite;" and mentions the case of a Newfoundland dog, the details of which are of the deepest interest. "On the other hand," he says, " there are rabid dogs whose ferocity knows no bounds. If they are threatened with a stick, they fly at and seize it, and furiously shake it. They are incessantly employed in darting to the end of their chain, and attempting to crush it with their teeth, and tearing to pieces their kennel, or the wood-work that is within their reach. They are regardless of pain. The canine teeth, the incisor teeth are torn away; yet un- wearied and insensible to suffering, they continue their efforts to escape. A dog was chained near the kitchen-fire. He was incessant in his endeavours to escape, and when he found that he could not effect it, he seized in his impotent rage, the burning coals as they fell, and crushed them with his teeth. If by chance a dog in ibis state effects his escape, he wanders over the country bent on destruction. He attacks both the quadruped and the biped. He seeks the village street or the more crowded one of tbe town, and he suffers no dog to escape him. The horse is his frequent prey, and the human being is not always safe from his attack." (p. 140.) (3) "In almost every case in which the dog utters any sound during the disease, there is a manifest change of voice. In the dog labouring under ferocious madness it is perfectly characteristic. There is no other sound that it resembles. The animal is generally standing, or occasionally sitting, when the singular sound is heard. The muzzle is always elevated. The commencement is that of a perfect bark ending abruptly and very singularly, in a howl a fifth, sixth, or eighth higher than at the commencement. Dogs are often enough heard howling, but in this case it is the perfect bark and the perfect howl rapidly succeeding to the bark. " Every sound uttered by the rabid dog is more or less changed. The huntsman, who knows the voice of every dog in his pack, occasionally hears a strange chal- lenge. He immediately finds out that dog, and puts him as quickly as possible under confinement. Two or three days may pass over, and there is not another suspicious circumstance about the anirnal; still he keeps him under quarantine, for long experience has taught him to listen to that warning. At length the disease is manifest in its most fearful form. "There is another partial change of voice to which the ear of the practitioner will by degrees become habituated, and which will indicate a change in the state ofthe animal quite as dangerous as the dismal howl; I mean when there is ahoarse inward bark with a slight but characteristic elevation of the tone. In other cases, after two or three distinct barks will come the peculiar one mingled, with the howl. Both of them will terminate fatally, and in both of them the rabid howl cannot possibly be mistaken." (p. 138.) (4) The dog not only " can look at, lick up, and drink water and other fluids," as here described, but Youatt says, has "an insatiable thirst," resulting from tbe altered character and diminished quantity of saliva presently noticed :—" The dog that still has full power over the muscles of his jaws continues to lap. He knows not when to cease, white the poor fellow labouring under the dumb madness, pre- 400 SYMPTOMS OF sently to be described, and whose jaw and tongue are paralyzed, plunges his muzzle into the water-dish to his very eyes, in order tbat he may get one drop of water into the back part of his mouth to moisten and to cool his dry and parched fauces. Hence, instead of this disease being always characterized by the dread of water in the dog, it is marked by a thirst often perfectly unquenchable." (p. 136.) (5) " Some very important observations may be drawn from the appearance and character of the urine. The dog, and at particular times when he is more than usually salacious, may, and does diligently search theurining places ; he may even, at those periods, be seen to lick the spot which another has just wetted ; but if a peculiar eagerness accompanies this strange employment, if, in the parlour, which is rarely disgraced by this evacuation, every corner is perseveringly examined and licked with unwearied and' unceasing industry, that dog cannot be too carefully watched, there is great danger about him; he may, without any other symptom be pronounced to be decidedly rabid ; I never knew a single mistake about this." (p. 135.) (6) This observation is corroborated by "V ouatt :—Much has been said of the profuse discharge of saliva from the mouth of the rabid dog. It is an undoubted fact that in this disease, all the glands concerned in the secretion of saliva, become increased in bulk and vascularity. The sublingual glands wear an evident cha- racter of inflammation; but it never equals the increased discharge that accompanies epilepsy, or nausea. The frothy spume at the corners of the mouth, is not for a moment to be compared with that which is evident enough in both of these affec- tions. It is a symptom of short duration, and seldom lasts longer than twelve hours. The stories that are told ofthe mad dog covered with froth, are altogether fabulous. * * * The increased secretion of saliva soon passes away. It lessens in quantity, it becomes' thicker, viscid, adhesive, and glutinous. It clings to the corners of the mouth, and probably more annoyingly so to the membrane of the fauces. * * * The dog furiously attempts to detach it with his paws. It is an early symptom in the dog, and it can scarcely be mistaken in him. When he is fighting with his paws at the corners of his mouth, let no one suppose that a bone is sticking between the poor fellow's teeth ; nor should any useless nor dangerous effort be made to re- lieve him. If all this uneasiness arose from a bone in the mouth, the mouth would continue permanently open instead of closing when the animal for a moment dis- continues his efforts. If after awhile he loses his balance and tumbles over, there can be no longer any mistake. It is the saliva becoming more and more glutinous, irritating the fauces and threatening suffocation." (pp. 135, 36.) (7) " In the great majority of cases of furious madness, and in almost every case of dumb madness, there is evident affection ofthe lumbar portion ofthe spinal cord. There is a staggering gait, not indicative of general weakness, but referrible to the hind quarters alone, and indicating an affection of the lumbar motor nerves. In a few cases it approaches more to a general paralytie affection." (p. 139.) (8) " In an early period of the disease in some dogs, and in others when the strength of the animal is nearly worn away, a peculiar paralysis of the muscles of the tongue and: jaws is seen. The mouth is partially open, and the tongue pro- truding. In some cases the dog is able to close his mouth by a sudden and violent effort, and is as ferocious and as dangerous as one the muscles of whose face are un- affected. At other times the palsy is complete, and the animal is unable to close his mouth or retract his tongue. These latter cases, however, are rare. A dog must not be immediately condemned because he has this open mouth and fixed jaw. Bones constitute a frequent and a considerable portion of the food of dogs. In the eagerness with which these bones are crushed, spicula or large pieces of them become wedged between the molar teeth, and form an insuperable obstacle to the closing of the teeth. The tongue partially protrudes. There is a constant dis- charge of saliva from the mouth far greater than when the true paralysis exists. The dog is continually fighting at the corners of his mouth, and the countenance is expressive of intense anxiety, although not of the same irritable character as in rabies." (p. 141.) (9) "Absence of pain in the bitten part is an almost invariable accompaniment of rabies. I have known a dog set to work, and gnaw and tear the flesh completely away from his legs and feet. At other times the penis is perfectly demolished from the very base. Ellis in his ' Shepherd's Sure Guide,' asserts, that, however severely a mad dog is beaten, a cry is never forced from him. I am certain of the truth of this, for I have again and again failed in extracting that cry. Ellis tells DOG-MADNESS. 401 that at the kennel at Goddesden, some of the grooms heated a poker red hot, and holding it near the mad hound's mouth, he most greedily seized it, and kept it until the mouth was most dreadfully burned." (p. 139.) Youatt makes a most important observation in regard to the diagnosis between the pain in the ear in canker and hydrophobia :—" The dog appears to suffera great deal of pain in the ear in common canker. He will be almost incessantly scratching it, crying piteously while thus employed. The ear is oftener than any other part, bitten by the rabid dog, and when a wound in the ear, inflicted by a rabid dog, begins to become painful, the agony appears to be of the intensest kind. The dog°rubs°his ear against every projecting body, he scratches it might and main, and tumbles over and over while he is thus employed. The young practitioner should be on his guard there. Is this dreadful itching a thing of yesterday, or, has the dog been subject to canker increasing for a considerable period ? Canker both internal and external is a disease of slow growth, and must have been long neglected before it will torment the patient in the manner that I have described. The question as to the length of time that an animal has thus suffered will usually be a sufficient guide. I he mode in which he expresses his torture will serve as another direction! He will often scratch violently enough when he has canker, but he will not roll over and over like a football except he is rabid. If there is very considerable inflamma- tion of the lining membrane ofthe ear, and engorgement and ulceration of it, this is the effect of canker; but if there is only a slight redness of the membrane, or no redness at all, and yet the dog is incessantly and violently scratching himself, it is too likely that rabies is at hand." (pp. 133, 4.) "In the dog I have never seen a case in which plain and palpable rabies occurred in less than fourteen days after the bite. The average time I should calculate at five or six weeks. In three months I should consider the animal as tolerably safe. I am, however, relating my own experience, and I have known but two instances in which the period much exceeded three months. In one of these five months elapsed, and the other did not become affected until after the expiration of the seventh month. * * * The duration ofthe disease is different indifferent animals. In man it has run its course in twenty-four hours, and rarely exceeds seventy-two. In the horse from three to four days; in the sheep and ox from five to seven; and in the dog from four to six." (p. 144.)] 359. The spittle (but according to Trolliet, who found the salivary- glands unchanged, the mucus secreted from the inflamed mucous mem- brane ofthe bronchi) is the vehicle ofthe mad poison, which has been proved beyond all doubt by Hertwtig's experiments. This poison is of a definite character, can impregnate various substances, and retains its activity for a long while. It need not be applied directly to an open wound to manifest its effects ; it may be taken up on parts which have a very thin epidermis, even without a wound. The poison seems to remain entirely- inactive when applied to the uninjured mucous membrane ofthe diges- tive organs. The contagion is also held in the blood ofthe mad beast, as proved by Hertwig's experiments with inoculation. Every bite of a mad beast does not produce madness ; perhaps a peculiar idiosyn- crasy is madness ; but the bite may be also where, the part being covered with clothes, the spittle is retained in them, and the wound is not poisoned. In beasts which have become mad from conta- gion, the contagion is developed, and can again propagate the dis- ease. In reference to grass-feeding beasts, the experiments have a dif- ferent result. The propagation of madness from the contagion of man to beasts, and especially to dogs, is proved by experiments, but no case is known in which it has been propagated from one man to another. [Appearances on dissection.—As these are most important in enabling us to deter- mine the actual nature ofthe disease with which the dog is affected, and consequent- ly to decide upon the safety or danger of the person bitten, I have thought it desirable to give Youatt's observations on this subject. 34* 402 APPEARANCES ON "In dumb madness," says he, "the unfailing accompaniment is to a greater or less degree, paralysis of the muscles of the lower jaw, and the tongue is discoloured and swollen, and hanging from the mouth; more blood than usual also is deposited in the anterior and inferior portion of it. Its colour varies from a dark red to a dingy purple, or almost black. In ferocious madness it is usually torn and bruised, or it is discoloured by the dirt and filth with which it has been brought into contact, and, not unfrequently, its anterior portion is coated with some disgusting matter. The papilla, or small projections on the back of the tongue, are elongated and widened, and their mucous covering evidently reddened. The orifices of the glands of the tongue are frequently enlarged, particularly as they run their course along the fraenum of the tongue. The fauces, situated at the posterior part of the mouth, generally exhibit traces of inflammation. They appear in the majority of cases of ferocious madness, and they are never deficient after dumb madness. They are usually most intense either towards the palatine arch or the larynx. Sometimes an inflammatory character is diffused through its whole extent, but occasionally it is more or less intense towards one or both of the terminations of the fauces, while the intermediate portion retains nearly its healthy hue. There is one circumstance of not unfrequent occurrence, which will at once decide the case—the presence of indigestible matter, probably small in quantity, in the back part ofthe mouth. This speaks volumes as to the depraved appetite of the patient, and the loss of power in the muscles of the pharynx. Little will depend on the tonsils of the throat. They occasionally en- large to more than double their usual size ; but this is more in quiet than in ferocious madness. The insatiable thirst of the rabid dog is perhaps connected with this condition of them. The epiglottis should be very carefully observed. It is more or less injected in every ease of rabies. Numerous vessels increase in size and multiply round its edge, and there is considerable injection and thickening. Inflam- mation of the edges of tbe glottis, and particularly of the membrane which covers its margin, is often seen, and accounts for the harsh guttural breathing which fre- quently accompanies dumb madness. The inflammatory blush of thelarynx, though often existing in a very slight degree, deserves considerable attention. The appear- ances in the trachea are very uncertain. There is occasionally the greatest intensity of inflammation through the whole of it; at other times there is not the slightest appearance of it. There is the same uncertainty with regard to thebTonchial tubes and the lungs; but there is no characteristic symptom or lesion in the lungs. Great stress has been laid on the appearance of the heart; but, generally speaking, in nine cases out of ten, the heart of the rabid dog will exhibit no other symptoms of disease than an increased yet variable deepness of colour in the lining membrane of the ventricles. No dependence can be placed on any of the appearances of the oesophagus; and, when they are at the worst, the inflammation occupies only a portion of that tube. With regard to the interior of the stomach, if the dog has been dead only, a few hours the true inflammatory blush will remain. If four-and-twenty. hours have elapsed, the bright red colour will have changed to a darker red, or a violet or a brownish hue. In a few hours after this-, a process of corrosion will generally commence, and the mucous membrane will be softened and rendered thinner, and, to a certain extent, eaten through. The examiner, however, must not attribute that to disease which is the natural process of the cessation of life. Much attention should be paid to the appearance of the stomach and its contents. If it contains a strange mingled mass of hair, and hay, and straw, and horse-dung, and earth,or portions of the bed on which the dog had lain, we should seldom err if we affirmed that he died rabid ; for it is only under the influence of the depraved appe- tite of rabies that such substances are devoured. It is not the presence of every kind of extraneous substance that will be satisfactory: pieces of coal, or wood, or even the filthiest matter, will not justify us in pronouncing the animal to be rabid ; it is that peculiaily mingled mass of straw, and hair, and filth of various kinds, that must indicate the existence of rabies. When there are no solid indigesta, but a fluid composed principally of vitiated bile or extravasated blood, there will be a strong indication of the presence of rabies. When, also, there are in the duodenum and jejunum small portions of indigesta, the detection of the least quantity will be decisive. The remainder has been ejected by vomit; and inquiry should be made of the nature of the matter that has been discharged. The inflammation of rabies is of a peculiar character in the stomach. It is generally confined to the summits of the folds of the stomach or it is most intense there. On the summits of the rugae DISSECTION. 403 there are effusions of bloody matter, or spots of ecchymosis, presenting an appear- ance almost like crushed black currants. There may be only a few of them; but they are indications of the evil that has been effected. From appearances that pre- sent themselves in the intestines, the bladder, the blood-vessels, or the brain, no conclusion can be drawn; they are simply indications of inflammation." (p. 141- 43.) The following observation of Youatt's cannot be too constantly inculcated in all persons fond of dogs, nor too carefully remembered by practitioners in making their inquiries, and coming to conclusions in cases where there is the slightest suspicion of hydrophobia. "In the early stages of rabies," says he, "the attachment ofthe dog towards his owner seems to be rapidly increased, and the expression of that feeling. He is employed, almost without ceasing, licking the hands or face, or any part he can get at. Females, and men too, are occasionally apt to permit the dog, when in health to indulge this filthy and very dangerous habit with regard to them. The virus, generated under the influence of rabies, is occasionally deposited on a wounded or abraded surface, and in process of time produces a similar disease in the person that has been so inoculated by it. Therefore it is that the surgeon so anxiously inquires of the person that has been bitten, and of all those to whom the dog has had access, ' Has he been accustomed to lick you? have you any sore places about you that can by possibility have been licked by him?' If there are, the person is in fully as much danger as if he had been bitten, and it is quite as ne- cessary to destroy the part with which the virus may have come in contact." (p. 134.) "The Hon. Mrs. Duff," says Lawrence, "had a French poodle, of which she was very fond, and which she was in the habit of allowing to lick her face. She had a small pimple on her chin, of which she had rubbed off the top, and allowing the dog to indulge in his usual caresses, it licked this pimple, of which the surface was exposed, and thus she acquired hydrophobia, of which disease she died." (p. 619.) With regard to the communication of hydrophobia from one human being to another, or from man to beasts, Lawrence observes, " numerous experiments of this kind have been made on animals, that is, the saliva of a human being, labouring under hydrophobia, has been inserted into the recent wounds of various animals ; but these experiments have all failed, except in one instance, and that is mentioned by Magendie and Breschet. They took the saliva of a patient, labouring under hydrophobia in the Hotel Dieu, and applied it to the recent wounds of two dogs, on the 27th of June* On the 26th of July one of the two dogs thus inoculated went mad, and that dog bit two others, one of which died rabid on the 26th of August; so that if this experiment be correct, and the high reputation of those who are said to have made it, leads us to place credit on the statement, we must, I suppose, admit that the saliva of the human subject has the power of communicating the disease. This, however, is the only instance or fact that I know of, which at all tends to establish the point." (p. 618.)] 360. The time of the outbreak of madness after the bite is very va- rious, according to the constitution of the person bitten, the place of the wound, the time of the year, and the various corporal and mental influences. Often from seven to fourteen, usually from twenty to forty days elapse, sometimes several months, or even still longer, before the madness breaks out. Frequently the wound is still open, but in most cases it has scarred, as it generally heals quickly without any particular symptom. [Very incredible statements have been made as to the interval between the reception of the bite and the appearance of the disease. These appear to have principally originated from hearsay evidence, and been brought forward by the writers of the middle ages. Galen says that he knew one case, in which after the lapse of a year the person was attacked with the disease called hydrophobia (a)." Meade says he "remembered one after eleven months." (p. 131.) And he was informed on undoubted authority of " a gentlewoman in Yorkshire, of the age of thirty-five years, who was bit by a mad dog in the forefinger; about a month after (a) E/c Ts \7T?nKf*Twt Trfiffurmmu /3 delirious during the night. The treatment consisted of low diet, little or no medical treatment, and the application of strips of adhesive plaster to the wound, which was entirely healed in six weeks. There was never any exfoliation of bone." He was alive and well seventeen years after, and the following is the interesting account of his then condition. " The eye shows the globe to be sound and healthy in structure, (this is not quite correct, as presently shown,—j. f. s.,) though less prominent than the other. Its muscular actions are all regularly performed, except that of the m. levator palpebrae superioris. The vision is entirely lost in that eye; the pupil dilated, and wholly insensible to the stimulus of light. All the senses are perfect excepting the vision of the injured eye. The memory is very defective. He is incapable of applying to any pursuit requiring mental activity. His disposition is irritable, especially after indulging in liquor, or after any unusual stimulus. He has occa- sional pain on the injured side of the forehead, and has once since had typhus (a) Lancet, 1827-28, vol, ii. 37* 43S REMOVAL OF FOREIGN BODIES. fever. His bodily health is now good, and he has the free use of his limbs." (p. 16.)] 399. In those wounds the first indication always is the careful search for and withdrawing of foreign bodies; if they stick fast in the mem- branes of the brain or in the brain itself, an attempt must be made to loosen them by a cut, and to draw them out without violence. Balls in the substance of the brain are to be discovered by careful probing: if they be superficial they may be often withdrawn with a pair of forceps ; care, however, must be taken that they be not pushed further into the brain (1). The head is to be put into such position that the fluids may readily escape, by which also the foreign body often moves, so that at a later period it can be drawn out. Trepanning is therefore always neces- sary when the given object cannot be attained by the existing wound (2). The dressing should be mild ; the wound covered lightly with dry charpie, a compress, and fastened with the three-cornered head- cloth. The after treatment must correspond to the degree of inflamma- tion. According to A. Cooper (a) pieces of bone penetrating the brain, if symptoms of pressure do not exist, should not be removed, because thereby, in all probability, extravasation would ensue. Brodie (b) recommends that foreign bodies penetrating the brain should only be drawn out, if it can be done without any fresh wound, and he endeavours to support this opinion by cases. [(1) Hennen's observations upon this point appear to me very important. He says:—"We would also naturally remove all extraneous bodies within view or reach ; but before we commence any unguided search after them, we ought seriously to balance the injury that we may inflict. I by no means wish to be understood to say, that we ought not to endeavour cautiously to follow the course of a ball, when unfortunately it has got within the cavity of the cranium. M. Larrey asserts that can be done with safety and effect. He informs us that he traced a ball which entered the frontal sinus of a soldier during the insurrection at Cairo, by means of an elastic bougie, from the orifice to the occipital suture, in the direct course of the longitudinal sinus ; and, by a corresponding measurement externally, he was enabled successfully to apply a trepan over it and extract it; the patient recovered. M. Percy, on the other hand, gives a fatal instance where a ball was absolutely within reach ofthe forceps, and yet, for want of a sufficient opening, and manual dexterity in the operator, it slipped into the brain; and although the opening was enlarged by the trepan, it could not be recovered. In the works of some of the older authors we meet with cases where epilepsy and various other bad symptoms have followed the attempts at extracting arrows and other missiles sticking in the brain; and in more modern practice there are many instances where patients have lain in a state of apoplectic stertor, with a ball lodged in the brain, for some time, but have expired on its removal. One instance of this kind has been reported to me, where a soldier died the very moment the ball was extracted. A modern surgeon would be severely and justly censured for not at least making a trial; but we are encouraged to look for the eventual safety of our patients, when the course or actual site of the ball or other body is unknown, by recorded and well-authenticated instances of life being preserved, when they either have not been looked after, or their existence has not been suspected. The records of Surgery furnish us with many proofs of metallic and other bodies lying for long periods between the cranium and dura mater; but experience shows that the extraneous bodies may lie even in the brain itself without producing death. I have seen no less than five cases where a ball has lodged in the substance of the cerebrum, without immediately producing a fatal event." (pp. 288, 289.) Lawrence also mentions an example of a young man who had discharged a brace of pistols into his mouth. One bullet " was found in the neighbourhood of the jaw, but the other was not to be met with at all. Inflammation of one eye took place (a) Lectures on Surgery, by Tyrrell, vol. i. p. 315. (b) Above cited, p. 413. INFLAMMATION OF THE DURA MATER. 439 after the accident, the cornea became turbid, and the sight of it was lost." He lived a fortnight, and on examination the other bullet was found to have gone through the orbit, behind the globe, on the side on which the sight was afterwards lost. It had entered the cavity of the cranium, by breaking through the orbital process of the frontal bone, going through the anterior part of the brain, and then passing upwards about as far as the coronal suture, making a distinct track throughout its course upon the surface of the brain. In this instance there was no one symptom during the fortnight the patient lived that could have led one to suppose that any injury what- ever had happened to the brain." (p. 523.) (2) As in wounds of the dura mater much danger is to be dreaded from the exten- sion of the inflammation to and throughout the serous arachnoid membrane by which it is lined, the younger Cline advised that a puncture should be forthwith made through the arachnoid and pia mater into the surface of the brain, for the purpose of exciting a more active and immediate inflammation, by which the general serous cavity might at once be shut off from the wound that he thus hoped to circumscribe. I once saw him adopt this practice, but the patient died; the injury he had received, upon examination after death, showing itself to be beyond remedy. Astley Cooper also recommended this treatment, but without acknowledging at whose sugges- tion.—j. f. s.] 400. When good suppuration takes place, a nourishing diet and con- stantly dry dressings arc advisable. If the suppuration be bad and thin, if fresh symptoms of inflammation arise, there is probably some splinter, which it must be attempted to remove; or the pus may not flow freely, in which case it may be necessary to enlarge the opening in the bone by trepanning. If an abscess form in the brain, it must be opened with a lancet (1). If the patient be weak, the suppuration bad, or the wound itself gangrenous, strengthening remedies must be used, especially bark, and it must be bound up with astringent remedies, as lime water, decoction of bark or of elm bark, with tincture of myrrh, with digestive salves and the like. If a portion of the brain be en- tirely spoiled, it must be taken away. Loose pieces of bone must be carefully withdrawn. The dressings should be changed each time as quickly as possible, so that the wound be not long exposed to the air; care must also be taken that the air surrounding the patient should not be foul. [(1) If there be any sufficient guide to the situation ofthe abscess, I do not see any objection to making a cut through the brain to it; but to ascertain this is always very difficult and generally impossible, as it by no means follows that the abscess is immediately opposite the part where the blow has been received. The case which Guthrie quotes from La Peyronie (a) appears to be merely a simple circumscribed collection of pus beneath the dura mater, which, as its quantity increased, enlarged its cavity at the expense of the brain, so that it was presumed to have attained the size of a hen's egg, and to have descended to the corpus callosum. It was imme- diately emptied by puncturing the dura mater. Dupuytren's case (b) is, however, an abscess in the substance of the brain. A young man was wounded on the head with a knife; the wound healed, leaving only a little pain, which occasionally came on about the scar. Some years after he was brought to the Hotel Dieu, in a state of stupefaction, with which he had been sud- denly seized. An incision through the scar exposed the point of the knife sticking in the bone, the removal of which gave no relief. The trephine was also applied without benefit. The paralysis continuing on the side opposite to that on which the wound had been received, it was determined to open the dura mater, and plunge a knife into the brain, which evacuated a large quantity of pus. The paralysis ceased that night; he recovered his speech, became sensible, and entirely though gradually recovered.] (a) Sur la partie du Cervcau oi l'Ame exerce ses fonctions; in Hist, de l'Acad. des Sci- ences, 17 14, p. 199. (b) Lancettc Franchise, 14th Oct. 1830. 440 INFLAMMATION AND 401. Foreign bodies often remain in the brain with different conse- quences. Sometimes they do not give rise to the slightest symptom through the whole of life; sometimes merely pain is produced when the head is placed in a certain position; sometimes they cause cramps, and epileptic fits; often sudden coma, convulsions, and death. [Numerous examples are given of foreign bodies lodged in the substance ofthe brain, and producing symptoms of less or greater severity; but in the greater number it will be found, that after a few months they die either suddenly, or from some inflammatory attack ofthe brain. If, therefore, they remain quiet during life, it may be presumed that they assist in shortening it. A very remarkable instance is mentioned by Langlet (a) of a seven-drachm ball remaining for eighteen months in the brain, enveloped in a sort of membranous covering attached to the dura mater, and which contained pus.] A.—OF INFLAMMATION OF THE BRAIN AND ITS MEMBRANES. 402. Inflammation of the Brain (Encephalitis) may occur in even- injury of the head; and its causes are, the operation of external vio- lence, the splintering and indenting of bone, injury ofthe brain and its membranes, violent separation of the dura mater from the skull, bruising of the diploe, collections of matter under the tendinous aponeurosis, and so on. Inflammation arises either sooner jor later after the injury, and is severe, quick in its course, or slow. Its appearances are various, according as the inflammation proceeds from the dura mater or from the brain itself, and as it passes from one structure to the other. Its usual termination, wheji it does not disperse, is suppuration. 403. Acute Inflammation of the Dura Mater (Meningitis traumatica acuta) appears most commonly fiorn the third to the fifth day; the pa- tient complains of severe oppressive headach, which spreads from the injured part over the whole head; the warmth of the head is increased, the pulse small, compressed and rather hard; the patient is heavy, difficult to rouse, his ideas become unconnected, quiet delirium comes on ; and lastly, when the inflammation proceeds to suppuration, the pa- tient falls into a continued state of stupefaction from which he cannot be easily roused: convulsions come on, continued shivering, irregular pulse, the pupils are wide and fixed, the breathing snoring and slow; the sphincters are paralyzed, and the patient dies. On dissection, the dura mater is found reddened, covered with exudation, separated from the inside of the skull, pus between it and the bone, and at this part the dura mater often gangrenous. 404. Chronic Inflammation of the Dura Mater, which in injuries com- mences only after a long space of time, often after seven or fourteen days, often after a month, begins with headach, with mental and bodily depression, heaviness, unsteady walk, gastric symptoms, quick pulse, and in its further course a circumscribed painful svyelling of the cover- ings of the skull commonly arises at the place of the injury, or if there be a wound it becomes pale, and secretes a thin sanious fluid, which sticks fast to the bandages. The pericranium separates around the wound, and the inflammation soon runs into exudation of a yellowish (a) Bulletin de la Faculte de Medecine, No, 19.—1812. ABSCESS OF THE BRAIN. 441 ichorous purulent fluid, which collects either between the skull and the dura mater, or between the latter and the surface of the brain, (par. 386). [Astley Cooper mentions the case of a woman who had this chronic inflamma- tion ofthe dura mater, which terminated in suppuration and caries of the bone above it. She had fallen upon her forehead against a chest of drawers, which produced a small wound and great contusion: but she got well, excepting some pain and a sftnse of weight in the head, which continued to increase, became very severe, and at the end of eight months she was attacked with epilepsy. She had then a puru- lent discharge from the nose and ears, which relieved her; but it ceased after three days, and she was as bad as ever. This occurred again and again. But she got worse, lost her appetite, had very distressing pain in the head, especially at the part where the blow had been received, which was increased by pressure. She slept but little, became very irritable, and was often convulsed on the slightest dis- turbance. At last she was quite comatose, and then Birch of St. Thomas's, whose patient she was, cut through the scalp, but did not observe any disease in the peri- cranium or bone. The discharge from the wound at first afforded some relief; but it became fetid, the pericranium separated, the bone was carious, and an aperture in it allowed the passage of pus at every pulsation of the .brain. A trephine was there- fore applied to render its escape more ready; and, on the removal of the bone, the dura mater was found inflamed and gangrenous. She died next day, about nine- teen months after the accident, (p. 326-28.) I have seen several cases of this chronic inflammation, which is always a very serious disease, and very difficult of control; often indeed entirely unmanageable. The patient goes on slowly from bad to worse, sometimes with intervals of im- provement, sometimes without, and will frequently live in a state of constant suf- fering for many months.—j. f. s. 405. Acute Inflammation of the Brain (Encephalitis acuta traumatica) begins immediately after the injury, with severe, constant, increasing pain in the head, uneasiness, sleeplessness; the eyes are red, intolerant of light, the pupils contracted, countenance red, the carotids beat actively, the head is hot, the pulse full, hard, and vibrating. Contrac- tions of the muscles of the face and of the whole body, and severe vio- lent delirium, ensue. If the inflammation do not subside, it may be fatal by its severity, by the gorging of the brain with blood, and para- lyzing of the brain thereby ; or it goes on to suppuration ; symptoms of pressure on the brain, constant sleepiness, but often broken by delirium, and all the above-described symptoms (par. 403) come on, and death ensues. On dissection, the brain is found full of blood, its medullary part reddened, and when cut through, a quantity of bloody points, and even extravasated blood; collections of pus may also be noticed at various parts on the surface ofthe brain, or in its substance. 406. Chronic inflammation of the Brain (Encephalitis chronica trau- matica) frequently comes on very late; its symptoms are commonly de- ceptive, and, at the first, easily overlooked ; often showing intermission or remission. Bodily and mental depression, continued headach, fe- brile shiverings, and the like, occur for a shorter or longer time ; and with the passing of the inflammation into suppuration, the disturbance of the brain becomes greater, or symptoms of compression come on. Examination after death shows either a defined or diffused collection of pus in the substance, or on the surface, ofthe brain (1). [(1) It is quite impossible to determine the length of lime which abscess in the brain has existed before it produces symptoms, as its only indications are the symp- toms of compression, which come on two or three, or three or four days previous to death. The size of the abscess often leads to the belief that it cannot have been formed in the few days during which symptoms have existed ; and its situation 442 ABSCESS OF THE BRAIN. seems to have material influence on the appearance of the symptoms, proportionate to the importance of the part of the brain immediately compressed. Thus a large abscess may exist in the upper parts of the brain, which probably has occupied some time in its formation, yet symptoms of pressure appear only two or three days before death. WThilst, -on the contrary, a smaller, or even a small abscess at the base ofthe brain, or near the origin of the nerves, will "produce symptoms, pro- bably at any earlier period, which are more decided and severe. Hence though it is customary to speak of death from abscess in the brain, at various periods after the reception of an injury, it must not be supposed that the abscess has existed during any very considerable portion of that time, though it has probably commenced its formation much before its existence was suspected. Sometimes the abscess in the brain appears to be sympathetic, with irritation and suppuration ofthe dura-mater; a good example of which is presented by the following Case under the care of my friend Green (a) :—A boy, aged twelve years, was admitted into St. Thomas's Hospital, Oct. 26, 1827, having ten weeks previously received a blow on the forehead, followed by abscess, from which several ounces of pus were discharged by puncture; and he recovered. Three weeks before his admission he had an epileptic fit, which was followed by incomplete paralysis of the left side. His limbs were shrunk; his face pale, his eye peculiarly wild, his countenance peevish and anxious. He was restless and irritable, and when spoken to he would only scream out, " my head aches," putting his hand at the same time to his fore- head. The scalp was hot, but the surface generally cool; the pupils, especially the right, much dilated ; pulse small and 120. He could not move either of the left limbs; the motion was very fetid, and passed involuntarily, as did also the urine. He pointed to what he wanted, rather than asked for it. His head was ordered to be shaved; leeches and cold lotion to be applied. Chalk mixture to check the action of his bowels, and a drachm of mercurial ointment to be rubbed in nightly. The leeches were repeated on the next day. Nov. 2.—The pain in the head still severe; but he moves his left side more freely. On the 5th his gums were affected by the mercury; the headach only at intervals, and the heat of the scalp diminished; a blister was put on the occiput. A week after he was capable of retaining both stools and urine, and the powers of motion were improved; but the headach was very severe; the pupils dilated and insensible to light; pulse still, quick, and small, and the surface quickly cooling when exposed. The mercurial friction was now left off. Another blister was applied in the course of the week, and on the 19th he was ordered dec. cinch. 5Jss. acid. mur. irt> viij. /. d. A puffiness soon after began to ap- pear above the cicatrix, and extended to the left eyelid : and on the 26//*, distinct fluctuation being felt, a lancet was passed into it, and blood flowed freely, as from opening a vein, without any pus, but after a minute ceased spontaneously. A deeper wound was then made, and about half an ounce of cheesy matter escaped. A poultice was applied, and a dose of calomel given. A slight discharge of pus followed, but in three or four days the wound healed. He continued still very irri- table; but the headach varied, and when most violent the pupils were dilated. On the 18th Dec. pus was again discharged from the forehead, and also at the left angle of the jaw; the bowels were much relaxed ; he gradually sunk and died on the 31s/. Examination.—The scalp was found to form the front boundary of the frontal sinuses, their external table being entirely absorbed; but there was little pus. The inner table was almost perforated in many places, and completely in one, but there was not any pus between it and the dura mater, which was vascular, especially over the sinuses. The longitudinal sinus was full of pus, and lined with organized lymph; both the lateral, the inferior longitudinal, and inferior petrosal sinuses were also distended with pus; in the right lateral was a hard plug of lymph at the part where it turned to the temporal bone, and the left was filled with lymph to' the lacerated hole: the orifices of many of the veins into the longitudinal sinus, and to some distance from it, were filled with pus; the pi-i mater was loaded with blood. A small abscess was on the surface ofthe right hemisphere, near to the longitudinal sinus, but not communicating with it. In the left lobe ofthe cerebellum was a large abscess. There were also abscesses in the lungs, one in the left kidney, and a few small ulcers on the mucous membrane ofthe ilium and colon. Prochaska (6) has also mentioned a similar case of a boy struck on the head by (a) Lancet, 1827-28, vol.i. p. 687, 88. (b) Observations Pathologicoc, sect. iv. Cis. tert.; in Opera Minorca. Vienna;, 1800. ABSCESS OF THE BRAIN. 443 the handle of a winch, whilst drawing water from a well. He received a slight wound, which soon healed; but he suffered much headach, became dull and heavy, and after some weeks was attacked occasionally with convulsions of the whole body, which ceased spontaneously. Rather more than four months after he fell suddenly into the same state, and was brought to the hospital in that condition a week after. Under treatment he began to recover the use of the paralytic hand and foot, and both to see and talk better. After some days a soft fluctuating swelling, without pain or redness, appeared on the forehead, where the blow had been re- ceived, and when cut into, a large quantity of black half-coagulated blood was dis- charged, and the frontal bone felt rough to the finger. At every daily dressing there was a free discharge of similar blood. Soon after he had very severe bleeding from the nose, which relieved the headach; it recurred every day till the fourth, on the morning of which he sunk into a deep sleep, broken only by convulsion, and in the evening he died. The examination showed the frontal bone rough and porous opposite the swell- ing ; the vessels of the dura mater were loaded with blood, and pressure upon the longitudinal sinus caused the blood to flow through the porous frontal bone, the sinus itself having several openings into the diphv, behind the injured part of the bone through which the blood passed. On the upper part ofthe left hemisphere the dura mater adhered so firmly to the brain, that they could not be separated without tearing. The cortical part of the brain was here very thin ; the convolutions had nearly disappeared; and beneath it was a large oval swelling, hard but fluctuating, over the left ventricle, extending throughout the whole hemisphere, and occupying two-thirds of the transverse extent of the skull, so that it thrust the fa/x much to the right, and compressed the right hemisphere. The cavity of the left ventricle was almost entirely destroyed ; the left striated body flattened, and the. optic bed, septum iiicidum, corpus callosum, and junction of the optic nerves, were driven much to the right. The size ofthe right ventricle was diminished, and it contained little fluid. The medullary substance was very soft around the swelling, so that the latter, which was distinctly encysted, and contained much pus, was readily turned out of it with the finger. In the right hemisphere the medullary matter was very firm.] 407. The symptoms and course of traumatic inflammation of the brain and its membranes may be variously modified by the simultaneous at- tack of both brain and membranes, by the occurrence of inflammation in existing pressure of the brain from depressed bone, or by previous concussion ofthe brain. 408. The prognosis of inflammation of the brain depends upon the possibility of removing its causes. If the inflammation continue, it runs on to suppuration, and then upon the seat and extent of the collection of pus depends whether it can be removed or not. It is, therefore, the first duty of the surgeon to examine closely the part of the head on which the external violence has acted, and if splinters, indents, and so on, be present, they must be removed according to the rules laid down. 409. The inflammation requires the strictest antiphlogistic treatment, bleeding from the arm, in the jugular vein, leeches to the head, to the neck, of which the bleeding should be kept up for from twelve to twenty- four hours, by the repeated application of the leeches ; internally, anti- phlogistic purgatives, calomel in smart doses (1), and especially the continual application of ice or Scjimucker's solution, (four ounces of nitrate of potash, two ounces of muriate of ammonia, a pint of vinegar, and ten pints of water,) no remedies being so efficient as cold fomenta- tions to prevent inflammation. They must, therefore, as well as the prophylaclic bleedings, be from the first employed in every injury of the head in which inflammation ofthe brain is to be feared (2). [(1) In the treatment of inflammation of the brain or its membranes, the principal reliance is to be placed on the use of mercury, till it produces ptyalism ; soon after 444 INFLAMMATION OF THE BRAIN. the appearance of which the symptoms begin to be less severe, and therefore the more quickly the constitution can be affected, the more favourable may be the ex- pected results. On this account the calomel should be given in two-grain doses, every eight, six, or even four hours, according to the severity ofthe symptoms, and even rubbing in mercurial ointment may be also employed twice or thrice a day. So soon as the mercurial fetor of the breath is ;observed, and the gums begin to separate from the teeth, it will be seen that the constitution is beginning to be laid hold of by the mercury, and then the quantity given or rubbed in must be diminished to that only which is sufficient to keep up the mercurial action. (2) After free evacuations of blood, which I think are most effectual when local, by cupping on the nape, temples, or behind the ears, a large blister over the whole scalp, or on the nape, if the scalp be wounded, is extremely beneficial.—j. f. s.] 410. If, with this treatment persisted in with sufficient energy, and for proper length of time, the symptoms of gorging and inflammation of the brain continue undiminished, or rather if they gradually increase, especially when the bared bone shows a grayish colour and change in its texture, trepanning must be had recourse to. In this case it is pro- bable that some cause, as a splinter or extravasated blood, exists within the skull, which keeps up the inflammation, and renders all treatment useless, but may be found out and removed by trepanning-. 411. If the symptoms of suppuration have already appeared, the prog- nosis is very unsatisfactory indeed ; there is, however, the simple pos- sibility of rescuing the patient by the speedy application ofthe trepan upon the spot where he first suffered the inflammatory pain. Generally, howTever, in these cases, if the suppuration be much extended, the trepan must be applied in several places, the dura mater, the surface of the brain itself cut into, if pus be collected beneath it. Trepanning, how- ever, can in any possible way only be useful when the pus is found cir- cumscribed between the skull and dura mater. In outpourings over the surface ofthe brain it is useless, and in collections of pus within the substance ofthe brain itself, even after the duramater has been cut into, the seat of the pus cannot be well determined. Many observations, however, show satisfactory results even in such extreme cases. The cases of La Peyronie and Dupuytren, in which abscess in the brain was punctured, have been already noticed, (par. 400, note.) In reference to abscesses in the brain found on dissection, and the opening of which have confirmed their position? see La Peyronie (a), Roux (b), Velpeau (c). 412. Every thing depends on averting the slow insidious inflammation of the brain which occurs at a later period. In every injury of the head, the patient is therefore to be closely watched, the antiphlogistic treat- ment, and especially the cold fomentations to be long persisted in, and the proper relief of the bowels attended to. If the symptoms already mentioned (par. 386) exist, the patient can only be saved, if the suppu- ration be confined upon the dura mater, by a slight cut in the swelling there formed, and by trepanning. But if the outpoured pus overspread the greater part of the dura mater or of the brain, every kind of treat- ment is generally useless. 413. It must, however, be remembered that oftentimes symptoms re- sembling those of inflammation of the brain arise from bilious and other (OP) Memoires de l'Academie de Chirurgie, (6) Archives Generates dc Mtdecine, vol. vol. i. p. 319. xxiv. p. 81. (c) Above cited, p. 85. PRESSURE ON THE BRAIN. 445 impurities in the bowels, which can only be relieved by vomiting and purging. J 8 B—OF PRESSURE ON THE BRAIN. 414. Pressure of the Brain (Compressio Cerebri, Lat.; Druck des Ge~ hirnes, Germ; Compression du Cerveau, Fr.;) may be produced by out- pouring of blood, lymph, or pus, within the cavity of the skull ■ bv depression of pieces of bone or by foreign bodies which have penetrated within the skull. L The general symptoms of pressure of the brain vary according to the degree of pressure. In a slight case the patient feels a dull headach faintness, singing in the ears, dimness of sight, wide pupils, difficult voluntary motions, deafness, loss of memory. In a more severe degree he lies in a deep sleep, from which he cannot be waked, his breathing is snoring (1) and difficult; the pulse full, hard, and irregular; the pu- pils wide, and the eyes fixed; there is palsy, convulsions, involuntary discharge of the stools and urine, a peculiar stiffness of the neck as if the head were nailed to the trunk; not unfrequently bleeding from the nose and ears, and high fever are present. In the greatest degree the patient dies apoplectic. [(1) Guthrie makes some very good observations on the uncertainty of snorina as a symptom of compression; and also mentions a peculiar whiff or puff at the corner ofthe mouth, which I have often seen, and do not think is to be considered a spe- cial symptom of injured brain. » Stertorous breathing," says he, » has always been considered a sign of extravasation causing compression of the brain; I have how- Tru se1enJmany cases of slight extravasation, with partial loss of power of one half of the body, accompanied by great numbness, without any stertor in breathing- although I have never seen a well-marked case of large extravasation without it or another peculiarity of breathing which is less thought of, although an equally cha- racteristic and dangerous sign of such mischief having taken place, when it is per- manent; I allude to a peculiar whiff or puff from the corner of the mouth as if the patient were smoking, and which, when observed among other urgent symptoms is usually followed by death. Stertorous breathing, and the whiff or puff at the corner of the mouth, are presumed to indicate an injury to the cerebro-spinal axis as well as to the cerebrum ; but whether the injury is direct or indirect is un- certain, although it is frequently accompanied by extravasation or laceration. When the breathing is only oppressed, or laboured, or heavy, neither extravasation nor lesion to any extent can in general be discovered after death." (p. 17.)] 415. The following general circumstances point out the causes of pressure of the brain. In fracture of the skull with impression, the surgeon discovers it by the sight and touch. In extravasation of the blood, the symptoms appear most commonly some time, some minutes or hours, after the injury. When extravasation at once produces symp- toms, it is generally fatal. The seat of the extravasation may be between the dura mater and the skull, beneath the dura mater, under the pia mater, in the substance ofthe brain, in the ventricles, or on several other places at once, but no definite symptoms mark the particular spot. Only in extravasation of blood between the skull and the dura mater is the pericranium always less attached, and in trepanning the bone does not bleed, so that even from the very onset ofthe extravasation its existence may be determined by that circumstance. In elderly persons however these signs are less certain. Serous or purulent extravasation always vol. 1.—38 J 446 PRESSURE ON THE BRAIN takes place some time after the previous accident, after symptoms of irritation, inflammation, or concussion have come on. If the extravasa- tion be between the dura mater and the skull, a circumscribed swelling is produced externally by the separation of the pericranium, (par. 386.) 416. The prognosis of pressure on the brain depends on its degree, its causes on the accompanying injuries, and on the constitution of the patient. What relates to impression of the skull has been already men- tioned. Extravasation of blood in young subjects and in small quan- tities may be dispersed. Outpouring of blood into the substance ofthe brain or at its base is generally fatal. If the symptoms of inflammation be accompanied with pressure, the prognosis is so much the more un- satisfactory. 417. The treatment of pressure ofthe brain consists in the removal of its causes and in preventing inflammation. In impressions of the skull or when foreign bodies have penetrated from without into its cavity, the rules already laid down must be employed. [The use of calomel to ptyalism, as already mentioned in treating of inflammation ofthe brain, (par. 409,) is here also indispensably necessary.—j. f. s.] 418. Extravasation of blood may be removed either by absorption or by trepanning. The absorption may be attempted if the symptoms be slight, do not increase, and if the seat of the extravasation be probably unconnected with any external injury. The means employed for this purpose are repeated blood-lettings, purging, and cold fomentations. 419. If the symptoms of extravasation be severe, if they do not subside under active antiphlogistic and derivative means, but on the contrary increase, if there be on the head any injured part at which the violence has especially acted, which is painful or swollen, and if it be found by a cut that the pericranium is not attached, but loose, then that part must be trepanned. The patient is often attacked with giddiness at that part of the head where extravasation has taken place. That it is met with on the opposite side to that on which palsy occurs, or that the palsy of a particular part points out the seat of extravasation is an opinion not generally confirmed by experience. If the extravasation be not found on one application of the trepan, another part may be trepanned where external violence has equally operated. If the extravasation be beneath the skull, it flows out after trepanning (1;) bleeding from the diploe must, however, be distinguished from it. If the dura mater be stretched, violet-coloured, fluctuating, it may be divided by a suitable cross-cut. If the extravasation be beneath the pia mater, it also must be cut into (2). Pressure of the brain from pus and lymph have been already treated of in considering inflammation of that organ and its membranes, (par. 400 and 411.) [(1) This is a very incorrect statement. The blood rarely, if ever, flows out after the trepan has been applied. It is almost invariably found coagulated; and, therefore, though a little bloody serum may escape, the bulk of the blood still remains upon the dura mater, and always requires removal by careful scraping with an eyed probe, or with the edge of a spatula where it can be easily reached. But the clot generally sticks so fast, that the dura mater cannot be entirely freed from it; and, even in the most favourable cases, suppuration of the surface of that membrane is the usual consequence.—j. f..s. BY EXTRAVASATED BLOOD, TREATMENT. 447 (2) There has been great difference of opinion amongst the Surgeons of this country in regard to the propriety of puncturing the membranes of the brain, when extravasated blood is presumed to be between the dura mater and the brain; and I must confess 1 am rather disposed to agree, for the reasons presently given, with those who think little advantage likely to result from cutting through the dura mater. The subject, however, is so important, that it is right to state the opinions which have been held by the supporters of the different practices. Pott is in favour of puncturing the dura mater. He says:—" If the disease lies between the dura and pia mater, mere perforation of the skull can do nothing; and therefore, if the symptoms are pressing, there is no remedy but the division of the outer of these membranes. The division ofthe dura mater is an operation which I have seve- ral times seen done by others, and have often done myself; I have seen it and have found it now and then successful; and from those instances of success, am satisfied of the propriety and necessity of its being sometimes done." He does not, how- ever, withhold the fact, that " wounds of the membranes of the brain, by what- ever body inflicted or in whatever manner made, have always been deemed and (which is more to the purpose) have always been found to have been hazardous." (p. 260.) He also observes, that " when the extravasation is situated between the meninges, or on the surface of the brain, the appearance is not the same" (as when between the dura mater and skull.) "In this ease there is no discharge upon removing the bone; and the dura mater, instead of being flaccid and readily obeying the motion of the blood, appears full and turgid, has little or no motion, and pressing hard against the edges of the perforation rises into a kind of spheroidal form in the hole of the perforated bone. If the extravasation be of the limpid kind, the membrane retains its natural colour; but if it be either purely fluid blood, or blood coagulated, and the subject young, the colour ofthe membrane is so altered by what lies under it, that the nature of the case is always determinable from this circumstance." (pp. 264, 65.) Brodie holds that there are cases in which puncturing the dura mater is warrant- able. He says (a) :—" We may regard it as a general rule, that an operation is not applicable to cases of compression of the brain from internal extravasation. But there are few general rules in Surgery to which some exceptions may not be made. Let us suppose a case in which a considerable portion of bone has been already removed, in which the dura mater is seen exposed, of a blue colour, lifted up by a collection of blood beneath it, and bulging as it were into the aperture which has been made in the cranium. Are we justified in puncturing the dura mater for the purpose of allowing the extravasation to escape 1 Every thing- that we see of wounds ofthe dura mater tends to prove the very great danger of this kind of injury. The dura mater should never be wantonly punctured ; but we cannot doubt that, in what may be regarded as desperate cases, it must be right to give the patient the chance, small as it may be, which the division of the dura mater affords him. The combination of circumstances which would lead to such an operation must be very rare, but it may occur nevertheless, and the surgeon should be prepared to meet it." In support of this opinion he mentions two cases :—A child of eighteen months old, under the care of Chevalier, had a blow on the head, lay insensible and was convulsed. No wound existed, but the fontanel appearing somewhat elevated, Chevalier raised the skin above the membrane forming it, and exposed the dura mater, beneath which the purple colour of the blood was plainly seen. He there- fore made a careful puncture, and " the blood issued rat first with considerable force, spouting to the distance of a foot. Three or four ounces of blood escaped; the symptoms were immediately relieved, and the child recovered." A woman who had fallen down the stairs of a cellar, was under Ogle's care, who found her without wound, and lying as if in a fit of apoplexy, but "she flinched very much when pressure was made on one spot near the anterior and superior angle of one of the parietal bones." He divided the scalp, applied the trephine, and " the dura mater of a dark colour rose into the opening nearly as high as the external surface ofthe cranium.'''' He made a puncture in it, which "was instantly followed by a stream or jet of blood which spirted out to the height of some feet. Immediately (a) Cited at head of Article. 448 PRESSURE OF THE BRAIN, &C. on the blood being discharged, the woman, who till that moment had continued totally insensible, opened her eyes. After looking about her apparently amazed, she exclaimed, 'What's the matter? what are you doing with mel and was able to give a clear account of the manner in which the accident occurred. From this time she recovered without any untoward symptom. It was impossible to ascer- tain the precise quantity of blood which escaped through the opening of the dura mater, but Ogle supposes it to have been about three quarters of an ounce." p. 388-91.) John Hunter properly observes (a):—"The dura mater must not be perforated without good grounds; we should be as certain that there is fluid contained under the dura mater, as we were certain of the necessity of applying the trepan in the first instance. In all cases where I have seen the dura mater wounded, it was by a crucial incision, and the patients have all died. Wben it is necessary to open the dura mater, I would recommend making a simple incision, for this would be more likely to heal by the first intention, and we could then move the edges to one side, and see if there were any injury below. Whenever I have seen the dura mater opened, the brain has worked through the opening, and the patients have died." (pp. 494, 95.) "If blood be not found between the dura mater and skull," says Astley Cooper, "do not puncture the dura mater, to seek for it; it is of no use, as the blood is coagulated and will not escape, and it is seated under the pia mater, or in the brain itself." (p. 289.) Abernethy was used to make the following observations (b) in reference to puncturing the membranes for presumed extravasation:—"Are you warranted to trephine to let out the blood from between the meninges] This is a very difficult question, and I would not undertake to reply to it. I think we are not warranted; there may be symptoms, but the bone not injured, and the vessel may be burst in the brain. Are we then to trephine at a hazard ? If we do, we shall find the brain thrust up as if there were blood ; we must then puncture, but if it is any time from the accident we shall not be able to let all the blood out, it is grumous, not coagu- lated, but as if it were mixed ; I have, however, seen it coagulated. Here we shall have inflammation, and we have taken away both the support of the bone and dura mater. I will tell you a " Case.—A woman had a thump of the head; she was in a state of apoplexy, but the bone was not broken. This occurred in a country town, and the older sur- geons said they would not trephine; but a young man who was also called in, said that the symptoms were so indisputable, that he would see what was the matter. He trepanned her, and found the dura mater thrust up through the opening; he put in a lancet, and eight or nine ounces of blood gushed out. Immediately the woman, who had been cold and like a corpse, sat up and hallooed out, ' What are you doing1?' " Lawrence observes:—"When blood is effused between the dura mater and the surface of the brain, it is not collected into one spot, but is diffused over the surface of the brain generally, and then we cannot get at it. W'hen the blood is effused on the external surface of the dura mater, it is collected in one spot, because it is confined by the adhesions between the dura mater and the skull; but when effused within the cavity on the internal side of the dura mater, there is nothing to limit its extension, so that it diffuses itself generally over the brain. I believe we may say, therefore, as a general rule, that if we make a perforation through the skull in ex- pectation of letting out blood that may be effused under it, and find none, but that the skull adheres in the natural way to the dura mater, we shall do no good by opening the dura mater in expectation of letting out the blood that may be sup- posed to be under it." (p. 525.) The advantage gained by trepanning, in cases where extravasation of blood is presumed to have occurred, is, as far as I have had the opportunity of observing, very slight, as it is utterly impossible to determine whether the blood be poured out between the skull and dura mater, between the membranes themselves, between the pia mater and the brain, or in the substance of the brain itself or in its cavities. Only when the outpouring is between the skull and dura mater is there the least probability of material benefit; and even here it mainly depends on the blood being (a) Lectures, Palmer's Edition, vol. i. (b) MS. Lectures. CONCUSSION OF THE BRAIN, 449 shed at one particular spot, so as to form a lump, for if it is spread thinly to a large extent, as commonly happens, it cannot be got at. Hence is it, that when the blow has been received upon the temple, upon or near the track of the middle artery of the dura mater, there is greater hope of a successful result than at any other part; though even there dodbtful. The trephine, however, ought always to be applied when there is reasonable presumption of that vessel having been burst or torn by the violence of the shock; and it is an interesting fact, that when the bone has been, under such circumstances, removed, and the artery, as usually happens, is found bleeding fiercely, as in one of Abernethy's cases, it ceases to do so immediately the clot has been cleared away. Perhaps, also, it may be advisable, when the blow has been received on the track of a sinus, to trepan on either side of it, and ascertain the existence of any out-poured blood. Another occurrence, by no means unfrequent, and which cannot be ascertained before operation, renders trepanning of still more doubtful success, to wit, the tearing of a vessel by the counter-shock, at some part far distant from that where the blow has'been received ; thus the right side, or the crown, or the front of the head, may have been struck, and the blood may be poured out on the left side, at the hase, or on the back of the head; circumstances which must not be forgotten. When the blood has been cleared away, if it have been poured out in one particular spot, there is always a corresponding hollow by the thrusting down of the dura mater into the substance ofthe brain; in one of Abernethy's cases it was an inch and a-half deep. I have never seen any depression so great as that; but I have seen a very distinct hollow, proportionate to the circumscription of the clot. After the removal of the clot, the dura mater, which has been thrust in, seems to hang loosely in the hollow of the brain; sometimes at first motionless, the brain apparently being in- capable of rising and effacing the hollow, so that hours may pass by before the brain and its membranes recover their natural place and form; at other times a little pulsating movement in the depressed dura mater is observed, which becomes more and more distinct, and simultaneously both it and the brain rise up, the hollow dis- appears, and at every pulsation the dura mater is driven upwards and protrudes slightly within the aperture formed by the trepan.—j. f. s.] C—OF CONCUSSION OF THE BRAIX. 420. Concussion of the Brain (Commotio Cerebri, Lat.; Erschut- terung des Gehirnes, Germ.; Commotion du Cerveau, Fr.;) produces, im- mediately after the operation of external violence, fainting, stupor, in- sensibility, or sudden death. There are various degrees of concussion of the brain characterized by the following symptoms :— The person who is struck by external violence, tumbles together, is unconscious, but soon recovers himself and complains of confusion of his ideas, faintness, disposition to sleep, singing and rushing in the ears. In a more severe degree of concussion the patient does not so soon re- cover from his insensibility, he lies motionless in a deep sleep, his countenance is pale, limbs cold, breathing easy, the pulse small, regular (1); the eyes are insensible to light; the breathing often scarcely perceptible ; and only a more or less warm perspiration tells of feeble vitality. Wrhen the patient comes to himself there often con- tinues some disturbance of the senses; he stutters, cannot utter single words or letters (2); one or other limb of the body does not move freely ; and he has generally not the least knowledge of what has happened to him. In concussion there is always more or less severe vomiting (3). In the most severe degree of concussion the person drops at the very moment when struck, and dies on the spot. [(1) "The state ofthe pulse," says Astley Cooper, "is curious, although, when 38* 450 CONCUSSION OF THE BRAIN, the patient is undisturbed, it is natural; it scarcely ever fails to be quickened if the patient is capable of making any effort to rise, and exert himself for that purpose. The carotid arteries sometimes beat, under an exertion, with a force disproportionate to the other arteries of the body; but generally this symptom is not observed until after a few hours." (p. 254.) Not only is the pulse excited by the patient's effort to rise, but even the mere shaking him to arouse him will often produce quickening of the pulse, as I have seen again and again.—j. f. s. (2) Many curious instances are recorded of the loss of memory in regard to an acquired language, and the re-employment of the vernacular tongue of the patient, following concussion. Astley Cooper mentions the case "of a man who, in St. Thomas's Hospital, was found talking in a language which was not understood, until a Welshwoman entering the ward heard him talking WTelsh ; the blow on the head having occasioned the loss of his recollection of English. I once witnessed a very similar circumstance;—I attended a German sugar-baker, with disease in his brain, and when I first saw him, he could speak to me in English; but as his disease in- creased he lost his English, and I was obliged to have an interpreter, for he could answer only in his native tongue." (p. 255.) Sometimes the patient forms a new language for himself, as in Larrey's case (a) of the soldier wounded in the head, who expressed assent by the word " baba," instead of " oui," dissent by " lala," and his wants by "dada," and " tata." In other cases of irritation of the brain, language appears to have been entirely lost, and the patient to have made his necessities known by manual signs, as in Cline's case. (p. 418.) Hennen observes:—" The powers of speech are often lost, while those of me- mory remain, and the sight is impaired while the hearing is perfect, and vice versa. I have met with numerous instances of this, and have had patients who told me that they could hear distinctly what I said, and distinguish my'voice from that of others, and have repeated my words, as a proof both of this fact and of their retention of memory, while they could not distinguish my person, or give utterance to their thoughts." (p. 305.) He also mentions a very remarkable instance, after compound fracture with depression of the skull from gun-shot, in which, though the patient continued sensible, he lost the power of utterance, and, although his efforts to speak were continuous, only on the sixth day did he manage to " utter audibly, though with much labour, the monosyllable 'ther,' to which in the course of the day he added, 'o;' and for the three next days, whenever addressed, he slowly, distinctly, and in a most pathetic tone repeated the words,' o ; ther: o ; ther;' as if to prove his powers of pronunciation. His general appearance, during all this time, amended considerably, and my hopes now began to revive. I therefore resolved to write to his family, and, before doing so, I printed in large characters on a sheet of paper, the folio wing(words,' Shall I write to your mother?' that being the wish which it appeared to me he so long and ardently laboured to utter. It is impossible to describe the illumination of his countenance on reading these talismanic words; he grasped and pressed my hand with warmth, burst into tears, and gave every demonstration of having obtained the boon which he had endeavoured to solicit." (p. 308.) The recital of this interesting case is an ample proof of the kindness of Hennen's heart, and of the sincerity with which he inculcated the propriety of" tenderness and sympathizing manner" in the conduct of surgeons towards their patients. (3) To the symptoms above enumerated Astley Cooper adds :—" At first a torpor exists in the intestinal canal, and a considerable difficulty in procuring an evacua- tion ; but afterwards the faeces are involuntarily discharged; in a few hours the bladder is distended from the accumulation of urine, which demands the introduc- tion of a catheter for its removal; but after some time the urine also passes involun- tarily." (p. 254.)] 421. The following circumstances distinguish concussion from pres- sure of the brain, depending on extravasation of blood : the earlier or later occurrence of symptoms in extravasation depends indeed on the quantity of blood and the quickness with which it is poured out; but the symptoms once set in increase or continue in the same degree. In concussion which immediately follows external violence the patient usually recovers himself in some degree. In extravasation he lies in an (a) Memoires, vol. iii. p. 322. SYMPTOMS—DIAGNOSIS. 451 apoplectic state, with snoring, difficult breathing, hard irregular intermit- ting pulse ; with wide pupils, but there is not any vomiting. In con- cussion the body is cold, the breathing easy, the pulse regular and small; the countenance little changed. Extravasation and concussion may occur together at the onset, or extravasation may accompany con- cussion. [It is often very difficult to distinguish between drunkenness, and either concus- sion or compression ; especial care should therefore always be taken to ascertain as far as possible the condition of the patient previous to the accident, lest he should be lost by too slight consideration of his symptoms. In persons of drunken habits, delirium tremens may come on after concussion, as well as after any other accident. I have seen one example of this kind, but believe it to be rare. The treatment will require the closest attention, and the administra- tion of opium is necessary as in other cases of the same disease.—j. f. s.] 422. Inflammation of the brain may be connected with concussion, and then the symptoms of oppressed sensation and motion may be ac- companied with those of irritation. The pulse becomes fuller, the patient more restless, appears wild, is delirious, convulsions come on, respiration is slow and snoring, and subsequently symptoms of pressure on the brain ensue. 423. The changes produced on the brain by concussion are various, and may be divided into primary and consecutive. They consist either in a sudden depression of the activity of the brain and nerves; in which after death no trace of any mechanical injury, frequently only a sinking together of the brain, which does not completely fill the cavity of the skull, is found ; or in tearing of the vessels, or even of the brain itself, and inflammatory congestion (1). In concussion the vessels ofthe brain are always more or less debilitated, so that when the first symptoms of concussion have passed by, they cannot withstand the subsequent influx ofthe blood, and in this way gorging with blood and its effusion through the relaxed walls ofthe vessels takes place. In concussion ofthe brain there are, therefore, various conditions to be remembered, namely, torpor and weakness of the nervous system, irritation and inflammation, extrava- sation, and not unfrequently concurrent affection ofthe liver. Dupuytren (a) distinguishes, in reference to these various changes of the brain, between Commotion and Contusion; the former he considers to depend on sudden depression of the activity of the brain and nerves, in which no trace of any injury can be discerned; the latter he holds as a similar change in the brain to that which occurs in bruises, viz., bruising, tearing, and extravasation of blood. The patient recovers from the symptoms; in the next few days inflammatory symptoms occur, and cause death, as has been already mentioned in unfavourable inflammation ofthe brain, (par. 404-406.) In tearing ofthe substance of the brain the symptoms should, according to Wal- ther (b), come on at once and without remission, but continue till the setting in of encephalitis without increasing or diminishing. Only in a single case has Walther noticed a perfect intermission of the symptoms. The most constant symptoms are loss of consciousness, the deepest coma without possibility of wakening, convulsions, vomiting, subsequently palsy comes on, probably at first as a symptom of inflamma- tion and perspiration. This statement does not concur with that of others. Astley Cooper (c) relates a case wherein, from tearing of the substance of the brain, no other symptoms of brain affection except loss of speech occurred, and this came on after three days. [" With respect to the state of the brain under concussion, when the injury has (a) Lecons Orales dj Clinique Chirurgi- (b) Above cited, p. 70. cale, p 503. (c) Above cited, p. 263. 452 EFFECTS OF CONCUSSION ON THE BRAIN. not been excessively severe, it seems that the symptoms are merely the effect of a disturbance of the natural course of the blood through the brain. A fit of vomiting, by forcing the blood through the brain, will sometimes almost immediately restore the functions of the mind and body. It seldom happens that this state of the brain destroys; but when it does, nothing is found upon the examination which will account for the symptoms. It is therefore an alteration of functions, but not a dis- organization. But when the concussion is very violent it is attended with lesion of the brain, with slight laceration of it accompanied with slight extravasation."—A. Cooper, (p. 262.)] 424. The causes of concussion are either shaking of the whole body (1), to wit, by a fall upon the feet; or violence, which strikes the skull itself and acts upon it to a certain extent. Most commonly in concus- sion the skull remains entire; it may, however, be injured in various ways. [(1) Astley Cooper says :—"I have known concussion arise from the general shake of the whole body, unaccompanied by any blow upon the cranium, pain in the head succeed, with the usual symptoms of concussion, and the patient's life be greatly endangered." (p. 262.) " A very curious example of pure concussion," quoted by Hennen, " is given us by Schmucker (a), in which a cannon-ball took away the queue from the nape of a soldier's neck, without injuring the integuments in any sensible degree. He con- tinued in a complete state of stupor for many days, during which he was bled at least twenty times. Twenty-four grains of tartar emetic, given at short intervals, produced some stools, but no apparent inclination to vomit, after having suffered a relapse from having been moved prematurely on a march with the army." (pp. 318, 19.)] 425. The prognosis is guided by the degree and complication of the concussion. In its most severe form convalescence is always tedious, and there frequently remains disturbance of some ofthe mental faculties, loss of memory, weakness of sight, amaurosis, loss of smell and taste, great irritability of the stomach, and so forth. Complication of con- cussion with extravasation and inflammation always renders it ex- tremely dangerous. 426. As to^the treatment of concussion ; this must be various, accord- ing to the different conditions of the patient (par. 426); as in concus- sion there is always gorging of the brain with blood, and subsequently attacks of inflammation to be dreaded, general and local blood-letting, cold fomentations, purging and irritating clysters, are especially indi- cated. Large blood-lettings are in most cases fatal; small bleedings are to be made as often as the pulse again becomes hard ; if, however, it becomes weak and intermitting, no blood must be taken away ; nor at the onset, when the pulse is scarcely to be felt, the countenance is pale, and so on, is blood-letting to be used, but only when the pulse rises (1). Too frequent bleeding often brings on convulsions. If the patient be found in a weak state, if the pulse after bleeding become smaller and weaker, spirituous frictions, a blister over the whole head, stimulating clysters, vomiting with tartar emetic, should be employed, the latter, however, with the greatest caution, because if blood be ex- travasated, or there be disposition to apoplexy, the patient's condition is thereby considerably damaged (2). Stimulating remedies, as arnica, musk, fluid alkalies, even wine as recommended by many, are, on ac- count ofthe danger of subsequent inflammatory irritation, rather disad- vantageous, and to be used only with especial caution. (a) Chirurgische Wahrnehmungen. Berlin, 1759, p. 393. TREATMENT. 453 [(1)1 presume there is now scarcely a surgeon who would take blood from a patient who was stunned, immediately after a blow on the head; a practice formerly advised, though in reality rarely carried into effect, as almost invariably some time elapses between the receipt of the injury and the arrival of the surgeon. No bleed- ing must be resorted to till the constitution have recovered the shock; till the cold- ness has subsided, and the heart has recovered its power: to encourage which the patient should be quickly put to bed, bottles of hot water or heated bricks applied to his feet; and, if he be very cold, and his pulse weak and low, a little brandy with hot water should be at once given, and repeated if necessary. When the patient has been brought round, when the warmth is returned and the pulse is improved, the surgeon must act according to circumstances. Bleeding is not always necessarily though it is generally required. But I do not think it advisable to bleed largely, although only at the first bleeding, as recommended by Astley Cooper; for, with the disturbed circulation in a brain labouring under concussion, a large bleeding may and in some instances will produce fatal fainting. The quantity of blood to be taken at the first bleeding, so soon as the quickness of the pulse requires it, which is gene- rally in six or eight hours, but sometimes later, must, therefore, be proportioned to the patient's constitution and the condition of the pulse ; and if even after a very few ounces only have been drawn the pulse should intermit, the bleeding should be im- mediately stopped, or fainting and convulsions will ensue. Five or ten grains of calomel should be given immediately, and the best mode of administering it is to mix it with a little sugar, or with a little honey, and put it on the tongue, so that it may gradually pass, with the spittle, down the throat. If in the course of a few hours it may not have operated, (and even if it have, there will be no objection,) a clyster of a pint of warm infusion of senna with Epsom salts, or castor oil in gruel, may be thrown up, which will at least empty the lower bowel, and often encourage the purging action above. If the patient after some hours continue insensible, and congestion in the brain be presumed, or if inflammation have begun, then bleeding must be employed again and again, either generally or locally, or both, according to the severity of the symp- toms. But above all calomel or mercurial friction must be employed till the symp- toms yield, or till ptyalism is produced, and .then sufficient only used to keep up that condition. If the treatment be successful the symptoms will gradually subside; but sometimes before this happens alarming fits of an epileptic character may occur, which happened to a young man under my care some years since, who, whilst labouring under inflammation after concussion, on the morning of the 6th day after the accident, had three such fits at intervals of two hours, became completely coma- tose, and had dilatation of the pupils; and on the following day had two more, so that I presumed effusion had taken place, and that he would die. Upon the eighth day, however, he began to answer questions, and on the thirteenth he began to com- prehend his condition ; in the course of the day became perfectly sensible, and at last completely recovered.—j. f. s. The quantity of blood which has been withdrawn, during concussion and its con- secutive inflammation is enormous. Astley Cooper mentions an instance in which " the whole quantity of blood, taken by bleeding from the arm, opening the tem- poral artery, and the application of leeches, as far as this could be estimated, amounted to about, two hundred and eight ounces; of which one hundred and eighty ounces were taken from the arm * * * This gentleman recovered." (p. 272.) (2) Vomiting with tartarized antimony, or any other emetic, should never be re- sorted to, as the effort to empty the stomach drives more blood to the brain, which is precisely contrary to that which is desired.—j. f. s.] 427. If the patient be improved by either of the prescribed treat- ments, he must long avoid every exertion and over-heating ; if any palsy remain the employment of stimulating strengthening remedies, mineral baths, emetics, electricity, and so on, are useful. If the concussion be accompanied with fracture and impression of the skull, these must be first treated according to the rules already laid down. 428. In order to prevent the insidious inflammation of the brain, which often first arises some time after concussion, the patient must be closely watched, kept very quiet, cold applications, spare diet, purgings, 454 PROPRIETY OF TREPANNING. tartar emetic in small doses, and long continued, must be employed, and the gastric symptoms especially looked after. In order to get rid ofthe remaining consequences of concussion, cold washes to the head, washes with caustic liquor of ammonia and water, the application of species cephalica (a), blisters, often an issue upon the head itself should be used; in long-continued determination of blood to the head, repeated blood-letting and aperient medicines, with a pro- perly regulated diet, must be employed. D.—OF TREPANNING IN INJURIES OF THE HEAD. 429. The opinions of surgeons as to the application and necessity for the trepan in injuries of the head are very different. Some (Dease, Desault, Richter, AbeRiYEthy, A. Cooper, Brodie, Laivgexbeck, Walther, and others) considerably restrict, and only have recourse to it when the secondary symptoms of irritation and pressure have set in severely. Others (especially Petit, Quesnay, Pott, Sabatier, Louv- rier, Mtjrsinna, Zang, Schindler, and others,) apply the trepan more generally, do not restrict it to the appearance of secondary symptoms, but determine its necessity according to the injury which is always to be feared on account of the peculiar condition of the coverings of the brain. Trepanning is, in their opinion, a preventive remedy in most cases. 430. The reasons which the former surgeons offer in support of their opinion are: 1. Experience shows, that in fractures of the skull, with and without impression, under proper treatment, the cure very often takes place, as they are counterbalanced, or the brain becomes accustomed to the pres- sure. Trepanning should therefore not be performed before the most pressing symptoms of irritation or pressure require it. 2. The same applies to effusions of blood, the absorption of which experience also shows may take place. 3. Trepanning is an operation not free from danger; to the existing injury fresh violence is added, the result of which cannot be determined. A more especial ground of danger in the operation is, that the coverings ofthe brain are bared. If inflammation then ensue, the brain is thrust up into the opening, the dura mater ulcerates, fungous excrescences (1), and so on, protrude ; this occurs particularly in children, in whom the dura mater is firmly connected with the skull. (Abernethy.) [(1) Fungus of the brain, after trephining, is not within my knowledge of so frequent occurrence as Abernethy's observations would infer. I have seen and operated on several cases of compound depressed fracture of the skull, and can scarcely recollect an instance of fungus, when the operation was performed early and the dura mater was uninjured. The fear of it, therefore, should not deter the surgeon from using the trephine in compound fracture.—j. f. s.] 431. To these objections it is replied, that the condition of the internal table ofthe skull, which is fragile, brittle, and glass-like, renders the fracture in it of greater extent than in the outer table, and that it spreads in a radiated form, and is accompanied with splintering; that in these injuries the vessels connecting the dura mater with the skull are torn, and that effusion of blood will occur. If it be remembered that in (a) Under this title are included several kinds of powders consisting of farragos of herbs. IX INJURIES OF THE HEAD 455 sabre and shot-wounds these conditions must be so much more certainly present, that in all these injuries the diploe is so bruised that inflamma- tion and suppuration must occur, so it must be perceived tlTThe absence of pressure and irritation can afford no certainty, as if these have once set in, the brain and its investments are already so decided v diseased that trepanning can be rarely considered as a means of cure hlnndSaraTeftiaPPenS S° m emPlo>ing the trepan in extravasation of blood. m If the surgeon, in expectation of absorbing in these cases, delay trepanning ill the symptoms have arisen to a high degree is it not then o be feared that, on account ofthe active infla^matufn of the brain anS ts membranes, perhaps even on account of the putrid state of the ex- travasated blood, little more can be done by trepanning? They cannot deny that fractures of the skull with and without imprfssion have been cured without trepanning; and it may be even added, that of ten cases which were trepanned, under the above-mentioned circumstances in two the operation was perhaps unnecessary (which, however, could no" have been previously determined). But if the patient be trephined upon he appearance of the consecutive symptoms, the result will be unS factory in most cases. Trepanning is not to be considered in itself as a dangerous operation ; it is so esteemed because most commonly it is only employed when the diseased changes have already become grea" or severe injury has been produced by the external violence. Besides the writers already mentioned, the following may be also compared • Henke's Zeitschrift fiir die Staatsarzneikunde, 1824, part i ™°™mVzreA' Klein; in Heidelberger klinischen Annalen, vol. i. part i. p. 86 ' Iextor; in Neuen Chiron., vol. ii. part ii. p. 381. 432 If we compare these various principles which have been advanced as to the necessity of trepanning in injuries of the head, and consider hem, unreservedly, according to the result ofthe experiments upon this important subject which have of late been made with the greatest care and aentiori ; if we consider that the treatment of wounds in general, as well as that of wounds of the head, has become more simple and satisfactory, we cannot agree to so extensive an employment of the trepan. I^xpefience has satisfactorily proved that simple fissure and fractures oj the skull, in most cases, occur without the severe injury of the neighbouring parts which has been said to be generally therewith con- nected and that the consequences thereto ascribed may, by proper treat- ment, be prevented. If in such injuries trepanning be employed as a pro- phylactic, it certainly, in most cases, only renders the state of things worse and the proportionate needless use of the trepan is proved to be much greater than Pott and Za^g have stated. If the danger of trepannino- has been estimated by many too highly, on account ofthe wound inflicted by it and for this reason its application has been too much restricted it is not' however, to be denied on the other hand, that it has been too lightly thought of, and such a mode of performing it recommended as must inflict an in- jury out of all proportion to the accident for which it was undertaken • for instance, Zang's practice, in penetrating fissures and fractures, of apply- ing the crown of the trepan as frequently as requisite to take away entirelv the fissured or fractured bone. The same also holds in reference to the bruising ofthe diploe. Severe bruising of the diploe may, without doubt be extremely dangerous in its consequences ; but how can it be distin- guished whether there be not also injury of the bone ? The severity of 456 PROPRIETY OF TREPANNING, the injuring violence is, indeed, an important circumstance in deter- mining the danger of injury of the head ; but experience shows, in this respect, so different effects and so different relations in respect of the skull, in each individual, in no way manifested in the former known condition, that it cannot be ventured to decide according to any definite scale. But, on the other hand, it is also equally improper to restrict the use of the trepan too much ; for instance, not to apply it in fractures with impression, or only when these are connected with wounds, or with symptoms of compression of the brain ; or in extravasation to do nothing, because the possibility of absorption cannot be denied, or the determination of its seat is often difficult, and frequently not possible with certainty. [The propriety of applying the trepan and under what circumstances has been already necessarily discussed in considering the treatment of fractures with impres- sion (par. 395); of separation ofthe sutures (par. 396); and of wounds ofthe brain into which foreign bodies have been admitted (par. 399). It is not therefore neces- sary to recur to these points.—j. f. s.] 433. The trepan should be only employed for the removal of de- cidedly dangerous conditions in injuries ofthe skull, which are certainly known, and of which it may be assuredly foretold that they will produce symptoms dangerous to life ; and, if these have once set in, the operation will not longer have a satisfactory result. If, also, certain injuries of this kind be cured without trepanning, it must not mislead to the sup- position that the trepan is useless or superfluous; the question is not, whether, in certain cases, a cure may not be effected without the trepan, but whether the trepan is the most proper and certain remedy for the restoration of the patient. As I was formerly a defender of the more extensive prophylactic application of the trepan, but from the result of careful observation and experience have withdrawn from it, the opinions here brought forward may be so much the less the object of doubt. 434. Upon the following grounds trepanning is to be considered as indicated, indeed, immediately required, without secondary symp- toms: 1. In fractures ofthe skull with impression. 2. In fractures of the skull, with splinterings of the bone, directed against the dura mater; for instance, in fracture of the frontal bone, in wounds inflicted with blunt swords, in stabs, in shot-wounds, and so on. 3. In separation ofthe sutures. 4. In cases where foreign bodies have penetrated from without into the cavity of the skull. For these cases the trepan may, however, be unnecessary, if the con- dition of the bony walls and the separation of their edges permit the removal of splinters and foreign bodies, and, if in separation of the sutures, the escape of the extravasation and of the secretion of the wound from both sides be allowed ; or when a piece of bone can be entirely removed, and no further splintering exists. 435. In the subsequent course of injuries of the head, trepanning may be necessary: 1. In fracture ofthe skull, with symptoms of compression, when they continue after bleeding and proper treatment. AND UNDER WHAT CIRCUMSTANCES. 457 2. In extravasations of blood, if the symptoms be not diminished by energetic and proper treatment, if it be certain that the violence have operated on one particular part ofthe skull, namely, at the course ofthe middle meningeal artery. 3. When, notwithstanding proper treatment, symptoms of inflammation ofthe brain continue, connected with those of pressure, especially when a circumscribed painful tumour rises, in opening which the pericranium is found separated ; or the bared bone shows a grayish colour, and its texture is changed. 4. When the secretion ofthe wound cannot properly escape from the wound in the bone, when the dura mater is separated to a greater extent, and there is also a collection of pus (1). 5. In caries and necrosis, with separation of the dura mater, and collection of pus between it and the skull (2). 6. In continued severe headach, with convulsions or epileptic symp- toms, which decidedly arise from the place ofthe earlier injury (3). [(1) Of these also have been considered already, compression from depressed fracture (par. 395;) from extravasation of blood (pars. 432, 33;) and from collec- tions of pus (par. 387.) (2) With regard to trepanning in cases of caries and necrosis, unless symptoms of compression have come on, which is not of very frequent occurrence, it is better to leave them alone, taking care, however, when pus collects beneath the scalp and cannot readily escape, which in these cases happens again and again during the course ofthe natural cure, that it should have a free outlet by cutting freely through the skin. From time to time a careful examination should be made to ascertain if the dead bone be loose, and when this appears to be the case it should be gently lifted with an elevator, and drawn out with a pair of forceps ; and if it run far beneath the scalp, as it often does, it is then best to cut through the skin, and lift up the flaps, by which means the removal of the dead bone is rendered much easier. In this way I have successfully treated a woman with necrosis of the skull, probably from venereal cause, and removed the upper half of each parietal bono, partly their whole thickness, partly only the external table, at two several times, and also portions of tbe occipital and frontal bones at other times, without the slightest inconvenience. And when these had been removed the exposed internal table and dura mater were found covered with healthy granulations, which soon coalesced with those on the under surface of the scalp, and where the latter was destroyed, united by a large intervening scar. The same result also follows the removal of bone which has been destroyed by violence, when the irritation of the brain and its membranes has been quieted.—j. f. s. (3) The preparations from the two following- cases are in the museum at St. Thomas's Hospital. The first related by Dr. Wells (a) exhibited the usual symp- toms of epilepsy; but the second, for which I have to thank my friend Green, has rather a cataleptic character. Case 1.—T. H., a negro sailor, aged about eighteen years, was admitted into St. Thomas's Hospital, November 15, 1804, for paralysis in his left limbs, and being subject to convulsions, both of which he says attacked him four years since, having been struck, a short time before, with the claw of a hammer on the right side of his head. On examining his skull a short narrow chink was found On the right parietal bone, into which the edge of a shilling could just be inserted. It was therefore determined to trephine him, though he had not had any convulsions whilst in the hospital; indeed he said they did not attack him except he was put in a passion. The operation was performed by Birch, in the beginning of December, and the piece of bone in which was the chink, removed. Great difficulty was experienced in raising the bone which appeared to be held by the dura mater, and whilst this was being effected tbe patient had a severe epileptic fit. A little spur of bone, about the eighth of an inch in length, descended from the under surface of the bone, and (a) Trans, of a Society for the Improvement of Med. and Surg. Knowledge, vol. iii. p.91. Vol. i.—39 459 REMOTE EFFECTS OF INJURIES seemed as if it were the piece driven down from the short narrow chink, of which there was still some appearance. The dura mater upon which this little spur had pressed was thickened around it. The convulsions continued to harass him fre- quently for nearly a fortnight. Before the wound in his head was healed, his master being about to sail for the West Indies, took him from the hospital. His palsy was then somewhat less than it had been before the operation. He returned to London about ten months after. During his absence he had grown both taller and stouter; the limbs too of his left side had become stronger, but they were still much weaker than those ofthe right, and he was still liable to convulsions when his anger was excited. Case 2.—A. B., aged seven years, a very pale-complexioned girl, but said to be very healthy, was admitted into St. Thomas's Hospital, Feb. 10, 1841; and the following account is given of her. On the 13th of May, 1836, she fell down from a second-floor window upon the curb-stone, and when raised up was senseless, and appeared as if dead. She was taken to St. Bartholo- mew's, where it was ascertained she had an extensive fracture of the right parietal bone, but without any external wound. She remained insensible for twelve hours; but by the application of leeches and cold lotion she got better, and left the house . seemingly well at the end of a fortnight. She remained well for two years and a half, complaining only of a headach when the heat was very great. After this period she had a fit commencing with giddiness; she looked very silly, and walked round the room several times, generally repeating the last words she had heard or said. This was followed by rigidity of the muscles, principally of the right arm and leg, and of the right side of the face, and the corner of the mouth was drawn down. If she had any thing in her hand and the arm were flexed, she would drop it, but the arm remained fixed in the same position. The fit lasted about three minutes, after which her senses returned all at once, and she would ask for any .thing she had before its accession, or resume her previous employment.— At first had only one fit a-day, afterwards seven, and then one every hour, and in this condition she remained for three months. After this time the character of the fits changed ; they came on w7ith violent spasmodic contractions of the limbs and contortions of the face, without any silliness, but suddenly, and she would fall backwards. After the convulsions her right arm and leg would be useless, and seem as if dead. Of these fits, which continued to recur for two months, she had three, four, or seven a-day, each generally lasting about five minutes, but the last affected her for several hours. Leeches, warm bathing, and other remedies were employed; and for the next seven months she did not have a fit, but enjoyed good health, and grew rapidly. On the lapse of this interval she had a fit exactly like the last, but the left arm and leg were affected in the same manner as the right arm and leg had been in the first attacks. These recurred sometimes twenty times, sometimes, only a few times a-day, and occasionally a day passed without any; and they continued for four months and a-half, during the last fortnight of which a swelling was observed on the right side of the head over the seat of injury ; this, on the application of leeches, subsided simultaneously with the cessation of the fits, which did not recur for a twelvemonth. But in October last she was again seized with the same kind of fits as in the first attack, and both sides were now affected with rigidity. At the present time she has three or four spasmodic fits a-day; and on gome days a fit, accompanied with rigidity, every hour. She often complains of headach and giddiness; and when the fit is coming on, the skin assumes a purplish appearance; she becomes very cold and trembling, and is often very mischievous and destructive. While taking these notes," observes Will. Adams, who reports the case, "she stood by me; suddenly her eyes were fixed, the pupils were dilated, and staring wildly at the opposite wall; her naturally very pale face became still more pallid ; the lips were separated, the corners of the moutb drawn up as if laughing, and the teeth closed. The right arm was bent, the fist clenched, very firmly drawn against the side, and the hand extremely cold. The left arm was very slightly affected. She retained this posture and expression of countenance; but thinking she might fall, I sat her upon my knee, and immediately the left leg was firmly bent upon the thigh. It was impossible to bend7the head either forwards or backwards, or to ro- tate it. The pupiis, at first dilated and fixed, after two or three minutes suddenly contracted, but again expanded slightly. She then winked for a few seconds, gave a sigh, and returned to a state of consciousness, appearing as if nothing had hap- UPON THE BRAIN. 459 pened to her, but only being very cold. The mother says she generally sighs very heavily at the end ofthe fit. She is aware of the approach ofthe fit, and lies down on her bed a minute or two before the attack. They last about three minutes; some parts of the body are slightly convulsed, while others are very rigid, the rigidity being always prevalent. On examination of the head there is perceived a broad fissure in the skull extending from about the centre of the sagittal suture obliquely across the right parietal bone to the lambdoidal suture, the integuments over which rise and fall with the pulsations ofthe brain." Feb. 12. She had two fits. 16. One. 19. Two. 20. One; as also on 26, 27, and 28th. March 2. Two. 9. One. 10. One. 11. Two more violent than usual. 12. One. 16. Three. Green considered that the cause of these curious symptoms was depressed bone, and therefore determined to trephine her. March, 20. A X-shaped incision was made through the integuments, the hori- zontal stretching obliquely across the hinder upper part of the right parietal bone, and the vertical one across the fissure. The flaps were then raised, and a triangular portion of bone being exposed, the crown of the trephine was applied just above the fissure where the bone was irregular. On the removal of the trephined bone a lace- rated hole was found in the dura mater, but no dura mater adhering to the under surface of the bone, or rather the dura mater was deficient. A probe was then slipped in, and passed beneath the edges of the fissure, but no depression could be felt. The arachnoid coat and pia mater were then cut through, for the purpose of exciting inflammation between them and the dura mater, to shut off the wound from the general cavity of the latter; and this done the flaps were laid down, a piece of lint wetted in cold water laid over, and the child put to bed. One vessel bled pro- fusely during the operation, but she had not any fit. On the following afternoon at half-past 4 she had a fit, and another four hours afterwards. A dose of scammony and calomel (15 grs.) given in the morning not having acted, an injection of castor oil and gruel was administered at night. She was kept on tea and toast and water till the 24th, when no inflammatory symptoms having appeared she was allowed a cup of beef tea. On the 26th having had a bad night she was restless and irritable. On the 27th the bowels not being open, fifteen grains of scammony and calomel were ordered, which freely relieved them. March 29, half-past 2, p. m. She had a fit attended with violent spasm of the muscles of the lips, lower jaw and eyelids, and biting of the tongue, so that blood flowed from the mouth. The dressings were now first removed ; the edges of the wound were separated and lifted up by a swelling rising above the level of the skin, part of which resembles brain, but most of the surface is covered by blood and pus. The child was sufficiently sensible to wipe her mouth, and to push away the hand of any one who touched her; but the fit continued for three hours. She was ordered twelve grains of scammony and calomel forth with. During the night she had three shivering fits. March 30. From half-past 8, a. m. till 10, a. m. she was insensible, did not seem to feel when pinched, and moved only twice during this time. At ten she spoke. At noon as the powder had not acted, an injection was given, which re- lieved the bowels, but not sufficiently, and therefore the powder was repeated. As she seemed low, eggs and arrow-root were ordered. During the night she had a slight shivering fit; and on the following day became very irritable. April 1. Has passed a good night, but has had five shivering fits; has taken little nourishment; continues exceedingly irritable. The pulse, which has not altered much in the last few days, is small, quick, and weak. April 3. Lies in an unconscious state, breathing quickly, and refuses food. On the following day she was in the same condition, but frequently screamed out, and her breathing was sonorous. She continued sinkiog, and, April 5, at 2, p. m., she died. Upon examination a protrusion of the brain ofthe size of a walnut passed through the trephine hole. In removing the calvaria two drachms of pus escaped, and when it was taken off the dura mater was found deficient throughout the whole length, and on each side ofthe fissure, so that the gap in it was about four inches in length, and one in width. Lymph had been deposited between the membranes, and in 460 REMOTE EFFECTS OF INJURIES ON THE BRAIN. front of the gap there was one small cavity, bounded by adhesions, and containing about two drachms of pus, and another between the gap and the inner edge of the right hemisphere, containing about a drachm and a-half, both causing irregular de- pressions ofthe brain without any ulceration or morbid state of the arachnoid. The vessels of the pia mater were much injected. Upon the posterior lobes ofthe cere- brum were some old adhesions, and also between both hemispheres in front. Upon the tentorium was some soft lymph, and much on the right side of the fa/.c. In both ventricles there was serum, but most in the left, and the hind wall of the right was remarkably tough, resembling a piece of chamois leather soaked in water. At the bottom of the skull there were about two ounces of serum and lymph. My friend Green has also mentioned to me another case, at the operation for which he was present. Case.—A young man became insane after a blow upon the longitudinal sinus. No depression existed, but as the spot where the injury had been received was known it was determined to try the effect of removing the bone; and he was accord- ingly trephined by the elder Cline; but no irregularity was found on the under surface of the bone. In the course of the operation the longitudinal sinus was wounded, but the bleeding was easily stopped by slight pressure. The insanity ceased so long as the wound remained unhealed: after which it returned. But ul- timately the patient got quite well. The following extraordinary case occurred many years since in St. Thomas's Hospital, of which the following brief account is given by Astley Cooper:— Case.—A sailor was admitted in May, 1800, who had a depression near the upper edge of the left parietal bone. Ho was in a great degree destitute of sensa- tion and voluntary motion; his pulse regular; his fingers continually and alternately closed and opened, nearly in corresponding frequency with his pulse. When hungry he ground his teeth; when thirsty sucked his lips : and when he wanted to void his stools or urine he moved about in his bed, but would sit on his chair to pass them. He was trephined by the elder Cline. During the operation he made a complain- ing noise; the motions of his hands ceased; and the pupils of the eyes were di- rected forwards. Three hours after he was found raised in bed, and when asked if he were in pain he put his hand to the wound. The next day, though he still remained stupid, he could answer "yes" or "no." He ultimately recovered, and when asked what he knew about the accident, he said the last thing he remembered was being engaged in taking a prize in June, 1799 ; but nothing further was ascer- tained, except that he had been first taken to Gibraltar, and then to Deptford from whence he had been brought to St. Thomas's; and during the whole period his mental faculties and his bodily powers were suspended. He got perfectly well. 436. In cases of necessity every part of the skull may be trepanned, although we carefully avoid when we can the frontal sinuses, the middle of the frontal, the scaly part of the temporal, the lower front angle of the parietal, and the crucial ridge of the occipital bone, and also the sutures. The choice ofthe part for the application ofthe trepan is in every case directed.according to the difference of the object to be attained. There- fore, in extravasation, that part is to be trepanned where the already described symptoms are supposed to have their seat; in fractures of the bone, so upon its middle that the pyramid of the trepan stands on one side ofthe fracture; in fracture with impression, on the edge ofthe im- pression, but so that the crown plays upon the edge of the fracture ; in small fractures or balls driven in, the whole may be surrounded with the trepan crown; in injuries on or into the sagittal and lambdoidal suture it must be applied on both sides. The number of applications of the crown cannot be predetermined ; they must be repeated till all the extravasa- tion be perfectly removed, pressure removed without violence, and splinters extracted. 437. Trepanning is divided into the following acts:—1, laying bare the bone; 2, perforating it; 3, elevating the piece of bone; and, 4, the various particulars necessary for the attainment ofthe object. TREPANNING. 461 438. As the kind of injury to the soft part varies, and the number of applications of the crown of the trepan cannot at the first be determined, the following general rules only can be given for laying bare the bone. The coverings of the skull are to be preserved, because thereby the scarring is promoted, although many object to flap-cuts because they are in the way, during the operation, and crumble together subsequently in the dressing. Upon the temporal bone a flap of the temporal muscle is to be made with its base above. If it be presumed that one crown will suffice, a simple long cut may be made, of which the edges are to be separated. For several crowns, a -f or T-shaped cut should be made, the flaps of which must be turned back. The head ofthe patient should be placed opposite the light on a solid table ; the kni(e so held that in making the incision that its edge should always be vertical, and the hand supported either on the thumb or little finger. The bleeding must be permitted to continue because thereby the symptoms are often dimi- nished ; it is to be stanched by rubbing the mouths of the vessels with cold water, or by tying them. The pericranium, should be scraped off with the scraper from the circumference to the centre of the space to be cut through by the application ofthe trepan, and removed. 439. The penetration of the bone is effected either with the improved arch-trepan, or with the hand-trepan (trephine). The application ofthe latter is more simple than of the former, but more wearisome for the operator. The perforation of the skull is effected more easily and more certainly by B. Heine's bone-knife (osteotom); inasmuch as with it an opening corresponding to the object of the operation may be made at pleasure into the skull; the dura mater is less liable to injury, and it is unnecessary to suspend trepanning for the purpose of cleaning the saw-teeth from the bone-dust; the sawing through is also accompa- nied with less shaking. Compare von Graefe and Walther's Journal, vol. xviii. p. 39. 440. In using the arch-trepan (1) the following method is adopted : after properly cleaning the bared bone, the pyramid or pin ofthe trepan crown is to be put a little over the edge, held firm, the crown attached to the arch, in the under part of which it is held like a feather, the pyramid fixed on the middle of the exposed part of the bone, and the trepan brought completely vertical. The left hand lies flat on the disc of the arch, the right grasps the handle. The trepan is now to be turned round from right to left rather quickly, and until it has sawn in a sufficient deep groove for the certain guidance without the crown ofthe pyramid. The trepan is to be then raised, the groove cleared with a pencil of charpie, from the saw-dust, (an assistant purifies the trepan with a brush,) an opening is to be made by the tirefond (2) into the pit formed by the pyramid: the trepan is then to be replaced in the former groove, and it's pyramid having been retracted, is to be brought into the vertical position, and to be again moved round quickly, the left hand pressing on the disc till it is presumed to have penetrated the diploe. The crown is to be again removed and cleaned by an assistant, and after the track has been again cleared of saw-dust, its depth throughout the whole ex- tent is to be ascertained by a chisel-shaped probe, or by a feather stem cut for the purpose. The trepan is to be again replaced ; the pressure is to be somewhat moderated, the trepan to be turned less quickly, and 39* 462 TREPANNING. more to that side where the groove is shallower. The trepan is to be again raised and cleaned, and the depth of the groove examined. If it have not yet penetrated the bone, the crown must be again set on, turned round a few times, with slight pressure, then removed, and the groove again examined. Thus is it proceeded with till the groove has penetrated in several places, and the piece of bone seems moveable when pressed with the nail of the left fore finger. In perforating the inner table of bone a peculiar crackling is heard. [(1) The trepan which was employed by surgeons of the olden time, both in this country and in France, but which, from Chelius's directions for its use, does not appear out of date in Germany, consists of a crown and pyramid or pin, much like that of the trephine now in common use, except that the stem of the instrument is not fixed in a cross handle, but in a stock similar to that used by carpenters in working a centre-bit, and turned round spindle-ways like it. The improved in- strument of which Chelius speaks has the stem-work through an arch, of which the legs rest on the skull and render the movement of the crown more steady. The trepan has long since been laid aside in this country. It is highly objectionable and dangerous, on account of the utter incapability of nicely moderating the pressure necessary for its use, and which is easily managed by the trephine. (2) The Hrefond is a kind of steel screw, with a single or double thread at one end like the screw point of a gimlet, and a ring handle at the other. Its point being put in the pit formed by the pin of the trepan, is turned round till it is fixed firmly in the trepanned piece of bone, which is then lifted out by pulling up the ring handle. This instrument, as well as the trepan, has been entirely out of use for many years in this country ; the trephine bone being raised by the elevator pre- sently to be described.—j. f. s.] 441. In perforation with the hand-trepan (trephine,) it is to be so held, after the pyramid or pin has been properly pushed down and fastened, with the right hand, that the thumb is placed on the one, the middle, ring and little finger on the other side ofthe handle, and the fore finger along the stem touching the top of the crown : the pyramid is to be fixed on the middle of the piece of bone to be perforated, and the crown moved, after being brought into a vertical direction, corresponding with the surface ofthe bone, in alternately contrary semicircular turns, with the upper and fore arm held steady, and the hand alone moving, till a suffi- ciently deep groove is formed for the further direction of the trephine. The instrument is then to be withdrawn, cleaned, the pyramid retracted, a sufficient opening made with the tirefond, and afterwards is to be managed as has been already mentioned in reference to the arch-trepan. [The trephine has with us entirely superseded the trepan, and except in rare cases of fracture with depression, or in making openings into the skull when no depres- sion exists, has itself also given place to Hey's saw. The pyramid, pin, or pivot, is made to travel up and down in the stem of the English trephine, and is capable of being fixed with a screw at any length within the cavity ofthe instrument, or pro- jected beyond the plane of its cutting edge. In commencing the operation the pin is fixed projecting beyond the plane of the trephine, and its point being placed on the skull is made to descend into its substance by alternate contrary turns of the handle ofthe instrument, till the toothed edge ofthe crown, which moves round it, begins to bite and cuts a track for itself sufficiently deep to prevent its slipping out, when the pivot is retracted into the stem of the instrument, which is necessary, as it being longer than the crown of the trephine, it would penetrate the skull before the crown of the trephine, and make a wound in the dura mater and brain, an ac- cident which, from gross carelessness on the part of the operator, I have once witnessed. As soon as the trephine has worked a track sufficient to retain it in place, an examination ofthe track should be made with a thin-eyed probe to ascertain whether the skull be penetrated, and at what points. This is a most important step in the TREPHINING. 463 operation, for as in adults the thickness of the skull varies considerably in different individuals, and even in different parts of the skull in the same individual, and as in elderly persons it is often thin, and in children always thin, and still thinner the younger the child is, so unless the depth of the trephine-cut through the skull be ascertained, the bone may be cut through at one or other part of the trephine-track, and the membranes below seriously torn, or even cut through, and the brain itself injured. In proportion as the trephine-crown descends into the bone, the pressure made on its handle in working it, is to be diminished, or otherwise the surgeon will, to his dismay, and the great danger of his patient, find the crown suddenly descend, all resistance cease, and that the dura mater and the brain are torn. This too I have seen happen. It must, therefore, be remembered that in both young and old persons, and in the former especially, the trephine is to be handled with only sufficient pressure to make its crown cut. When the crown is found to have descended so low that there is reasonable ex- pectation that the internal table of the skull is on the point of being cut through, or when, by examination with the probe, it is found to have been cut through at one or more points, the edge of the elevator is to be carefully introduced into the trephine track, and the piece of bone included within the latter gently prised up, which is easily done if the remainder of the unsawn inner table be very thin, and it then yields with a crack and is lifted out. If, however, the remaining unsawn part will not yield, the trephine must be again applied with a light hand, and the examination with the probe repeated. If the bone be sawn through at one part of the track, but the other part will not break with such justifiable force as can be applied with the elevator, the sawing must be resumed, but with the trephine tilted, so that it shall act only on the part not cut through; and this is to be repeated again and again, with intermediate examination with the probe and repeated attempts with the elevator, till the trephined piece of bone can be separated. In adults the detached bone is generally lifted off the dura mater without diffi- culty, and always easily if blood or pus be poured out between that membrane and the skull. But in young persons, and children especially, this is not the case, for the numerous vessels at that age passing through the skull bones, from the dura mater to the pericranium, and in the contrary direction, hold it, like hooks, very tightly, and offer so great a resistance to its removal as often to lead to the supposi- tion that the separation from the adjoining bone is not complete. This is a very important point, and cannot be too carefully remembered. It must also not be forgotten that, in operating for depressed fractures ofthe skull, the trephine is applied not on the depressed portion of bone, but on the neighbouring part, which retains its natural place, to form an opening through which an elevator may be introduced beneath the depressed portion, for the purpose either of raising it to its proper level, and relieving the brain from pressure, or for taking it entirely awayt if it be detached as well as driven in. Therefore the operation is not con- cluded by removing the trephined piece, but only the preliminary step taken to the actual object ofthe operation, to wit, the raising of the depressed bone, which is to be done by carefully passing the elevator through the trepan hole, and insinuating it between the dura mater and the depressed piece; which done, either the finger ofthe left hand or the edge of the trepan hole is to be made the fulcrum on which the elevator rests, whilst its handle being depressed, the point rises and lifts up with it the depressed bone to its proper level. If, after thus doing, the fractured bone be only loosely connected or entirely de- tached, or if several pieces be broken and thrust in the dura mater and brain, it is best to remove them either with the elevator alone, or with a pair of forceps, as may be most convenient.—j. f. s.] 442. In cases in which the pyramid cannot be at first used to direct the crown, as where balls are driven in, or pieces of bone entirely broken off, which can be completely surrounded by the crown, a disc of sole leather is employed for the more perfect direction ofthe crown, with an edge so broad that the finger point of an assistant may fix it properly. In the hollow of this disc the crown is placed, and carefully directed till it have formed a sufficient groove, when the disc may be removed. The piece of bone is to be raised with an elevator, or with a pair of pincers. 464 TREPHINING. Hennemann (a) proposes a crown director instead of the pyramid for a more perfect guidance of the crown. 443. If it be necessary to trepan on the frontal sinuses, the instrument must be so arranged that it shall come at the same time on the deep part ofthe frontal sinuses, where the anterior is furthest from the posterior bony table, as upon the inner table above, and thus perforate it at the same time ; or the external table may be first cut through with a large crown, and removed, and then the internal perforated with a smaller one. [Trepanning on the frontal sinuses, at least in civil practice, is rarely necessary. The usual blows from falls, or with blunt or even sharp instruments, rarely causing depression of the inner table of the skull, and therefore not producing compression of the brain, nor requiring operation. Should, however, such a case happen, I should prefer Chelius's second mode of treatment, to wit, removing first tbe outer and afterwards the inner table.—j. f. s.] 444. For the purpose of talcing out the piece of bone the tirefond is to be screwed into the hole made for it (par. 440 ;) it is to be held with the thumb and fore finger ofthe left hand close to the edge of its screw, and to be turned about with the same fingers of the right hand at its handle. When the tirefond is sufficiently screwed in, (without injuring the dura mater,) the piece of bone can be raised from that side where it is still fast. If any irregularities or splinters remain on the edge of the internal table they must be removed with the lenticular, which must be held with the whole hand, its head placed between the skull and dura mater, and its edge pressed against the pieces of bone to be removed. The thumb must be set against it to render this motion safe. [The mode of removing the depressed and detached bone has already been men- tioned (par. 441.) If any points remain projecting from the edge of the fracture, they may be removed either with bone nippers or with Hey's saw, a spatula having been previously introduced between the bone and dura mater, to defend the latter from injury. The lenticular is never used by English surgeons.—j. f. s.] 445. If several crowns are applied (1), it must be so managed that either a fracture of different width should remain between two openings, and which may be taken away, either with bone-nippers or with Hey's saw, or if a piece, not directly corresponding to the crown ofthe trepan, is to be perforated, the crown must be so placed that it shall play over only half of the already existing opening (2). It is also advised, for the purpose of not always removing round pieces of bone, to take away, with Hey's saw, an irregular piece of bone, proportioned to the injury. [(1) It very rarely happens, so far as I have had opportunity of observing, that in depressed fracture the application more than once is requisite. I have, however, in a very few instances known it needful to apply ita second time; perhaps it might have been from the first selected spot having been chosen with insufficient judg- ment, or perhaps that the depressed bone was so circumstanced that it could not be raised without simultaneous elevation at both sides. The rule, however, should be to make as few trephine holes as possible, so as to avoid increasing the quantity of exposed dura mater. And, if practicable, no undepressed bone, in case of fracture, should be removed. (2) If the edge of the fracture be regular and without any corners, there is no choice, if it be determined to raise the depressed bone, but to apply the trephine on the undepressed edge. But if that edge present any angle at which the elevation (a) Beitrage zur Medicin und Chirurgie, vol. i. part i. p. 145. AFTER-TREATMENT. 465 maybe conveniently effected, then Hey's saw is preferable for its removal, as being most manageable, and less likely to injure the dura mater, more especially, if the depressed bone have descended so low that the whole thickness of the skull is ex- posed, or if a spatula can be insinuated between the dura mater and the portion of bone to be removed.—j. f. s.] 446. After the performance of the trepan the further treatment de- pends upon the circumstances it indicates. The extravasation must be removed by a proper position of the head, by sopping it up with a moist sponge, or with charpie, when it lies be- neath the skull. If the place of the extravasation be not hit, the cir- cumstances already mentioned (par. 415) must determine the surgeon whether the operation is to be repeated at some other spot. If the extravasation be beneath the dura mater; if this be thrust up into the hole in the bone, fluctuating and violet-coloured, it must be divided with a cross cut. Bleeding from the middle meningeal artery must be stanched by pressure, with a bundle of charpie, with a ball of wax, or with a proper compressor, (Faulquier's (a) or Graefe's) (b), or by cauterization with a red-hot pin. The bleeding from a wounded sinus is to be stanched with dry lint and a proper degree of pressure. A piece of bone completely broken off must be removed with care. Impressed fractures must be raised with a simple elevator, the one end of which is to be introduced under the depressed piece of bone, the other held with the right hand, and depressed, whilst the fore finger of the left hand is placed on the edge of the trepan opening, and the elevator rested upon it. Splinters which are thrust into the membranes, or enter the brain itself, must be withdrawn with care, and without violence; if they be firmly fixed, the opening of the dura mater must be enlarged. [The mode of treating extravasated blood has been already spoken of (par. 419, note 2). Bleeding from the meningeal artery, as far as I have had the opportunity of observing, never requires pressure, beyond a minute or two with the finger, but commonly not even that, as in general the bleeding ceases when the clot has been completely removed, as I have mentioned above. I should certainly never think of applying the actual cautery. Slight pressure will generally stop bleeding from a sinus.—j. f. s.] 447. The dressing after trepanning is as simple as possible. A mass of charpie, smeared with mild ointment, is to be placed between the edges ofthe wound in the skin, so that without pressing the membranes ofthe brain, it lies at the edge of the aperture in the bone ; this is to be covered with a thin compress, and the whole retained in its place by a triangular head-cloth or a bandage (1). The healing of a trepan-wound by quick union, after the removal of all foreign bodies, proposed by many, is not advisable. The experiments upon the replace- ment of perforated pieces of bone and the cure of wounds by quick union, prove in- deed the possibility of the union of pieces of bone again replaced; but the danger that the replaced piece will not heal, but, as a foreign body, produce irritation, inflammation, and suppuration, is certainly as great if not greater than the proba- bility that the healing will be rendered quicker and more sure thereby. This (a) Perret, L'Art de Coutelier, plate zur Lehre von der Trepanation; in von cxxxv. fig-s. 21 22. Graefe und Walther's Journal, vol. ii. p. (b) Hufeland's Journal der praktischen 576, and the Supplement to this paper by Arzneik, vol. xxvii. part ii., xxxi. p. 35.— Sich, ibid. p. 592. Ibid. vol. part ii. p. 35, plates i. ii. Ferg 466 AFTER-TREATMENT. replarement of the piece of bone can specially only be attempted when an injured skull has been trepanned and nothing found beneath. [(1) The practice here recommended by Chelius should on no account be fol- lowed ; as the introduction of lint or charpie will necessarily prevent any union by adhesion, which it is always highly necessary to promote, and which, unless the scalp be very severely bruised, will commonly take place throughout the greater part of the wound. It is much better to lay the flaps down over the aperture in the skull, and apply two or three narrow strips of adhesive plaster so as to keep them in place, with room between to allow the escape of any bloody or serous oozing. No other bandage or compress, or, if any, only a single turn of the former should be applied, so as to avoid the least pressure on the exposed brain; and if there be much contusion, a thin light bread poultice between muslin, so that the crumbs should not get into the wound, should be applied.—j. f. s.] Merrem, Animadversiones quaedam Chirurgias Experimentis in animalibus factis illustratae. Giessae, 1810. Walther, Ueber die Widereinheilung desbei der Trepanation aus geborhten Knochenstiickes; in the Journal fiir Chirurgie und Augenheilkunde. Vol. V. Part IV. 448. In the general treatment, after the operation, bleeding, cold ap- plications, purging must be employed, according to circumstances, for the purpose of preventing or putting aside the inflammation; and the patient must preserve the strictest quiet. 449. The dressing must be replaced once or twice a-day, or as often as the discharge renders it necessary. If no particular symptoms come on after trepanning, the dura mater gradually loses its glossy appear- ance, secretes pus, is covered with pale-red granulations, which gradu- ally rise into the aperture in the bone, unite with the granulations of the bone, and of the external parts, and form a tough scar (1). During this proceeding we must endeavour to assist the union of the parts by bandaging, and by gradually passing to a nourishing and strengthening regimen. If, after trepanning, symptoms of pressure and iritation of the brain continue or first arise, it must be ascertained whether the cause be in the wound, in the presence of splinters, or in biliary impurities, for the removal of which a repetition of the opera- tion, or the treatment already laid down, may he necessary. Various are the opinions and notions which have been put forward upon the nature and way in which the opening in the skull is filled up after trepanning or other loss of bone. But the process which nature employs for closing holes in the skull is distinguished in no respect from the process of regeneration observed in other bones. The dura mater, pericranium, and bone all contribute thereto. A tissue in form of granulations is developed from each structure which fills up the aperture, and in which, as in the original formation of bone, bony granules are de- posited, unite with each other, and thus either perfectly or partially make up for the loss of the bone. In the latter case, the growth of the bone is for the most part restricted to the circumference, and seems to project from the edge of the aperture and spread to a certain distance from it. Hereon is grounded Larrey and others' incorrect opinion, that the loss of substance in wounds of the skull depends on length of time and on the thinning of the opposed concentric bony fibres. As the dura mater, pericranium, and bony tissue, according to their secretive activity and plastic power, contribute to the restoration of the skull-bones; so is it also seen that according as the dura mater is entire, the pericranium not much destroyed, hut especially that there is not any great loss of bone, the tissue filling the hole in the bone is, in proportion to the various degrees of plastic activity in young and old persons, eitber completely or partially converted into actual callus, which is often merely fixed like a pad about the edge of the bone, or has in it no bony growth. In the latter case the edges ofthe bone are covered with cartilage without a trace of actual bony deposit. In one case which was consequent to the penetration of a stake through the skull into the brain, I observed a cure, although distinct dis- turbance of the brain remained: the patient died long after. FUNGOUS GROWTH OF BRAIN. 467 Upon this subject refer to Scarpa, De Anatome et Pathologia Ossium Com- mentarii. Ticini, 1827. sm. fol. Weissbrod, Ueber die Heilung der Trepanationswunden und der Knockenver- letzungen iiberhaupt; in den Jahrbuchem des artzlichen Vereins in Miinchen, 1831. Parti. van Dockum, D., Dissert. Anat. path, de Cranii regeneratione. Traj. ad Rhen., 1837. Vrolick, G., Bemerkungen fiber die Weise, wie die Oeffnung in dem Schadel nach der Trepanation oder anderem Knocken verlust ausgefulltwerd. Amsterdam, 1837. Dubreil, Ueber Regenerations thatigkeit der Kopfknochen; in Presse Medicale. 1837. No. 57. 450. If the pus be thin and bad, strengthening internal medicines must be given, and applications of the same kind put on the dressings. If any irritation keep up the suppuration, it must be removed; if any pieces of bone be loose, they must be withdrawn. If the dura mater be tense and dirty; if a fungous growth rise from its upper surface, and prevent the escape of the discharge, it must be bound up with drying remedies, pressure applied, and careful touching with lunar caustic em- ployed ; and, if the fungus do not subside therewith, it must be taken away with the handle of a scalpel, or cut off with a knife. The brain may also grow up luxuriantly through the opening ofthe trepan, partly as consequent on expansion ofthe brain after the removal of the pres- sure, partly when, as consequence of external violence or of inflamma- tory congestion, the delicate vessels of the brain pour out blood into its substance, in consequence of which the brain stretches towards the aperture in the bone, and ulcerates the dura mater. The brain thrusts through the opening and grows in bulk as the effusion of blood adds to it; at last it tears through the pia mater, and the layer of brain sur- rounding the blood, which then pours out, coagulates and collects as the bleeding recurs. The treatment consists in blood-letting, purging, and the application of moderated pressure; if the swelling continue increasing it must be emptied by introducing a lancet, or removed with a knife. If with an increasing swelling, the aperture in the skull be too small for the escape ofthe blood, it must be enlarged with the trepan. Flourens, Memoire sur les Exuberances du Cerveau par l'Ouverture du Trepan. Paris, 1830. 451. As the scar of the trepan opening, in young subjects only gra- dually, in adults rarely, and in old persons never acquires the solidity ofthe other parts of the skull, it must to maturity, or, in adults through- out the rest of their life, be covered with a plate of dressed leather (a less bulky one is made of metal lined with wool) to protect the brain from pressure and from external violence. Larrey (a) has observed that after closure of the hole, the shape of the skull is changed, being flattened on the side of the injury; the mental activity is simulta- neously diminished. 452. The various bandages recommended for injuries of the head maybe ranged in three classes. I. Many-tailed bandages—1, the six- tailed ; 2, the eight-tailed; 3, the four-tailed or Galen's sling: II. Head-cloths and caps.—l, the four-cornered or great head-cloth; 2, the (a) Velpeau, above cited, p. 265. 468 CONSECUTIVE ABSCESS OF LIVER. three-cornered, or little head-cloth ; 3, Schreger's three-cornered head- bandage; 4, the night-cap; 5, Stark's net; III. Rollers—1, the single roller; 2, the scaphoid bandage; 3, the T-bandage, especially Schre- ger's moveable one; 4, Dionis's frontal bandage; 5, Hippocrates's cap; 6, the knot bandage for compressing the temporal artery. Of all these bandages I employ Schreger's moveable T-bandage, for all wounds with flaps, and for fastening separate bandages, the three-cornered head- cloths as a general covering bandage, and Hippocrates's cap as the general compressing bandage; all the rest are superfluous. 453. Abscesses in the Liver, and also in other intestines of the belly, not rarely occur after previous injuries of the head. They often hap- pen without the intestines having suffered any shock; and often they do not take place, although there has been a severe shock (1). They more frequently appear after injuries of the head, which suppurate, than after concussion without wound. They are frequently observed in af- fections of the brain which depend on internal causes; for instance, in chronic inflammation of the membranes, in the so-called fungous growth of the dura mater, and so on. [(1) "In the liver," says Hennen, "morbid appearances are found throughout every shade of affection of its membranes or its secretion; either pain and tumefaction with bilious diarrhoea, or the same with a perfect torpor of its functions, and inflam- matory affections, from increased vascularity, to the formation of extensive collec- tions of matter. In the spleen, pain, tumefaction, hardness, and abscesses are occa- sionally observed. The stomach suffers more frequently than any other organ; but it appears to be more from general nervous sympathy than from any organic affec- tion, which is seldom discoverable on dissection." (p. 310). Hennen further, and very justly remarks:—"It often happens, however, that neither the liver nor any other organ seems to sympathize with the injuries of the head, while in other cases, almost every viscus wili appear to suffer more or less. The sympathetic affections vary in the organs which they attack, and in the degree of violence. In the thorax they appear from simple increased secretion of the lungs, to tubercles and extensive purulent formation in their substance. Serum is also found in the cavity, and very frequently in the pericardium, and even in the heart itself abscesses have been discovered." (p. 310). The same writer mentions that "priapism is occasionally observed in wounds of the head," and mentions a case in which, "on dissection, the dura mater was found extensively separated all over the head. This separation included the tentorium cerebelli, and beneath its edge about four drachms of coagulated blood were found, the principal part of which lay on the cerebellum" (p. 304). As to the " loss of the generative faculty, and atrophy of the organs connected with it, which have been attributed to blows on the back ofthe head," Hennen ob- serves, "the fact is certain; but whether the anti-aphrodisiac effects proceed from injury to the organs of sexual love or to a general loss of power, is a subject for future inquiry." (p. 302). On this point he quotes the two cases mentioned by Larrey, and that of a Portuguese soldier who was his own servant, and in whom, "a piece of shell shattered the superior part of the occipital bone from within half rn inch of the great knob on the left side to the lambdoidal suture. An irregular an- gular portion of the left parietal bone, nearly an inch in length and about an inch in breadth, was also fractured and beaten inwards." This man laboured under very dangerous symptoms, but had recovered five months after; but he "repeatedlycon- sulted Hennen on the means of recovering his virility, which, he said, the shell had completely carried away with it." (p. 303.)] 154. Abscesses of the Liver, after Injuries of the Head are not always produced by one and the same cause. They are either the consequence of an indistinct but intimate sympathetic change of rela- tions between the liver and brain, owing to which, when one organ is WOUNDS OF FACE. 469 affected, slight disturbances occur in the others (1), or they are con- sequent on the shock of the whole body, connected with injury of the head, and by which the liver, on account of its bulk and its loose con- nexions, suffers more than all the other intestines, and is often torn so that fatal effusions of blood take place into the belly. [(1) With regard to the sympathy between the brain and liver, Hennen observes that "it is by no means such a universal occurrence as some practitioners imagine; nor does the affection of the liver, I suspect, so very often depend upon the direct injury ofthe head as upon certain circumstances connected with it. A class of men more peculiarly liable to hepatic affections than others, are the most frequent subjects of fractured skulls, I mean quarrelsome and habitual drunkards, particularly those who indulge in ardent spirits; and we often find that the liver has been diseased long before the infliction of the injury of the head. It is scarcely necessary to say, that it will very often occur in men ofthe most temperate habits, and totally uncon- nected with the affections of the organs from habitual drinking; I have known it take place within thirty-six hours from an accident in a temperate female." (p» 309.)] 455. These abscesses of the liver often form without being noticed ', often are they preceded by symptoms of more or less active inflamma- tion. The pus is frequently superficial, but most commonly deep in the substance of the liver, and the entire parenchyma of that structure is not unfrequently entirely destroyed by it. In such abscesses swelling and fluctuation may be observed in the region of the liver, and the abscess opens externally; it may also empty itself into the general cavity of the belly, into the stomach, into the intestine, or into the cavity of the chest. 456. It is therefore necessary to prevent such abscesses, which, how- ever, on account of their concealed mode of origin, is often impossible. In symptoms of inflammatory irritation of the liver, bleedings and long continued antiphlogistic purgings, especially antimonial wine properly diluted, are indicated. If the abscess show externally, it must be, as usual, opened. If the outflowing pus be good and of white colour, the prognosis is more favourable than if it be of a yellowish brown colour. The powers of the patient are to be supported by strengthening medicine, and a ready outlet must be furnished for the pus. Upon the various opinions regarding abscesses of the liver after injury of the head, compare, Pare, A., CEuvres Chirurgicales, livr. x. chap. xii. Bertrandi, Memoire sur les Abces du Foie, qui se forment a l'occasionde Plaies de la Tete; in Memoires de PAcad. de Chirurg., vol. iii. p. 486. • Pouteau, QSuvres Posthumes, vol. ii. p. 120. Desault, CEuvres, Chirurgicales, vol. ii. p. 63. Richeraud, sur les Abces du Foie, qui accompagnent les Plaies de la Tete; in Journal de Medecine, etc., par Corvisart, Leroux et Boyer. Frimaire, an xin. Ansiaux, Clinique Chirurgicale, Liege, 1816, p. 35. Textor, in Neuen Chiron., vol. i. part iii. p. 409. Dance, Archives Generates de Medecine. Jan. 1829. OF WOUNDS OF THE FACE. 457. A very important object in the treatment of wounds of the face is the prevention of scars; in all cases, therefore, if the wound gape Vol. i.—40 470 WOUNDS OF THE REGION OF THE widely, if it be irregular and large, if a strong beard or the peculiar position ofthe wound prevent the close lying ofthe sticking plaster, and no contra indications to quick union exist, the suture should be applied. Although wounds of the face usually bleed freely, yet the bleeding from the little vessels is safely stanched by the proper union of the edges. [The twisted suture upon thin pins is the best remedy in all wounds about the face, excepting those of the eyelids, where, in consequence of their recession behind the bony margin of the orbit, they cannot be used. A cold wet rag is to be kept constantly applied, whichever suture is employed, and the suture itself must be removed after thirty or forty hours. Even if the wound be produced by a blunt in- strument, it is advisable to attempt union with the suture. If the cut be at any part where there is hair, the edges of the wound must be so carefully adjusted that no hairs should jut into them, as thereby the union will be prevented, and irritation excited.—j. f. s.] 458. Wounds of the region of the Eye-brow, when they are especially disposed to union, if they be vertical, are always united with sticking plaster; but transverse wounds require the suture. If such wounds heal by suppuration, their dressing consists only in covering them simply with masses of charpie, fastened with sticking plaster. Wounds in the region of the eye-brows often cause blindness or weakness of sight: 1. From concussion of the nervous coat (retina) of the eye. Amaurosis appears in this case directly after the injury, and the iris is completely motionless. This amaurosis frequently subsides of itself, or by the use of purgatives. If the concussion produce tearing of the retina, extravasation takes place in the chamber of the eye, deep-seated pain, extraordinary sensibility of the eye on the slightest touch, complete blindness, in this case incurable, and especially indicating a strict antiphlogistic treatment for the prevention of inflammation. 2. From bruising and imperfect tearing of the great branches of the frontal nerve. Hence, also, follows diminution of the powers of sight, sometimes at once, sometimes later. The place and condition of the wound must lead the surgeon in his diagnosis. The frontal nerve must then be cut through on the upper eyelid, and the wound treated according to the general rules. 3. From dragging of the frontal nerve, as consequent on the formation of a scar. The diagnosis is clear, on account of the subsequent occurrence of weakness of sight. Cutting through the nerve is the only remedy. 4. From complication of the above mentioned causes. The treatment of the wound here requires the first attention; subsequently the commotion of the retina is to be looked to. The same states of the eye may also be produced b)r wounds of the infraorbital region. I have seen a case of complete amaurosis occur suddenly eight days after a blow on the region of the eye-brow, though there was not any trace of it on the skin, in which the pupil was natural and moveable, and there was not the slightest pain. By repeated bleedings, rubbings-in of mercurial ointment, and several blisters along the course ofthe frontal nerve, a perfect cure was effected. [John Thomson mentions "a frequent and most distressing species of injury, which occasioned blindness by the passage of balls through or near to the eyes. In the cases where balls had passed near to the eyes, the vision was destroyed ; in some without any apparent injury of the eye-ball itself; and in others, with the occurrence of every degree of inflammation in that organ. In one case, where the ball had passed through behind the eyes, from temple to temple, one eye was destroyed by inflammation and the other affected by amaurosis. In another case where the ball had taken precisely the same direction, both eyes Avere affected with amaurosis, but without inflammation being produced. In another case where the bullet had entered the face on the upper and left side of the nose, and passed out anterior to the right ear, the patient was affected with amaurosis of the right eye. The left eye was similarly affected in a case where the ball had entered the right side of the nose, and had come out before the left ear. We had occasion to see from eight to ten patients, in whom musket-balls had passed through behind the eyes, from temple to temple; and in all of these there was great swelling, pain and tension of the head and face. EYE-BROWS AND EYE-LIDS. 471 A careless examination would have led one to suppose that in these cases the ball had entered the cranium. Cases of this kind are recorded in which the blindness is supposed to have been produced by the balls passing through the inferior part of the anterior lobes of the brain; but the results of my own observation would lead me to doubt whether, in those cases, the substance of the brain itself had been actually injured. In some of the patients in whom amaurosis had been produced, there was reason to believe, from the course which the balls had taken, that the optic nerves were divided. In a considerable proportion, however, of those affected with amaurosis, it was obvious that the balls had not come into contact with these nerves." (pp. 65, 6.) Fardeau (a) relates the case of a soldier wounded at the battle of Pultuska, in 1806, by a dismounted bayonet impelled by a ball, which struck him " on the right temple two fingers' breadth beyond the angle of the orbit, and a little above it,]passed up to the hilt, from before backwards, and from above downwards, so as to traverse the maxillary sinus on the opposite side, and projected five inches. The man was knocked down, but did not lose his senses. He made several ineffectual efforts to pull the bayonet out, and two comrades, one holding the head, whilst the other dragged at the weapon, also failed. The poor wounded man came to me leaning on the arms of two fellow-soldiers. I endeavoured with the assistance of a soldier to pull out the bayonet, but it seemed to me as if fixed in a wall. The soldier who helped me desired the patient to lie down on his side, and, putting his foot on the man^i head, with both hands he dragged out the bayonet, which was immediately followed by considerable hemorrhage, the blood pouring forth violently and abun- dantly. The patient then first felt ill, and, as I thought he would die, I left him to dress other wounded. After twenty minutes he revived, and said he was much better, and I then dressed him. We were in the snow, and as he was very cold the whole of his head was well wrapped up in charpie and bandages. He set off to Warsaw with another wounded soldier ; went partly on foot, partly on horseback, or in a cart, from barn to barn, and often from wood to wood, and reached Warsaw in six days. Three months after I saw him in hospital, perfectly recovered. He had lost his sight on the right side; the eye and lid had, however, preserved their form andjmobility, but the iris remained much dilated and immovable." He mentions another case in which "a ball passed through a soldier's head, from the top of the base of the right parietal bone, and which he extracted from the zygomatic pit on the other side. He was cured in four months, and walked about at the end of a month." He refers also to a case of he Limbourg's, of which the following is an extract:—A young man was ramming down the powder in his fowling-piece with an iron ram-rod, the gun went off, and the ram-rod struck the head of a person a few paces distant, and, entering a finger's breadth by the side, and as much above the outer corner of the eye, at the root of the zygomatic arch, passed through the teguments at the back of the head, at the posterior superior angle of the parietal bone, a finger's breadth from the sagittal suture, and as much above the superior angle of the occipital bone. The wounded man immediately endeavoured to pull the ram-rod out, but ineffectually; but one of his companions at last pulled it out, as straight as when it left the maker's hands. He lost little blood and only at the apertures of the wound, which healed quickly and completely by simple but proper treatment. In speaking of gun-shot wounds in the neighbourhood of, or penetrating, the orbit, the following are some ofthe most important mentioned by Hexnen :—" Sometimes the ball passes behind the eyes, destroying their power, either by cutting the optic nerves at once, or causing their subsequent inflammation and thickening. An addi- tional proof of the decussation of these nerves is afforded by the effects of gun-shot wounds of the eye; for, in many instances, an injury by a ball inflicted in the neigh- bourhood of one produces paralysis of the other." (p. 340.) " In some cases the ball passes into the orbit without bursting the eye-ball, although the power of vision is totally lost." (p. 341.) " Diplopia sometimes, though rarely, takes place from gun-shot wounds in the neighbourhood ofthe eyes, of which the following case is an example:__A. B. received a wound from a musket-ball, which brushed along the root ofthe nose and onwards towards the right eye-brow, but without producing (a) Observation sur une Plaie de tete par Journal Gen. de Mi'd. de Chirurgie et de une bayonette lancee par une boulet; in Pharm.. vol. xxiv. p. 287. An 1809. 472 WOUNDS OF THE EAR, NOSE, CHEEK, any injury to the bone, and so little derangement that the wound healed in a very few days. Immediately on being struck by the ball, double vision took place. * * * In about two months the disease was removed, but on running into some excess in drinking, it returned again, and the wound burst out afresh. A recurrence to a more rigid regimen perfected the cure in a fortnight, and he was discharged en- tirely from hospital." (p. 345.) Sometimes a ball will enter the orbit, and after- wards descend into "the posterior part of the fauces, forming a tumour behind, and nearly in contact with the velum palati," which happened to a soldier, who, in consequence, suffered severe pain, bad his respiration impeded, his deglutition ob- structed, his speech rendered indistinct, and much irritation in the fauces, attended with constant flow of saliva and frequent inclination to vomit." (p. 341, 42.)] Platner, Progr. de Tulneribus Superciliis ilatis, curcaecitatem inferant ad locum Hippocrates. Lipsise, 1741. Beer, Lehrevon den Augenkrankheiten, Wien, 1813, vol. i. p. 168. von Walther, in his Journal fur Chirurgie und Augenheilkunde, vol. iii. p. 1. Chelius, Handbuch der Augenheilkunde, vol. i. 459. Slight longitudinal and transverse Wounds of the Eye-lids may be always united by court plaster, if it be only so placed that its ends are not loosened by the moisture ofthe tears. In vertical wounds, dividing the eyelid, the suture is always to be recommended, the threads, how- ever, are to be drawn only through the external fold of the skin, and between the threads strips of court plaster are to be applied. The eye is to be kept closed with a vertical strip of plaster, and covered with a compress. Horizontal wounds ofthe eyelids, if large and connected with loss of substance, require the suture for their perfect closure, although, in many cases, they can be united by strips of sticking plaster stretched from the cheek to the forehead, and the cheek is to be kept up by the bandage called monoculus. Small strips of plaster are to be laid between the threads, and the motions of the eye-lid are to be prevented by ver- tical strips of plaster. 460. Wounds ofthe Ear are difficult to unite on account of the many elevations and depressions ofthe auricle ; and it is for the most part ne- cessary to put in, at several points, sutures, which should penetrate only the external skin. If the ear passage be also injured, it must be stopped with charpie, by which the edges of the wound are brought together, and its secretion prevented collecting there (1). Charpie having been laid about the whole ear and in its cavities, it is to be covered with a compress, and the whole fastened with a cloth folded together, which being placed under the chin is carried up over the ears and bound together on the head. If the external ear be completely cut off', or at- tached only at a small part, its union must always be attempted. [(1) If the gristly part of the ear-passage be cut or torn, on no account must Chelius' recommendation of stuffing it with charpie or lint be followed. It is not necessary, for the parts can easily be kept together by supporting the back of the auricle; and it is sure to be mischievous and painful, because it plugs up the hollow- in which the inflammatory swelling has opportunity otherwise to take place. If there be much bruising, it is preferable to cover the whole ear with a bread poultice, and bring the edges of the wound together afterwards when they have begun to granulate.—j. f. s.] 461. Wounds of the JYose may split it either in the middle or on its wings, or a part ofthe nose may be almost or completely divided like a flap. Cuts which split the nose in the middle may be united with sticking plaster, and the union assisted with compresses and a double T-bandage, or by a piece of sticking plaster, cut out in shape ofthe letter U. If the wings of the nose be divided, they must be united with the TONGUE, AND NECK. 473 suture, which should hold only the skin. Wounds which divide the length of the nose horizontally, or more or less obliquely, so that a piece is either entirely divided, or remains only slightly attached, must be united by the stitch and by sticking plaster. But when a small por- tion ofthe tip ofthe nose, in this direction, is lost, apiece of plaster put on obliquely may be useful. Elastic tubes are to be placed carefully in the nostrils, and properly fastened to the bandage. The bandages for the nose, to wit, 1st, the simple bandage; 2d, the single accipi- ter; 3d, the double accipiter,- 4th, the nose-sling; 5th, the upsilon-bandage; 6th, the T-bandage; 7th, the double T-bandage of Schreger, the operation of which consists either in lateral compression of the nostrils, in pressure upwards or downwards, are, as regards their application and operation, extremely uncertain, and maybe rendered superfluous by the proper employment of sticking plaster (as the four-headed stick- ing plaster, and plaster bandage of Bottcher.) 462. Wounds ofthe Cheek may mostly be united by sticking plaster; but when they gape much, are angular, the lips completely divided, or the salivary duct injured, they require the suture. In all penetrating wounds of the cheeks and lips, when any vessels are to be tied, the ligatures are to be applied in the mouth, and to be led out from one or other of its corners. If, in injuries of the salivary ducts, the wound do not heal perfectly by quick union, and the spittle flow from the still open aperture, the healing of the duct must be always attempted, and the origin of salivary fistula prevented by repeatedly touching with lunar caustic, and by compression of the parotid duct with the halter bandage. Chewing and speaking are also to be forbidden. 463. Wounds of the Tongue, when superficial, heal if it be kept at rest; but deeper and especially transverse wounds require sutures. The patient must neither speak nor chew; he must be fed with strong broth, which is to be conveyed into the stomach by an elastic pipe passed through the nose, or by nutritious clysters. [Lawrence observes (a), when the tongue is severely bitten during fits, "that bleeding takes place which is very difficult to stop. I remember," says he, " having had a child under my care who had bitten very deeply into the substance of the tongue, just at the broadest portion of its loose under part; he had divided it hori- zontally, nearly in the middle line, and bleeding took place, which I found it impos- sible to restrain by any styptic application. I employed in vain the oil of turpen- tine, and a saturated solution of alum freely, and the child had lost so much blood, that I deemed it in danger, if haemorrhage continued or recurred. But at last I stopped the bleeding by the following measure, which, however, seems rather a rough one: I introduced at the basis of the loose part of the tongue, bringing it downwards, a strong needle armed with a ligature, and cutting the ligature off after I had brought the needle through, made two ligatures; I tied them tightly one on each side, "so as to embrace between the two the whole surface of the wound, including nearly half of the loose under part of the tongue. This stopped the hae- morrhage. I was rather apprehensive that, by causing the loss of so much of the substance ofthe tongue, some bad effect might have been afterwards produced, but it was not, and the subsequent articulation ofthe child was perfect." (p. 763.)] OF WOUNDS OF THE NECK. 464. Wounds ofthe Neck either injure merely the coverings, the super- ficial muscles, or the deeper-lying vessels and nerves, the wind-pipe and (a) Lectures in Lancet, 1829-30. vol. ii. 40* 474 WOUNDS OF THE WINDPIPE. gullet, or even the spinal marrow. Cuts are the most frequent, and have either a vertical or transverse direction. If they penetrate merely through the skin and superficial muscles, they may be united with sticking plas- ter, and the union of transverse wounds on the front of the neck may be assisted by binding the neck forwards, but in longitudinal wounds it must be stretched backwards. Bleeding from the external jugular vein may be stanched, either of itself or by slight pressure. In wounds with loss of substance, or such as suppurate largely, the head towards the end of the cure must always be kept straight, and the sinking of the pus behind the breast-bone prevented. [Astley Cooper says that the wound above the larynx, which passes through the museles of the jaw and tongue, into the pharynx, being generally inflicted between the chin and os hyo'ides, is the most frequent injury." (p. 242). The wound may be either above or below the tongue-bone, and in the iatter case the epiglottis is commonly more or less completely sliced off, which renders the case more danger- ous on account of the irritation to which the larynx is subjected. In one such case Astley Cooper stitched the epiglottis to the thyroid cartilage, and the patient re- covered, but he was uncertain whether the recovery was attributable to that pro- ceeding.] 465. Deeper penetrating wounds, in which the large vessels are wounded, are usually soon mortal from the sudden bleeding. In injury of the carotid artery assistance is still possible if it be at once compressed by an assistant at the wounded part, the wounded end laid bare and tied (a). In slight injury of the internal jugular vein, the bleeding should be stanched by compression, or, if it be completely cut through, it must be compressed above the injury, and the upper end tied after proper enlargement of the wound. In making these ligatures sufficient care should be taken that the nerves lying close to the vessel, especially the pneumo-gastric, be not included in the ligature. The injured branches of the carotid artery may be tied either in the open wound, or after carefully enlarging it, or, if this be not possible, the principal trunk ofthe carotid is to be tied (1). [(1) The celebrated Marquis of Londonderry destroyed himself by stabbing the carotid artery with a penknife ; and, at the time, it was believed that had his medical at- tendant acted promptly and properly, his life might have been saved. I recollect an instance many years since under my friend Travers's care in St. Thomas's Hospital, in which either the lingual or facial artery was also wounded with a penknife in an attempt at self-destruction. The wound was enlarged with the intention of tying the bleeding vessel, but the wound in it was too close to its origin to admit such proceeding. The common carotid artery was therefore tied; but the case was un- successful, as adhesion never took place, and when the ligature ulcerated through, bleeding occurred several times; at last a large clot formed in the wound, from which eonstant oozing went on; and on the removal of this to secure the artery, a violent gush of blood followed, and the patient died immediately.—j. f. s.] (a) Hebenstreit; in his additions to Ben- jamin Bell's Surgery. Abernethy's Surgical Works, vob ii. p. 115. ' Larrey, Memoires de Chirurgie Mi itaire, vol. i. p. 115. Hennen, John, Observations, &c, p. 356. Collier; in the Medico-Chirurgical Trans. actions, vol. vii. p. 107. Cole ; in London Med. Repository, May, 1820. Thomson, John, M. D., Report of Obser- vations made in the British Military Hospitals in Belgium, &c, 1816. Lon- don. 8vo. Breschet ; in French edition of Hodgson's TreHtise on the Diseases of Arteries and Veins, &c, 1815. London, vol. ii. sect. v. p. 37. note. Textor ; in Neuen Chiron., vol. ii. p. 2. WOUNDS OF THE WINDPIPE. 475 466. Injuries of the Pneumo-gastric Nerve cause loss of voice, spas- modic symptoms, and death. Injury ofthe Recurrent Nerve also causes loss of voice; this, however, may occur subsequently. Injury of the Laryngeal Nerve is mortal from arrest of breathing (a); and this is also the especial branch which so quickly produces death after the division of the whole nerve. According to Dupuy's (b) experiments, animals may live for some time after division of both pneumo-gastric nerves, if the air-tube be opened below the larynx; but, if the opening be not made, the animal dies on account of the palsy of the nerves spreading over the muscles opening the chink of the glottis. If the Sympathetic or Phrenic Nerve, or the spinal marrow be injured, death in convulsions follows. 467. Wounds of the Windpipe are either longitudinal or transverse ; the windpipe may be either only cut into, or cut through, or a piece of it taken away as in shot-wounds. Vertical wounds of the windpipe re- quire union with sticking-plaster, and that the head should be inclined much backwards. Transverse wounds divide it either partially or en- tirely ; they are mostly consequent on attempted self-destruction, and are usually found at the upper part of the neck, between the larynx and the tongue-bone ; penetrate to a great extent into the back ofthe mouth ; allow the air, spittle, and drink to escape through them, or even pene- trate into the larynx. They are rare at the lower part of the windpipe. In these wounds, if the voice be at once lost, the air passes through the wound (1), frequently an air-swelling is produced (2), and blood flowing into'the windpipe may give rise to dangerous symptoms. This may occur without the carotid artery, jugular vein, or pneumo-gastric nerve being wounded ; the bleeding may come only from the superior thyroid, or from the lingual artery. [(1) The loss of the voice in large wounds of the windpipe simply depends on the air passing out through the aperture, instead of proceeding through the larynx; this is readily proved, if by bringing the head forwards, the edges of the wound can be brought sufficiently close to prevent the escape of the air through it, as then the air takes its natural course through the larynx, and a whisper more or less loud, or even a feeble voice can be heard. (2) Hennen says :—" Emphysema is also a frequent though not dangerous symp- tom of wounds of the windpipe; indeed I have met with it oftener in wounds of the larynx and trachea than in those ofthe lungs, probably because the action ofthe muscles subservient to respiration is exerted in such a manner as to send a current of air through the larynx, whence it is drawn forcibly into the cellular substance. Simple puncture is, in these cases, the best remedy." (p. 362.)] 468. When in transverse wounds of the windpipe the bleeding is stanched, the edges ofthe wound should be brought together by bend- ing the head much forward towards the chest, in which position it is to be retained. This is done less certainly by bandages than by Kohler's cap; the patient is at the same time to be slightly inclined to one side, so that the secretion may not readily flow into the windpipe. If the windpipe be not completely divided, the edges ofthe wound should not be sepa- rated far apart, and the position already mentioned is favourable to union, as the stitches excite only irritation and cough, which mostly hinder (a) Pye. Aufsatze und Beobactungen aus (b) Journal de Medecine, par Le Roux, der gericbtlichen Arzneiwissenschaft. Saml. etc. vol. xxxvii. p. 351.—Meckel, Handbuch vii. p. 185. der gericbtlichen Medecin. Halle, 1821, p. 476 WOUNDS OF THE WINDPIPE. the union. Only when the windpipe is cut through, and the edges of the wound gape widely, should they be drawn together with a broad ligature fastening the external skin merely. According to Fricke (a), severe wounds of the neck should not at once be healed with the stitch; he prefers waiting for a perfect suppuration, and the production therewith of new granulations, and then first puts in the suture to bring the suppu- rating edges into contact. [Position in the treatment of wounds of the windpipe, at whatever part, is always preferable to stitches, which are really of little service, as from the constant drag upon them in the frequent attempts made to get rid of the mucus, and ofthe adhe- sive matter which begins to be secreted a few hours after the injury, they speedily ulcerate and are of no use, but rather hurtful from their additional irritation. The only real benefit obtained from them is that of preventing the edges of the skin turning into the wound, which interferes with the union ; but even in this attempt they often fail. Keeping the edges of the wound as near together as possible with strips of adhesive plaster, applied longitudinally and obliquely across the neck, and over these a roller twice or thrice around the neck, is all that is either necessary or proper. It must, however, be recollected that even at the very first it is not always proper to close the edges of the wound, and the surgeon must therefore carefully notice, in dressing the wound, how the patient can breathe when the edges are brought to- gether and covered up. Not unfrequently the breathing cannot be carried on by the mouth, but only by the wound; under which circumstances, if the wound be shut up, difficulty of breathing and even suffocation may ensue, unless all the dressings be removed and the air allowed to escape by the wound. Its complete closure, therefore, must be dependent upon the freedom or difficulty of breathing by the mouth; if there be no difficulty the wound may be carefully closed; but, if there be difficulty, a sufficient space must be left opposite the wound into the windpipe, to permit the free passage of the air. Another circumstance maybe also noticed as to the unneedfulness of stitches, that is, that these wounds rarely, if ever, unite by adhesion, but almost invariably by granulations, even under the most favourable circumstances. But the use of stitches after the establishment of the granulating process, as proposed by Fricke, is quite superfluous. It is certainly proper at first to attempt union by adhesion, and sometimes the angles of the external wound will effect it; but generally the parts have been so much handled in search of bleeding vessels, as well as irritated by their continual separation by the air and mucus forced through the wound, that the greater part of the surface becomes sloughy. When this happens, it is better to remove all the dressings, except two or three strips of plaster for support, and to surround the whole neck with a light bread poultice in a muslin bag, so as to prevent any of the crumbs dropping into the air-tube.—j. f. s.] 469. In these wounds there always occur severe inflammation of the windpipe, spasmodic symptoms, especially severe cough, which is more violent in injuries of the larynx than of the windpipe (1). If the wounded person have not lost much blood, he must be bled freely from a vein, and nitre in emulsion must be given internally. If pain and cough arise, bleeding from a vein, (even the application of leeches) must be repeated, and calomel wdth extract of hyoscyamus given. The food must be entirely fluid. Persons who have attempted self-destruction must be carefully watched, lest they disturb the bandages. This treat- ment must be persisted in so long as the inflammatory and convulsive state ofthe windpipe continues. If union do not completely occur, the wound is to be covered with lappets dipped in lukewarm water. If the discharge be great, and the (a) Funfter Bericht uber die Verwaltung des allgemeinen Krankenhauses, 1832. p. WOUNDS OF THE WINDPIPE. 477 powers of the patient give way, Iceland moss, bark, and narcotic reme- dies, must be used. The hoarseness which remains for the most part gradually subsides. In injuries of the cartilaginous part of the wind- pipe, there sometimes remains for a long while a fistulous opening, which often closes of itself (2). When the bandage is removed, the patient must guard against a deep inspiration, and much drawing the head backwards (3). [(1) If there be much inflammation and cough it is always best to remove the dressings, even though the breathing by the mouth may be comparatively easy, and allow the mucus or other secretion to be coughed through the wound, as their dis- charge by that passage is more easily effected than through the chink of the glottis, and consequently the necessary exertion and irritation are lessened. If the case pro- ceed favourably, after a week or ten days the secretion from the lining membrane of the air-tube diminishes, it becomes less viscid, and is separated with less exertion; the granulations begin to close the aperture, and breathing begins to be performed through the laryngeal chink, and daily increases till the wound has entirely healed. Astley Cooper mentions an instance of ossification and exfoliation of the thyroid cartilage in a case where the cure occupied several weeks (p. 246); but I believe such occurrences are rare. I have had a case of fistulous wound between the thyroid and cricoid cartilage, which had been of some weeks' standing before I saw it, and the passage through the latter into the windpipe had become so narrowed, either by the falling together ofthe cricoid cartilage, of which the front had been perhaps cut off from the hind part, or by the adhesions which had formed between the lining membrane, that breathing was performed with extreme difficulty, and with a loud hissing noise. As these symptoms had been gradually increasing it was thought advisable to in- troduce a short silver tube, to do which it was necessary to enlarge the aperture with the knife, and the tube having been passed in the breathing immediately be- came easy, and the hissing ceased. She wore the tube for several weeks without inconvenience, and left the house with it still in. In this case, as might be ex- pected, the voice was entirely lost.—j. f. s. (2) These cases are very uncommon. Astley Cooper says, that in a wound upon the thyroid cartilage, which remained fistulous, he raised a piece of skin from the surface of the neck, above the opening, and turned it over it, having previously pared the edges, and it united extremely well." (p. 246.) (3) Sometimes after a cut has been going on well for some days, a sudden bleed- ing may come on, either during the exertion of coughing or any other effort, and it will be extremely difficult, if not impossible, to ascertain whether the blood come from an artery or vein. A case of this kind recently occurred in our hospital under my colleague Mackmurdoe's care. A man cut his throat nearly from ear to ear, on the night of the 7th of July, 1845; he lost a large quantity of blood, but when he was found the bleeding had ceased. On examining the wound it appeared that he had cut between the hyoid bone and thyroid cartilage, separating with the former the epiglottis. The edges of the wound were brought together by bending the head down to the chest, and cold water dressing applied. On the next morning one suture was put through the lips of the wound, and on the day following other two. On the fourth day they were all removed, as there did not appear any dis- position in the wound to union. On the afternoon of the 14th the sutures were again introduced. At 5, a. m., of the 15th, he had a violent fit of coughing, and, whilst trying to reach the chamber-pot from beneath his bed, a sudden bleeding came on, said to be in a twisting stream. It was checked by pressure, but on the removal ofthe finger bleeding recurred, and he lost about half-a-pint of blood; but it was controlled by thrusting a piece of sponge into the bottom of the wound, which was left open, and cold water applied. No further bleeding having occurred, the sponge was removed on the 18th, and the wound has now (26th) filled with granu- lations, and the case has every appearance of doing well.—j. f. s.] 470. In stabs of the Windpipe, owing to the parallelism of its inner and outer walls, the air readily escapes into the cellular tissue. If slight pressure upon the wound do not prevent the escape ofthe air, the outer 478 WOUNDS OF THE WINDPIPE. wall must be enlarged with the bistoury, so that the air may more readily escape. 471. Bruised Wounds of the Larynx and Windpipe, Shot-wounds with loss of substance, require besides the general treatment already men- tioned, a simple linen bandage spread over with a mild ointment. : If the edges of the wound skin over, and fistulous passage form, which especially occurs in bruises and in wounds connected with the loss of substance, the edges must be refreshed, (re-pared with the knife), and, if possible, united vertically with the twisted suture. Attempts have been made to close the opening by healing over it a flap of skin (a). 472. Wounds of the Gullet occur with an entirely, or, for the most part, divided windpipe, (in stabs only is injury of the former p'ossible without that of the latter), and the gullet is either cut into or cut through. Severe wounds of the gullet are usually accompanied with wounds of the larger vessels and nerves, and are then speedily mortal. Without this simultaneous injury, however, wounds of the gullet may be very large; it may even be entirely divided without the wound being absolutely fatal (b). Injuries of the gullet in large wounds can be ascertained by the eye, by examination with the finger, and also by the fluid swallowed by the wounded person, escaping through the wound, and exciting severe cough. 473. When in wounds of the gullet the blood has been stanched, the same treatment is to be pursued as in wounds of the windpipe: the ex- ternal coverings must be fixed, and the head bent towards the chest. If the wound be large, the patient must be supported with nourishing clysters, baths, or what is best, by strong broths introduced by an elastic tube into the stomach. If the tube excite vomiting, coughing, or bleed- ing, it must be removed, and nourishing clysters and baths only used. The tormenting thirst of such patients is best relieved by putting into the mouth slices of lemon or Seville orange sprinkled with sugar. As the wound advances towards healing, pappy gelatinous food must be cautiously given by the mouth. The elastic tube kept in the gullet should be about as thick as the little finger) and provided with a valve at its top. It is introduced through the nose or mouth ; it generally slips the first time into the windpipe, which must be ascertained by the motion of a taper flame held before the opening of the tube. In this case, the tube is to be drawn back, and an attempt made to pass it more backwards into the gullet. It may remain many days, its outer end being fastened. [(1) Astley Cooper "objects entirely to the introduction of tubes into the pharynx and oesophagus, as worse than unnecessary, for they are highly injurious by the cough which they occasion by their irritating the wound; and, if adhesion or granulation have taken place to close the wound, such tubes tear it open again and destroy the process of restoration." (p. 249). The correctness of this opinion is fully borne out by the following case related by Stark (c) :— Case.—A man cut his throat; "the external jugular veins on both sides were perfectly divided ; the carotid arteries laid bare; the trachea arteria divided from the larynx immediately above the pomum Adami; the epiglottis and glottis, along with the os hyoides, perfectly detached from the rima glottidis; the pharynx cut through, except about a finger's breadth of the back part, which was very much stretched, for the trachea thus divided had retracted equal to the clavicles, as had also the fore (a) La Lancette Frangaise. 183], 26 Nov. und ihr Lethalitatsverhaltness, in hisMaga- —Froriep's Notizen, 1831. No. 692. zin, vol. vii. p. 262. (6) Rust, Einige Beobachtungen (iber die (c) Medical and Philosophical Common Wunden der Lull und Speise rohre, mit Be- taries, by a Society in Edinburgh, vol. iv. merkungen in Bezug auf ihre Behandlung part i. London, 1776. AND GULLET, TREATMENT. 479 part of the oesophagus, which very much stretched the remaining fibres of the pha- rynx. As the os hyaides was perfectly detached from the rima, consequently every muscle that arises from the different cartilages, &c, ofthe windpipe, and which are inserted in the os hyoides, were cut through. * * * I endeavoured to attach the fore part of the (esophagus to the pharynx with needles and waxed thread; but it was found very difficult to accomplish, as the wound was very iao-cred, the patient averse to have any thing done for him, and the pricking of the needles brought on violent retching to vomit, so that the contents of the stomach were evacuated by the wound. I next endeavoured to attach the trachea to the larynx, which was likewise difficult, on account of the constant convulsive coughing; however, it was at last done, and the patient in this situation could swallow a little water, though the greatest part still ran out by the wound." Some adhesive straps were afterwards applied. His bowels were kept open with clysters. No nourishment given by the mouth, but nutritive clysters thrown up every two hours. He went on very well till the sixth day, when he became very feverish; the discharge ichorous and offen- sive; the breathing quick and difficult, with a loud rattling noise. Hot dressings were applied to the wound. On the ninth day the fever had subsided, and the dis- charge from the wound thick and hardly in any degree offensive. On the following day, when the dressings were removed, "all the stitches had given way, and the windpipe and gullet had retracted as before. * * * Between the os hyoides and the clavicles there was only one continued gash, which looked as if the windpipe and the gullet had been cut out entirely." As he was now very much reduced, and both very thirsty and hungry, attempts were made "to introduce nourishment by the external wound, by means of a bent catheter that had a bladder tied to it; but the catheter had no sooner touched the top of the gullet than it produced violent efforts to vomit, and convulsive coughing, which tore the wound quite open. Find- ing this method would not succeed, 1 laid it aside, and trusted to strono- nutritive injections only. I again put in a stitch or two into the fore part of the°windpipe, but soon found they could be of no service, for they not onlv prevented a reunion, but kept up a constant irritation on these sensible parts/ I therefore next day removed them, and only continued the stitches in the external wound, for the mucus and matter now prevented adhesive plaster from sticking; and in order that there might be very little stress on the external stitches, I kept his chin confined close to his breast by means of pillows under his head, and a night-cap with straps that tied under the arm-pits. About this period small granulations of flesh made their appearance on the wound." On the twenty-fourth day he was "sitting up in bed with a plate before him containing boiled rice. I asked if he had swallowed any, to which he made signs that he had, by patting his belly, and expressing great joy of countenance. I desired he would make another attempt, and found, to my great astonishment, that he could swallow some, though by much the greatest part came out by the wound." He continued to mend, and "about the end'of six weeks from the accident, the external wound healed up entirely, except over the pomum Adami, which, by being a little hurt, gradually separated; and as the separation was very slow, a small part of the external wound turned fistulous, and so left a passage into the windpipe, through which he could breathe at pleasure, though he generally breathed by the mouth as before, and could swallow either liquids or solids without any part coming by the wound." A fortnight after, he went out, got drunk, and vomiting the following morning, " some of the remains of the liquor probably got into his windpipe, for he fell back on his bed and expired in an instant." On ex- amination, there was found "a perfect reunion of all the injured parts; the os hyoides was rejoined to the windpipe in the fore part by means of a soft but tough substance, which occupied the place of the scutiform and thyroid cartilage. The rima glottidis was attached to the sides of the os hyoides by a tough membranous cicatrix, which marked the extent of tbe wound in its first state. All the muscles inserted into the os hyoides and originating from the cartilages, &c, had, after being cut throuo-h in the accident, retracted, and one side formed a large and hard substance, about twice the size of the pomum Adami.''' (p. 434-443). Dr. Ryan also relates (a) another, and very similar, case, in which, as in the former nature, seems to have had most to do with the cure. Case.—A negro received several wounds in the neck, which, when seen some (a) Duncan's Medical Commentaries, vol.'viii. London, 1783. 480 CONSEQUENCES OF WOUNDS OF NECK. time after the accident, appeared to be " thrusts or incisions with a knife between the upper edge of the right side of the thyroid cartilage and the os hyoides; one^in- cision was made transversely, it began below and opposite the middle of the base of the os hyoides, and extended almost as far as the right carotid; it seems to have totally divided the sterno-hyoid and hyo-thyroid muscles. This incision was crossed by another, which was made in a longitudinal direction." When first found, " they gave him some drink, but it all came out through the wound ; and they, as well as he himself, declared, that till the thirteenth day after the attack he swallowed nothing whatsoever. Hence he was almost exhausted, and his situation thought so desperate that recourse was had to none of the means usually employed in such cir- cumstances in order to support life. From the time he began to swallow he has gradually recovered some strength, and he can now eat plantains, the chief fare of the negroes." When Ryan had removed the dressings, " on his attempting to drink some water, the most part rushed out by the orifice ; but when it was closely stopped up by the application of another's hand, he swallowed pretty freely, though not without some coughing. It is always necessary to make a pressure of this kind when he takes any food. I had his mouth and nostrils closed for some time, but he breathed through the wound." (p. 319-21). Hennen has mentioned a case in which '■ the larynx was completely severed between the thyroid and cricoid cartilages, and the oesophagus laid open throughout half its calibre. * * * I confess we were at a loss what to do; for when we attempted to close the wound he could not breathe at all. We therefore left it open, keeping his head reclining forward, and expecting that he would soon be suffocated. This did not happen, however, for he breathed very well through the wound; but his greatest suffering proceeded from thirst, as every thing he attempted to swallow came through the opening. We tried to introduce liquids through a flexible tube, but we succeeded very badly, on account of the great irritability of the fauces, trachea, and oesophagus. As there was great abundance of milk to be had, he was put in a bath of this fluid several times a-day, and clysters of various nutritious fluids were assiduously thrown up. By these means he was entirely supported during the space of eighteen days, and nothing but common dressings applied to the wound. At the end of this period, the oesophagus became retentive, when liquids were taken, and the breathing was beginning to be partly carried on through the mouth. From this time he rapidly recovered, excepting a considerable loss of voice and power of articula- tion." (p. 364.)] 474. As wounds of the gullet very rarely heal by perfect agglutina- tion of their edges, but the interspace is filled by the neighbouring parts, there usually remains some contraction at this part, or it bulges like a bottle, in either of which cases swallowing is difficult. 475. Stabs of the Gullet, if there be no accompanying severe injury, often heal without any symptoms. If the gullet be wounded at the lower part, the food that is swallowed may pass into the cavity ofthe chest. 476. Deep wounds at the back of the neck often produce a palsied condition, and also frequently a wasting ofthe lower limbs. Wasting of the testicle and loss of the generative power have also been observed in these cases. [Ofthe severe nervous symptoms occasionally following gun-shot wounds ofthe throat, Hennen mentions an instance in an officer who received a ball in " the sternal portion of the m. sierno-cleido-mastoideus, about an inch above its origin, which passed inwards towards the thorax, but no trace of its route could be disco- vered. On receiving the shot, he instantly dropped, not, however, perfectly sense- less, but very much stunned. He felt as if he had received three distinct wounds, the most severe of which he referred to the arm of the wounded side, the two others, of nearly similar severity, to his throat and stomach." He lost "an enormous quantity of blood, which also gushed copiously from the wound at every effort to cough or vomit. * * * His left arm hung nearly lifeless, with a pulse scarcely perceptible; that ofthe sound arm was excessively quick, 120 in a minute, and very feeble. On the following day he was better, but had such an oppression along the course of the diaphragm, that he urged Hennen to cut for the ball, as he was certain, SUPERFICIAL AND PENETRATING WOUNDS, &C, 481 he said, it was the source of this pain. * * * He spat up a florid frothy blood very copiously, and the same issued occasionally from the wound. The efforts to vomit, and spasmodic catchings of the throat with globus and hiccup were very severe. On the third day the dyspnoea was almost suffocating, and the nervous symptoms ran very high. On the fourth day his voice was entirely lost, till the sixth, when it began gradually to return. On the thirtieth day, after severe spasmodic bilious vomiting, the speech was again affected suddenly. His arm, which had, after the first twenty-four hours, given him occasional uneasiness, and in which he felt a prickling sensation on the inner side, was particularly painful at the period of this spasmodic attack. It had been wrapped in flannel, and gentle friction had been employed to it; but upon examining it more particularly, it was found somewhat shrunk, and the fingers cold and nearly insensible to pressure. In about six weeks he went home to England, and continued improving." (p. 358-61.) A case is related by Kennedy (a) of a man wounded on the right side of the thyroid cartilage by bullet, which, passing behind the m. slerno mastoideus, was next day found lodging a little above the superior costa of the scapula, and when cut upon two bullets joined by a neck were removed. The wound healed kindly in five weeks. " Immediately upon the patient receiving the shot, his right arm, from a little below the neck to the finger-points, became pale, quite cold and benumbed." Aromatic and spirituous fomentations were used, and the arm covered with bags. " In about twelve hours after the arm recovered some heat; but the thumb of that hand was seized with violent pain, which kept him all night from sleep; and the next day the pain was so unsupportable, that he was in danger of turning delirious, though his pulse was scarce quickened and he had no thirst or other sign of fever." Blood was taken from the arm again, (he having been bled also on the day previous,) clysters thrown up, and anodyne fomentations and poultices employed without relief. Some laudanum was given, which relieved the pain, but did not cause sleep, and the pain recurred next morning. The quantity of laudanum was therefore increased, and on the third night he had sleep; and afterwards it was given also in the morning, but in smaller quantity. As the effect of the opium diminished its quantity increased, till in the course of six or seven months the opium amounted to 250 drops of lau- danum. Two months after he had received the wound, not only his thumb was pained, but such another pain was felt, at the joint of the elbow, without either swelling or hardness in the pained parts, or in the parts between them, and the fore- arm remained free from pain." At the end of seven months the pain began to abate, "but as the pain became less uneasy the feebleness of the member increased; and in twelve months the pain was gone, and the use of the arm entirely lost. About two years and a half after receiving this wound he went to Bath and used the waters for a season : when I saw him after that time at London, he told me he had recovered the full use and strength of his arm." (p. 167-70.) IV.—OF WOUNDS OF THE CHEST. Vering, fiber die eindringenden Brustwunden. Wien, 1801. 4to. Herold, fiber die Behandlung trefer Wunden der Brust. Kopenhagen, 1801. 8vo. Larrey, Memoires de Chirurgie Militaire, vol. ii. p. 150; and in the Memoires de l'Academie Royale de Medecine. Paris, 1828. Vol. I. Rumebe, E., Dissertation sur les Plaies d'Armes k feu penetrantes dans la Poitrine. Paris, 1814. 4to. Hknnkn's Principles of Military Surgery. 2d Edit. Mayer, C, Tractatus de Vulneribus Pectoris penetrantibus imprimis cum Haemor- rhagia conjunctis. Heidleb., 1823. 4to. Heidelberger klinische Annalen, vol. i. part iii. p. 365. Reybard, J. H., Memoires sur le Traitement des Anus artificiels, des Plaies des Intestines, et des Plaies penetrantes de Poitrine. Paris, 1827. 8vo. (a) Medical Essays and Observations, published by a Society in Edinburgh, vol. i. Edinburgh, 1752. i2mo. Vol. i.—41 482 REMARKABLE INSTANCES OF 477. Wounds of the Chest (Vulnera Thoracis) are either superficial or may penetrate into the cavities of the chest. 478. Superficial Cut and Sabre Wounds require the same general treatment, and their union can always be produced by sticking plaster. Superficial Stabs (of which we satisfy ourselves by their direction, by the depth to which the injuring instrument has penetrated, and by ex- amination with the probe, after placing the patient in the same position he was at the moment ofthe injury, and by the absence ofthe symptoms to be described in penetrating wounds of the chest) are also to be treated, according to the general rules, although the more active inflammation, which usually occurs in these wounds, requires a stricter antiphlogistic treatment. But when extravasation of blood takes place in the cellular tissue, and compression is not sufficient to stanch the bleeding, or when in the after-course of the wound a collection of pus takes place, and difficulty of breathing and so on occurs, the wound must be enlarged, the bleeding stanched, or a proper opening made for the escape of the pus. Bruises and shot-wounds of the coverings of the chest may produce large outpourings of blood in the external parts, inflammation of the pleura and lungs, difficult breathing, spitting of blood, and so on, and require a strict antiphlogistic treatment, repeated bleedings, and cold applications to the chest. 479. Penetrating Wounds ofthe Chest (Vulnera Thoracis penetrantia) either simply open the cavity of the pleura, or at the same time wound the viscera lying within the chest. Their danger depends generally on the bleeding which comes out of the walls of the chest, or from the visceia contained in its cavities, from compression of the lungs and heart by the collected fluids, from inflammation of the viscera of the chest, and their passages. 480. We ascertain that a wound of the breast actually penetrates into the cavity of the chest, or even injures the viscera contained therein, by the depth and direction to which the injuring instrument penetrates ; by the careful examination ofthe wound with the finger or with the probe, the patient being put in the same position as at the injury ; by the in- flux and efflux of the air through the wound in inspiration and expira- tion ; by an air-swelling (emphysema) which forms around the wound ; by difficult respiration in consequence ofthe air which enters the cavity ofthe chest compressing the lung and preventing the flow of the blood. In simultaneous injury of the lungs the patient suffers deeply fixed pain ; breathing, especially inspiration, is very difficult; a frothy, pale-red blood pours in an unbroken stream out of the wound (1); the patient spits blood (the absence of spitting blood is, however, no proof of the lungs being uninjured); sometimes also there are symptoms of internal bleeding and compression of the lungs, which are hereafter to be con- sidered. The distinction of these wounds is more or less difficult ac- cording to their various size and direction (2). Examination with the probe is, in most cases, illusive and uncertain; it may be very injurious, from the irritation connected with it, and is in most cases useless, because the diagnosis is determined by other symptoms; and in a simple pene- trating wound scarcely any other treatment is employed than in a wound that does not penetrate. The examination, by injection, as advised by many, is still more unsatis- factory, and always dangerous. PENETRATING WOUNDS OF THE CHEST. 4S3 The air passes freely in and out only when the wound is direct. The lungs do not always collapse, or fall together, when the cavity of the chest is opened, but remain in contact with the pleura costalis, which, in some cases, may depend on adhesion between the lungs and the pleura, but in others, it is not to be explained. The opening, therefore, of both cavities of the chest is not directly mortal. Wil- liams concludes from his experiments, 1st, that a lobe ofthe lung when exposed to the air does not collapse, so long as the functions of the other lobe and of the as- sistant organs continue undisturbed in respiration; 2d, that one lobe of the lung possesses a peculiar power of moving for some time, entirely independent of the diaphragm and intercostal muscles, when, indeed, the other lung respires : the origin of this power Williams cannot determine; 3d, that a sound lung recovers its natural expansive power when the pressure of the external air is removed; 4th, that although the external air passes freely and uninterruptedly at the same time through tubes ofthe same size into the cavities ofthe chest, the lungs, however, do not col- lapse, if the assistant respiratory organs have their activity still unrestrained ; 5th, that a healthy lung never completely fills the cavity of the chest, at least in natural respiration. In my experiments on dogs, I always found great collapse of the lungs, and the motions which I noticed in them seemed to me less dependent on a distinct expansive power in the lungs themselves, than much rather on elevation and de- pression of the collapsed lungs in the laborious inspiration and expiration of animals, as will be described in accidents of the lungs. [(1) To these symptoms Astley Cooper adds "considerable irritation and tick- ling in the larynx." (p. 230). (2) In endeavouring to determine the course which balls take when wounding the chest, Hennen's observation must not be forgotten, that "a ball striking the body or a limb will run round under the skin, and appear to penetrate right across the member or the cavity. By the deep-seated course which balls sometimes take, the deception is rendered still greater. Thus I have traced a ball by dissection, passing into the cavity of the thorax, making the circuit of the lungs, penetrating nearly opposite the point of entrance, and giving the appearance of the man having been shot fairly across, while bloody sputa seemed to prove the fact, and in reality rendered the same measures, to a certain extent, as necessary as if the case had been literally as suspected. The bloody sputa, however, were only secondary, and neither so active nor alarming as those which pour at once from the lungs when wounded. There is also another source of deception as to the actual penetration of balls into the cavities or the limbs; this is where they strike against a handkerchief, linen cloth, &c, and are drawn out unperceived in their folds." (p. 368.) In the museum of the Royal College of Surgeons, London, there is a prepara- tion of a most remarkable penetrating wound of the chest which recovered, and which was under the care of Maioen of Strafford, Essex (a), and the late Sir Wil- liam Blizard. In this case the lungs were probably not wounded. Case 1.—T. T., aged thirty-five years, on the evening ofthe 13th of June, 1812, having incautiously taken off the bridle, before disengaging his horse from the harness and chaise, the animal became unruly, and T. T., catching hold ofthe fore- top, attempted to replace the bridle; "whilst thus occupied the horse made a violent plunge, and thrust him by the end of the off-shaft against the projecting part of the chaise-house; at which instant he felt the shaft perforate his side, under the left arm; whereupon he made a violent effort to draw himself back, while the horse kept plunging forward, and he soon felt the end of the shaft pass from under his right arm,"occasioning acute pain. * * * The horse continuing to press forward occasioned on the left°side a second wound, by the front tug-hook under the shaft." A person alarmed by his cries came to him, and drawing back the shaft discovered that its "end, which had confined T. T., had also entered the weather-boarding of the chaise-house, and passed through it, * * * and that he was pierced through the body by the shaft of the chaise, and apparently standing on tiptoe with both arms extended;" and that " the end projected several inches beyond the trunk of the body." The shaft was then gently withdrawn, and when released he respired two or three times, and found no alteration in his breathing; after which he walked up two flights of stairs to bed. Whilst being undressed, for the first time (a) An Account of a case of Recovery after the shaft of a chaise had been forced through the thorax. London, 1821. 4to. 484 REMARKABLE INSTANCES OF felt faint, and soon had extreme difficulty of breathing, feeling as he said, "as if he should be suffocated by the blood trickling on his lungs." He was very speedily bled by a large orifice to the amount of four pounds, when fainting came on, but no stimulants were used, and only a little cold water given. Upon the left side of the chest there were two wounds, the lower by the iron under the shaft, and the upper where the shaft itself entered, immediately under the arm. On the right side was also a wound in nearly the same direction, through which the shaft came out; the latter two wounds, each four inches in extent. The left shoulder and side ofthe chest were slightly emphysematous. He had not thrown up any blood. On the morning of the 15th, as the difficulty of breathing had much increased, with considerable pain, weight and soreness, he was bled to thirty ounces with much relief: and in the evening, as there was fulness ofthe belly and nausea, a castor-oil injection and five grains of calomel were given. On the following day vomiting had come on, and also pain about the region of the diaphragm, in addition to the previous symptoms ; he was therefore bled to eighteen ounces. The vomiting in- creased, and was accompanied with hiccough, but towards evening these were relieved by effervescing mixture. On the 17th the difficulty of breathing being worse, seventeen ounces of blood were taken away, which alleviated the symptoms; and the bowels had been cleared by the calomel, which had been taken nightly. He had no pain in his back, nor any on either side except smarting at the wounds; but he thought from the great pain and tenderness about the breast-bone that it was broken. Next day the breathing being very laborious, he was bled to twenty-twoi ounces; but, though his respiration was relieved, he had still general tenderness in the chest and epigastric region, and therefore a large blister was applied over the front ofthe chest, which benefited him. On the evening of the 20th the breathing had become more difficult, and nineteen ounces of blood were withdrawn. Some threads of flannel were observed deep in the wound under the right arm, but were not disturbed. On the 22d he had less pain and difficulty in breathing than since the accident, but complained of distressing sensations about the chest, which he could not describe. To-day his body linen was for the first time changed, and care- ful examination being made, not the smallest trace of injury couldjse found on the back. This done, it was thought advisable to take away fourteen ounces of blood, which relieved him more than before, not feeling any pain, only a smarting sensa- tion, similar to that he had experienced in the wounds under the arms, on each side of the breast-bone internally, in the direction in which he was convinced that the shaft had passed. A blister was then re-applied, and kept open for some days. From this time he slowly recovered, and at the end of nine weeks the wounds were nearly closed. He lived for five years without inconvenience, except being put out of breath, on making any exertion, sooner than usual, and having the motions of his arms backwards, or raising them upwards, restricted by a feeling of tightness across the chest. After this time he occasionally suffered from considerable difficulty of breathing, irregular pulse, and struggling rather than pulsating action ofthe heart. He did not take much care of himself, and, after a time, became, more seriously ill, and died March 2, 1823, nearly ten years subsequent to the accident. Examination.—The thorax was somewhat distorted, from an angular projection at the union of the upper and middle portions of the sternum, on each side of which was an irregular depression; on the left, and four inches and a half from the middle of the bone, the depression extended forwards three inches, along the intercostal space between the second and third ribs; on the right, at three inches distance, the depression extended backwards two inches between the same ribs. The upper cica- trix, on the left side, was behind the margin of the great pectoral muscle, and the under one an inch below it. The right cicatrix was opposite the intercostal space of the third and fourth ribs. The m. pectoralis minor adhered to a membranous substance occupying the place of the destroyed intercostal muscles, thin, smooth, strong, and transparent, through which the lung could be seen on the left side, but not on the right. The cartilage of the left second rib had been broken, and was only united by ligamentous substance, and the rib itself also fractured, two inches behind, had united with its inner edge turned a little into the chest; the third and fourth cartilages had been fractured, but united by bone. The right third rib had been broken. On opening the chest, the lungs were found strongly adherent, at their back part, to the pleurae. In front, on the left side, the lung adhered to the displaced second rib, and to the membrane between the second and third ribs, the PENETRATING WOUNDS OF THE CHEST. 4S5 adhesions extending to the mediastinum as low as the fifth rib. Another portion 01 lung also adhered between the third and fourth ribs, where probably the tug-iron had entered. On the 'right side, the* lung adhered to the membrane between the ribs, to the extent of an inch and a half around its margin. The pericardium was almost entirely adherent to the heart, but not very firmly. The heart itself was larger than usual, and the cavity and fibres on the right side proportionally greater than on the left. Maiden observes, in regard to this case, and which the examination seems to bear out fully:—"I have no hesitation in declaring my firm belief that the shaft, being small at the top and of a wedge-like form, was forced between the ribs, on the left side, into and through the cavity of the thorax, under (behind) the sternum, and out between the ribs on the right side; not suddenly, but by several distinct move- ments, whence the lungs, large blood-vessels, &c, escaped injury." (p. 32). For the following case I am indebted to my friend Andrews, of the London Hos- pital, under whose care the man was. In this there can be no doubt that the left iung was penetrated. Case 2.—J. T., aged nineteen years, a Prussian sailor, whilst engaged in lower- ing the trysail-mast (a), the rope supporting it gave way, and he was transfixed by its bolt, to the deck. At the time of the accident the mast had been lowered to within about six feet of the deck; the man raised his arms to lay hold of and guide the bolt into its proper place, when at the moment the suspending rope slipped or broke, and the mast dropping perpendicularly, fell on his chest, knocked him down on his back, and the bolt passing through his chest, pinned him to the deck, which it penetrated to the depth of an inch, so that his chest must have been compressed, from before backwards, to a space not exceeding four inches. Some time elapsed before the bolt could be drawn out, and he was then carried to the hospital,— Feb. 25, 1831. On his admission, 10, a.m., the countenance was livid, the breathing excessively distressed; small quantities of frothy blood were occasionally spat up, the pulse intermitting; and for some time after his admission, these symp- toms increased, threatening almost immediate suffocation. The bolt had entered the chest, between the fourth and fifth ribs of the left side, about an inch and a half from the middle of the breast bone, passed obliquely downwards and outwards, and came out between the eleventh and twelfth ribs, four inches from the left side of the spine, but was prevented passing further by the collar, which chipped out a piece of cartilage, leaving the point of the heart with very insecure protection. The fourth rib was broken at its junction with its cartilage, as was also the twelfth, and that side of the chest was flattened. In addition to his hurt, the scalp on the right side was considerably lacerated, extending from the frontal to the lower part of the occipital bone, and exposing a great part of the temporal muscle. The lower jaw was also badly fractured. A pledget oflint was applied over the wound, and fastened with adhesive straps, but nothing more was done, and two hours after his admission the more urgent symp- toms of suffocation had subsided, and he rallied a little. 7 p. m. The pulse had become full and rapid, varying between 100 and 110; the respiration on the left side was inaudible, except at the upper part of the chest; and on the right side it was puerile; twelve ounces of blood were taken from the arm, which slightly relieved him, and a dose of calomel and rhubarb given, which freely purged him. Feb. 26. Has passed a restless night; pulse 110; tongue brown and dry in the middle. In the afternoon thirty leeches were applied to the chest; two grains of calomel ordered every four hours ; milk at his pleasure. In the evening the same number of leeches were again applied; and, the pulse continuing accelerated, towards midnight ten ounces of blood were taken from the arm, which produced syncope, and on his revival the patient thought himself better. Feb. 27. Had passed a quiet but sleepless night; pulse 110. Leeches were applied morning and evening. Feb. 28. He passed a tolerable night, occasionally getting half an hour's sleep. The pulse continued rapid but weak. On applying the ear to the chest, the pulsa- (a) The try-sail mast, about thirty-five feet long, and two feet in circumference at the bottom has at this part an iron bolt five and a half inches long, and two and a half wide, by which it fits into the boom, with a collar above to prevent it entering fuithcr. 486 REMARKABLE INSTANCES OF tions of the heart were found violent, much more than indicated by the pulse. Thirty leeches were therefore ordered to the region of the heart. In the afternoon his bowels were copiously relieved. As towards evening he became restless, and dreaded a long night, fifty minims of laudanum were given at bed-time, which threw him into a profound sleep that lasted four hours. March 1. Was not so well this morning; and the pulse being quick and fuller, the leeches were repeated on the chest, and fifteen ounces of blood, which was highly buffed and cupped, were taken from the arm; these rendered him faint, but somewhat relieved him. At midnight, the pulse continuing rapid, twelve ounces of blood were taken away, and a draught containing forty minims of laudanum and thirty of tincture of digitalis were given- March 2. Has passed a good night, and had some refreshing sleep; pulse less frequent; tongue white, but the mouth not affected by the calomel. The leeches were repeated, the calomel ordered every six hours, with half a grain of opium at each dose. [The notes do not state, but probably the calomel had run off by the bowels, and therefore had not affected the mouth; to check the purging, I presume, the opium was added.—j. f. s.] The leeches were repeated in the evening, and the anodyne draught at bed-time. March 3. Has had a good night and five hours' sleep; pulse continued quick; the wound was dressed, and the leeches applied to the chest, and repeated in the eve- ning ; forty drops of laudanum were given at bed-time. March 4. Has passed a good night; thinks himself better, and that he shall get better if undisturbed. The leeches repeated; the calomel only to be taken twice a day. In the evening his pulse 132; tongue dry and brown. Leeches repeated, and also the night draught. March 5. Has had a better night than he expected ; pulse 120; he complains of soreness of his gums and mouth ; wounds in the chest rapidly granulating. Leeches repeated. March 6. Mouth very sore, especially near the fracture; pulse 134, very weak; tongue moist and less coated. The scalp wound was first dressed, and found to be united throughout; the wound in the chest going on well. The calomel and the anodyne draught continued. March 1. Has slept well; pulse 120, and fuller; the respiration continues inau- dible at the lower part of the left lung, with dulness on percussion; the mouth being less sore the ealomel was ordered four times a-day; the leeches repeated, and anodyne draught continued'. On the following evening he was ordered arrow-root and biscuit powder. March 9. Better; calomel thrice a day; on the following day only three grains were given, and only twenty-five minims of laudanum given at night. March 12. Has passed a very good night; says he feels quite well, and is astonished so many inquiries are made about his health. A grain of calomel twice a-day ; the anodyne at night. Milk, arrow-root, and biscuit powder, as he pleases. From this time be continued improving-, till March 23. When he had a slight rigor; the pulse became very rapid, varying from 140 to 150; tongue dry, and excessive thirst; is very restless, and apprehensive that all is not right; the bowels have not been relieved for two days. Sixteen ounces of blood were taken away, which was rather buffy; a cathartic injection immediately, and a cathartic draught ordered every three hours till the bowels are moved. March 24. Has slept but little ; tongue dry; pulse very quick and weak. Thirty leeches applied to the chest; saline mixture and two grains of calomel every three hours ordered. He was rather better in the evening. Sixteen leeches to the chest. March 25. His mouth being slightly affected, the calomel was ordered only every six hours, and twelve leeches to the chest. Feels himself better; pulse 118. March 26. Says he feels quite well again; pulse above 100. This morning for tbe first time complains of a cough accompanied with tickling in the throat. Twelve leeches to the chest. Two grains of calomel thrice a-day; and next day, he com- plaining of soreness ofthe mouth, it was ordered only night and morning. March 28. Says he feels quite heafty again: cough is troublesome; respiration returning in the left lung; very feeble just below the wound on the front of the chest with slight rhoncus mucosus. Blanc-manger and a little coffee twice a-day. PENETRATING WOUNDS OF THE CHEST. 4S7 April 2. Since the last report has been going on as well, except that his bowels have been disposed to costiveness, and it has been therefore necessary to give sulphate of magnesia in peppermint water every three or four hours, and a purging clyster. Complains of his cough becoming more troublesome. April 4. Has been going back for the last day or two. The cough harasses him very much, and prevents him sleeping: pulse rapid and very weak. The wound in his chest looking well, but a sinus about three inches long passes obliquely outwards between the ribs and skin, which, being laid open, exposed a small portion of the cartilage ofthe fourth rib. April 8. Much the same: cough as troublesome: gets but little sleep: pulse 120, feeble. He takes syrup of poppies and squill vinegar three or four times a-day, when the cough is urgent. To continue the blanc-manger, milk and broth as he pleases, and have one egg every morning. April 9. Has had a better night and less cough. April 12. Going on satisfactorily; says he feels quite himself again; sleeps well; appetite good; pulse about 90. April 22. Continues improving daily : respiration more audible, except at the lower part of the left lung; pulse perfectly quiet; sleeps well. Allowed table-beer and half a chicken daily. After this time nothing of consequence happened ; and on the 30th of May he was convalescent. The quantity of blood spat up in this case, did not exceed that commonly coughed up in broken ribs. The discharge of pus from the wounds till they had healed was very trifling. The pulsation of the heart was very violent, and distinctly raising the bed-clothes. He recovered his health perfectly; first went into service as a footman, but returned to the sea, and was twice shipwrecked, and saved his life by swimming a considerable distance. In 1841 he was well, and went a voyage to the West Indies. Astley Cooper mentions the case of "a man who had been wounded through the intercostal muscles with an iron spindle; the wound healed, but tetanus super- vened, of which he died. Upon inspecting the chest after death, the lung was found to have assisted in closing the wound by adhering to the injured pleura." (p. 230.) Opportunities of examining the condition of the wounded lungs after their cure are of rare occurrence. Hennen says he has "never had the opportunity of exa- mining the lungs after recovery from a severe wound." (p. 386.) An account of such a case has, however, been given by Everard Home (a,) thirty-two years after the injury had been received. "In searching for the course of the ball, the spot where it entered the lungs of the left side was very readily dis- covered by the remains of a small cicatrix, the membrane at that part being thinner than common, and having a puckered appearance which terminated in a central point. This part of the lungs had not the slightest adhesion to the pleura, but was in its natural detached state. The course of the ball through the substance of the lungs was readily traced by dissection, for an induration ofthe substance ofthe lungs was formed wherever it had passed ; this was best seen by making transverse sections of this thickened part. The appearance ofthe lungs in the right side was ofthe same kind, but in a less degree. The course of the ball was nearly through the upper lobe of both lungs, at nearly the distance of two inches and a-half from the highest part of them where it entered the left lungs. The portion of lungs above the ball did not contain air, but the cells were filled with serum, so that it was more dense than natural, and sunk in water; but this part was not in any degree shrunk or con- tracted. It had no communication with the branches of the bronchia, the adhesive inflammation consequent to the wound having consolidated all the parts above the line through which it passed." (pp. 171, 72.) Upon this subject see also Bkemond; in the Memoires de l'Academie des Sciences, an 1739. Norris; in the Memoirs ofthe Royal Society of London, vol. iv. Richters, Chirurgische Bibliothek, vol. iv. p. 695. (a) The case of a person who was shot through the lungs and survived for thirty-two years; with an account of the appearance of the contents of the thorax after death; in Trans, of a Society for the improvement of Medical and Chirurgical Knowledge, vol. ii. London, 1300. 489 TREATMENT OF PENETRATING Abernethy's Surgical Works., vol. ii. p. 178. Williams, On the Effect of Air penetrating the Cavities ofthe Chest in Wounds ofthe Thorax; in London Medical and Physical Journal, June, 1823. [Finley, On the Effects of Atmospheric Air on exposed Cavities, in North American Med. and Surg. Journ. vol. iii. Philadelphia, 1827.— g. w. N.] Reybard, above cited. [480* In regard to the prognosis of wounds of the chest, Hennen ob- serves :—" I should be unwilling to lull either a patient or a surgeon into a false security, or to underrate the teal danger of any case ; but I have seen so many wounds of the thorax, both from pike and sabre thrusts, and from gun-shot, do well ultimately, that I cannot but hold out great hopes, where the third day has been safely got over, for though occa- sional heemoptysis may come on, at almost any period during a case, and its approach can neither be entirely prevented nor anticipated, the more deadly hemorrhages are usually within the first forty-eight hours; and yet to this alarming symptom, when within moderate bounds, the safety of the sufferer is often due. Dr. Gregory of Edinburgh was in the habit of stating in his lectures, that of twenty-six wounds ofthe thorax received at the battle near Quebec two only were fatal." (pp. 386, 87.)] 481. Penetrating wounds of the chest are most conveniently treated under the following conditions :—1. Simple penetrating wounds; 2. Wounds complicated with the presence of foreign bodies; 3. Penetrating wounds with bleeding; 4. Penetrating wounds with protrusion of part of the lungs. 482. Simple penetrating Wounds of the Chest, or those in which the cavity of the pleura merely is opened, are rare. Their treatment consists in the speedy closing ofthe wound, and in the prevention of inflamma- tion. The patient, after a deep inspiration, should expire, and then the wound is to be carefully closed with sticking plaster, covered with a compress, and fastened with a broad chest-bandage and a shoulder- bandage. The patient is to be treated on a strictly antiphlogistic plan. If the inflammation be prevented, the wound heals quickly. If inflam- mation come on and be long-continued, consecutive extravasation from exudation of the pleura is frequently produced after a lapse of fourteen days, and renders the opening of the cavity ofthe chest necessary. 483. Foreign Bodies, which complicate penetrating wounds of the chest, are either broken pieces of the injuring instrument, balls, pieces of clothes, driven into the wound, or splinters of the ribs. If the state of the injury do npt itself point out the presence of foreign bodies, the symptoms by which it can be inferred are very equivocal. They excite constant irritation, difficult respiration, pain at the wounded part, even though the most severe antiphlogistic treatment has been long-continued ; or although the symptoms had diminished, a fresh accession, copious suppuration, and so on, may occur. The circumstances ofthe accident must be carefully reviewed, in order to determine on the presence and position of the foreign body, which is often most decidedly possible by the introduction of an elastic or metallic sound, for the purpose, either by suitable enlargement, or by a fresh opening in the interspace of the ribs corresponding to its position, when it can be done, to extract it. The longer suppuration is kept up by a foreign body in the cavity of WOUNDS OF THE CHEST. 489 the chest, so much more difficult is its extraction, because the interspace is much diminished by the falling together ofthe ribs. Larrey '(a) has in one such case cut out the upper edge of the lower rib with the lenti- cular, as deeply as needful, for the purpose of extracting the ball, and did not wound the intercostal artery. Bullets may penetrate the chest, run round the lungs, and pass out nearly oppo- site their point of entrance (1). Instances have occurred in which bullets have lain in the cavity of the chest for a long while, without producing inconvenience; in such cases they have been enclosed in a covering of coagulable lymph, as in a capsule (2). (1) See Hennen's Observations on this point (par. 480, note 2). (2) In one case the ball remained in the substance of the lung for twenty years, the patient continuing in good health, and no symptoms occurring to indicate its position. In another, the ball rolled about in the cavity on every motion of the body (6).] 484. In penetrating wounds ofthe chest bleeding may occur from the arteria intercostolis, ihe arteria mammaria interna, from the lungs, or from the great vessels of the chest. In large and direct wounds the blood flows out freely ; if the wound be narrow, if it form a long, and, perhaps, curved canal, the blood empties itself into some one space internally, and the quantity poured out is relative to the size of the w^ounded vessel, and the space in which the effusion has taken place. 485. Under such collection of blood in the cavity of the chest the face is pale, the pulse small and quick, the countenance shrinks, there is singing in the ears, cold sweats over the whole body, exceedingly difficult breathing, danger of suffocation ; that side ofthe chest in which is the extravasation is more full and moves less during respiration ; the patient breathes best on his back, with the upper part of his body raised; suffocation threatens if he lie on the sound side. As the extravasation increases, the symptoms become more severe, and the patient dies suffo- cated. 486. The symptoms of extravasation of blood in the chest are very different and often very equivocal. If the extravasation be slight, or if it have been slow in its production; if the lung be adherent with the pleura to a great extent; if the individual be less sensible on account of the loss of blood ; if previous disease of the chest exist; if spas- modic symptoms accompany the injury, then the diagnosis is extremely difficult. 487. The most certain and determinate signs of extravasation of blood in the chest are, the continued symptoms of an internal bleeding, diffi- cult, quick and short breathing, with spitting of blood in wounds of the lungs,'in which inspiration becomes easier and expiration more difficult, and in sleep threatens suffocation ; constant anxiety in a greater or less degree; difficulty or utter incapability of lying on the sound side ; a dull sound on percussion of the chest, increasing with the increase of extra- vasation; the respiratory murmur accompanied with a gurgling murmur, and in a severe case of extravasation subsiding entirely, or perceptible only at the upper part ofthe chest; a tolerable condition when lying on the'back with the chest much raised; irregular action of the heart and pulse; loss of sleep ; pale, sparing, and even suppressed urine. (a) Memoires de Chirurgie Militaire, vol. iv. p. 250. (b) Manqetus, Bibliotheca Chirurgica. Geneva, 1721, folio. 490 TREATMENT OF PENETRATING The less certain and constant symptoms are, increased expansion of the wounded side of the chest, by which the ribs are separated from each other, and their mobility interfered with; oedematous swelling of the chest (in some parts at least the muscles appear more full); in the greater extent over which the pulsation of the heart can be felt, and its displacement to the opposite side by the pressure of the fluid; a sensa- tion of weight on the chest, or an audible squash on the patient's motions ; a swelling beneath the short ribs and in the region of the belly, from depression of the diaphragm; ecchymosis on the short ribs of the injured side, first occurring some days after the accident; cedema of the hand and foot, and redness ofthe cheek upon the injured side. 488. The existence of extravasation may be distinguished with cer- tainty when the symptoms described, (par. 487,) or if not all, yet the most part of them appear together, continue, and increase ; if they be unaccompanied with any other organic affection, and do not yield to general treatment in the first twenty-four hours. 489. The blood extravasated into the cavity of the chest operates not only as a mechanical hinderance to respiration by compression of the lungs, so that they gradually lose their cellular character, and unite with the pleura; whence it happens that, after long-continued extravasation, its discharge is of no use, the lung being no more capable of expanding itself; inflammation ofthe surface, with which it is in contact, also soon takes place, as the blood operates fatally by its decomposition, though it often continues long in its naturally fluid state. The bleeding must therefore be stanched, the further extravasation be prevented, and the effusion into the chest removed. ["In incised or punctured wounds, haemorrhage takes place," observes Hennen, " instantaneously, and profusely; in gun-shot wounds, if the intercostal artery or lungs are only brushed, or some of the more minute vessels opened, it is not so violent; and we have rather to prepare for what may occur on the separation of the eschars, than to combat any existing symptoms, the general tendency to pneumonic inflammation excepted. In the event of secondary bleeding from the lungs them- selves, we are in possession of no external means for remedying it; but whenever the tenaculum can be used to an injured intercostal artery, it should at once be ap- plied, and the vessel secured by ligature. Unfortunately, however, we but too often are disappointed in finding the source of the haemorrhage; and here judicious pressure is our only resource. In some slight injuries I have used the graduated compress with success; but if the sloughing is extensive, nothing but the finger of an assistant, relieved as often as occasion may require, and pressing direct upon a com- press placed along the course of the vessel, or so disposed as to operate upon its bleeding orifice, will be of any avail." (p. 375.)] 490. It is very difficult in most cases, in many quite impossible, to determine the origin ofthe bleeding in penetrating wounds of the chest. 491. Injury of the Intercostal Artery may be presumed when the wounded person does not spit blood, and when the symptoms of extra- vasation are urgent. If the wound be large, bright-red but not frothy, blood spirts from the wound in an unbroken stream ; if the finger be put on the point where the artery is wounded, its spirting may be felt. The wound is directed towards the lower edge ofthe rib. The insertion of a gutter-shaped curved piece of card-board, recommended by Richter and others, is useless. The finger alone can distinguish the bleeding ves- sel, if the blood pour into the cavity of the chest, in which case, in expiration or in coughing, it always flows from the wound in a full stream. In the symptoms WOUNDS OF THE CHEST. ( 491 already given, it must not, however, be overlooked, that they refer to injury of the intercostal artery alone, but that ordinarily injury of the lung happens at the same time. This objection applies also to the canula proposed by Reybard (a), provided at its front end with a lateral aperture to be held against the wounded vessel, and at its hind end connected with a bladder. [An interesting example of a fatal gun-shot wound of the intercostal artery is given by Graefe (6), which was the cause of considerable dispute on account ofthe shot not having been found in the neighbourhood of the wound :— A young man, aged fifteen years, received a discharge of small shot in the chest and belly at the distance of about forty-eight paces. He instantly fell, but soon afterwards got up and ran for about six hundred paces when he again fell exhausted. About an hour afterwards he was discovered and taken home. On examining his person, the following external injuries were observed :—1, a small round wound of the form of a middle-sized shot on the right side of the chest near the sternum and the interspace between the first and second ribs; from this wound a quantity of florid blood continued to issue: 2, a wound of about the same size and shape, on the right side of the belly, between the navel and ribs. This wound appeared to be superficial: no blood issued from it: 3, a slight contusion of a circular form on the left side of the belly not far from the navel. He died thirty-eight hours after the receipt of the wound. On examining the body and tracing the wound in the chest, the substance of the m. pectora/is major, through which the shot had passed, was found filled with thick black blood ; a quantity of the same kind of blood continued to escape from the chest through the orifice during the inspection. On laying open the cavity the quantity extravasated amounted to twenty-eight ounces, the greatest quantity being in the right side. The right lung was collapsed, occupying only about one-fourth of its cavity. There was an opening on its anterior surface at the upper part, corresponding to the external wound. From this a canal was traceable for about an inch and a quarter into the substance of the right lung backwards; it then passed towards the surface of (he organ for about an inch and a half, and ter- minated in a cul de sac. At the inferior margin of the sixth rib, and at about two inches from its head posteriorly and internally, a lacerated opening of about an inch in depth was discovered. On carefully dissecting this part, the sixth inter- costal artery was found torn through, and the muscular structures around filled with blood. No foreign body was here discovered by which the wound might have been caused, nor was there any communication externally and posteriorly, by which such a body might have passed out. The abdominal wound was about the size of a pea; it had penetrated the abdominal cavity, but the viscera were uninjured. No shot could be discovered to account for this wound. The Medical College to which the dispute was referred, after giving a review of the case, decided that "the only wound penetrating the cavity of the chest being that already described as situated anteriorly between the first and second ribs, through this opening the shot must have entered, which produced the deep-seated laceration. From the examination of this wound during life and after death, it is clear that the canal which the shot had formed did not pass horizontally backwards, but in a direction from above downwards. Under these circumstances, the part at which the shot would strike posteriorly would be between the sixth and seventh ribs. The circumstance of no shot having been found in the neighbourhood ofthe wound, is no obstacle to the admission of this opinion of its origin; since it is well known that large musket-bullets are often deflected from their course by a slight resistance, and lie concealed in parts remote from the wound. If this be observed with regard to such large masses of lead, a fortiori it would take place with small shot.] 492. We are rich in remedies proposed for stanching bleeding from the intercostal artery, but equally poor as to the facts which determine their fitness and applicability. To these belong the tying round of the rib according to Gerard (c), Goulard (d), and Leber (e); the tying (a) Above cited, plate iii. fig. 3. gie, par De la Faye, Paris, 1771, p. 341. (b) In Henke's Zeitschrift fur die Staats- (d) Memoires de l'Academie des Sciences, nrzneikunde, 1836, and British and Foreign an. 1740. Medical Review, vol. iii. p 536. 1837. (e) Plenck, Sammlung von Beobachtungen (c) Dionis, Cours d'Operations de Chirur- vol. ii. p. 2]0. 492 TREATMENT OF PENETRATING the artery (without the rib) by means of an armed needle, jointed at its fore part, after the manner of Reybard and NeVermann (a) ; its imme- diate ligature proposed by Ben. Bell (o); the compression of Lottery (c), Quesnay (d), Belloq, (e), and Harder (/); the compressors of Desault and Sabatier (g), by means of a square piece of linen, of which the middle is so deeply thrust into the wound and fitted with charpie, that if the ends be pulled the middle is pressed as a plug against the artery; or by a proper thick plug, furnished with a strong thread, passed through the wound, and, by means of the thread brought to the rib. According to Medin the wounded vessel should be completely cut through with a myrtle leaf, pushed back, and a tent pressed upon it. Assalini proposes cutting the artery through, and allowing it to retract; to close the wound carefully, and subsequently to discharge the existing extravasation. Grossheim (h) recommends von Arendt's aneurismal needle. My observations to the contrary are in the Heidelberger klinischen Annalen (i). Nevermann (k), after enlarging the wound to the intercostal muscles, divides the latter together with the pleura, a little from the lower edge ofthe upper rib for some lines, and introduces a staphyioraphic needle armed with a thread flat into the chest upwards, so that the point of the needle is some lines above the rib; the needle is then drawn round, so that the point readily turns forwards to the incision, and passed with it close to the bone, and specially on its under edge; he then pulls the thread out of the needle's eye, withdraws the needle, and ties together the inter- costal artery, vein, and nerve. 493. To employ the greater number of the plans of treatment recom- mended and above described, for stanching bleeding of the intercostal artery, a large wound is always needed, and if the wound be not large, it must be increased. They are generally to be considered as exceed- ingly dangerous proceedings, the result of which is always uncertain. If the uncertainty be remembered, in which the Surgeon generally finds himself as to the source of the bleeding, and that in simultaneous injury of the lungs, the bleeding from those organs is increased by the employ- ment of most of these remedies, the application of immediate ligature or of compression must not be unconditionally recommended. Injury of the intercostal artery, near the breast-bone or in the middle of the ribs, where most wounds of the chest occur, does not always produce severe bleeding, as foreign and home practice proves (1). The injury of the intercostal artery, near its origin, always indeed causes very dan- gerous bleeding; but in this case also, on account of the depth of the artery, and also the knowledge of the source of the bleeding, is the ap- plication of the preceding means difficult and indeed impossible (m). (a) Above cited, p. 141, plate iii. fig. 2. ungen zu stillen in Berliner Med. Central- (6) System of Surgery, 3d Edit. Edin- zeitung, 6 Aug., 1836. burgh, 1787. (I) Ravaton, Pratique Moderne de la Chi- (c) Memoires de l'Academie de Chirurgie, rurgie. Paris, 1785, vol. ii. p. 130. Spiess, vol. ii. above cited. (d) Dissertatio de Hcemorrhagia Arteriae (m) Chelius, Ueber die Verletzung der intercostalis sistenda. Berol., 1823. Art intercostalis in gerichtlich medicinischer (e) Medicine Operatoire, vol. i. p. 179. Hinsicht; in Heidelberger klinisch Annalen, (/) Neue Bemerkung-en und Erfahrungen vol. i. part iv., also vol. iii. part ii., and in Berhn, 1781, vol. i. p. 59. Spiess, above cited. See also Vox Graefe, (g) Manuale de Chirurgia. Milano, 1812. Bericht uberdaskliniscbe chirurgisch-augen- (h) In von Graefe und Walther's Jour- arztliche Institut der Universitiit zu Berlin nal. fur das Jahr 1826. Berlin, 1827. And in (i) Vol. iii. part ii. Journal fiir Chirurgie und Augenheilkunde, (k) Ueber das beste Verfahren, eine Hie- vol. x. p. 369. morrhagie der Art intercostalis nach Verwund. WOUNDS. 493 It is most suitable, therefore, in bleeding from the intercostal artery, to employ only such treatment as is pursued when the bleeding is from a vessel of the lungs, and to hope that by closing of the wound, by strict antiphlogistic treatment, by cold applications to the. chest, by the pressure of the blood retained in the cavity of the chest, the wounded artery will become closed with a clot, after which the extravasation may be discharged in the usual way. Only in large, open wounds is the immediate ligature of the intercostal artery possible. If the pleura be not wounded at the same time with the intercostal artery, it may be at- tempted to stanch the bleeding by filling the wound with charpie. ' 494. Wounds of the internal Mammary Artery must be distinguished on anatomical principles and by examination, as in wounded intercostal artery. Between the fifth, sixth, and seventh ribs it must be nearly always accompanied with a division of the rib-cartilage; and it maybe wounded without effusion of blood into the cavity ofthe pleura. What has been said in reference to stanching bleeding from the inter- costal, in part, also, applies to that from the mammary artery. It may, perhaps, be taken up on the second, third, and fourth intercostal spaces. As to the other modes of treatment, only compression, by means of folds of linen filled with charpie, and the remedies advised for stanching bleeding from the lungs are to be employed. 495. When the large vessels in the cavity of the Chest are wounded, the person dies quickly; only when the wound is small can he live for a little time. If no very large vessel be wounded, the symptoms vary. If the lungs be wounded at a part where they are connected with the pleura, there will not be any effusion into the cavity of the pleura, and that space only made by the wounding instrument into the lungs will be filled with blood; it flows out, if the external wound be sufficiently large, or filters into the cells of the lung itself. But if the lung be wounded at an unattached part, the blood will flow into the cavity of the pleura, and the symptoms already described will be produced. 496. The stanching of bleeding from wounded lungs can only be effected indirectly. 1. The power of the circulation must be so reduced by the most strict antiphlogistic treatment, by large repeated bleedings, that by the greatest quietude of the patient, by continued use of cold application to the chest, and cooling medicines, a plug may be formed in the opening of the vessel, which, under the weakened circulation, cannot be thrust out by the force of the moving blood, and consequently the wounded vessel is obliterated. The bleeding must therefore be so often repeated as the pulse begins to rise and to threaten, by the increased motion of the blood, the thrusting out of the just formed clot. 2. The blood must be retained in the cavity of the chest, partly for the purpose of assisting the formation of the plug, partly to prevent its early throwing off. The wound must be, therefore, as already said, Well closed with sticking plaster. If under this treatment the bleeding stop, of which we become aware by the cessation of the primary symp- toms, by the return of the natural warmth, and so on, and the symptoms of extravasation still continue, then, after two or three days, we must proceed to open the cavity of the chest. Only when there is manifest Vol. i.—42 494 TREATMENT OF PENETRATING WOUNDS. danger of suffocation is this to be done earlier; in which case, however, a repetition of the bleeding is always so much earlier to be feared. The union of penetrating wounds of the chest, recommended on the grounds just mentioned, is objected to by Vering (a), for the following reasons :—" 1. In most penetrating wounds of the chest, injury of the thoracic viscera also exists, and if primary bleeding do not at once take place, most commonly, in injury ofthe lungs, consecutive extravasation occurs. 2. The signs of a penetrating wound are ex- tremely doubtful, and equally so are those of extravasation; they may be so com- plicated with the constitution of the patient, with organic disease of the chest, with nervous causes, with supervening inflammation, and so on, as to render the most acute practitioner doubtful. Such stabs of the chest only are, therefore, to be con- sidered simple wounds, in which the most careful examination does not prove pene- tration. In all vertical and oblique wounds, however, in which the examination gives no certain grounds, or when the wound has certainly penetrated; further, in those wounds where local examination has not proved penetration, but when, either immediately or some hours after the injury, only some symptoms of extrava- sation or of internal injury begin to appear, the wound is to be enlarged not only to its very bottom, but, if it penetrate, also through the pleura. A correct knowledge of the direction of the wound is thereby obtained, air and blood can freely escape, all infiltration is prevented, all the symptoms may be attacked as they arise, and if there be no internal injury nor extravasation, the wound may be closed. But wounds in the neighbourhood of the spine or sternum must be treated as simple wounds, and, if symptoms of extravasation come on, an opening into the chest must at once be made in the usual place." To this mode of treatment it may be objected, that the closure of the wound is, in many cases, the only mode of stanching bleeding from the lungs; that in many cases of penetrating wounds of the chest, even with injury of the lungs, a cure without extravasation follows, or the effused blood is absorbed, of which experience refers to many cases; that consecutive extravasation certainly occurs earlier when the wound is enlarged, because the inflammation of the lungs and pleura is thereby rendered more severe. It is, therefore, generally more advisable to close the wound, and only to have recourse to its enlargement if it be not too high on the chest, pretty nearly midway between the spine and the breast-bone, and tbe medical attendant must be guided by the symptoms of extravasation as to opening the cavity of the chest. The enlargement of the wound is to be made either upon the finger or on the director, and always in such direction that the lower edge of the rib be avoided, and the cut have a conical form towards the pleura. The further treatment is the same as that already stated in reference to opening the cavity of the chest. These reasons are also opposed to Reybard's (b) recommendation of introducing into the chest a canula with a bladder, around which the wound is to be closed with sticking plaster; and in this way both the air collected in the cavity of the chest and the extravasated blood are to be discharged. [Astley Cooper says that danger in three ways results from wounds of the lung; first, from haemorrhage; secondly, from inflammation of the lung, and effusion into the cavity of the pleura ; and thirdly, from emphysema. As to their treatment, he states, that In haemorrhage " the patient must be freely bled to prevent the continuance ofthe haemorrhage from the wounded lung, and the opening mustwo^ be closed in the parietes, until all the bleeding from the lungs have ceased, otherwise the blood will remain in the cavity of the chest, and produce irritation and inflammation." (p. 230, 31.) Hennen observes on the same point:—"In whatever part of the thorax a ball, bayonet or sabre strikes, our first object is to diminish the quantity of circulating blood, so vast a proportion of which passes through the contents of the cavity. On this the very existence of our patient depends, and we cannot from reasoning a priori fix any bounds to the quantity to be taken, or determine the intervals at which it is to flow: our practice in both respects must be governed by the effects. * * *. The mode to be instantly adopted in these cases as is follows:—Without searching after balls or fragments of bone, or attempting to ascertain the precise track of the bayonet or pike, or expatiating on the particular vessels or their branches, which may be in- jured, let the man lie quietly along, and lose from thirty to forty ounces of blood (a) Above cited, p. 32. (6) Above cited. EMPHYSEMA. 495 from his arm by a large orifice. This done, we should remove the clothes or hand- kerchief, whicb may have been put hurriedly over the wound to stanch the blood. If he has fainted during the bleeding, or if we find him in that state when we arrive, instead of administering any 'cordials to him, we should put our finger into the wound, and extract every thing within reach, whether cloth, ball, iron, splinters of bone, or clots of blood. If the orifice be not sufficiently large, we must not be afraid of making it moderately larger by the cautious use of a probe-pointed bistoury, or the sharp one with a small morsel of wax on the end of it. By this means we make way for the removal of extraneous bodies, and may possibly dis- cover the bleeding orifice of one of the intercostal arteries, which sometimes are cut, but not at all so often as speculative writers would lead us to believe." If it be a gun-shot, a mild light dressing is sufficient; "but if incised, the lips should be closed at once; and this treatment will be found to afford the most certain preventive to emphysema, future haemorrhage or collections of matter. I scarcely recollect an instance where it was necessary to remove the adhesive straps, or (where it was gun-shot) the usual dressings." The patient is to be left quiet, in a cool place, and often needs no further aid ; "but if the case is very severe, he will possibly lie for some hours in a state of comparative ease, till the vessels again pour forth their con- tents, and induce fresh spitting of bloody froth, and a repetition of all the symp- toms of approaching suffocation. The lancet must again be had recourse to; and, if by this management, repeated as often as circumstances demand, the patient survives the first twelve hours, hopes may begin to be entertained of his recovery from the immediate effects of the haemorrhage. In the after-treatment of a wound of the nature here described, we shall be considerably assisted by the aid of medi- cine, but until the danger of immediate death from haemorrhage is over we must not think of employing any thing, except depletion, by the lancet; it and it only can save the life of the wounded man." (pp. 372, 73.)] 497. Emphysema is that swelling which arises from the escape of air into the cellular tissue. It only rarely occurs in large and direct wounds; more commonly in those of which the external opening is not wide, and which have an oblique direction, as in stabs; and it is very common in broken ribs, when the bony points penetrate the lungs, and in shot- wounds, on account of the great swelling which closes the external opening. 498. Emphysema takes place when the air penetrates through the external wound into the chest, and on account of the outer and inner wound not being parallel, is driven into the cellular tissue ; or in wounds of the lungs when the air is driven through the cells of the lungs into the cavity ofthe pleura, and thence through the wound into the cellular tissue. In the former case the swelling'is not large, and does not spread beyond the circumference of the wound; in the latter the swell- ing is much more extensive and may spread over all parts of the body, the palms ofthe hand and the soles ofthe feet excepted, in consequence of which the patient has a frightful appearance. Emphysema is readily distinguished from all other swellings by the natural colour of the skin covering it, and by its peculiar crackling sensation when touched. ["Emphysema, the third consequence of wounded lungs, is," says Astley Cooper, "less dangerous than the others. It sometimes extends to the face, cover- ing the neck and also a large part of the trunk." (p. 232.) Hennen observes that in military surgery emphysema "does not occur perhaps in one case of fifty, and that, in a oreat proportion of those where it does take place, under judicious treatment it is triflino-. Sometimes, however, it is indeed tremendous in appearance, and most distressing in reality. * * * I have seen a bayonet thrust in the chest, where all distinction of chin, neck, and chest were confounded in one general and unbroken surface • and it has been found that the air has entered the more condensed cellular substance forming the envelopes ofthe different organs, and even into the substance 496 EMPHYSEMA. of the viscera themselves: one proper application of the scalpel would have penetrated it all." (p. 376.) I have seen one case of emphysema, merely from broken ribs, much like that mentioned by Hennen, in which the whole upper part of the chest, the neck, and head were swollen so much, and the features so destroyed, that together they were as formless as, and had a great resemblance to a large loaf which had been soaked in water. A few punctures, however, gradually voided the air, and the patient did well.—j. f. s.] 499. When the air escapes from the lungs into the cavity of the pleura, and there collects, the same symptoms of compression of the lungs are produced as in extravasation of blood. Breathing is disturbed, and becomes extraordinarily difficult; the patient sits up, and bends forwards; the countenance becomes reddened and swollen, the pulse small and contracted ; the extremities cold, and the oppression will quickly destroy the patient. [Hennen relates a very remarkable case of secondary emphysema, in a soldier who was shot by a rifle bullet, which entered a little above and behind the articula- tion of the left clavicle with the scapula, in front of the edge of the m. trapezius, passed apparently across the back, and was cut out forty-eight hours after, below and behind the right acromeon. About ten minutes after blood flowed copiously from the mouth on turning from side to side, and was brought up by hawking or coughing slightly. About the same time also air was discharged from the orifice, and continued to be so whilst the wound remained open. In about five months the wound had healed, several spicula of bone having been discharged during the cure. Some time after, whilst exercising with the dumb-bells, "air was forced from the chest among the soft parts on the left side of the neck and the posterior part of the shoulder, and was easily recognised by the emphysematous crepitus. This spread considerably, became painful on pressure, and his breathing was difficult, and at- tended with great pain on the left side of his chest." An incision it healed. A month after the air re-appeared, and the dyspnoea and pain recurred ; subsequently also severe cough and expectoration of mucus, streaked with blood. When he coughs or shuts the glottis and makes an effort to expire, a sudden eroaking noise is pro- duced, which can be heard at a considerable distance, and on placing the hand at the root of the neck at these times, the soft parts are felt to be suddenly distended, and to communicate a feeling of crepitation, which continues at all times to a greater or less degree in the neighbourhood ofthe wound. This noise, and the accompanying escape of air, can be prevented by pressure with the point ofthe finger in the course of the first ribs, a little above and nearer to the spine than the cicatrix of the original wound." An incision made into the root of the neck discharged only a little air, and did not afford much relief. He sunk, and died hectic. Examination.—The cavity of the chest diminished; the lungs on both sides adhering very firmly to the pleurae; their structure firmer, and their air-cells almost obliterated; the bronchi filled with puriform mucus. " At the upper and posterior part of the left side of the thorax a cavity, between the surfaces of the pleura pulmonalis and costalis, capable of con- taining from ten to twelve cubic inches of air, and thickly lined with coagulable lymph, particularly where the lungs adhered to the parietes of the chest, and con- taining only a small quantity of pus. Two small openings were observable at the upper part ofthe cavity, penetrating through the pleura costalis, between the second and third ribs, and communicating with an abscess, which existed in the upper and back part of the shoulder, immediately beneath the skin, and extending several inches backwards and downwards from the external wound. The second rib had been fractured, much callus had been thrown out for its re-union, and a part of it was bare." (p. 380-83.)] 500. If the emphysema be not very great, merely confined to the neighbourhood ofthe wound, it may be got rid of by the application of dispersing remedies. If it be gieater, and raise the skin from the muscles, deep scarifications must be made in different parts, and the air CONSEQUENT INFLAMMATION OF LUNGS, &C, 497 discharged by squeezing. If suffocation threaten, the wound must be enlarged or a fresh but direct one made into the chest, by which the air passing from the lungs may freely escape. By enlarging the wound, or by opening the chest at another place, merely pressure on the lungs is prevented. Abernethy (a) considers the application of a broad chest- bandage especially advantageous in emphysema, in order to prevent the motions of the chest. The practice of sucking, (pansement a secret,) pumping, and so on (6J, to draw out the air collected in the cavity of the chest, as well as any extravasation, is doubtful and dangerous; for, so long as the wound in the lung is not healed, the air soon again collects, a bleeding scarcely stanched is thereby renewed, and opportunity is given for collapse of the lung; the same also applies to the detachment of the plug. If the air pass out freely from the wound, the pressure upon the lungs and diaphragm can never be very great. The air remaining in the cavity of the chest is soon absorbed. ["In whatever proportion," says Hennen, "the effusion of air (into the chest) may be, the wounded lung is incapable of perfectly performing its functions; did it dilate and contract by the inhalation and expiration of air, it never could heal at all. Fortunately it lies for the most part sunk, and always quiescent; and when the wound in its parenchymatous substance coalesces, it gradually extends so as to fill, as it originally did, the side ofthe chest to which it belongs. Whenever the orifice in the teguments is open, the air has a free passage through it, and continues to be forced out at every attempt at expiration until the process of adhesion has taken place, if not prevented by art. If the lung lies collapsed at the bottom of the thoracic cavity, and that the external wound is healed up before it has resumed its natural inflated state, any small portion of air that may remain there is soon decomposed or absorbed. In many cases, however, where adhesion exists, or has subsequently taken place, between the wounded lung and the thoracic pleura, air in small quan- tities continues to be discharged through the external orifice, (whenever the dressings are removed,) until it is perfectly healed, without any serious inconvenience to the patient." (pp. 377, 78.)] 501. Protrusion of a Portion of the Lung in Wounds of the Chest is rare. It cannot arise, as has been falsely held (c), from expansion of the lungs, but from the air in expiration streaming violently out of the wound, which as it is partially behind the lungs, forces, by its violent escape, the edge of one or other lobe of the lung into the wound. At least in animals I have never seen any other part protruded (d). If the protrusion be recent, the lung healthy, and the condition of the wound permit, it must as quickly as possible be gently returned. In general it is necessary to enlarge the wound for this purpose. To pre- vent its reprotrusion, the wound must be properly closed and covered with a compress, which is to be fastened with a bandage. If the pro- trusion have existed long, if the protruded part be in a state of gangreno from the constriction, a ligature must be put on its base, and the pro- truded gangrenous part cut off in front, or left to itself. [" The sinking of the lung is not," according to Hennen, " a uniform conse- quence of a penetrating wound ofthe thorax. We have sometimes occular proof of this, not only by the close contact in which the lungs lie to the wound, discoverable at first sight, but by protrusions which occasionally happen, and which, in the hands of the older surgeons, were removed by the knife,—a practice now rejected, and gentle pressure substituted." (p. 378.)] (a) Above cited, p. 183. (<0 Richter, Anfangsgriinde, vol. iv. p. (b) Anel l'Artde sucer les Plaies sans se 441.—Mayow, De Respiratione, Lugd. Ba- servir de la Bouche d'un Homme. Amster- tav., 1671, p. j.—Nalliday,. Observations dam 1707 8vo — I-unwic, Progr. de Sue- on Emphysem*. London, 1807. tione Vulnerum Pectoris. Lips., 1708, 8vo. (1Dld- . (b) Neue undsiehcrc Mcthode,.den Bruch Ce) American Journal,1836. No. 35. 604 FRACTURES OF THE COLLAR-BONE. laid backwards on the body (a), or the fore-arm and elbow put in the horizontal position, supported by means of a sling, and the arm fastened by a bandage to the body (b), as well also by connecting the elbows together behind the back. Cruvelhier's apparatus (0 is only a modification of Desault's; the same also is that of Laserre (d); of Flammant (e); and Delpech (/). Earle, H. (g), proposes for fracture of the collar-bone an arm-sling, for the pur- pose of more perfectly fixing the upper end, which is also applicable in fractures of the acromion and neck of the blade-bone. Amesbury (h) gives a modification of Earle's apparatus. Richerand (i) puts the arm in a simple sling, so that the elbow is supported, and the arm kept against the trunk; a simple compress is put in the arm-pit to ab- sorb the perspiration and prevent excoriation. Wattmann (k) puts the hand upon the uninjured shoulder, fastens it with cloths, and puts a ring beneath the point of the elbow. Mayor (I) puts a triangular cloth beneath the under third of the upper- arm around the chest; he then carries the depending triangular corner between the fore-arm and breast, upwards, and the one end over the injured, and the other over the sound shoulder, and fastens them behind on the breast part ofthe cloth. Huberthal's (in) or Fox's (n) apparatus may also be used. Renaud's (o) apparatus for simultaneous fracture of both collar-bones. 640. The apparatus which draw back the shoulders (those of Heis- ter, Brasdor, Evers, Brunninghausen, Wilhelm, and others) have this objection: that they do not preserve the setting, easily produce excoriations of the arm-pit, swelling of the arm, and often unendurable pain, especially if the straps be broad and not roundly padded. Keep- ing in bed is very annoying to many patients. The apparatus of Desault and Boyer is therefore usually considered most preferable in this fracture. In the former a pillow, three and a-half inches thick at the base, gradually thinning, and from five to six inches long, is applied with its base upwards, between the arm and the breast, and confined with a bandage. The elbow is to be brought forwards, upwards and inwards, and retained by a bandage in that position. A moistened compress is to be laid on both sides of the broken collar-bone, and upon the fracture a pasteboard splint, fastened with a bandage, and carried into the sound arm-pit, over the breast, the injured shoulder, upon the back of the arm to the elbow, and thence again to the sound arm^pit, over the back, the injured shoulder and front of the arm be- neath the elbow, over the back to the sound arm-pit, and when these turns have been repeated, the bandage is to be expended in circular turns around the trunk. The fore-arm is to be supported in a sling. (a) Flanjani, Collezione d'Observatione e Rifflessioni di Chirurgia. 4 vols. 8vo. Roma, 1803. (fc) Larrey; in Dictionnaire abr^ge des Sciences Medicales, vol. iv. p. 365. 1821. (c) Medecine pratique eclairee par I'Ana- tomie et la Physiologie pathologiques, cah. i. Paris, 1821. {d) Dissert, sur la Lithotomie, etc. Paris, 1814—Froriep's Chirurg. Kupfert, plate, ccxxvii. (e) Journal Compl. du Dictionn. des Sci- ences Medicales, vol. xxxvi. (,/) Gerdy, Traite des Bandages et Ap- pareils de Pansement. 8vo. et Atlas, 4to. Paris, 1826. (g) Practical Observations on Surgery 8vo. London, 1823. (h) Syllabus of Surgical Lectures on the nature and treatment of Fractures, &c. Lon- don, 1827, p. 66. (i) Histoire des ProgrCs recens de la Chi- rurgie. Paris, 1825. p. 132. (k) Med. Jahrbucher des k. k. Oststaates, vol. vi. p. 2. (I) Gazette Medicale,4835, No. 15. (m) Rust's Magazin, vol. xlix. part 1. (n) [Medical Examiner, vol. i. 1838. Phila. --G. W. N.] (o) Bulletin.des SciencesMedicales, 1811, Nov. FRACTURES OF THE COLLAR-BONE. 605 The apparatus of Boyer effects the same as Desault's, but is prefer- able for its simplicity, its easier application, and that it does not com- press the chest so much. The pad is held up by two bands which are tied upon the sound shoulder,and the arm fastened in a proper position by a body-girdle. But even both these apparatus have great deficien- cies. If they be applied so tightly that the broken ends are kept in close contact, they cannot be endured, on account of the constriction ofthe chest; in women with full bosom, they cannot be applied at all. They also yield easily, must be very often re-applied, and commonly there remains, long after the cure, a decided stiffness of the whole limb. Therefore many surgeons (Dupuytren, Cloquet, Salamon, Xeger) employ a cushion only with bands, put the arm in a sling, and fasten it to the chest with a circular bandage partially around the fore- arm, and some turns over, the injured shoulder. It is considered also that the close union of the fracture of the collar-bone depends less on the apparatus, than on the position and direction of the fracture, (there- fore in spite ofthe most careful application of this apparatus, some de- formity often remains); and, finally, that in children, on account ofthe yielding of the ribs, these apparatus have not any steadiness. The proper support of the arm must therefore be effected by a sling, or by an arm-tray, by which the arm is at once kept properly to the body, as the most simple and fitting treatment, and' so much the more, as it is unaccompanied with inconvenience, and the cure is as good as with many other apparatus. After numerous experiments, I prefer Bre- feld's apparatus before all others, (in which-both shoulders are brought together towards a board provided with a thick covering, placed upon the back, and to which they can be drawn back by padded straps), on account of its simplicity, its easier application, and the little inconveni- ence it causes. Whether by the pasteboard apparatus, in any way applied, (Meyer), any advantage could be gained, is matter of great doubt, after the preceding review ofthe various apparatus. [With Chelius's general observations on the treatment of fractured'collar-bone I fully agree, but I prefer merely bending the arm close to the sidey with a thick pad in the arm-pit to keep the shoulder out and prevent the broken ends ofthe bone riding over each other; the elbow should also be supported and brought a little for- ward by a short sling tied upon the sound shoulder. This sling helps to keep up the outer end of the fracture in its proper place. I do not like any of the apparatus in which the shoulders are drawn back by bandages, as these invariably annoy the patient, often cause excoriation, and never kept long in place, the person continually wriggling them off to relieve himself of the pressure.—J. f. s.] "611. At first the apparatus never should be tightly applied, but sub- sequently it may be made tighter. For the first days after its application the patient should be kept quiet, but afterwards he may go about. It is- however to be observed, that a sitting posture, in which the patient can lie only on the sound side, and leave the other quite free, best prevents the displacement ofthe apparatus and the broken ends ofthe bone, and therefore the patient should sleep in that posture. In five or six weeks the fracture is consolidated. The accompanying symptoms must be treated after the general rules. 642 In Fracture of the Collar-bone between the coracoid p-ocess ana the scapular end there is scarcely any displacement, and therefore the 51* 1506" OF FRACTURE* OF' THE UPPER-ARM. diagnosis is often very difficult. The treatment consists in fastening the arm to the trunk upon a moderate-sized pillow, and getting rid of the bruises. XII.—OF FRACTURE OF THE UPPER-ARM. (Fractura Humeri, Lat.; Bruch des Oberarmbeines, Germ.; Fracture de VHume- rus, Fr.) 643. Fracture of the Upper-Arm is distinguished into that ofthe neck and of the body. 644. The Fracture ofthe Neck ofthe Upper-Arm-bone (Fractura colli humeri) is that which takes place either near the tubercles of the bone, in them or above them, at the properly so-called collum humeri. In the first case, the upper part of the fracture is drawn outwards and upwards by the m. supra-et infraspinatus, whilst the m. latissimus dorsi, pec- toralis major and teres major, draw the lower end inwards: in the second case, there isnot any displacement, because the seat of fracture is equally surrounded with muscles; and in the third case, the lower end is dis- placed inwards. 645. The diagnosis of this fracture is often very difficult, especially if much swelling have taken place. The patient feels, at the moment of the injury, severe pain, often hears a crack, and cannot move his arm. A hollow is noticed beneath the acromion, but the shoulder has still its natural form. The limb may be moved in all directions, although with pain. If one hand be put on the shoulder, and the lower end of the arm- bone be pulled with the other, rotation being made at the same time, crepitation is often felt, and diminished motion of the head of the bone. If the lower end of the bone be inclined inwards, a projection, not rounded, is felt in the arm-pit. This fracture is for the most part consequent on severe violence, which acts immediately on the shoulder; it is therefore commonly ac- companied with severe bruising and much inflammation. It more rarely happens by a fall upon the elbow or hand, wtien. the arm is apart from the body; and is most common in children and old persons, but rare in mid-age. [Fracture of the greater tubercle of the upper-arm-bone sometimes happens, of which there is an example in St. Thomas's Museum; the process appears as if sliced off from the shaft of tbe bone, and remains attached to the tendons of the outward ?otating muscles. Astley Cooper dessribes (a) a fracture "at the junction of the head of the os humeri with the tubercles at the part at which the capsular ligament is fixed, and where, in young people, the epiphysis is placed. In them it is a very frequent oc- currence; it sometimes, though more rarely, happens in the old; in middle age it seldomoccurs;" and he gives the following signs :—" The head of the bone remains in the glenoid cavity of the scapula, so that the shoulder is not sunken as in disloca- tion. A projection of bone is perceived on the coracoid process, and when the elbow is raised and brought forwards, this projection is rendered particularly conspicuous. By drawing down the arm, the projection is removed, but it immediately reappears upon giving up the extension, and the natural contour is lost." (pp. 277, 78.) (m ohi- Inversion of the Foot in Fracture of the rurgischen Klinikum zu Landshut, 1826. neck and upper part of the Thigh-bone; in (b) Annalen des Hamburg Krankenhauses,, Med.-Chir. Trans, vol. xiii. part i. p. 103. vol. ii. p. 286. (/) Case of fractured Femur, with Inver- ts) Wiirtemb. Corrcspondcnzblatt, 1836, sion of the Toes; in Edinburgh Medical and No. 26; Surgical Journal, April, 1826, p. 308. (d) Above cited, p. 320. (g) Gazette Meciicale, vol. iii. Second (?)RQ«.ajiks on the Diagnosis and on the Scries, No. 36, 1835. OF THE THIGH-BONE. 619 patient will incline outwards, the foot previously turned inwards, an effort of the will is required, to make the whole limb perform the necessary half circle on the heel. The difficulty is very remarkable if there be only a slight bending of the limb at the knee-joint. If in a healthy state an effort be necessary for this purpose, how happens it that when the* thigh is broken, especially when the muscles which rotate outwards, ean no longer act? The limb must therefore remain turned in- wards when that is the position given to it. Larrey assumes rotation of the foot inwards in every such inlocking of the broken ends, an opinion which, although confirmed by many observations as those of Delpech, is generally without founda- tion. The diagnosis of fracture of the neck of the thigh-bone is otherwise generally easy; the crepitation which is frequently very obscure, becomes usually so much less so than the other signs of fracture already noticed, and the motions of the limb which are necessary to produce crepitation, endanger greater irritation, and espe- cially in extensive tearing of the fibrous covering of the neck of the thigh-bone. A separation of the head of the thigh-bone from the neck consequent on external violence, when ossification is incomplete, which is possible only in young subjects in which the epiphysis is not yet consolidated to the rest of the bone, is in no re- spect distinguished from the fracture within the capsular ligament (1). [(1) A case of this kind I have at present (Aug. 1845) under my care, in a boy often years of age, who fell out of afirst floor window upon his left hip. The foot was slightly turned out, and scarcely any difference in the length of the two limbs could be observed. The thigh could be readily moved in any direction and without much pain; but on bending the knee and rotating the limb outwards a very distinct dummy sensation was frequently felt, as it seemed within the hip-joint, as if one articular surface Tiad slipped off another, which led me to suppose that the head of the bone had been broken from the neck, through the epiphysis within the capsule. Two days after my colleague Green carefully examined the case with me and agreed in the opinion I had formed of it. The boy himself suffered so little incon- venience that he had two or three times got out of bed and walked about for a short distance. He was put upon a double inclined plane, the presumed nature of the in- jury not seeming to require further treatment.—j. f. s.] 671. Fracture ofthe neck of the thigh-bone is distinguished from se- vere contusion ofthe hip-joint in the length of the limb, in the latter case, being unchanged if put in the same position as the sound one ; in the absence of crepitation and by the usual circular movement of the great trochanter in rotation ofthe limb. It is distinguished from dislocation of the thigh-bone outwards and upwards, and outwards and downwards, by the turning ofthe foot inwards, which always accompanies these disloca- tions, but in this fracture is very rare, and even then less complete than in dislocation; the foot also, when in fracture there is inversion, is more easily, though with pain, drawn outwards and lengthened. It is distin- guished from dislocation upvmrds and inwards, in which the foot is directed outwards, whereby, as especially in dislocations, the limb be- comes very immovable, and it is impossible, without great violence, to restore it to its natural position; the dislocated head can also be felt. [In the examination of thigh-bones, instances have been often met with, in which from the diminution ofthe length of the neck of the thigh-bone, in old persons espe- cially, it has been thought that such had been fractured and were united by bone. In reference to this point, Astley Cooper observes :—"The neck ofthe thigh-bone in old persons is sometimes undergoing an interstitial absorption, by which it be- comes shortened, altered in its angle with the shaft of the bone, and so changed in its form as to give an idea, upon a superficial view, of its having been the subject of fracture, so as to lead persons into the erroneous suppositioa of tbe bone having been partially broken and re-united." (p. 124). Gulliver, however, has shown (a) (a) Cases of Shortening ofthe neck ofthe McdicaJ and Surgical Journal, vol. xlvi. p. Thigh-bone, with remarks; in Edinburgh 97, and p. 31 £ 183G. 620 FRACTURES OF THE NECK OF THE that the same appearances may be observed in younger persons, and he gives several remarkable instances, all of which followed injury to the hip, although at the time the patients were not materially influenced by the blow; but limping and shortening of the limb from shortening of the neck of the bone gradually came on. The most striking examples are the case of the soldier Fox, (p#99), who had fallen down a ship's hold five years prior to his death; and also the case of the soldier Lynn, (p. 315), who met with the accident in the same way, but continued his duty without inconvenience for three years, after which he gradually became lame, and in the course of eighteen months was entirely unfit for service; soon after he was bitten by a poisonous snake and died. In both these instances examination of the parts after death was made, and the neck of the thigh-bone found much shortened, together with spreading of the head.—j. f. s.] 672. The opinions of surgeons on the prognosis in fractures ofthe neck ofthe thigh-bone are very different. Some believe that a greater or less degree of limping is in this accident an irremediable consequence ; others that bony union is impossible; others consider this fracture as differing only from others in the difficulty of its treatment. A. Cooper admits bony union of the fracture external to the capsular ligament, but considers, that in fracture within the capsular ligament, it does not take place with callus, on account ofthe absence of proper apposition and con- nexion of the fractured ends, (wherefore also no continued apposing pres- sure of the two broken surfaces can take place, although the proper length of the foot is preserved), on account of the low degree of vital activity, on account of the want of activity in the head of the thigh-bone to produce bone, and on account of the extension ofthe capsular ligament by the increased quantity of synovial fluid. A. Cooper held bony union possible only in those cases in which the fracture passes through the head ofthe thigh-bone, and the end itself is not completely separated, or the bone is broken without tearing of its periosteum, or of the surround- ing ligament, or when the fracture has an oblique direction and is par- tially within partially without the capsular ligament. A. Cooper has never otherwise seen bony union of the fracture within the capsular liga- ment. These reasons, which had even earlier been advanced, were contradicted by Boyer, and more recently by Earle; experience also has proved that bony union may take place in these cases (a). That this has hitherto in England been little observed may depend on the very careless treatment of fractures known to be within the capsular ligament. The condition of the head of the thigh-bone has nothing to do with it, but rather the difficulty of keeping the fractured ends for a proper time in sufficient contact; frequently, in complete tearing of the fibrous cover- ing of the neck ofthe thigh-bone, or in bad constitution, or old age, of the patient, is the union of the broken ends often protracted or entirely prevented. Sometimes the upper end is enclosed by bony masses grow- ing from the lower end ; and though commonly considerable mobility remains, yet the motions of the limbs are very much interfered with. The broken ends are often connected by a fibrous mass which is not suf- (n) Brunmnghausen, above cited, fig. 2,4. Brulatour, A case of Fracture ofthe neck Liston : in Edinburgh Medical and Sur- of the Femur; in Med.-Chir. Trans, vol. gical Journal, April, 1820, p. 21?. xiii. p. 513. 1825. Langenbeck neue Bibliothek fiir Chirur- Langstaff, G., in Med.-Chir. Trans, vol. gie and Ophthalmologic, vol. iii. p. 121. xiii. pt. ii. p. 487. Begbie; in Edinburgh Med. and Phys. Richter, Handbuch der Lehre von den Jour. Bruchen und Verrenkungen, p. 314. Earlk, above cited. Delpech, J., above cited. THIGH-BONE—UNION. 621 ficiently firm to sustain the weight of the body; the lameness is conside- rable, and the shortening of the limb gradually increases. The broken ends frequently wear away by rubbing against each other; suppuration in the cavity of the joint takes place, and death soon follows. Some- times, if one or other ofthe broken ends be worn by rubbing, and both surfaces become like ivory, a cartilaginous capsule is formed by the thickening ofthe fibrous covering of the neck of the thigh-bone for the reception ofthe lower piece of bone, which is capable of supporting the weight of the body. In v. Soemmering's rich collection there is a preparation of a fracture within the capsular ligament closely united by callus. I possess a similar one, which I had treated in an old woman. The kinds of union just mentioned have been confirmed by Colles' observations on eleven cases (a). Cruvelhier (b) supposes that the callus is produced by ossification of the parts surrounding the broken ends of the periosteum, and of tbe muscles, which at first become cartilaginous and afterwards bony. Hence it follows that tbe broken bone, which on one side only is covered with soft parts, upon that only enjoys a bony union, and that when no soft parts lie around the broken parts of the bone, no union by bony substance takes place. In the former condition are the knee-cap and ole- chranon, in the latter the neck ofthe thigh-bone. [In St. Bartholomew's Museum there are several cases of fractured neck of the thigh-bone within the capsule united by ligament. The two following cases prove beyond ail doubt the possibility of bony union in fracture of the neck of the tbigh-bone, and put an end to the disputes upon this sub- ject which had been long and angrily held by English surgeons. Case 1, was Swan's patient, (c) a woman of eighty years, who having fallen down, he " believed there was fracture of the neck of the thigh-bone, although the limb remained quite as long as the other, and he could neither perceive any crepitus nor any altered appearance in its position, except a slight inclination ofthe toes out- wards." (p. 15.) She died five weeks after the accident; and on examination it ap- peared that " the greatest part of the fracture of the neck of the thigh-bone, which was entirely within the capsular ligament, was firmly united. A section was made through the fractured part, and a faint white line was perceived in one portion of the union, but the rest appeared to be entirely bone." (p. 17). This preparation is in the Museum ofthe Royal College of Surgeons. Case 2, is related by Stanley (d). A young man of eighteen years fell from the top of a cart on his right hip. "He was wholly unable to move the limb, and suffered severe pain when it was moved by another person. The thigh was bent to a right angle with the pelvis, and could not by any means be extended. Abduc- tion of the thigh was difficult. The limb was everted, at first slightly, afterwards in a greater degree. The soft parts around the hip joint were considerably swollen. There was no shortening of the limb, but rather the appearance of a lengthening of it in the erect posture, probably from the obliquity in the position of the pelvis. No crepitus could be felt in any movement of the limb." (p. 256). It was thought from the patient's age not to be a fracture of the neck of the bone; but under the supposition of it being a dislocation into the foramen ovale, the pulleys were applied and forcible extension made. Two months after he was admitted a patient into St. Bartholomew's Hospital, and at the end of the subsequent month he died of small- pox. On examination, "the capsule of the hip-joint was found entire, but a little thickened. The ligamentum teres was uninjured. A line of fracture extended (a) Fractures of the neck of the Femur, Med.-Chir. Trans., vol. xix. 1. London, illustrated by dissections; in Dublin Hospi- 1835. tal Reports, 1818, vol. ii. p. 334. (c) An Essay on Tetanus, &c. London, (b) Anatomie Pathologique, pt. xxiii. pi. 1825. 8vo. j o (d) Case of bony union of a Fracture of ' Bauer in Heidelberger klinischen An- the Neck of the Femur, within the Capsule, nalen vol. iii. pt. i. p. 155.—Howship, J., in occurring in a young: subject; in Med.-Chir. Trans., vol. xviii. 1833. 622 FRACTURES OF THE NECK OF THE obliquely through the neck of the femur, and entirely within the capsule. The neck of the bone was shortened, and its head, in consequence, approximated to the tro- chanter major. The fractured surfaces were in the closest apposition, and finally united nearly in their whole extent by bone. There was an irregular deposition of bone upon the neck of the femur, beneath its synovial and periosteal covering along the line ofthe fracture." (p. 258). This preparation is in the Museum at St. Bartholo- mew's Hospital, where I have had the opportunity of examining it, and in addition to the above account I may add that nearly half of the head of the bone projects free beyond the hind surface of the neck and forms a well-marked inner boundary to the trochanteric pit. In this Museum there is another example of bony union, in which the broken head having dropped, its upper part is driven into the neck, which is less shortened than usual, and the lower third of the head descends free below the neck. In the same Collection there is another preparation in which the heads of both thigh-bones are considered to have been fractured and united by ligament, and there certainly is a distinct and narrow line apparently of ligamentous character which marks the presumed place of fracture in each; but I must confess I have some doubts of these having been fractures, for the appearances so nearly tally in the two that I am inclined rather to think they must be the remains of the epiphysal junc- tion, of which they occupy the precise place.—j. f. s.] 673. Setting a fracture ofthe neck ofthe thigh-bone is easy in so far as extension only of the limb is requisite to restore its natural length; we cannot, however, be thereby satisfied ofthe close contact ofthe two broken ends. Fixing them in close contact till their consolidation, is in no fracture more difficult. 674. The setting is to be performed in the following manner:—One assistant fixes the pelvis, placing his hands on the spinous processes of both hip-bones; another makes extension at the foot, and brings the limb at the same time into its natural position. The surgeon assists the rotation of the limb, and placed on the outside of the thigh, raises the trochanter, in order to lessen its pressure on the fibrous covering of the neck of the thigh-bone, and to press the lower end of the bone against the upper. The arrangement of the bed in fractures of the lower extremities requires parti- cular attention. The bed should not be more than three feet wide, and should not be provided at the foot with a high board. Instead of feather bed a firm mattress should be used ; and for the support of the head a single pillow. Under the patient should be placed a folded sheet for the purpose of carefully raising him in the ne- cessary movements. To the ceiling of the room a rope should be fixed, at the end of which, hanging opposite the patient's chest, across handle should be attached, by which he may take hold. The patient-lifter proposed by Leydig (a) is the most convenient for lifting a patient from one bed to another, or to another place. 675. Fixing the broken ends has been attempted by various bandages and machines, in which, (without employing the earlier practice of fasten- ing the feet to the lower, and the upper part of the body to the upper part of the bed, and the simple contentive apparatus,) either permanent extension is produced by the extended position ofthe limb, or the limb is kept in a half-bent position with or without extension. The simple contentive apparatus, and fastening with the spica coxae (Pare) ; with two chaff pillows on both sides of the limb, fixed with straps (Sabatier) ; by tying both feet together with a pad between the thighs (Guyot) (b) by concave splints of tin, wood, leather, and the like (Farr, Hildanus, La Faye, Arnaud, Duverney, Hedenus, Theoen, Botticher) ; by a pelvis-belt, and bending the thigh on a splint (a) Der Krankenheber, seine Anwendung BrQcheder unteren Gliedrnassen; with two und Vortheill vorzuglich bei Behandlung der copper-plates. Mainz, 1824. 4to. (6) Journal Hebdomad, vol. xiii. p. 30. THIGH BONE—TREATMENT. 623 placed in the ham, and binding the feet together (Bernstein); by enveloping the limb with compresses, and an eighteen-tailed bandage, by straw splints on both sides of the limb, enclosed in a wide napkin, fastening of the outer straw splint with a broad pelvis-girdle, and along the limb with bandages (Larrey) (a), are not suffi- cient in true fractures ofthe neck of the thigh-bone: they can only be employed in cases in which, for the above mentioned reasons, there is but little shortening or in- locking of the upper fractured piece. 676. To the machines for extension ofthe limb in the directly straight position belong— 1. Desault's Apparatus.—The essential point of which is, that after the whole limb has been swathed in Scultetus's bandage, a permanent extension is kept up by means of a splint reaching from the crest ofthe hip-bone to beyond the sole ofthe foot. At the upper end of this splint is fastened a long pad, which is applied on the inner upper side of the thigh, and at the lower end a similar one, which is applied over the ankle. Besides this, a second splint is to be placed on the inner side, and a third on the front of the limb, which last is to descend from the groin to the knee ; between these splints and the limb chaff pillows are to be placed, and the splints fastened with five straps; the outer splint especially, by a girdle running round the pelvis. Van Houte's alteration of Desault's splint is for the purpose of keeping up ex- tension in the long axis of the limb by means of a cross board connected at right angles with the splint (6). Similar to this, except that to the cross board an inner splint is fastened, is Volpe's machine (c). Also Josse's (d) apparatus, with a pecu- liarly arranged bed. Meyer's (e) machine. Physick's (/) apparatus, in which the external splint is continued to the arm-pit; that of Houston (g); also Alban's (h) machine, which consists of a strong splint fixed on the outside of the ailing limb and to the pelvis; the extension is effected by means of a kind of lever contrivance at the lower end of the splint. Gressley's (i) apparatus. 2. Brunniivghausen's Apparatus.—A soft cotton strap is first applied upon a soft pad, over the ankle of the ailing limb, and carried like a stirrup around the sole of the sound foot. To prevent the rotation of the limb outwards, a suitable splint of padded tin or lacquered leather is to be applied on the outside ofthe thigh, and fastened with a padded bandage around the pelvis and knee. Bending of the knee-joint on the sound side is to be prevented by a gutter-like splint, which should ex- tend from the middle ofthe thigh to the middle ofthe leg. 3. Boyer's Machine.—This acts in the same manner as Desault's apparatus, only the extension is kept up in a direction corresponding with the long axis of the limb; by means of a screw the extension may be increased or diminished, and the power of extension distributed over a large part of the leg. Heyne has altered this machine. 4. Hagedorn's Machine consists of a strong wooden splint reaching (a) Journal compl. du Diet, des Sciences Medic., pt. xxx. p. 96; Recueil des Memoires de Chirurgie, Paris, 1821, \>. 271. {b) Aver der breuck van den Hals des Dijebeins. Rotterdam. 1816.—Chirurg. Kupcrtaf., pi. lxxxii. f. 2. (c) Chirurg. Kupertaf., pi lxxxii. f. 4, 5. (d) Repertoire Generate d'Anatomie et de Physiologic Chirurgicales. 2c,Tu(h. 1828.— Frorief's Chirurg. Kupfert., pi. ccxiu. (e) Die droppclte Ausdehnungs-^chienc zur Heilung des Schenkelhalsbruches.— Wurzb. 1826; with one copper-plate. 4to. (/) FROiUEr's Chirurg. Kupfert, ccxiv. f. 10, and Dorsev's Surgery, vol. 1. lg) lb. pi. cccli. f. 1. (A) Langenbeck's neue Bibliothek fiir die Chirurgie und Ophthalmologic, vol. i. p. 262. (i) Memoire sur un nouvel Appareil pour les Fractures du Col du Femur. Paris, 1832. —Velpeau, Examen d'un nouvel Appareil imagine par Gresely. Paris, 1832.— Frorief's Chir. Kupsf.. pi. cexc. 624 FRACTURES OF THE NECK OF THE from the crest ofthe hip-bone to the sole ofthe foot, and furnished with a transverse piece. It is applied on the side of the sound limb, and fastened with padded straps around the pelvis and extremity. The foot ofthe sound and that of the ailing side are both fastened to the cross piece, and thus the injured limb preserves its proper extension. Dzondi's (a) improvement of this machine consists in the splint extending above the crest of the hip-bone to the side of the chest, and the bandages for extending the ailing limb being applied above the ankle and below the knee. Nicolai's machine (b), that of Klein (c), and that of Gibson (d), of Beck (e), Schurmayer (/) and of Weckert (g), are all to be considered as modifications of Hageoorn's machine. 677. Various plans have been attempted to keep the limb in the bent position. 1. By Sauter's (h) Suspensory Machine. The pelvis is thereby fixed ; the tubercle of the haunch-bone is the special point for counter-exten- sion ; the extension is made from the foot with a long pad connected to the foot-board. 2. After the setting of the fracture is completed, both feet are to be bound together, for which purpose a bandage is to be applied spirally, from the instep to the knee ; a firm pillow is then to be put under the knee so as to bend the thigh at the knee and hip-joint, and the spiral turns are to be continued to the upper third ofthe thigh. The upper part of the body should be raised rather high, and inclined forwards (Mursinna.) Or a firm pillow may be put into the ham of the limb, bent at the hip and knee joints, which is to be kept in this position by a folded cloth carried over the lower part of the thigh and leg, and fas- tened on both sides to the bed. (Dupuytren, Richerand.) 3. A. Cooper, in fracture without the capsular ligament, keeps the limb half bent, putting it upon a wooden machine, consisting of two pieces of board fastened together at an angle, and corresponding with the bend of the knee-joint. A long splint, laid upon the outside of the thigh, is to be fastened by straps on the side ofthe great trochanter, and buckled on above the knee, and around the pelvis. In fracture within the capsule, a pillow should be laid beneath the whole length ofthe ailing limb, and a well-rolled pad in the bend ofthe knee-joint, and in this manner the foot kept extended from ten to fourteen days, till the pain and inflammation have passed by. Then the patient should get up daily, and sit on a high stool, in order to diminish the painfulness in bending the limb. After some days he may go on crutches, subsequently with a stick, and in a few months he is generally capable of using his foot, (a) Beitrage zur ervollkommnung der (e) Froriep's Chirurg. Kupfert., pi. 350, Heilkunde, part i. Halle, 1816. 8vo.; with f. 7. plates. (/) Ibid., pi. 350. f. 2-6. (6) Journal fiir Chirurgie und Augen- (g) Ibid., pi. 319. heilkunde von v. Graefe und von Walther, (h) Anweisung die Beinbriiche der Glied- vol. iii. part ii. p. 260. pi. ii. f. 1-9. maassen, vorziiglich die complicirten und (c) Ibid., vol. iv. part i. p. 17 ; pi. i. f. 1-6. den Schenkelhalsbruch, nach einer neuen, (d) Ibid., p. 189. pi. i. f. 7-13, [and Phila., leichten, einfachen, und wohlfeilen Methode Journ. of Med. and Phys. Sciences, vol. 3. ohne Scbienen sicher und bequem zu heilen. 1821.—g. w. N.J Constanz, 1812; with plates. THIGH-BONE—TREATMENT. 625 without any further support. In every doubtful case the treatment should be as if the fracture were without the capsular ligament. 4. Earle has proposed a peculiarly constructed bed for the bent posi- tion, in which, by the weight of the pelvis, counter-extension, and by the attachment ofthe foot to a foot-board, the proper length and position ofthe limb are preserved, and the relief of natural needs made possible, without moving the patient. Hereto belong also the machines of Amesbury (a), Smith (b), Koppenstjedter (c), Hager, and others, in which extension is connected with tbe double inclined plane. 678. Of all these modes of treatment, I consider the use of Hagedorn's machine the best. It is more simple, its operation more certain than that of any other extending machine, and not more troublesome than the double bent position in one or other way, which, excepting the relaxa- tion of certain muscles, has scarcely any advantage, and even renders the limb less secure against motion. Dupuy'tren, however, will have it that by the doubly bent position (par. 677) the results are more satis- factory than by any other treatment; inasmuch as in this posture, by tbe relaxation of the m. adductor femoris, the limb loses the disposition to roll outwards, and that this position is accompanied with less inconve- nience to the patient than in the extending apparatus (d). A. Cooper's practice in fracture within the capsule, leaves the impression that the diagnostic marks which he proposes are not always to be depended on. In old persons also, and with all the signs of internal fracture, a per- fect cure may be effected by Hagedorn's machine, on which point both home and foreign practice agree. A similar contrivance to Earle's bed for preventing motion whilst relieving the bowels may be added to every mattress; it is however unimportant, as it may be advisable to move the patient daily into another bed (e). 679. As in fracture of the neck of the thigh-bone there is always much irritation and contraction of the muscles, if this come on subse- quently, it must be attempted to moderate it by rest and antiphlogistic treatment before the application of the extending machine. If perma- nent extension of any kind be employed, we must always endeavour to keep it up to the same degree; it must only be slackened when the pa- tient complains of pain, and if he cannot bear it another treatment must be resorted to. The patient should keep as quiet as possible during the treatment. The apparatus must not be removed before the sixtieth to the seventieth day, and then the limb should be enveloped in a cir- cular bandage ; the patient must remain some time in bed, and must only be allowed to stand up, and, supported by crutches, to move about very cautiously, when, with the leg straight, he can bend the whole limb at the hip-joint. Dupuytren assigns to length of the cure eighty, one hundred, and even a hundred and twenty days. The weakness and stiffness of the muscles and joint gradually subside ; but volatile infrictions and baths may be ordered. Even in the most satisfactory cases, there commonly remains a little shortening of the ex- (a) Medical Repository, vol. xix. p. 113. und verbesserten Maschine fur alle Arten (b) New York Medical and Physical Beinbrucbe. Augsburg, 1823, p. 29. Journal, Oct. Dec. 1825. p. 174. (d) Above cited. . (c) Beschreibung einer neu crfundenen (e) Dzondi, Lehrbuch der Chirurgie, p. 590. Vol. i—53 626 FRACTURES OF THE THIGH-BONE tremity, which can often be alone observed, on close examination, in the straight posture, but may always be perfectly counterbalanced by a rather thick-soled shoe. 680. When the fracture passes obliquely through the great trochanter, and the proper neck of the thigh-bone does not participate therein, (which fracture may happen at every period of life,) it is characterized by the following appearances:—the extremity is very little and frequently not at all shortened-; it is stiff; the patient is incapable of turning himself in bed without assistance, and the attempt always causes great pain ; the broken part of the trochanter is in many cases drawn forwards to- wards the hip-bone, in others it sinks against the tuber ischii, but is or- dinarily far separated from that part of the great trochanter which remains connected with the neck ; the foot is turned very much outwards, the patient cannot sit, and the attempt always causes severe pain ; crepita- tion is difficult to be discovered, when the trochanter either sinks back- wards or is drawn much forwards. This fracture requires the same treat- ment as that for fractured neck ofthe thigh-bone, and unites firmly. A. Cooper (a) gives a proper bandage, which consists of a broad cloth, enclosing the hips, and sewn together; at the point where it passes under the great trochanter, it is widened with a piece let in, and padded ; behind the great trochanter a wedge- like pad is to be placed, so that when the bandage is sewn the trochanter may be kept in place. At the same time a thick wedge-shaped pillow is to be put under the uper part of the thigh, and the foot fastened in such way that it cannot turn either inwards or outwards. B.—OF THE FRACTURE OF THE THIGH-BONE BELOW THE GREAT TROCHANTER. Pott, P., General Remarks on Fractures and Dislocations; in his Works, vol. i. Edition of 1783. Richter, C. F., De situ femoris crurisque fracti laterali minus apto. Lipsiae. 1788. 8vo. Desault, ffiuvres Chirurgicales, vol. i. p. 219. Bell, C, A System of Operative Surgery founded on the basis of Anatomy. 2 vols. London, 1807-9. 8vo. Sauter, Above cited. 681. This fracture happens either in the upper, middle or lower third of the thigh-bone; but it is most common in the middle. Its cause is either violence acting directly on the thigh, or a fall upon the knee or foot; in the former case it is always accompanied with much bruising, frequently with splintering. The direction of the fracture is in old subjects mostly oblique ; in young persons and children usually trans- verse. 682. The signs, are fixed pain at the seat of fracture, sudden incapa- bility of the patient to move the thigh, unnatural motion in its continuity, deformity of the limb in reference to its length, thickness and natural direction ; distinct crepitation on moving the thigh. The upper fractured end is drawn less upwards and forwards in fracture ofthe upper than in that of the middle third ; the lower end is drawn backwards and upwards at the same time; the lower end is turned out- wards partly by the contraction of the muscles, partly by the proper weight of the limb. If the broken surfaces do not touch, the limb is shortened, especially if the fracture be very oblique. In transverse fractures, specially in young persons, the broken surfaces often remain in actual contact, and the thigh is curved forwards by the contraction (a) Above cited, p. 158. BELOW THE GREAT TROCHANTER. 627 of the muscles. In fractures in the lower third, which are mostly oblique, the lower end is drawn backwards towards the ham and the condyle upwards, in consequence of which the knee assumes a peculiar form, and the point of the upper fractured end may penetrate the m. rectus and through the skin. 683. Fracture of the thigh-bone is always a severe accident, as the broken ends are retained in proper contact with great difficulty. The cure takes place most commonly with deformity and shortening of the limb, especially in oblique fractures, and those which occur in the upper and lower third of the thigh-bone. Compound fractures are so much more difficult to treat. [In simple fractures of the thigh-bone except with great obliquity I have rarely found difficulty in retaining the broken ends in place, and in effecting the union without deformity and with very little and sometimes without any shortening. For the contrary results the medical attendant is mostly to be blamed, as tbey are usually consequent on his carelessness or ignorance. Compound fracture ofthe thigh is a very serious accident; its danger depends upon the injury of the soft parts and extent of the wound, and also upon the obliquity of the fracture and its disposition to drive through the wound or among the muscles. These are points which must be well weighed in deciding whether amputation should be performed or not. If the patient be young and healthy, we may often undertake the cure without amputating, and with a fair prospect of a happy result. —j. f. s.] 684. The difficulty of retaining the broken ends in complete contact till consolidation is effected, has led to various modes of treatment. 1. The Contentive Apparatus, with splints, and the limb in a straight position. The setting is to be effected by extension and counter-exten- sion as in fracture of the neck of the thigh-bone (par. 674). The sur- geon, standing on the outside of the thigh, endeavours with both hands, to bring the broken ends into their proper place, and to equalize all irregularities. The apparatus is to be slipped beneath the limb, kept in a proper degree of extension. It consists of five double bands, a piece of linen, as long as the limb, and sufficiently broad to include the splints on both sides of Scultetus's bandage, of three splints, and their corresponding chaff pads, of which one should extend from the crest of the hip-bone to beyond the sole of the foot; the second from the upper inner part of the thigh, just as far; and the third from the groin to the knee. At the seat of fracture two wetted compresses are to be ap- plied, which should surround three-fourths ofthe thigh; the whole limb is then to be swathed in Scultetus's bandage, from below upwards, and the splints rolled up in the piece of linen on both sides, till they are brought to two to three fingers' breadth from the limb. The interspace is then filled up with the pads, the third splint laid with the chaff pad upon the front of the thigh, and the splints surrounded with the bandages, of which three are to be put on the thigh, and two on the leo-. The foot should be supported in a stirrup (1). This apparatus is°to be wetted from time to time with lead wash, replaced every six days up to the fiftieth, or, in old people, to the sixtieth day (2). If the callus have become sufficiently firm, which is known by the patient beinc able to raise the limb freely, rendering it some support with his hanefs at the fractured part, the apparatus may be removed, the whole limb enveloped in a circular bandage, and the patient allowed to go about carefully with crutches for several days. 628 FRACTURES OF THE THIGH-BONE [(1) In general, I think the straight position in treating fracture of the shaft of the thigh-bone is far preferable to either of the other methods. But the plan 1 em- ploy is rather different from that here advised. I use four splints, flat pieces of deal about one-sixth of an inch thick, and three or four fingers wide, which any carpenter can quickly furnish; the hind one should reach from the tuberosity of the haunch- bone, against and immediately below which it should rest, to within four inches of the sole, so as to be quite free of the heel; the front one should extend from just below the groin, not quite so low as the bend of the ankle-joint, and should have two or three transverse saw-tracks where it rests upon the knee-cap so that it may not press it severely; the inner splint should extend from the perineum, and the outer from the great trochanter to the sole of the foot, and a large hole made in each corresponding to the ankle. All the splints should be thickly padded and have their ends well defended with the pads. A Scultetus's bandage of sufficient length to cover the whole limb and foot having then been laid upon the padded hind splint, the limb is to be gently lifted, and the splint having been put behind it up to the tuberosity of the haunch-bone, the limb is placed upon it, gentle extension made, the bandage and side splints applied, and then the front one, after which all the splints are tied together with three bands upon the thigh and two upon the leg. If there be any disposition to spasm or dragging up the lower part of the fracture, a sand-bag may be attached for two or three days to the foot; after which it is rarely needed. I prefer this to most other apparatus, because the patient is generally very easy with it, and is capable of moving about a little in the bed without disturbing the fracture. (2) The plan here proposed of replacing the splints after every six days is faulty, as being liable to produce disturbance of the fracture. They are best left alone as long as possible, except so far as merely tightening the bandages when they be- come loose. If the case do well, it is rare that the splints need reapplication more than once or twice during the cure. It must be remembered, however, that, under these circumstances, the fracture has not been set till after subsidence of all swell- ing, during which time the limb is merely laid upon a pillow.—j. f. s.] 2. The Apparatus with splints, ivith the limb bent, and lying on the side or on the back. The bent position of the limb was proposed by Pott, for the purpose of relaxing the muscles ofthe thigh. The ailing thigh is to be laid on its outer side, with the knee-joint half bent; the whole of the patient's body should be inclined to the side. The setting is perfected in this half bent position. The apparatus consists of two splints, placed on the hinder and fore part of the thigh, and attached with the eighteen-tailed bandage. The whole limb rests on a pillow. As with this apparatus the motions ofthe knee are not interfered with, the position does not tend to the perfect relaxation of the muscles, and imperceptibly the upper part of the body sinks down in the bed straight, by which displacement ofthe broken ends is favoured, the bent position has been changed, and, as in fracture of the neck of the thigh-bone, (par. 677), the limb is put on a wooden stage formed of two boards, connected at an obtuse angle, and of which the oblique surfaces re- quire a suitable bending of the limb. These are covered with pillows and provided with pegs on the sides, to prevent the displacement ofthe limb. When the limb is placed on this stage, the setting is to be com- pleted, the thigh surrounded with compresses, and Scultetus's bandage, and steadied with three splints on the outer, inner, and fore part. (C. Bell, A. Cooper). 3. The permanent extension may be employed either on the plan of Desault, as in fractured neck of the thigh-bone; or after Brunntng- hausen, also as in fracture of the neck of the thigh-bone, except that together with the outer splint, a second is to be applied on the inner, a third on the front, and a fourth on the back of the thigh. If both ex- tremities be connected at the foot and knee, according to Boyer and BELOW THE GREAT TROCHANTER. 629 JIagedorn, as in fractured neck of the thigh-bone; or according to Sauter, in which case the permanent extension is made whilst the limb is bent, and the limb kept suspended. Here also Earle's bed (par. 677) is suitable, and the apparatus proposed by Granger (a), for the purpose of connected permanent extension with a double in- clined board. For the same purpose is Mossisovic's (b) equilibrium plan. The permanent apparatus is put on by Seutin in the following manner:—After the bed has been properly arranged, bandages, a straw cloth, Scultetus's bandage in three or four layers of strips sufficiently long to reach once and a-half round the limb, are to be laid upon it. The swathing of the foot is now to be commenced with the stirrup bandage from the root of the toes, which remain uncovered, and at the same time serve as an index to determine the position of the bone. The first layer of bandages is then as usual to be applied from below upwards, and then plaster of Paris spread over it. This acts merely for the gluing of the second layer, without by its hardness injuring the skin. The second layer is to be applied in a similar manner, and. an assistant smears it over with plaster with a large brush. The pasteboard splints are then cut to fit, broadest at the back part of the thigh and calf. At the edges of the foot they are to be cut with two broad pieces, which, connected in the middle, form a sole, and reach only to the lateral projections of the head of the first and fifth mid-foot-bones. A single sole does not give sufficient firmness, though one sole may be put on, and the ends of the pasteboard splints made to overlap it. The pasteboard splint must not press the edge of the shin-bone, and should be sufficiently wide that there may remain behind and before a finger's breadth between their edges. In the edges of the splints, notches should be made with the shears, or indents, which are still better, whereby they stick closely to the underlaying parts. The pasteboard splints should be soaked in water, spread with plaster, applied, and at once overspread on both sides with a thick layer of plaster, so that in drying they form as firm a substance as a wooden splint; and now the third layer of bands is applied. The foot is then to be somewhat raised, and a conical pillow stuffed with tow, placed between the heel and calf, to keep the hind part of the apparatus perfectly horizontal, and to diminish the dropping through of the heel and calf. The heel-pad is also to be spread with plaster, and fixed in the fourth layer of bandage; or it may be applied earlier between the bandage straps, so that subsequently it is not necessary to raise the limb higher. As it is important that the Achilles' tendon should not be compressed, two pieces of the same com- press should therefore be previously laid on both sides of it. The lower part ofthe splint, which bends over the sole of the foot, is fixed within a circular bandage. As till the complete drying of the apparatus, displacements easily occur, straw splints are usually applied by means of straw splint cloth, and the whole firmly bound with rollers, as in the common contentive apparatus. The assistants, who have hitherto kept up extension and counter-extension may now let go the limb. If the fracture be very oblique and the fractured ends easily separate, a sling must be applied at the lower part of the limb by means of a double bandage, fastened on both sides of the foot and leg, and connected at its end with bags, more or less full of sand, which are allowed to hang down over the foot of the bed, in order that in the perfectly horizontal position of the patient, a continued extension may be kept up, by which necessarily the counter-extension can be made to operate, not merely by the simple weight of the body, but also by a cloth folded longitudinally, carried between the thighs, and fixed to the bed's head. On the day after the drying of the apparatus, the straw splint-cloth and the straw splints are to be removed, and a cir- cular bandage applied from the foot to the hip. Two or three days after the patient may be allowed to go with crutches, in which case the foot should be supported by a bandage slung round the neck. 685. In transverse fractures in the middle ofthe thigh a simple appa- ratus with splints and the limb put straight are sufficient. In fractures of the upper and lower third, the half-bent position is preferable on (a) Edinburgh Medical and Surgical brilche ohne Verkurzunjr. Wien , 1812. Journal April 1821, p. 191, f. i- "• Blume, Einfache Beinbruchmaschine zur (b) Darstell'uno- der oequilibrial Methode Heilung der S< benkelbruehe in gebogcner zur sichercn Heilung der Oberschenkel- Lage. Wurzburg, 1831 ; with one plate. 53* 630 FRACTURES OF THE account ofthe special displacement of the broken ends (par. 682); and in fracture in the upper third, immediately under the great trochanter, a position approaching the sitting posture is preferable, because thereby only can the lower end be kept in corresponding position with the upper end of the fracture. But it must be here observed whether the fracture be not so near the joint and connected with such injury that stiffness will ensue, in which case the straight position, with or without tension according to circumstances, must be employed. The half-bent position of Bell and Cooper is preferable to Pott's posture on the side. 686. In oblique fracture this treatment is rarely sufficient, as the broken surfaces after having been apposed cannot be kept in contact. In these cases the permanent extension is necessary, and in fractures in the middle of the thigh, is best effected by the machines of Boyer and Hagedorn ; but in fractures of the lower and upper third, the machine of Sauter, or the double inclined plane, are especially serviceable on account ofthe advantages connected with the half-bent posture. If the fracture be complicated with wound, one or other position may be advantageous as may best suit the care ofthe wound. 687. In children, after properly setting the fracture, it is usual to swathe the whole limb up to the hip in a circular bandage, several turns being made round the seat of fracture. Pasteboard splints are then to be applied on the outer, inner, fore and back part of the limb from the groin to the foot, swathed in a roller, and the whole wrapped in a cloth to protect the apparatus against displacement. The application of the common contentive bandage is, however, more suitable, because it can be more easily renewed, and without changing the position of the limb. 688. If much inflammation and swelling have set in, they must be treated according to the rules laid down, (par. 587.) 689. The management of the patient during the cure of the fracture is directed by the general rules. Stiffness of the joint after the cure, especially if the fracture be near the knee-joint, is often of long con- tinuance, but gradually subsides with motion and with volatile rub- bings-in. 690. In rare cases, the outer or inner condyle of the thigh-bone may be broken obliquely, or it may be separated by a vertical cleft which descends from a fracture. This is distinguished by the great swelling of the knee- joint, by the deformity, and by the crepitation observed in the movements of the condyles. It is difficult in these cases to prevent deformity, and great interference with the motions of the joint. The limb is to be put straight on a pillow and the inflammation sought to be repressed with leeches and cold applications. This done, a simple contentive bandage is to be applied. If in an oblique fracture with separation of the con- dyles, the upper end of the fracture be driven out through the coverings, amputation ofthe thigh is indicated. XVI.—OF FRACTURE OF THE KNEE-CAP. (Fractura Patellae, Lat.; Bruch der Knieschiebe, Germ.; Fracture de la Rotule, Fr.) Meibom, Dissert, de patella ejusque laesionibus. Francf., 1G97. Bucking's Abhandlung von Kniescheibenbruche nebst der Beschreibung einer neuen Maschine. Stendal, 1789. KNEE-CAP. 631 Sheldon, On Fracture ofthe Patella and Olechranon. London, 1789. Camper, P., De fractura patella? et olechrani. Cum fig. Haag. 1790. 4to. Desault, above cited, vol. i. Boyer, above cited, vol. iii. p. 291. Cooper, A., above cited, p. 200. Alcock, Observations on the Fracture of the Patella and Olechranon. London, 1823. Ortelli, Dissert, de fractura. patellae. Berol., 1827. Fest, Dissert, de fractura. patellae. Berol., 1827. Lachmund, lnaug. Abhandl. fiber den Bruch der Kniescheibe und die Zerreissung des Knieschiebenbandes. Wiirzb., 1838. Dupuytren; in Lecons Orales de Clinique Chirurgicale, vol. ii. p. 297. 691. Fracture ofthe Knee-cap, has most usually a transverse, rarely a longitudinal, and often more or less oblique direction; or the bone is split to pieces. In the former case it may be consequent on violent contraction of the muscles attached to the knee-cap in violent bending ofthe leg; in other cases it is always produced by direct external vio- lence and is accompanied with great contusion, with effusion of blood into the joint, or with wound. 692. The diagnosis is easy. There has been previous violent tension whilst the knee was bent, to preserve the equilibrium of the body, or a fall upon the knee whilst the leg wasbent; the patient feels severe pain, often hears a crack, and can neither stand up nor stretch out his foot after the fall. In transverse fracture a space is distinctly felt between the two ends of the bone, which are separated, the upper piece being drawn upwards. This separation is the greater, the more the fibrous covering ofthe knee-cap is torn, and may extend to four or five inches ; but it is lessened when the leg is straightened. Crepitation is not ob- served because the broken ends cannot be brought into immediate con- tact. In vertical, oblique, or splintered fractures of the knee-cap, the separation and mobility of the broken ends and crepitation are felt on examination. 693. The union of the fractured pieces is effected by means of a fibrous intersubstance, the cause of which does not depend on the spongi- ness and isolation of the bone, nor on the want of blood between the fractured surfaces, nor on the intrusion of the synovia, and paucity of vessels in the bone and surrounding parts, but on the difficulty of retain- ing the fractured ends in sufficiently close contact. The opinion, how- ever, that in transverse fracture the consolidation does not depend on callus, is unfounded and disproved by experience (a). In splintering of the knee-cap, the broken ends are usually connected by callus. If the intersubstance which effects the union be not very broad, the motions of the joint are scarcely hindered, but under contrary circumstances the gait is more unsteady. If with fracture of the knee-cap there be severe bruising or a wound of the joint, the injury is always important, as anchylosis or suppuration of the joint with fatal consequences may ensue. Even in simple fracture, by the use of unsuitable and especially of too tight bandages, destruction of motion, union of the upper part of the knee-cap with the front ofthe thigh-bone, with atrophy ofthe ligaments and extending muscles may occur, which is worse than if a broad inter- substance had been formed. (a) Dupuytren; in Ammon Parallele der Langenbeck, neue Bibliothek for Chirurgie franzoischen und deutscher Chirurgie, p. 151. und Ophthalmologic, vol. iii. pt. i. p. 49. 632 FRACTURES OF THE From Gulliver's observations (a), it appears 1. That if the aponeurosis be completely divided, as is the case in fracture from muscular contraction, a bony union is not to be expected; 2. In transverse fractures in which bony union is deficient, the fragments and the interposed fibrous tissue are well provided with vessels; the want of union, therefore, is not to be ascribed to imperfect nourishment; 3. If the union in transverse fractures be effected by fibrous substance, there is often a bony deposit on the ends of the bone, so that the fragments have the appearance of two symmetrical bones ; 4. Bony union is simply the result of immovable adjustment of the fragments which, in many cases of fracture, the uninjured state of the aponeu- rosis on the fore part effects; 5. New bones, which in fracture ofthe knee-cap seem to be formed ofthe broken pieces. The surrounding cellular tissue rarely or never becomes converted into bone; the fibrous tissue goes directly to the production of new bone. No cartilaginoid substance appears during the ossification. 694. In transverse fracture, the two broken ends are in general easily brought into perfect contact, if the joint be completely straightened, the hip bent, so that the thigh forms an obtuse angle with the axis of the body, and the broken ends pressed together with both hands. If the broken ends be not far apart, that position of the limb is favourable to the cure, in which it is supported on a pillow laid beneath it, upon which it is to be closely pressed with a cross cloth carried round over the lower part of the thigh and fastened an both sides to the bed ; or the whole limb is put upon a machine in which the foot is fixed to a foot- board, and motion at the hip-joint can be restricted at pleasure. This is even to be considered as the most proper mode of treatment, as after it less stiffness of the knee is to be expected than after the use of ban- dages (b). The close union ofthe fractured ends may also in this position be further assisted by properly applied strips of adhesive plaster (c). 695. In considerable separation of the broken pieces, a special ban- daging is, however, necessary, which should counteract the contraction ofthe muscles, and press together the two ends ofthe fracture, in order to produce union with the smallest possible interspace. After the coap- tation ofthe fractured ends as already directed, two long pads are to be applied above and below the knee-cap, so that their ends may cross in the ham. By means of a single or double-headed roller they are to be so fastened that a figure of 00 is formed around the knee-joint. On the front of the limb is put a strip of linen, four fingers wide, somewhat longer than the limb, with two clefts in its middle, corresponding to the seat of fracture. This is to be fixed, its lower end being somewhat enveloped by spiral turns from the ankle to the knee. The remainder of the roller, with the loose strip of linen, is to be given to an assistant, and a second strip of linen, split to its middle into two heads, applied upon the front of the thigh, and fastened with another roller carried in spiral turns from the groin to the upper part ofthe knee-cap. The cir- cular bandage is then given to an assistant, and the head of one strip of linen brought through the cleft of the other, both drawn in opposite di- rections, and their two ends turned in and fixed with the continuation of the spiral turns. The extremity thus placed has a splint laid behind the ham, in order to prevent the motion of the joint. (a) Edinburgh Medical and Surgical Journal, 1837. No. 130. (b) Frajani, Medicinisch-Chirurgische Dupuytren ; in Ammon. Beobachtungen, Nurnberg, 1799, vol. ii. p. (c-) Alcock, Practical Observations on 151. Fracture of the Patella and of the Olechra- Richerand, Histoire des Progres recents non. London, 1823. de la Chirurgie, p. 142. KNEE-CAP. 633 Langenbeck (a) puts the extremity in a horizontal posture, allows the patient to sit, and envelops the leg with ascending, and the thigh with descending spiral turns, to the two fragments of the knee-cap. [I cannot agree with Chelius in the use of this bandage, for the pressure neces- sarily made upon the front of the broken knee-cap will be very irksome, if not pain- ful to the patient. It is far better, after fixing the circular pads above and below the knee-cap, to draw them together on each side with a tape; by doing which, as the pads are brought together, so is also the upper part of the knee-cap brought down to the lower without any pressure being made on the front of the bone.—j. f. s.] 696. Besides the apparatus mentioned, which best serves the purpose, numerous bandages and apparatus have been proposed, but which for the most part have the objection that they do not counteract the muscles which draw up the upper fractured piece, nor press equally strongly upon both upper and lower broken end, in consequence of which the patient cannot bear them. To these belong the bandages and apparatus of Bucking (&), Evers (c), Mohrenheim (d), B. Bell (e), Boyer (f), A. Cooper (g), Baillif (h), Fest (i), and many others. 697. If, as is generally the case, inflammation and swelling immedi- ately set in together they must be first got rid of by proper treatment, the joint being kept in the position already described, (par. 694), be- fore proceeding to set the fracture, and to the application of bandages. As often as the apparatus becomes loose, it must be reapplied; in seven or eight weeks' time it may be removed, but the patient must still be very careful in moving about. The longer the patient remains quiet, the sooner bony union takes place. A stiffness of the joint frequently continues, which only gradually subsides; often incurable anchylosis en- sues (1). The latter seems to arise from the application of the ban- dages, before the inflammation of the joint is got rid of. If the inter- substance be very wide, the knee must be supported with an elastic bandage. The motions ofthe limb in these cases may be also often im- proved, if gradual and more violent motions of the leg be performed, by which the contracted m. rectus again lengthens itself to a certain degree (2). [(1) I have never seen anchylosis ofthe knee-joint from fracture ofthe knee-cap, and can only imagine its occurrence under very peculiar circumstances.—j. f. s. (2) John Hunter observes:—" Other things are to be done after the union has taken place. First, the accommodation of the muscles to their new situation, where less length is necessary, from the patella having become longer; secondly, the new- contraction in this new situation; thirdly, acquiring sufficient strength in it. \\ e have reason to believe that the greatest contraction in a muscle is somewhat greater than the joint will allow of; for we find them firm when the limb is stretched, as if the power was greater; and when the part is deprived of this firm band, we find the muscles draw the bone up higher than they should. Thus the upper part of the patella is always drawn up when the bone is broken. While the union is taking place, the muscles are accommodating themselves to the great length of the bones. After this it will be necessary to bend the limb and keep it so, in order that the muscles may be thus enabled to admit of an elongation equal to the flexure of the limb by which means the patient will be enabled easily to bend the limb. Exten- sion will not be so easy; still, by perseverance, it may be acquired." (p. 512). He then mentions a case in which the broken pieces of bone having been left far apart, the patient had lost the use of her limb, although it could be swung backwards and forwards as she sat upon a high table; and he considered that he cured her simply by (a) Above cited 0» Ibid. (/) Above cited. P1- »»• c) R.cter's chirurg. Biblioth., vol. x. p. (g) Above cited, pi. ix. f. 9 10 11. . -o (ft) Ortalli, De fractura. Patellae, licrol, (d) Beobactungen verschiedener chirur- 1827 p. 52. zischen VorfUlle, vol. i. Wcin. 1780, (t) Dissert, de fractura Patellae. 1*27. (e) Lehrbegriff der Wundarzncikunst, 4to. vol. iv. p. 430, pi. iv. f. 1,2, 3. 634 FRACTURES OF THE KNEE-CAP. inducing her to direct her will to the excitement of the action of the rectus muscle. And he explained how this was effected, first, by reference to the condition of the muscle, "that the space between the two attachments of the rectus being much Shortened, while the muscle continued of the same length, the utmost degree of its contraction would scarcely be able to straighten itself, much less move the patella and leg also." And then, that " if the influence of the mind was frequently exerted on the muscle, it would gain this power of contraction, in which it would probably be aided by the interstitial absorption taking place, and actually shortening the mus- cle, and suiting its length to the office it was to perform." (p. 513.) In other words, and more briefly, the object is to produce in the rectus muscle a recovery of its toni- city, by educating it to contract and permanently shorten itself, so that it may re-ac- quire the power of acting on the knee-cap, and extending the leg which it previously had, but of which it is deprived by the ascent of the broken part of the knee-cap, rendering it lax instead of tort when the leg is straight. I believe the best mode of recalling the m. rectus to its proper function is, after having kept the patient in bed five or six weeks, by which time it may be presumed whatever union will, has taken place, to get him up, place him on a table, with his ham on its edge, and direct him to swing the leg backwards and forwards, frequent- ly during the day. At first he can do this very little, not because, as Hunter and Chelius suppose, the m. rectus is too short and requires lengthening, but on the Contrary because it is too long and must be instructed to shorten itself still more, so as to compensate for the approximation of its points of attachment by the unna- tural space between the broken ends of the knee-cap. When the muscle has re- acquired sufficient power to throw the leg and foot forwards, then some weights must be attached to the foot, and the same exercise continued till the muscle can freely move it when so loaded. In this way the muscle becomes shortened, and ca- pable both of sustaining the erect posture and throwing the leg forwards. It may be here observed, that if the fibro-ligamentous union of the broken pieces of the knee-cap be long, the patient's gait is very odd, the foot and leg are not carried forward steadily and set on the ground, but as it were jerked or thrown forward from the knee, and when the foot rests on the ground and the weight of the body is transferred to that limb, the knee is in an extreme state of extension, as if supported almost entirely by the posterior ligament of the joint.—j. f. s.] 698. The longitudinal fracture requires merely a common contentive bandage, which may compress the broken pieces on their sides, with a less elevated position than in transverse fracture. The splintered fracture requires the same apparatus as the transverse, when the broken ends are displaced upwards, or as the longitudinal frac- ture if they be displaced at the side; but here also the inflammation and swelling must be first got rid of, before the application of the apparatus. If fracture of the knee-cap be accompanied with wound of the joint, it must be treated according to the general rules of compound fractures. [Compound fracture of the knee-cap almost invariably requires amputation, as the injury producing it is so severe that there can be little expectation of a satisfac- tory issue.—j. f. s.] 699. If the ligament of the knee-cap be torn, the knee-cap ascends, and the treatment must be the same as in transverse fracture. I have employed this same practice in five cases with the happiest success. I once observed, in a weakly man, in whom the ligament was torn on the left side, and from improper treatment the bone was displaced upwaids five inches, a tearing ofthe fleshy fibres ofthe m. rectus, which had oc- curred from a false step, and from the attempt at preserving the equili- brium ofthe body, consequent on muscular contraction. The seat of rupture is distinctly felt, of which the space becomes greater on bending the leg, and is diminished by straightening it. The application of the prescribed apparatus was successful. Although the apparatus above mentioned is most suitable for transverse fracture of the knee-cap and rupture of its ligament, it must, however, be observed that its FRACTURES OF THE BONES OF THE LEG. 635 application must be made with the greatest accuracy and attention, as also its re-ad- justment when the bandages are loosened, in which special care must be taken that the broken ends be not displaced, and the scarcely formed union disturbed and de- stroyed. In this respect it were perhaps convenient to spread the above-described apparatus with plaster, and thereby render certain its lasting close application. XVII.—OF FRACTURE OF THE BONES OF THE LEG. (Fractura Ossium Cruris, Lat.; Bruche der Knochen des Unterschenkels, Germ.; Fracture des Os de la Jambe, Fr.) Pott, P., above cited. Desault, above cited, p. 270. Boyer, above cited, p. 324. 700. Both bones of the leg may be broken at once, or the shin-bone or splint-bone may be broken separately. The fracture is produced either by a fall upon the feet, or by the operation of direct violence. 701. If the shin-bone alone be broken, (Fractura Tibia, Lat.; Bruch der Schienbein, Germ.; Fracture du Tibia, Fr.,) the fracture has usually a transverse direction, and may happen in the middle or at either end. The broken ends are rarely displaced, and then only according to the thickness of the limb. This happens so much less frequently, the nearer the fracture is to the upper end of the bone. The diagnosis is, there- fore, often difficult; the patient frequently can walk after the injury ; he feels a fixed pain ; an irregularity is often discovered at one part of the shin-bone, and often crepitation on moving the broken ends. The treat- ment of this fracture is easy ; a slight extension is sufficient, if the broken ends be displaced, to put them right, and a simple contentive apparatus, as recommended in fracture of both bones of the leg. 702. Fracture of the Splint-bone (Fractura Fibula, Lat.; Bruch der Wadenbein, Germ.; Fracture du Perone, Fr.) may be produced by an inward or outward turning of the foot, or by the immediate effect of violence; and the fracture may be either in the body of the splint-bone, or in the neighbourhood of the outer ankle. In fracture of the body of the splint-bone the limb is not shortened, and retains its natural direc- tion ; a slight yielding is scarcely felt at the seat of fracture in pressing the finger along the bone. The violence received on the outside ofthe leg, and the great ecchymosis assist the diagnosis. This fracture is frequently accompanied with dislocation inwards of the shin-bone, and if it be mistaken, the foot retains its disposition to dislocate after seeming reduction. The inner ankle always again leaves the joint surfaces of the astragalus, thrusts the skin violently inwards, which becomes in- flamed, breaks, and even runs into mortification. The broken end may alone be displaced, and driven inwards against the shin-bone. If the seat of fracture be very low down, it may be discovered by the touch, which is not possible in the upper third ofthe splint-bone. Crepitation is often observed on pressing the fractured ends inwards, or in alternate adduction and abduction of the foot. The most striking sign is always the inclination of the foot outivards, so that its inner edge is downwards, and the outer upwards. If dislocation of the shin-bone inwards be con- nected with this fracture, the bone is shorter, its long axis falls on the inner side, the whole shin-bone lies obliquely from above inwards, and produces beneath the skin, especially at the lower part, a considerable 636 TREATMENT OF FRACTURES prominence. The splint-bone follows the same direction as the shin- bone to the seat of fracture, from which it is directed obliquely outwards. The foot is not only inclined outwards, but so turned upon its own proper axis, that its sole is turned up, and its inner edge directed down- wards. Fracture of the splint-bone may also be connected with dislo- cation of the foot outwards, often simultaneously with fracture of the inner ankle or of the shin-bone, and other complication may exist, as, in dislocation ofthe ankle-joint, will be more particularly described. 703. The treatment of simple fracture of the splint-bone is unattended with difficulty. The foot must be kept bent inwards, to separate the broken ends from the shin-bone. This is effected by the same apparatus as that for fracture of both bones of the leg, with this difference, that the inner splint is applied only to the inner ankle, but the outer continued below the outer ankle. Or, upon the inside of the leg is put a folded chaff pad, the bottom of which rests on the inner ankle, and the upper end upon the inner condyle of the thigh-bone. A sufficiently strong wooden splint is fixed upon this pad with a circular bandage, so that its lower end may project from four to five inches beyond the sole of the foot. With a second roller the foot is drawn inwards towards the shin, the bandage being turned like a 00 around the shin, foot, and ankle- joint (a). This apparatus, however, has the objection that it frequently becomes displaced, or presses too tightly. In five or six weeks the fracture is consolidated. In fracture connected with dislocation of the foot, the splint-bone must, after reduction of the dislocation, be kept in place by the prescribed apparatus, and by a general and local treatment according to circumstances, to which often very important symptoms are opposed. 704. Fracture of both bones of the leg (Fractura Cruris, Lat.; Bruch der beiden Knochen des Unterschenkels, Germ.; Fracture des deux Os de la Jambe, Fr.) is either transverse or oblique, and may be either in the middle, upper, or lower third. The diagnosis is always easy. The displacement ofthe broken ends, according to the length ofthe limb, is more rare, than that according to its straight direction and circumference; but, in oblique fractures, the leg is always shortened, the lower end turned outwards and backwards, the upper inwards and backwards. Only when the fracture is near the top of the leg, is the upper fractured end drawn much upwards and backwards by the operation of the bending muscles. Very frequently, particularly in oblique fractures, the broken ends protrude through the skin. 705. The treatment varies as the fracture is transverse, oblique, in the neighbourhood of the knee-joint, or connected with injuiies of the soft parts. 706. In Simple transverse Fracture the setting is always easy. One assistant holds the limb above the knee, and another at the heel and instep ; slight extension is generally sufficient to bring the broken ends into place. As they have little disposition to displacement, the simple contentive apparatus is sufficient. Two moistened square compresses are to be put upon the leg, and to surround two-thirds of it; it is then (a) Dupuytren, Memoire sur la Fracture et Hospices de Paris. Paris, 1819. 4to.— de l'extremite inferieure du Perone, les luxa- Leyons Orales de Clinique Chirurgicale, vol. tions et les accidens qui en sont la suite ; in i. p. 189. Annuaire medico-chirurgical des H6pitaux OF THE BONES OF THE LEG. 637 to be swathed, from below upwards, with Scultetus's bandage, wooden splints, three fingers wide, are to be applied on both sides, which should reach beyond the knee and ankle-joints, in a sufficiently large piece of linen, and they should be two fingers distant from the leg. This space is to be filled with chaff pads, a smaller pad and splint are to be put on the front of the leg, which should reach from the tubercle of the shin- bone to the ankle, and the splints are to be fastened with three double bands, of which that on the seat of fracture should be first tied. A compress is to be put on the sole of the foot, and crossed on the instep, and by its ends attached to the apparatus. The leg should so rest on a chaff pad, that it may easily be bent at the knee-joint; and care should be taken that the heel lie in a proper hollow. At first the appa- ratus should be moistened from time to time with a dispersing lotion, and renewed every six or eight days. On the fortieth or fiftieth day the conso- lidation is perfected, when the leg may be enveloped in a circular roller. 707. The oblique Fracture of the leg is also generally set with ease, though the mere contentive apparatus is not sufficient to keep the broken ends in proper place, as they have not any opposite support, and are, therefore, very easily displaced. Posch's (a) foot-bed or Sauter's (b) machine serves best for permanent extension. 708. In fractures of the leg near the knee-joint, the setting is best managed in the half-bent position, which is the most proper during the cure. The contentive apparatus is to be applied with this difference, that one splint is to be put in front, another upon the inner, and one upon the back of the leg, which should lie on the outer side, or on a double inclined bed. If the head ofthe shin-bone be broken obliquely into the knee-joint, the leg must be kept straight, fixed by the contentive appa- ratus, and stiffness prevented by early motion. 709. Fracture of the leg is frequently connected with a wound pro- duced by external violence, or by tearing of the soft parts by pieces of bone being driven outwards. In the latter case the wound must be enlarged, and often the piece of bone sawn off, in order to effect the proper replacement. The seat and direction of the fracture determine the kind of apparatus. The simple contentive bandage has in these cases the disadvantage of requiring frequent renewal, on account of attending to the wound. Here the suspensory apparatus, in which the limb lies free, and the wound can be properly attended to, is best. Bhaun's (c) machine is merely a suspender, and can therefore principally serve in those cases only in which the broken ends, after being set, have no disposition to displacement. When this is the case, Posch's foot-bed, with Eiciiheimer's (d) improvement, or Sauter's machine, best answer the purpose. These two machines have the advantage that they not only suspend the leg, but also keep it permanently extended. (a) Beschreibung einer neuen, sehr be- (d) Beschreibung und Abbildung einer quemen Ma--chii