NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service fi A SYSTEM OF SURGERY, BY J. M. CHELIUS. TRANSLATED FROM THE GERMAN BY . JOHN F. SOUTH. VOL II. 4 » A SYSTEM OF SURGERY, BV J. M. CHELIUS, DOCTOR IN MEDICINE AND SDRGERY, PDBLIC PROFESSOR OF GENERAL AND OPHTHALHIG SDRGERY, DIRECTOR OF THE OHIRURGICAL AND OPHTHALMIC CLINIC IN THE DNIVERSITY OF HEIDELBERG, &C. &C. &.C. TRANSLATED FROM THE GERMAN, AND ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS, BV JOHN F. SOUTH, LATE PROFESSOR OF SDRGERY TO THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, AND ONE OF THE SURGEONS TO ST. THOMAS'S HOSPITAL. IN THREE VOLUMES. PHILADELPHIA: LEA & BLANCHARD. 1847. Entered according to the Act of Congress, in the year 1847, by Lea Si. Blanchard, in the Clerk's Office of the District Court of the Eastern District of Pennsylvania. d 6lSVi nc>>. \$tt1 Griggs & Co., Printers. II—OLD SOLUTIONS OF CONTINUITY.* A.—ON SOLUTIONS OF CONTINUITY WHICH DO NOT SUPPURATE. I.—OF UNNATURAL JOINTS. Hildanus, Fabr., Observationes Chirurgicas, cent. iii. obs. 91. Salzmann, De articulationibus analogis, quae ossium fracturis snperveniunt. Ar- gent., 1718. a Meckern, Job, Observat. Med.-Chir., cap. Ixxi. White, Chas., Cases in Surgery. London, 1770. Schmucker, Joh. Lrb., Vermischte Chirurgische Schriften. 3 vols. 8vo. Berlin, 1785-97. Laroche, Dissertation sur la nonreunion de quelques Fractures, et en particulier de celle du Bras, et sur un Moyen nouveau de guerir les fausses articulations qui en resultent. Paris, an xm. Phvsick, P. S., in New York Medical Repository, vol. i. p. 122. 1804. 8vo. Roux, De la Resection ou Retrenchment des parties d'Os Malades. Paris, 1812. Wardrop, in Medico-Chirurg. Trans., vol. v. p. 358. Boyer, above cited, vol. iii. p. 86. Langenbeck, Von der Bildung widernaturlicher Gelenke nach Knochenbriichen ; in his neuer Bibliothek fur die Chirurgie und Ophthalmologie, vol. i. p. 81. Oppenheim, Ueber die Behandlung der falschen Gelenke; in Rust's Magazin, vol. xxvii. p. 203, has collected all the hitherto known cases of treatment of false joints. Buchanan, Thomas, An Essay on a new mode of Treatment for Diseased Joints, and the Non-Union of fracture. London, 1828. 8vo. Amesbury, Joseph, Practical Remarks on the Nature and Treatment of Fractures, &c. London, 1831. 8vo. 2 vols. Seerig, De Pseudarthrosi de fractura proficiscente. Regiomont, 1838. Oppenheim, Ueber die Behandlungs weisen der Pseudarthrosen und eine neue Heilmethode derselben; in Hamb. Zeitschrift fur die gesammte Medicin, vol. v. pt. 1. Brodie, Sir Benj., Clinical Observations on Ununited Fractures; in London Medical Gazette, vol. xiv. p. 676. 1833-34. Reisseisen, De articulationibus analogis, qua? fracturis ossium superveniunt. [* Although, as translator of this work, I neither analogy nor connexion. The latter am of necessity compelled to follow the comprehend ulcers of various kinds, which course which the Author has thought right to are as various in their times of appearance, pursue, yet I cannot avoid stating, in refer, from the period at which the action causing ence to this division of his Book, that it ap- them has been set up—and fistulas, which pears to me improperly named and mis- have really (of the three) the only pretension placed, and far -from well arranged and (slight indeed as it is) to be called old solu- composed in itself. "Old Solutions of Con- tions of continuity, as they really are none tinuity, consisting of those which do not and other than a chronic condition of abscess; those which do suppurate." Among the that is, an abscess which the constitution former are included enduring solution of has not had sufficient power to fill up and parts which have originated in injury, as obliterate with new parts, although it is unnatural joints and torn perineum, with capable of sustaining with less or more ef- original imperfect (or as it is the fashion to feet upon itself, the suppurative disposition say, abnormal) formation of parts, as hare- already established.—J. f. s.] lip and cleft palate, between which there is Vol. ii—2 14 CAUSES OF UNNATURAL JOINTS. [Hartshorne, On Pseudarthrosis, in American Journal of Med. Sci- ences, vol. 1. N. S. Norris, On Non-Union after Fractures, in American Journal of Med. Sciences, vol. 3. N. S. Jan. 1842.—g. w. n.] 712. When the two ends of a broken bone, not united by firm car- tilage, are covered with cartilage, or the soft parts have got between them, an unnatural joint (Articulatio prceternaturalis, Pseudarthrosis, Lat.; vVidernaturliches Gelenk, Germ.; Fausse Articulation, Fr). is pro- duced. The broken ends in this case are movable, but the natural motions of the joint are greatly interfered with, or entirely prevented. [On the subject of unnatural or false joints John Hunter (a) observes:—" Some- times simple fractures will not unite at all. This is a worse consequence than any of the foregoing, there being no soft union even, or if there ever was, that being absorbed. Here the surrounding parts thicken and form a kind of capsular ligament, and the extremities of the bone rub against each other at each motion of the limb, by which stimulus the broken parts are absorbed, and the extremities become smooth, and in time are covered with something similar to cartilage, and at length the cavity between them becomes filled with a fluid very much resembling synovia." (p. 504.)] 713. The cause of such unnatural joint may be bad setting of the fracture, improper apparatus, too frequent movements of the limb (1), general disease, and advanced age {par. 579) (2). A firm union of the broken ends may also be prevented by particular circumstances under which the bone may be absorbed, and the fractured ends connected only by cartilage. The formation of an unnatural joint depends espe- cially on impeded ossification, on excessive absorption, and the con- dition of such joint ordinarily presents no actual resemblance to the construction of a natural joint. Frequently, however, the ends of the bone are rounded and enveloped in a thick fibro-ligamentous capsule attached to the ends of the bone, above and below, and its internal surface lined with a smooth membrane, resembling the synovial, and, like it, capable of secretion (Brodie, Gibson, Amesbury) (3). The period at which firm union takes place in fractures is indeed very dif- ferent {par. 578). An unnatural joint may, however, be considered as formed, if more than six months have elapsed after the fracture, and the ends of the fracture be still movable. Unnatural joints have been noticed in almost every bone, but they are. most frequent in the upper arm. [(1) Amesbury says:—"By far the most frequent cause of non-union that I have noticed is want of rest in consequence of the inadequacy of the plans of treatment which have been employed. I consider this to have been the primary cause in almost all the cases I have examined." (p. 716). (2) I do not think advanced age can justly be considered as the cause of want of union or imperfect union, at least as regards the shaft of bones. In almost everv ununited or imperfectly united fracture I have seen, the patient has scarcely if ever, exceeded the middle age, but has generally been younger. (3) Among the causes of want of union, Astley Cooper believes that it " is sometimes the result of continuing cold applications for too long a period to the part, thus checking that degree of inflammatory action which is absolutely necessary to bring about a restoration of the parts." (p. 679). Pregnancy has been held to be a cause of want of union, but Amesbury says he has " seen about ninety cases of non-union, but has not met with more than two which happened during the process of gestation. He is therefore disposed to attri- (a) Lectures on Surgery, Palmer's Edition, vol. i. TREATMENT BY RUBBING, PRESSURE. L5 bute non-union, in persons so circumstanced, more to the inadequacy of the usual modes of treatment than to the peculiar disturbance of the system which is observed in pregnancy." (p. 714). Sometimes after fracture the union of the broken bone is entirely prevented by one end being dragged from the other by muscular effort; such occasionally hap- pens when the spoke-bone being broken just above the insertion of the m. pronator quadratus, its lower end is drawn-in by that muscle. Sometimes a portion of neigh- bouring muscle slips between the fractured ends, and getting free, prevents union. At other times, in a comminuted fracture, a fragment dies and as effectually opposes union as a bullet, piece of cloth, or any other extraneous body is occasionally known to do; and this may happen either in simple or compound fracture. A very good example of an ununited simple fracture from this cause occurred within the last twelvemonth to my colleague Mackmurdo, and was discovered at the operation performed for sawing off the ununited ends. The fracture was of the upper arm, had happened ten months previously, and been kept in splints six weeks, after which it seemed to have united, but in a few days' time was again broken, whilst the woman followed her usual occupation. The splints were reapplied, but without benefit, and afterwards two setons, at some interval of time apart, were passed by the side of the ununited bone, but not between its ends, and worn for some time, but no union resulted. It was then determined to cut down and saw off the ends of the fracture, and when the incision was made for this purpose, the upper end of the bone was found covered with cartilage, and the lower surrounded with a sort of capsule, containing several loose pieces of bone. These were removed and the ends of the fracture sawn off; suppuration continued for some time, and she left the house at the end of two months, the wound not having scarred, and no fixing of the frac- ture having occurred. Some time after an abscess formed nearer the elbow, and several small pieces of bone have voided by it, and continue so to do. At present, eight months after the operation, there is not any union.—j. f. s.] 714. According to the variety of the cause of unnatural joints, the mode of treatment must vary, to prevent their occurrence. If, how- ever, they already be formed, their cure is only possible by the broken ends, which are covered with cartilage, being put in the condition of a recent division, that is, by producing in them a suitable degree of in- flammation, which is sought to be effected by rubbing the fractured ends against each other, by an apparatus of pressure, by the application of caustic, by sawing off the ends, and by the introduction of a seton. [John Hunter proposes a different method from either of these. He says :— " In this case it is necessary to lay open the new cavity and irritate the ends of the bones, and then, by keeping them in position, bony union will often take place. It has been recommended to saw off the ends of the bones; but all that seems neces- sary is, to irritate them sufficiently to excite a fresh inflammation." (p. 505). He does not, however, mention any examples in which either of these modes of practice was successful.] 715. Rubbing the fractured ends together {Exasperatio, Lat.; Reibung der Bruchfldchen gegen einander, Germ.; Frottement des extremites oVune fracture, Fr.,) and subsequently fixing them with a suitable ap- paratus, can only be advantageous during the establishment of the un- natural joint, because afterwards it can seldom produce a sufficient degree of inflammation (1). With the same object it has also been attempted to fix the broken ends by tightly-fitting bandages, for the purpose of exciting inflammation by the patient's standing and. walk- ing (2). [(1) Rubbing the ends of the bone together is at least as old as Celsus (a), as quoted by Oppenheim. " Si quando vero ossa non conferbuerunt, quia saepe soluta saepe mota sunt, in aperto deinde curatio est; possunt enim coire. Si vetustas oc- (a) De Medecina. 16 UNNATURAL JOTNTS TREATED cupavit, membrum extendendum est, ut aliquid laedatur ossa inter se manu dm- denda, ut concurrendo exasperentur, et si quid pingue est, eradatur, totumque id quasi recens fiat, magna tamen cura habita, ne nervi musculive laedantur." Lib. viu. c. x. sect. vii. ,. Boyer considers that this coarse and uncertain practice often destroys a callus when first forming, which by longer continued rest and contentive bandaging might have effected a firm union. Cittadini's case (a) of a false joint in the thigh-bone cured by violently rubbing together the fractured ends and by the subsequent ap- plication of a contentive bandage, can scarcely be considered to support this prac- tice, as the fracture was only two months old; and, as is well known, many cases unite after as long or longer period of seeming want of union, as completely as under the most favourable circumstances."—j. f. s.] (2) In cases of this kind I have covered the limb with compresses, and over these applied wet pasteboard splints, so as to enclose it completely; and then employed the usual swathing, with Scultetus's bandage, and the common splints with chaff pads, and having made the apparatus sufficiently tight, have left it for a long while. 716. The use of Pressure for the cure of artificial joints rests partly on the close coaptation of the broken ends, and the preservation of complete quiet, and partly on the excitement of a due degree of inflam- mation. The pressure may be employed either with the usual ap- paratus of splints, as in recent fracture, and at the same time with pad- ded straps and tourniquets upon the fractured ends (b), or by simple strong pressure, with swathing of the whole limb, and graduated com- presses with tightly drawn rollers (c). These modes of treatment, although many cases prove their good effect, do not, however, fre- quently effect a cure, because the necessary degree of inflamma- tion cannot be produced, and applies rather to cases of not long stand- ing and to those in which no firm intersubstance is formed. The repeated application of blisters on the surface, opposite the seat of fracture, has been recommended, at six or eight weeks after the occurrence of the accident (d). Cauterization of the skin with caustic potash (e), and painting with tincture of iodine (/). [I believe that pressure and perfect rest are the most efficient remedy for fractures in which there is tardiness or indisposition to deposit earthy matter in callus; and I have very great doubt whether firm union is ever effected except when its absence has arisen from this deficiency alone. In simple fracture it can only be surmised what the actual cause of the want of union is, and in operating on such cases it ap- pears quite as often that the diagnosis which has been formed is wrong, as that it is right. It must also be remembered that the deposit of earthy matter in the callus is frequently a very slow process, double and treble the time beyond that ordinarily requisite for the purpose, sometimes elapsing before a fracture is perfectly united. Chelius has just mentioned that an unnatural joint may be considered as formed if more than six months have elapsed after the fracture, and the ends of the fracture be still movable. But Amesbury mentions cases which have united by pressure after six, eight, ten, and even sixteen months have gone by. And therefore I cannot but think that these must only have depended on deficient earthy deposit; for cases have occurred again and again in which pressure of all kinds has been employed without advantage, and when operated upon no callus oonnexion has been found. (a) In Omodf.i Annali Universali de Mi- Hopitaux du Midi, par Delpkch Sent 1830 lana, vol. xxxvii. p. 415, 1826. p. 539. > p •» (b) Amesbury, Jos, above cited. (d) Brodie ; in London Medical and Sur- (c) Wright's three Cases of Cure of False gical Journal, October 1803. Joints, by a pressure apparatus; in Ame- (e) Hartshornk, Philadelphia Medical rican Journal of Medical Sciences, vol. ii. Recorder, 1826. April. P-2T0- ™ m , , ^ • , (.-0 Buchanan, cited at the head of this Fleury,Dcs efiets de la Compression dans article.—Trusen, in Preuss Vereinszeitun? le traitement de plusieurs maladies externes Juni, 1834, p. 114.—Willoughbv in Trans' et surtout dans les Fractures et Fausses actions of the Medical Society of the State of Articulations, avec quelques reflexions sur New York, Albany, vol i. pt. ii, p. 76. cette derniere maladie; in the Memorial des BY CAUSTIC. 17 That the pressure to be employed in these cases should be sufficiently great and so directed as to bring the fractured ends closely together cannot be doubted, and in fractures which unite slowly is absolutely necessary. But I am not quite sure it is necessary that the pressure should be so great as to produce pain in the course of a few days after the application of the apparatus, as stated by Amesbury, although "in the different cases it differed very much in degree. In some of them it amounted only to a slight aching pain, accompanied with now and then a lanci- nating sensation in the fracture; but the inconvenience felt in all the cases varied more or less in the course of the day; and I am not aware that in any one of them it was at any period sufficiently severe to affect the pulse—certainly not so as to produce any noticeable fever." (p. 806). External irritation in these cases, so far as I have seen, is of little value.— J. f. s.] 717. For the purpose of destroying the cartilaginous surfaces on the ends of the bone, and to produce a suitable degree of plastic inflamma- tion, various kinds of caustic have been employed, strong nitric acid (Ollenroth) {a), caustic potash (the younger Cline) (1), Hewson, Norris) (b), butter of antimony (Weilinger) (c) and nitrate of silver (Kirkbride) {d). Here also belong (Mayor) (e) experiments of re- peatedly introducing between the ends of the bone a metallic canula, and in it a steel probe dipped in boiling water, and the injection of some irritating fluid into the wound (Hulse) (/). Cases of happy cure of ununited fractures of White, Cline, Lehmann, and Barton, are collected by Oppenheim and others in Rust's Magazin. [(1) Chelius has quoted Hewson as having first proposed the use of caustic potash in ununited fractures. The fact is, however, that it was practised by the younger Cline more than twenty years before in St. Thomas's Hospital, in proof of which, I copy from my notes the following Case.—P. M., a sailor aged thirty years was admitted into St. Thomas's Hospital, April 13th, 1815; having on the 7th of September, of the preceding year, fallen down a ship's hold, by which compound fractures of both legs were produced. For these accidents he was received into Chatham Hospital, and there continued till the 1st of March last. During this time the wounds of both legs healed, and the left shin-bone united properly by bone, but the right only by fibro-cartilage. Strengthening plasters and blistering were employed to promote bony union, but without effect. When first admitted into St. Thomas's, he was directed to walk about for the purpose of exciting the ossific inflammation, but although this was attended with much pain, there was no improvement. Towards the latter end of May, the part was blistered, but without advantage. It was therefore determined to have recourse to an operation, which was performed. June 12th'. The skin was cut through on the inner and fore part of the shin-bone, and the connecting substance, which was soiled, being completely laid bare, portions of it were cut away with a small crowned trephine, till the ends of the bone were reached. Into the hole thus formed, caustic potash was introduced, and allowed to remain for a few minutes, after which a poultice was applied. The patient suffered great pain when the intermediate substance was cut into, and indeed was much excited during the whole operation. He had no pain till the evening of the 14/^, when the leg became very painful, continued so for ten hours, and then became easy. On the 16th the pain recurred, and continued for the same length of time, after which it ceased. In a day or two after a free discharge was established, and there was not any return of the pain. On the 21st the poultice was left off, adhesive plaster applied, (a) Bernstein, tiber Verrenkungen und (c) Rust's Magazin, vol. xxxiv. p. 330. Beinbrache, Second Edit, Jena. 1819, p. (d) American Journal of the Medical Sci. 280. Feb., 1835. (b) North American Medical and Surgical (e) Nouveau Systeme de Deligation Chi- Journal. Philadelphia, 1838, Jan. rurgicale, &c. 8vo. Geneva, 1832. [American Journal of Medical Sciences, (/) American Journal of Medical Sciences, vol. xxiii. 1838.—g. w. n.] Feb., 1834. 18 UNNA.TURA.L JOINTS TREATED BY SAWING OFF. and an outside splint put on to support the leg. On 9th of July he got up and talked about on crutches. On the 20th he felt that his leg was stronger. On the Zltn ne left the house with the connexion of the broken ends decidedly firmer; but the wound was not healed, and he returned again, Aug. 17, with the sore still opened. He continued in the house till Oct. 10, and then left, at which time the union was complete.—j. v. s. f , Hewson's case was successful, and union was complete in twelve weeks alter tue operation.] 718. To saw off the cartilage-covered ends of the fracture, they must be laid bare by a longitudinal cut on that side of the limb' where the bone is most superficial, and the large nerves and vessels can be avoided; they are then to be separated from the surrounding and connecting parts, thrust up through the wound, the soft parts protected by a spatula intro- duced beneath, and first the lower, then the upper portion of the fracture cut off with a suitable saw. The bleeding vessels are to be tied during the operation; the broken ends are to be brought into contact, and the case is to be treated as a compound fracture. In the after treatment, subsequent to the removal of the ends of the bone, it must be especially remembered not to expect too early the consolidation of the ends of the bone, because, from my experience, this occurs only after a very con- siderable time. I am convinced that, in many cases, amputation of the ends of a fracture have had an unsatisfactory result from want of attention to this circumstance (1). If the ends of the bone lie very deep and cannot be easily protruded through the soft parts, it is best to use Heine's osteotome. It is frequently very difficult and even impossible to reach that end of the bone which is overlapped by the other end, and surrounded with much soft parts. In such cases it is advantageous according to Dupuytren's experience to saw off that end which can be reached, and bring it in contact with the other which has not been cut off (Pigne). Brodie (a), in a case of false joint of the leg, in which seton and pressure had been used in vain, cut upon the shin-bone, removed the half ligamentous and cartilaginous mass with which the ends of the bone were united, scraped both broken surfaces, and filled the wound up with lint. This was left for three or four days in order to fill the wound with granulations, and then pressure was employed to keep the fractured ends in firm and close contact. (1) In a case of section of an artificial joint in the upper-arm in a young scrofulous man I found the ends of the fracture still quite movable, but complete consolidation ensued two months after under the continued use of the apparatus. [According to Guido de Cauliaco (b), the Arabian physicians recommended cutting down on the fractured part and getting rid of the callus either by rubbintr or scraping. " Verum si multum infestitur et aliter fieri non potest, consulet Avicenna incidatur caro et atrosboth (callus) fricando separetur. Si fuerit attritio et timetur membri corruptio, scarpelletur." (p. 45.) This appears, however, from Avicenna's account to have been a very severe and not unfrequently fatal operation. The operation of sawing off the broken ends of the bone seems to have been first proposed and successfully practised by Charles White (c), in 1760, on the upper- arm of a boy, nine years old, which had been fractured six months. In his second case, which was a fractured shin-bone, he could only saw off the upper end, behind which the lower had so fallen that it could merely be scraped, and it was found necessary to introduce butter of antimony, to destroy some muscular fibres between the fractured ends. Both cases did well. This operation has been repeatedly per- formed, but with very variable success. I think it is only applicable to the upper- arm and leg where the bones are not very thickly covered with muscles; but not in the thigh or fore-arm. Lawrence's observations (d) on the subject are well worthy (a) London Medical Gazette, July, 1834. («) Phil. Trans., vol. Ii. 1760. Also in his (b) Chirurgia Magna. Venetiis, 1498. cases, above cited. (d) Lectures in Lancet, 1829-30, vol. ii. BY SETON. 19 of attention. " If the operation be in the fleshy part of the thigh, it must be a very difficult thing to accomplish: you have to inflict a very severe wound, a wound very likely to be followed by considerable inflammation, and that with a still more serious effect. In many instances in which this has been done the patient has at least been left in a worse situation than he was in before." (p. 265.) My friend Green's operation on an ununited fracture of the thigh-bone, detailed by Amesbury (a), fully proves the difficulty to which Lawrence refers. "A semicircular incision was commenced about the middle of the rectus and then carried round through the belly of the vastus externus. The flap was dissected back and the fractured end of the upper portion of the bone brought into view. Upon clearing away the muscles it was seen that the two broken extremities of the bone were connected together by a thick dense capsule, resembling the capsule of the hip-joint, the inner surfaces of which were perfectly smooth and shining. The integrity of this capsule was destroyed, by removing a portion of it from the upper fragment; but in consequence of the difficulty which was experienced in getting at the fractured end of the lower portion, which, as has been said, lay on the inner side of the upper, it was left covered with the ligamentous matter. In removing about half an inch of fractured end of the upper fragment, which was done by one of Hey's saws, in order to give room, it was found that the bone had become soft and spongy at this part, apparently from interstitial absorption. From the manner in which the ends of the bone lay, it was evident that the lower portion could not be cleared of the ligamentous deposit which covered it, without enlarging the wound in the soft parts, a proceeding which appeared objectionable." (pp. 821, 22.) The greater part of the wound soon healed without any constitutional excitement, but there was suppuration, and the matter burrowing, an abscess was formed at the upper inner part of the thigh, which was punctured. He was immediately placed on a fracture-bed with inclined planes and no splint applied till the tenth day, when one well padded was put upon the outside of the thigh, and worn for seven weeks, but no union was effected. An inner splint was then also applied and the fractured ends pressed tightly together by the web of a tourniquet twisted closely on them and continued for a fortnight. But no advan- tage was gained;.the limb was amputated above the seat of fracture, and the patient did well. On examination, it was found that the unnatural joint "was now again complete. The greater part of it was nearly the thickness of the capsule of the hip- joint, but at one part it was thin like the capsule of the shoulder-joint; the capsule was accidentally torn at this part with the finger, and the inner side was seen smooth, and had very much the appearance of synovial membrane, being moist and shiny. The ends of the bone were rounded, and where they came in contact, were flattened and covered with a dense fibrous structure, very similar in appearance to the inter- vertebral substance when divided transversely, but especially that part of it which is found half-way between the centre and circumference." (p. 826.) It appears to me, in regard to this case, that if White's treatment had been followed out and the ligamentous covering of the lower end of the bone had been destroyed with caustic, the result might probably have been more favourable. As it was, the object of the operation, to wit, that of getting rid of the ligamentous or cartilaginous coverings of the fractured ends, was only partially effected.—J. F. s.] 719. The introduction of a seton is to be effected in the following man- ner :—It should be attempted by extension and counter-extension to bring the broken ends into proper position, and even to separate them somewhat from each other. With due caution the place is to be chosen, where the seton-needle armed with silk can be so thrust into and through the whole limb, that no large vessel nor nerves should be wounded, and so that the seton thread be placed between the two ends of the fracture. It might be better, perhaps, in most cases, to cut down on both sides to the bone, for the purpose of more certainly and accurately carrying the seton through between the fractured ends. The limb should then be duly extended, and kept in proper position by a suitable apparatus. The seton-threads are to be drawn daily backwards and forwards be- (a) Above cited. 20 BY SETON1 tween the fractured ends, and to be entirely removed as soon as the ends are found to be knit together. If, after three or four months, no firm union have ensued, all hope of cure must be given up ; there remains then, if the patient will be relieved of the inconvenience of the unnatural joint, no other remedy than amputation. Weinhold (a) himself employed with advantage his needle-trephine, with which he introduced a wedge-shaped seton smeared with some irritating matter. Oppenheim (b) recommends, in order to make the operation of the seton more powerful, enduring and effectual, where the circumstances previous to the introduction of a seton had not promised, a priori, any result, the introduction of two setons, not indeed, as already proposed, through the newly formed cartilaginous intermediate mass, but in such way that each seton should be in contact with one of the fractured ends; the setons not to be left too long, but only till such time as suppuration was properly established, and then at once withdrawn, instead of by repeated and gradual thinning the .size of the seton. In two cases Oppenheim pursued this practice with success under the most unfavourable circumstances. According to Jobert's opinion (c), the seton should be left in only eight days. 720. The use of the seton may be accompanied with difficulty and danger, when in an oblique fracture the surfaces of the fracture corre- spond, so that in passing the needle through, important vessels and nerves may be injured. If the fractured ends be so close together that their surfaces touch only at one little point, the proper position of the bone must be first attained by permanent extension, after which by the introduction of the suture, some advantage maybe gained. 721. The introduction of the seton is more simple and less dangerous than sawing off the ends of the fracture ; healing also takes place without shortening of the limb ; but in many cases, on account of its less activity, it is not beneficial, as when the ends of the bone are united by a wide mass of cartilage, or by an actual false joint. The seton should be left for a long time, for four or five months, even to the consolidation of the bone (Physick). Smearing the seton-thread with irritating ointment, for the purpose of strengthening its operation, may easily excite erysipelatous inflammation, abscesses, and -constitutional irritation. The symptoms after sawing off' the fractured ends may be very dangerous. Great in- flammation, suppuration, and gangrene may occur, and these may even proceed to a fatal result. In the thigh the section is always effected with great difficulty, and much danger; it has, however, been there performed with success (d); in limbs which have two bones the section has been considered imprac- ticable ; Fricke (e), however, and Citta'dini (/), have performed it suc- cessfully on the fore-arm. Opinions as to the preference of the seton or of the section are very much divided; by both one as well as by the other mode of treatment, fortunate and unfortunate results have taken place ; and equally celebrated surgeons have held with the one and against the other practice (g). (a) Von der Heilung des falschen Ge- (g) Note the comparison of the cases of lenkes.u.s.w.; in Hufeland's Journal, May, the one and other mode of treatment by 1826. Oppenheim and Norris. (6) Hamburg Zeitzschrift. Ballif, Apparat zur fixirunjr der falschen (c) ArchivesGenerales de Medecine, 1840, Gelenke. See Troschkl, Dissert de PseT Octobre, p. 224. darthrosi. Berlin, 1826 ' . (d) Medico-Chirurg. Trans., vol. ii. p. 47. Somme, on the Cure of a False Joint hv (e) Oppenheim, above cited, p. 242. the introduction of a silver loop and exten (/) Ommodei, Annah universah de Medi- sion apparatus; in Med.-Chir Trans vol cina, Marzo, 1826, p. 411. xvi. p. 36. ' '' OF HARE-LIP. 21 [As far as my own observation and experience are concerned I cannot say that there is great encouragement for the performance of any operation for ununited or imperfectly united fracture, and I think a comparison of the results of the numerous cases which have been variously treated will confirm, this opinion. The most favourable cases are those in which the ends of the bone are connected by cartilage or a cartilage-like substance, and in such I should certainly prefer the introduction of caustic potash. The least favourable cases are tbose in which the fractured ends have acquired a cartilaginous covering and are enclosed in a sort of synovial capsule, which indicates a total indisposition to the formation of callus ; and therefore cut- ting off the ends, or scraping off their thin cartilaginous covering, is a very doubtful proceeding, as union will commonly not occur and the fractured ends be re-covered, as in Green's case. Perhaps, where the union is prevented by loose pieces between the ends of the broken bone, if these be removed, union may take place; but that this is very uncertain is proved by Mackmurdo's case. The great difficulty to contend with, in determining on the performance of any operation with the reasonable hope of success, is the almost utter impossibility ef distinguishing the real cause of the want of firm union, which can only be ascer- tained when the fractured part is exposed; and which very frequently disproves the diagnosis previously made. I think therefore that it is advisable in all cases of un- united fracture in which operations are performed that the surgeon should fairly warn the patient of the great uncertainty of their result and leave him to determine for himself.—j. f. s.] II.—OF HARE-LIP, (Labium Leporinum, Lat.; Hasenscharte Germ.; Bee de Lievre, Fr.) Heister, L., De Labio Leporino. Helmst., 1744. Louis; in Memoires de l'Academie de Chirurgie, vol. iv. p. 385. Locher, De Operatione Labii Leporini. Jenae, 1792. Freter, De modis variis quibus Labium Leporinum curatur. Halae, 1793, Cellier De Clermont, De la Division Labiale. Paris, an xi. Rieg, Abhandlung von der Hasencharte. Frankfurt, 1803. Desault, 03uvres Chirurgicales, vol. ii. p. 173. Rau, J. D. L., Dissert, de Labio Leporino cum proeminentiis Maxillae Superioris complicato. Berol., 1818. Caspar, C. R., De Labio Leporino. An iv. Goetting, 1837. 4to.; with en- graving. Mettauer, John P., M. D., On Staphyloraphy; in American Journal of Medical Sciences, vol. xxi. 1837. Demoncy, C, Dissert, de Labio Leporino. Mosquae, 1839. 722. The hare-lip is a division of the lip upon which the red edges are continued. It is always a vice of the original formation, though an old division of the lip may be consequent on external violence, if the edges of the wound have not united, but have skinned over. In the former case the edges of the cleft are smooth, and overspread with a delicate epidermis; in the latter irregular and callous. The hare-lip is always in the upper lip. The lip may be either partially or completely cleft, and is often accompanied with a cleft of the upper jaw and palate {Wolf's Jaw; Palatum fissum, Lat.; Wolfsrachen, Germ.) The cleft is sometimes simple ; frequently is there between its edges a larger or smaller middle piece. Bony processes often project into the cleft, or in adults the teeth protrude between the edges. Only when the hare-lip is connected with a cleft in the bone does it hinder children from sucking (1). In adults the speech, especially the pronunciation of the labial letters, is always indistinct in hare-lip. Vol. ii.—3 22 OPERATION FOR [(1) This is commonly stated, but is not always so; the gap in the jaw and pa- late of, course is a great obstacle to sucking, but it does not entirely prevent it, and the infant manages to acquire a compensation for a seeming want of Which it was not aware.—j. f. s.] 723. Hare-lip, when an original vice, is an arrest of the development of the lip; as is wolf's jaw, of that of the jaw-bone. Both of them usu- ally occur on the left side, whilst the right is naturally formed. When the cleft in the lip and jaw-bone is double, that is, running into each nostril, they are often separated at the underpart of the nasal partition by a projecting piece of bone which contains more or less incisive teeth (Double Wolf's jaw, doppelter Wolfsrachen.) In several cases of hare- lip and cleft palate the olfactory nerves have been observed to be . wanting (1). [(1) I have been obliged to alterthis paragraph very considerably, as the descrip- tion given by Chelius is very obscure and not quite correct.—j. f. s. Pigne (a) has very properly stated, that "an acquired hare-lip may affect inde- finitely all kinds of direction and position; but that the congenital form is always perpendicular to the free edge of the lip, and but very rarely met with in the mesial line."] 724. Hare-lip can only be cured by operation, which consists in re- moving the edges of the cleft with the bistoury, or with scissors, and uniting the fresh cleft. This is easy in proportion as the cleft is simple. If the palate be at the same time cleft it frequently closes after the cure of the cleft in the soft parts, but it may continue during the whole life. Although experience has shown, that the operation may be successful in very young children, it is, however, best to delay it till eight months (1). Only when wolf's jaw is connected with hare-lip, and the child cannot suck, may the operation be undertaken within the first six months (2). In children of two years the operation may be delayed till they have become intelligent. The previous drawing together the edges of the cleft with sticking-plaster or bandage, with a view to its more speedy union, is useless; but it may be advantageous in accustoming the child to the dressing. If there be a bony growth in the cleft it must, after the skin covering it has been raised, be removed with the nippers, and the bleeding having been stanched, the skin which has been preserved must be used for covering the septum. If the incisive teeth project, they must be extracted, if of the first set; but if of the second it must be attempted to give them their proper direction by continued pressure, and if this be not possible they also must be extracted (3). Previous to the operation the child should be kept awake a longtime (4). [(1) Lawrence thinks "it is very desirable to remove the defect early on every account; in my opinion it is also advantageous as respects the success of the opera- tion, that it should be performed at a comparatively early period. I should say then, that in the third, fourth, or fifth month after birth it should be performed at all events, you should perform it at such a period that it will not interfere with the process of dentition. There is often a good deal of irritation goino- on in the neigh- bourhood of the part which is the seat of this defect at the time of teethino- so that it is desirable you should accomplish the cure before dentition commencesfor put it off Ull after the child has^got its teeth^it is, however, in my opinion, desirable to a the result from it considered as an operation, nor a failure"of the ultimate object o?the (a) In his Translation of this Work. HARE-LIP. 23 operation, that is, the closure of the preternatural fissure. It has sometimes been said that children are liable to convulsions at this time, and that a considerable loss of blood may act seriously on them, so that they may die from the mere effect of the operation. This has not occurred in any case that has come within my observa*- tion." (p. 819.) Mutter says :—"If called a few days after birth, and the child is healthy, I ope- rate for the hare-lip as soon as possible, believing as I do that the earlier the opera- tion is performed the better. Much needless dread of convulsions, sloughings, fevers, &c, exists in the minds of some when they refer to operations of this kind upon very young children, but I have over and over again succeeded, without the occurrence of an untoward symptom, in infants of three, four, and five days old." (p. 25.). (2) I do not think even eight months is sufficient age for the performance of this operation. Some surgeons, as just mentioned, do not hesitate to perform it at six weeks or a month, or even at a shorter period after birth. But it is objectionable, because sometimes the child's crying more or less tears the new adhesions, and an ugly notch remains in the lip; or, what is still more important, it produces danger- ous, fainting from the loss of blood, or subsequent convulsion, which are only checked by the removal of the threads, and allowing the original gap to be repro- duced. It should not therefore be lightly undertaken in very young children, as it exposes them to much danger. I would never perform it before two years old ; but if the parents can be persuaded to wait till the child is six or eight, it is preferable, as the lip being thicker and larger, and the child being capable of understanding the advantage of keeping quiet for a few hours, the operation is more successful, and a better and more even lip is formed. (3) Whether the teeth be of the first or second set, if they stick out much, there is little hope of bringing them into proper place by pressure, and it is therefore better to remove them, which should be done a day or two previous to the operation. (4) As to keeping the child awake for some time before the operation, it is not matter of much consequence; for in general he will soon drop off to sleep.—j. f. s.] 725. The operation is to be performed in the following manner:—The child is to be held by one assistant, with his legs between his, and the child's hands within his. A second assistant presses the child's head against the breast of the former; and with his hands placed on each side beneath the jaw, at the same time he brings the skin of the cheeks somewhat forward, and compresses the facial arteries. The head of the child is always to be inclined a little forward (1). If the lip be united with the gum it must first be separated to a sufficient extent with a curved bistoury. The surgeon takes hold of the lower angle of the left edge of the cleft part with the finger and thumb of the left hand, or with a pair of forceps, and drawing it towards him, thrusts the blunt blade of a strong pair of scissors (2), curved at an obtuse angle on their outer edge, under the lip, and so high that the point reaches above the angle of the cleft. He then pushes the scissors a little upwards, and cuts off lengthways the whole red part of the cleft lip. Next with the thumb and finger of the left hand, he takes hold of the lower corner of the right side of the cleft, and operates on it in the same manner, with his hands crossed. Both cuts must unite closely with each other above the angle of the cleft. If the cut be not perfected at once, it must be continued in the same direc- tion, and without stretching too much the already divided part. [(1) The position of the child's head is a matter of no slight importance; for if laid on the back, as often carelessly done, or if not so placed as to favour the stream' ing of the blood from the mouth, it will run back into the throat, and produce vio- lent coughing and even choking.—j. f. s. (2) Lawrence considers that "the scissors are the most convenient mode (of per-. 24 OPERATION FOR forming the operation for hare-lip) and that you will do it best with that kind which have knife edges; * * * they cut with great facility, without bruising the edges be- tween the blades, and such scissors are the most convenient for paring off the edges of a hare-lip." (p. 819.)] 726 In using the bistoury the lip should be fixed upon a piece of wood introduced beneath it, or, still better, by Beinl's lip-holder (a), of which the one blade of cork or wood placed beneath the lip, is to be carried so high that both blades rise above the angle of the cleft, and when closed leave about half a line of the naturally conditioned skin, together with the red edge of the cleft uncovered. The bistoury is then thrust in a line above the angle of the cleft, and its edge being applied, beneath, is drawn down along the side of the upper blade, so that the whole edge of the cleft is cut off. The second edge is to be treated in like man- ner, the knife being introduced at the point where the first cut was com- menced (1). [(1) The bistoury is certainly preferable to scissors, which bruise the parts they divide. But I think our common mode of using it, is better than that recommended by Chelius ; and a phimosis knife the most convenient and the only instrument re^ quired. The surgeon should grasp either corner of the cleft lip which he fancies most con- venient, with the finger and thumb of his opposite hand, and then passing the point of the knife behind the lip, he thrusts it through about a line above the angle of the cleft, draws it down till it has cut through the red part of the lip, taking care to eut off the whole piece which, entering into the cleft, rises above the proper level of the lip, for unless this be attended to, an ugly notch remains after the union of the wound. The other edge is afterwards to be pared in like manner. There need be no fear of freely cutting away the lip, as the edges always readily come together, and if they seem to need any dragging at the upper part to effect this it is better to divide the neighbouring membrane of the mouth, to prevent such drag.—j. f. s.] 727. The bleeding is generally inconsiderable, and stanched by the close junction of the fresh-made edges, which is best effected by the twisted suture. For this purpose gold or silver needles are used, with steel points which can be removed (1). The left edge of the lip is to be held with the thumb and finger of the left hand, and the needle thrust vertically through near the red edge of the lip, and from three to five lines distant from the edge of the wound, to the lining membrane; it is then to be brought horizontal, so that by pressing, its point appears near the edge of the lip in the surface of the wound. The other edge of the wound is now to be brought with the fingers of the left hand to that already pierced, and the needle introduced in the same direction and made to pass through externally. The point of the needle is now to be removed, a thread applied around it, and its ends drawn down by an assistant. , At two or three lines' distance from the former a second needle is to be introduced, whilst with the thumb and finger of the left hand its point is pressed against the right edge of the wound. If the cleft be large, the employment of a third or fourth needle maybe neces- sary. A stout thread is then to be twisted around each needle in form of 00, first upon the upper pin, and then on the others, and to be suffi- ciently drawn till the edges of the wound are brought into close contact. The ends of the thread are to be tied in a slip knot; and care must be taken that the threads should regularly and closely cover every part of the wound. Beneath the ends of the needles pieces of sticking plaster (a) Beobachtungen der Chirurgischen Academie zu Wien, 1801, vol. i. pi. ir. HARE-LIP. 25 should be put, for the purpose of preventing their digging into the skin. The union is to be supported by strips of sticking plaster with their ends cleft, their middle being placed on the nape of the neck, and the cleft ends carried beneath the ears over the cheeks, which are to be pressed forwards, continued in the interspaces of the needles, crossed and fastened upon the opposite sides. Dif.ffenbach, instead of the common pins for twisting the threads upon, employs the most del icate^ Karlsbad insect-needles, which he separately envelopes in thread, and cuts off the two ends of the needle with scissors (2). As regards the result of the operation, it is nearly the same whether the edge of the cleft be removed with the bistoury or with scissors. In thick, puffy, and irre- gular edge, the bistoury is always preferable. The union of the cleft by the twisted suture and sticking plaster is most preferable, as the interrupted sutures, reoomr mended by some, do not produce so close union, and the threads easily tear out. The uniting bandages and dressings of Richter, Stuckelberg, and others, are easily displaced. Mayor (a) pierces the left edge of the wound near its free end with a needle, which he introduces at a right angle from within outwards, drawing with it a double thread, at the end of which a ball of cotton is attached; by its pressure the edges of the wound are united, and, by tying together the ends of the threads upon a ball of wool put between them, the union is supported probably as well as in the seam suture. [(1) "It has usually been the practice," says Lawrence:, " to employ two hare- lip pins, (consisting of a hollow silver cylinder with a steel point,) and to put one just at the point where the red part of the lip joins the external integuments, and another near the upper angle of the wound; but in performing the operation on the young subject at the age I have mentioned, and I have always performed it thus early, I have invariably found it sufficient to use a single hare-lip pin, introducing it at the lower part of the fissure, near the red portion of the lip, and to unite the wound at the upper angle with a simple suture. * * * Having introduced the pin, I take out with the forceps the steel point, the silver part only being left in its situa- tion. * * * Then having secured the pin with two or three turns of the silk, you can put in the simple suture. * * * You do not put any thing further over the wound, there is nothing wanted, in fact; you leave the wound, and find that you can remove the pin and cut out the simple ligature placed above it, about the fifth or sixth day, when you will usually find the fissure completely united." (pp. 819, 20). (2) The thin insect-pins recommended by Dieffenbach are much the best kind of pin for this operation; and the thinner they are, if they will only bear the neces- sary pressure for their introduction, the better, as they leavea proportionally smaller scar. I generally use three pins. The application of strips of sticking plaster is as unnecessary as it is irksome.—j. f, s.] 728. After the operation the child is to be laid a little on one side, and attention paid to the continuance of the bleeding (l)j he should be soothed as much as possible, and the food should be given only at the corner of the mouth. If he cry much, some syrupus opiatus should be given. The dressings must be cleaned daily with luke-warm water from the mucus flowing from the nose, and the needles smeared with oil. On the fourth day after having removed the plaster and cleansed and oiled the needles, they are to be removed, the upper first, and after- wards the lower, during which the lip is to be held together with the fingers of the left hand, sticking plaster must be applied till the wound is perfectly consolidated (2). [(I) Bleeding after the edges of the wound have been applied and fixed with the pins and threads is of very rare occurrence; indeed I have never known it happen. As no plaster should be used, scabs very quickly form on the wound and about the (a) Nouveau Point de suture pour l.'operation du. Bee de lievre; in Gazette Medicale de 26 OPERATION FOR HARE-LIP. threads, which are best left alone. If there be any oozing, or if drivelling from the nose, it may be gently mopped with a piece of soft linen, but as little as possible. (2) The time recommended by Chelius for leaving the pins in is too long; thirty or forty hours at the utmost is amply sufficient, and sometimes even less; for so soon as pus is observed about the needles it is proper they should be withdrawn, as they then cease to be of use, and ortly cause irritation; and this occurs more or less quickly according to the powers of the constitution. In removing the pins it is best to draw them gently through each coil of thread with a pair of stout dressing forceps, supporting the wound at the same time with the finger and thumb ; and after their withdrawal the thread should be gently picked off with the finger-nail or with a probe. The upper two pins and threads should be first removed, and a long strip of plaster carried across the lip from ear to ear, which done, the lower pin and thread are to be taken away. The plaster may be reapplied two or three times daily or every second day, but its use is rather precau- tionary than necessary.—j. f. s.] 729. If much inflammation of the wound occur after the operation, the threads, if too tightly drawn, must be loosened, and lead wash ap- plied. Cramps and convulsions require narcotic remedies. If the needles tear out, the union must be again restored by the twisted or in- terrupted suture (1); or if the separation of the edges of the cleft be partial, the union must be assisted by the continued application of stick- ing plaster. This is, indeed, best in the first instance, because the needles introduced through the inflamed edges of the wound again tear out. The needles are most certainly prevented tearing out if they are passed in and out from the edge of the wound, and not left in more than three days. Van Onzenort's advioe is to pass the needle on each side of the wound through pieces of leather, to prevent the tearing away. [(1) If the needles tear out, an accident which I have never known to occur, I think it would not be advisable to reintroduce them, as there could be no more probability of union occurring than in a torn wound, and their presence would there- fore only increase the irritation. It would therefore be best to leave the parts alone, and to repeat the operation at a future opportunity.—j. f. s.] 730. In double hare-lip, when the middle piece is sound and large, the edges on both its sides must be pared and the needle passed through the edges of both cleft and middle piece ; but if it be small and crum- pled it must be removed. If the cleft pass into the nostril, the lip must be separated from the gum equally high, the upper part of the cleft freely pared, and the upper needle introduced as high as possible (a). 731. Nothing has been done towards the union of the cleft in the hard palate. It has been recommended to make continued pressure on both upper jaw-bones with a stirrup-like apparatus (1). If nature do not close these clefts, the inconvenience may be diminished {b) by a sponge introduced into it and fastened upon a silver or leather plate. [(Matter, who advocates early operating on cases of hare-lip and cleft palate, mentions, among the advantages of so doing, that " the influence exerted by the pressure of the cheeks and lips upon the maxillary bones is sometimes sufficient of itself to cause an entire closure of the fissure in the hard palate. We have thus when the patient grows up, only the cleft of the soft palate to contend with " * * * After the lip has entirely healed, I have derived much advantage from causing the nurse to introduce her finger and thumb as far as possible into the mouth between the cheeks and alveolar processes, and make lateral pressure upon the latter several (a) Froriep's chirurgische Kupfertafeln, (b) Diepfenbach's proposition • in Heck pi. ccxxv. ccxxvi. er's literarische Annalen, July, 1827. OPERATION FOR CLEFT IN THE HARD PALATE. 27 times a day. I have also resorted, in very bad cases, to a small silver clamp, com- posed of two flat blades and a regulating screw. The blades being properly adjusted, one upon each side, the screw is gently turned so as to produce the requi- site degree of pressure. If called to a child a few years old, affected with hare-lip and a cleft palate, we have no time to lose, and should operate on the lip at once. Even in these cases I have seen quite a wide cleft closed by the action of the cheeks aided by the silver clamp." (p. 26.) (2) As to the use of obturators, I think Mutter's observations are well worthy attention. " It is highly improper in these, as well as in all other cases of the defect in young children, to use an obturator fastened by means of a sponge, as the foreign body effectually prevents the closure of the opening. An artificial palate, fastened to the teeth or gums, by preventing the passage of food into the nostrils, will, on the other hand, prove exceedingly useful, as well as a source of decided comfort to the patient." (p. 27.) Operation for Cleft in the Hard Palate. Mettauer has proposed and practised successfully; as has also Mutter, a mode of Staphyloplasty by granulation, as the latter calls it, in cases " where there is a separation of the margins (of the fissure in the hard palate) to an extent which will not allow them to be approximated. * * * The first operation contrived by us in a case of this description, oonsisted of a series of incisions more or less extensive, formed exterior to the margins of the cleft and parallel with them, extending from the faucial to the nasal surface on both sides. These incisions being designed as granulating surfaces, were not allowed to re-unite by the first intention, but kept apart by interposing between them small portions of buckskin or soft sponge, there to remain until suppuration should be well established and then to be removed. Incising from the supporting portions of the lips of the cleft a belt more or less wide and supported at each extremity by the natural continuity of the textures through which they may be nourished by blood, enables us to create an extensive surface for eliciting and rearing of granulations without the least hazard or danger of disorganizing the parts separated or their respective lips. In this condition they take on inflammation, which speedily terminates in suppuration; and granulations soon sprouting out from these newly created surfaces, fill up the incisions by which they are separated, and thus widen the lips to a greater or less extent. The first incisions are to be most extensive; and as the lips are expanded they should be less so, or the cicatrices may ulcerate or become disorganized and slough. The newly formed parts cannot be safely incised until perfectly organized. It would be most safe to perform the succeeding sections exterior to the cicatrices and in the original textures, as they granulate most readily and freely, and are not liable to ulcerate or slough. Should the parts be deficient in length, the method which we have been describing may be employed in a transverse direction guided by the views just sub- mitted, but not to divide the tensor palati muscle. * * * Cures by this method must necessarily be tedious, and the time required for their accomplishment more or less protracted, as the cases are distinguished by fissures of greater or less extent, or lips thin or the reverse." He therefore proposes another more expeditious operation, which "consists in making the sections of the lips of the cleft oblique instead of perpendicular, as in the preceding operation; and as it were to divide or split them, so as to separate the nasal from the faucial portions of the lips. This method unites the advantages of the flap and granulating process. * * * The surgeon commences the operation by denuding the margins of the lips of the fissure, as already described. As soon as the bleeding ceases, an incision is to be commenced in one of the lips, a little exterior to its margin and a few lines anterior to its uvulal verge. The marginal incision on the faucial surface should commence nearly a line and a half or two lines from the margin of the lip. At this point, the knife is to be inserted and directed in such a manner as to cut the lip obliquely from a line continued from the point of its insertion parallel with the margin of the lip to the angle, to another line passing in or near the base of it on its nasal surface, thus forming the section in the diagonal between these points of the faucial and nasal surfaces of the lips of the cleft. * * * It will always be found most convenient to dissect from the uvula upwards, as by that means the blood, which otherwise might essentially perplex and embarrass that step, will, in some degree, be avoided. 28 OPERATION FOR CLEFT IN THE HARD PALATE. These incisions should always extend a few lines above the angle, and must never be carried nearer than two or three to the uvulal margin of the lip of the cleit. The section of the opposite lip is to be performed in the same way, as soon as the bleeding from the first has ceased. "The ligatures must be now introduced, and with as little delay as possible, or the lips may become so tender as to render their application exceedingly painful; and should much time be delayed, even dangerous. For this purpose the canulated needle-porte, armed as already directed, should be employed. * * * The sutures are in these cases to be inserted a little interior to the margins of the labial cuts on their faucial surface, so as to permit a belt of the natural covering of each lip of the cleft to be interposed between the denuded mar- gins and the incisions, and embraced by the noose of each of the sutures. * * * Under no circumstances will it be prudent to begin the insertion of the sutures of the lips elsewhere than at the angle of the cleft. Although we have described this mode of operating for cleft palate, as if executed upon the lips of the fissure their whole length, it is not to be inferred that we advise the measure in every case. On the contrary, this will seldom be safe, especially when the fissure is very extensive. The sections may be formed as we have described them, the whole length of the lips of the cleft, but it will not be safe to attempt to insert ligatures, at the first operation, to more than a third or half of the margins thus incised. * * * After the margins of the denuded and incised lips have been approximated and firmly united at the median line of their contact, and sufficient time has been allowed for the sub- sidence of the several traumatic, irritative and inflammatory movements, as well as for the consolidation of the union of the parts involved in the operation, the remainder of the cleft may be closed in the same manner, only extending the diagonal section now quite through the uvulal margins, whieh, after they are approximated in the line of the fissure by the suture, but not confined in close contact, may themselves have sutures applied on their posterior margins, merely to prevent the displacement of the cut edges, and to keep the surfaces in contact as far as they are opposed to or overlap each other. * * * This operation will be equally applicable when the fissure extends entirely through the palatine and alveolar processes of the superior maxillary bone, with or without a division of the lip, and when the margins of the cleft, as is usual in such cases, are permanently separated. But when the lip is in- volved and the case complicated wim hare-lip, staphyloraphy as well as the opera- tion for this last infirmity, will be demanded. In such a complication the long cleft must be first connected, as the parts then will be more easy of access to the operator, and the operation more easily executed while the division of the lip remains open; after the long cleft is closed, the operation for hare-lip may be performed at once, or after the cure of the fissure is perfected. * * * As soon' as the union between the lip has become firm, the sutures may be cut away; generally on the sixth or seventh day, the first nearest the angle may be removed; and on alternate days, as shall be found safe, the remainder may be removed." (p. 325-31.) In a case of chronic mercurial disease in which there was an oval opening three- fourths of an ineh in length by nearly half an inch in breadth, on the right side of the roof of the mouth, through which the finger might be readily passed into the nostril of the same side, but in which the velum palati was barely involved, Mutter successfully practised Warren's operation of sliding the flap modified so as to embrace the operation by granulation of Mettauer."* * * With a small thin convex-edged bistoury he made a crescentic incision through the mucous mem- brane, and down, in fact, the bone, commencing the incision nearly opposite the superior extremity of the opening, and continuing it until it reached a point nearly opposite its inferior. A strip of mucous membrane, about three lines and a half in breadth, was thus separated, except at its extremities, from the adjacent parts. A similar incision was then made on the opposite side. The lips of the little wound were then detached from the subjacent bone to the extent of one line on each side, and then folded, as it were, upon themselves, thus leaving a gutter, into which he inserted a small cylinder of soft buckskin. * * * Inflammation followed by suppura- ration speedily supervened, and on the removal of the cylinder, seventy-two hours after its introduction, a fine crop of healthy granulations was discovered at the bot- tom of the wound; these rapidly increased in size, and soon filled up the space be- tween the lips of the incisions, rendering the introduction of any foreign body for the accomplishment of this object needless. . In six days after the first operation and when the granulations were in full vigour, I performed the second series of in- OF CLEFT SOFT PALATE. 29 cisions, which were carried between the extremities of the other two, and treated in precisely the same manner. In six days from the execution of this second ope- ration I found the opening in the palate surrounded by a strip of granulations, and in a proper condition for the last and by far the most difficult step in the whole at- tempt, the detachment and approximation of the flaps. * * * I commenced by de- taching the mucous membrane all around, dissecting from the margins out to the granulations, which being very yielding, allowed me without difficulty to bring the flaps together at or near the centre of the opening. To accomplish this a pair of small forceps was employed, and while the flap was held tense by an assistant, I passed the ligature first through the flap on the left side, at its centre and about a line from its edge, and then-allowing that to escape from the forceps, the opposite one was made tense .and the ligatme passed through it at a point directly opposite the little wound in the other; the ligature was then tied, and the flap above, or that next the anterior portion of the mouth brought into the concavity formed by the ap- proximation of the two lateral flaps, and attached by a ligature on each side. The lower was next brought to its proper position, and there held by similar stitches. The opening in the palate was thus completely covered in. The usual after-treat- ment was pursued, and in three weeks from the date of the last operation my patient was perfectly relieved of every vestige of his deformity. The ligatures were cut away on the fourth, fifth, and sixth day, and nothing of consequence occurred during the period of confinement." (pp. 21, 2). III.—OF THE CLEFT IN THE SOFT PALATE. (Fissura Palati Mollis hat.; Spalte im weichten Gaumen Germ.; Divisiondu Voile du Palais, Fr,) Graefe, Die Gaumen-Naht, ein neuentdecktes Mittel gegen angeborne Fehler der Sprache; in Journ. fitr Chirurg. und Aungenheilk, vol. i. p. 1, and p. 556. Stephenson, Dissert, de Velosynthesi. Edinb., 1820. Doniges, De variis uranoraphes methodis Aphorismi. Berol., 1824. 8vo. Ebel, Beitrage zur Gaumen-Naht; in v. Graefe and v. Walther's Journal, vol. vi. part i. p. 79. Wernecke, Ueber die Gaumen-Naht; ib., p. 102. Roux, Memoire sur la Staphyloraphie, ou Suture du Voile du Palais. Paris, 1825. 8vo. Dieffenbach, Vergleichende anatomische Untersuchungen iiber den Gaumen- Segel; in Hecker's literarischen Annalen.—Beitrage zur Gaumen-Naht; ib., Febr,. 1826, p. 145; July, 1827, p. 343. Schwerdt, F., Die Gaumen-Naht; a description of all the various methods and the instruments known to have been used in, up to the present time; with a preface by v. Graefe and four copper-plates. Berlin, 1829. 4to. Velpeau, Nouveaux Elemens de Medecine Operatoire. Paris, 1832. 8vo. Hosack, A., Memoir of Staphyloraphy; with cases and description of the instru- ments requisite for the operation. New York, 1833. [Bushe, On Cleft Palate. New York, 1835. 8vo.—g. w. n.] Mutter, Thomas D., M. D., A Report on the Operation for Fissures of the Pala- tine Vault. Philadelphia, 1843. 8vo. 732. The cleft in the soft palate occurs, not very unfrequently, as an original vicious formation, confined often merely to the uvula, which is then bifid, or including the whole soft palate. It is often also connected with a cleft of larger or smaller size in the hard palate, and also with hare-lip. The consequences of this misformation in early life, are great difficulty or complete incapability of sucking, especially in the horizontal posture. The bringing up of such children is, therefore, often accom- panied with the greatest difficulty, suckling being only possible when the child is held quite upright, and when the flow of the milk is assisted 30 OPERATION FOR by pressure on the breast, or the food is in this position allowed to flow into the mouth, in very small quantities at a time. The consequences of this misformation are manifested at a later period of life, by its inter- ference with the speech, which is more or less indistinct and unpleasant. The person so affected cannot blow out air from the mouth with any force ; and fluids cannot be swallowed in the horizontal position without great difficulty. 733. Artificial palates, such as are employed in cleft of the hard palate, are ordinarily useless in this ailment; because they always pro- duce the same interference in the articulation of tones; but very care- fully made elastic obturators may in some degree lessen the difficulty (a); their use, therefore, may be permitted in those cases in which the union of the cleft does not succeed, or is especially impracticable (b). The cure can be effected only by the union of the cleft after previous paring of the edges. This operation, (Gaumen-Naht, Germ.; Staphyloraphy, Kyanoraphy Uranoraphy Uraniskoraphy,) first proposed by Graefe, and performed in the year 1816, is in itself of no great importance, but, on account of the difficulties in its performance, is one of the most delicate operations. The more full and the less apart the edges of the cleft are, and the less they are stretched, the more complete is usually the result of the operation. If there be at the same time a cleft in the hard palate, the perfect union of the cleft in the soft palate is but rarely effected ; most commonly the operation is quite unsatisfactory. The operation should not be performed on children, but only in adults. Staphyloraphy may be also employed in other diseased conditions of the soft palate than congenital clefts ; as, for instance, in wounds (c), and in the division produced by syphilitic ulcers and the like. Ebel's advice is to prepare the patient for this operation by frequent dabbings, and brushings of the palate-curtain, by pressing down the tongue and the like for the purpose of accustoming these parts to irritation. Graefe's proposition is to excite active inflammation and superficial suppuration, by frequently touching with concentrated muriatic or sulphuric acid, the parts lying near the cleft in the palate- curtain, in order to render them fitter for union, by altering their tissue if it be too open, too soft, too full of the juices, too muco-membranous (d). 734. The operation of staphyloraphy, for the performance of which so many different, and some extremely complicated and unsuitable, modes have been proposed, is most simply and suitably conducted in the following way:—The patient being placed opposite a good light, the mouth wide open, and the tongue well depressed by the patient's own efforts; or the mouth kept open with a piece of cork introduced between the hinder grinding teeth, and the tongue depressed by an as- sistant with a simple spatula, half a line of the lower part of the left edge of the cleft, is to be caughi hold of with a pair of sufficiently long hooked forceps, gently drawn out, and a lancet-shaped cataract knife is to be thrust near the forceps through the edge of the cleft. The knife is then to be sawed from below upwards, and a strip as wide as (o)Graefe's artificial palate-curtain; in (6) For bow liltlebenefit is obtained from his and Walther's Journal, vol. xii. p. 655. them see DrEFFENBACH in Rust's Magazin, Snell, J., Observations on the history, use, vol. xxix. p. 491. and construction of Obturators or Artificial (c) Ferier ; in Revue Med., 1823, July. Palates, illustrated by cases of recent im- p. 245. provement. London. Seoond Edition, 1828. (d) Schwerdt, above cited, vol. ix. CLEFT SOFT PALATE. 31 a straw separated up to the angle of the cleft. And, lastly, the little part where the forceps have been applied is to be cut off from above downwards. In the same manner the opposite side is to be treated, and especial care should be taken that, at the angle of the cleft, both cuts are very close, and joining at an acute angle, and that the removal of the edges be every where equal. The patient is then to be left quite quiet, and may frequently gargle with cold water, by which the slight bleeding is easily stopped, and the viscid mucus got rid of. [The operation of staphyloraphy appears to have been first performed by Le Monnier, and is thus mentioned by Robert (a):—"A child had the palate cleft from the velum to the incisive teeth. M. Le Monnier, a very clever dentist, at- tempted with success to re-unite the two edges of the cleft, first making several points of suture to hold them together, and then refreshing them with a cutting instrument. Inflammation ensued, terminated in suppuration, and was followed by union of the two lips of the artificial.wound. The child was perfectly cured." Upon which Velpeau observes:—"A child, a cleft, the suture, the refreshing, the cure, every thing, in spite of the somewhat vague expressions of Robert, scarcely permits us to doubt that this dentist, truly had recourse to staphyloraphy, and not to the suture of a simple perforation of the palatine vault." He also mentions, that "in 1813 experiments upon the dead body were made by Colombe, and that he was desirous of repeating them on a patient in 1815, who, however, refused." (p. 573.)] For the purpose of keeping the mouth open and pressing down the tongue, arti- ficial means, as the introduction of cork between the back teeth, Suchet's katago- glos (b), as well as the introduction of a blunt hook at the corner of the mouth, are superfluous; and the depression of the tongue with a spatula is so much the more dangerous, as thereby choking is only more provoked. The fixed purpose of the patient is fully sufficient. It must, however, be remarked, that during the opera- tion the patient is to be often allowed rest and the mouth rinsed with cold water, partly to stanch the bleeding and partly for the removal of the mucus hanging about. The refreshing of the edges of the cleft from below upwards in the way proposed, is more certain than from above downwards, because the flowing of the blood does not interfere with the direction of the knife. According to Graefe's original proposal, the edges of the cleft should be brought into a suitable condition for union, by removal with a chisel-like instrument, fur- nished with a counter-hold, or by touching them with muriatic, or sulphuric acid, caustic potash, tincture of cantharides, and the like. Subsequently, when this operation had been performed by others in a more simple manner, Graefe also employed for the removal of the edge of the cleft, a pair of curved forceps ftnd a nar- row knife, which he carried from above downwards. Roux, who commenced with the introduction of the threads, then laid hold of the lower part of one edge of the cleft with a pair of forceps, drew it out, and cut it off with a straight button-ended bis- toury, sawing it from below upwards. Ebel (c) also and Krimer (d) use a pair of forceps and a simple knife, directing it from below upwards. Dieffenbach (e) freshens the edges of the cleft with a bistoury, laying hold of the edge of the cleft with a hook, and cuts off a straw's breadth with the bistoury, directed from below upwards. Berard (/) makes his incision from below upwards. Alcock (g) used the fine scissors, which Roux also partially employed, in a bent form, in his later operations. 735. For the purpose of uniting the raw edges, a thread is to be used, on which two straight needles are threaded; each needle is to be held with a needle-holder, and thrust through, the edge of the cleft be- ing fixed with a pair of forceps, from behind forward, at three and (a) Memoires sur differents objets de Me- (e) Above cited, Feb., 1826. tlecine. Paris, 1764. (/) In Schmidt's Jahrbiicher, vol. iv. (b) Journal complement, du Dictionnaire pt. iii. des Sciences Medicales, November, 1822. (g) Transactions of Apothecaries and Sur- (c) Above cited, p. 86. geon-Apothecaries of England and Wales. (d) In Graefe und Walther's Journal, London, 1822. vol. x. p. 622. 32 OPERATION FOR a-half to four lines distance from the edge; the point of the needle is now to be taken hold of with the forceps which had hitherto held the edge of the cleft, and drawn out together with the thread. The other edse of the cleft is to be similarly treated. The number of stitches which are thus to be introduced, differs according to the size of the cleft. If the uvula be completely cleft, then from three to four stitches are necessary, and the upper must always be first put in. After the patient has been allowed a little rest, and cleared his mouth with water from blood and'mucus, the threads must be tied together by means of the extended fore-finger against the wound, first with a sur- gical, and afterwards with a common knot, and cut off close to the knots. Various modes of treatment have been recommended for bringing the cleft to- gether. Graefe's hook-like needles, and the threading of the two ends of the suture into the lateral openings of a canula placed on "the palate, and when the threads have been sufficiently tightened, is closed by means of a screw. Subse- quently he employed nearly straight needles, and tied the threads (which were black and soaked with oil) in a surgical and afterwards in a simple knot (a). Roux used needles of a small curve and a needle-holder, and tied the threads to- gether in two simple knots, in which the first is held with forceps till the second is looped, so that it may not meanwhile give way. Ebel (b) employs for the sew- ing, short, straight, double-edged needles, and a needle. Doniges proposes a long needle, like an aneurismal needle, with a very sudden curve, a sharp point having an eye immediately behind it and the stem fixed in a handle bent down, for convenience, like the handle of a gorget. The needle threaded, is passed from behind through either edge of the cleft, and the end of the thread on the inside of the needle curve, being caught with a hook or forceps, is drawn forwards and com- pletely through; the needle itself still unthreaded, is then drawn back, its point carried behind the other edge, and having been thrust through, the thread on the outside of the needle curve is drawn forwards out of the needle-eye, which being thus set at liberty the needle is withdrawn entirely, the threads passed through each other and tied, by thrusting down between them a little plate six lines long, with a notch at each end for the threads to*run in, two lines broad, and fixed on a stem four inches long, with a handle. Warren (c) proceeded in a similar manner, not only in the case he describes, but also in another on which he operated some years pre- viously. "The principal difficulty he met with in this operation was in disentang- ling the ligature from the hook after it had perforated the palate, and he therefore proposed a curved needle with a movable point, which after having been passed through the soft palate, can be separated from the stem, unthreaded, and having been refixed and rethreaded with the hinder end of the thread, is passed through the other edge of the palate, and separated from the stem as before. As to the objections to this treatment, see Schmidt (d). Wernecke used a needle with an eye in front, and a whalebone handle. LeseNberg's (e) needle is similar to that of Doniges, but its point can be covered with a guard. Krimer (/) also uses a similar needle, which can be closed. The instrnments for drawing the knot have also been varied by the above-men- tioned practitioners. Wernecke carried the knot up to the palate with two small grooved probes, and cuts of the end of the thread. Ebel used small tubes, and Doniges the special knot-tier, already mentioned. Dieffenbach by means of a nearly straight needle, into the hinder hollow part of which a leaden thread has been introduced, unites the cleft by drawing the wire together; cuts it off a few lines distant from the soft palate, and turns the twisted ends upwards, so as not to irritate the root of the tongue. The lead wire allows (a)ScHWERDT, above cited,and in Graefe's (d) von Graefe and von Walther's Jour- Journal, vol. x. p. 371. nal, vol. v. pt. ii. p. 338. (b) Above cited. (e) Dissert, de Staphyloraphia quredam. (c) American JoUr. of Med. Sciences, Rostochii, 1827. 1823. Nov, (/) von Graefk and von Walther's Jour- nal, vol. x. p. 622. CLEFT SOFT PALATE. 33 loosening and much tightening. Dieffenbach also proposes to effect the union with a pair of peculiar forceps. Hruby's palate-holder, is similar to Beinl's lip-holder (a). Schwerdt's cleft needle for the introduction of the thread (b). Berard (c) thrusts in the needle from before backwards.—Smith's needle (d) is long lance-shaped, and furnished with a notch for the reception of the ligature. [But Mutter objects to it, " first, as being mounted on a straight handle, which renders it more difficult to introduce its point at the proper places; and secondly, the difficulty of disengaging the thread, which may be drawn back along with the needle in the attempts of the surgeon to disengage the latter from the margin of the palate." (p. 9.)] Alcock (e) operated at intervals, so that he made raw, and united only one part of the cleft; in one case he only effected perfect union after five operations; in the first four he used the interrupted, and in the last the twisted suture. Hartig (/) effects the union by means of a palate-cramp (fibula seu retinaculum palati.) [Liston (g) introduces a double ligature on a curved needle fixed in a handle, through the front of the palate curtain, "the noose of which is caught by a blunt hook and pulled out into the mouth whilst the instrument is withdrawn. A second and smaller ligature is carried through opposite to this, and by means of this se- cond thread the first and double one is brought through." (p. 503). Mutter uses a much curved needle half an inch in length and mounted on a cylindrical neck, a portion of which is held in the grasp of the porte, (Schwerdt's), and the other part made rough, is intended to be grasped by the forceps of an assistant. The cutting edge of the needle being wider than the diameter of its neck, will make an opening large enough for the easy transmission of the ligature. The forceps too may be improved, by causing them to close with a spring instead of a catch." (p. 9.)] Fergusson, of King's College Hospital, has proposed a new mode of staphylo- raphy, and has successfully treated two cases by it. " The principle of this new proposal is to divide those muscles of the palate which have the effect of drawino- the flaps from each other, and widening the gap between them when they contract! so that the stretched velum may be in a state of repose, and the pared edges may not be pulled asunder by any convulsive action of the parts during the process of union. In other words he advises, as an important accessory to the operation of staphylo- raphy the division of the levator palati and palato-pharyngeus muscles, and, if requi- site, the palato-glossus (h). 736. If in very large cleft, the closure be difficult and only to be ef- fected with great stretching, in consequence of which severe inflamma- tion and tearing of the sutures are to be dreaded, the satisfactory result of stitching the palate is rendered most certain, according to Dieffen- bach {%), by making"an incision with a bistoury down to the bone on each side of the closed cleft of the palate, and half an inch distant from the lower edge of its arch. This immediately produces relief from all tension, the united edges hang loosely in the middle, unite together and the threads neither cut in nor through ; the patient breathes freely through the holes, as otherwise the great swelling of the palate renders breathing very difficult. In the previous tension of the palate there is also great increase of substance as the lateral openings are closed by granulation in from ten to fourteen days. When at the same time there is a cleft in the hard palate and considerable separation of the edges of (a) In von Graefe and von Walther's zur. Vereinizung des gespaltenen Gaumens Journal, vol. ix. p. 323, pi. iii. f. 2. ohne Naht. Braunschweig, 1841. (b) Above cited, pi. iv. f. 7. (g) Practical Surgery, London. 1837. (c) Above cited. 8vo. (d) North American Archives of Medical (h) Medical Gazette, N. S., vol i p 389 and Chirurgical Science, October, 1834. 1S44-45. ••*»■• (e) Above cited. (i) In Rust's Magazin, vol. xxix. p. 491. (/) Beschreibung eines neuen Apparates Vol. ii.—4 34 OPERATION FOR CLEFT SOFT PALATE. the cleft, it maybe necessary for effecting the union to separate the soft palate, to some extent from the hard palate, by two horizontal in- cisions. Bonfils (a), after paring the edges, separates a V-shaped piece of skin from the palate, corresponding to the cleft, and unites it by the interrupted suture. In a case in which the cleft of the soft was connected with that of the hard palate, and the distance of the edges was great, for the purpose of bringing them into con- tact, Roux, after putting in the stitches, and paring the edges, made two horizontal cuts, which divides the soft from the hard palate, and extended from the edge of the cleft somewhat above the perpendicular of the ligatures on both sides. The edges of the cleft may in this way be easily united. In one case, in which With a cleft of the soft palate there was also a very conside- rable wolfs jaw, and the union of the soft palate thereby rendered impossible, Krimer (b) made on both sides two longitudinal incisions, four lines distant from the edge of the cleft, which joined together at an obtuse angle in front, and termi- nated behind at the still projecting portion of the soft palate; the soft parts were then divided by these cuts towards the edge of the palate, that a pair of wedge like flaps were formed with their bases behind. After the bleeding had been stanched with sage-water and alum, the flaps were turned inwards, so that their palatine sur- face was level with the floor of the nostrils, and the sewing together of the palate was then effected with the needle-holder in the ordinary way. Dieffenbach (c) proceeds more simply; after closing the cleft in the soft palate, he separates the soft parts on the hard palate, shaves the bone, and draws together the edges with lead wire. [Mutter mentions that Warren of Boston, U. S., had succeeded in closing a deficiency in the upper part of a palatine cleft, or that portion which extended into the hard palate, by detaching the mucous membrane, and sliding it from each side to the median line, uniting the flaps by two or three sutures." (p. 20)]. 737. After the operation, the patient may neither speak, nor take food, nor swallow his spittle, but must have it removed from his lips with a cloth, or carefully allowed to flow into a vessel, and every thing must be avoided which may excite coughing, sneezing, or laughing. At the end Of the third the upper, and at the end of the fourth day the lower stitch may be removed, the knots being held with a pair of forceps and the thread cut by its side with a pair of scissors and drawn out in the contrary direction. Nourishing broths may be taken at first in small quantity and with great caution, and when the union has become firm, more solid food may be allowed. According to Graefe, if the spittle be collected in the throat in quantity, we should attempt its removal by injecting, or by brushing off with a brush made with charpie or linen. A solution of from one to two grains of extract of belladonna may be at once given in a little water, by which the patient is much relieved. On the first days also he permits strong wine, with yolk of egg, given with a spoon, and nourishing clysters. The living activity in the edge of the wound may be increased by pencilling with muriatic acid, naphtha, equal parts of tincture of eu- phorbium, cantharides, and myrrh, or in torpid persons, with tincture of cayenne pepper or capsicum. The stitches should only be removed when they entirely or partially fall out of themselves. Dieffenbach also says that the patient may take fluid food without fear. [Although the operation of staphyloraphy is generally unattended with danger, yet, in a few instances it has been fatal from the inflammation spreading along the windpipe to the lungs, as happened in the case of an English nobleman's daughter, who was operated on by Roux; the only one, of sixty cases on which he operated, which he lost. Berard (d) also mentions that he lost one case from pneumonia (a) Journal de Medecine, 1830, December, (c) Rust's Magazin, vol. xxx. p. 288. P-937- (d) Article—Staphyloraphie; in Diet, de (b) von Graefe und von Walther's Jour- Med., ou, Repert. gen. des Sciences Medic nal, voh x. pi 625. vol. xxviii. p. 547* OF THE OLD DIVISION OF" THE FEMALE PERINEUM. 35 originating in the same cause; and that, in another instance, the face was attacked with erysipelas, from which, however, the patient recovered.] 738. If the union be only partially effected, the mouth may be washed gently with red wine, and the open parts pencilled with honey of roses, tincture of myrrh and borax, only strong fluid nourishment is to be per^ mitted ; and the patient not allowed to speak. If an opening of two or three lines remain, it may be frequently closed by touching with muriatic acid; but if this be not effectual, these parts, three or four weeks after the completion of the scar, must be again stitched up. If the cleft do not unite at all, the edges soon scar with using red wine as a gargle and the pencilling just mentioned. The cleft is generally smaller. Dieffenbach (a) endeavours to close such apertures in a peculiar manner. He makes on each side of the opening penetrating but parallel incisions, at the distance of a line from the edge, by which the tension is relieved, and an approach of the edges effected, which Dieffenbach still favours by introducing into the incision charpie soaked in almond oil. After the scarring of the latter he makes two similar incisions, though in contrary directions, which are held together in the same way. 739. Although after most of the modes of treatment for effecting the suture of the palate successful results occur, yet is the above-described simple mode of treatment to be considered most preferable, as from my own experience I have proved. That the lead wire has not the many inconveniences attributed to it by Graefe and Schwerdt {b), that by its hardness it presses, by its weight it tears, that cutting-in is not pre- vented, and that severe traumatic re-action is produced, have been long since disproved by the satisfactory and numerous results of Dieffen- bach's practice even in the most difficult cases. To him owe we espe- cially the greatest thanks in reference to his perfection of suture of the palate. 740. Even when the cleft is perfectly closed, the speech only becomes gradually more distinct as the tension of the soft palate subsides. The person operated on must first use himself to utter single letters, and afterwards syllables and so on. IV.—OF THE OLD DIVISION OF THE FEMALE PERINEUM. Noel ; in Journal General de Medecine, vol. iv. Saucerotte, ibid., vol. vii. Mursinna ; in Loder's Journal, vol. i. p. 658. Viet, De Ruptura Perinaei. Goettingae, 1800. v. Fabrice, C. E., Medicinisch-chirurgische Bemerkungen und Erfahrungen, Nurnberg, 1816. p. 1. Schreger, Annalen des chirurgischen Clinicums auf der Universitat zu Erlangen, 1817, p. 73. Roux, in Journal Hebdomadaire, vol. i. No. iii. Dieffenbach, Chirurgische Erfahrungen, besonders uber die Wiederherstellung zerstorter Theile. Berlin, 1829. No. v. p. 64; and in the Medicinischen Verein- szeitung in Preussen. 1837. No. 52. Duparque, Histoire complete des Ruptures et Dechirures de l'Uterus, du Vagin, et du Perinee. Paris, 1836. 8vo. Mercier; in Journal des Connaissances Medico-chirurgicales, 1839, March, p. 89. 741. Tearing of the perineum may be consequent on difficult labour, (a) Schwerdt, above cited. (b) Above cited, vol. viii. p. 102. 36 OPERATION FOR when there is disproportion between the size of the child's head and the extensibility of the external organs of generation or artificial narrowing. The tear is often only at the vaginal edge of the perineum, but frequently extends throughout the greater part, more or less following the raphe to the edge of the rectum, or the whole perineum is torn into the rectum.— Slight tearings of the perineum are of little consequence and general y heal without assistance, the patient remaining constantly on her side with the thighs kept close together, and proper attention paid to cleanli- ness. But this rarely happens in large tears, as the wound is continually fouled by the lochial discharge, and at every time of going to stool the wound is opened. In complete tearing of the perineum between the vagina and rectum it is quite impossible to retain the stool if the greater part of the sphincter ani be torn. If in a torn perineum union cannot be effected, the two edges of the wound skin over, and the cure is only pos- sible by removing the skinned edges and by union with the stitch. From what has been said, it follows that in considerable tears of the perineum it is most safe immediately to effect its enclosure by stitching. It must not be over- looked, however, that the parts are rarely in a suitable condition for quick union, and that if there be swelling and inflammation of the edges of the wound, union is thereby contra-indicated. If the woman herself object to this treatment, if accom- panying indisposition, or the circumstances already mentioned forbid it, the position on the side must be persisted in, with the thighs a little drawn up towards the body and tied together (1), care also being taken for proper cleanliness, for soft motions, and for drawing off the urine from time to time with the catheter. The healing which in this way takes place in small tears of the perineum, does not depend on any union of the edges, but on its shortening backwards, so that the labia pudendi extend back and occupy the place of the former wound. The greater the tear the shorter becomes the perineum, and the longer, on the contrary, the labia and great fissure, the former at the same time losing their fulness, and becoming thinner. If the tear of the perineum extend into the orificium, ani, the labia are drawn backwards by the scarring, and their hind extremities are held together by whitish callous scar; it seems as if the anus had moved further back, and the labia were drawn with it. Sometimes there is a central tear of the perineum, and the whole child is thrust through it (a). The cure in this case may be effected by the natural powers; but if the tear extend on the sheath of the rectum, it has never been seen to take place. Large and recent tears of the perineum can be alone satisfactorily treated with the stitch, as all other remedies proposed for bringing the wounded edges together, either graduated compresses on both sides, and fixing them with bandages, (Jorg.) Moulin's perineal forceps (b), or the introduction of different bodies into the vagina for the purpose of removing and absorbing all fluids, are extremely uncertain. [(1) Duparcque does not agree withdrawing up the thighs. He says:—"I think it better to leave the thighs completely extended, a position, in which the buttocks being more close together, at the same time diminishes the perineal space," (p. 422). He also thinks other means more effective in producing compression may be had recourse to, and mentions a case in which he " introduced into the vagina a large flattened gum elastic pessary, having a large central aperture, into which he fixed the funnel-shaped extremity of a large elastic tube. The pessary pretty exactly fit- ting the vagina prevented the lochial discharge filtering between it and the sides of the canal, and consequently from getting between the lips of the tear. As the instrument reached above the top of the wound, it could not prevent the meeting of its edges; besides, the compression which it exercised on the rectum contributed to keep up the constipation he desired." In addition to this he placed a long cotton cylinder along each side of the torn vulva and perineum, confined them by a double- (a) Dupuytren, Pourchier ; in Gazette Medicale, vol. iii. First Series, pp. 684,866. (6) v. Froriep's Notizen, vol. xxiii. p. 26. TORN PERINEUM. 37 tailed T-bandage, the tails of which, continued between the trochanters, and ischial tuberosities, had their inner edges brought together by sewing. The case did well.] 742. Small tears of the perineum, cured as already mentioned, are ac- companied with no further inconvenience than with the disagreeableness of a great width of the vagina. Larger tears cause besides the usual relaxation of the vagina, protrusion of its front or hind wall, also drop^ ping and prolapse of the womb ; the ability of retaining the stools is not prejudiced, but wind frequently escapes, and in diarrhoea the needs are very pressing. As the woman is generally alarmed at her condition, such cases rarely become the object of definite treatment. The changes of the external generative organs thereby produced, are, however, of such kind, that all simple tears of the perineum should be treated with the greatest care. In the old tears which have extended into the vent, the impossibility of retaining the stools continues; at least, in that case the flatus and soft motions pass away unexpectedly on the slightest ex? citement. ["Slight cases (of torn perineum) will often," says Dr. CJhurchill (a), "heal without assistance. Even when the rent is more extensive, a cure may be effected without further interference than great cleanliness, keeping the patient in one posi- tion, so as to preserve the edges of the wound in contact, and constipating the bowels after free purgation." (p. 409.) My friend Dr. Waller informs me that most of the cases of torn perineum which have come within his knowledge, have done well with- out any operation: and that even after the most severe tears, as when the m- sphinc- ter ani is torn through and both rectum and vagina are laid into one, he has known instances of recovery with capability of retaining the motions, and with the simple inconvenience of the patient being compelled to hasten quickly to the water-closet, immediately on feeling the slightest disposition to go to stool, as when the motions approached the vent they could not be restrained from voidance. How under such circumstances the stools are retained may perhaps be explained by Dr. Burns's observation (b), that " it sometimes happens that the torn extremity of the rectum or the anterior parts containing a fragment of the sphincter or a portion of the internal sphincter, as it has been called, forms a kind of flat valve, which rests on the pos-» terior surface at the coccyx, so that the orifice now resembles a slit, and the faeces, unless very liquid, remain in the hollow of the sacrum and do not pass through the valvular orifice till an effort be made to expel." (p. 68.) y The scarring of the lips of the torn perineum Duparcque describes as taking place " in two directions; at first in its thickness, so that the skin of the perineum and the mucous membrane of the vagina approach and run into each other, except where the perineal partition is very thick arjd'there an intermediate scar is produced, having the characters of mucous membrane. The scarring occurs also at the same time in the longitudinal direction of the lips of the wound; this shortening is only effected at the expense of the tissues corresponding to the angles. In the case of tearings of the furcula and perineum, the labia which alone can readily stretch, are then drawn back by this mode of scarring; thus we may be assured that in women who have had the furcula deeply torn, the size, which the vulva has preserved depends in great part on this lengthening of the labia; sometimes even their commissure is con- founded with the margin of the anus without any distinguishable trace of interme-s diate scar. This mechanism of the scarring explains, why the existence of a bridle separating the vulva from the wound, in central tearing of the perineum, renders scarring much more difficult and tedious than when the tear has been complete. In reality, the presence of this bridle, which is formed by the posterior commissure of the vulva, preventing, to a certain degree, the assistance afforded to the scarring lengthways by the elongation of the labia, either retards it considerably, or causes a fistulous opening. Cut this bridle, and you then observe the scarring, which up to (a) Observations on the Diseases incident (b) Principles of Midwifery, &c. 6th Edit. to Pregnancy and Childbed. Dublin, 1840. London, 1824. 8vo. 8vo. 4* 38 OPERATION FOR that period had seemed stationary, make rapid progress and completely perfected. He farther observes, that " what has been mentioned in regard to the uw^a applies also to the anus,- it is by a similar mechanism, that tearings or ruptures which in- volve this opening and a part of the recto-vaginal partition, scar; the scarring oc- curs both in the direction of thickness and length; by the latter extremities of the divided sphincter ani stretch and approach the rectal angle of the wound, contributing more or less to fill it up ; the anus is then actually enlarged. In fact, the sphincter being then much outspread, at last embraces nearly the whole of this very large anus, which to a certain point is only as large as ordinary. Thus the excretion of the stercoraceous matter, which was involuntary, often terminates by returning to the natural control of the will. On the other hand, the edge of the rupture formed by the recto-vaginal partition, having been drawn together, in consequence of this mode of scarring, descends lower, forms a sort of spur, a kind of valve which opposes itself to the passage of the intestinal contents into the vagina, which had previously occurred. Thus, then, the deep ruptures or tearings of the perineum extending to the anus and recto-vaginal partition, may be had without any other inconve- nience than that resulting from a very large opening." (p. 415-18.)] 743. Operation on an old tear of the perineum, when extending into the rectum, is always most uncertain as to its consequences, and so much the more so if the tear be large, and connected with loss of substance and much callosity of the edges, and if the endeavour to bring the edges together be fruitless. In bad condition of the powers, in lymphatic scrofulous persons, in habitual diarrhoea, the operation is contra-indicated if these evils cannot be got rid of by suitable treatment. 744. The skinned-over edges of the torn perineum are to be refreshed in the following manner. After suitable purging, the patient is to be laid on either side, with the thighs drawn up towards the belly, so that the breech projects beyond the edge of the bed, or she is to be laid in the same position as in cutting for the stone. If the perineum be covered with hair, it must be carefully removed. An assistant separates the but- tocks from each other, and holds back any accompanying protrusion of the vagina. The operator, after having ascertained the extent and state of the separation, takes hold of the lower edge of the cleft with a pair of forceps, used as in the operation for entropium, and cuts off the part taken hold of with a bistoury, or less advantageously with scissors. He then proceeds with the upper edge in a similar way, and freshens both edges of the cleft to such extent as will enable them to unite; care is also to be taken that no part covered with skin remain. As soon as the bleeding has been perfectly stanched with a sponge dipped in cold water, and all the clotted blood has been removed, the cleft is to be united with two interrupted sutures, for which purpose a sufficiently strong curved needle, with a handle, and furnished with waxed threads, is to be introduced and thrust through the whole thickness of both edges, an inch and a half from the angle, the threads being drawn after it; and, in this manner, four lines nearer the pudendum a second, and if the size of the cleft require it, a third bundle of threads is to be introduced. The edges of the wound after proper cleansing are to be brought together, and the threads next the rectum are to be drawn together with a double knot sufficiently to bring the edges of the wound into contact. Instead of the interrupted, the quill stitch may be employed, which by its equal operation on all parts of the wound keeps the union close, as is especially confirmed by Roux's successful results. The wound is to be covered with a pledget and compress, which may be fastened with a T-bandage TORN PERINEUM. 39 or left uncovered ; or a piece of sponge is applied, which is preferable, as the fluid flowing from the vagina does not collect upon the superficial pieces of the bandage. If in the union there be much tension of the edges of the wound, two parallel cuts must be made through the skin (Dieffenbach). The patient should remain after the operation upon her side, with the thighs drawn up and close together. This operation was first proposed by Ambrose Pare, and successfully performed by Guillebonneau ; Mauriceau, La Motte and Smellie have recommended it; Noel and Saucerotte have successfully practised it; and subsequently it has been undertaken by Dupuytren, Mursinna, Menzel, Osiander, Dieffenbach, Montain, Roux and others. The mode of proceeding as to refreshing the edges is the same in all cases but varies considerably as regards the union. Guillebonneau employed the interrupted stitch ; Moriceau, La Motte, and Smellie recommend the su- ture with penetrating stitches; Noel, Saucerotte employ the twisted stitch; Dieffenbach both it and the interrupted; Roux and Montain the quill stitch. Ritgeon (a) took a thread with two needles, thrust the one deeply on one side into the cleft at the edge of the skin, and carried it through an inch from the edge of the wound into the vagina where he drew it tight with a slip-knot. In this way the membrane of the vagina is brought together in several folds, which keep the fluid from the wound. If there be at the same time injury of the m. sphincter ani the twisted stitch must be applied. [In a successful case operated on by Davidson (b), he "passed deeply a strong double ligature by means of a common curved needle, close by the edge of the rectum, and another, rather more than half an inch from the first, towards the vagina ,■ after which he pared the edges of the wound, which he had not previously done, that he might not be annoyed by the oozing of blood, so as to be enabled to place the ligatures more accurately. The ligatures being introduced, he employed as cylinders two pieces of elastic gum catheter, about an inch and a-half in length, one of which was placed in the loops which the double ligature formed on one side, and the other between their separate ends, tying them firmly upon the cylinder." To prevent the eversion of the edges of the wound which Roux found to be produced by the quill suture, and which he remedied by several small stitches at different points between the sutures, Davidson "armed a curved needle with a piece of nar- now tape, four inches long, having a knot at one end; this was down each end of both cylinders about half an inch, and brought outwards, the end of the tape being prevented slipping through by the knot; the tapes were then placed in such a situa- tion as to be intermediate to the ligatures; this being done, he turned the cylinders gently towards the edge of the wound, and tied the corresponding tapes over it." p. 225.] 745. The principal object after the operation is to produce, by the use of gentle purgatives, daily, soft motions, which should be received into a draw-sheet, and the patient must strain as little as possible. The urine must be received into a tin receptacle from which a leathern pipe passes into the night-stool, without needing any change of posture. Only when there is retention of urine the catheter is to be used, directed merely by the fore-finger of the right hand. The dressing is to be re- newed as often as cleanliness requires, and if there be any unnatural se- cretion from the vagina, cleansing injections are to be used each time. Between the eighth and twelfth day the threads are to be removed and the perineum covered with charpie dipped in lead wash. If the union be only partial, the inconvenience is, however, often diminished ; but if this be not the case a second closure must be undertaken. Many observa- tions" prove that a perfectly united perineum remains uninjured in a sub- sequent labour. (a) Gemeinsame deufsche Zeitschrift far (b) Lancet, 1838-9, vol. ii. die Geburtskunde, vol. iii. pt. i p. 168. 40 ulcers; Attempts have been made to sustain an artificial retention of the faeces, for six or eight days, and even longer, so that the union might be undisturbed. Dieffenbach gives, for two days prior to the operation, little but. nourishing food, then a laxative, and on the day of operation an opium pill to produce and to keep up costiveness for six or eight days, after which he gives castor oil. But with all care and em- ployment of remedies for facilitating the discharge of faecal matter after long cos- tiveness, their discharge is very difficult, accompanied with severe effort, and may destroy the scarcely effected union. Thus in Saucerotte's case, in which the union failed, the stitches tore on the eleventh day on account of the violent effort ingoing to stool, and in which a second operation, in which a tight suture had cut through the m. sphincter ani, succeeded, care having been taken for the easy relief of the bowels. Roux employed in one case costiveness, which the patient had learnt by refraining from food, and by the use of opium, so perfectly to effect, (for the purpose of improving the unpleasantness of her situation,) that the motions were retained till the twenty-second day, arid on account of their hardness required to be helped forward by pressure of the finger from the vagina,- he recommends, however, on the contrary, when not habitual costiveness is to be relied on, to render the excrements fluid, and he proposes this as a principal point in the after treatment. [In Davidson's case, the bowels were constipated by opium, the urine drawn off night and morning, and the diet was confined to small quantities of gruel and hard biscuit. The ligatures were removed on the seventh day, the union being com- plete. After nine or ten days the urine was voided naturally, and on the seventeenth the bowels were relieved. At the end of six or seven weeks she went about as usual.] Horner (a) recommends, after the union is perfected, to cut through the m. sphincter ani, so that the sutures should not be torn out in going to stool. Old perineal tears rarely heal by quick union; on the contrary, experience shows that such are more liable, by suppuration and ulceration, to a change, whereby in- deed its connexion cannot be again naturally produced, but a certain continuity of skin may be attained, similar to the formation of a mucous membrane, which, from the pressure and rubbing in walking, becomes gradually insensible, and thus the patient's condition is much improved. In all cases in which, where the lono1 continuance of the perineal tear gives less hope of the quick union, or where it is not effected, this mode of skinning over should be attempted, in which the callous edges are removed, the inflammation properly excited by digestive remedies and by lunar caustic ; but especially by keeping from the wound the faeces and urine, and if the granulations will not harden, to endeavour to effect this by the use of lead or zinc. Schreger (b). Nevermann's proposition (c) may be mentioned, to persons fearing the knife, to strew upon the skinned edges unslaked lime, or strips of linen powdered with lime, which after sufficient operation, is to be washed off", and the patient kept perfectlv still with her thighs together. B.—OLD SOLUTIONS OF CONTINUITY WHICH SUPPURATE. I.—OF ULCERS. First Chapter.—OF ULCERS IN GENERAL. Astruc, J., Traite des Tumeurs et des Ulceres, &c. Paris, 1759-68. 2 vols 12mo. Bell, B., A Treatise on the Theory and Management of Ulcers, etc., 1778 Edinburgh, 8vo. ^Hebenstreit's Zusatze zu Bell's Abhandlungen von Geschwuren. Leipz., Weber's allgemeine Helkologie, oder nosologisch-therapeutische Darstellnno- der Geschwure. Berlin 1792. 8vo. S (a) American Journal, 1837. (6) Above cited, p. 75. (c) Above cited, p. 487. DIVISION. 41 Bertrandi, A., Opere Anatomiche e Cerusiche. Torino, 1786-96. Henke, Fragmente iiber die Pathogenie und Therapie der Geschwiire; in Horn's Archiv., vol. ii. p. 1. Rust, J. N., Helkologie, oder iiber die Natur, Erkenntniss und Heilung der Geschwiire. Wien, 1811. 2 vol. Second Edit.; with copper plates. fol.^Berlin 1838. Rust, J. N., Einige Bemerkungen iiber das WesenderGeschwure. Ein Beitrag zur Bearbeitung der Helkologie; in his Magazin fur die gesammte Heilkunde, vol. xii. pt. iii. p. 512. Rust, C, De Ulcerum diagnosi etaetiologia nonnula ; cum tab. vii. col. Berol., 1831. 4to. Bluff, M. J., Helkologie. Lehre von Erkenntniss und Behandlung der Ge- schwiire, Berlin, 1832. 8vo. Hunter, John, Lectures on Surgery. Palmer's Edition. Vol. i. 746. An ulcer {Ulcus, Helcoma, Lat.; Geschwiir, Germ.; Ulcere, Fr.) is a long existing division of organic parts depending on irregularity of the vegetative processes, and accompanied with the secretion of an icho- rous and sanious fluid, and a continuing destruction of the parts in which it is situated. Ulcers are therefore distinguished from abscesses and suppurating wounds, but may originate from them, if by a ehange of vitality in the suppurating surfaces the process of regeneration be con- verted into ulceration or ulcerative absorption. 747. The causes of ulcers are either internal or external. The former consists in a peculiar deviation of the whole organism, or of single or- gans, from the natural type, with a great degree of weakness and flabbi- ness, or with those diseases, of which the ground depends on some change in the assimilation, for instance, acute and chronic eruptions of the skin, scrofula, syphilis, gout, scurvy, dropsy, suppression of the usual discharges, and the like. These diseases, either of themselves, or after the operation of an occasional cause, produce an ulcer. The external causes are all injuries which, producing inflammation and sup- puration, break up the connexion of parts; wounds, abscesses, the heal- ing of which is prevented by an existing disease, or by improper treatment; specific diseased matter operating locally, and the like. 748. Ulcers are divided into simple and complicated. Simple ulcers are those which are connected neither with peculiar local nor general disease, but depending only on the decided destruction of connexion which accompanies them, according to the condition already stated (par. 746). Complicated ulcers are, on the contrary, those connected with peculiar local or general disease. In regard to local complication, there may be distinguished fistulous, callous, cedematous, varicose, fungous, sloughy, and carious ulcers; further, ulcers, with a secretion of thin, lardy, acrid, stinking, saline, and variously coloured matter. General complications consists in the presence of the diseases and dyscrasies above mentioned {par. 747); hence are distinguished atonic, scorbutic, arthritic, syphilitic, carcinomatous, and impetiginous ulcers. From what has been said it results that ulcers may be local and general ailments. It is, however, to be herewith remarked, that ulcers which at first depend on a decided internal cause, often previous to healing, become merely local; and so, on the contrary those which at first were actually local, in their course draw the whole body into participation, and may become complicated ulcers. 749. The reaction of ulcers upon the whole organism varies according to their nature. In specific ulcers the general indisposition is increased by the absorption of the pus secreted in the ulcers, and tainted with the 42 ULCERS; specific poison. In ulcers in which the secretion of pus especially is very great, and of a bad kind, there arises a general weakness, partly from the continual loss of the juices, partly from absorption of the baa pus ; in the end complete cachexia, with altered pulse, often chills alter- nating with heat, difficult breathing, drawing pains in the limbs, dryness or great secretion in the ulcer, purulent urine, dropsical swellings, colli- quative sweats, and diarrhoea. If the ulcer be of long standing, its secretion operates in relation with the other secretions, and the ulcer is to be accepted into the series of natural secreting organs. This is espe- cially the case in old persons, in whom, with long-continued ulcers, the urinary secretion is considerably diminished. Ulcers may, therefore, themselves be considered as useful discharges in certain cases, and be- long to the relative well-being of the patient so affected. 750. The prognosis in ulcers varies:—1. According to the nature of the cause which produces or sustains it. 2. According to th&position of the ulcer. Here the importance of the affected part and of the neigh- bouring tissues must be considered. Ulcers in the skin and in fleshy parts heal more readily than those in tendinous parts or glandular organs. Ulcers in bones are always very intractable. In parts distant from the heart the cure is always difficult. 3. According to the duration and ex- ternal form of the ulcer. The older an ulcer is, the more tedious is its cure, and if this be forced, dangerous symptoms may be produced by suppression of its usual secretion. The more foul an ulcer is, the more spotty its bottom, the more everted and hardened its edge, the more ill- conditioned the fluid secreted in it, the deeper it penetrates and the larger the destruction of soft parts which it produces, the more difficult is the cure. Round ulcers are generally more tedious in their cure than oval ones. 4. According to the constitution and age of the patient. In young subjects, if the constitution be little affected by the reaction of the ulcers, the healing is quicker than in old and already much debili- tated peisons. 751. The treatment of ulcers in general, depends on the removal of the causes which, have given rise to them, and on such alteration in the living activity of the ulcerated parts, that by the natural manifestation of the reproductive processes the destruction of continuity may be again repaired. In the progress of ulcers towards healing three stages are to be noticed: ]. The stage of purification {Stadium Digestionis, Detersionis); the ulcer loses its foul appearance, and instead of ichpr, good pus is secreted. 2. The stage of the formation of granulations (Stadium In- carnationis, Granulationis.) 3. The stage of Scarring, (Stadiam Cica- trizationis,) in which the granulations become harder, become connected, and are covered with a delicate skin. 752. The treatment must be variously directed, according to the cause of the ulcer, its living disposition, and its form. First, of its treatment in reference to the latter two points. 753. Every ulcer may have an inflammatory, erethetic, or torpid cha- racter. In the inflamed condition of an ulcer which is produced, either by the constitution of the patient or by the improper use of irritating reme- TREATMENT. 43 dies, the parts surrounding the ulcer are swollen, hot, and painful; its base is much reddened, sensitive, covered with white streaks, and the secretion of pus especially small. In these cases every local and gene- ral irritant must be removed, the ulcer covered with lukewarm softening fomentations, poultices, or mild salves, and in strong constitutions, even general antiphlogistic treatment must be employed. In proportion as the inflammation diminishes, the secretion of pus increases. If an ulcer be in an erethetic condition, its base is also very much reddened, but its sensibility extraordinarily increased. Here are ser- viceable narcotic remedies, both internally and externally; rubbings in of warm oil of henbane, poultices of hemlock, henbane, and the like. In torpid conditions, depending on local or general weakness, the ulcer shows relaxation; the surrounding parts are pale, relaxed, and cedematously swollen ; the ulcer is insensible, and secretes a quantity of ill-conditioned thin pus. Here such local and general treatment must be employed as may increase the living activity and thereby promote the secretion of goTod pus. (Compare par. 62.) 754. The variety of ulcers, in reference to their form, requires pecu- liar attention in their treatment. The Foul or Gangrenous Ulcer {Ulcus putridum, gangrenosum, Lat.; faule oder brandige Geschwiir, Germ.; Ulcere gangreneux, Fr.) is cha- racterized by a foul, grayish-yellow or blackish surface, by insensibility, and by the secretion of a discoloured very fetid pus; the sloughy cha- racter often spreads over the whole extent of the ulcer and the parts are either gangrenous or sphacelated. The causes of this change in the ulcer may be neglect of cleanliness, improper treatment, impeded cir- culation, foul air, bad food, gastric impurities, weakened constitution, debility of the vascular system, cachexia, and the like. The treatment consists in removing the causes, and in employing such remedies as promote throwing off the gangrenous parts or the restoration of those, not yet completely destroyed to their natural vitality, which is to be attempted by the use of internal and external remedies. Bark, valerian, camphor, naphtha, the mineral acids, and so on, are employed internally; externally, decoction of bark, or oak bark with lime water, of walnut shells, of water-germander, with spirits of wine, vinegar, and so on ; aromatic spirituous washings of the surface surrounding the sore, charcoal powder with bark, oil of turpentine, digestive salves of myrrh, or camphor, solution of chloride of lime, fermenting poultices of flour, yeast, and honey. In general the resins or essential oils are more effective than moist remedies. If general dyscrasy exist, suitable reme- dies must be employed. When portions of the surface of the ulcer have separated, they must be removed ; and cuts made when collections of pus beneath the destroyed parts are to be feared. Frequent cleans- ing especially, the local application of oil of turpentine, spirituous remedies, tincture of aloes, or sublimate, must be had recourse to against the worms and maggots which are not unfrequently produced in these ulcers. More suitable than these numerous and in their operation very different remedies, is the use of mild aromatic applications, or poultices, by which the living activity is best increased, and the foul smell also diminished, as already mentioned, {par, 72) in the general treatment of gangrene. 44 ulcers; The solution of chloride of lime in water in different proportions, according to the vital disposition of the ulcer, is recommended as most highly efficient in gangre- nous, and especially in foul and torpid ulcers (Percy, Labarraque.) Lisfranc (a) bandages the ulcer with a moistened compress, and applies on it charpie soaked in a solution of chloride of lime. Lemaire (b) uses one part of chloride ol lime and three parts of water. Ekl (c) first employed fifteen grains of chloride ol lime in eleven ounces of water, and afterwards four grains to an ounce. According to Cli- mates (d) it should only be applied when all inflammation has subsided. Biett, Clocquet, and others have used it with much advantage; and according to Cuill- vier and Boulay, the ill smell is immediately got rid of on its application (Pigne). 755. The Callous Ulcer {Ulcus callosum, Lat. ; callose Geschwur, Germ.; Ulcere calleux, Fr.) is surrounded by a whitish, dry, insensible edge, not unfrequently of considerable thickness, aad cartilaginous cha- racter. This callosity often spreads over the whole ulcer. The cause of this change is a' want of blood or of the nourishing juices in the edges of the ulcer; hence these callosities occur most commonly in old persons in those places where naturally the course of the blood is lan- guid, or is prevented by accidental pressure, in bad treatment, in the improper use of relaxing ointments, or as consequent on a continued irritable condition of the edges of the ulcer, whereby a stagnation of the juices, and a similar change is produced, as in induration. Such cal- losities prevent the cure of the ulcer, and must therefore be resolved or removed. Only when they are not very hard, and quite insensible, softening and at the same time exciting, applications of aromatic vegetables may be employed, the empl. de cicutd cum ammoniaco,—mer- curiale,—gummosum, saponatum, diachylon cum gummi; a solution of muriate of ammonia. If" these remedies be of no avail, then we must proceed to the use of escharotics, as butter of antimony, lunar caustic, caustic ammonia, a solution of caustic potash ; scarification, or complete removal of the callosity with the knife, if the situation of the ulcer permit. 756. The (Edematous Ulcer (Ulcus cedematosum, Lat.; cedematose Geschwiire Germ.; Ulceres edemateux, Fr.) is, in its origin, connected with dropsical swelling, which receives the impress of the finger; its edges are flabby, pale, often even oedematous; the granulations pale, and the secretion of a watery ichor very copious. The causes are either local, mechanical, or internal, as pressure on the vessels retaining the blood, general or local weakness, lymphatic habit, and the like. The treat- ment of this ulcer requires, besides the removal of the cause, and beside those remedies which alter the torpid character of the sore, a continued compressing bandage, by swathing the whole part on which the ulcer is situated. 757. Fungous Ulcers (Ulcera fungosa Lat.; Schwammigten Ge- schwiire, Germ.; Ulceres fungueux Fr.) are beset with growths"either on their entire surface, or only on certain parts, or at their edges, which vary considerably as to their condition, being sometimes flabby, pallid, or deep red, insensible, and bleed easily; sometimes they are of a more firm chaiacter, have a bluish red colour, and are very sensitive. The (a) Revue Medicate, 1821. (c) Rat. Med. in echola cl. med. et chir (b) Archives Generates, vol. ix. p. 138. univers. Landish, 1826. (d) Froriep's Notizen, vol. xvi. no. 7. p. 107. VARICOSE ULCERS. 45 former are merely unnatural growths of the granulations, but the latter must be considered as malignant degenerations. The causes of this fungous degeneration may therefore be, long-continued torpid condition of the ulcer, improper use of debilitating remedies, too slight bandaging, the neighbourhood of carious bone, or the carcinomatous condition of the ulcer. The removal of such growths, which is necessary for healing the ulcer, is affected, if the granulations be of moderate growth, by a simultaneous treatment corresponding with the vital disposition of the ulcer, by a suitable compression with dry charpie, and frequent touching with lunar caustic; but if they be more considerable and exist as a ma- lignant degeneration, they must be removed by the energetic application of escharotics, by cutting off, or by tying. The usual escharotics are lunar caustic, caustic potash, butter of antimony, sulphuric acid, sulphate of zinc, burnt alum, and the like. These should be especially employed if the fun- gous growths be equally spread over the whole surface of the ulcer. The dry escharotics may be strewed upon the sore, or applied in form of ointment; the fluid painted on with a pencil after the ulcer has been pro- perly cleared of the effused ichor. The former are more suitable rather in a flabby state of the fungous excrescences, and great secretion of ichor; the latter in greater firmness of the growth, and less effusion. If the fungus grow only partially from the ulcer, it may be most easily removed with the knife, by cutting it off at the base ; by tying, when the fungus has a neck, and the patient dreads the knife, and much bleeding is feared from the excision. In those cases in which the remedies prescribed do not effect the destruction of the excrescence, or may produce awkward symptoms by their fluidity and spreading, if the use of the knife or liga- ture be not possible, then the destruction of the fungus is only to be ef- fected by the use of the actual cautery. The bleeding which often arises spontaneously, or in either of the preceding modes of treatment, from the fungous surface, must be stanched by styptics, compression, actual cau^ tery, or by the entire removal of the fungus. 758. Varicose Ulcers (Ulcera varicosa, Lat.; varicosen Geschwiire, Germ.; Ulceres variqueux, Fr.) occur most commonly in the lower ex- tremities; are for the most part oval and superficial; their base bluish, their secretion serous and bloody ; the edge in old ulcers mostly callous, and the surrounding skin brown ; accompanied wTith various veins of the leg, especially around the ulcer, and cederaatous swelling. Not un- frequently do they bleed periodically; ordinarily they are not painful, but frequently very painful, even without any trace of inflammation. These ulcers are in direct relation to the varicose affection, and all those evils which produce hindrance to the return of the blood, as pressure, continued standing, remaining in warm or cold moisture, must be con- sidered as their cause; hence certain trades, pressure of the pregnant womb and the like. Predisposition to varicose affections is grounded especially on plethora, full juicy lax habit, venous stagnation, and loaded state of the intestines; hsemorrhoidal disposition; suppressed hcemor- rhoid and menstruation. Hence it happens that, in many instances, these swellings of the veins are only symptoms of a deeper affection, and may even belong to the relative well-being of the patient. They arise either from accidental injury in existing varicosity) or from the Vol. ii.—5 46 ATONIC ULCERS. blood-knots running into suppuration; or other ulcers of a specific cha- racter are converted into them. In the treatment of these ulcers, their causes must be first attended to; venous stagnation and loaded bowels must be relieved by purging, re- gulation of the mode of life, diminished standing, relief of pressure, and the like. The whole ulcer is to be simply covered with dry charpie; but the varicose and (edematous swellings are to be especially counter- acted by swathing with bandages and by the circular application of sticking-plaster. If the cure be effected, its recurrence must be pre- vented by careful diminution of the occasional causes, with continued swathing by means of laced stockings of dog's skin (a). The rules already laid down in abscesses (par. 65) apply to the treatment of fistu- lous ulcers. 759. If the ulcers have existed a long while, and have attained the rank of natural secreting organs, derivatives by issue, and so on, must be established before they are perfectly scarred. If in the sudden suppression of the secretion of an ulcer symptoms of metastasis ensue, the ulcer should be, as soon as possible, again brought to discharge by using acrid irritating remedies. In an ulcer, where for these reasons a cure cannot and, dare not be undertaken, we are restricted to proper cleanliness, and the getting rid of local complication, for the purpose of diminishing the inconvenience wrhich the patient suffers. Second Chapter.—OF ULCERS IN PARTICULAR, IN REFERENCE TO THE CAUSES WHICH PRODUCE AND KEEP THEM UP. I.—OF ATONIC ULCERS. Underwood, Mich., A Treatise upon Ulcers of the Legs, Scrofulous Sores, kc. London, 1783. 8vo. Ib., Surgical Tracts on Ulcers of the Legs, &c. London, 1788. 8vo. Meytler, F. H., Abhandlungen iiber die alten Geschwiire der unteren Glied- masseri. Wien, 1793. 4to. Home, E., Practical Observations on the Treatment of Ulcers of the Legs; with observations on varicose veins and piles. London, 1801. 8vo. Baynton, Thos., A new descriptive Account of a new Method of treating Ulcers of the Legs. London, 1797. 8vo. Oslhof, A., Untersuchungen und Beobactungen fiber die chronischen Geschwiire mit besonderer Ruchsicht auf die sogennanten alten Schaden an den interen Glied- massen. Lemge, 1804. 760. Atonic Ulcers {Ulcera atonica, Lat; atonischen Geschwiire, Germ.; Ulceres atoniques, Fr.) are kept up by general or local weakness, which is manifested by lax fibre and flabbiness. They are mostly situated in those parts, of which the living activity, under natural circumstances, is not very great. Hence are they most frequent on the feet, of which the left is much more commonly affected than the right. Certain occu- pations which interfere with the flow of blood in the lower extremities, and are connected with continued standing, are favourable thereto. They (a) Kotiie, Varicose Venen und varicose Geschwiire an den Unterschenkeln • in Rust's Magazin, vol. xxx. p. 82. ' TREATMENT. 47 are either produced by an external injury, or they may originate in in- dependent patches, in which case there appears at some one single spot redness and slight swelling; the skin becomes thin and breaks; the ulcer enlarges, is more or less painful, and usually produced the local amd general changes which have been mentioned. These ulcers are commonly accompanied with cedematous or varicose swelling of the feet, or with callous edges. They are mostly of a torpid character, though they may, from accidental causes, assume an erythetic, or in- flammatory condition. 761. The prognosis is guided according to the general circumstances already laid down {par. 750); and it is to be especially noted, whether the patient can or cannot diminish the occasional causes. 762. The treatment of these ulcers, which seem to me most satis- factory, is the following:—If the ulcer be without peculiar complication, and if it have a good appearance, I make use, with rest and suitable support, of frequent bathings with lukewarm decoctions of chamomile flowers, and compression with sticking-plaster, in the manner to be prescribed. If the ulcer be torpid and foul, the limb must be kept in the horizontal position, warm fomentations of decoction of chamomile flowers, or solution of chloride of lime must be used; and when the ulcer has been thereby sufficiently cleansed, sticking-plaster must be applied, according to Baynton's plan. The sticking-plaster, cut in strips of sufficient length, and according to the thread, is to be applied, beginning an inch below the ulcer, in ascending spiral turns, around the ailing part, till the ulcer is completely covered. Over this sticking- plaster, should the leg be swathed to the knee with a linen bandage, in order to give moderate pressure to the whole part, which is especially necessary in varicose or cedematous state of the leg. According to the quantity of the pus secreted by the ulcer, is the plaster to be re- newed daily, or after several days, by which the ulcer is properly cleansed; and when scarring commences it is to be touched with a weak solution of sublimate. If the ulcers be accompanied with inflam- mation, erythism, or with any other complication, they must always be first brought back to their simple condition by preliminary treat- ment, before proceeding to swathe them in sticking-plaster. If these be attended to, and the sticking-plaster be applied with carefulness, no bad symptoms, no pain, no in-creased developments of heat, (under which circumstances the part should be moistened with cold water as often as the increased heat seems to require it), no excoriation, nor fresh ulceration, and the like will be observed. If the ulcer, under this treatment, be reduced to a certain point, without seeming inclined to become further healed, or if it again becomes worse, the cause depends either on the insufficient support of the patient, specially in his too early moving about, or there is a general ailment, in causal relation with the ulcer, or the ulcer has become habitual to the patient; and according to these circumstances, the treatment must be directed. I have never observed with this treatment even in ulcers of fifteen or twenty years* standing any symptoms arising from suppression of the usual secretions. UNDERWOOD and Boyer (a) allow the patient to walk during the use of Baynton's (a) Rapport en conseil des hdpitaux. Paris, 1831. 48 SCORBUTIC ulcers; swathing with stieking'.plaster,. and maintain that thereby a more firm and regular scar is produced; as, on the oootrary, the sear which is produced whilst the patient is kept quiet, easily breaks out again in standing and walking, on account of the stretching which it suffers in walking. In these Ulcers all the aromatic and astringent remedies have been recommended for local use; bathing the ulcer and its neighbourhood with decoction of oak bark, of willow, of the leaves or shells of walnuts, of the leaves of plantain, of the herbs Water-germander, or rue, either alone, or with tincture of myrrh and the like. When the secretion from the ulcer is considerable, it is best to apply the remedies in form of powder, thus, strewing with bark, oak bark, chamomile flowers with camphor, myrrh and the like; or stimulating salves and plasters, digestive oint- ment with camphor, red percipitate ointment and the like. When, on account of the peculiar state of the patient, neither rest nor swathing can be made use of, I employ according to the degree of foulness of the ulcer, daily, a foot-bath of chamomile flowers or potash, and bind up the sore with a salve of ung. nutrit., and red percipitate ointment. Rust (a), in chronic ulcers of the foot, employs the hunger-cure, (quarter portion daily), and twice a-week a purge; on the following day a lukewarm bath, and cold fomentations of soft water to the ulcer. [In the application of sticking-plaster to the ulcers, or indeed when the limb re- quires support alone, it is much better to put it on in single straps like Scultetus's bandage, than in the spiral way here recommended. The advantage gained is its more close and regular application. As to the frequency of the dressing, I prefer its renewal every day, whether the discharge be much or little, as by the patient's movements it slackens, and does not give the necessary support, unless daily re- applied.—j. f. s.,} 763. With this local treatment must be connected internal treatment proportioned to the state of the patient. In weakness and want of tone strengthening remedies must be used; if there be stoppage of the bowels, which is very often connected with ulcers on the lower extre- mities, purgative and gently strengthening remedies with a regulated diet must be employed. The gratiola in suitable doses is advisable in these cases,, as well also as when there is no stoppage in the bowels, but a general sluggishness and phlegmatic habit,, 764. Relapse after the healing of atonic ulcers are very frequent, especially if the occasional causes be not diminished. They usually break out in, autumn or in winter. The best mode of preventing them is perseverance in moderate compression of the foot by a laced stock- ing of unyielding leather; at the same time a proper diet is to be ob- served, and every violent motion of the foot to be avoided. H.^-OF SCORBUTIC ULCERS. Anson, George, afterwards Lord Anson, A Voyage round the World, in the years 1740-4, London, 1748, 4to., contains the best account of Sea Scurvy. Lind, Jas., M. D., A Treatise on the Scurvy. Edinb., 1753. 8vo, Hulme, Libellus de natura, causa et curatione Scorbuti. London, 1768. Milman, Sir Francis, Bart., An inquiry into the source from whence the symp- toms of Scurvy and of Putrid Fevers arise and into the seat which those affections occupy in the Animal Economy, &c. London, 1782. 8vo. Blane, G., M. D., Observations on the Diseases incident to Seamen. London, 1785. 8vo. Trotter, Thos., M. D., Observations on the Scurvy, &c. London, 1792. 8vo. 765. Scorbutic Ulcers (Ulcera scorbutica, Lat.; scorbutischen Ge- schwiire, Germ.; Ulceres scorbutiques, Fr.) are always indications of (a) Magazin fur die gesammte Heilkunde, vol. ix. p. 517. TREATMENT. 49 more or less developed scurvy. The immediate cause of scurvy is a dis- position in the blood and other juices to decomposition and breaking up with predominating weakness of the capillary vascular system. Its symptoms are therefore all grounded on weakness, flabbiness, decay or entire destruction of the contractility of parts, which especially show themselves in the vascular system. The natural colour of the skin fails, it becomes pale and puffy; the patient feels a general weakness, and tires with the slightest motion. The gums begin to be painful, swell and bleed on the slightest touch; the breath stinks. Upon the surface of the body appear here and there, especially upon the feet, bluish spots of various size, which spread and often enlarge into streaks. In hot climates cedematous swellings of the limbs occur. Mostly there appear on the skin small swellings with bladders, which drop in and are followed by purple-coloured spots. Pains come on in the feet, swellings of the knee-joints, ulcers, and fre- quent bleedings from the gums. The weakness becomes very great; the patient spits, coughs, and vomits blood; loses blood with his urine and by stool. The gums are often gangrenous; the blood is poured out in every interspace; old scars break out, and the weakness from repeated bleedings is so great that the patient faints on the least movement. He dies either in such fainting or of consumption. 766. Scorbutic ulcers are generally flat, their edges and circumfe- rence cedematous, swollen, and bluish; their bottom dirty, beset with fungous granulations, and bleeds on the slightest touch. The ichor flowing from the sore is thin, mingled with blackish blood, and very stinking. The neighbouring bone is often attacked and destroyed. They usually occur on the gums, on the calves of the legs, and thighs, either in distinct patches in severe scurvy, or from other ulcers, if a general scorbutic disposition exist. 767. The occasional causes of scurvy are, want of oxygenated air, moist foggy air, bad food, sluggishness, want of exercise or too great exertion. These causes mostly show themselves after long sea voyages on the coast of the North Sea (Sea Scurvy). The influence, however, of similar evil influences may produce scurvy on shore in men of phlegmatic temperaments, who live in damp dull dwellings and feed on bad food. The land scurvy is therefore observed, especialty in time of scarcity, in besieged towns and the like. A condition similar to scurvy has been also observed after the immoderate use of mercury. [The land scurvy here mentioned is the chronic form of Purpura-hsemorrhagicr' of Bateman (a), who says, that "it appears occasionally, and; in its severest and fatal form, where none of these circumstances ever existed; for instance, in young persons living in the country and previously enjoying good health, with all the necessaries and comforts of life. This circumstance tends greatly to obscure thp pathology of the disease; for it not only renders the operation of these alleged causes extremely questionable, but it seems to establish an essential difference in the origin and nature of the disorder, from that of scurvy, (the true scurvy formerly prevalent among seamen in long voyages), to which the majority of writers have contented themselves with referring it. In scurvy the tenderness of the superficial vessels appears to originate from deficiency of nutriment, and the disease is re- moved by resorting to wholesome and nutritious food, especially to fresh vegeta- bles, and acids; while in many cases of Purpura, the same diet and medicine (a) Practical Synopsis of Cutaneous Diseases. Second Edit., 1813. 8vo. 5* 50 OF SCROFULOUS ULCERS. have been taken abundantly, without the smallest alleviation of the cemplamt. (p. 110-11.)] , 768. The cure of scorbutic ulcers requires, before everything else, the removal of the scorbutic diathesis upon which they dePrs neue zuverlassige Heilart von vol. ix. 1835. Lustseuche, und die Louvrier's RusT'sche Martius, Einige Bemerknngen iiber das Inunctionskur. Hamburg, 1826. Decoctum Zittmanni ; in Heidelberg med. Bartels einige Bemurkungen fiber Dzon- Annalen, vol. ix. pt. iii. p. 418. di's neue Heilart der Lustseuche; in von (b) S. Gandy, Aperju sur l'efficacite du Graefe und von Walther's Journ al, vol. ix. Traitement dit arabique dans les Maladies p. 513. 100 TREATMENT OF According to Kluge (a), Dzondi's treatment is not to be depended on,- in certain cases, however, especially in ulcers of the bones and nose, it is very efficacious. 855. In reference to the efficacy of the friction cure, of Zittmann's decoction and of Weinhold's treatment, I must undoubtedly give the preference to the former over the latter, which, according to my expe- rience more frequently checks than actually cure the disease ; often in- deed it cannot be borne, and may often continue injurious and scarcely to be gotten rid of disturbance in the functions of the alimentary canal, which depend on a usual and peculiar treatment. The friction cure and Zittmann's decoction, in general, act more surely; but the latter is connected with by far less inconvenience to the patient, on which account, according to my present experience, I prefer Zittmann's decoction to the friction cure, and only employ the latter when the former has been inefficient. The effect of this decoction I have proved, not merely in all forms of syphilis, but also in other inveterate diseases. Compare my above-mentioned statement, in which I have endeavoured to contra- dict the opinions put forward by Neumann (b) against the friction-cure, and in favour of Weinholo's mode of treatment. What is the result of Weinhojld's treatment, when, from the coming on of saliva- tion, it be not determined to interrupt the cure, (which Weinhold and Neumann expressly enjoin,) I cannot from my own experience determine. 2.—TREATMENT OF SYPHILIS WITHOUT MERCURY. 856. The various diseased conditions which have been considered incompatible with the use of mercury, as great debility, with a disposi- tion of the juices to deficient mixture, suppuration of internal organs, aneurisms, scorbutic diathesis, have, on the one hand, as also the evils ascribed to the use of mercury, have on the other, led to the proposal of the various modes of treatment without mercury. To these belong, the sudorific decoctions of the radix sarsce, caricis arenarice, chines, as- tragali ex scapi, and bardancs, of the lignum guiaiaci, cortex mezerei, stipites dulcamaree and green walnut shells. Poixftu's decoction, the rob anti-syphilitique of Laffecteur, the sarsaparilla cure of St. Marie, (drank like mineral water,) Vigoroux's drink, the hunger cure of Osborn and Struve, the volatile alkalies, (Bernard's Tinctura anti-syphilitica,) various antimonial preparations, the acids, especially muriatic acid, gold, especially its muriate (1); hydriodate of potash, and various other remedies. These modes of treatment were, for the most part, less destined for the primary, than for the secondary and older symptoms of the venereal disease, especially for those where much mercury had been (a) Bericht iiber die,, auf hoheren Befehl anzuwenden; in von Graefe und von Wal- mit der DzoNDi'schen Heilmethod gegen die ther's Journal,, vol. ii. p. 405". Lustseuche in dem Berl. Charite-Kranken- Wittckjs, Dissert.de Weinholdii Hydrar- hause angestellten Kurversuche und deren gyrum adhibendi methodo. Berol. 1821. Resultate, nebst Gutachten, iiber die Methode Neumann, iiber die Lustseuche; in von selbst; in Rust's Magazin, vol. xxvi. p. Graefe und von Walther's Journal vol. 211. xvii. p. 1. (b) Vergleichung der LouvRiER'schen und Heinze, Ueber die Bekampfung der Lust- WEiNHOLD'schen Methode, das Quecksilber seuche durch cine modificirte Inunctionskur, u. s. w. Wien, 1836. SYPHILIS WITHOUT MERCURY. 101 already used without effect; or where, on account of the state of the constitution, its use could not be borne. The greater number of these remedies had merely ephemeral reputation, and could not supplant mercury. See my opinion already given upon Zittmann's decoction, in which the greater number of these modes of treatment have been more fully mentioned, and their effects compared. Gold, first substituted for mercury by Pitcairn, but especially introduced by Chrestien, was as gold filings, gold powder, oxide of gold, and muriate of gold, (Chrestien's salt of gold,) recommended in primary and secondary syphilitic affec- tions ; it increased the appetite, raised the pulse and heat, produced thirst, burning of the gums, salivation, (of a milder character without smell, without ulcers, and not exhausting as when mercury is used,) febrile re-action, sweating, increased secretion of urine. It cajled forth the syphilitic symptoms previously suppressed, and the recovery when it took place was permanent. The effect is greater in using the salt, less in the use of the oxide, and weakest with the powder. In an irritable State it could not be employed. Of the gold powder, the first grain was divided into twelve, the second into eleven, the third into ten, and the fourth into nine parts; it was used so many days as there were parts into which the medicine had been divided, and it was rubbed into the tongue, the gums, or the sensible parts of the face. In buboes and very painful ulcers, rubbing in the powder or salts of gold was effected with cerate. Very numerous observations show that the effect of the gold against syphilis was much less and more uncertain than Chrestien and Niel had held: in our climate, large doses (according to my experience) are required to bring about the before-mentioned results. In irritable constitutions gold is a dangerous remedy (a). Ricord (b) treated in 1824 of the use of iodine in gonorrhoea and bubo; Eusebe de Salle is fond of it in hard swellings of the testicles, and also Lallemand, Biett, and Pailland ; but especially Wallace (c), Robert Williams, M. D., Judd (d), Tyrrell (e), Ebers (/), Von Hasselberg and others (g) have used the hydriodide of potash in the different forms of the general venereal disease, and in doubtful cases, with remarkable success. The iodine tincture, the hydriodic acid and iodine strong have been used; the hydriodide of potash, however, with especial success. According to Wallace, two, three, or four table-spoonfuls, and according to Hacker (h) eight or nine spoonfuls daily are given, of a mixture composed of hydriodide of potash two drachms, and distilled water eight ounces. Its operations generally are increase of the vital activity, cheerfulness, increased appetite, increase of flesh, brighter colour of the skin, return of sleep, greater activity of the excreting organs; sometimes diarrhoea and colic; in one case salivation occurred (i). The hydriodide of potash is especially efficient in secondary syphilis, with increase of substance particularly in the bones and skin. Hacker observed in eleven cases that there was always remarkably quick improvement, but not proportionately quick cure. The treatment must often be continued for more than two months. According to Evers, the urine is to be tested during the cure with sulphuric acid, with solution of starch or of chlorate of lime. (a) Chrestien, Methode iatraleptique..— Paris, 1814. Second Edit. Gozzi, Sopra 1' uso di alcuni remedii au. rifici nelle Malattie Veneree annotationi teoretico-pratiche. Bologna, 1817. Dictionnaire des Sciences Medicales,— Art., Jatraleptique. Percy ; in Journal Complementaire du Diet, des Sciences Medicales. Oct., 1818. Odhelius; in Hufeland's Journal, vol. xliv. p. 117. Delpech, above cited. (b) Journal Complement., vol. xix. (c) Wallace, above cited. (d) Judd, A practical Treatise on Urethri- tis and Syphilis. London, 1836. (e) Tyrrell, On the use of Iodine in Syphilis. jfc lodin. gr. £; potass, iod. gr. |; syr. papav. 3iv. aq. destill/Jviij. Ft. mist.; coch. duo ter die sumend. (/) Ebers, Ueber Anwendung des Kali hydrojod. gegensecundare Lustseuche; in med. Veriarzeitung in Preussen, 1836, 5 October. (g) Staberoh ; in Casper's Wochenschrift, 1838. No. 5. \h) Hacker ; in Summarium, u. s. w., vol. viii. part vii. 1836. (i) Butlock ; in Edinb. Med. and Surg. Journ., 1837. 102 TREATMENT OF [(1) Forster gives some cases (a) of syphilis cured by the conjoined use of chloride of gold and soda, and observes, " in all these cases and in some which have since occurred, the only evident effect of this remedy was, the perspiration, which gradually diminished in quantity as the system became accustomed to the stimulus. In only one case was any dressing but dry lint applied, and this difference did not seem to be influential." The form of preparation of this remedy was the following: —"Dissolve ninety-six grains of pure gold in nitro-muriatic acid; evaporate and crystallize; dissolve the crystals of the chloride of gold obtained, in pure water; add thirty grains of decrepitated chloride of soda. Evaporate the solution and crystallize. The salt is slightly deliquescent, and must therefore be kept in a stopped phial." 857. In England, however, the treatment without mercury, formerly restricted to the so-called pseudo-syphilitic diseases, has been extended to all syphilitic affections, and this has been continued and mercury dis- carded for more than eighteen years in the greater number of the military hospitals, and by many of the most distinguished civil practitioners (1). The mode of treatment is the following: In primary syphilitic sores, as long as their inflammatory character continues local, and in severe inflammation general blood-letting must be employed, especially in phimosis and paraphimosis; the patient must preserve the strictest quiet, and be continually in the horizontal posture; he must use purging neutral salts and strict antiphlogistic diet. The local treatment of the ulcer is to be guided only according to its special condition and not with reference to a specific contagion. In painful sores with everted, hard, irregular edges, and scabs, softening anodyne fomentations and applications must be used two or three times a-day ; and after these symptoms have subsided, solutions of lead, of sulphate of zinc and copper, lime water, and so on. In phagedenic and gangrenous sores, whilst inflammation exists, bleeding must be employed, with strict antiphlogistic diet, softening anodyne applications, afterwards solutions of lunar caustic, diluted sulphuric acid, tincture of myrrh, turpentine and similar remedies, in which the frequent change of the remedies specially promotes the healing, and very much seems to depend on keeping the dressings moist. In indolent ulcers more stimulating remedies must be employed. By this treatment all ulcers of the generative parts may, without exception, be healed in a short time. The dispersion of buboes is to be promoted by a compressing bandage, and in their painful state they must be treated by the frequent application of leeches. If suppura- tion occur, the abscess must be opened with caustic, and the wound afterwards treated as a primary sore. Secondary symptoms, when oc- curring affsr the just-mentioned treatment, appear as inflammation of the throat, eruptions of various kind, inflammation of the eyes, periostitis, and swellings of the bones. If these symptoms be very mild they may be cured by sudorific woody drinks, antimonials, strict diet, and anti- phlogistic treatment, agreeable to circumstances. Severe and dangerous symptoms, as great and continued pain in the bones, caries, destructive ulcers, of the throat and other parts, will never be seen after this treat- ment. [As regards the continuance of this treatment, the frequency of buboes following upon primary ulcers, and subsequently the occurrence of secondary symptoms, the opinions of English practitioners differ from each other. According to Hill, ulcers (a) Lancet, 1829-30. vol. ii. p. 590. SYPHILIS WITHOUT MERCURY. 103 with the proper syphilitic character heal in from eight to twenty-five days: accord- ing to Hennen, the primary in fifty-five and the secondary in from fifty-five to eighty-five days. Previous mercurial treatment and scrofulous constitution have special influence on the difficulty of the cure. The proportion of the secondary to the primary symptoms is, according to Rose, 1 : 3; to Guthrie, 1 : 10; to Thom- son, 1 : 12; to Hennen, 1:5; and to Hill, 1 : 10. (1) It must not be supposed that the practice of treating syphilis without mer- cury is at all the general practice throughout England; for beyond all doubts it is de- cidedly the reverse, as the treatment of these cases in almost all, if not all, the civil hospitals, and by the greater number of surgeons proves. It is not to be supposed, however, that mercury is used in the pjofuse and improper manner in which in former times, and even within my own recollection, it was employed for true syphilitic symptoms, either primary or secondary. Nor indeed is it used for all or for a large proportion of sores on the genitals, in which heretofore it was indiscriminately pre- scribed. The surgeon now first takes care to discriminate between the syphilitic and non-syphilitic sore, and adapts his treatment accordingly, with mercury, under careful regulations, for the former as a specific, but for the latter, as either an altera- tive, or simply as an occasional purge, taking care at the same time to improve the general health by diet, medicine, and good air. Far from employing mercury too frequently or too freely, the fault is now rather in the contrary direction, and an imperfect cure is the result of leaving off that medicine too quickly, and not continuing it a week or ten days or more after the symptoms have apparently subsided, whilst in reality the syphilitic poison has not been entirely cast out. The consequence of this is, that secondary symptoms, espe- cially eruptions, are, so far as I have had opportunity of observing, much more frequent than formerly. The surgeon therefore should be especially cautious, that whilst he avoids overdosing with mercury, in whatever form it be used, that a sufficient quantity should be administered to affect the constitution fully, and this should be steadily, though moderately, kept up till some days after all symptoms have disappeared. Chelius's own observations in the following paragraph fully bear out all here mentioned.—j. f. s.] 858. Many of the objections formerly made against this plan of treat- ment when the here mentioned observations had not been sufficiently numerous nor sufficiently long continued, though the pseudo-syphilitic affections were cured by it, but not the true syphilis, have on the con- trary lost all weight, if it be remembered how long this treatment has been employed, and by some of the most experienced and best instructed English practitioners. The frequency of the secondary symptoms always remains as the most important objection ; but seeing that we are still in want of careful and sufficiently numerous statements in reference to the employment of mercury, so must, after the impressive testimony of the English practitioners, the mild and by far less destructive character of the secondary symptoms outweigh this objection. Certain as it may be on the other hand, that by the immoderate use of mercury, syphilis as- sumes a peculiar destructive character, so little can I, however, agree with the banishment of mercury in the treatment of syphilitic dis- eases, that I am convinced by experience, that a moderate use of mercury, with a strict and corresponding dietetic treatment, effects more quickly and constantly the cure of syphilis. The reproach, that the mercurial treatment of syphilis first imparts to it a direct destructive character, applies, only to the negligent, common use of this remedy without re- ference to the constitution, and without correspondent mode of living. It is satisfactory in other respects to know, that in those conditions which especially contra-indicate the use of mercury, this treatment may be em- ployed with confidence. For the literature of this subject, see— Ferguson, Observations on the Venereal Disease in Portugal, as affecting the Constitutions of the British Soldiers and Natives; in Med.-Chir* Trans., vol. iv* 104 SYPHILIS IN INFANTS. Rose, Observations on the Treatment of Syphilis, with an account of several cases of that disease in which a cure was effected without the use of Mercury; in Med.-Chir. Trans., vol. viii. p. 349. Guthrie, On the Treatment of the Venereal Disease without Mercury. Hennen, John, Observations on the cure of Syphilis without Mercury, &c; in Edinburgh Med. and Surg. Journal, vol. xiv. p. 201, 1818. Hill, Saml., M. D., On the Simple Treatment of Syphilis without Mercury ; in Edinburgh Med. and Surg. Journal, vol. xviii. p. 567. 1822. Thomson, John, Observations on the Treatment of Syphilis without Mercury; in Edinburgh Med. and Surg. Journal, vol. xiv. p. 84. Alcock, Observations on the successful Treatment of Syphilis in its primary stage without Mercury; in London Med. Repos., vol. ix. p. 489. Rousseau, J. B. C, M. D., On Venereal Complaints; in American Med. Re- corder, vol. iii. p. 171. Phiney ; in New England Journal, vol. ix. p. 235. • Ware, ibid. vol. iv. p. 354. Stevens; in Med. and Surg. Register of the New York Hospital, part ii. 1820. [Harris, Thos., in N. American Med. and Surg. Journ.—g. w. n.] Todd; in Dublin Hospital Reports, 1810, vol. ii. p. 147. "Kruger, Darstellung der jezt in England, ublichen Behandlung venerischer und Syphilitischer Krankheiten ohne Mercur; in Horn's Archiv., 1822, Jan. Feb., p. 99. Hufeland, Bemerkungen fiber die neue Englische Methode, die Syphilis ohne Mercur zu behandeln; in his Journal, 1822, Sept., p. 20. Wedemeyer; above cited. Huber, Bemerkungen fiber die Geschichte und Behandlung der venerischer Krankheiten. Stuttgart und Tubingen, 1825. Otto, C, M. D., Ueber die Behandlung der Syphilis ohne Merkur, und die Aus- breitung dieser Heil-methode in Grossbritannien; in Von Graefe und Walther's Journal, vol. viii. part i. p. 46. Becker, Ueber die Behandlung der Syphilis ohne Quecksilber, mit Beruchsich- tigung der in Grossbritannien angestellten Beobactungen; in Horn's Archiv. fur Med. Erfahrung. Oppenheim, die Behandlung der Lustseuche ohne Quecksilber oder die nicht Mer- curiellen Mittel und Methoden zur Heilung der Lustseuche. Hamburg, 1827. Fricke, Annalen der Chirurgischen Abtheilung des allgemeinen Krankenhauses in Hamburg, vol. i. Hamburg, 1828. Wilhelm, Clinische Chirurgie; mit Kupf. Miinchen, 1830. 8vo. vol. i. SYPHILIS IN INFANTS. [Infant children are occasionally affected with syphilis, either whilst still in the womb, during birth, or from sucking a diseased nurse. The latter two modes of infection are those generally admitted, but Evanson and Maunsell state that " the first mentioned has been in their experience by far the most usual, and that they have not in their own recollection any cases decidedly proving the occurrence of the third." 1 do not, however, see any sufficient reason why infection during de- livery should be infrequent, as it is far from uncommon that the medical attendant of a woman [with primary sores, and Whose hands are not long in contact with the sores, becomes subject of chancre. Evanson and Maunsell state that the communication of syphilis to thefaius in the womb "happens commonly in one of the following ways: one or both parents may have the disease at the time of the conception of the child, or they may have had it previously, and perhaps, at the period in question, present no sign of ill health whatsoever. Under either of these circumstances a child may be born apparently healthy, and continue so for an un- certain period, varying from a fortnight to five or six months,) when marks of syphilis may show themselves; the most usual period for the disease to appear, is, according to our experience, from the third to the fifth week." (Huguier (a) says (a) Archives Generales de Medecine. Aug., 1840. SYPHILIS IN INFANTS. 105 that syphilis shows itself in an infant in from three to thirty days after birth.) " In this way the symptoms may be developed in several successive children of the same parents, but usually such cases are alternated with miscarriages or premature births of children, dead and covered with syphilitic eruption ; or all these occurrences may take place in the same family; for example, a woman may miscarry once or twice; may then produce a dead syphilitic child, and subsequently give birth to one ap- parently healthy, but showing disease when it has attained the age of four or five weeks. There is no regular succession in the occurrence of these different events, as they indifferently precede or follow each other. During the whole period of the production of these diseased children, both parents may appear perfectly healthy, and one of them may never have had any sign of the disease;" The child may also be infected from a syphilitic nurse, but whether simply from the infected milk, or whether only from sore nipples, I am not prepared to state ; for though Dyckman (a) maintains that a child may become diseased simply by the milk of an infected nurse, Lawrence's case presently mentioned, however, seems to disprove this state- ment. But, on the other hand, the child can infect the nurse of which the case re- lated by John Hunter (p. 413) as one instance of disease resembling syphilis, is a most excellent example, for the history of the case proves beyond all doubt that the disease was genuine syphilis, and the child successively infected three wet-nurses, by the first two of whom their own children were consequently infected. Law- rence also mentions a case in which a syphilitic child gave the disease to a healthy woman who nursed it, but at the same time, her own child having been kept at the other breast, did not receive it. " The woman that so nursed this child had a pri- mary sore on the breast, an affection of the absorbent glands, and an eruption over certain parts of the body similar to what we would regard in other cases as second- ary symptoms of the venereal disease. The child then appearing to be well, was put to a second nurse, who had also a primary sore on the breast, and eruptions on the body ; she became pregnant and five weeks after delivery her infant was covered over from top to toe with syphilitic eruptions." (p. 783.) Whether in these cases the nurse be infected through a sore on her nipple, or merely by the application of the poison to the skin, is disputed. Colles doubts whether the child can infect the nurse unless she have ulceration of the nipple. Todd mentions (b) a very re- markable case of an old woman of seventy years of age who spoon-fed her grand- child which was infected with syphilis, and died a fortnight after birth. Three days after the woman had a rash on the arm's like itch', and in three or four days more she had excrescences on the labia, a few elevated blotches on her breast and back, and a deep ulcer in each tonsiL This woman was speedily cured by the mercurial treatment. When a child is born dead, and has been so for some time previous, its putridity prevents determination from its appearance of the existence of the disease; but when born alive, the child appears healthy for an uncertain period (from a fortnight to five or six months) after birth. The first distinct symptom usually is the occurrence of a peculiar mode of breathing through the nose, known by nurses as the snuffles, (and depending on the nostrils being inflamed and stuffed with a thick viscid yel- low secretion) ; at the commencement this is attributed to cold, and seldom attended to until the eruption appears. In the interim, however, the child's health is much affected, and without any obvious reason. It has no bowel complaint, and is not undergoing dentition, but yet wastes away, and is feverish, fretful, and pallid. In about a fortnight an eruption comes out rather suddenly, at first upon the lower ex- tremities and buttocks, and subsequently upon the face and body; * * * first in the form of copper-coloured blotches, about the size of a split pea, and slightly raised above the level of the skin. These are, in a slight degree, moist upon the surface, and in situations exposed to the air they soon become scaly, and subse- quently are converted into dark-yellowish scabs; Where portions of skin are naturally in contact, as between the buttocks, in the wrinkles of the neck, &c, scales are not formed, but raised condylomatous sores. As the disease advances, the skin in the intervals of the scabs becomes throughout of a copper colour, and perpen- (a) On the Pathology of the Human are generally considered as primary symp. Fluids. toms of Syphilis, &c.; in Dublin Hospital (b) Surgical Report, containing an ac- Reports, vol. ii. p. 182. count of those Affections of the Penis which Vol. ii.—10 106 SYPHILIS IN INFANTS. dicular fissures are formed in the lips, giving the mouth a very peculiar and cha- racteristic appearance, which cannot be verbally described, but to those familiar with the disease, is in itself diagnostic of its real nature. The voice at this period be- comes feeble and stridulous ; the inside of the mouth often covered with aphthae ,• extreme emaciation attends, and, if medical aid be not afforded, the child is reduced to a state of excessive debility, and lies covered with disgusting scabs and ulcera- tions." (Evanson and Maunsell.) In addition to these, Lawrence mentions that he has seen two cases of iritis as symptoms of syphilis in infants; and that sometimes there are ulcers pretty much indurated, that is, with a superficial edge, and rather indurated base, about the anus. " The diagnosis is to be derived partly from its history, but in investigating this the greatest caution is required, as a hint of any suspicion upon the subject might, in many instances, be productive of the most unhappy domestic results. * * * The snuffles of syphilis having nothing at first to distinguish them from those of common catarrh, the disease with which the. eruption is most likely to be confounded is common itch, which in the delicate skin of the child may assume a frightfully severe form. It is to be known from syphilis by its pustular character, by the itchiness which it occasions, and by the absence of the copper colour of the skin, and the peculiar fissured appearance of the mouth. Itch is also commonly communicated to the attendants. * * * The prognosis is always favourable when the case is seen early and properly treated, few diseases being more under the influence of medicine. If left to itself, however, Syphilis infantum is cer- tainly fatal. " The treatment is exceedingly simple—mercury being always required, and, when judiciously exhibited, seldom failing to produce a beneficial effect. * * * Adminis- ter from one to two grains of hydragyrum cum cretd two or three times a-day (accord- ing to the age) until the eruption and snuffles disappear. The child usually fattens under this treatment; and salivation is never produced, at least we have never seen it, in a child under three years of age. Should the mercury affect the bowels, which sometimes happens, we must combine with each dose from half a grain to a grain of Dover's-powder, or of the powder of chalk and opium. The time required for treatment is from six weeks to two or three months, and the medicine should always be continued for two or three weeks after every symptom has'disappeared ; even when this precaution has been observed, the disease may return and the mercurial treat- ment must be again and again resumed." Black wash or dilute citrine ointment may be applied to the sores, and when they'become indolent they may be stimulated with nitrate of silver or sulphate of copper. Giving mercury to the nurse so as indirectly to affect the child is insufficient for the cure of the disease in the latter. When the mother is suckling her own child it will be well to treat her with alter- atives, as for example, sarsaparilla; but unless she labours under actual syphilitic symptoms the giving of mercury to her should not be thought of until the child is Weaned, as by affecting her general health it would be likely to deteriorate her quali- ties as a nurse." (Evanson and Maunsell.) Some practitioners make use of cor- rosive sublimate in treating syphilitic infants; but it is objected to both by Swe- dia'ur and Bacot as likely to disagree and produce violent griping. In connexion with this subject one very important question may be here adverted to, namely, Whether syphilis can be communicated by co-habitation, if the husband labour only under secondary symptoms. Hey is, of opinion that the wife may be so infected, although he is not able to state any positive facts supporting it. Lawrence also says that the same is the impression on his mind from circumstances that have come under his own observation; and Todd's case of the grandmother already mentioned might be brought in support of these views, as in her case as well as in those of married people, the only conceivable way of the infection being communicated is, the application of the secretion of the secondary sores to the surface of the healthy party* It must not, however, be forgotten that Hunter, from experiment, asserted that the secretion of secondary sores(is not in- fectious, and Ricord says that his own experiments on the same point have confirmed Hunter's statement. The possibility of infection from secondary syphilis would therefore seem more than doubtful; and I am rather disposed to believe, that in cases where it is said to take place, that the male patient purposely deceives his medical attendant with a false history of his ailment or of the correctness of his moral conduct after marriage, than that two so able and attentive observers as John Hunter and Ricord should be in error. Be this however as it may, the con- MERCURIAL DISEASE. 107 sequences to the female and her children are so distressing and*so serious, that in my opinion an infected person ought not to be allowed intercourse with his wife; or should at least be warned of the results which, according to the opinions of some able and experienced surgeons, might by possibility accrue from such intercourse. —j. f. s.] Hey, William, Facts illustrating the effects of the Venereal Disease on the Child in utero; in Med.-Chir. Trans., vol. vii. p. 541. Evanson, Richard, T., M.D. and Maunsell, Henry, M.D., A Practical Trea- tise on the Management and Diseases of Children. Dublin, 1838. Second Edit. 8vo. Lawrence, William, Lectures on Surgery; in Lancet, 1829-30, vol. i. Bacot, John, A Treatise on Syphilis. Colles, A., M.D., On the Venereal Disease, London, 1837. 8vo. Beatty, M.D., A Letter from, on a species of Premature Labour, &c; in Trans- actions of the Dublin College of Physicians, vol. iv. p. 31. VIII.—OF THE MERCURIAL DISEASE. Alley, G., Essay on a peculiar Eruptive Disease arising from the exhibition of Mercury. Dublin, 1804. Moriarty, Description of the Mercurial Lepra. Dublin, 1804. Spens and M'Mullin; in Edinburgh Med. and Surg. Journ., No. I. and V. Pearson, John, On the Effects of various Articles of the Materia Medica in the Cure of Lues Venerea, London, 1809. Mathias, A., The Mercurial Disease. London, 1819. Carmichal, Richard, An Essay on Venereal Diseases. Dublin, 1825. 8vo. Second Edition. Bacot, John, A Treatise on Syphilis. London, 1829. 8vo. Bateman, Thomas, M.D., A Practical Synopsis of Cutaneous Diseases. London, 1813, 8vo. Second Edition. Lawrence, William, Lectures on Surgery in Lancet, 1829-30. vol. i. Wendt, S. C. W., De abusA Hydrargyri. Hafniae, 1823. Heim, E, M. A., Inaug. Abhandl. uber die Mercurial Krankheit. Erlangen, 1835. Dietrich, G. L., Die mercurial Krankheit in alien ihnen Formen, geschichtlich, pathologisch, diagnostisch, und therapeutisch dargestellt. Leipzig, 1837. 859. The immoderate and too long-continued use of mercury, espe- cially with improper dietetic treatment, and catching cold, produces a peculiar cachexy, which has been first well described within the last thirty years, as the Morbus Mercurialis (1), Erethismus Mercurialis (2), Erythema, and Exanthema Mercuriale, &c. This disease has various stages, and appears, 1. As an eruption which generally occurs on suddenly catching cold, during the use of mercury; it is preceded by a feeling of great debility, oppressive sensation at the pit of the stomach, and frequent horripila- tions, followed by increased beat, quick pulse, headach, nausea, and thirst; then pale or dusky-red vesicles, rarely a purple-red eruption without vesicles, or similar to nettle-rash, appear most commonly first on the purse, on the insides of the thighs or fore-arms, and gradually spread over the whole body. After a shorter or longer time, the cuticle is shed in thin whitish scales; but if the ailment be left to itself, a large quantity of vesicles or pustules arise which contain an acrid, stinking, very irritating fluid, and on their bursting more or less thick crusts are formed by the drying of the fluid (3). 2. As ulcers in the throat and mouth which are characterized, not 108 MERCURIAL DISEASE. merely by their grayish-white and flabby appearance, but also by their whole external form, which is more easily distinguishable by the eye than to be described by words. Pain and tension arise in the soft palate, and in the tonsils, with heat and a peculiar sensation of dragging of the pa- late towards the hindeF part of the nostrils; much excoriation on the soft palate, the uvula, and tonsils, and actual ulcers, having the appear- ance of whitish discoloured spots, especially on the hinder wall of the pharynx (4). A peculiar characteristic is the disposition the ulcer shows to change its place. Even true syphilitic sores may, by the too long continued use of mercury, degenerate into mercurial sores. As the dis- ease proceeds the pendulous palate is destroyed, and ozcena, caries of the nose-bones, pains in the bones, (wanting, however, the nightly ex- acerbation), enlargement of the bones,, and caries occur. Upon the varied appearances and degrees of the mercurial cachexy, see the be- fore-mentioned excellent Paper of Dietrich. [(1) Carmichael does nothold with the notion of a mercurial disease. He says:— " In ascribing those symptoms (mercurial chancres, ulcers, pains, &c.) to mercury, we have entirely overlooked this obvious circumstance, that that medicine, when exhibited even to profusion for liver, or any disease which is not venereal, has never in any one instance produced those results. With respect to the deteriorating influ- ence of mercury, I am perfectly willing to allow, that when it does not altogether supersede the actions of a morbid poison, it may so far alter or modify its symptoms, as to change, in a great measure the appearance and natural progress of the disease, but this is essentially different from an admission, that the remedy will produce symptoms which can scarcely be distinguished from those of the poison itself." (p 46.) Lawrence observes:—" Among the prejudicial effects of mercury, are enumerated, by those who are unfavourable to its use, eruptions, iritis,, affections of the nose, affections of the bones, and affections of the joints, that is, a considerable portion of those symptoms which we know are secondary symptoms of syphilis. It has been con- tended by those who in modern times have been the great advocates for the treatment ofsyphilis without mercury, that a great portion of those symptoms ordinarily described as secondary, are really owing to the action of the remedies employed to counteract the syphilis. Now, in the first place, we may observe that all these symptoms may be produced without the employment of mercury; we know perfectly well that each of them is seen in individuals who have taken no mercury at all. We have, there- fore, clear evidence that all these effects may be produced by the disease. We have not the same evidence that they may be produced on the contrary, by the em- ployment of mercury. Mercury is given in many cases besides those of syphilis; it is given to a very considerable extent in other cases, but in no instance where it is given in other diseases do we find it produce eruptions like syphilitic eruptions ; in no such instance, do we find it produce iritis, swelling of the nose, or of the bones, or of the periosteum. The effects then, in question can be produced by pox without mercury, but we have not the same evidence that they can be produced by mercury without pox; now, it is true, that mercury and pox acting together may produce a something that neither would produce singly. I can readily admit that the injudi- cious use of mercury; that the employment of it in cases in which it ought not to be used ; that persevering in the employment of it in cases where it exerts one or other of its noxious effects, may aggravate the symptoms, may tend to produce their return, more readily make them more difficult of cure ; and thus, I think, we can have no difficulty in admitting that the employment of mercury, under such circum- stances, may add to the difficulties which may attach to the disease itself. I can- not, however, for my own part, see any evidence that mercury is capable of pro- ducing those effects which we are in the habit of observing from syphilitic poisons in cases where no mercury has been used." (pp. 731, 732.) To the same effect, also, Travers (a) observes, in speaking of syphilitic cachexia: (a) A further Inquiry concerning Constitutional Irritation, &c. London, 1835. 8vo. ERETHISMUS MERCURIALIS. 109 —"Mercury, it may be said, has much to do with the production of this cachexia; as an aggravant, I do not deny this to be frequently the case, but not as an element!." (p. 87). (2) The Erethismus mercurialis, as it was named hy John Pearson, differs from either of the two forms of mercurial affections mentioned by Chelius, as from it results no local manifestations, but merely disturbance, severe enough indeed, of the constitutional powers. Pearson's attention appears to have been directed to this formidable complaint, by having " observed that in almost every year one, and some- times two instances of sudden death occurred among the patients admitted into the Lock Hospital; that these accidents could not be traced to any evident cause, and that the subjects were commonly men who had nearly, and sometimes entirely, completed their mercurial course." (p. 154). He obtained no satisfactory informa- tion by inquiring of his colleagues as to the cause of these fatal eases; but after having given " a constant and minute attention, to the operation of mercury on the constitution in general, as well as to its effects on the disease for which it was ad- ministered, and after some time had elapsed, I ascertained," says he, "that these sinister events were to be ascribed to mercury acting as a poison on the system, quite unconnected with its agency as a remedy, and that its deleterious qualities were neither in proportion to the inflammation of the mouth, nor to the actual quan- tity of the mineral absorbed into the body. The morbid condition of the system which supervenes on these occasions during a mercurial course, and; which tends to a fatal issue, is a state which I have denominated Erethismus (a); and is charac- terized by great depression of strength, a sense of anxiety about the prxcordia, irregular action of the heart, frequent sighing, trembling partial or universal, a small, quick, and sometimes an intermitting pulse, occasional vomiting, a pale contracted countenance,a sense of coldness, but the tongue is seldom furred, nor are the vital or natural functions much disordered. [What then are to be considered the symp- toms just mentioned.—j. f. s.] When these, or the greater part of these symptoms are present, a sudden and vioieat exertion of the animal power will sometimes prove fatal; for instance, walking hastily across the ward; rising up suddenly in the bed to take food or drink; or slightly struggling with some of their fellow patients, are among the circumstances which have commonly preceded- the sudden death of those afflicted with the mercurial erethismus." (p. 155-57). Burder says (b):—"This peculiar irritation may arise from the administration of mercury in any form, and may occur during any period of a mercurial course^ though most commonly at its commencement. The exact circumstances which favour its occurrence in the parti- cular individuals attacked have not hitherto been ascertained. While resident medical officer of the Lock Hospital he has seen it produced hy the inunction of a single drachm of mercurial ointment, and- reproduced in the same individual after the discontinuance of the medicine for a whole month, by three frictions, each con- sisting of only one drachm of the ointment. Et is remarkable, however, that in the greater number of instances, a full and adequate course of mercury has been after- wards borne without any recurrence of erethismus, by the very persona who had suffered from it during-the commencent of the course." (p. 105). The seeming rarity of this disease, even "in pubKc institutions where the atmo- sphere of the wards was actually loaded with the remedy," (mercury,) " would," as Bacot has very justly observed, "be a very imperfect mode of estimating the fre- quency of the occurrence of erethismus,- because although few die, very many per- sons have been, affected by it in an inferior degree, without, in fact, being at all aware of the cause of their sufferings." (p. 272). To this I would, however, add, that this violent degree of constitutional disturbance is now rarely if ever seen even in hospitals, not only because their syphilitic wards are no* longer polluted by a mercurial atmosphere, but because surgeons, using mercury in the treatment of syphilis, take especial care to suspend or give up its use, when the constitutional symptoms show that the mercury is: beginning to do mischief,' and if persisted in would excite the irritable condition above described. The relation of Dt; Bateman's own case by himself (c) is probably the best (a) Principles of Surgery. London, 1788. Svo., (b) Forbes,, Tweedie, and Conolly's Cyclopaedia of Practical Medicine, vol. ii«—article, Erethismus Mercurialis. (c) Notes of a Case of Mercurial Erethism; in Med. Chif. Trans., vol1..ix..p.220i 10* 110 CACHEXIA SYPHILOIDEA. account of this disease. Being the subject of amaurosis, he rubbed in a drachm of strong mercurial ointment nightly; on the seventh day his gums were a little tender, and he had slight fever at night; on the eighth he was languid and feverish, and the gums reddish and spongy; on the following day he had violent and irregular action of the heart, which did not yield to laudanum or stimulants, but went off suddenly in the afternoon; on the next two days he was severely griped and purged; on the tenth day, the mouth being sore, and the irregularity of the circulation continuing, the mercury was omitted, but as he was more comfortable on the following day, it was resumed, but the palpitation returned, and continuing on the twelfth day, the mercury was abandoned. During the whole of the following month the symptoms of irregular action of the heart, of extreme debility, and a strong tendency to syncope, accompanied with cough, evidently proceeding from a deranged stomach, and attended with violent retchings, continued to increase in severity, and his condition became very precarious. No solid food could be taken without an alarming increase of the feelings of oppression and faintness; and stimulants, as brandy in small quantities, ammonia, and xther, were principally beneficial. Among the most cu- rious circumstances of this case, was the impossibility of attaining sleep even for a very short period, without bringing on the most painful sense of suffocation and dis- tress, so that he was obliged to be removed immediately into a current of fresh air. These attacks were so violent, and recurred so frequently, as to entirely banish sleep. He recovered, but for more than a twelvemonth after, complained of a hur- ried circulation, want of strength, and lassitude." Pearson speaks of a Cachexia syphiloidea, of which he says, he has "not yet attained to that complete and satisfactory knowledge which would authorize him to obtrude a publication on the subject; but," observes, "the experience I have already had in the treatment of that multiform disease, has taught me that it may appear under the following different circumstances:—1. Where the syphilitic virus has lately existed in the constitution, and the patient has employed the accustomed course of mercury; 2. Where the patient has been repeatedly diseased with syphilis, and has used several courses of mercury; 3. Where a great length of time, from three to twelve, and sometimes twenty years, has elapsed since the patient has been exposed to the agency of the disease and its remedy ! ! 4. After the gonorrhoea, where small quantities of mercury have been used; 5. Where no venereal com- plaints, genera] nor local, have preceded the appearance of the Cachexia syphiloidea, and where the patient has never been exposed to the hazard of contracting that dis- ease, nor has laboured under complaints requiring the aid of mercury." (pp. liv. v). This is all he says upon the subject, and why he shonld prefer applying the term Cachexia syphiloidea to Cachexia mercurialis, which the disorder undoubtedly is, does not appear very satisfactory. No more reasonable is Bacot's persistance in using the same title, under which he well enumerates the symptoms which occur in this affection, to wit, " emaciation, long-continued, and severe nocturnal pains and enlargement of the bones; severe and extensive ulcerations, fever, profuse perspira- tion, followed not unfrequently by hectic fever and death. The most usual history which a case of this kind affords, is that of a patient, who, perhaps for some common sore of no great extent or severity, has employed mercury until his health has given way, and until symptoms have arisen of so equivocal a nature as to lead to the belief that the original disease is making inroads into the constitution; it is under this conviction that the patient either devotes himself to a fresh course of mercury, or his surgeon, if a decided mercuxialist, advocates the same plaa; from that moment the disease becomes complicated; bone generally becomes affected,, fresh attacks of nocturnal pains, new and unobserved forms of eruption make their appearance, and are all referred to the original poison, until perhaps a severe form of fever is excited, or some local mischief obliges a discontinuance of the treatment. Then it is that the patient rallies, the constitution appears daily to acquire strength; but, as in this condition it is, not unusual for the osteopic pains to be renewed, and partial relapses to take place, the fatal misapprehension is again renewed, until another exhibition of mercury effectually overpowers the efforts of nature, and the patient sinks under the exhausting influence of the remedy." (pp. 276, 77). " The mercurial cachexia," says Travers, " is characterized by irritable circula- tion, extreme pallor and emaciation, an acute and rapid hectic, and an almost invari- able termination in phthisis, the utter destruction of the palate, extensive cicatrices, eruptions, or ulcers of-an anomalous character in various parts of the body, and large cranial exfoliations are seen, ip combination with it." (p. 87). ECZEMA MERCURIALE. Ill (3) This disease is called Eczema rubrum by Willan and* Bateman, who state that it "is not exclusively occasioned by mercury, either in its general or more partial attacks ; it has been observed to follow exposure to cold, and to recur in the same individual at irregular intervals, sometimes without any obvious or adequate cause." (p. 254.) " The quantity of this ichorous discharge," says these distin- guished writers, "is very considerable, and it gradually becomes thicker and more adhesive, stiffening the linen which absorbs it, and which thus becomes a new source of irritation; it emits also a very fetid odour. This process takes place in the suc- cessive patches of the eruption, until the whole surface of the body, from head to foot, is sometimes in a state of painful excoriation, with deep fissures in the bends of the joints, and in the folds of the skin of the trunk; and with partial scaly in- crustations of a yellowish hue, produced by the drying of the humour, by which also the irritation is augmented. The extreme pain arising from the pressure of the weight of the body upon an extensive portion of such a raw surface, is suffi- cient to give rise to an acceleration of the pulse and white tongue, but the functions of the stomach and of the sensorium commune are not evidently disturbed by this disease. The duration of this excoriation and discharge is uncertain and irregular; when only a small part of the body is affected it may terminate in ten days, but when the disorder has been universal, the patient seldom, completely recovers in less than six weeks, and is often afflicted to the end of eight or ten weeks. By so severe an inflammation the whole epidermis is destroyed in. its organization; and when the discharge ceases it lies loose, assuming a pale brown colour, which changes almost to black before it falls off in large flakes. As in other superficial inflamma- tions, however, the new red cuticle that is left is liable to desquamate again, even to the third or fourth time, but in smaller branny scales of a white colour, and a roughness sometimes remains for a considerable period, like a slight degree of psoriasis. In some instances, npt only the cuticle but the hair and nails are also observed to fall off; and the latter, when renewed are incurvated, thickened, and furrowed, as in lepra.'''' (pp. 255, 56.) Carmichael mentions that he "knew a gentleman who was always attacked by this eruption when he took but a single grain of calomel, and, also an instance of the disease being produced by the application of the black mercurial wash to a venereal ulcer." (p. 326). . "Although the Eczema mercuriale is produced by the action of mercury, yet the disease is not always exasperated by persisting in the use of it; for in some par- ticular cases, 'where,' says Pearson, 'I judged it to be; of great moment to continue the mercurial frictions, the eruption neither spread universally, nor was it materially increased, although the patipn.ts.were not relieved froniiit till mercury was discon- tinued.' " (p. 173). (4) Bacot says:—" The character of the mercurial ulceration of the throat is that of an apthous. superficial spre, surrounded with a general blush of inflammation. The tonsils are the usual seats of the ulceration, and they are sometimes also met with pu the. velum pendulum palati. Occasionally there is much stiffness and diffi- culty of swallowing, without the appearance of any breach of surface at all. Now, independently of the mere appearance of the sore, these symptoms will always be found in connexion with, or almost, immediately following the use of the remedy— that is to say* that when towards the termination of a mercurial course, whether the effects of the mineral have been suchaS might have been wished for and expected or not, if the patient begins to complain of pain or difficulty in swallowing, and upon examination the tonsils.are found either studded with small ulcers or affected with only one.larger superficial sore, the patient being himself not quite free from fever, with disturbed rest and feelings-of general discomfort, there can be no hesi- tation in believing that this disease is the result of mercurial action. The same symptoms making, their approach within two or three weeks after the mercury has been discontinued', will also admit of the same explanation, and more espe- cially if our patient, after having been confined to the house, or nearly so, during his cure, has been exposed, to sudden, or severe transitions of temperature." (pp. 265, 66.)] 860. The character of the mercurial disease is diminished cohesion and atony ; it is a cachexy similar to the scorbutic. The means recom- mended for it are, leaving off' the mercury, the employment of warm 112 TREATMENT OF MERCURIAL DISEASE. and strengthening dietetic treatment, sarsaparilla, saponaria, smilan chince, dulcamara, bardana, guiaiacum, mineral acids in connexion with wood-drinks, the tinct. arom. acida,—sulphurico-acida in decoction of fine buds or malt; mild, strengthening, and astringent remedies, bark, cascarilla, folia aurantiorum and fol. ilicis aquifolii in decoction or in- fusion ; subsequently, steel. In the mercurial disease, disturbance of the functions of the liver usually occurs, against which the laxative extracts, and especially the extract, chelid. maj., recommended by the English practitioners, in connexion with soda and the like, are of con- siderable service (1). For the local treatment, penciling the ulcers with muriatic acid, and gargles of hemlock and honey; in the eruptions on the skin, sometimes antimonial, sometimes guiaicum preparations, liq. sapon. stibiati, tinct. guiaic. ammon.; in pains of the bones, bark, opium, and aromatic baths, Struve's hunger-cure has been recommended as a most important remedy, as also the use of sulphur and ferruginous baths. If after the removal of this cachexy syphilis still exist, the red precipitate of mer- cury, with wood-drinks, is very efficient. Although it is characteristic of the mercurial disease, that it becomes worse under the use of mer- cury, and although this disease arises by the immoderate use of mercury, without syphilis being present, for instance, from the operation of mer- curial vapour, and so on ; yet, however, on the other hand, it is certain, that it frequently is only the consequence of immoderate and improper mercurial treatment, of a repeated suppression of the syphilitic dis- ease, which however continues only under an altered form ; a me- thodical suitable mercurial treatment is therefore capable of curing both the mercurial disease and the syphilis. From my own experience, I must give the preference to Zittmann's decoction before all other treat- ment (a). Schmalz has, in electrifying patients, in whom it could not be made out, which was to be considered the consequences of syphilis, or which of the immoderate and improper use of mercury, observed salivation occur without further employment of mercury, and to such an extent, that severe mercurial fever and profuse sweating came on at the fifteenth day. He administered the electric aurato the patient either by a dome placed on his head, or put the chain into his hand, and continued the electric stream at first only for a quarter of an hour. Therewith also he gave water- gruel, with medicine twice a-day; took care to keep the bowels open, and to pre- serve the warm temperature of the chamber,, which the patient was not allowed to leave (b). [(1) "To prevent the dangerous consequences of this diseased state (Erethismus mercurialis) the patient ought to discontinue the use of the mercury," says John Pearson ; " nor is this rule to be deviated from, whatever may be the stage, or extent, or violence of the venereal symptoms ; the impending destruction of the patient forms an argument paramount to all others. * * * The patient must be expressly directed to expose himself freely to a dry and cool air, in such a manner as shall be attended with the least fatigue. It will not be sufficient to sit in a room with the windows open; he must be taken into a garden or a field, and live as much as possible in the open air until the beforementioned symptoms be considerably abated. The good effect of this mode of treatment, conjoined with a generous course of diet, will be soon manifested; and I have frequently seen patients so far recovered in the space of from ten to fourteen days, that they could safely resume the use of mercury, and, what may appear remarkable, they can very often employ that specific efficiently afterwards without suffering any inconvenience. * * * In (a) Wedemeier, above cited. (b) Froriep's Notizen, 1826, Oct., p. 207.—Hecken's lit. Annalen, Mai, 1827, p. 107. ULCERS OF BONES. 113 the early stage the farther progress of mercurial erethismus may be frequently pre- vented by giving the camphor mixture, with large doses of volatile alkali, at the same time suspending the use of mercury." (p. 157-159.) "As a general rule," in Eczema mercuriale, says Pearson, "I would premise that the administration of mercury must be discontinued on the first appearance of the eruption. The Eczema mercuriale certainly admits of a natural cure, not only when it affects the body partially, but when it is universal; yet, although the troublesome symptoms which arise may be relieved by their proper remedies, I am doubtful whether any plan of treatment has the power of interrupting its regular course, or abridging its duration. I have been confirmed in this opinion of the inefficiency of any medical aid in curing the disease, in the proper sense of the term, by observing that under all the various modes of treatment which I employed, this disease, like some of the exanthemata, pursued its usual mode of progress, without undergoing any apparent change, either in the number of its essential symptoms, or in the com- parative mildness and continuance of them." (pp. 176, 177.) Pearson, however, thinks the patient may derive advantage from medical treatment, so that his general health should not suffer material or permanent injury; and recommends anti- monial powder and saline draughts, or liquor of acetated ammonia at the onset, with gentle purging, and opium to allay irritation either with camphor or Hoffmann's anodyne (spir. xth. sulph. comp.),- and "when the discharge is no longer ichorous, and the tumefaction is subsiding, sarsaparilla with bark may be given liberally." " The cure of the sore throat proceeding from constitutional irritation or cold taken upon mercury must," says Bacot, "be effected by purging, by antimonials,by an,ab- stinent diet, as far as animal food and fermented liquors are concerned. * * * When all febrile heat is removed, the bark or sarsaparilla will be found of great efficacy in restoring the vigour of the constitution and expediting the healing of the sore." (p. 266.)] The subjects gummata and nodes are considered under Exostoses. VIII.—OF ULCERS OF BONES. Duvernav, Traite des Maladies des Os. Paris, 1751. Part ii. Ferrand, Dissert, de Carie Ossium. Paris, 1765. Clossius, C. F., Ueber die Krankheiten der Knochen, Tubingen, 1798, p. 40. Scarpa, A., De penitiori Ossium Structura. Lipsiae, 1799. Hemmer, Dissert, de Spina. Ventosa. Hafnise, 1695. Augustin, F. L., Dissert, de Spina. Ventosa. Halae, 1797. Louis; in Memoires de l'Academie de Chirurgie, vol. v. p. 410. David, Observations sur une Maladie connue sous le nom de Necrose. Paris, 1782. Weidmann, J. P., De Necrosi Ossium. Francof., 1793. Russell, J., A Practical Essay on a certain Disease of the Bones termed Necrosis. Edinb., 1794. Ringelmann, De Necrosi Ossium. Rudolst, 1804. Wissmann, L., De rite cognoscendis et curandis nudatione, carie et necrosi ossium, observations pathologico-medicae. Halae, 1820. Richter, Die Necrose pathologisch und therapeutisch gewiirdigt; in von Graefe und von Walthejr's Journal, vol. vii. part iii. p. 402. Sanson, L. J., De la Carie et de la Necrose comparee entre elles. Paris, 1833. 4to. Miescher, De Inflammatione Ossium eorumque anatome generali. Berol., 1836. Richter, A. L., Die organischen Knochenkrankheiten. Berlin, 1839. Lawrence, Will, Lectures on Surgery in Lancet, 1829-30. vol. ii. Hunter, John, Lectures on Surgery; by Palmer. Syme, James, The principles of Surgery. Edinburgh, 1838. Second Edit. Troja, Mich., De Novorum Ossium, in Integris, aut maximis ob Morbos Deperdi- tionibus, Regeneratione Experimenta, &c. Lutet. Paris, 1795. 12mo. 114 CARIES. Stanley, Edward, Abstract of Lectures delivered before the College geons; in London Medical Gazette, vol. xx. 1837. A.—OF CARIES. (Caries, Lat.; Knochenfrass, Beinfaule, Germ.; Carie, Fr.) 861. Caries consist in a diseased change of the substance of bone, analogous to ulcers in soft parts (1). If the diseased bone be bared of the soft parts covering it, it is found to be brownish, often blackish, its surface rough and uneven, yielding, worm-eaten and destroyed to a considerable extent; the bony layers are fragile, may be easily penetrated with a silver probe, and a grayish brownish or blackish ichor escapes, which gives out a filthy and peculiar smell; the bony layers are fre- quently loosened, and spongy or fleshy growths {Caries fungosa) spring up from the surface of the ulcer (2). [(1) " The term caries," says Lawrence, " does not apply to all the circumstances under which ulceration of a bone takes place. When a portion of a bone dies, that part is separated from the sound portion by a process of ulceration; but that ulcera- tion does not come under the denomination of caries. Ulceration of bone, in fact, like that of the soft parts, is various in its nature. There is a healthy ulceration in soft parts, enabling them to repair injuries, and there is a similar ulceration in bone. Now to that healing kind of ulceration we do not give the term caries; but we apply the term caries of the bone to an unhealthy species of ulceration, an ulcera- tion whieh is not of a salutary but of a destructive nature. This kind of ulceration, like the morbid ulceration of soft parts, is preceded by inflammation ; the bone first inflames and then ulcerates, just as you observe in the case of a sore leg, where the skin inflames first and then proceeds into a state of ulceration. This state, too, is accompanied by the formation of matter, in which respect caries, or the ulceration of a bone, is analogous to the same process in the soft structures of the body. Such then, is the sense in which we employ the term caries; it is a morbid ulceration of the bone, preceded by inflammation, and attended with some kind of suppuration or formation of matter." (p. 356.) (2) As Miescher states, " Granulations are not entirely deficient, inasmuch as every bony surface, affected with caries, is covered with a certain soft substance, corresponding to the growing granulations in healthy suppuration; but they are of a bad kind, of livid colour, and when touched bleed easily; mostly they are scanty, but sometimes so luxuriate in a kind of fungus, that the roughness of the bone itself can be scarcely, or not at all, examined. Of whatever kind they be, they never go on to scar, but having been produced by humours, the commixture of which has been corrupted by general disease, and acquiring their life from, that part of the body of which its own life has been altered by disease, they have an organic structure but little perfect, and only enjoy a short existence, in consequence of which they soon die, and together with them also larger or smaller particles of the bone itself. Under them new granulations sprout up, but unless the existing disease be got rid of, are not better than the former, and die also in a short time; and thus, with the caries always creeping further, the suppurative inflammation elsewhere of its own nature producing new substance, here seems to run on to nothing but a sort of destructive process. But nevertheless even in caries it appears nature provides, that new organic substance should be produced from the growing granulations, which although of scanty and of bad character, are never entirely deficient. Indeed this is often proved even by the formation of new bony substance; for dyscrasic inflammations as they are called, and especially the syphilitic, not unfrequently, from the very first, pro- duce new formations, from which we know that exostoses are mostly first pro- duced ; but the very carious surface is sometimes studded with new bony, spiny, spongy fomentations, which as Clocquet observes, 'are analogous to the fungous flesh springing up in soft parts.' The surrounding periosteum is swollen, and CARIES. 115 between it and the bone itself new bony matter is poured out, and often forms large exostoses." (p. 209-10.) "The distinguishing character of caries," observes Syme, "is the same as that of cancerous ulcers in the soft parts, viz., obstinacy of action. * * * The disease has, for the most part, remissions more or less complete, and of considerable duration, in which the pain and discharge nearly or altogether cease and the ulcer seems to be on the point of healing, or actually becomes covered with a thin soft cicatrix. But these amendments are only partially and temporary, being always followed by relapse, and there is no natural limit to the duration of the disease, except the life of the patient, who, after months, or even many years of suffering, becomes finally exhausted, either by the caries itself or some other disorder which the irritation pro- duced by the caries has excited." (p. 170.) " The diseased part," observes Mayo, " often neither can recover itself, nor be absorbed; neither does it become necrosed. Left to itself, the caries would continue year after year, undermining the constitution of the patient, gradually invading the adjacent sound bone and finally threatening with destruction the neighbouring joint. It is often extremely difficult to tell whether an inflammatory enlargement of bone is abscess, or caries, or necrosis." (p. 38.)] 862. These changes of the bone are always dependent on previous inflammation, which has its seat either in the periosteum and outer layers of the bone, or in the medullary membrane, in the parenchyma of the bone. The formation of a bony ulcer is therefore always preceded by dull, deep-seated, frequently very severe, wide-spreading pain, the swelling, not very great but slow, over which the colour of the skin is not changed. After a shorter or longer time a swelling dependent on the collection of puriform fluid takes place, sometimes on the very seat of the diseased bone, sometimes at a distance from it, which, if the bone be covered with few soft parts, seems connected with it, and is sur- rounded at its base with a hard edge. If this swelling be opened, an ill-conditioned variously-coloured ichor is discharged, which sometimes has a very bad smell. If the destruction be great, hectic fever some- times occurs. If the inflammation have begun in the interior of the bone, it is often thereby changed partially, or throughout its whole extent, into a spongy, wide-spreading mass accompanied with severe pains which increase especially as the patient warms in bed; the neighbouring soft parts are also much expanded, and finally fistulous sores arise {Spina ventosa, Caries centralis, Pcedarthroce, Lat.; Winddorn, Germ.) Besides these appearances the diagnosis is specially determined by examination with the probe, in which the bone is found rough and variously changed; further, by the peculiar form of the ulcerated open- ings in the soft parts, which have a shrivelled appearance, are con- tracted, and callous, or have their circumference surrounded with fungous excrescences. The silver probes employed in examining carious ulcers are frequently blackened; this, however, is no very definite sign, as it may be produced by any impure and ill-conditioned pus. The patient usually feels deep-seated pain. ["In considering the primary attack of bone by caries, the question," says Miescher, "arises, in what way is the bony substance in this disease destroyed? how is it that suppuration, naturally producing a new substance, should in this case deviate into a destructive process? Comparison of caries with ulcers in soft parts throws no light on the subject, nor is it more set forth in them, how organic substance is destroyed by ulceration. * * * Doubtless ulceration of bones or caries, is most suitable for clearing up this ambiguous question, because this tissue, abounding in earthy parts, even when deprived of life, for a long while resists chemical decom- position, and then may be distinguished in the pus or adhering to the very surface 116 CARIES. of the ulcer. We see it asserted in the works of not few writers, that in a carious ulcer the pus may be perceived to be as it were sandy to the touch, and containing bony particles oftentimes pretty apparent, and that if a probe cannot be used to the affected bone, that this alone certainly indicates caries. But nothing final can be obtained on this very point, as no one speaks distinctly upon the question. For what Himly (a) contends for, that the surface of the bone always dies, is not suf- ficiently confirmed by argument. And the same may be observed as to Bell's statement, that in caries there, is often no exfoliation; and who has even described that peculiar form of it which he calls phagedenic, which spreads most rapidly on every side, without any exfoliation, and merely by the violently excited action of the absorbent vessels." (p. 210-12). In the instances of caries in different bones examined by Miescher, he says:—"In all these, minute bony plates were dis- covered dead, and more or less separated ; some entirely separated lay on the sur- face of the ulcer, and beneath them was a soft substance, consisting of numerous vessels, overspread with bone, as is constantly observed in a separated necrotic bone; some still adhered to this soft substance by some tougher filaments; in others the separation had proceeded less far, so that more or less still adhered to the bone itself. These dead plates were not only found on the external surface of the bone, but more frequently at that part where the ulcer penetrated more deeply, and their irregular surface appeared here and there covered with mucous dirty matter, which probably was produced by the decomposed soft substance. Elsewhere, this soft substance only was observed; in which places the dead parts seem to have flowed off with the pus. The whole surface therefore attacked with caries presented various stages of separation of the dead plates, by which the roughness felt with a probe, was easily explained as well as the Corroded appearance of the softened bone, which although less conspicuous, is discovered after the separation of large pieces of bone." From the review of these circumstances and of those connected with sim- ple suppuration of bone, Miescher concludes, that " the organic matter in caries is destroyed by necrosis, and that caries might very properly be named ' necrosis in particles,' as the very able and experienced Rust had called it in his Lectures. It appears that dead and separated bony particles are not to be found in every carious ulcer; for when that destructive process exists, ulceration proceeds no further, but it is only occupied in secreting sanious pus and producing granulations of a bad character, the previously dead particles having separated, and been thrown out with the pus, and no more make their appearance. It is further to be observed, thatit is of no consequence what dead parts are separated and what destroyed by caries, but that in the destruction of the organic tissue much is to be attributed to the more active ab- sorption as fitted for separating the dead parts." (p. 212^13). " When a carious bone has been macerated, the diseased part/' remarks Syme, "is found excavated and rough, the cancellated structure being remarkably spicular, white and brittle, so as to resemble a spongy bone which has been exposed to the action of fire. The surface thus affected, is often of considerable extent, though fre- quently very small, even in cases of old standing; but the disease seldom reaches to a considerable depth. The field of the disease seems to be determined by the primary inflammation, and after being thus established, has little or no tendency to become larger. Around the carious part there is always an effusion of new osseous matter, in the form of warts or tubercles, extending to a considerable distance, and greatly increasing the thickness of the bone. This new massj which is no doubt produced in consequence of the irritation of the disease, like that formed to re-unite fractures, and supply the place of exfoliations, is characterized by compactness and smoothness when minutely examined, though on superficial inspection it appears rough and porous. The pores are apertures for the transmission of blood vessels, but their form is circular, and their edges rounded off, so that sharp edges can- not any where be perceived. The newly effused bone may thus be readily dis- tinguished from the diseased part, to the irritation of which it owes its origin." (p. 170-71)]. 863. All injuries, producing inflammation of bone which ends in ulcer- ation maybe considered as causes of caries {1). They are either ex- ternal or internal; to the former belong external hurts, kicks, blows, (a) Ueber den Brand der harten und weichen Theile. Goet., 1800, p. 96* CARIES—ITS CAUSES, PROGNOSIS, TREATMENT. 117 wounds, tearing of the periosteum, fractured bones, continued pressure, suppuration^in the neighbourhood of the bone; exposure of the latter, especially if the air be freely admitted or the treatment have been im- proper. The internal causes are especially, scrofula, syphilis, scurvy, rickets, gout, rheumatism, suppression of customary discharges, metas- tasis after previous active or chronic eruptions of the skin (2). Ordinarily from the external causes rather the superficial, and from the internal rather the parenchyma or internal substance of the bone is affected. Caries most commonly occurs in the soft spongy bones. As regards the distinction of bony ulcers from suppurating wounds of bone, and the exposure of the bone, what has been already said (par. 746) of the distinction of ulcers, especially from abscesses, here applies. Delpech (a) believes that the diseased changes which syphilis produces in bones does not deserve the name of caries, as therein the bones suffer little from change in their structure, but rather become necrotic. Although this is commonly the case, as already mentioned, (par. 823), yet is it, however an opinion, which cannot in general be assented to. [(1) "In caries," says Mayo, "absorption is preceded by a change in the bone, which (with very few doubtful exceptions) has a well-marked inflammatory cha- racter. The same condition exists during the progress of the absorption. There is further present an imperfect restorative action, which is shown in the more or less partial growth of unwholesome granulations from the ulcerated surface. Of these changes, the inflamed condition of the bone is the primary and mest important, the absorption is secondary and accidental." (p. 36). (2) Miescher points out the seat of the various kinds^of caries from internal causes as follows :—" Scrofulous caries, for the most part, attacks the spongy tex- ture, as the bodies of the vertebrx, the carpal and tarsal bones, and the joint-ends of the long bones; beginning in the previously formed internal tubercles of which, it excites in them inflammation and swelling, and afterwards attacks the soft parts, which at the commencement of the disease, were almost, or entirely free from it. The scrofulous differs especially from rheumatic caries, which is also situated in the joint-ends, but arises from inflammation of the soft parts, the ligaments and syno- vial membrane, and thence sometimes seizes on the articular surface itself. The arthritic no less prefers the region of the joints, but attacks the external surface of the bone, having been mostly preceded by the formation of exostoses. In general, arthritic concretions are observed, in its immediate neighbourhood. The syphilitic caries seems to be next to the scrofulous, most frequent, but contrariwise, almost only resides in the compact substance of the bone; and then the scorbutic. These are especially distinguished, in that for the most part, the former is accompanied with the formation of exostoses, and these exostoses axe the seat of ulceration; whilst in the latter, but very rarely do exostoses appear." (p. 216)]. 864. The prognosis depends on the constitution, age, and circum- stances of the patient, on the causes which have produced the caries, and on its seat. The prognosis is most unsatisfactory in very great general and especially in scrofulous ailment, and if the caries exist in the neighbourhood of a joint. If the hectic fever have exhausted the powers of the patient, the removal of the limb is often the only remedy. But in many cases, especially in young persons who have reached the age of puberty, nature effects the cure by her own powers, and in the following manner:—the air being kept from the diseased bone by the contraction of the fungous edges of the aperture of the ulcer, it either dies completely and is thrown off with suppuration as a granular pow- der, or in flakes, or in its whole thickness {Exfoliatio sensibilis); or it is removed by absorption, (Exfoliatio insensibilis), whilst at the same time (a) Chirurgie Clinique de Montpellier. Paris et Montpellier, 1823, p. 454. Vol. n—11 US TREATMENT OF CARIES. granulations arise from the bone, the suppuration improves and dimi- nishes, and the external ulcer gradually closes. 865. As regards the treatment of caries, its causes must be first coun- teracted ; the suitable mode of cure must be directed against scrofula, syphilis, rickets, gout, and so on, and close attention must be paid to the state of the patient's powers which are to be supported by proper remedies, and especially by good nourishing diet, and by the enjoyment of good air. 866. The local treatment of the ulcers requires great cleanliness in dressing; the carious part must be defended from the approach of the air, and the free escape of the ichor must be provided for. To this end, if the situation of the ulcer in the soft parts do not permit the ready escape of the ichor, enlargement of the ulcerated opening is frequently needed. In other respects the local treatment agrees entirely with that generally applied to ulcers. The openings of the sores are to be covered superficially with lint, all stuffing and introduction of tents are to be avoided, moist warm applications of chamomile or other aromatic vege- tables are to be used, rubbing in of volatile salves or spirituous fluids on the neighbouring parts, and the use of general or local aromatic baths. In inflammatory affections, leeches should be applied around ; gray mer- curial ointment rubbed in, and softening applications made. By this treatment it is expected that the vitality of the diseased bone may be changed, and that it should exfoliate imperceptibly or perceptibly; and in the latter case, provision must be made for the removal of the sepa- rated portion of bone. This mode of treatment is preferable to the use of injections of warm water, of slightly astringent decoctions, or aromatic vegetables, as chamomiles, oak, chestnut, or Peruvian bark, or green ^ walnut shells; of dilute phosphoric acid, of a weak solution of subli- mate, of lime-water, kreosote, and so on ; or if the secretion of the ichor be copious and stinking, some slight aromatic remedy must be strewed in powder on the ulcers. But if the treatment mentioned be inefficient, the ulcers not being kept up by a general diseased cause, and the posi- tion of the carious bone permitting, the cure may be attempted by the removal of the carious part and the simple treatment of an exposed sound bone, by cutting into the caries of a rib, of the breast and collar bones, the skull and face bones, the bones of the meta-carpus and -tarsus, of the articular surfaces, if the caries be not very extensive. If the latter be the case with the bones of the limbs, and especially in the joints, and destruction is to be feared from hectic fever, amputation or exarticula- tion of the limb is the only remedy. The numerous remedies proposed for caries, as asafcstida, phosphoric acid, rubia tinctorum, semina phellandrii aquatici, muriate of barytes and so on are not sus- tained by experience. Rust (a) recommends pills of equal parts of asafaiida, phos- phoric acid, and rad. calam. arom., from six to ten portions, three times a-day, as especially effective, particularly if scrofula be the cause of the disease. The use of acrid remedies, as tinct. euphorbii, aloes, myrrhse, the acrid setherial oils, and the like for the purpose of bringing about a more complete death of the diseased bone, for which purpose also the actual cautery has been employed, are to be entirely dis- carded, as their effect is not restricted merely to the diseased bone, but may also extend to the underlying healthy bone; only in caries fungosa, has the actual cautery (a) Handbuch der Cbirurgie, vol. ii. p. 398. TREATMENT OF CARIES. 119 often appeared advantageous. Fricke (a) considers the complete exposure of the diseased bone as the best mode of producing its quick exfoliation. ["The absorption may be prevented," says Mayo, " by subduing the inflamma- tion ; or may, having begun, be arrested, and the crop of unhealthy granulations converted into a healthy restorative growth, if the case is of such a nature as to allow of the suppression of the inflammatory or specific action." (p. 36). "The treatment must, in the inflammatory stage o£ caries, be antiphlogistic," says Lawrence; "take blood from the part locally, and adopt other antiphlogistic mea- sures, and after this, counter-irritation, by the application of tartar emetic ointment, moxa, and so on, in the neighbourhood of the diseased bone. When we come to the ulcerative stage of the affection, we must employ the counter-irritant plan. So far as local means go, perhaps, we have no more effective methods of producing it, than by counter-irritation, issues, and moxae. Further, as a local means of treatment, we are recommended, when the carious affection occupies a small portion of bone within our reach, to denude the bone, and remove the diseased part by means of Hey's saw, or a stout pair of scissors, or pliers, or by any other mechanical means, to cut away that which is the seat of disease." (p. 359). "The treatment of caries," says Syme, "is to be conducted on the same principle as that of cancer, and consists in the use of means which have the effect either of destroying the life of the morbid part, or of removing it at once from tiie system. There is this difference, however, that there being no malignant tendency to take on the same diseased action in the neighbouring parts, it is not necessary to remove any of them, except in order to gain access to the seat of the evil. Notwithstanding this favourable circumstance, it is found extremely difficult to eradicate the disease by depriving the part affected of its vitality. * * * The effect of all these appli- cations, to wit, the concentrated mineral acids, nitrates of silver and mercury, red oxide of mercury, and the actual cautery, (with a view of killing the morbid part), bowever carefully employed, is very superficial, and it is extremely difficult, if not impossible, to ensure their operation on the whole surface of the diseased part. They therefore always require to be frequently repeated, and generally prove quite inadequate to destroy the disease, unless it is very limited and accessible ; and it is even not improbable that some of them, as the actual cautery, may occa- sionally make the matter worse, and extend the disease to the neighbouring bone by exciting inflammation in it. For these reasons, excision ought to be preferred to caustics for removing the carious bone; and if the part affected be within reach, which can always be ascertained previous to commencing the operation, it may by this method, be surely and thoroughly eradicated at once. If the disease is super- ficial, and of small extent, it is easily scooped out with a gouge, the toughness and compactness of the sound bone distinguishing it from the morbid portion. If exten- sive and deep-seated, it is best removed by taking away the whole of the articu- lating extremities. When the situation of the caries prevents it from being cut out, amputation ought, if possible, to be performed; if this be impracticable, the disease will sooner or later, prove inevitably fatal." (p. 172)]. 867. If from examination with the probe it appear, that the diseased bone is partially or completely loose, it must be seized with the forceps, and drawn out, for which purpose the ulcer in the soft parts oftentimes must be enlarged. Commonly after the removal of the bone, the part upon which it was situated is covered with granulations, which must be very carefully destroyed with stimulating remedies. In cases where a large piece of bone has been completely destroyed, but will not separate, its removal must be effected by taking hold with the forceps, and moving it backwards and forwards; or if this be insufficient, it must be assisted even with the trepan, or with the scraper, if the posi- tion of the diseased part permit. (a) Funfter Bericht iiber die Verwaltung des allgemeinen Krankenhauses zu Ham* burg, 1832, p. 237. 120 NECROSIS. B.—OF NECROSIS. 868. Its low degree of vitality, is the cause of bone easily dying, and necrosis, which is analogous to the gangrene of soft parts, occurs as a consequence of inflammation, suppuration, or of a considerable tearing of the periosteum. According as the necrosis occurs from inflammation and suppuration, or from destruction of the connexion of the nourishing vessels of the bone, it may be distinguished into consecutive and pri- mary. 869. JYecrosis takes place at every age, in every condition of life and in both sexes, although usually in childhood and at the period of man- hood; it is most frequent in the compact part of tubular bones, in the shin-bone, thigh, lower jaw, collar-bone, upper-arm-bone, splint-bone, spoke-bone, and cubit; rarely in their spongy extremities. It also fre- quently attacks the flat bones. JYecrosis is situated sometimes in the external, sometimes in the internal layer of the bone, or attacks it throughout its whole bulk. . All ailments which destroy the nourishment of the bone by the peri- osteum, or by the medullary membrane are to be considered as causes of necrosis. They may be either external, as mechanical violence, tear- ing of the periosteum, exposure of the bone, particularly if it be long subjected to the influence of the air, or be treated with acrid irritating remedies, contusions, and so on ; or internal, in which may be included all the dyscrasic diseases already mentioned (par. 863) from whence in- flammation and death of bone arise. The external causes rather pro- duce necrosis of the external layers of the bone, as the internal causes do internal necrosis. Oftentimes both causes operate together. [" If the periosteum, which, by its own vessels is in most intimate connexion with the vessels of the bone, be destroyed to any considerable extent, the external layer of the bone (not its whole thickness) dies," says Muller (a), " because the vessels of the outer layer are rendered useless by the destruction of the periosteum. If the medullary tissue alone be destroyed by inflammation, or artificially in an animal's bone which has been sawn through, the inner layer (not the whole thick- ness) of the bone dies, because the vessels of the inner layer of the bone are in the closest connexion with the medullary vessels. Now the process which ensues, in internal necrosis, in the still living external part of the bone, and in external necrosis in the still living internal part of the bone, is remarkable : it becomes inflamed to the extent of exudative effusion, as in an inflamed fractured bone, and subsequently the effused matter, as in that Case, hecomes organized and ossified. If the bone be injured externally and there be an outer necrosis, the exudation takes place within the cavity of a tubular bone, and the medullary cavity is therehy diminished. This callus on the interior of the cavity of a tubular hone strengthens its walls, of which the outer layer is dead. If, on the other hand, the medulla of a sawn-through tubular bone be destroyed, in consequence of which the inner layer dies, the exudation takes place on the outer surface, from the external still living layer of the bone. Most writers have not distinguished the swelling of an inflamed bone, called by Scarpa its expansion from the deposition of bone following the exudative condition in the former case into the medullary cavity, and in the latter on the external surface between the periosteum and the bone. The exudation is a process continuing only for a certain time, but the swelling continues during the whole period of the inflam- mation, and first appears distinct when the bone softens and becomes very vascular opposite the necrosed piece. This expansion of the inflamed and softened bone, in the mammalia, plays the principal part in the regeneration of the necrosed piece of (a) Physiologie des Menschen, vol. i. NECROSIS. 121 bone. At the part where the healthy external layer touches the internal necrotic, or where the sound internal layer touches the dead external, the still living inflamed bony layer is quite soft, red, and granulating, and in internal necrosis increases ex- ternally, whence, however, no new tube is formed around the internal necrotic layer, (sequester), but a strengthening of the outer layer, or beneath the external separated necrotic layer, a strengthening of the internal layer ensues, both externally as well as towards the medullary cavity. This swelling proceeds whilst the sur- face of the inflamed and softened bone begins to suppurate, either internally opposite the internal necrosis, or externally opposite the external necrosis. If the whole thick- ness of a bone be dead, no bone is regenerated; the periosteum has nothing to do with it; on the contrary, regeneration ordinarily takes place when merely the outer or inner layer is destroyed; here, however, no new bone is formed, but the dead por- tion of the tube in internal necrosis is only the inner layer of the tubular bone, and the new tube around the dead is only the strengthened and swollen outer layer of the tubular bone." (pp. 403, 404). Of necrosis produced by irritation, two very remarkable instances may be here mentioned, Bromfield's (a) case, in which the pea of an issue slipping frequently out of its bed, was confined by " a compress with a shilling in it bound very tightly; this, by its pressure, soon destroyed the periosteum, and not long after made its way through the surface of the bone into its spongy parts. Though a deep bed was thus obtained for the pea, yet violent pain and great swelling of the knee en- sued ; by throwing out the pea and dressing the bone properly a large piece of the spongy substance came away and the sore healed." (p. 10.) In the case referred to by Lawrence, "the patient had received a slight injury over the tibia, the sore put on the appearance of sloughing phagedxna or gangrene, and the concentrated nitric acid was applied to it. It appears that the acid affected the periosteum of the bone, at the part to which it was applied, and inflammation and necrosis of the tibia were the consequence." (p. 361.)] 870. The inflammation preceding necrosis has either an acute or chronic course, and is accompanied with more or less severe symptoms. If the inflammation be seated within the bone, there is first produced violent deep-seated pain, not increased by motion nor pressure, and fre- quently accompanied with severe fever, and exhausting perspiration ; a hard swelling appears, which gradually spreads, and over which the skin is neither tense nor red. After a longer or shorter time, according to the severity of the inflammation, abscesses form in different parts, which burst and discharge pus, without the swelling being diminished. These openings often correspond to the position of the diseased bone, often they form, especially if the bone be covered with much soft parts, fistulous passages, of which the external openings are surrounded with a wall of flesh, a line thick; some of them close and others again break out. ["When the ossific inflammation is not cured," says John Hunter, "suppura- tion takes place, first, on the surface of bones or on the periosteum; secondly, in the substance; thirdly, (p. 50S), in the medullary parts. * * * The first species.— When inflammation attacks the surface of a bone, the first efreets are adhesive; and when suppuration takes place, the periosteum is separated as far as the suppu- ration extends, making underneath a cavity for the matter. As the adhesive states take place some way round the abscess, there is in many cases a circle of adventi- tious bone formed in the periosteum round the abscess. * * * Often, from the separation of the periosteum, part of the bone dies, and must exfoliate. The second species is of greater consequence, as more of the bone becomes diseased. When inflammation attacks the substance of the bone, it is seldom that the whole diameter of the bone swells, generally only one side, where the suppuration is. This must at first be much confined, from the solid parts around, and' ulcerative inflammation is obliged to take place early; and accordingly as= in common abscesses^ the ulcera- tion goes on towards the soft parts, and until it arrives there it is impossible to tell (a) Chirurgical Observations and Cases, vol. ii. London, 1773. 11* 122 DISTINCTION BETWEEN IT AND CARIES. whether there is abscess in the bone or not. * * * The third species.—Inflamma- tion in the medullary part is still more serious in its consequence than the last. The body of the bone thickens from the adhesive disposition, and also the ossific disposition takes place in some degree in the periosteum all round, so that the external parts are much increased in bulk: this only takes place in the bones of the extremities, where strength is necessary, and never in the scalp, &c. The ossific disposition in the medullary parts takes place at all points of the abscess, and by this the other part of the marrow is saved. When suppuration takes place, there being no vent obliges the ulcerative inflammation to take place. * * * In the two last mentioned we have often exfoliations, as well as in the first (species) ; but they are less favourable from their situation being different, and are called internal exfo- liations." (pp. 513-15.)] 871. The diagnosis is more certain, if the piece of bone be apparent in the aperture of the ulcer and be black ; but if it be white and dry, the previous symptoms and the duration of the disease must decide whether it be exposure or actual death of the bone. In all cases, ex- amination with the probe or with the finger, if the size of the aperture will allow its introduction, with which the dead bone is sometimes felt to be moveable, affords sufficient information. If the previous symp- toms have been slight, it is probable that the necrosis is superficial. This may be presumed with more certainty, if the earlier swelling have not spread to the whole extent of the bone and the pain.be more super- ficial. The size of the dead piece of bone is determined by the extent of the swelling, and the distance of the orifices of the fistulous openings from each other. If there be several dead pieces of bone at the same time, they are felt on examination by the several apertures at different places, and a swelling answering to each of them is observed. The corresponding fistulous apertures also do not heal, although some pieces of bone have been removed ; they often, however, do not heal after the complete removal of the dead pieces of bone, because they go very deeply, and considerable suppuration occurs. Ill-conditioned, stinking blackish pus is no certain sign of necrosis; on the contrary, the suppu- ration is mostly good, and only degenerates when the general health is disturbed. Although caries and necrosis are alike in many symptoms, as in the two diseases similar causes give rise to both, as the bones are laid bare by the removal of the soft parts, and less or greater portion of the substance of the bone is lost and suppuration is present, yet they are distinguished by the following circumstances :—Caries occurs especially in bones of a spongy texture, necrosis, on the contrary, in bones of a closer character; in superficial caries the swelling has not at first so great extent as in bony gangrene ; the swelling in caries mostly opens itself to a greater extent, fistulous passages often occur which become callous ; in necrosis these openings have ordinarily a fleshy wall; in caries stinking ichor flows but in necrosis true pus, which is only bad when retained too long by improper treatment, or when the neighbour- hood is much irritated, or when caries also exists; in caries there are vital appear- ances, injection of vessels, loos2ning up, suppuration and successive destruction, therefore is the touch of the probe painful, whilst the necrosed bone is insensible and pain is only produced by harsh touching,and which spreads to the sound parts; the softening whioh accompanies or precedes caries extends further and loses itself imperceptibly, and above all, where it exists the bony cells are filled with reddish fluid ; in necrosis it is developed in sound parts, is less extensive, and produces only one layer of granulations, which are formed between the healthy and dead parts; the fungosities of a earious bone are softer, grayer, more discoloured than those above and below a piece of the necrosed bone, and the latter have more of the appearance of the granulations of as uppurating wound; in caries the bone is rough, uneven, soft, broken up, fungous, and the probe easily penetrates it; in necrosis the bone is even and hard, and though rough, not, however, yielding and spft; the beny splin- SEQUESTER. 123 ters thrown off are in caries small, dust-like, and destructible; in superficial necrosis they are layer-like, in deep necrosis large, firm, and of the natural condition of bone; the periosteum or medullary membrane is in caries usually much changed or de- stroyed, whilst the one or the other or even both in necrosis preserve their integrity, therefore nature does little in caries,- in favourable cases the openings become cal- lous, and similar changes are produced in the bony substance, or granulations arise from the bone which become connected with those from the soft parts butare rarely converted into bone and form only misshapen masses, whilst in necrosis a more or less complete reproduction of the destroyed bone is effected. The course of necrosis is mostly tedious, but often also quick and connected with active inflammation, which is rarely the case in caries. After opening the abscess, the pain in necrosis usually subsides, whilst in caries it mostly increases (a). The notion that in caries the organic principle (bony gelatine) has entirely disap- peared, and instead of it a peculiar fatty matter produced which fills the cells of the carious bone, whilst in necrosis the formative principle remains unchanged and its respective relations, that is as they are found in health, remain, (Delpech, Berard, Pouget and others,) is not confirmed by Mouret's experiments (b), as according to him the fatty matter in which every writer believed, is always found in recent caries, well distinguished from rancid fat by its smell, which may serve as its cha- racteristic ; but all the'bones he examined have a fibrous jelly-like substance, and contain a proportionate quantity of saline substances, as in healthy bone ; it is there- fore impossible by the chemical characters indicated to distinguish caries from necrosis. 872. Nature endeavours to separate a piece of dead bone, usually called a sequester, from a healthy bone, by the process of absorption, which at the line of connexion between the dead and the healthy bone, produces a loss of substance (1). As long as the exfoliation goes on by absorption and granulation, the small fleshy wall surrounding the fistu- lous opening remains, according to Dzondi's observations, unchanged ; but it shrivels as soon as that process is completed, and the separated piece is thrown off'externally, at the same time the previously very small round hole becomes irregularly enlarged. After this separation^of the sequester, its expulsion is possible, and usually happens without hin- drance, excepting such as the soft parts offer, if the dead piece belong to the external surface of a flat or tubular bone. Compensation for the lost piece of bone is effected by nature in various ways. If the necrosis extend only to the external layer of the bone, whilst the internal re- mains alive, which happens only in slight injuries from mechanical in- fluence, abscess and the like, the piece of bone, if the periosteum and soft parts remain uninjured, is enclosed in bone newly formed by the periosteum and is separated within by the granulations formed from the living layer. The piece of bone exhibits a rough surface, produced by absorption. If the periosteum and the soft parts be destroyed on the af- fected parts of the bone, and it is bared of soft parts, or entirely sepa- rated from them by blood, suppuration, and the like, the granulations arisino- from the compact bony mass can only effect imperfect compensa- tion so that a depression or deficiency remains at the place of loss. Here the piece of dead bone keeps its smooth surface and its whole thickness. In every severe inflammatory irritation of the surface of the bone, there occurs a corresponding plastic activity in the medullary canal, and new bone is produced, which opposite the point of greatest irritation, fills up the medullary cavity, In internal necrosis, if the layer of bone concealed (a) Richter, above cited, vol. viii. pt. i. p. 128.—Dictionnaire de Medecine et Chirurgie Prat, Article, Osteite. (b) Revue Medicale, 1835. 124 MODE OF EXFOLIATION.- within the medullary canal die, the compensating substance is formed from the periosteum, and becomes one with the external layer of the cor- tical substance, which remains healthy, excepting that the latter swells and softens, and thus assists in repairing the loss. If the whole thick- ness of the bone die, new bone is formed by the periosteum around the old, and the latter is diminished by absorption, in consequence of these in- creased vascular action and sympathy with the periosteum, and thereby its bulk is lessened, in proportion as the formation of the new bone from the periosteum proceeds. If a portion of a tubular bone with the invest- ing periosteum be destroyed and separated, the compensation results less from the opposite ends of the bone than from the soft parts. The granula- tions filling up the interspace gradually thicken to a cartilage-like mass, in which subsequently ossification follows. In the capsule which surrounds the sequester, openings {cloaca) are produced, the origin of which is not yet sufficiently made out, of various form, size and number, which com- municate with the fistulous passages in the soft parts. The reproduction of the bone does not depend on the periosteum, but only on the softened and outstretched tissue, which naturally close set, forms the thick texture of the bony walls. [(1) "Necrosis and exfoliation are not," justly observes Lawrence, "synony- mous expressions. When a portion of bone has perished, has. become mortified or gangrenous, it is separated by a natural process from the healthy portion of the bone; and that separation, under certain circumstances, is called exfoliation,- so that exfo- liation is consequent on the necrosis; that is, the necrosed or mortified or dead por- tion of bone exfoliates or separates. Exfoliation is, therefore, a subsequent process, consequent on the previous death or necrosis of the bone." (p. 360). The term exfoliation commonly applied to the separating sloughs of bone, in con- sequence of their occasional leaf-like form, is not improperly objected to by Wein- hold, who observes, that "as much more frequently the sloughs assume other and very different forms, it is evident that this designation is not quite fitting, but that it would be better to call it separation, by which would be more correctly expressed what was intended to be said." (p. 22). At least as early as 1786-7 (a) John Hunter observed :—" We have many opi- nions of this process (exfoliation) from different authors* but all are very imperfect. The bone that separates cannot come away by rotting, for it is only dead, and not in the least putrefied. * * * When a piece of bone becomes absolutely dead it is then to the animal machine as any other extraneous body, and adheres only by the attraction of cohesion to the machine. The first business of the machine, therefore, is to get rid of this cohesion and discharge it. For effecting this separation there are several natural and successive operations. The first effect of the stimulus is on the surface of the living bone, which becomes inflamed; whether new vessels are formed, or the old ones become larger, is undetermined; but by injecting the surface of the part it appears evidently much more vascular than the other parts. The surrounding parts also inflame, as the periosteum and cellular membrane often take on ossific in- flammation. This produces another process; first, absorption of the earthy matter, and all the surface between the living and dead parts of the bone become as soft as it steeped in acid, while the dead parts remains as hard as ever. To complete the separation the absorbents continue their office and absorb the livino- parts also, and the first process is in a small degree attended with the second. The operation of separation does not take place equally; it begins at the circumference, and conti- nues on to the centre, and before the centre has begun the absorption of the earth the circumference has begun the second. This progressive process in the suppuration causes the exfoliation to be tedious, so that the centre is the last place that separates. In pretty broad exfoliations, long before the centre has gone through the operation, the living parts perform their office in producing granulations from the surface and continue, m proportion to the waste, to fill up the space." Shortly after, in speak- (a) The date of the copy of notes from which Palmer has published his edition of Hun- ter s Lectures on the Principles of Surgery. MODE OF EXFOLIATION. 125 ing of the spicula which remains on the exfoliating ring of a trephine-hole in the skull, Hunter also observes :—" It appears from this last supposed case that it is my opinion that the absorption is of the surface of the living bone, but I by no means wish to be understood that no absorption of the dead piece can take place; for, on the contrary, I believe that nature sometimes finds it necessary to the completion of her process; it generally takes place when the separation is slow and the granu- lating process is quick. This absorption of the dead bone takes place in the fangs of the shedding teeth." (pp. 525-27). This extract proves that John Hunter had taught the true nature of the exfoliating process at least six or seven years before the publication of Weidmann's work on Necrosis. And it is very remarkable how nearly the expression of Weidmann's opinion on this subjeet Corresponds with Hunter's. " The actual cause," says he, " of that separation consists in the re- moval of those adjacent and cohering particles between the living and dead part, in such way, however, that the greater portion is removed from the living and some from the dead part." (p. 25.) "The first appearance of separation," says Hunter, "is an alteration in the part round the exfoliating piece. This alteration is first a sponginess; next its becoming fuller of little holes; then a small groove is produced, a kind of worm-eaten canal about the thickness of a shilling, becoming gradually deeper and deeper, and the depth is irregular, according to the extent of the original cause. The small holes appear at first in the surrounding parts and these appear more vascular the more so the nearer the diseased bone. Sometimes parts become dead without any change of colour, dying almost suddenly, perhaps by exposure or a blow, and the surround- ing parts beccme spongy ; the dead portion then looks the soundest, but when killed by previous diseases it is black. After exfoliation the living surface still continues soft until bone is formed. If it be a cylindrical bone it has the appearance of a foetus's bone deprived of its epiphysis; it is hollow, but fills like a growing bone, in every respect, by bony matter deposited." (p. 527). The subject of exfoliation has been well gone into by Miescher, and it is inter resting to observe how completely his experiments and observations confirm Hunter's statements. "For the first few days," says Miescher, "it is not possible to determine how far the necrosis extends; although the colour appears changed in the external surface, yet it so gradually subsides into the healthy colour of the bone, that it is impossible certainly to define the boundary between them. Gradually, however, there appears a certain thinning of the bony tissue, the medullary canalicules seem here and there enlarged, so that a sort of diploe, as it were, is producecf, the cells of which are filled with a kind of soft reddish substance. The walls of the cells become daily thinner and thinner, till at length they entirely disappear, so that the living and dead bone are no longer connected by bony substance ; the necrotic part now alone adheres by a few very delicate fibres to the soft substance I have mentioned, and is moveable, but at length these fibres either subside of their own accord, or are easily separated ; which done, the exfoliation is completed, and the bone appears covered, with a layer of that soft substance, or with granulations. These changes do not take place at the same time in the necrotic piece, but first at its external edge forming the so- called groove, and thence by little and little pass on towards the centre. Hence it appears that in the part where the dead and living bone touch, absorption of the bony substance is taking place, proceeding as it would seem from the medullary canal- icules and thence gradually breaking up the cohesion between the dead and living bone, till at last it is completely destroyed. The gaps, moreover, as they are gra- dually formed, we perceive to be filled with soft substance, which, when the sepa- ration is perfected, covers the bone sometimes with a thicker, sometimes with a thinner layer, secretes pus, and rises into granulations. Many have considered this to be softened bone; but this doctrine agrees neither with the production nor struc- ture of that substance, for following it out from its beginning, we find, as already noticed by that very able and diligent observer Troja, first, a reddish matter, little tenacious, almost gelatinous; subsequently when it has become somewhat firmer we perceive, by the aid of the microscope, a structure similar to granulations, such as are on soft parts; not, indeed, like the cartilage of bones, which ought to be found, if this matter be taken for softened bony tissue, that is deprived of its earthy parts. Therefore is it believed to be recently formed, precisely as every kind of granulation; which opinion, its very nature, afterwards, especially favours. * * * What has 126 MODE OF EXFOLIATION. been here said in regard to superficial necrosis and the external powers, applies to every kind of necrosis; which from whatever cause arising whether it attack the ex- ternal or internal surface of the bone, or its whole mass or only part, always presents in its exfoliation the sam,e phenomena, and always when separated, leaves the sur- face of the bone covered with granulations and secreting pus. (pp. 200, 201.) Upon the disputed question whether in the separation of a necrotic piece of bone there be any absorption of the dead portion, or whether the absorption be confined only to the living bone, Miescher declares himself a supporter of the latter opinion. "I have already observed," says he, "that at the same time the groove began to form around the necrosis, the thin edge of the bent plate was somewhat bent down by the just growing granulations and that it wasted in minute scales. I was able to follow this out,0as it were, step by step, *y observation in necrosis produced by baring the surface of bones in rabbits, cats, and in the calf, in which throughout the whole proceeding, the wound remained dry; the little scales, separated in the crust covering the lips of the external wound, could be most distinctly demonstrated; which crust having been cautiously removed, the very thin edge of the dead plate appeared as it were corroded, and a lancet being introduced beneath it, very readily fell into minute particles. Small particles, therefore, having separated, it seems, like scales the necrotic plate gradually diminished to sometimes more than half its size; nor was it doubtful, that in the cases mentioned by Ruysch, La Peyronie, and Rou- hault, the dead piece of bone thus by degrees entirely disappeared. This exfolia- tion in particles might be more difficult to demonstrate in those cases in which the wound is constantly moist with pus and poultices, and the thin plate is as yet perhaps dead; but, when the other phenomena do not at all differ, and absorption by a solid lifeless body seems opposed to the very laws of physiology, and when there is no fluid, by the solvent power of which it can happen that the dissolved dead bone should be absorbed,—we cannot, even in these cases, though more doubtful, but think that the exfoliation by particles, or insensible exfoliation is performed. In addition to this, the acute Tenon says, that in the experiments he performed on dogs, he always observed, that the granulations which sprung up from the bared surface of the bone, as soon as they made their appearance, were covered with a minute crust, which might justly be considered as bony scales separated and thrown off by the granulations. Every support is, therefore, torn away from the opinion of those who, in the separation of necrosis by absorption, consider that something is taken away even from the dead bone; and we can now certainly contend, that the necrosis is separated by absorption occurring in the living parts alone; which is of no little moment for rightly understanding the separation of bones destroyed by necrosis." (pp. 207-8.) I cannot agree with Miescher that absorption takes place only in the living parts during the process of separating a sequester. Hunter's opinion is certainly correct, " that nature sometimes finds it necessary to the completion of her process," that there should be some absorption of the dead bone and that "it generally takes place when the separation is slow, and the granulating process is quick." I think that absorption of both dead and living part of the bone occurs most commonly in all ex- ternal exfoliations; but of its almost invariable occurrence in exfoliations of the bones of the head there can be no dispute; for not merely is the under surface of the exfoliated piece hollowed in correspondence with the granulations beneath, but it rarely happens that there are not two or three regular holes eaten completely through both tables of the bone, with fungous growths from the dura mater pro- truding in the latter case, or the granulations alone in the former.—j. f. s.] The following is the account given by Troja of the incipient production of new bone seven days after the shell of the shank-bone of a pigeon had been killed by sawing the bone through and breaking up its medullary structure with a probe. " Having killed the pigeon on the seventh day, I was astonished, on removing the muscles, to observe the very great thickness of the shank-bone, which in comparison with the opposite healthy bone was enormously thickened. On examination I found fresh bone newly produced around the shank-bone. On separating the periosteum, which was every where a little swollen, except at the lower end, where it was swelled up with a dense or semi-cartilaginous jelly, blood-vessels were evidently perceived entering into the substance of the new bone. When I divided this bone lengthways into two parts, the new bone, now divided, dropped, almost of its own accord, into two equal portions, from both sides of the old shank-bone. Surprised MODE OF EXFOLIATION. 127 at the speedy separation of the new from the old bone, I endeavoured to ascertain the cause. Therefore Carefully viewing the internal surface, I perceived a certain Softer substance, and by bringing the point of my knife to the side of the bone, the membrane seemed to me to be lifted up. Struck with the novelty, I gave my atten- tion to it; I inverted a true, entire, very juicy and thickish membrane. Whilst this was separated from the bone, which was very easily done, an almost infinite num- ber of very delicate membranous threads were seen to draw out, which proceeding from the little apertures spread over the inner surface of the bone, were inserted into the membrane itself. Its ground colour was white, and transparent when raised against the light, but it was tinged and almost covered with very numerous red streaks, or, if you please, with an almost infinite number of spots collected together, but much less numerous at the lower end of the bone, which was also white. It well resisted pulling, nor did it dissolve, nor loose the characters of membrane when strongly rubbed with the fingers; but it was not to be considered as strong as periosteum,- for as yet it had less cohesion. The substance of the new bone seemed spongy, and tinged every where with the red colour of the blood, except the lower end, which, as already said, was rather whitish and softer." When this sub- stance was cut out and its thickness pressed with the fingers, a few drops of blood and lymph, like a scanty dew, exuded, (pp. 21-24). Its internal surface was fur- nished with an infinity of little holes, as well as the external; nor was the hole in the middle and outer side of the shank-bone for the passage of the vessels deficient. There were also some very large holes, which penetrating from the external to the internal surface of the bone, were covered without by the. external periosteum, and within with the internal membrane; they contained a dusky whitish and dry crust; whence it was very clear that they originated in a defect of the ossification. I shall name them foramina, or grandia foramina." (pp. 27, 8). Weinhold says, that these holes, "as they give passage to the escaping pus and the loose pieces of bone, would be better called cloacae." (p. 35). "Beginning from the sixth hour and going on to the seventh day," says Troja, "I did not perceive in the new bone, these spaces and grandia foramina, except when the legs were swollen, and then they were constant. In the twice that I proceeded to the seventh day, I did not make out whence were these spaces and foramina. At first I thought they were the insertions of muscles; but their irregular situation and uncertain number, one, two, and even to eight, and more careful examination, proved to me that such was not the case. Their absence in legs which had not swelled, and the periosteum raised from the bone in vesicles, assured me that no jelly could be collected in the spaces, and that the foramina in the bone must be produced by want of substance or of ossi- fication. But it might be conjectured that the dry crust in them originated in the juice which the broken vessels poured out, drying on the surface of the torn periosteum, and perhaps from some layer of it which was dead." (pp. 58, 9). Weinhold says he has " seen a small portion of dead diploe of the os innominatum contained in a bony cavity without any cloaca. If there be many cavities in the same bone con- taining sequestres, each has at least its own cloaca. * * * Their form is round or oval, or somewhat like; their size is commonly sufficient to admit a quill; there are however some larger, though rarely so. Inwardly their edges are converging, and as it were contracted like a funnel, but outwardly their lips spread downwards, and their intermediate passage is sometimes long, sometimes short, and sometimes scarcely existing," (p. 35). Upon the disputed point, whether the newly formed bone enclosing the sequester, in internal necrosis, be produced by the swelling of the outer layer of the bone, or from the investing periosteum. Muller observes :—"It is not in itself conceivable, that a membrane like the periosteum, which is merely the vehicle for the vessels entering into the bone, and also its covering, should form an organized mass of bone. (p. 405). It is a most entire misconception, to suppose that one organic part can be the nourishing organ of another organized part, for instance, that bony sub- stance should be produced by periosteum, and that bone should be nourished by that membrane. * * * Bone is nourished by vessels from the periosteum and medullary membrane; it therefore dies if either of these be destroyed to some extent, the ex- ternal layer on the destruction of the periosteum, and the internal on that of the medullary membrane. But it does not follow that these membranes deposit the lime in bone. The periosteum is the vehicle of the vessels penetrating the bone, which therefore dies when they are torn through at that part. The nourishment and 128 EXFOLIATION, ITS KINDS. growth of bone depends on the sympathy of the bony particles between the capillary vessels and the blood, (p. 361). But it can be distinctly shown by experiments on beasts, (which for this purpose are better than birds), that the formation of the new tube is partly effected by the exudation, during the exudative stage upon the surface of the bone, which is to be viewed as exudation from the inflamed bone, and not from the periosteum, but that the greater part of the bony mass is alone formed (in internal necrosis) by the spongy swelling of the external layer which continues during the whole period of suppuration." (p. 405). Lawrie of Glasgow (a) in treating on the subject of necrosis, asks:—" What part does the dead bone play in this process ? does it act as a stimulant to the deposit of ossific matter? does it serve as a mould for the new bone? if it were removed, would the process be arrested ? To all of these questions I would reply in the nega- tive. I do not think that the presence of dead bone is more required to assist in any of the processes involved in the above queries than the presence of a slough of the soft parts in the generation of new flexible tissues. When the entire thickness of a cylindrical bone dies, the first step towards regeneration consists in an attempt to get rid of the dead part, by the absorbents forming a groove around the dead portion, gradually cutting it through and isolating it from the living. The next step, to a certain extent contemporaneous with the first, is the deposit of new osseous matter all around this groove, springing from the bone; the last, is the surrounding of the old bone with new, which begins to form before the old has separated, and continues after the connexion of the two has been quite dissolved. Currie's case (one he re- lates) appears to me to entitle us to answer the second and third queries in the negative; the old bone was removed long before the new was deposited; the pro- cess so far from being therefore arrested, was greatly accelerated, and the form of the new bone was much more symmetrical than if it had been deposited slowly around the old as a mould. It may be asked, if this view of the matter be correct, why is it not thrown off as a slough of the cellular tissue ? I believe that the impediments to its escape are mechanical and not physiological (physical ?); the soft parts which cover it, the irregular line in which it dies, and the vitality of the cancellous struc- ture next to the epiphysis extending for some distance within the dead outer case, render its escape impossible long after its presence has become a source of retarding, it may be, of fatal irritation." (p. 684). "So soon as any bony part, in which there has been previous sensible or insen- sible exfoliation, is covered with granulations, the process," says Miescher, "is. the same as with another suppurating wound : the same pus, the same granulations. These having attained the height of the granulations of the surrounding soft parts, coalesce with them and as it were become one; after which the scar is covered in the ordinary way. That part of the granulations immediately next the bone, is converted into bony substance; but the exterior layer is not so changed, but like the granulations of soft parts has a cellular structure, and thus as it were forms a new periosteum." (p. 208.) John Hunter observes:—" There can only be two species of exfoliation, viz. external and internal, but they are often mixed, and then admit of a third kind, which I call the enclosed exfoliation. The external arises from internal causes, and is in many parts a simple operation, meeting with no obstructions, as in the head, ribs, &c.; but in the extremities it is often complicated, and becomes enclosed, and then appears as an internal exfoliation. Internal Exfoliation.—These less frequently arise from accidents than the former; but may arise from the last two suppurations of bones (of which, the one is where only one side of the bone suppurates, and the other where the suppuration is in the medullary cavity.) The part which is to be exfoliated loses its life, and ulceration goes on in the internal surface of the sur- rounding living bone to make room for the exfoliation. In internal exfoliations a part of the centre of the bone becomes dead, while the enlargement of the cavity lessens the substance of the surrounding part, and consequently weakens that part. But nature wishes to furnish a substitute; for the stimulus of weakness being felt, the surrounding parts become affected, and undergo the ossific inflammation by which the bone is thickened; and this continues in proportion, and as long as the internal part is unremoved or not cast off. Mixed Cases of Exfoliation.—The first (a) Cases of Necrosis, with remarks; in London and Edinburgh Monthly Journal of Medical Science, vol. iii. 1843. NECROSIS. 129 is when an external one appears to be internal; the second is an exfoliation of the whole thickness of the bone in one part; the third, of the whole bone. These I call enclosed or encased exfoliations, generally occurring in the lower extremities. These three being very different, at first are not very easily conceived. First species of en- closed. Sometimes when the surface of a bone becomes dead, before the separation of the piece of bone takes place, the ossific inflammation comes on, and entirely covers the exfoliating piece, leaving only a little hole for the discharge of matter. This takes place, first, when the periosteum is inflamed, and the granulations from the edges of the exfoliated pieces also ossify; but the process for freeing the por- tion of bone has been already described. The second species is when a piece of any given length becomes dead throughout; the appearance of internal exfoliation is here still stronger than in the last case. Exfoliation or separation begins on the living surfaces of contact, at the two ends of the dead bone or piece, and ossific in- flammation comes on in the surrounding parts, so that it becomes encased. This rarely happens; but when it does, the separation of the exfoliated piece is very tedious, as the stimulus is given to all surrounding parts. The third species is where the ossific disposition takes place in the soft parts, from end to end, and the whole becomes enclosed in a case of bone. The difficulty lies in conceiving how it be- comes enclosed at the ends where the joints are constituted; but probably it is from these ends being alive, and exuding coagulable lymph from their surfaces, or else from lymph being exuded from the surrounding ligaments, and that becoming a basis, so as to keep the joint complete." (pp. 529, 30.)] Upon the reproduction of bone, the following notices are to be especially com- pared :— Troja, M., De novorum ossium, in integris aut maximis ob morbos deperditioni- bus regeneratione experimenta, &c. 12mo. Lut. Par., 1775. Blumenbach, in Richter's Chirurgischer Bibliothek, vol. iv. p. 107. Kohler, Experimenta circa regenerationem ossium. Gottingae, 1786. Weidmann, Above cited. Boyer, Traite des Maladies Chirurgicales, &c, vol. iii. 8vo» Paris, 1822-26. Meding, Dissert, de regeneratione ossium per experimenta illustrata; cum tab. aeneis. Lipsiae, 1823. Kortum, Dissert, proponens experimenta et observations circa regenerationem ossium; cum tab. ten. Berol., 1824. Richter, Above cited. Scarpa, De anatome et pathologia ossium. Ticini, 1827i Miescher, Above cited. 873. JYecrosis is always a serious disease, of which the duration is indefinite. The prognosis is, however, various, according to its cause and its seat. Its cure may be hoped for by the natural powers alone, or by simultaneous artificial assistance, if the necrosis be superficial, of no great extent, in no bone of important function, not in the neighbour- hood of important parts, produced by external causes, and when the patient's general health is good. On the contrary, the cure is difficult, and the prognosis is doubtful, if the necrosis be of great extent, connected with other affections of the same, or of other bones, if the diseased bone be of great importance, if the necrosis be internal or exist in several places; further, if it be produced by internal causes, especially those dyscrasic diseases, against which we have not any decidedly efficient remedy, and if the patient be old and very weak. JYecrosis rarely ex- tends into joints, but then always require amputation (1). The circum- stances which especially produce sequestres are different; the granulations arising from the interior of the capsule enclose the sequester, which is gradually but completely removed by absorption ; or it acts upon the walls of its cavity like a foreign body, and keeps up in it and in the neighbouring soft parts a copious suppuration, which debilitates the patient; or the sequester lies in a very spacious cavity, the walls of which Vol. ii.—12 130 TREATMENT. have already become callous, and produces no neighbouring irritation, but only a scanty pouring out of a thin purulent fluid (2). [(1) Of necrosis indirectly affecting joints, and in which from the symptoms it was presumed that the joint was diseased, and the limb consequently removed, I have known two instances, both of which are in the museum at St. Thomas's Hospital. In the one, a boy of ten or twelve years old, the necrosed piece, about the size of a marble, was contained in the epiphysal head of the shin-bone; in the other the dead bone was nearly similarly placed, and the cloaca from it, had opened into the knee-joint. (2) Other, and very dangerous consequences may attend necrosis, as the very remarkable case mentioned by Porter (a), which he calls "Aneurism in a case of necrosis," but which was doubtless no other, than a wound of the popliteal artery, by the accidental movement of the point of a sequester. The patient had, fourteen or fifteen years previously, violent pain in the left knee, which, as well as the lower part of the thigh, shortly after swelled to a great size, but without redness. A year after, a small swelling appeared four or five inches above the inside of the knee, which he himself opened and voided some matter, and the aperture remained fistulous. In August 1832 he had an alarming haemorrhage from this fistulous opening, but no recurrence of it till the night of Jan. 1, 1833, when he bled with great violence, the blood at intervals spirting forth to a considerable distance, at others trickling down the limb, but in neither case restrainable. He lost great quantities of blood, and fainted seven or eight times. When admitted on the following day his face was quite blanched and very anxious; he was extremely exhausted; pulse small, thrilling, and 150. On pressing the small livid fistulous opening in the thigh, thin serous blood slowly discharged, and the finger seemed to sink into a deep cavity; pulsation was quite distinct in the swelling; the lower part of the thigh-bone was enlarged, and the popliteal space filled up, but the artery was felt pulsating below. Amputa- tion was proposed, but he would not consent. The thigh continued swelling above the bandage, became gangrenous nearly up to the buttock, and he died on the evening of the 6th of January. On examination the popliteal space was found filled with thick grumous clots ; on the artery, just below its entrance into the space, was an opening. The lower part of the thigh-bone was considerably enlarged, rough, and a large portion of its posterior or popliteal aspect destroyed, so as to admit the fingers into a large cavity within. In the upper part of this cavity was discovered the sharp point of a sequester, moveable, and accurately corresponding to the aperture in the artery, which it evidently seemed to have occasioned.] 874. In the treatment of necrosis, nature must be assisted in throwing off' the sequester, which is then to be removed. If at the first there be severe pain, inflammation and fever, it must be attempted to lessen them by general and local blood-letting, according to the strength of the patient, by softening poultices and the like. If syphilis, gout or other dyscrasic diseases be connected with necrosis, the contraindicated remedies must be made use of. Where the general condition of the patient is good, and the necrosis originating from external causes, the separation of the sequester usually occurs soon, provided nature have not been disturbed by improper treatment. If the patient be well, his powers must be supported by good nourishing diet and strengthening remedies. The local treatment must be quite mild; moist, warm, slightly aromatic applications should be used, as in caries, and the fistulous openings covered with charpie, soaked in mild ointments. All irritating treatment to promote the throwing off of the sequester, as the enlarge- ment of the fistulous apertures, the application of sharp spirituous remedies, the actual cautery, the repeated boring of the dead piece of bond, are hurtful, inasmuch (a) Surgical Report of Cases treated in the Meath Hospital; in Doublin Journal ol Medical and Chemical Science', vol. V. p. 190. 1834. CARIES OF THE SKULL-BONES. 131 as by their effect on the living part they increase the destruction, but on the dead bone have no effect at all (a). 875. When, the sequester has separated, which is known, on exami- nation, by its mobility, it is not unfrequently thrown out by nature, or gradually removed by absorption. But if, on account of its peculiar position, on account of the surrounding soft parts, or of the bony capsule enclosing it, this be not possible, the sequester must be removed by art. For which purpose, oftentimes a simple incision of the soft parts of suffi- cient size is alone needed ; if the sequester be enclosed in a bony capsule, after exposing it by a longitudinal incision, the apertures must be en- larged with a bistoury, if the bone be soft enough ; boring the%capsule with the trepan, or the removal of a portion with chisel and hammer, or with Hey's saw, may be required. The sequester is then to be seized with the forceps, or with the fingers, and gently drawn out, especial care being taken that none of it be left behind, and that the inner wall of the bony capsule be not injured. If the sequester be so large that a consider- able opening is required for its removal, it is often better to break it to pieces with the forceps, so as to be able to remove it by a small opening. After its removal, the wound is to be lightly filled with charpie, every thing removed which can disturb the development of the granulations, and care taken for the sufficient outlet of the pus. 876. If the necrosis have been of long continuance, if the outflow from the fistulous openings be slight, if the sequester cannot be felt, if already several pieces of bone have been separated, the diagnosis is doubtful, whether there still exists a sequester, or whether it be not already removed by absorption. In this case the laying bare or boring through the bone is useless, and it is advisable to watch the state of things for some time, with simple treatment, in order to decide with certainty upon the diagnosis. 877. Amputation is only indicated in necrosis, when the cavity in which the sequester lies communicates with a neighbouring joint when there are several sequestres, of which each has its proper cavity, when the sequester lies so deep that its removal is not possible, and when the patient's powers are so sunk that throwing off the sequester cannot be expected, or its removal cannot be undertaken without the probable danger of exhausting the patient. A.—OF CARIES OF THE SKULL-BONES, 878. Caries may occur in all parts of the skull, though it is most commonly observed in the mastoid process and in the occipital bone. It occurs either on the external or internal table of the skull; in the former case it arises either from external violence, exposure of bone, and so on; or as consequence of a tophus, or of an exostosis which has run into suppuration. The caries may be also distinguished by examination. In the second case severe symptoms are sometimes produced by the col- lection of pus between the dura mater and the skull. The patient com- plains of a constant pain, always confined to the same spot, though externally nothing is apparent. Frequently giddiness, convulsions and (a) Wiedmann, P., above cited, 132 CARIES OF THE SKULL-BONES, coma; in short, all the symptoms of pressure on the brain come on. ^ At last there appears externally, at the part where the patient has complained of pain, a slightly painful, and from the first fluctuating swelling. If this break of itself or be opened, an aperture is found in the skull, of which the edge is thin and irregular, because the destruction of the internal extends further than that of the external table of the skull, out of which by the motions of the brain, a more considerable quantity of pus is driven up than from the external extent of the ulceration would be thought possible. The dura mater is covered with discoloured granulations, often depressed, and separated to a greater or less extent from the* skull, often even ulcerated. If the caries be in the mastoid process, hearing is almost always destroyed ; in consequence of the com- munication of the cells of this process with the ear-drum, the pus sinks into it, and produces suppuration and destruction of the drum-mem- brane. [The consequences of caries or necrosis in the mastoid process are very often fatal, and therefore the disease should be most carfully attended to. Most commonly it seems to begin with common ear-ache; abscess of the drum ensues; its lining is destroyed, and the bone either ulcerates and is gradually destroyed, towards the cavity of the skull, or dies outright and attempts are made to throw it off. I do not * know any mode of distinguishing between simple chronic suppuration of the ear- drum which is occasionally accompanied with pain, and the suppuration accom- panying caries or exfoliation; nor is there any distinction between the latter two, from either of which, however, the irritation set up on the dura mater may produce inflammation, ulceration and suppuration of that membrane, which consequently attack the brain, and either ulcerates its surface or produce, by remote sympathy, abscess in its substance, of which I have seen instances ; and in the last case I had of this kind, the abscess was as large as a pigeon's egg, but the young woman had no symptoms of compression till about three or four days before she died, though at intervals, for some time before, she had suffered agonizing headach in paroxysms of several hours. When the vault of the skull is attacked with necrosis, not unfrequently very large portions of bone die, as does also the scalp covering it, excepting at the circum- ference of the dead bone, which the skin still overlaps and seems as it were folded in. When both tables of the bone die, which, as far as I have had opportunity of observing is most common, though not to «qual extent, as in general the external table is more largely destroyed than the internal, suppuration begins between the bone and the dura mater, and if near a suture, the pus makes way between its teeth and is seen welling up at every pulsation of the brain. By degrees the granulations formed on the surface of the dura mater eat away holes of various size through the dead bone, and funguses appear, which, however, rarely exceed externally the size of the aperture. But on removing the dead bone, very large funguses are found on the dura mater, and in the course of a few hours, when freed from the pressure, rise above the surface of the scalp, sometimes to the size of half a split egg. These funguses are generally very foul, sloughy, blackish, green-coloured and horribly offensive; and when of large size the patient generally sinks with symptoms of inflamed brain. Instances do, however, happen in which enormous portions of the vault of the skull do separate, and the patient recover; I have at this time under my care a woman, who in the course of the last eight or nine years has lost by exfolia- tion, the greater part of both parietal bones, and some portions of the temporal and occipital. All one side of her face supplied by the facial nerve, (portio dura), has been paralyzed for many years, though it cannot be ascertained how this is connected with the necrosis during the course of which it has arisen. Other portions of the skull have from time to time exfoliated, but after the principal exfoliations, the deficient parts of the skull have filled, as usual, with tough fibrous membrane, and she has been able for four or five years to follow her ordinary occupation as one of the hospital servants. If the external table only have been destroyed, the bony granulations beneath as frequently make holes through it as those from the dura mater do through both tables. CARIES OF THE TEETH. 133 Caries occurs also in the bones of the face as well as of the skull, and more espe- cially of the nose-bones, where it is very frequently consequent on lupoid ulceration of the soft parts. 1 have also at present under my care a boy in whom the upper jaw-bone has been destroying slowly for the last four years from this same cause, and who has lost the greater part of the front of the alveolar arch and of the bony plate, nor has any remedy arrested the diseased process but for a very short time, after which it has burst out again with greater activity. The disease which results from mercury is necrosis, rather than caries, whether happening either on the skull or face; and even in syphilis except when the bone is affected secondly by the extension of the ulcerative process from a sore in the soft parts, necrosis is more frequent than caries. Syme (a) relates the case of a woman who at the age of twenty years had a sore on her nose, for which she took large quantities of mercury. The sore rapidly extended, the bones became affected, and a rapid exfoliation commenced, which soon deprived her of all the face except the lower jaw and part of the ossa malarum. Five years after her eyes were divested of their coverings, the pharynx completely exposed to view, the tongue lay exposed from root to apex surrounded by the foul and vacillating teeth of the lower jaw, and the whole surface had a most unhealthy ulcerated appearance. In the course of the following four years the whole ulcerated surface had healed, and the eyes were covered with a thick skin. She was very weak and for a long period had existed on little else than laudanum, of which she took half an ounce daily. She died shortly after, and on examination it was ascertained that the remaining bone was every where perfectly sound, (p. 238).—j. f. s.] 879. What relates to the causes of caries of the skull-bones has been already said on the general subject; it is, however, most frequently con- sequent on syphilis. The prognosis is determined according to the variety of the causes as well as the extent of the caries. If it occur on the inner table of the skull, or if the skull be eaten through from without to within, pressure on the brain or ulceration of its membranes, which often extends to the brain itself, is to be feared. 880. The treatment of this caries is guided by the general rules. Only when both plates of the skull are destroyed, especially if the caries have been developed on the internal, trepanning is often necessary in order to relieve the collection of pus beneath the skull, or even to remove the whole diseased part of the bone. In caries of the mastoid process espe- cial care must be taken for the proper escape of the pus, so that it should not collect in the drum. If the dura mater itself be ulcerated or covered with unhealthy granulations, it must be bound up with slightly stimu- lating remedies, with decoction of bark and lime water, with' digestive ointments and the like, and the vital activity assisted by aromatic applb cations. B.—OF CARIES OF THE TEETH. Fauchard, P., Chirurgien Dentiste. Paris, 1786. 2 vols. Berdmore, T., A Treatise on the Disorders and Deformities of the Teeth and Gums. London, 1768. 8vo. Plenk, J. J., Lehre von den Krankheiten der ZaLhne. Wien, 1779. 8vo. Hunter, John, The Natural History of the Human Teeth, explaining their struc- ture, use, formation, growth and diseases.. London, 4to. Bucking, J. J., Vollstandige Anweisung, zum Zahnausziehen. Stendal, 1782. 8vo. With copper plates. Jourdain, Traite des Depots dans le Sinus Maxillaire, des Fractures, et des CarieSj de l'une et de l'autre Machoire. Paris, 1761. 12mo. (a) Edinburgh Medical and Surgical Journal, vol. xxxii., 1829. 12* 3 34 CARIES OF THE TEETH. La Forgue, L., Semeiologie Buccale et Buccamancie, ou Traites des Signes qu'on trouve k la Bouche. Paris, 1814. 8vo. Serre, J. J., Darstellung aller Operationen der Zahnarzneikunst. Berlin, 1804. 8vo. With copper plates. Gallete, J. F., Blieke in das Gebiet der Zahnarzneikunde. Mainz, 1810. 8vo. -------Anatom. Physiolog. und Chirurgische Betrachtungen fiber die Zahne. Mainz, 1813. Maury, C. J., Manuel du Dentiste pour l'application des dents incorruptibles, suivi de la description de quelques instrumens perfectionnes. Paris, 1814. With plates. Fox, Jos., The Natural History and Diseases of the Human Teeth. Second Edit. London, 1814. 4to. Kugelman, K. J., der Organismus der Zahne, deren Krankheiten und Ersetzun- gen. Nurnberg, 1823. 8vo. Bell, Thomas, The Anatomy, Physiology, and Diseases of the Teeth. London, 1829, 8vo. v. Carabelli, Systematisches Handbuch der Zahnheilkunde. Wien, 1831. 8vo. Linderer, Handbuch der Zahnheilkunde. Berlin, 1837. 8vo. With lithogra- phed plates. Nasmyth, A., Researches on the development, structure and diseases of the Teeth. London, 1839, 8vo. [Goddard, P. B. The Anatomy, Physiology, and Pathology of the Human Teeth, with the most approved methods of treatment. Phila- delphia, 1844. 4to. With plates. Harris, C. D. The Principles and Practice of Dental Surgery. Phi- ladelphia, 1845. 8vo. 2d. Edit.—g. w. n.] 881. The teeth belong to the bony system, and therefore analogous diseased appearances are observed in them. Caries occurs in all the teeth, though more frequently in the molar than in the incisive teeth. Most commonly it begins in the crown, but not unfrequently also at the root of the tooth. 882. Caries is developed at the crown of the tooth, either from without inwards, or from within outwards. In the former, the enamel of the tooth is observed to lose its natural white colour and polish at one or more parts, either on the sides, or upon the top of the crown ; clefts and hollows are seen which have a brown or blackish appearance, and gra- dually enlarge. The affected tooth gives out a nasty smell, and if the destruction penetrate to the inner substance so that the nerve be exposed to the contact of the air and food, pain of varying severity and duration occurs, frequently also inflammation of the gums and the like. In the second case, no change is in the begining, observable on the crown of the tooth, but pain first occurs, is more or less severe and of indefinite continuance, though always soon returning, as often as it is suddenly excited by cold air, cold drinks, and the like. At last, on examining the tooth, a brownish or blackish spot, more or less deep, is observed in the enamel, which gradually enlarges, becomes darker, and destroys the enamel, when the internal substance of the tooth is found to be decayed, so that enamel is often merely a thin shell which is easily broken. When the crown is destroyed by caries, it spreads also to the root of the tooth, which is likewise destroyed, and then commonly the gums and alveolar process suffer. The gum surrounding the diseased root, CARIES OF THE TEETH. 135 puffs up and inflames, {Parulis,) and not unfrequently an abscess is formed. Oftentimes the membrane lining the tooth-socket also inflames, pus wells up between the gum and the tooth-fang, frequently very severe pain occurs which spreads over the entire half of the face, and is ac- companied with swelling of the cheek. [Occasionally it happens, that without any caries of the tooth, irritation is set up in its socket, and when the jaws are firmly closed the pressure of the tooth into the particular socket causes severe pain. In a very few hours the lining of the socket begins to swell and inflame, lifts the tooth much above its proper level, and conse- quently renders the closing of the jaws still more painful, and chewing the food almost agonizing. This continues for hours, and sometimes for two or three days, when suppuration commences, the pain and swelling subside, and the tooth again descends to its natural place. This unpleasant process is of very frequent recurrence, gradually separates the gum from the fang till the two are quite apart, and the tooth seems held merely by the vascular and nervous connexion of the ends of its fangs, when its looseness and the constant source of irritation it becomes, leads to the tooth being pulled out. Under these circumstances I have unfortunately had personal experience, that the fang is encrusted with a granular deposit seemingly bony. Leeching the neighbouring gum is all that can be done; but when the process has been once set up, it recurs again and again, till the connexions of the tooth and gum are entirely destroyed, although the tooth itself remains entirely free from caries.— j. F. s.] 883. Caries at the root of the tooth is often announced, for a long while, by very equivocal symptoms. Pain occurs in the tooth, but rarely of long continuance, inflammation and swelling of the gums about the diseased tooth, which frequently becomes very severe, abscesses in the gums, outside the mouth, upon the cheek, at the part corresponding to the root of the affected tooth {Tooth-fistula.) The crown is, under these circumstances, often still completely healthy, and the diagnosis can only be properly determined by particular observation of the symptoms men- tioned and by the circumstance of the tooth smarting when touched with a metal probe. 884. Besides these symptoms caused by carious teeth, there occur not unfrequently, caries of the alveolar processes, diseased changes of the Highmorean cavern, if the tooth be in the upper jaw (1), as well as swell- ings and excrescences upon the gums, (Epulis,) which are of different kinds, sometimes soft and spongy, sometimes firm and hard,, sometimes slightly or not at all, but at others severely painful; sometimes they have a broad, sometimes a pedicled base, and various size, but always red, and they are situated more commonly on the under than on the upper jaw (2). [(1) Occasionally the inflammation extends from the sockets of the upper molar teeth into the Highmorean cavern, the lining of which becomes inflamed and suppu- rates. This is accompanied with much deep-seated aching pain, and dusky redness, with tenderness of the cheek. When these symptoms are present, the condition of the cavern may be suspected; and the mouth must be examined, to ascertain whether there be any stumps of teeth in the neighbourhood exciting the irritation. If there be any such, they should be removed, and a probe, or iron wire, or a small trocar must be thrust up the tooth-socket, to open a way into the cavern, by which the pus may escape. This aperture will require for its establishment, the insertion of a little wooden plug, which should be removed three or four times a-day, so that the pus may flow out. It is also a good plan to syringe the cavern with warm water through this hole, especially if the discharge be offensive; and if there be reason to suppose any ulceration of its lining membrane exist, injections of weak solutions of nitric acid may be used with advantage. 136 EPULIS. (2) "The tumour of the gum, epulis, is often," observes Liston (a), "a simple growth of the consistence of the structure from which it proceeds, and not likely to be reproduced, if the exciting cause is removed, and the entire disease extirpated; the cause is decay of some part of one or more teeth, of the crown, neck or fang, or it may arise from their being crowded and displaced. The lower jaw is the most common situation of epulis; it appears in the front of the mouth, occasionally at the root of the molares, and the upper jaw is by no means exempt from it. Some of the large tumours in my collection, removed along with this bone, appear originally to have commenced in the alveolar ridge. The size and extent of epulis is various; it may be confined to the gum betwixt two teeth, or it may have been neglected long, have taken in several, and may be attended with alteration in structure of the alveolar processes and their covering. The disease is generally connected with affections of the permanent teeth, but it is met with as a disease of infancy. * * * The tumour is of slow growth; it remains generally of the same firm consistence, and its attach- ments are broad and firm; its surface, even when large, is covered by membrane, is unbroken, it becomes lobulated, unless it projects from the mouth, and is exposed to injury; the teeth are loosened, and present in various parts of the tumour; around their base some excitement may be kept up, and even some ulceration and discharge. The tumour is not of a malignant nature in general, and even in its advanced stages is not inclined to contaminate the parts in its neighbourhood ; if thoroughly removed, it does not return. A soft tumour of the gum, rapid in its progress, broken on its surface, and furnishing fetid and bloody discharge, is sometimes, it is said, met with; there is no danger of mistaking the one kind for the other, the remediable for the malignant; fortunately the latter is rare." (pp. 255, 56.) I have occasionally, though not often, seen epulis of both kinds mentioned by Liston; that which seems merely a luxuriant growth of one particular part of the gum, is most frequent, but that directly connected with the teeth is more rare. Of the latter kind I operated some time since, on a boy of twelve years old ; the tumour was about the size of a bean, on the outside of the left branch of the lower jaw, when first observed, but in the course of two years it spread slowly, as far back as the last molar, and forward to the outer incisive tooth; it had risen to the edge of the gum, but had not descended quite so low as the base of the jaw; in front, its lower edge had either absorbed and imbedded itself in the jaw, or bony matter had sprung up around it, as it had there a distinct though irregular edge, but behind the ridge was less marked ; its size was that of half a walnut; it was elastic, fluctuating, and seemed enclosed in a tough cyst, thinnest above; the membrane of the mouth moved freely over it. At the operation, the cyst was found to have a cartilaginous feel, and the shell of the jaw-bone evidently involved in it. When opened by a crucial cut, about a drachm of glary fluid was discharged, and at the bottom of the cavity, against the side of the jaw, was the second permanent bicuspid tooth, like the so-called lady (the grinding teeth) in the lobster's stomach. The tooth was drawn, the whole sac removed with scissors close to the surface of the jaw, and the remaining capsule sliced off. The case did well at the time, but eighteen months after he came again with a return of the swelling in the same place, but of a firmer texture. Having lost sight of him since, I do not know what has ensued.— J. F. S.] 885. The causes of caries of the teeth are either external or inter- nal. To the former belong the improper use of acrid acid substances, negligent cleansing of the mouth, alternate use of cold and hot food, tobacco chewing, and mechanical injury of the teeth, by which the enamel is destroyed, and its internal substance is exposed to the air. In most cases, however, caries of the teeth depends on an internal cause, namely, on that kind of caries which is developed in the interior of the tooth. This opinion is especially grounded on the circumstance, that rottenness of the teeth frequently appears in every member of the same family, that the conesponding teeth on both sides are attacked together, and the caries is accompanied with general disease, as rickets, scurvy, (a) Practieal Surgery. TREATMENT OF CARIOUS TEETH. 137 mercurial cachexy, bad constitution, weak chest, and the like. The spreading of the caries to the neighbouring teeth seems rather grounded on the collection of part of the food, which putrefies, or on the general causes, as in a peculiar participation, from the first, of the affected teeth. Coffini:ere imagines that in persons with weak chests, the cure of the toothach should not be effected by drawing the tooth, as by retaining the diseased tooth a good derivation may be kept up (a). . 886. As to the treatment of carious teeth nothing can be done to prevent the further spread of the caries than removing the causes and improving the constitution, which in many instances is indeed impos- sible, as often no actual cause can be discovered. 887. For the purpose of restricting the further destruction of carious teeth many remedies have been proposed, which either destroy the carious part, or protect it from the contact of the air or food. To these belong spirituous aromatic tinctures, aetherial oils, kreosote, and even the actual cautery. In superficial caries, the carious part may be removed, by filing or scraping, for the purpose of preventing its effect upon the neighbouring teeth. As to the former remedies, they diminish the sensibility by their irritation of the nerve of the tooth, therefore the pain is lessened, and even the offensive smell of the tooth improved, but the progress of the caries is not in the least arrested. Filing the carious tooth, only for the time, suspends the evil; usually it soon reappears, and makes quicker progress than before, especially in old persons. Filling up the carious tooth with thin lead, tinfoil, or with tooth-cement, and the like, (stopping), after the sensibility has been put an end to by acrid remedies, keeps the air and the food from the carious part, but the caries is not thereby removed. The cavity of the tooth always increases, and the metal at last falls out. In order to avoid drawing the teeth, and whilst keeping them in, to get rid of the pain, the destruction of the nerve with hot platina thread or with hot iron, as well as, if the crown be tolerably healthy, the trepanning of the tooth in the direction of its root, by which the nerve is destroyed and then the tooth stopped, as also the in- troduction of a drop of concentrated sulphuric acid has been employed (Ryan). [Chelius's observations as to the falling out of the stopping are very correct, and it is frequently on this account necessary to repeat this operation, however skilfully performed. Before stopping, however, it must be ascertained whether the carious cavity be tender on touching with a probe, for if it be, the pressure of the stopping, whatever it may be, cannot be borne, and often excites such violent pain, that the tooth at once requires removal. I much prefer filling the hollow, once or twice a-day, with a bit of cotton steeped in camphorated spirit, as it gradually diminishes the sensibility of the nerve, and sometimes entirely destroys it, so that it either renders the stopping bearable or sometimes even unneeded. All severe escharotics should be avoided, for they often increase the mischief, and compel the removal of the tooth.—j. f. s.j 888. It is most proper to recommend especial care of their teeth to persons affected with carious teeth, consisting in frequently rinsing the mouth, with water not cold, especially after every meal, and in re- moving with a quill toothpick every thing between and in the teeth. For cleaning the teeth, which should be done every morning, a fine powder of linden wood charcoal and bark, with a not too stiff tooth- brush is best; the mouth should also be frequently rinsed with sage (a) Ondet, Dictionnaire de Medecine, vol. x. p. 174, 138 TOOTHACH. water, and some tincture of myrrh or catechu, partly to improve the smell and partly to harden the gums. 889. If the tooth be painful, the treatment must be, in reference to the causes which produce the pain. The toothach is often of the rheumatic kind, in which it is not merely confined to the affected tooth, but the pain extends, more or less, over all the teeth of the same row, and over half the face. Warmth is here serviceable, covering the af- fected side of the face with flannel, a blister behind the ear, and if in- flammatory irritation be also present, leeches applied to the affected side. The toothach often arises from bits of food remaining in the hollow of the tooth, which must therefore always be examined and freed from such impurities. If, however, the pain continue, its diminu- tion must be attempted by remedies, which either subdue the excited irritability, as rinsing the mouth with warm water with the addition of tincture of opium, the application of cotton soaked in the same tincture, an opium pill in the hollow tooth, and the like; or, to destroy the sen- sibility, acrid remedies, the setherial oils, kreosote on wool in the-tooth, have been used, to which also belong most of the empyreumatic reme- dies recommended against the toothach. [Toothach commonly so-called is much more frequently arising from inflamma- tion of the lining of the socket than from affection of the tooth itself. It is therefore highly necessary to discriminate between the two, as otherwise a good and useful tooth may be drawn which might be saved, simply by repeatedly leeching the gum; and even when the gum is affected secondarily after curies, the tooth may even then be often preserved by this practice, and the exposed nerve becoming gradually destroyed, the toothach after a time subsides, and the pain of drawing the tooth is spared.—j. f. s.] Among the various remedies proposed, Bedingfield (a) advises as an improve- ment on smoking tobacco, often used for the toothach, the application of the fumes of henbane seed, in the following way:—" Put from one to two drachms of the seed upon a red-hot iron, or some lighted cinders, and immediately cover them over with a basin. As soon as you suppose the seed to be consumed and the vessel impreg- nated with the fumes, place it upon its bottom and fill it with boiling water. The person affected with the toothach is then to inhale the vapour for twenty minutes or half an hour, a blanket or some other covering being previously thrown over the head and shoulders, to prevent its escape." (p. 492). 890. If the pain cannot be in any way removed, or if the diseased tooth produce any ailment of the jaws, lips, or maxillary cavities, and so on, it must be drawn. This is also necessary if a tooth of the first set prevent the development of the second. If with carious crown the root be sound, the crown may be removed with a pair of sharp nippers or with a fine saw, and the exposed medullary cavity cauterized, which, however, is usually only employed in the introduction of a tooth. 891. The proceeding in drawing a tooth varies according as the forceps, the key, the pelican, the punch, or the pyramidal lever be em- ployed. The preference of one or other depends on the condition of the tooth to be drawn, and the individual dexterity of the operator with one or other instrument. In general the drawing of a tooth with for- ceps, is the least painful; it is, however, only applicable to the front, or to loose back teeth. The key is best, for drawing the hind teeth, as it permits the use of greater force, without injury to the other teeth, and has not any rest upon the neighbouring teeth; the gums are, however, (a) Edinburgh Medical and Surgical Journal, vol. xii. 1816. TOOTH-DRAWING. ' 139 thereby frequently crushed, and the tooth not rarely broken. The pe- lican acts more safely; it is applicable to all the hind teeth and their stumps, the gums are not crushed, and the tooth not easily broken; but the neighbouring teeth must afford it support and are liable to be thereby depressed ; the tooth can also be drawn with it only outwards. The punch and the pyramidal lever are only in the removal of stumps. 892. In drawing the front teeth of the lower jaw, the operator must place himself before the patient, who sits upon a sloping chair; he de- presses the lip with the fore-finger of the left hand, puts the thumb on the next tooth, and the other fingers beneath the jaw, and with the curved forceps seizes the neck of the tooth as low as possible, makes a little movement inwards and outwards, and then gives the forceps a pull upwards, by which the tooth is drawn. In drawing the front teeth of the upper jaw, the operator stands behind the patient, who sits on a low stool, separates the lip with the thumb of the left hand, seizes the tooth with the straight forceps, moves it a little in and out, and draws it with a pull directly downwards. 893. The hind teeth are drawn, either with the key or with the pelican, In the former case, the operator envelops the bolster of the key with soft linen, after he has fitted it with a claw, of corresponding size to the diameter of the tooth, and places himself before the patient sitting on a common chair. He then fixes the claw of the key with the right hand, if the diseased tooth be in the left side of the jaw, but on the opposite side with the left hand, extends the fore-finger on the stem of the key, fixes the point of the claw, by means of the guiding fore-finger of the unoccupied hand as deeply as possible, on the inside of the tooth, and keeps it fixed with that finger. He then turns the handle in a half circle downwards on the teeth of the lower, and upwards on the teeth of the upper jaw, by which the tooth is either at once drawn, or remains still connected with the gum, from which it may be completely separated with the fingers or forceps. If on account of the inner side of the tooth being destroyed, it must be drawn inwards, the point of the claw should be fixed externally, and the turn made with the handle of the key in- wards. In using the pelican, after having chosen a claw proportionate with the thickness of the tooth, and this distance of the point of support from the diseased tooth, and having covered the crown of the instrument with soft linen, the operator places himself behind the patient sitting on a low stool, fixes the pelican with the right hand in drawing a right side tooth, and the contrary, with the left hand, puts the point of the claw as deeply as possible, on the inside of the tooth, fixes the crown against the two neighbouring teeth in front, and the thumb of the unoccupied hand against the inside, and with the other fingers of the same hand grasps the jaw outwardly and beneath. The handle of the pelican is then moved from behind, forwards and laterally, by which its crown is pressed against the teeth, serving as the pressure point, and the tooth is some- what raised. If there be no adjoining teeth to support the pelican, a piece of cork must serve the purpose. 894. In the use of the punch, which is advisable only in teeth not very firmly fixed, the operator stands in front of the patient sitting on the 140 OCCASIONAL CONSEQUENCES OF TOOTH-DRAWING. sloping chair, if the teeth be of the lower jaw, but behind the patient, who is to sit low, if the teeth are of the upper jaw; he fixes the claw of the instrument against the root of the tooth, and the forefinger of the left hand against its inside, and then lifts the tooth inwards and upwards in the lower, and the contrary in the upper jaw. 895. The stumps and roots of teeth may be removed by one or other of these means. If they be loose, they are especially fitted for the for- ceps, or punch; those which are firmly fixed for the key, or if there be still neighbouring teeth left, for the pelican. Only when by these me- thods the stump cannot be removed, must the lever be used. The head of the patient is to be supported, the point of the lever fixed sufficiently deep, between the edge of the alveolar process and the root of the tooth, a lever-like motion is to be made to either side, where there is least opposition, and the root lifted out. In very firmly fixed roots, two levers may be applied in the same way on the two sides. 896. The awkward circumstances which may occur from drawing teeth are, breaking off the crown of the tooth, breaking the alveolar processes, bruising, tearing, or complete stripping off the gums, loosen- ing the neighbouring sound teeth, partial dislocation of the teeth, frac- ture of the jaw, slipping of the claw from a diseased to a sound tooth and its extraction, severe bleeding, inflammation and suppuration of the gums, and caries of the alveolar processes. If the crown of the tooth break off, the removal of its stump is to be attempted as already mentioned. In splintering the alveolar process, the loose pieces must be removed, and those which are fixed pressed into place. Bruising of the gums must be treated with slightly astringent gargles. If part of the gum remain only slightly connected, it must be cut off with scissors. Teeth which have become loose must be fastened to those adjoining with threads, and hard food should be avoided. If a tooth be partially dislocated, the pain is often thereby completely got rid of, and it remains firm in the socket, although caries go on ; but the dis- located tooth may operate in its socket as a foreign body and cause pain, the gum and the lining of the socket may become affected, and thereby the removal of the tooth be rendered necessary. Fracture of the lower jaw requires its proper treatment. A sound tooth which has been pulled out may be put in again, and fixed by threads to its neighbours. A slight bleeding occurs after the drawing of every tooth ; this is to be permitted for a little while, because thereby is the imflamraation of the gum best prevented; washing of the mouth with water and vinegar, and compression of the tooth-socket are usually sufficient to stop it. Frequently the bleeding is very severe, because perhaps the artery going to the tooth is torn, where it is in the bone and cannot retract, or on ac- count of scorbutic diathesis. In this case firm compression must be employed, the socket filled with lymph soaked in a solution of alum, in Theden's arquebusade, and the like, or with oak agaric strewed with styptic powder, or with a ball of wax j small compresses are to be put upon these, and the patient made to bite the jaws firmly together. In doubtful cases, the application of the actual cautery has been recom- mended. In the scorbutic diathesis the simultaneous internal use of acids is not to be neglected (1). BLEEDING FROM THE TOOTH-SOCKETS. 141 The inflammatory swelling of the gums requires a soothing treatment, • bathing with warm milk, figs boiled in milk, and so on. In general it runs on readily to suppuration, and if the abscess do not soon burst of itself, it must be opened with a lancet. The aperture usually closes under the continued use of soothing gargles. Parulis requires the same treatment if caused by a decayed tooth, and if that be the reason of the aperture not closing, the tooth must be drawn. If there be caries of the alveolar process, it must be treated according to the general rules. [(1) The bleeding which ensues occasionally in consequence of drawing a tooth of a person who has haemorrhagic diathesis, is a matter of very serious consequence, and has sometimes destroyed life. I have seen several severe, though not fatal cases of this kind, and as it seemed to me that the blood came from the very bottom of one or other of the fang-sockets, when the tooth had more than onte, I presume that the bleeding vessel was the proper artery of the tooth, and that the difficulty in arresting the haemorrhage depended on the difficulty of getting at the vessel itself; for unless it can be immediately acted upon, whatever be the local ap- plication, it is sure to fail. Various remedies have been proposed ; I have tried most of them without success, but I have never failed with the actual cautery, when I have properly applied it, that is, when its point has been sufficiently small to descend into the very bottom of the fang-socket. When I first had recourse to this practice I failed from not thrusting the hot wire (which makes the best cautery for this pur^ pose, and should not be more than a line thick) down to the very bottom of the socket; but having corrected this error, I have never failed since, in at least half-a- dozen cases ; and, therefore, believe that its inefficiency in the hands of others has arisen from the same cause which at first foiled me. There is nothing very frightful in the employment of this remedy, nor does it produce more than momentary and slight pain, and I think it is, therefore, best to resort to it at once without wasting time, and allowing the patient to lose blood to such extent a"s to disturb the con- stitutional powers, and excite any latent phthisical tendency, of which I have known an instance. Blagden mentions (a) the case of a person, who, whilst a boy, after the extrac- tion of a tooth, bled from the socket for twenty-one days. Whenever he cut himself, or received a sligh wound, there was always great difficulty in stopping the bleeding. At twenty-six years of age he had a trifling wound on the foreheaed, which bled pro1 fusely, and could not be stopped by pressure or styptics, or even by tying both ends of the artery, but was finally checked with caustic potash, which caused a large slough. In the next year he was much troubled with caries of the second upper molar tooth, which, remembering what had previously happened, he bore with for some time, and but at last the pain became so severe that he had the tooth drawn June 30, 1816, at its bottom was an abscess ; free bleeding immediately ensued, and this continuing on the next evening, Blagden being called to him, applied lunar caustic to the bot- tom of the socket without effect; then introduced a sponge tent soaked in solution of sulphate of copper, which checked the bleeding for a few hours, but it recurred, and continued profuse, notwithstanding that the socket was carefully plugged. On the morning of July teh, Brodie applied the actual cautery, and stopped the bleed- ing for six hours, but in the evening it broke out afresh, as violent as before, not- withstanding the socket was again carefully plugged, and the cautery twice applied; in doing the latter, a large quantity of matter apparently from the maxillary sinus, escaped. The bleeding still continued, and next day the patient being very low and depressed, although he had never fainted, it was determined to tie the common carotid artery, which was done by Brodie at 10 a. m., but " the haemorrhage still con- tinued. The wound made in the operation bled very little at first, but in the course of a few minutes after the operation it began to bleed profusely. No single vessel could be observed bleeding, but there was a general oozing from its surface. Ice was applied to the wound, and while this was continued the bleeding from it was suppressed, but it returned immediately on the ice being removed. Ice was also applied to the left side of the face, and there was reason to believe that it stopped the bleeding for a few hours; however, the haemorrhage afterwards returned, and (a) Medical and Chirurgical Transactions, vol. viii. 1817. Vol. ii.—13 142 BLEEDING FROM the patient died at 5 a. m. on the 1th July, a week from the time of the removal of the tooth." (pp. 224-27). The following case was under my own care :— C. K., aged 20 3'ears, a leather-dyer, of delicate frame and not very temperate habits, was admitted into Georges's Ward. June 17, 1837. Twelve years since had leeches on his left arm, which bled for several days. Three years ago had leeches on his hip, which continued bleeding for three or four days. Eighteen months since had the first right upper bicuspid tooth drawn, which did not cease to bleed for four days. On the 12th of this pre- sent month, at 8 l\ m., he had the second left upper molar tooth pulled out, which was immediately followed by considerable bleeding, and which continued during that night and the following day and night, he only attempted to stop it by fre- quently washing his mouth with cold water. On the morning of the IMh he went to his medical attendant, who applied nitrate of silver to the fang-socket; the bleed- ing ceased for a couple of hours, but recurring, he introduced some nitric acid, which, however, only checked itfor a short time, and the patient was content with washinghis mouth with cold water till 1 p. m. of yesterday afternoon, when he came to the hos- pital, and the dresser plugged the socket with sponge dipped in tincture of myrrh and alum; after which the bleeding ceased for eight hours, but then came on again, and continued through the night till 11 o'clock this morning, when he came again to the hospital, and the dresser applied a hot Wire to the socket, which checked but did not stop the bleeding entirely. It soon, however, burst out afresh, and at 7 p. m. he returned to the hospital, and having been admitted, the dresser applied muri- atic acid, but without effect. I saw him Soon after, and having cleared away the clot, found two bleeding points, one by the alveolar partition of the third molar tooth, and the other deeper in the socket. To these I applied the actual cauteryata black heat, and the bleeding ceased, but soon recurred ; and when I saw him again four hours after, I found a clot about the socket as big as a nut, with a free arterial stream flowing from beneath it; this I removed, plugged the socket with cotton steeped in tinct. benz. comp., and directed pressure should be kept up so long as there was any bleeding. After four hours it seemed to have stopped, but in half an hour burst out again and continued through the night. At 8 a. m. June 18, a pencil of lunar caustic was introduced, and the surface of the socket being freely cauterized, the bleeding was checked for a short time, but the oozing soon recurred, and when I saw him three hours after, a fresh clot had formed and the bleeding continued as before. T tried to make pressure upon a pad of cotton thrust into the socket, with a bell- spring carried over the crown of the head, but could not affect it. I then made a paste of tannin and cotton mixed With spirits of wine, thrust it into the socket with a probe, and pressed it doWn with the finger till it had become converted into a con- crete, by which the bleeding was completely stopped, and so continued for six hours, when it broke out afresh, and continued streaming till 8 p. m., at which time I saw him again, found the plug thrust out completely and the socket filled with clot. This I removed entirely, and after squeezing for a few minutes the soft parts about the socket, which Were swollen, with my finger, and the lint which gave him great pain, but stopped the bleeding, I left the socket alone, and applied linen dipped in spirits of wine as an evaporating lotion on the cheek. His bowels not having been relieved for the last two or three da/s, three grains of calomel, with some in- fusion of senna and sulphate of magnesia, was ordered forihwith. Nobleeding for five hours, after which it came on again, but pressure being made for a little time, it ceased for an hour, arid then returning, continued through the night till I saw him at 11a. m. of the 19th June, when I removed a clot as big as a walnut, and plugged the socket with cotton steeped in kreosote, and ordered one grain of acetate of lead three times a-day. There was no bleeding for twelve hours, but it then re- turned and continued through the night till next morning, when I saw him, and having cleared out all the clot and made a little pressure, it ceased. As he com- plained of pain in his belly, the lead was omitted after he had taken four doses. In the evening the bleeding returned, but was stopped during the whole night by plugging with cotton and kreosote. On the morning of the 21st June the bleeding returned, a fresh clot formed and the oozing from beneath it as before. On the lUth he had not appeared to have suffered much, his coun- tenance was not particularly pallid, and his pulse, though rather quickened, was firm and free from hsemorrhagic jerk; but now he is pallid, complains of faint- FISTULAS IN GENERAL. 143 ness, the pulse is quick and has the jerk which has not been previously noticed. On consultation with my colleague Green, it was determined to apply the actual cautery again; and having made a careful examination, I was only able to discover one fang-socket, through which however the protie readily passed into the maxillary cavern. I then passed a conical iron at a black heat to the very bottom of the socket, which caused great pain, as I expected, from the already irritable and in- flamed state of the parts after so much handling; and I also seared the sides of the cavity and the gum, from which there was some oozing. The bleeding then ceased. He was ordered to take every eight hours two grains of acetate of lead, with half a grain of opium. There was no recurrence of the bleeding after this ; the lead was continued for two days and then left off, and in the course of a week he was quite well and left the house. On the 4th March, 1841, he had the second left lower molar tooth drawn at the hospital, from which, excepting a very few hours, bleeding continued till his re-ad- mission, March 8th. The socket was then filled with putty by the surgeon in attendance, and over it a pad of lint, by which it was stopped for about twelve hours, when it burst forth again, and continued through the night. On the following morning two irons of different size were introduced into the cavity at a red heat, but the bleeding was not checked till the socket had been plugged with lint steeped in tincture of myrrh. After twelve hours the bleeding returned, continued through the night, and till the afternoon of the 10th March, when a small iron at black heat wras introduced, and lint soaked in solution of alum applied to the part; after sixteen hours the bleed- ing returned, and on the morning of the 11th he had a little bleeding from the left nostril. The solution of alum was continued, and now was ordered pulv. gallarwm. alum, sulph. aa gr. v. 4tis., but without benefit, and at 3 a. m. March 12th, a small iron at black heat, was introduced; but the bleeding did not cease till the socket was plugged with lint soaked in alum. At 9 a. m. the bleeding returned ; a blad- der of ice was then applied to the throat and cheek, and he was ordered plumb, acet. gr.j. op. gr \ seconda qudque hord per sex vices, tunc tertia vel quartd qudque hord per sex vices sequentes et postea sextd qudque hord. There was not any recurrence of the bleeding till the evening of the 14th March, when he again bled freely, and the lead and opium were again ordered every two hours, but on the following day, only every four hours. March 16th, he was directed to take a grain of muriate of morphia, which was continued for a few days. On the 18ih the bleeding was again free, but finally stopped on the 21st; and he left the house well on the 29th. How long the lead was continued in the second part of this case, the notes I have quoted, which were not my own, do not distinctly state, and I think it doubtful whether the eure was to be ascribed to it or simply to the loss of blood, by which in a case related by Davenport (a), the bleeding had certainly been put a stop to after thirty hours' continuance, and depressing the patient very considerably. I cannot help, however, thinking that in the second part of this case the actual cautery was never effectually applied; for as I have said before, I have never failed when using it, neither has my colleague Green, who also employs it. From the above cases it will be perceived how various have been the remedies made use of to stop these violent bleedings after drawing a tooth, but many other plans have been advised and strongly urged as most efficient. Some persons re-insert the extracted tooth in the socket as the best plug which can be used. Cortez (b) re- commends the introduction of a wax model into the socket, which he has found effec- tual in three or four instances. Peter Cltllen (c) prefers a very fine soft phial-cork gently squeezed into the socket, and upon the point of the cork, a bit of lint with some styptic may be put. Kendrick (d) advises a pledget of cotton dipped in the strongest alcohol as very efficacious. And among the cases of haemorrhage effectu- ally treated with the internal use of ergot of rye, one of bleeding after drawing a molar tooth is given by Dr. Ryan (e). An interesting circumstance in reference to these cases is, that not unfrequently other individuals of the family to which the patient belongs, are subject to this bleeding disposition. It was so in my own patient's family, and with that of Ken- nedy's patient, and I have known it in many other instances. (a) Medical Gazette, vol. ii. 1842. New Series, p. 58. (6.) Ibid., vol. iv, p, 490. 1829, (c) Medical Gazette, vol. v. p. 564. 1830. (d) Ibid,, p. 788. (e) Ibid^ vol. xiii. p. 368. 1833. 144 OF FISTULAS. It is scarcely needful to observe, that if the practitioner be aware of the patient or his family being subject to this disposition to bleed, he should be extremely cautious in undertaking the removal of a tooth, or indeed of any operation; and if compelled to resort to it, should at once be prepared to attempt arresting its bleeding at the onset, and not permit its continuance, for hours, much less for days, before employ- ing any efficient remedy.—j. f. s.] 897. Tooth-fistulas {par. 883) require the speedy drawing of the decayed tooth, and the use of astringent gargles. If the fistula do not then close, it is probable that there is still another decayed tooth, which must be drawn; or caries of the alveolar process may exist, which must be treated in the usual way. Carcinomatous excrescences on the gums {par. 884) are mostly con- sequences of a decayed tooth or of a carious part of the alveolar process. They must be removed from their base with the knife, and the great bleeding which generally ensues must be stopped with astringent reme- dies and pressure, or with the actual cautery, which last is also service- able in preventing the recurrence of the excrescence. If after the removal of epulis a decayed tooth or caries of the alveolar edge be dis- covered, the former must be drawn, and the latter treated according to the general rule. Cancerous sores and schirrus will be considered with degeneration of the organic tissues. II.—OF FISTULAS. (Fistulas, Lat.; Fisteln. Germ.; Fistules, Fr.) 898. Unnatural, old apertures, by which fluids are emptied from any cavity or duct externally, or into another cavity, are called Fis- tulas. By this definition fistulas are distinguished from fistulas sores. ["The term 'fistula' gives a very inadequate notion of the disease," observes John Hunter, "the fistulas canal being only the sign of the disease,—the means of conveying a fluid or extraneous matter to the surface. A fistula is the consequence of the powers of a part not being able to remove the original cause, so that the original cause and some of its effects remain." (p. 577)]. 899. The cause of fistulas, are either injuries, by external violence, of the cavities in which the fluids are collected, or of the ducts by which they are discharged, if they be not cured by quick union, or stopping up of the ducts, by which the fluids collected in large quanti- ties produce tearing, inflammation, suppuration, and mortification, causing extravasation of the fluid, and the cellular tissue, and an un- natural opening for its escape; or inflammation and ulceration on or in the walls of the cavities and ducts, by which the latter are destroyed. Fistulas, if not consequent on injury, usually commence with abscess, which on bursting, discharges pus of different kinds, by one or several apertures, communicating either directly with the cavities, or running in various turns and windings. If the fistulous passage be very short, it diminishes in size, as the inflammation lessens, the external opening contracts, and its edges scar, but without closing. If the fistulous canal be longer, the external opening contracts, is surrounded by a little fungous wall, which presents in its middle a narrow and often scarcely observable opening. By the continuance of the inflammation, OF FISTULAS. 145 to a certain degree, in the whole canal, and in the neighbouring parts, the whole internal lining of the canal is gradually converted into a mucous tissue, distinguished only from true mucous membrane, by the absence of mucous glands, and of the epidermoidal covering, and itself prevents the healing of the canal. But, for the most part, in long con- tinued fistulas, the neighbouring parts become hardened,, and form, more or less, grayish white, thick hard masses, {callosities), between which the fistulas run. The same changes also occur in fistulous pas- sages (par. 65). ["The causes of fistula," says Hunter, "are various, hut maybe divided into two classes -.—first, the obstruction of the passage of some natural secretion, as- fistula of the parotid gland; or of the canal for the passage of extraneous matter, as. the intestines being strangulated, so as to mortify, or being wounded; but all ob- literations of the ducts, where the fluids make a new passage, will not be termed fislulse; secondly, the formation of pus or extraneous matter in a part requiring a passage, as in fistula in ano, fistula in the joints, and fistula from diseased bone." [It will be observed that this second class of fistulas has not been enumerated by Chelius, although, however, he subsequently treats of them.—j. f. s.] " We shall consider the cause of fistulas,—1st, The obliteration of ducts^ or canals, is the first cause. This arises from obstruction of the natural passage, in consequence of which a new one is formed for the passage of the natural secretion. These obliterations often arise from a thickening of the sides of the ducts, as in the urethra, nasal duct, &c, from inflammation; sometimes from the venereal disease, or scrofula,- and some- times from accident, as in the parotid duct. These obliterations are often very trouble- some, obstructing the evacuation of the natural secretions, whieh is very teasing to the part, and when complete is very serious in its consequences. In most there is a new passage when complete, which is made by inflammation and ulceration; these new passages are called fistulous; the discharge is the natural secretion, mixed with thepu& from the inflamed vessels of the sides ot the passage.. If this new passage answers all the purposes of the original one, it cannotwell be called fistulous; when from a morti- fied or wounded intestine, it is called an artificial anus,- when in theperinseum, it is: for the passage of the urine. There are often accumulations of secreted juices besides- the above, arising from the same causes and producing the same consequences, yet not called fistulous." (pp. 577, 78). 2d. The second species of fistula or that from disease, arises from the disproportion in the disposition to heal of different parts, viz., the internal and external; the skin healing, while the deep seated parts or seat of the disease, have no disposition for it. It may arise from two causes : 1st, from any extraneous substance in the inner parts; 2dly, from; a diseased state of the original part when the disease formed. The first happens in large deep-seated ab- scesses, which are prevented healing at the bottom by the pressure of the matter. The second has two causes; the first, from the part being naturally ind'olent, as tendons; the second, from a disease in parts naturally ready to heal, but the disease being deep-seated, the skin is more ready to heal than the bottom of the fistula, and thus obstructs the necessary, free discharge." (p. 579)]* 900. The prognosis in fistula depends on the possibility of conducting the fluid through the' natural ducts; further, on the condition of the fis- tulous openings, whether they be accompanied with or without loss of substance, whether they communicate immediately, or by a more or less long canal with the cavity, or with the duct, and whether their walls be converted into a mucous tissue, or callosities. In fistulas of long stand- ing that part of the duct in front of the fistulous opening, and through which fluid no longer escapes, loses its natural area, shrivels up, and the cure is only possible by making an artificial aperture in the cavity, into which the fluid should be conveyed'by the natural duct, as for instance,, in; Salivary Fistula, 13* 146 SALIVARY FISTULA. 901. The indications for the cure of fistulas are, therefore,—1. The restoration of the natural ducts and the conduct of the fluids from the fis- tulas. This is usually sufficient, and the fistula closes of itself, if the mucous lining, or the callosities have not formed. In this case the canal of the fistula must be either divided, or a sufficient degree of in- flammation and adhesion produced by stimulating remedies and suitable compression. The callosities usually subside, if the flow through the fistula be prevented by the use of soothing applications. 2. The esta- blishment of an artificial duct, if the restoration of the natural passage be not possible, which effected, the fistula closes, either of itself or under the above-mentioned treatment. If the fistula be an immediate opening to a duct, without narrowing of the latter, cauterization about the fistu- lous opening is the best remedy to produce gradual lessening and ulti- mate closing of the fistula. The paring the edges of the fistula, and their union, has rarely had satisfactory results. This treatment by cau- terization (with caustic remedies or with the actual cautery) is founded on the central contraction occurring in burns {a). If with such fistula there be considerable loss of substance, the opening can often only be closed by implanting or drawing forward skin from the neighbourhood. ["The cure of fistulas" observes John Hunter, "consists in first removing the immediate cause; for frequently they get well by simply removing the obstruction. * * * Tbe cause of our first division of fistulas, arising from confined matter, is sometimes easily removed, but not always, by opening the suppurated part in the most depending situation, when if the parts, are readily disposed to heal, a cure takes place. The second, from, a diseased state, must have the disease removed or extir- pated if possible; but this is often impracticable. A perfect exposure is the next object; b,ut the case will not. often admit of it, and then becoming incurable, it some times produces hectic, as in lumbar abscesses and abscesses of the liver which open exlemally, but cannot be exposed. The constitution in such cases is to be most attended to, and every thing done to lessen the irritation; but in most cases life is miserable, and we only protract it a little longer by our best efforts." (p. 581)]. A.—OF SALIVARY FISTULA. (Fistula Salivalis, Lat.; Speihelfisteln, Germ.; Fistule Salivaire, Fr.) Duphenix, Morand, Louis, Observations sur les Fistules du Canal Salivaire de Stenon; in Mem. de l'Acad. de Chir., vol. iii. p. 431. Desault, CEuvres Chirurgicales, vol. ii. p. 216. Viborg, Vorschlag zu einer verbesserten Behandlung der Speichelfistel; in Samm- lung von Abhandlungen fur Thierarzte, Copenhagen, 1797, vol. ii. p. 33. Jobert, Observations des Fistules Salivaires, suivies de quelques reflexions sur ces Maladies; in Arch. Gener. de Medecine, 1838, Sept., p. 58. 902. Salivary Fistula is characterized by an opening surrounded with callous edges most commonly very narrow, in the neighbourhood of Steno's duet, or of the salivary glands, out of which the spittle flows, especially during talking and chewing. The flow of spittle is often so great, that loss of appetite, disturbed digestion,-and wasting result from it. 903. Salivary fistula is produced either by accidental injury of the salivary glands, or their ducts, if the first union do not take place; or (a) Roser, Ueber eine besonders Art von Fisteln, welche durch Cauterisation im Um fange der FistelOffnung zu heilen sind; in Archiv. fur Physiologische Medicin, von Roser und Wanderlich, 1842, pt. i. p. 145. TREATMENT. 147 by ulceration of this tissue, or by the salivary duct being stopped up by means of stony concretions ; and in the latter case, a fluctuating swelling arises in the course of the duct, which gradually enlarges, bursts, and discharges the spittle. 904. The treatment of salivary fistula varies according as it is situated on the duct itself, or on one of the small ducts from the gland. 905. The salivary fistula, which can be distinguished, partly by its seat, and partly by a probe introduced from the mouth into Steno's duct, is usually cured by continued pressure, which diminishes the secretive activity of the gland. A compress an inch and a half thick is to be put on it, and fastened with the halter bandage. At every renewal of the bandage, camphorated oil is to be rubbed upon the region of the gland, and the fistulous opening touched with lunar caustic. The mere re- peated application of caustic, especially of nitrate of silver, is common- ly sufficient for the cure. 906. The treatment of fistula of the Stenonian duct, consists either in the restoration of the natural passage for the spittle, or in the formation of an artificial passage by which the spittle may flow into the mouth. 907. The restoration of the natural salivary duct, is only possible when its division has not been of long standing, and the lower end is still per- vious, which may be ascertained, with a fine probe, from the mouth, or by injection into the fistulous opening. The modes of treatment pro- posed for this purpose are,—1. The union of the edges of a recent division by the twisted suture, in which one, two or three stitches, ac- cording to the size of the division, are put in. 2. The introduction of a silken thread, by means of a delicate eyed probe, through the lower end of the duct into the fistula, and its removal when the duct is thought to be sufficiently widened; after which the fistula closes, either of itself, or by the application of caustic (a). 3. Compression of the duct from the fistula up to the gland, in consequence of which cedematous swelling of the gland and the neighbouring parts ensues, which soon destroys the use of the divided parts (b). 4. The efficient touching of the fistulous opening with nitrate of silver, or the application of a paste of sublimate and bread crumbs moistened with decoction of marshmallows, which should be covered with a compress dipped in spirits of wine, and sup- ported with a suitable compress, for the purpose of preventing the escape of the spittle by the slough produced, and also to induce its flow into the lower end of the duct. By this plan, as well as by compression of the duct, in most cases its closure and destruction is effected, which Desault and Richter aim at in reference to the salivary gland, by en- deavouring to destroy its function with continued pressure. Schreger (c) also notices a fistula which closed by compression of the duct be- hind it, with a steel neck circlet descending from the top of the head, and by touching it with lunar caustic. Here also belongs Viborg's proposition in cases of salivary fistula, where the usual modes of treatment have been inefficient, to lay bare the hinder end of the duct, by a cut directly down from the cheek-bone, and to bind and unite the wound with sticking plaster. In this way, from Viborg's experiments on brutes, it results, that after tying the Stenonian duct, the parotid gland swells, gra- dually subsides, and the destruction of the gland is effected. (a) Louis and Morand, above cited. (c) Grundriss der chirurgischen Opera- (b) Masseneuve; in M6moires dal'Acad. tionen vol. i. p. 84. Third Edit. de Chirurg., vol. iii. p. 452. 148 TREATMENT OF 908. The production of an artificial duct is the usual mode of treating a salivary fistula, and is always indicated, if the division of the duct have been of long standing, the fistulous opening callous, and the lower end of the duct have become impervious. It is effected in different ways: 1. The callous edges of the fistula having been pared with the knife, a tube with a small trocar is thrust through the cheek, near the hinder opening of the salivary duct, somewhat downwards, and in an oblique direction, in doing which the tongue is to^ be defended from injury by the finger introduced into the mouth, or by a piece of cork. The trocar is now withdrawn and a thread of silk-worm gut introduced through the tube, which is also then to be removed. The patient should now chew, for the purpose of discovering the aperture of the salivary duct by the flow of the spittle, and the gut in the wound is then to be thrust into this opening for about six lines; the patient then chews again to see whether the spittle flows out between the gut and the wall of the duct, on failure of which, a thinner gut must be introduced. The end of the gut hanging in the mouth is to be brought out to its corner, and fastened with sticking plaster on the cheek. Tbe edges of the wound are to be brought, by properly applied sticking plaster, into the closest union, covered with lint, which should be fastened with sticking plaster, and a cloth placed beneath the chin and bound together on the head. The bandage must not be renewed till the edges of the wound have united, which happens in from thirty to forty hours, if the operation succeed ; and some hours after, the gut also may be removed. De Rov was, according to Boyer (a), the first who employed an artificial opening by means of perforating the cheek, for which purpose he used the actual cautery which he thrust directly from without inwards. Percy (b), after penetrating the cheek, introduced a leaden thread into the upper end of the Stenonian duct, and the other end of the thread through the artificial opening in the mouth, where he bent it round, and fixed it by slight pressure of the cheek against the teeth., This treatment rendlers the suture and cauterization unne- cessary. 2. The cheek being penetrated, as in the former case, a leaden thread or string is introduced through the tube, the two ends, of the thread bent round like a hook after the removal of the tube, and left for four or six weeks; the external fistulous opening, after having been pared, is to be closed with sticking plaster. For the purpose of rendering the opening callous, after perforating the cheek, the introduction of a sufficiently thick thread, first smeared with digestive salve, and subsequently with drying remedies, a»nd to be moved daily till suppuration have ceased, has been recommended ; in that case, the closing of the external fistulous opening first takes place, which, if small, may be effected by frequent touching with lunar caustic; or, if larger and very callous, by paring with the knife, and drawing together with sticking plaster. The aper- ture is also sometimes attempted to be kept open, by the introduction of a golden or leaden tube, over which the external wound heals. Dupho3NIx penetrates the cheek with the bistoury, and puts, a canula into the inner half of the wound, for the purpose of preventing its union, and at the same time to conduct the spittle into the mouth, till the external wound, the edges of which are brought together with sutures, has healed. (a) Traite des Maladies Chirurgicales^voL (b) Boyer", above cited, p„ 280. xvii. p. 276. OF SALIVARY FISTULA. 149 Atti (a) introduces, into the opening made with the trocar, a leaden canula, the end of which in the mouth he splits into three, and bends back on the membrane lining the cheek; the outer end must not reach the skin, and is kept in its place by a thread carried round the ear. After a sufficient time the thread should be divided, the canula removed from the mouth by the nail of the fore-finger, and the internal opening remains permanent. 3. The membrane of the cheek is to be penetrated twice, obliquely at the bottom of the fistula with a trocar, and through these openings a leaden thread is introduced, the middle of which should lie in the bottom of the wound, and the ends projecting within the mouth, are to be brought together and cut off near the inside of the cheek. The external wound is to be closed by the twisted suture. The spittle flows along the leaden thread into the mouth, the external wound closes, and the thread drops into the mouth. This treatment is preferable to the others, as no repeated bandaging of the wound is necessary. I have proved this plan in several cases where other modes of treatment have been em- ployed without benefit (b). Croserio (c) proposes, instead of perforating the cheek from without to within, according to the plan of DEGUisEand Beclaird, to thrust the trocar from within out- wards, also to make the second perforation with a trocar from without inwards, the canula of which has no shoulder, and therefore after the introduction of the leaden thread may be withdrawn through the mouth. 4. In simple fistula, the membrane of the cheek should be pierced with the bistoury, and the external edges of the fistula brought together. But complicated fistulas must be cut out, and the outer edges of the wound brought together {d). Bonafont (e) exposes the Stenonian duct to the extent of a centimetre, isolates the corresponding ends of the fistula for some millimetres, perforates the cheeks with a trocar, draws the ends of the Stenonian duct, with a thread into the ca- nula, which is left behind, and fastens the thread in a cleft of the canula. The union of the external wound is effected by suture. [The fistulous orifice into the parotid duct, resulting either from abscess of the gland or any other cause, is not so easy of union as Chelius would wish to infer, but on the contrary often very tiresome to treat. Desault punctured the cheek with a trocar and canula, through the fistulous opening, and introduced a seton into the mouth. The seton was removed daily, and gradually increased in size till a permanent passage into the mouth was formed, and then the seton having been re- moved, the external wound which had been left open, was touched with causticand healed. Beclard in two cases successfully employed a leaden style, one end of which he passed into the mouth and the other into the interrupted duct, and com- pleted the operation by bringing together the edges of the external fistulous orifice, which had been previously pared, with a twisted suture. A much more simple and equally effectual plan is to pass, through the fistula in the cheek, into the mouth a needle and thread, the latter of which is to have a knot made on its end, only of sufficient size to be received when drawn from the mouth into the bottom of the fistulous aperture. The end in the mouth is to be tied on a little bit of stick close to the inside of the cheek. In the course of two or three days the knot ulcerates into the mouth and a new way is formed, by which the secretion of the gland passes, and if the case turn out well, the fistulous orifice soon contracts and heals, care being (a) Begin; in Diet, de Medec. et Chirurg. Vernes ; in Journal General de Medecine, Prat, vol. viii. p. 225. Nov. 1828, p. 270.—Does he use a golden (b) Deguise; in Journal de Medecine, thread in the same treatment? etc., par Corvisart, etc, vol. xxi. (c) Archives Generales de Medecine, Mai, Beclard; in Archives Generales de Me- 1825, p. 137. decine, Octobre, 1824, p. 285; in Richerand, (d) Jobert, above cited. Histoire des Progres recens de la Chirurgie, (e) Annales de Chirurgie, Aofit, 1841. p. 38. 150 TREATMENT OF SALIVARY FISTULA. taken by a compress to prevent the saliva finding its way out externally. Some- times, however, it is very difficult to induce the external wound to unite, and the production of a new surface, either by paring the edges or touching with caustic, and keeping them in apposition is necessary.—j. f. s.] 909. It is always necessary that the patient, when the external fistulous orifice is to be closed, should keep the lower jaw as quiet as possible till the cure is completed ; and only take fluid food, through a tube. A carious tooth is often the cause of failure of the operation for salivary fistula, and must therefore he removed before the operation is repeated. 910. The swelling up of the Stononian duct into a fluctuating tumour, which must be distinguished from an encysted tumour, may if the duct only be stopped up, be perhaps removed by the introduction of a fine probe. If this be not possible, the swelling should be opened with a lancet from the mouth. If a stony concretion have formed in the salivary duct, it must be cut upon within the cheek, and taken out. The continued flow of the spittle prevents the closing of this opening. ["The ducts both of the parotid and submaxillary glands," says Syme (a), "are liable to become the seat of calcarious concretions, which are named salivary calculi. Their composition is phosphate of lime, agglutinated by a small quantity of animal matter. They have usually a yellowish-white colour, oval figure, and finely tuber- culated surface. They vary in size from that of a millet-seed to that of an almond with the shell. In the parotid duct, they are very rarely met with, but in the sub- maxillary duct, not unfrequently. [I doubt their frequency even in the submaxil- lary duct; Astley Cooper in his Lectures used to mention having removed one from the mouth of the elder Cline, and Lawrence in his Lectures (b) speaks of having taken out one "which was about the size of a small bean." (p. 765.) In the Museum of the Royal College of Surgeons of England there are only six specimens, either from the duct or substance of the submaxillary gland ; but one from the paro- tid gland ; and some small concretions from the tonsils. Besides these I do not know of any other instances, and have never seen one.—j. f. s,] " They occasion pain, swelling, and hardness," continues Syme, " and sometimes impede the flow of the saliva or give rise to the formation of an abscess. In the parotid duct the symptoms thus produced are apt to be confounded with those of rheumatism, tooth- ache, gumboil, or suppuration of the maxillary antrum; while under the tongue, they may be occasionally mistaken for those of encysted tumours. In all cases of doubt it is right to seareh the duct with a probe, and to feel for the calculus, by pressing on the place where it is suspected to be. So soon as a free incision is made, the concretion escapes, together with the fluid accumulated about it. The original situation of these concretions is immediately within the orifice of the ducts; but they have also been found imbedded in the substance of the submaxillary gland, where they excited an increased and unhealthy secretion, with general swelling and hardness of the gland, in such cases the calculus, if distinctly recognised, may be extracted by cutting down upon it, from the mouth." (p. 427). Among the speoimens at the College (c) there is one large submaxillary calculus an inch and a half long and three quarters of an inch broad, taken from a very old man, who "was oonceived to be dying, being nearly choked by the tumour, when in consequence of an effort, the calculus was thrown out and he recovered." In another the stone is stated "to have occasioned a quinsy." One specimen was removed after it " had been twelve years breeding," and another " formed in twelve days." (p. 191.)—-j. f. s. ] (a) Lancet, vol. iiv 1830. of the Calculi, &c, &c, contained in the (6) Principles of Surgery. Museum of the Royal College of Surgeons (c) A descriptive and illustratedCatalogue in London. 1845. 4to. BILIARY FISTULA. 151 B.—OF BILIARY FISTULA. (Fistula biliosa, Lat.; Gallenfistel Germ.; Fistule biliaire Fr.) 911. Biliary Fistula originates in a division of the gall-bladder, or ducts, after they have become adherent to the peritoneum. The bile is poured from the fistulous opening, and although its loss be often very considerable, it is rarely that important symptoms are produced. Not unfrequently the fistulous opening closes of itself, in general after the escape of a gall-stone ; often it breaks again, and the patient then usually finds himself better. The fistula is mostly situated in the region of the liver; frequently, however, at a tolerable distance from it. I have observed the case of a woman in which, after severe symptoms, a fistulous opening formed near the navel, and out of it a considerable quantity of gall-stones, of the size of peas, escaped from time to time. 912. The cause of biliary fistula is usually a collection of bile in the gall-bladder, {Hydrops vesiculce fellis,) by which is formed beneath the short ribs a swelling, at first defined, regular, and fluctuating, which slowly increases, and is accompanied with pain, that had existed pre- vious to the swelling and at first not severe. It often is diminished by pressure, or spontaneously when the gall-bladder is much distended, in which case part of the bile is forced into the intestine, and is followed by bilous stools, with colicky pain. These symptoms distinguish the filling of the gall-bladder from abscess of the liver. If the swelling of the gall-bladder be considerable, it adheres, by means of the inflam- mation set up in it, with the peritoneum, and forms an opening by ulcera- tion, through which the bile escapes. Gall-stones are usually the cause of this collection of bile* The gall-bladder or the bile-ducts may also be ulcerated by abscess ; in which case, after it has opened, pus is dis- charged, mixed with bile. [Biliary fistulas, from whatever cause, are very rare. I have never seen a single example of this disease; but I much doubt the1 possibility of distinguishing its pre- cise origin. It certainly is possible that if, when the bile-duct is stopped, the gall- bladder be over-distended, it may adhere to the wall of the belly, and that ulceration may ensue, by which its contents are discharged externally, and the aperture may con- tinue fistulous. But there is in the museum of St. Thomases Hospital an enlarged gall-bladder, from stoppage of the common biliary duct, capable of holding at least three, if not four pints, of fluid, which did not ulcerate, but was mistaken for an ab- scess of the liver, and tapped once or twice, and also another, in which the duct being stopped, the gall-bladder had become adherent to the duodenum, ulceration between them had taken place, and the bile thus finding an immediate passage into the bowel, the gall-bladder ceased to serve as a receptacle and shrivelled to the size of an al- mond. And it is in this way probably that the gall-bladder more frequently empties itself than externally. The aperture by which abscess in the liver discharges itself, may become fistu- lous, and have the bile flowing from it, at first, mixed with pus, but afterwards al- most, if not quite pure. My friend Dr. Roots informs me he has seen one case in which after an abscess of the liver, bile was discharged; and my dresser, Guest, tells me, that he saw in the Manchester Infirmary a man who, two months after fall- ing on his loins, had an abscess burst in the right hypochondriac region, from which pus and bile at first escaped, subsequently only bile ; and that he had seen this per- son alive, and in tolerable condition as to health, eighteen months after the accident although his motions being very white, it is probable that little bile could have as- sisted in the process of digestion.—j. f. s.] 913. The cure of biliary fistula requires first, the removal of its 152 FjECULAR FISTULA. usual causes, viz., gall-stones (the existence of which is shown by the careful introduction of a probe). After which the fistula soon closes of itself. For the removal of the gall-stones, the enlargement of the fis- tulous orifice is necessary, which is best done with catgut, or with a tent, so as not to destroy the adhesion of the gall-bladder to the perito- neum, under which circumstances effusion of bile into the cavity of the belly would occur. The fistula must be so much enlarged, that a pair of forceps may be introduced with the left fore-finger, the stone grasped therewith and withdrawn ; in doing this, care must be taken, in moving the forceps about, that no part of the gall-bladder itself be caught hold of. The opening of the fistula should not be closed, so long as gall- stones are believed to be still there; otherwise the fistula will break out afresh. When all the stones are removed, the fistula usually soon closes with a simple covering bandage; and the scarring may be pro- moted by careful touching with lunar caustic, and suitable pressure. At the same time such remedies must be employed as will diminish the disposition of the bile to concrete, and will assist nutrition. C—OF F.ECULAR FISTULA. (Fistula Stercorea, Lat.; Kothfistel, Germ.; Fistule Stercoraire, Anus conire nature, Fr.) Sabatier, Memoires sur les Anus contre nature; in Memoires de l'Academie de Chirurg., vol. v. p. 592. Desault, QSuvres Chirurgicales, vol. iii. p. 352. Schmalkaloen, Praes. Kreysig, Dissert. Nova Methodus intestina uniendi. Vieb., 1798. Travers, Benjamin, An Inquiry into the process of Nature in repairing Injuries of the Intestines, &c. London, 1812. 8vo. Scarpa, Sull' Erneie, Memorie Anatomico-chirurgiche. Milan, 1809. fol. Trans- lated by Wishart as A Treatise on Hernia, with Notes. Edinburgh, 1814. 8vo. Reisinger, F., Anzeige einer vom Prof, Dupuytren zu Paris erfandenen und mit gluchlichsten Erfolge ausgefuhrten Operationsweise zur Heilung des Anus ar- tificialis, nebst Bemerkungen. Augsburg, 1817. 8vo. With a copper-plate. Nachtrag in Salzb. medic, chirurg. Zeitung, 1818, No. 18, p. 286. Brosse, Beobachtung eines mit der Darmscheere von Hrn. Prof. Dupuytren in Hotel-Dieu zu Paris augestellten Heilungs versuches eines kunstlichen Afters; in Rust's Magazin, vol. vi. p. 239. Breschet, Anatomisch-chirurgische Betractungen und Beobachtungen fiber die Enstehung, Beschaffenheit und Behandlung des widernaturlichen Afters; in von Graefe und von Walther's Journal, vol. ii. pt. ii, p. 271, and pt. iii. p. 479. Liordat, Dissert, sur le Traitement de I'Anus Contre nature. Paris, 1819. Dupuytren, Memoire sur une Methode Nouvelle pour traiter les Anus acci- dentales, lu k l'Academie Royale des Sciences, en Janvier, 1824; in Mem. de l'Acad. Roy. de Med., vol. l. Paris. 4to. Also De l*Anus contre nature, des dis- positions anatomiques des effets, du siege du prognostic, du diagnostic et du traite- ment; in Lecons Orales de Clinique Chirurgicale, vol. ii. p. 193. Reybard, J. F., Memoires sur le traitement des Plaies des Intestines et des Plaies penetrantes de Poitrine. Paris, 1827. Hennen, John, Principles of Military Surgery. Third Edition. London, 1830. 8vo. Lawrence, William, A Treatise on Ruptures. Fifth Edition. London, 1838. Teale, T. P., Article Intestinal Fistula; in Cyclopaedia bf Practical Surgery, vol. ii. p. 191. London, 1841. [Gross, S. D., Experimental and Critical Inquiry into the Nature and Treatment of wounds of the Intestines. Louisville} 1843.—g. w. n.] . FjECULAR FISTULA. 153 914. Fcecular Fistula is an old opening communicating with the cavity of the intestine, which, according to its size, discharges either only a part of the fsecal matter, whilst the rest passes by the natural pas- sage, or by which all the excrement passes, and then the disease is called an unnatural or artificial anus (Anus prceternaturalis, artificialis). The external opening is mostly round, contracted, and surrounded with radiated creases of skin ; its edges are red and irritable ; frequently there are several external openings leading to one canal: for the most part, the skin is firmly attached to the muscles, it is rarely degenerated, raised from the muscles, and forming a canal; the ends of the bowels are fre- quently connected directly with the peritoneum ; frequently they are re- tracted, and the peritoneum forms a funnel-like elongation. 915. The effects of the faecular fistula, and in a more advanced de- gree of the artificial anus, upon the whole organism, is very decided. By the escape of the chyle, which passes only through a part of the intes- tinal canal, is the nourishment lessened, though the appetite be great, and the patient quickly wastes, especially at first. The nearer the ar- tificial anus is to the stomach, the more severe are these symptoms. If it be further down, at the lower end of the ileum or in the colon, more decided stools are passed, and the nourishment is not so much affected. By the continuance of the out-flow, the parts excoriate and become very painful. The mucous membrane of the intestine exposed to the air becomes redder, and less villous, but does not cease to secrete a large quantity of mucus. In artificial anus merely mucous fluid of a white colour, and varying consistence, which is secreted from the large intestines, passes through the rectum. The lower part of the intestinal canal gradually contracts together, but retains its permeability. Begin (a) has, however, observed an almost complete closing and wasting of the lower portion of the intestines. [Astley Cooper (b) mentions the case of a man "with a strangulated umbilical hernia, which sloughed, and occasioned an artificial anus. As he was recovering from the effects of the strangulation and sloughing, and was allowed to take food in any considerable quantity, it was observed that part of what solids he ate passed out at the artificial anus within half an hour after he had swallowed them, and that fluids passed out in ten minutes after they had been taken into the stomach. Although he took sufficient food to support a healthy person, he wasted rapidly, and died in three weeks. On examining his body after death, and tracing the jejunum, the lower part of that intestine was found entering the hernial sac, and in it the opening was situated," (p. 52)]. 916. Not unfrerjuently a prolapse of the intestine is produced suddenly in artificial anus, as a consequence of straining, or gradually by en- sheathing, which often attains considerable size (nine inches and more). It occurs mostly only at one end of the intestine, has usually a more or less conical form, is contracted at the base, and its point has an opening through which the stools escape. The protruded part has a red colour, is well moistened with mucus, and usually is not very sensitive; fre- quently a peristaltic motion is observed, as in the intestines, and at first it is so contractile that the slightest touch causes retraction ; it increases with straining, and diminishes or entirely recedes in the horizontal pos- ture, or with sufficient pressure. The constant irritation to which it is (a) Dupuytren, Legons Orales, p. 211. (6) Lectures on Surgery, vol. iii. Tyrrel's Edit. Vol. ii.—14 154 NATURAL CURE. exposed, thickens and renders it like the external tegument; it even becomes blackish. The protrusion may form adhesions with the open- ing from which it projects, and may even become strangulated. If the protrusion be of the lower end of the intestine, there escapes from it only a white, mucus-like fluid -, but the stools pass out from the side of its base. If both upper and lower part of the intestine protrude at once, there are two projections, and the stools are discharged from the middle of the upper end of the intestines. From this protrusion often arise very painful draggings in the belly, which prevent the patient keeping him- self upright, and compel him to bend the upper part of his body almost horizontally forwards. In this complication of artificial anus, the symp- toms are always more severe, digestion is highly affected, wasting makes quick progress, and leads to marasmus, if the local relations of the parts be not changed. 917. Fsecular fistula and artificial anus may be the consequence of pene- trating wounds of the belly, accompanied with injury of the intestine or with a protrusion which runs on to gangrene, also of gangrenous rup- tures, of abscesses, of foreign bodies in the intestinal canal, and so on, by which either only one part of the wall of an intestine, or an entire coil of intestine is. destroyed, in which case adhesion with the peritoneum takes place, at the circumference of the destroyed gut, and the effusion of stools into the cavity of the belly is prevented. [Teale gives in his essay a very good tabular account of cases of artificial anus resulting from these various causes]. 918. Upon the different position and state of the upper and lower por- tions of the intestine in artificial anus depends, whether the cure can be effected merely by the natural powers, or by the simultaneous assistance of art, or only by the intervention of an operation. The destroyed in- testine, together with the corresponding part of the peritoneum-, to which it adheres, retracts into the belly, where it forms a funnel-like cavity, which, in proportion as it enlarges, directs the passage of the stools from the upper end of the intestine into the lower. This, however, cannot happen in artificial anus, which forms after penetrating wounds of the belly, after old umbilical and ventral ruptures, when either the injured gut heals up with the edges of the outer wound, or the hernial sac be- comes firmly adherent with the aponeurosis and abdominal coverings, and the extensible cellular tissue, which surrounds it in other ruptures, is deficient, consequently the adherent piece of intestine cannot retract into the belly sufficiently to form the funnel-like cavity by which the communication of the two ends of the intestine is produced. The cure of artificial anus in this way most readily occurs, when only part of the wall of the intestine is destroyed ; but when both ends of the gut, be- tween which a coil has been destroyed, are so connected and held by the mesentery, that they lie more or less parallel, and form an acute angle, a projecting partition is thereby formed which prevents the com- munication between the upper and lower ends of the intestine. If the projection of this partition cannot be removed by the retraction of the pieces of the bowel, the restoration of the natural passage of the stools is possible by destroying this partition. The retraction of the piece of intestine specially depends on the movements of the FiECULAR FISTULA. 155 bowel and dragging of the mesentery, which, stretched like a cord from the back of the partition projecting between the openings of both portions of intestine to the spine, is always striving to retract the piece of adherent bowel. Thus is easily seen the effect which the recumbent posture and motion have upon the cure of arti- ficial anus. Dupuytren (a) had two cases in which, by this dragging, the adhe- sions of the intestinal portions were torn through, and effusion of faeculent matter into the cavity of the belly caused. Examination after death of persons who have died of other diseases many years after the cure of artificial anus either by nature or art, shows the intestine either connected by a fibro-cellular band with the place of the artificial anus, or these connexions destroyed and the intestine floating freely in the cavity of the belly. In a case of artificial anus at the femoral ring, in a woman, which withstood the usual remedies, a spontaneous cure took place during pregnancy, (Wedemever), which Dupuytren attributes to the gradual retraction of the intes- tine from the external opening and the lengthening of the funnel-like cavity. [Lallemand (b) had the opportunity of examining an intestine seven years after performing Dupuytren's operation for artificial anus upon it; and of which the external scar in the skin had twice given way after violent exertion, discharging fetid pus mingled with gas and faecal matter, but subsequently closed. He gives the following account of the appearances he met with:—"There was found in the left inguinal region an oblique fistulous opening leading into the canal, of the size of a crow-quill. Round this, to the extent of five or six lines, was a thin shining cicatrix, in which wrinkled folds of the surrounding integuments terminated. A portion of ileum, not differing from the usual appearance of the intestines, was adhe- rent to the left inguinal region by two slender columns. One of these, four lines long by two in width, contained the canal of communication between the fistula and the cavity of the intestine. This canal passed through the inguinal ring, which was short and nearly direct. The other was an ordinary slender fibrous adhesion. There were several ulcerations of the mucous membrane towards the ileo-ceecal valve. As soon as the fistulous communication had passed through the ring, it began to enlarge and assume the funnel-shape, and was quickly lost in the cavity of the intestine. When the latter, which presented the usual circular figure was laid open, a slight prominence marked the situation which had been occupied by the edge : the mucous membrane was just the same here as elsewhere." Dupuytren (c) himself also states that on examining the bodies of many persons who had been subject to artificial anus, but died years after of other diseases, in- stead of finding the intestine fixed, to the wall of the belly, he saw it free and float- ing in the cavity. "I should," says he, "have fancied I had been mistaken, had not the patient's identity been indisputable, and had I not discovered a fibrous cord stretched from the point of the abdominal wall corresponding with the accidental anus up to the intestine. This cord, some lines in diameter and some inches in length, larger at its extremities than in its middle, covered with peritoneum and en- tirely formed of cellular and fibrous tissue, without any cavity, was evidently the progressive elongation of the cellular tissue which had united the intestine to the wall of the belly, and the cause of this lengthening could only be the constant drag- ging of the intestine by the mesentery, in the different motions of the body during life." (p. 208). The following account of the dissection of a case of artificial anus, after mortified strangulated rupture, given by Scarpa (d), explains the formation of the funnel:— "I found," says he, "that the great sac of the peritoneum had not only become firmly adherent to the portion of the intestinal tube, which had been unaffected by the gangrene behind the inguinal ring, and, properly speaking, in the cavity of the abdomen, but likewise that this sac of the peritoneum, like a membranous funnel, (imbuto membranoso), extended from the cavity of the abdomen, through the inguinal canal, into the fistulous tube communicating externally by a narrow hole in the groin. * * * Havino- divided longitudinally the narrow fistulous canal, and the membranous funnel,°I saw distinctly that the two orifices of the intestine had re- mained parallel, without being at all turned towards each other; and the ridge (pro* (a) Legons Orales. to acknowledge making use of Lawrence's (b) Repertoire general d'Anat. et de Phy. translations (from his work on Ruptures) of Biol. Patholog., vol. vii. p. 133. this portion of Scarpa as well as that from (c) Legons Orales. Lallemand.—j. f. s. (d) Sull' Ernie, Mem, iv. sect, iv,^-I have 1S6 ARTIFICIAL ANUS. montorio) projected between them, which would have been sufficient of itself to prevent the direct passage of the faeces from the superior to the inferior orifice. The alimentary matters must therefore have been poured from the upper end into the membranous funnel, and have passed thence, by a half circle, into the lower end of the intestine." Upon the same point Dupuytren observes:—"In examining the opening of the skin and the bottom of the artificial anus, a sortof funnel is discovered, the dispositions of which have been best observed and described by the celebrated Scarpa. It is formed of parts, which inflammation and contact have reduced to the same nature, to wit, that of mucous membrane. Its point is at the skin, its base at the intestine; its length, direction, form, and dimensions vary to infinity, and have the greatest influence on the cure of the complaint. The greater its extent and ca- pacity, the greater disposition, in general, has nature to cure this ailment, or to second the efforts of art for that purpose. At the bottom of the funnel are found the most remarkable and important circumstances relating to the/artificial anus. There are the orifices of the two ends of the intestinal canal, and there the partition by which they are separated. Of these two orifices, the one belongs to the upper part of the intestine, is always penetrated by the food and stercoral matter, is the most free and widest of the two. The other is the continuation of the lower end of the bowel, and as it does not receive either alimentary or stercoral matter, or only in very small quantities, it is usually narrow, contracted, and difficult to find. To these orifices succeed the extremities of the intestine, villous, and lined with mucosities. within, smooth covered with peritoneum, and bathed in serosity without, buried in the belly, sometimes crossing, sometimes twisting about each other, sometimes running parallel, but most commonly separating from each other at an angle more or less acute; and they are lost by curving more and more in the circumvolutions of the intestinal canal. On examining the space between the two orifices, a projection, more or less distinctly angular is perceived, and more or less near the entrance of the funnel just mentioned. This projection, the so called spur (ipcron) already per- ceived and pointed out by Saviard and Morand, results from the application and union, at an acute angle, of the corresponding walls of the two parts of the intestine which abut inartificial anus. * * * After a time this spur does not divide the bottom of the funnel into which the two ends of the intestine open, into two equal parts. Continually pressed on by the matters which the upper end brings down, this fold yields to their pressure, and is gradually carried towards the lower end, upon which it advances more and more, till at last it covers its orifice with a sortof valve, which hermetically closes its entrance, and renders its discovery very difficult. Towards the intestinal cavity the spur has constantly a crescentic form, of which the angles di- rected from the concavity towards the convexity of the new curve of the intestine, are confounded with it, and gradually lost either in the walls of the organ or on the edges of tbe deepest part of the wound of the belly. On the abdominal surface it is seen doubled, and the two equal halves of which it consists separate and receive the mesentery in their interval." (pp. 202-5). "Thus," says Lawrence, "the two portions of the bowel lie near together, but are not adherent; they are separated by the ridge called by Scarpa promontorio, and by the French iperon. If we introduce a finger into each orifice, and bring the fingers together, they are separated merely by the sides of the two portions of intestine. When it is described that they are kept apart by an intervening partition, we must remember that there is nothing but the intervening tunics. We might pass an instrument from one end of the bowel into the other, and thus cause a direct communication between them by perforating their coats; but as the bowels are simply contiguous without adhering, we should make a double wound into the cavity of the abdomen," (p. 383)]. 919. The treatment of fsecular fistula or artificial anus, consists at first merely in attention to the proper discharge of the stools, in covering the opening with a wad of lint, and the removal of all pressure from it; good nourishing food, and easy of digestion, should be given, and fre- quently clysters and gentle purgatives. If there be externally several fistulous passages, they must be slit up, the irritation and callosity re- moved by poulticing and cleanliness of the dressings, and hard, tough, dry callosities, which will not disperse, are to be removed with the TREATMENT. 157 knife. If the opening contract too quickly, or the stools cannot escape sufficiently, the opening must be enlarged with sponge-tent or the knife, which, however, is less safe, as the adhesions of the intestine may be easily divided. A sufficiently large pad should be put into the opening to prevent it narrowing; and its introduction is also the only mode of preventing the protrusion of the bowel. If this occur, attempts must be made to return it, and if that be not at once possible, we must try to effect it by continued pressure with a bandage. The patient must be kept in bed, and avoid all exertion. In strangulated protrusion, the stric- ture must be carefully divided at the root of the protruded part. If under this treatment the excrements be gradually discharged by the natural passage, and so continue for some time, the opening may be allowed to close, gradually, except the patient feels pain in the belly, or uneasiness from collection of stools ; it is, however, advisable to keep up a small opening for some time longer by the introduction of a bougie. If the opening close too quickly, or if the stools collect largely at the opening of communication of both ends of the intestine, severe pain oc- cur at the region of the artificial anus, painful distension of the belly, vomiting, and even bursting of the distended bowel, and effusion of faecal matter into the cavity of the belly. In this case, if the opening be not yet entirely closed, an elastic tube must be introduced, through it into the upper portion of the intestine, or escape must be afforded to the collected excrement by a sponge-tent or by incision. [I have had but one case of artificial anus, and that in a boy of about ten years old, and at the navel, the middle of the scar in which projected a little beyond the surface and was perforated by a small hole of sufficient size only to admit a probe. Through this hole a very small quantity of dark-coloured faeeulent matter daily escaped, and its acridity kept the edge of the aperture constantly sore. Neither how this had originated (though probably from absess in the navel) nor how long it had existed can I state, having mislaid my notes; but the child was in tolerable health, though not very stout. Various means were tried without success to induce the hole to heal, among which attempting to form a scab with chalk and calamine powder, and the use of a pad and pressure. It was, however, finally cured by tying a ligature around it as low into the hollow of the navel as it could be de- pressed. This separated without any inconvenience, the wound healed and the fistula was cured. King (a) considers that similar cases (of which he gives two) with that I have just mentioned, depend on a communication with the diverticulum ilei, and founds his opinion on the analogy which exists between the umbilical vesicle of the human sub- ject and the yolk sac of the chick in ovo; in the latter of which " omphalo-mesenteric vessels communicate between the yolk sac and mesentery; and there is also a trace of a tube, on the plan of a diverticulum, opening into the intestine." (p. 467). The correctness of this view was fully confirmed by examination after death of the first case he relates, of this umbilical fistula which had been cured by making the edges raw and pinning them together. On examination, "a diverticulum, about three inches long, was found adhering to the umbilicus; and an adventitious cord appears to have compressed the ileum, just below its connexion with the diverticulum." (p. 472). I have also seen another oase ol aperture, in the navel of a woman about twenty- five years old, from which there was a constant flow of colourless fluid, and free from smell, in such quantity as to wet a napkin through one or twice a-day. Whence this fluid came I cannot determine, it could scarcely have been from an intestine; I once thought it might have been obtained from the bladder by passing through an urachus, but it had not any urinary character. She had been subject to (a) On a Fseculent Discharge at the Urn- tieulum ilei; in Guy's Hospital Reports, bilicus from communication with the diver- Second Series, vol, 1. 1843, 14* 158 ARTIFICIAL ANUS. it for years, but her health was not at all affected and she was only inconvenienced by it.—j. f. s. In concluding this review of Dupuytren's operation for artificial anus, Lawrence observes :—" Cases of artificial anus must be much more numerous in Paris than in London. Dupuytren employed his method in between twenty and thirty in- stances within a short time. No opportunity has occurred to me of putting it into practice, either at St. Bartholomew's Hospital or elsewhere for several years; and I believe that it is hardly been employed at all in this country." (p. 415)]. 920. If with this treatment the cure of the artificial anus be not pos- sible, because the partition between the two openings of the intestine projects too much, the partition must be cut off' with the intestinal scissors {enterotome) invented by Dupuytren. For this purpose the position of both ends of the gut are to be most carefully ascertained with a thick sound oiled, or with the finger; to do which, previous enlargement of the external wound with sponge-tent is often necessary. The fleshy growths, which, however, must be carefully distinguished from the in- testinal protrusion are to be removed with caustic, ligature, or scissors. Finding the two openings of the intestine is often attended with much difficulty, because the partition is always pressed against the opening of the lower part by the stools flowing down from the upper, and the former is at last completely closed. The more readily the openings of both portions of the intestine are found at the bottom of the artificial anus, the more favourable is the prognosis. If thick probes (female catheters) be used for examination, they must be connected externally together after their introduction into the upper and lower end of the intestine, and turned upon their axes, which movement is opposed by the parti- tion. When the ends of the intestine are discovered, the arms of the intestinal scissors should be so introduced into both ends of the gut upon the finger, or on the hollow sound, that when closed at least two and a-half inches of the partition shall be taken hold of. The same turn is to be made with the introduced arms of the scissors as with the sounds, to ascertain that they have entered completely. By the screw on the handle of the scissors, they are to be closed only sufficiently to produce a little pain; the handle of the forceps is to be wrapped in linen and fastened to a T-bandage. Every day, or every two days, the forceps are to be screwed a little tighter. If little pain follow it is well, but if severe the forceps must be loosened. The patient must take light nourishment, and soothing clysters may be given. Against pain in the belly, oily mixtures, soothing clysters, and applications are to be used, and inflammatory symptoms, the proper antiphlogistic remedies. Ac- cording to Dupuytren's observations, however, these symptoms rarely occur. Dupuytren's first intestinal scissors crossed each other with a disjoinable lock; but Seiler has modified them by making the arms parallel (a). Liordat's emporte-piice, for the purpose of removing a larger piece of the par- tition (b). Reybard (c) seizes the partition between the upper and lower end of the intestine with forceps, and divides it by pushing forward his enterotome. The forceps, are left attached to produce the union of the corresponding wounds of the intestine. Delpech's enterotome (d) differs from that of Dupuytren in each of its branches, being a little curved, and ending in an oval plate an inch in length. When intro- (a) Seiler, above cited, pi. vi. f. 14. (d) Froriep's Notizen, No. 583. p. 169.— (6) Above cited. (c) Above cited. Chirurgische Kupfertafeln, pi. cclxviii. TREATMENT. 159 duced and brought together by the screw, in consequence of the curved form of the branches, such portion only of the intestinal partition is compressed as is enclosed between the two plates. The object is to destroy a smaller portion of the partition at one time, and to repeat the process until a sufficient opening shall be made in it. The form of the opening, Delpech also holds to be preferable to the lengthened slit made by Dupuytren's instrument (a). Desault was aware of the partition between the two ends of the intestine pre- venting the passage of the excrement, and endeavoured to retract and diminish the protrusion, partly by closing the external opening with a plug, partly by the intro- duction of long rolls of charpie into the two ends of the gut, which he gradually brought straight, pressed back, and diminished. With the same object Schmal- kalden, (b) made an opening into the projecting partition, which he endeavoured to preserve by introducing tents, and by careful notching, to increase and establish the natural passage for the excrement. [Our American brethern seem disconcerted at the invention of this mode of treat- ment being generally assigned to Dupuytren. After referring to Desault's prac- tice just mentioned, Dr. Gibson (c) observes:—"A more expeditious and less troublesome operation was proposed and successfully executed by Dr. Physick be- tween the years 1808 and 1809. * * * An operation similar to that of Dr. Physick was afterwards performed by Dupuytren in Paris, and to him the merit of the proposal is awarded by European writers without the slightest foundation." (p. 316.) Now certainly, though our French neighbours are occasionally not particular in claiming that to which they are not strictly entitled, yet in the present instance, whatever may have been awarded to Dupuytren, he himself mentions in a note to his Memoir, Schmalkalden's dissertation, though without giving particulars, and also specially quotes Dr. Physick's plan of treatment from Dorsey's Elements of Surgery, vol. ii. p. 67. He is therefore, so far at. least as Dr. Physick is concerned, entirely free from misappropriation. It cannot, however, be denied that Physick's account is merely the recital of a case and of a novel operation for its relief, without entering into the consideration of the nature and circumstances of artificial anus, to which first Scarpa and subsequently Dupuytren have paid especial attention, and of which they have given very excellent account. Physick's operation is, however, well worthy of being better known, and it is therefore here given from Dr. B. H. Coates's report (d):— " The two ends of the intestines," says Coates, " were found, by careful exami- nation, to adhere to each other for some distance, and the form thus presented has been compared in this case to that of a double-barelled gun. The next method proposed by Dr. Physick, was to cut a lateral opening through the sides of the in- testines when they were adherent. But not knowing the extent of the adhesion inwards, he thought it necessary to adopt some preliminary measures for ensuring its existence to such a depth as might admit of the contemplated lateral opening, without penetrating the cavity of the peritoneum. By introducing his finger into the intestine through one orifice, and his thumb through the other, he was enabled to satisfy himself that nothing intervened between them but the sides of the bowels. He was thus enabled, without risk, to pass a needle, covered with a ligature, from one portion of the intestine into the other, through the sides which were in contact, about an inch within the orifices, which ligature was then secured with a slip knot. This operation was performed on the 28th January, 1809. The ligature was nearly drawn sufficiently tight to ensure the contact of those parts of the peritoneal tunic, which were within the noose. When drawn tighter, it produced so much pain in the upper part of the abdomen, of a kind resembling colic, that it became necessary immediately to loosen it. The ligature in this situation, gradually made its way by ulceration through the parts which it embraced, and thus loosened itself. It was at several periods again drawn to its original lightness. After about three weeks had elapsed, concluding that the required union between the two folds of peritoneum (a) [An ingenious instrument for the cure (d) Account of a Case in which a new of Artificial Anus, has been described by and peculiar operation for Artificial Anus Lotz in the Amer. Journ. of Med. Sci. vol. was performed in 1809 by Philip Syng xviii. 1836.—g. w. n.] Physick, M.D., then Professor of Surgery (b) Above cited. in the University of Pennsylvania. Drawn (c) Institutes and Practice of Surgery, up for publication in North American Med. vol. ii. Philadelphia, 1827. and Surg. Journal, vol. ii. p. 269. 160 ARTIFICIAL ANUS. was sufficiently ensured, Dr. Physick divided with a bistoury all the parts which now remained included within the noose of the ligature. No unfavourable symptom occurred in consequence. On the 28th February, the patient complained of an uneasy sensation in the lower part of the abdomen, and on the 1st of March he ex- tracted with his own fingers some portions of hardened faeces from his rectum. On the 2d March two or three evacuations were produced in this manner. On the 3d an enema, consisting of a solution of common salt, was directed to be given twice every day. The first of these occasioned a natural stool, about two hours after its administration. The same effect was produced on the 4th, 5th, and 6th, and the discharges from the orifices in the groin now became inconsiderable. Adhesive plasters, aided by compresses, were employed, not only to prevent the discharge of faeces from the artificial opening, but with the additional object of procuring the ad- hesion of the sides. This last effort was unsuccessful. On the 24th June, an attempt was made to unite them by the twisted suture. Pins were left in for three days, and adhesion was in fact effected; but owing to the induration of the adjacent parts, the wound again opened. On the 27th July, a truss of the common con- struction, furnished with a very large pad, and surmounted by a large compress, was applied to the wound. By these means the discharge of fasces from the groin was completely prevented, and the patient had regular evacuations per anum, except when from improper diet or cold, he became affected with diarrhoea. At such times, a small portion of the mere fluid matter escaped by the sides of the compress. Not satisfied with this state of things, Dr. Physick made several attempts to improve the patient's condition. On the 2d August, a mould of the parts was taken in plaster of Paris, and being covered with buckskin, was employed as a pad for the truss. This expedient answered extremely well, as long as the patient continued in the same posture in which the mould was made; but as soon as the form of the parts was altered by a change of position, fasces escaped from the orifice. A bandage was then applied to the body, furnished with a thick compress, and having that part of it which crossed the patient's back formed of elastic extensible wire-springs, such as are used in braces.. This also, however, proved ineffectual. The truss, with a compress and a large pad stuffed in the common way, was then reapplied, and found to answer completely the purpose of preventing the discharge of fasces, the hope of an entire closure of the orifice being abandoned. On the 10th of November he was discharged from the hospital in good health and spirits, and applied himself, with very good success, to acquire the profession of an engraver." (pp. 271-72.)] 921. When the intestinal scissors have divided the partition, which happens usually in from seven to ten days, and the separated part of the bowel is found between its arms, soothing clysters must be continued, and closing of the fistula only attempted, when the relief of the bowels has been effected for some time in the natural way, even without injec- tions. The closing of the fistula (often the most difficult part of the whole treatment) may be effected by quiet, by a moderate compressing apparatus with variously-formed pads and elastic belly-band, by touching with lunar caustic, by pressing the edges of the fistula together with a peculiar compresser (a) invented by Dupuytren, by sticking plaster, by- suture, or by the removal of the whole circle of mucous membrane pre- venting adhesion at the mouth of the fistula, and even by detaching part of the external coverings above the opening, and laying it before it. In general a small fistulous opening remains for years, then only occasionally do a few drops of intestinal dirt escape, and afterwards it closes of itself. In those cases where artificial anus cannot be cured, various proposals have been made to catch the excrement. The most simple, and in most cases most suitable, is a belly-band, which, instead of a pad, is furnished with an ivory plate having an opening in its middle, and connected by (a) Breschet, above cited, pi, iii. fig. 2, RECTAL FISTULA. 161 means of a cylinder of elastic rosin, with a silver vessel, out of which the escape of the stools is prevented by a valve (a). Dieffenbach (b) at last cured an artificial anus arising from a lance wound, which had withstood every plan of treatment, in the following manner:—He destroyed with the hot iron not only the edge of the intestine adhering to the opening, but also a considerable portion of the intestine within the belly, and in every cauterization the peritoneum participated. This burning was free from pain. He first burned the edges of the intestine; some days after, he introduced a curved hot iron, of the thick- ness of a feather-stem, through the hole, into the cavity of the intestine and carried it round. The opening gradually became smaller; granulations sprung from within and by repeated burnings with smaller hooks, which he introduced to the extent of an inch about the inner edge of the opening, it diminished to the size of a small fistula. This also closed by the repeated introduction of a heated fine silver probe. The patient was perfectly restored after nine months. 922. If an unnatural anus communicate with the caecum, and arises from ulceration, neither funnel-shaped lengthening of the peritoneum, nor projecting partition are produced, as after gangrene of a coil of intestine ; and it is therefore more difficult to cure. Suture is useless. The skin has been detached about the opening, and brought together with some stitches, but equally without avail. Autoplasty has been attempted, but the laps have sloughed. The skin about the opening may be pared off, without the inner parts being touched, so that the escape of faeculent matter may be prevented, and that the dragging of the threads may be better borne; otherwise, for the purpose of rendering the tearing and dragging less, semi-circular cuts may be made in the skin, of which the concavities should be directed towards the unnatural anal opening, upon which, when the operation is finished, slight pressure may be made by graduated compresses. Velpeau(c) also proposes the introduction of a tube of gum elastic, provided with several holes, through which waxed threads are to be carried, from within outwards, through the previously pared edges of the opening. When the aperture has scarred, the threads are to be cut through, and the tube being set free, passes by stool; a mode of treatment similar to that proposed by Reybard for the union of wounds of intestines (par. 525). Perhaps Dieffenbach's above-men- tioned burnings may be applicable to such cases of artificial anus. D.—OF RECTAL FISTULA. (Fistula Ani, Lat.; Mastdarmfistel, Germ.; Fistule a FAnus, Fr.) Pott, Treatise on Fistula in Ano; in his works by Earle, vol. Desault, GSuvres Chirurgicales, vol. iii. p. 380. Detzmann, Dissert, de fistula ani. Jenae, 1812. 4to.; with plates. Reisinger, F., Darstellung eines Verfahrens, die Mastdarmfistel zu unterbinden. Augsburg, 1816. 8vo. Kothe, Darstellung und Wiirdijungder Kurmethoden der Afterfisteln; in Rust's Magazin, vol. i. pt. ii. p. 259. Schreger, Ueber die Unterbindung der Mastdarmfisteln; in his chirurgische Versuchen. Niirnberg, 1818. vol. ii. pt. i. (a) Collier, in Fothergill's Medical and Physical Journal, 1820, June. (6) Casper's Wochenscrifl, fur die ges. Heilk., 1834, p. 265. (c) Memoire sur l'Anus contre nature depourvu d'eperon, et sur une nouvelle maniere de le trailer. Paris, 1836. 162 RECTAL FISTULA. Copeland, Thomas, Observations on the principal Diseases of the Rectum and Anus. London, 1814. 8vo. Bell, Charles, A Treatise on the Diseases of the Urethra, Vesica Urinaria, Pros- tate, and Rectum. Third Edition; with Notes by Shaw. London, 1822. 8vo. Brooie, Sir Benjamin, Lectures on Diseases of the Rectum; in Medical Gazette, vol. xviii. 1836. [Bushe, George, A Treatise on the Malformations, Injuries, and Diseases of the Rectum and Anus. New York. 2 vols. 8vo.; with a 4to. vol. of plates. Coates, R., Article Anus, in the American Cyclopaedia of Practical Medicine and Surgery. Vol. ii. Philadelphia, 1836.—g. w. n.] 923. Under the term Rectal Fistula is comprehended every fistulous suppurating passage in the neighbourhood of the rectum, in which either merely the tissue surrounding the outer walls of that gut is destroyed, or the fistulous passage communicates with the cavity of the rectum. Rectal fistulas are therefore distinguished into the perfect, {F. ani complete,) and imperfect {F. ani incompleta,) according as they have an external and internal opening communicating with the cavity of the rectum; or they have an internal or external opening alone, imperfect internal (external blind) and imperfect external {internal blind) rectal fistulas. They also piesent numerous other differences; the fistulous canal may extend far up into the cavity, may be accompanied with many external openings, may extend far beneath the external skin, and be accompanied with callosities and hardening, with foreign bodies, with disease of the neigh- bouring parts, the bladder, urethra, vagina, and so on, or even with caries of the bones of the pelvis. 924. The causes of rectal fistulas, are injuries of the internal coat of the rectum by foreign bodies which pass with the stools, producing in- flammation and suppuration, suppurating bunches of haemorrhoids, by which the internal membrane of the rectum, is destroyed. These fistulas generally form slowly; the patient has for a long time itching at the anus, and a knobby swelling forms about it, which often merely empties itself by a small opening, or the fistula has little disposition to break externally, but rather spreads upwards, and may be connected above by a second opening with the rectum {a); or an abscess may form about the anus from hardening, from injury, from burrowing of pus from another part, which deprives the exterior wall of the rectum more or less com- pletely of its cellular tissue. These abscesses are often critical, and the patient is thereby freed from other complaints, from affections of the chest and so on ; often they are merely consequent on gorging of the haemorrhoidal vessels, from diseases of the breast and liver. 925. The condition of the fistula is in part shown by the nature of its origin, the faecal or merely purulent discharge, and the passage of intes- tinal gas from it, especially after examination with the probe. 926. According to the observations of Sabatier, Larrey {b), and Ribes (c), the internal opening of rectal fistula is most commonly found (a) Schreger, Annalen des chirurgischen Clinicum's auf der Universitat zu Erlangen, 1817, p. 92. (6) Memoires de Chirurgie Militaire, vol. iii. p. 415. (a) Recherches sur la situation de l'Orifice interne de la Fistule a l'Anus et sur lea parties dans Pepaisseur desquelles ces ulceres ont leur siege; in Revue Medicale Historique et Philosophique. Paris, 1820, livr. i. p. 174. RECTAL FISTULA. 163 immediately above the part where the internal membrane of the rectum joins the external skin, rarely about, but never higher than five or six lines; at least such was the case in seventy-five corpses in which Ribes examined rectal fistulas. [Astley Cooper mentions a case of fistula which had a very remarkable course : —" A man died of a discharge from a sinus in the groin, having also a fistula in ano; and upon tracing the sinus in the groin, it passed under Poupart's ligament, and taking the course of the vas deferens, descended into the fistula in ano." (p. 326.)] 927. These observations, which agree with my own experience, must assist the surgeon in the examination of rectal fistulas. A thickish probe should be introduced horizontally and nearly parallel with the perinceum at least in women, because in them the opening of the rectum is less drawn in, than in the male, in whom the probe must be directed rather more upwards. The probe should be introduced into the canal of the fistula, and without leaving it, carried, toward the lower end of the rectum, where sometimes the opening is found, and the probe may be felt penetrating into the gut by the fore-finger therein introduced. In many cases when the patient protrudes the rectum, and the edges are drawn aside with the fingers, the internal opening of the fistula may be seen. If the examination be not thus proceeded with, the internal open- ing must be sought at the bottom of the fistula ; the wall of the rectum may be easily penetrated. If several external fistulous orifices be present, they all must be examined in order to determine whether they be con- nected with each other. The examination must be repeatedly made whilst the patient is on his side, with the trunk bent forwards, upon his back with the thighs drawn up, and whilst standing. Catgut bougies and injections may also be employed for the close examination of the state of the fistula. In the examination of incomplete internal fistula, those parts at which the patient has always specially felt pain, or which are indicated by softness, hardness, or laxness, must be carefully ex- amined, partly with the finger and partly with the probe, which should not be hook-like and curved, but straight, as the canal of the fistula often stretches upwards (a) {par. 924). The part, which about the anus is harder and painful to the touch, shows the bottom of the external blind fistula. The colour of the skin is here usually changed, and on pressure pus flows into the rectum. These symptoms, however, are often want- ing, and the patient merely feels pain. 928. The cure of the rectal fistula which has an internal opening, is only to be effected by division of the sphincter muscle, and the partition between the fistulous passage and the gut. If the canal of the fistula extend far up, a relapse is more certainly prevented by beginning the division from the external opening. Many observations support this, and there is the proof that the most important part of the operation for rectal fistula consists in the division of the sphincter muscle, whereby the collection of faecal matter in the rectum is prevented, and the union of the walls of the fistula possible. An imperfect external rectal fistula does not always require this division of the partition, because if in such case due care be taken for the proper escape of the pus, the stripping of the rectum is not so considerable as to render doubtful the connexion (a) Schreger, above cited, p. 98 164 RECTAL FISTULA. of the walls of the fistula with the neighbouring parts. The operation for rectal fistula must be considered to be contra-indicated, when it seems to be a vicariously secreting organ, by which other ailments are lessened or removed, (here the annoyance of the patient may be relieved by en- larging the external opening of the fistula, and by cleanliness, and the cure must be proceeded in at least not without careful preparation, ac- cording to the circumstances of the patient,) and if it be connected with other diseases of the pelvic bones, of the bladder, of the prostate gland, of the vagina and so on, or with phthisis, or incurable disease of the liver, which cannot be removed by the operation for fistula. Those rectal fistulas are to be considered incurable which are very old, have many openings, are connected with ruptures and callosities, where too much must be done to destroy them, and where the internal opening is out of reach. If the fistula have existed a long while, the operation must not be undertaken without the introduction of issues ; and also if the fistula and the neighbouring parts be much swollen and inflamed, the operation must be withheld till these symptoms are put aside. [The following observations of Brodie should always be borne in mind when considering the propriety of operating for fistula:—"In those cases in which a fistula in ano occurs in connexion with some organic disease of the lungs, or liver, I advise you never to undertake the cure of the fistula. No good can arise from an operation under these circumstances; but if you perform it one of two things will happen: either the sinus, although laid open, will never heal, or, otherwise, it will heal as usual, and the visceral disease, will make more rapid progress afterwards, and the patient will die sooner than he would have done if he had never fallen into your hands." (p. 186.) And Astley Cooper also observes :—"The surgeon often brings discredit upon himself by operating in these cases, in the last stage of phthisis, when no operation ought to be performed, and when it is impossible that the disease can be cured: therefore that death which is the result of pulmonary disease, is falsely attributed to the fistula in ano." (p. 328.)] 929. The abscesses which form in the neighbourhood of the rectum are either phlegmonous, defined and accompanied with throbbing pain, or they arise gradually in form of little not very painful knobs, or they occur after the protrusion of the rectum, with simultaneous collection of faecal matter and pus, are of great extent and commonly produce, espe- cially with persons of bad constitutions, wasting suppuration and gan- grenous destruction. In the former case leeches and soothing applica- tions are to be employed, and the abscess should be opened early with the lancet, to prevent the destruction of the cellular tissue in the neigh- bourhood of the gut; and if the canal do not communicate with the gut, it may be hoped that simply by the covering bandage and the use of soothing applications, or in old fistulas of this kind, by injections ex- citing inflammation, the cure may be effected. In hard and little pain- ful swellings, soothing poultices and dissolving plasters may be used ; they should be opened when soft and the further treatment be such as in the former case. But if in internal blind fistula the outer wall of the rectum be exposed to some extent, the division of the partition between the fistulous passage and the gut is requisite. When a large abscess has formed about the anus, if it have arisen from tearing of the wall of the. rectum, a sufficiently large opening (but not a transverse cut, which would at the same time divide the wall of the gut) must be made, attention paid to the free escape of the pus, to the necessary means for supporting OPERATION. 165 the powers, and afterwards when the fistulous passage has become more contracted, the division of the partition between the fistula and rectum must be proceeded with. (Sabatier) (a). "In speaking of large abscesses which sometimes form high up by the side of the rectum and above the sphincter muscle, Brodie makes the following excellent observations :—" When the existence of such an abscess is ascertained, you ought without delay to puncture it; otherwise not only will the patient have to undergo a great deal of unnecessary pain, but the abscess will extend itself in the pelvis until it attains an enormous size. You must ascertain the situation of the abscess, by observing to what part the pain is referred, and by examining the rectum with the finger. Then introduce a lancet through the external skin by the side of the anus, in the direction of the abscess, until the matter flows. Frequently the abscess is at such a depth that the lancet does not reach it until nearly the whole of the blade has penetrated the soft parts ; and sometimes an ordinary lancet is scarcely of sufficient length to accomplish what is wanted. You are then to introduce a probe- pointed bistoury through the opening thus made, and divide the rectum at the lower part of the abscess, carrying the incision downwards, so as to include the sphincter ani muscle, as you would in an ordinary case of fistula. These incisions make a free opening into the abscess, which is immediately emptied of its contents. The wound is then to be dressed in the ordinary way, and nothing more is wanted. It is quite unnecessary, in these cases, to lay the whole abscess open into the rectum; the free division of it at the lower part is sufficient; and if the incision were to extend further, it might give rise to a dangerous haemorrhage from large blood- vessels beyond the reach of the finger. I have met with abscesses, such as I have now described, containing from half a pint to a pint of matter. I have had no op- portunities of dissection so as to ascertain their exact locality ; but from examinations made with the finger, after they have been opened, I am led to suspect that their usual situation is between the levator ani muscle and the pelvis, and that the division of the lower part of this muscle, as well as that of the whole of the sphincter ani, is necessary to the cure. " These large pelvic abscesses occur in some instances as the original and only malady. In other cases, as I explained in my last lecture, they are the result of an abscess lower down, or a common fistula. I have met with several cases such as I am about to describe. I have been consulted concerning a fistula near the lower part of the rectum, which I have laid open in the usual manner. But, after some time, I have found that the parts showed no disposition to heal, or that they healed imperfectly, and that there was a discharge of pus much greater than could be accounted for from the apparent extent of the sore surface. I have thus been led to make a further examination; and at the upper part of the sinus which had been previously laid open, I have discovered a small orifice, through which a long probe might be passed to a great depth. I have laid open the lower part of this upper abscess into the rectum, and could then introduce my finger so as to feel the broad inner surface of the pelvis on one side, and what seemed to be the levator ani, on the other. After this second operation, the purulent discharge has immediately become much reduced in quantity, and in the course of a short time the patient's cure has been completed." (p. 186.) 930. The usual modes of operating on rectal fistulas are incision and ligature, as the early mode of treatment with the hot iron or caustic is now put aside, and cutting out the fistula must be confined to those cases in which it is connected with scirrhous or carcinomatous degene- ration. 931. For the operation on the rectal fistula by cutting a quantity of instruments have been invented, as the syringotome, the curved bis- toury, the special apparatus of Drummond, Rettler and Brambilla, the fistula-knife of Pott, Savigni, Remm, Dzondi, and others. But the most simple and certain proceeding is, when, for cutting the wall of the fistula only a common straight bistoury, a grooved probe without a blind (a) Medecine* Operatoire. Nouv. Edit., 1822, vol. ii. p. 309. Vol. ii.—15 166 RECTAL FISTULA. point, and a wooden gorget are used. After having emptied the rectum with a clyster and removed the hair in the neighbourhood of the fistula, the patient is to be laid in his bed, or on a couch upon the side of the fistula, with the thigh of the affected side stretched out straight, and the other bent towards the pelvis. The grooved probe is to be intro- duced through the canal of the fistula and its internal opening into the rectum, where it is found by the finger which has been therein intro- duced. The oiled gorget is then to be passed into the rectum, its hollow directed towards the side of the fistula, and the probe pressed against it. The probe and gorget being felt to touch distinctly, are to be held with either hand, and moved together. The probe is given to an assistant, who at the same time separates the buttocks, and the gorget being pressed against it, a straight bistoury is to be introduced along its groove, till it reaches the gorget, and in drawing out the bistoury all the parts between the probe and the gorget are divided, which is shown by the probe and gorget being drawn out through the wound without dis- turbing their contact after the incision is completed. If the canal ex- tend higher than the internal fistulous opening, a pair of blunt scissors should, according to the advice of some, be introduced into the wound, upon the forefinger, and the remaining partition divided. This, how- ever, is according to foreign and home experience not indispensable (par. 928.) If the internal fistulous opening be very deep, a fine flexible, silver, hollow sound may be introduced by the fistula into the rectum, its end brought down out of the gut with the forefinger, and the parts lying upon it divided with a bistoury pushed along the groove. Further observations on the seat of the internal opening in rectal fistula must decide, whether this be not always connected as above said, (par. 928,) and whether the division of the wall of the fistula from the inner opening be sufficient for the cure although the fistulous canal extend higher. [My common practice in operating on rectal fistula, has been for years, to use a soft silver director which will bend. Having introduced the fore- finger of one hand into the rectum, I pass the director through the fistulous passage, and if, as is generally the case, there be a hole in the gut, into the rectum, but if there be not an opening, or if it cannot be readily found, I bore the end of the director against the wall of the gut, upon the finger introduced, and thus speedily penetrate into the cavity of the rectum. Having thrust the end of the director well through, I bend it round with the top of my finger, till I have brought it through the anus externally, and then thrust it a little further, till its point rests upon the opposite buttock. Having both ends of the director, and both apertures of the fistula well in sight, I divide the sphincter and its tegument, by running a pointed curved bistoury along the groove of the director. I think this mode of pro- ceeding is best, because it shows to what extent the parts are divided ; and also that thereby the upper part of the wall of the fistula tears, and is therefore less likely to unite by adhesion, than when clean cut, as quick union is not desirable. Brodie also recommends the practice of bringing the end of the director through the anus, and dividing upon it. If I do not bring the probe out, I prefer the old practice of cutting on the finger, which must be first introduced into the gut, then the fistula should be examined with a probe, and its direction and extent being ascertained, the probe is withdrawn, and a button-ended curved bistoury passed in its room, through the opening in the gut, if there be one, but if not, the bowel is to be rubbed between it and the finger till it make one; the end of the finger is then carried over the end of the knife, which being thus defended, the hand that holds the handle of the knife grasps the other, and the finger and knife are together drawn down, cutting through the sphincter as they are brought out. There are, however, two inconveniences as regards this operation, the surgeon may cut his finger severely, or break the knife in the fistula, which I have seen when the patient has been unsteady.—j. f. s.] ACCIDENTS AFTER OPERATION. 167 932. In an internal blind fistula, the director should be carried to its bottom, pressed against the gorget introduced into the rectum and the partition divided with the straight bistoury, as in the former case. 933. After the completion of the operation and after the wound has been properly cleaned, the fore-finger of the left hand should be intro- duced into the rectum, to the upper end of the wound, and then by means of a probe or pair of forceps well oiled, a tent of lint should be passed up and put lengthways between the edges of the wound, so as to prevent them touching; wad of charpie is then to be put on, to be fixed with sticking-plaster, then a compress, and the whole held together with a T-bandage. After the patient is put to bed in a convenient position upon his side, an opiate should be given, and the bandage is to be removed every time the bowels are relieved, (which should be every twenty-four hours), after that the rectum has been cleared with lukewarm water; with the remark that in the following dressings the tent is no longer to be oiled, is to be thinner and thrust in less deeply as the wound is lessened by granulation. The scarring is promoted by the careful application of lunar caustic. The opinion of Pouteau and others, that after the operation of cutting a rectal fistula any dressing is unnecessary and injurious, which of late has found advocates in von Walther, Jaeger, and others, I cannot accede to, inasmuch as experience has only shown that without dressing, the edges of the divided partition readily in part unite, and the fistulous passage does not close. That kind of dressing in whieh the wound is completely filled with several tents, and one thick tent is in- troduced into the rectum, as Boyer, Sanson, Textor, I myself, and others have re- commended, I consider as unsuitable, and have given it up for the above-mentioned more simple treatment. A. Cooper (a) put after the operation a dry tent in the wound, and on the following morning applied a soothing poultice; in two or three days the tent comes out, and a probe should be frequently introduced into the wound for the purpose of preventing the adhesion. Poultices are to be continued, and when granulations spring up the tent must be again introduced, and by this treat- ment much pain and severe inflammation and suppuration are prevented. 934. The accidents which may occur during and after the operation by cutting are severe bleeding, too much or too little inflammation, copious suppuration, colic, diarrhoea, retention of urine, and costive- ness. A severe bleeding, if the bleeding vessel cannot be tied, or if the bleeding cannot be stopped by the application of styptics, requires plug- ging, in which a firm wad of lint bound crossways with two strong threads must be introduced into the rectum, up to the bleeding vessel, and between them, as they hang down from the gut, sufficient lint is to be introduced to fill the rectum, and then the threads are to be tied upon it. In females the vagina must also be plugged (1). Severe inflammation requires besides loosening or removing the bandages, cold applications, leeches, soothing applications, clysters, oily mixtures, and the like; copious suppuration needs a corresponding strengthening treatment; spasmodic colic, oily mixtures with opium, soothing clysters and warm applications; for retention of urine, the use of the catheter, warm applications to the region of the bladder, soothing remedies and clysters, which are also equally indicated in cos- tiveness (2). (a) Lectures on Surgery, vol, ii. p. 333. 168 RECTAL FISTULA. [(1) Instances, though rare, have occurred of death from bleeding after the divi- sion of a rectal fistula, and I recollect seeing such a case very soon after I became a student, in which the patient died within twenty-four hours of the operation. Copeland objects very properly to the practice here advised of stuffing the rectum for the purpose of stopping the bleeding. "I have." says he, "so frequently seen the haemorrhage kept up as long as this method of plugging the intestine was per- severed in, and cease spontaneously when every kind of application was omitted, and the parts left for a short time exposed to the open air, together with a cool room, and avoiding all drink that hurries on the circulation, that I cannot help thinking that the irritation of the compresses keeps up the bleeding, and that the most eligible mode of treating it, when it is impossible to secure the vessel with a ligature, is to take off every kind of dressing, and to suffer the part, as much as possible, to be exposed to the external air. * * * I am persuaded, from repeated experience, that by being too busy with compresses, and styptics, and astringents, and such like applications, we most frequently only hide the bleeding and rather prolong its con- tinuance, than otherwise. * * * After many unsuccessful attempts to secure a bleeding vessel under such circumstances, I once accomplished it by introducing a blunt gorget into the rectum; and by keeping the gut thus dilated, I was enabled to see the orifice of the bleeding artery and to secure it." (pp. 90-91). (2) Brodie observes, that "in a very few cases erysipelas appears to extend up the mucous membrane of the rectum into the other parts of the intestine; and this is a most formidable disease indeed. The symptoms are very peculiar, and as far as I know, are not described by writers. The pulse becomes very rapid and at the same time weak; then it is irregular and intermitting; the abdomen is tympanitic in consequence of the intestines being distended with air; hiccough takes place; there is a great prostration of strength, and the patient, often dies in the course of three or four days, sometimes sooner. * * * This internal erysipelas, however, is not necessarily fatal. I have known more than one case in which it manifestly oc- curred, but without the usual prostration of strength, and the patient recovered. When I have met with a case of this kind, I could never entertain a doubt as to the medical treatment which should be employed. It is sufficiently indicated by the symptoms; and for the most part, the great failure of the vital powers demands the free exhibition of cordials and stimulants." (pp. 185-86)]. 935. The ligature of a rectal fistula {Ligatura Fistulce Ani) consists in tying together the whole wall, separating the rectum from the fistula, with a thread which, by gradual tightening, cuts it through ; in this case as the fistulous wall is divided, the part cut through, heals from above downwards. The proceeding in tying the rectal fistula varies according to its seat and condition. The best materials for the ligature are several hempen or silken threads put together, or a silken loop-shaped thread, and the silver or leaden thread recommended by many persons. [Luke, of the London Hospital (a), during the course of the present year has advised the treatment of fistula in ano, by tying it with a thread, and says:—"The advantages of this method over that by the knife, are; first, the shorter period which usually elapses before the final cure; second, the less pain which is felt during the treatment; third, the absence of the dread which the knife generally inspires, and the consequent inducement which it offers to the patient to submit to effective curative treatment; and lastly, the avoidance of all haemorrhage. The treatment is to be conducted in the following manner:—an eyed-probe,armed with dentist's silk, is introduced through the fistula into the rectum, from whence the silk is withdrawn through the anus, by means of a catch-spring, introduced into the rectum upon the finger of the operator. The parts to be divided are then en- closed between the two extremities of the ligature, to which a small fistula-tourni- quet is subsequently attached, by passing them through holes provided for the pur- pose. The requisite amount of tension is maintained by a screw. Care must be taken that the ligature be not so tight, as to oause more than slight uneasiness. After the lapse of two or three days, ulceration of the enclosed part commences and the tourniquet becomes loosened, indicating the necessity of the ligature being made tighter." (p. 221). (a) Lancet, vol. i. 1845, New Series. TREATMENT BY LIGATURE. 169 Dr. Nelken (a) has proposed for this operation "an instrument composed,first, of a rod about eleven and a-half inches in length, the upper third of which is divided into four equal parts, united to each other by hinges so arranged that they can be closed only in one direction, the last being furnished with a knot and a hole to pass the ligature, and second, of a tube, through which the former is passed when threaded. The finger being placed in the rectum, the apparatus thus prepared, is passed upwards into the fistula until the extremity reaches the finger, the tube is then withdrawn to an extent equal to one of the four divisions of the rod ; the whole is next pushed forwards, the finger in the rectum causing the rod to bend down- wards as it penetrates into the intestine; the same manoeuvre is repeated until the ligature appears at the anus, when the surgeon seizes it, and terminates the operation." (p. 403). Although Luke mentions nine cases in which he had in this way successfully tied anal fistula, I must confess I should not feel disposed to adopt it unless the patient would not submit to the knife, which I am quite sure produces a cure quite as quickly and with less inconvenience; for after the inflammation excited by the fresh cut subsides, there is scarcely any pain during the two or three weeks, usually necessary for healing the wound.—j. f. s.] 936, In complete rectal fistula, of which the internal opening is not very high, a flexible leaden probe should be introduced through the canal of the fistula into the rectum, which is then with the fore-finger of the left hand already in the gut to be drawn out at the anus and a thread passed into its eye. In the same way, in complete fistula, silk- worm gut may be introduced into the rectum, and by it the thread car- ried in. 937. For tying complete or inwardly blind fistulas which extend very high up, Desault, Reisinger, as well as Weidmann, Schreger, and Demme have proposed particular apparatus, of which that of Reisinger is preferable. It consists of a blunt silver tube and a probe, provided with a trocar point, which fits the tube, of a watch-spring, which in front has a button and behind an eye, and of a pair of forceps with a move- able gorget. 938. In a complete rectal fistula, Reisinger's apparatus is to be used in the following manner:—The patient being put in the same position as for cutting, the silver tube with its ensheathed probe is to be passed through the fistula into the rectum for about three lines' length, which is ascertained by the finger already there. The forceps having been oiled are then introduced into the rectum without the gorget, opened, and passed somewhat deeper in, that the tube may project between the arms of the forceps and be held fast by them. An assistant then removes the probe from the tube and passes in the watch-spring, which is provided with the ligature, through the tube into the rectum. As the watch-spring projects from the tube, it must be seized with the forceps, which, being closed, are drawn back, so that the watch-spring is drawn out of the anus, after it the ligature, and then the tube is to be removed. In a fistula of the rectal sheath the tube must be brought through the sheath and the fistulous opening into the rectum, and then treated in exactly the same way. According to Mott (b) a seton should be first introduced into this kind of fistula, and left there for some days; a thread is then to be drawn through the fistulous opening, and by means of an eyed needle the ends found in the sheath are to be drawn through the perinssum and the two ends tied together, as in rectal fistula. 939. In an inwardly blind fistula, the tube with its probe is to be car- ried by the fistulous canal to its very bottom, the blunt probe removed, (a) Medical Times, vol. xi. 1845. (b) Gazette Medicale de Paris, 1841. No. 18. 15* 170 TREATMENT EY LIGATURE. and the trocar-pointed one introduced, without projecting it from the tube. The forceps, opened, are then passed with the gorget into the rectum about an inch above the tube, and both instruments inclined towards each other so that the tube becomes situated between the arms of the forceps. The assistant now thrusts the trocar-point out of the tube, by which the rectum is perforated and the trocar-point between the forceps' arms pressed against the gorget, so that the latter may recede from the forceps. The tube being then kept pressed against the gorget, an assistant draws out the trocar, and by means of the fore-finger of the hand holding the forceps, the gorget is withdrawn, and removed from the forceps, which are then closed and the tube held by them. The watch- spring is then introduced through the tube, and proceeded with as already described. 940. The two ends of the thread introduced, are passed into the two openings of a small silver tube, and tied with a simple knot and loop, so tight that the patient may feel a degree of pressure but no pain. For the first day he must keep quiet, but afterwards may go about his usual business. Every three or four days the knot should be tightened as already directed; and care must be taken for the daily passage of soft motions. If much pain arise, the ligature must be tied more loosely, but in other respects the treatment is to be, as after the operation of cutting. The same mode ofjreatment is to be continued till the partition of the fistula is divided. In order to prevent the destruction of the ligature, at the end of the third or fourth week, if the cure be long protracted, a new ligature must be tied to the old one and drawn through. Usually, after the partition is cut through by the thread, there remains a little cleft, which still suppurates for some time, and heals by the application of some dry lint to the suppurating part. 941. As to the preference of cutting or tying, the latter mode is usually accompanied with little or no pain; the one indeed is longer, but the patient may go about his business, no bleeding is to be feared, and it may be employed when the fistula is very high. The operation on rectal fistula by ligature has, therefore, considerable preference and is especially indicated in cases, where the fistulous orifice is high up, where the haemorrhoidal vessels are very large, and in persons who are subject to an habitual diarrhcea% Many surgeons, indeed, dispute the necessity of dressing after cutting; but experience contradicts this opinion, and dress- ing is necessary throughout, if there be bleeding. On the contrary, in rectal fistula the preference is given to the operation by cutting, when the internal opening is not very high, when several neighbouring passages exist, a considerable exposure of the rectum is present and the external openings are distant from the anus. Mention must be made of the propositions for compressing rectal fistulas by the introduction of tubes into the rectum (a), or by a cylinder of linen stuffed with charpie (6). 942. In the externally blind fistulas, if the bottom of the. fistula can be ascertained by the appearances already mentioned, (par. 927,)it may be cut into externally, and then treated as complete fistula. (a) Bermontj These, Paris, 1827,. p. 33.—Colombe Bibliofcbeque Medicale, 1828, vol. ii. (b) PiEDAGNEfc, Velpeau, Diet, de Medecine, vol. iii. p. 328. SPASMODIC CONTRACTION, &C. 171 [SPASMODIC CONTRACTION OF THE ANUS, AND ANAL FISSURES. This would seem to be the most convenient place to treat of this subject, which was first clearly described by Boyer (a), and afterwards by Dupuytren (b), and subsequently by Brodie (c). Boyer does not consider the "rhagades ou fissures" mentioned by Lemonnier as the fissures of which he treats, as they neither originate in the same causes, nor are-cured by the same treatment. According to Boyer, "Adults seem to be almost exclusively subject to this disease. I have never seen it," says he, "in children nor in,young persons. The greater number of those attacked with it have been between twenty-five and forty years of age; some even above it, and a single person was sixty years old. No class of society is exempt from it; both sexes are alike liable to it; but females perhaps more frequently than men. The characteristic of fissure is a fixed pain at one spot of the circumference of the anus. This is always worse whilst passingthe stools, but it gradually subsides afterwards. The m. sphinc- ter ani is so contracted that the introduction of the finger, of a bougie, or canula is very difficult and extremely painful. The causes of this-affection are very obscure. I have only observed that in many persons it has been preceded by haemorrhoidal swelling, and that in some persons pile's had been previously cut off". The disease commences insensibly; the voidance of the stools is attended with heat and smart- ing; some hours after the evacuation the troublesome pain ceases; the patient is believed to have piles or to have chafed. Sometimes after a few days these symp- toms subside. * * * But soon the heat and smarting returns, the evacuations become more painful, and the distress continues longer. The dejections are some- times mingled with blood, and the pain increases. * * * When the pain is felt the slightest things exasperate it; coughing, urining, leaping, are sometimes sufficient; one patient cannot stand upright and at rest, and another cannot remain sitting. * * * After the disease has continued some time, in addition to these local symptoms there is wasting, and extreme nervous sensibility, sometimes hypochondriasis, sometimes even retention of urine." (pp. 126-30). " Although there is not the same danger in regard' to Fissures at the Anus, as in some other diseases in the neighbourhood of this part, yet," says Dupuytren, "'they are in general accompanied with such violent pains, that it is of importance to re- lieve them as soon as possible. The pains have a,character in some degree pecu- liar ; they increase gradually, and continue long after passing stool; sometimes lancinating; they are, however, most frequently burning; and patients abound in extreme terms to describe them. Usually they compare them to the sensation of a hot iron penetrating the rectum ; they so dread passing their motions, on account of the horrible pain which accompanies and follows that function, that they are often observed to strive for a long time against this imperious need, and even to deprive themselves of food to restrain it. These peculiarities are sufficient to discover the nature of the disease. * * * The disease consists in a lengthy and superficial ulceration, about the margin of the anus, in the radiating folds of the mucous mem- brane of this part. On separating the orifice, and directing the patient to strain, a narrow cleft is observed, with its bottom red, and its edges slightly swollen and callous. But to ascertain its extent upwards, it is often necessary to introduce the finger into the rectum. It is more commonly seen at the sides or back of the anus, than at its fore part. * * * It very rarely extends through the whole thickness of the mucous membrane. The importance of this affection depends principally on the painful spasm of the constrictors of the anus. The fissures is but accidental, as is proved by the existence of painful constriction, without any cracking, which, ac- cording to celebrated surgeons, is as 1 to 4. This spasm is so great, that the in- troduction of the mildest bodies is intolerable; the tip of the finger, the pipe of a syringe, excites the most violent pains; and the resistance offered by the anus to every attempt at introduction,-^ a new characteristic sign of the affection. The causes of anal fissures are numerous; constipation and the spasm it produces, specially dis. (a) De la Fissure ou Gercure de PAnus, accompagnee du reserrement spasmodique du Sphincter; in his Traite des Maladies Chirurgicales, vol. x. Paris, 1825. (b) De la Fissure a l'Anus; in Leeons Orales, vol. iii. 1831. (c) Lectures on Diseases of the Rectum; in Med. Gazette, vol. xvi. 1835. vol. xviii. 1835. 172 TREATMENT pose to the disease ; very hard substances which scrape the mucous membrane, and distend it exceedingly, may give rise to it; the administration of clysters by awk- ward persons, especially when metallic tubes, pointed or rough are used, are often the immediate cause; they are met with in persons affected with haemorrhoids, and venereal poison flowing from the generative organs, which happens with many women, is a very common cause of this affection." (pp. 282-85.) Brodie (a) says that " the contraction of the sphincter at first appears to be merely spasmodic without any other change of its condition; but in proportion as muscles are called into greater action, so they become increased in bulk; and in conformity with this general rule, when spasmodic contraction of the sphincter muscle has ex- isted for a long time, the muscle becomes considerably larger than it was in its natural state before the disease existed. This disease is not of uncommon occur- rence ; it is met with chiefly in women, especially those disposed to hysteria. It is, however, met with in other women, and sometimes in the male sex. The patient under these circumstances is forced to strain very much in passing her evacuations; and this is especially the case when the fasces arehard, or even solid. There is pain not only when the fasces are being passed, but for a very considerable length of time afterwards; and in some cases the pain will remain from the period of one alvine evacuation to that of another, so that it is constant or nearly sn." (p. 26). The fissures present various differences according to their situation, " those below the m. sphincter ani, affecting almost entirely the cutaneous tissue, and not the anal mucous surface, produce," says Dupuytren, "a more or less severe pruritus, but they interfere little with going to stool, occasion no constriction of the sphincter, and consequently are little painful. They most commonly result from venereal af- fection. The fissures above the sphincter, attack the mucous membrane, and can only be discovered by the use of the speculum. On introducing the finger into the rectum, there is felt at the part where they are situated, a cord knotty and hard, pres- sure upon which excites severe pain. They excite when the patient goes to stool, an indescribable pain, but which ceases immediately after the motion. The fasces are covered with puriform mucous, and of a bloody appearance next the fissure. Usually they result from ulceration of internal piles, during the passage of har- dened substances. Finally the fissures at the top of the sphincter are more serious than the former ; and it is in them that the so painful constriction of the sphincter, and the other symptoms already mentioned, are observed." (p. 284). It is doubt- less to this form that Brodie refers, when he says, " in connexion with the spas- modic contraction of the sphincter muscle, you will frequently find a small ulcer of the mucous membrane of the rectum, which is always in a particular spot at the posterior part, opposite to the point of the os coccygis. (p. 26). But he also observes, that, " in some instances the ulcer exists independently of the contracted sphincter muscle. * * * It is very difficult to heal, and very frequently it goes on spreading till it becomes of considerable size. It is a superficial ulcer of exquisite sensibility, and great pain is always produced by the passage of the fasces over it, lasting for a considerable time after each evacuation. In some instances, consider- able haemorrhage takes place from an ulcer of this kind." (p. 27.) Treatment;—" The spasmodic construction," says Dupuytren, " is the true ailment; the lengthy ulceration, named fissure or crack, is merely a secondary symptom. If the constriction be removed, the complaint is cured. The application of belladonna under these circumstances is naturally indicated, and has been used very frequently with great advantage, when combined with acetate of lead in. the following form : of lard 6 gros, of extract of belladonna and acetate of lead, of each one gros. With this a bougie of moderate size is to be greased, and its size gradually increased to that of the little finger. Its continued use for a few days often completely removes the pain." (p. 286). Brodie, however, observes, thatthoughhe "formerly used a suppository with extract of belladonna with manifest advantage^ yet that he is not in the habit of frequently employing it.. Even used in the form of a suppository, the belladonna sometimes produces very serious symptoms, by its influence on the brain." (p. 26). He, therefore, only gives purgative medicine to prevent hard stools, directs the introduction of a bougie before going to the water-closet, and lets an opium suppository be introduced at night- " The fissures helow and above the sphincter most commonly heal," according (a) Lectures on Diseases of the Rectum; in Med. Gazette,, vol. xvi. OF ANAL FISSURES 173 to Dupuytren, " without any operation; the former, with linen or lint spread with simple cerate, opiate cerate, cucumber pommade, poplar ointment, mercurial pre- parations, &c, and the latter, by soothing and narcotic lotions of decoction of marsh- mallow, poppy heads, nightshade, henbane, stramonium, and other remedies, thrown up into the rectum. * * * But in very painful fissures accompanied with spasmodic contraction of the anus, and situated at the very top of the sphincter muscle, the most prompt and certain method is that introduced by Professor Boyer, which re- quires only a common and a button-ended bistoury," (p. 290,) and which is thus described :—"I place the patient," says Boyer, "upon his side, as in the ope- ration for anal fistula; I then introduce the fore-finger of my left hand, smeared with cerate, into the rectum, and upon it slip up a bistoury laid flat, of which the very narrow blade is square, and with a rounded tip. The cutting edge is directed right or left, according to the situation of the fissure, and I divide, at a single stroke, the intestinal membrane, the sphincter, cellular tissue, and tegument. I thus form a trian- gular wound, of which the top corresponds to the gut and the bottom to the skin; it is sometimes necessary to lengthen the wound, and I then make a second cut. Sometimes the intestine slips from the cutting instrument, and the wound of the cel- lular tissue extends higher than that in the gut; the bistoury must then be again intro- duced into the rectum, for the purpose of lengthening the incision of the gut. If the constriction be. very great, I make two cuts, one on the right and the other on the left, and when the fissure is before or behind, I do not include it in the wound. A large bougie is then to be introduced into the wound or into the two wounds, to prevent their edges uniting irregularly. A slight plugging with lint is then made, some pads applied, and the whole supported by a bandage." (p. 137). A very important caution, in reference to operating on women, is given by Brodie. "In a female subject, whether you divide the sphincter in a case of fistula, or in one of any other disease, I caution you, that you should never make your incision exactly in front, towards the vagina. The wound made in this direction does not heal in a proper manner; the muscle, if divided at this point, is never a perfect sphincter afterwards, and the patient labours under an incontinence offaeces, from which she never completely recovers, and which makes her miserable for life. Then, it is not advisable, in either sex, that you should divide the sphincter directly backwards towards the os coccygis. If you do, you will find that the wound does not very readily close, and that it is liable to crack and be re-opened afterwards. There is a sufficient anatomical explanation of what I have now mentioned. You will recol- lect that the sphincter ani consists of two parts or layers. The inner layer is cir- cular, embracing the anus like a ring; the external layer on each side is attached posteriorly to the apex of the os coccygis, by elastic ligament, and anteriorly to the central portion of the perinasum. If you cut in the direction backwards towards the os coccygis, you divide, it is true, the inner or circular layer of fibres, but not of the outer layer. The knife passes between the two lateral portions of this outward.layer and simply splits or separates them; and the contractive power of this part of the muscle remains and-interferes with the cicatrization of the wound." (p. 186). "The operation of dividing the sphincter," he elsewhere observes (a), " is not very painful, except in those cases where the disease is complicated with ulcer at the back of the rectum ,• neither is there ever any haemorrhage of consequence, as the pressure of the finger or a plug of lint will command it. The relief is immediate, and the very next time that the patient has an evacuation there is an end of all the pain and difficulty which she suffered before. It is better, however, that she should not have an evacua- tion immediately after the operation, and, therefore, I generally give her an active 3 purgative on the preceding day, and some opium afterwards, to keep the bowels constipated. After two or three days, castor oil may be exhibited and the bowels opened. The wound requires very simple treatment; a little dressing of lint may be applied to it till it is cicatrized, and cicatrization is generally completed in about three weeks. No inconvenience whatever follows the division of the sphincter muscle, except it be made as I have mentioned, in the female, in the direction for- wards. The patient retains her faeces as well as ever, and yet the difficulty of voiding them is relieved." (p. 27.)] (a) Med. Gazette, vol. xvi. 174 URINARY FISTULA. E.—OF URINARY FISTULA. (Fistula Urinaria, Lat.; Urinfistel, Germ.; Fisiule Urinaire, Fr.) Desault, G3uvres Chirurgicales, vol. iii. p. 287. Howship, A Practical Treatise on the symptoms, causes, &c. of the most im- portant Complaints that affect the secretion and excretion of the Urine. London, 1823. 8vo. Chopart, Traite des Maladies des Voies Urinaires. Nouv. Edit, par Felix Pascal, Paris, 1824, vol. ii. p. 269. Bell, Charles, above cited. Brodie, Sir Benjamin, Clinical Lecture on Perinaeal Fistula; in Medical Gazette, vol. xvii. 1836. 943. Under the term Urinary Fistulas, strictly, are understood, long and narrow ulcers opening in any part of the urinary passages; fistulous sores, however, in their neighbourhood are included under the same head. Urinary, like rectal, fistulas are therefore distinguished into com- plete and incomplete, according as they have an internal aperture com- municating with the urinary passage, and an external opening, or the latter only. The incomplete urinary fistulas are either incomplete in- ternal, or incomplete external. 944. The external opening of urinary fistula may be situated either in the perinceum, scrotum, penis, buttocks, thighs, loins, belly, in the vagina or in the rectum; as the internal opening may be connected with the kidney, ureter, bladder, or urethra. The direction of fistulous passage is mostly curved, several passages often run into one and the same open- ing ; but rarely do several external apertures lead to as many internal. Usually the walls of the fistulous passages are very hard and the callosi- ties wide-spread. 945. The incomplete external ox false urinary fistula (Fistula urinaria incompleta externa, seu spuria) occurs mostly in the neighbourhood of the urethra, after abscess or ulcer, in which pus has collected and burrowing in different directions, has destroyed the cellular tissue surrounding the urethra or bladder, and produced a sinuous ulcer which resists the healing powers of nature. They may be connected with hardening, with caries of the pelvic bones, and the like. Besides the preceding appearances, they are characterized by no urine escaping from them nor any pus from the urethra, and by the probe used in examining them penetrating neither into the urethra nor bladder, nor touching a catheter introduced into the latter. 946. The incomplete internal urinary fistida {Fistula urinaria incom- pleta interna) usually occurs in the urethra, rarely in the ureters or blad- der, and depends on tearing by external violence, retention of urine, neighbouring abscesses, ulcers, rough catheterism, or an imprisoned stone. The diagnosis depends on the previous symptoms, on the sensa- tion of pain during or after passing water, on the bloody purulent dis- charge from the urethra, but especially on a swelling, which increases during micturition, diminishes or disappears entirely by pressure, in consequence of which urine mixed with pus, flows from the urethra, or on the appearance of an undefined extravasation of urine into the cellular tissue. URINARY FISTULA. 175 In persons who have lost flesh by sweating or in any other way, there often occurs, without any previous contagion, a flow of mucus from the urethra, and a swelling at some part of its neighbourhood, which runs into suppuration, bursts, and gives escape to the urine, in which the flow of mucus from the bladder continues, but without any stricture existing. The destruction of the urethra depends on ulceration of the mucous membrane or abscesses in the lacunae (a). [This incomplete fistula I have seen though not very frequently, and have more commonly observed it in front of the perinssum, and involved in the scrotum, some- times at its hind and at other times in its front part. It has been exceedingly well described by Brodie in the following terms:—"I shall next describe a case which used to perplex me very much when I first met with it. A patient may come to you who has, perhaps, had gonorrhoea formerly, which has been followed by a stricture, perhaps a very slight one, of the urethra, or at any rate there has been a discharge from the urethra, which he calls an obstinate gleet, telling you at the same time that nothing will cure it. You examine the perinaeum, and you find in it a little tumour, not bigger apparently than a horse-bean or filbert. You can just feel it, at some distance below the skin, and the patient tells you that he has had it ever sinCe he has been the subject of this obstinate gleet, and that sometimes there is a little pain in it. Now such a little hard tumour is nothing more nor less than a blind fistula. There is a small orifice in the urethra, and a narrow channel communicating with it, which leads into a cavity in the centre of this hard lump, and every time the patient makes water a very small portion of urine finds its way into this cavity. In consequence of the smallness of' the central cavity and the great deposit of solid matter on its outside, the fluctuation of fluid in it is not perceptible. Such a case as this is not a very uncommon occurrence, and I have known a patient labour under this sort of hard lump in the perinaeum for many successive years, suffering a good .deal of in- convenience from it, but not suffering excessively. I have cured several cases of this kind by a very simple process. All that you have to do is to make an opening into the cavity in the centre of the tumour. But the cavity is very small and how are you to find it] You may run a lancet into it; but it is very probable that it may pass on one side of the cavity, and therefore some management is necessary in per- forming the operation. You are to introduce the lancet a little obliquely, so that you may, as it were, almost cut the tumour in half. When you have done this the blood and the deep-seated situation of the tumour prevent you seeing whether you have made the opening into the central cavity or not. Introduce a piece of lint, so as to prevent the wound uniting by the first intention. Two or three days afterwards you take out the lint, and then you ascertain whether, when the patient makes water, any comes by the opening made with the lancet. If this be the case you may be certain that you have penetrated into the cavity, and then you have only to dilate the urethra with a proper instrument and the patient will get well. But if you find that the urine does not flow through the artificial opening, you may thus proceed:— Introduce a piece of caustic potash through the opening you have made down to the bottom of it, in the centre of the tumour, so as to make a slough there. A portion of the tumour will slough out, and it is most probable that the cavity in the centre will be exposed, and then a cure follows. You should apply the caustic potash in such a manner that it may act on the part on which you wish to act, defending at the same time the neighbouring textures, the skin especially, by washing it with vinegar." (p. 489.)] 947. Complete urinary Fistula {Fistula urinaria completa) is the most common. Its internal opening arises either from the kidneys, ureters, bladder or Urethra, and its external aperture, often very far distant fiom the internal, is found in the loins, in the groin, above the share-bone, in the perinceum, and so on; or it communicates with the rectum, w7ith the colon, with the vagina in women, or with the cavity of the belly, in which case there is always a fatal effusion of urine into it. Complete urinary fistulas are mostly consequent on retention of urine, tearing, injury of the bladder, or an incomplete internal or external fistula. These, which in men open into the rectum, frequently occur after the (o) Cooper, Astlet. 176 URETHRAL FISTULA; operation for the stone, as those connected with the vagina take place after difficult delivery, or after ulceration of the vagina. Cancer of the rectum and of the vagina may also produce urinary fistula. Complete urinary fistula is characterized by the escape of urine, which is constant, if the fistula be from the bladder, but only whilst making water, if from the urethra; this escape, however, is not always present in complete fistula, as if the fistulous passage be very narrow, and the urethra not obstructed, the urine often passes by the latter alone, and in fistula of the bladder, if the canal be very narrow and curved, often only by straining whilst emptying the bladder. It also depends on the con- dition of the fistulous canal, whether the probe introduced into it can be made to touch a catheter in the urethra or bladder. If the fistula com- municate with the vagina or rectum, the urine escapes by these canals; or the opening of the fistula is felt by the finger introduced into it, or merely by the sound passed into the bladder. If the fistula be connected with the rectum the urine flows through it or is mixed with stool. Less constant are these symptoms, viz., hardening of the course of the fistu- lous canal, or in the whole extent of the perineeum, inflammation, un- healthy suppuration, proud flesh about the fistulous opening, loss of power, wasting, hectic fever, and the like. 948. The prognosis in urinary fistula depends on its situation and ex- tent, on the constitution of the patient, and on other diseases connected with it. Complete fistulas, of which the internal opening is connected with little loss of substance, heal more easily than those which have it with greater loss of substance ; fistulas of the urethra, under similar cir- cumstances, heal mote readily than those of the bladder. When the canal of the Urethra is considerably changed, greatly narrowed, or en- tirely obstructed, and cannot be re-opened, the cure is impossible. Urinary fistulas communicating wTith the vagina or rectum are extremely difficult, and frequently not to be healed. A bad state of the patient's powers renders the prognosis very doubtful. 949. The cure of incomplete external fistula requires the general treatment of fistulous sores. Suitable pressure often assists the healing; often must the fistulous orifice be enlarged by a conical cut, of which the point is directed towards the urethra or the bladder, the source of the pus laid bare, every neighbouring passage opened, and care taken for the free flow of the pus. If there be callosities, dispersing bran poultices and proper digestive remedies must be employed. If caries be connected with this fistula or any general affection be connected with it, the treat- ment must be modified according to general rules. 950. Incomplete internal urinary fistula requires the introduction of a catheter, which often, if the urethra be narrow, must be preceded by the use of the bougie. The catheter must be of moderate size ;• otherwise it fills up the urethra too much, or the urine escapes by its side. If the fistula be old and the cure do not in this way take place, the incom- plete must be changed into a complete fistula, by a suitable cut, which is also necessary in extensive urinary infiltration, where several incisions often must be made, in order to prevent the gangrenous destruction caused by the escape of the urine. Stones frequently lie in the sac of a blind fistula, in which case cutting into it and TREATMENT. 177 the removal of the stone is necessary, and afterwards the treatment is to be as in complete fistula. Compare also what is hereafter said about urinary stones exterior to the urinary passages. 951. Complete urinary fistulas communicating wTith the kidneys, or ureters, require no assistance, unless kept up by the pressure of a foreign body or by prevention of the flow of urine from the bladder, in which case perhaps the restoration of the natural area of the urethra, or the removal of the foreign body, may contribute to the cure. 952. Complete urinary fistula is situated either between the scrotum and the glans penis, or between it and the anus in the perinaeum. The difference of the seat of the fistula depends on its course, and requires different treatment. 953. In the first case, {Fistula urinaria penis), the fistulous opening is most commonly on the under side of the penis, varying in size, so that either all the urine and semen, or only part of it, escapes thereby. It presents different conditions, according to its cause and duration; it is often connected with surrounding hardness and copious suppuration, especially if it arise from stricture; often it forms an extremely minute and obliquely running aperture; often the skin and the neighbouring mucous membrane of the urethra, skin over, and do not suppurate ; often is a large portion of the lower wall of the urethra destroyed, and the opening varying in size, surrounded with a hard scar, as in destroying ulcers or wounds with loss of substance. In narrow and obliquely run- ning fistulas, the introduction of a probe, through the fistula, and of a catheter through the urethra, shows the seat of the internal opening. 954. If the fistula be accompanied with narrowing of the urethra, this must be first got rid of by bougies, and then by the continual wearing an elastic catheter, which should be properly fastened, the urine must be conveyed from the fistula. At the same time, any disease, standing in causal relation to the fistula must be attended to, and care taken for the cleanliness and diminution of the irritated condition of the parts surround- ing the fistula, by warm hip-baths, leeches, poultices and so on ; and the patient's constitutional powers must be improved by attention to diet and tonic remedies. The cure usually takes place without further as- sistance, if the fistulous orifice be not too large, and its walls not too much changed. 955. If, when the urethrahave attained its proper size, the cure of the fistula do not take place, or if there be scarcely any diminution in the size of the stream of urine, the cause of the obstinacy of the fistula is its callous or some other condition. Then, if the fistula form a canal, it must be divided and filled with lint to promote the development of granu* lations ; or the edges of the fistula, especially if they be callous, must be touched with caustics, as lunar caustic, nitric acid, (A. Cooper,) a solu- tion of caustic potash, or with tinct. canth., (Dieffenbach), because this is less destructive than irritative. In the application of the caustics, a moderately thick bougie should be introduced into the urethra,the cauteri- zation repeated after the separation of the slough till good granulations are produced, the scarring of which may be assisted with lunar caustic. After the narrow or oblique fistula has been dilated, Dieffenbach recommends the cauterization of the whole fistulous canal, by means of Vol. ii.—16 178 TREATMENT BY STITCHING. a pencil, three times within six or eight hours, a wax bougie being.in the urethra, after which an elastic catheter is to be introduced and fastened; next morning the slough is to be removed by introducing a fine piece of sponge into the fistula, and the cauterization repeated after suppuration has been set up, till good granulations are developed. The catheter should always be changed twice a-day. In two or three months the cure of a tolerably large fistula may be effected, rarely however is the healing thus produced, and although the external opening be closed, it may be again burst open by a large stream of urine or during con- nexion (Dieffenbach). If the cauterization of such fistulas do well, it may not merely be confined to the callous edges, but may be extended to the immediate neighbourhood, as Roser especially has done, and my own practice has assured me. 956. For closing these urethral fistulas, the suture of various kind, has been used, the interrupted stitch, (A. Cooper, Dieffenbach and others), the glover's stitch, (Zang), the twisted stitch with five insect-pins, (Dieffenbach and others), the quill stitch, (Friemann), and the splint stitch, (Dieffenbach), which resembles it. The result has been, how- ever, rarely satisfactory, because the thin edges of the skin afford in- sufficient points of union, and are little disposed to adhesion, which is also easily destroyed by the trickling urine, in spite of the catheter which has been introduced. The patient should be placed, as in the operation of cutting for the stone, and after a catheter has been introduced, the edges of the wound should be made raw, in small fistulas with caustic, or by shaving off the skin with a thin knife, and in larger openings a thin slice must be removed. According to the different size of the fistulas are a sufficient number of threads to be introduced with a fine needle, or sufficient insect-pins to be passed into the bottom of the fistula, and the union effected by tying together the threads, or twisting the silk around the pins. If much tension of the skin arise in consequence, a longi- tudinal cut must be made into the skin, half an inch from the wound and stretching beyond it, in order to relieve the tension, and to prevent the pins tearing out. 957. In fistulas not of large size, if surrounded with healthy skin and not immediately behind the glans, Dieffenbach has proposed and proved the running stitch as the most efficient. A catheter is to be introduced and the fistula frequently pencilled with tinct. canthar. On alternate days the blisters which have been produced are to be removed, and a short tolerably thick elastic bougie introduced into the urethra. A thick, double-waxed silken thread is now to be passed, with a curved needle, a quarter of an inch from the edge of the fistula, so that the threads may lie deep, without injuring the urethra. As the needle cannot be at once thrust through the whole extent, it must be thrice passed through, and introduced again through the same punctures, till in the end it comes out through the first puncture and the threads are drawn after it. Both ends of the thread are now to be tied with the double knot, so that the threads lie deep in the cellular tissue. The bougie is then removed, and no catheter introduced. A slight swelling of the penis occurs; towards the seventh day, the threads become loose and can be somewhat drawn out; they may then be cut through and the part covered with URETHRAL FISTULA. 179 sticking plaster. If a slight fistulous orifice remain, it may be touched with tinct. lyttce, or the operation repeated. 958. In those fistulas which have much loss of substance, various ex- periments have been made to close them by grafting skin {Urethroplasty). A. Cooper, Earle, Alliot, Delpech, Ricord have formed the cover- ing flaps from the skin of the scrotum and groin twisted round; but Cooper and Alliot alone have obtained any satisfactory result. The ground of this frequent disappointment is easily perceived, and Dieffen- bach has proposed for such cases a corresponding operation by trans- planting by means of removing the skin. 959. In fistula near the scrotum, after the catheter has been introduced into the bladder, the edges of the fistula are to be seized with a pair of hook forceps, and so drawn out that a transverse wound with two sharp points stretching on each side of the penis is formed. A longitudinal fold of the skin of the scrotum is to be then raised and cut through to the extent of two inches, so that a transverse wound, parallel to the former, is produced, and the bridge of skin which has been formed by it is de- tached from its base by cutting horizontally, then drawn forwards and fastened with five or six twisted stitches to the edge of the skin of the penis. Beneath the hinder edge of this bridge of skin, an elastic bougie two inches long is to be introduced to the aperture in the urethra, in order to divert the urine pressing out by the side of the catheter. After some days the threads are to be removed, and the union to be sustained with sticking plaster. 960. In large fistulas in the middle or fore part of the penis, the trans- planting of the skin may be effected in various ways. In great deficiency of the urethra in the middle of the penis, with destruction of the skin, so that the edges of the latter cannot be drawn over the opening by lateral incision and setting free the bridge, the edges of the skin about the aperture must be set free, without separation, so far as may be easily done, then a longitudinal incision must be made on each side of the root of the penis, so that the wound occupies two-thirds of the extent of the penis. The outer skin of the prepuce is then to be diawn somewhat back, the skin of the first incision raised on the opposite side of the penis, behind the corona glandis, in a large longitudinal fold, and here also two- thirds of the skin of the penis cut through. The covering of the penis included between the two incisions and usually forming a bridge of skin two inches broad, is now to be separated, the edge raised with a pair of forceps, and the cellular tissue divided with a pair of sharp eye-scissors. The skin is now to be diawn completely down, so that the sound skin of the back of the penis descends and completely covers the hole in the urethra. Any tension of the skin is relieved by lengthening the incision. To prevent the collection of blood between the skin and the penis, the bleeding must be carefully stanched, and then the retraction of the skin to its old situation prevented, and its union promoted by some stitches and by some narrow strips of well sticking adhesive plaster. From the hinder edge of the wound, on the under side of the penis, a piece of elastic bougie is pushed beneath the skin, towards the hole in the urethra, in order to conduct externally the urine dribbling by the catheter. Erections must be especially prevented, and on their occurrence the 180 TREATMENT BY URETHROPLASTY. strips of plaster must be cut through. After four or five days, if the skin be grown together, the threads may be cut, but the application of the sticking plaster must be continued. The bougie is only to be left off'after the most complete healing. 961. According to Dieffenbach, if there be a hole close behind the prepuce, the external layer of the prepuce should be transplanted back- wards as an entire ring, the outer layer of the prepuce being raised up before the fistula and cut through, so that the wound may occupy more than two-thirds of the circumference of the penis. Behind the fistula a corresponding incision is formed by the oblique division of a longitudinal fold, so that the two cuts join at their extremities, and thus an oval island is formed, having in the middle the fistula which has been prepared by some strokes of the knife laid flat. The edge of the wound in the pre- puce is now raised with a pair of hook forceps, the cellular tissue con- necting the outer and inner folds of the prepuce, divided with eye- scissors, the frcenulum cut through, as well as the outer fold of the prepuce, where connected with the glans, and thus an opening is formed of half an inch for the introduction of a small bougie, for the escape of the secretion of the wound and the prevention of urinary effusion. The hinder edge of the outer layer of the prepuce is to be drawn back and united to the corresponding wounded edge of the skin of the penis by seven or eight stitches and the connexion supported by narrow strips of plaster crossing in the back of the penis. In very narrow prepuce both its layers must be divided to the corona. 962. In large openings immediately behind the glans, if the prepuce be deficient, Dieffenbach recommends the removal of the callous edges, so as to form a transverse cleft, and then by depressing the glans the edges of the wound are brought together and united by two interrupted stitches, the one end of which is to be cut off and the other carried by a blunt needle through the fistula to the mouth of the urethra. The neighbourhood of the fistula and the whole under surface of the glans is then to be set free, to the extent of a line with a pair of hook forceps and a small scalpel. The extent of the cut must be bounded by pene- trating perpendicular incisions, and the wound, have the shape of a half oval, of which the rounded part is to be directed towards the orifice of the urethra, its straight part backwards and its two angles reaching up to the back of the penis. The skin is now raised in a longitudinal fold, at the hinder and under part of the penis, and cut through obliquely, so that the ends of the cut are directed upwards and forwards. This bridge of skin, so entirely separated that it remains connected only on the back of the penis, is drawn forwards over the surface of the wound and over the fistula, and connected with the edges of the wound of the glans by fine interrupted stitches. The hinder surface of the wound is covered with soft lint and sticking plaster, and beneath the hind edge of the ring of skin, a piece of bougie is introduced in order to carry off the urine somewhat escaping by the side of the catheter. Inflammation is to be prevented by cold applications and subsequently lukewarm lead wash, and the threads projecting from the urethra, as well as the catheter, are to be drawn out when they have cut.through the edges. In one case Dieffenbach had a favourable result; in another the cure was frustrated by erection and discharge of the semen. PERINEAL FISTULA, 181 Upon Urethroplasty compare— Cooper, A., above cited. Delpech, Chirurgie Clinique de Montpellier, vol. ii. p. 581. Blandin, Autoplastic, p. 180. Dieffenbach, Ueber die Heilung widernatiirlichen Oeffnungen in den oorderen Theile der mannlichen Harnrohre; in Hamburger Zeitschrift, vol. ii. pt. i. Zeis, Handbuch der plastischen Chirurgie, p. 506. In one case in which, by a deeply-eating ulcer, the urethra was completely de- stroyed to a considerable extent, Charles Bell undertook the formation of a new passage for the urine. A hollow sound was introduced through the fistulous opening, and through the orifice of the urethra a silver tube six inches in length, into which a metal sound and a pointed stilette could be passed, was passed by the urethra to the beginning of the fistula. He then thrust the stilette through the body of the penis, near the original canal of the urethra, and endeavoured to bring its point on one side of the fistula into the.groove of the hollow sound, following the proper canal of the urethra. This canal was then rendered callous by continuing the tube in it. During the course of this operation no blood was lost, the symptoms were not severe, but there remained a small lateral opening at the previous seat of the fistula (a). 963. Complete urinary fistula in the hinder part of the urethra, of which the inner opening corresponds to the bulb, the membranous or prostatic part of the urethra, (Fistula urethro-perincealis,) arises either from a previous incomplete fistula, (par. 946,) or after infiltration of urine, most commonly depending on stricture, bruising, tearing, or wound of the urethra, or stone, severe inflammation and ulceration. The external opening is either in the perinaeum, in the neighbourhood of the rectum, on the penis, or in the groin ; often there are several openings existing at once on these several places, which, however, are connected only with one internal opening. These fistulas are generally accompanied with considerable hardening of their neighbourhood, with hardness of the whole perinaeum, and even of the scrotum. The urine, whilst being passed, escapes through them only in part, or it flows entirely through the fistula ; in which case, if long continued, the fore part of the urethra contracts and shrivels up. If in old strictures there be a paralytic con- dition of the neck of the bladder, the urine will constantly and unwittingly flow by the fistula. In consequence of the continued irritability of the fistula, and its neighbourhood, of the suppuration and soon, the general health gradually suffers much, the patient wastes, the digestion becomes bad, and on the least occasion, severe though generally slight consecu- tive fever ensues. [Brodie, observes, that "afistula'inperinaeo occurs in some cases, as a conse- quence of gonorrhoea,- in other cases as the consequence of stricture, either indepen- dently of gonorrhoea, or long after it has subsided. These two kinds of fistulas in perinaeo require each a separate notice. A man has a severe gonorrhoea,- the urine comes away in a very small stream, because the urethra is inflamed, swollen, and contracted. At last he complains of pain in the perinaeum ,- a tumour is found there, and this state of things is frequently attended with a complete retention of urine in the bladder; at other times, however, it is attended only with an increased difficulty of making water. By-and-by the tumour bursts, or perhaps the surgeon feels fluc- tuation in it, and opens it with a lancet, pus is discharged, then the difficulty of making water subsides, and a day or two afterwards the patient finds that whenever he voids his urine, a portion of it comes by the opening in the perinaeum. In another case, the patient has, perhaps, never had gonorrhoea; or if he has had one, it has subsided and left a contraction or stricture of the urethra. On some occasion he has more than usual difficulty in making water, but not amounting to a complete (a) System der operativen Chirurgie, vol. i. p. 102. 16* 182 terinjEL fistula; retention of urine. Under these circumstances, he discovers a swelling in the peri- naeum, which increases in size, and becomes painful and tender. The tumour bursts, or the surgeon opens it; matter escapes also in this case, and afterwards a portion of the urine comes away through the opening. Where this disease is connected with gonorrhoea, there is generally only a single abscess; but when it is connected with a stricture of the urethra, there may be many abscesses formed in succession; so that a patient having a stricture of the urethra of long standing, may have fistulas formed in various directions, opening into the perinaeum, in the middle of the scrotum, nay, even in the groin, or on the nates, or one of them may, perhaps, open into the rectum." (p. 486.) As regards the immediate cause of these kinds of perinaeal abscess, as "in many cases the contents of the abscess bear manifest indications of urine having been mixed with them, and that in all cases, in the course of two or three days after the abscess has burst, urine begins to flow through it; I think you will be inclined to believe with me, that an aperture must have formed by ulceration in the mucous membrane of the urethra in the first instance. Such ulceration would allow a little urine to dribble in to the cellular membrane, and the formation of an abscess would be the necessary consequence. This is the simplest way of explaining the formation of these fistulas, and it explains every thing about them. The escape of even a single drop of urine into the cellular membrane,would be sufficient to do all this mischief." (p. 487.)] 964. As these urethral fistulas are for the most part connected with narrowing of the urethra, the first indication consists in the proper widening of this canal, with wax or elastic bougies, to its proper size. For the clue carrying off the urine from the fistula, the introduction of the elastic catheter occasionally, through which the urine may pass, is necessary. If in this treatment, any disease having causal relations to the fistula be attended to, if care be taken for cleanliness and the di- minution of the irritation of lhe~ parts surrounding the fistula, by poul- tices, warm hip-baths, leeches, and the like, the patient's condition is improved ; if any foreign body in the fistula be removed, it generally heals without further assistance. Opinions vary as regards the introduction of a catheter, in the cure of the urethral fistulas. The objections made by Hunter, B. Bell (a), Richter (b), and others (c), to the introduction of the catheter in the cure of urethral fistulas, are, that the catheter, if suitable for its purpose, must completely fill the urethra, by which the edges of the fistulas are separated, and the cure prevented; if the catheter be too small, the urine escapes by its side and comes in contact with the fistula. The continuance of the catheter in the urethra is extremely painful to many patients, and does harm by keeping up the irritation; experience also shows that fistula" of the urethra, when the latter has attained its natural size, heals without the in-lying of the catheter. As, however, experience declares as well for the contrary, so if the internal fistulous opening be a small one, the introduction of the catheter be very painful for the patient, and therefore it is impossible that the whole canal of the urethra can be filled by it and the urine completely withdrawn from the fistula, the introduction of the catheter must be given up. On the other hand, under opposite circumstances, and if it be observed that the cure of the internal fistulous orifice give rise to a narrow- ing of the urethra, the introduction of an elastic catheter may and should be attempted. Only in fistula arising from ulceration of the urethra without stricture, (par. 946), is the use of the bougie and catheter doubtful, as they only increase the disposition to ulceration, and the local as well as the general irritation. Corresponding reme- dies must, be employed internally to the constitutional powers. [As the cause of the continuance of perinaeal fistula is the dribbling of the urine through it in consequence of the contraction of the urethra, in front of the aperture by which it escapes by that canal, "to cure the fistula you must," as Brodie ob- (a) Bell, Benjamin, System of Surgery, lerischer Operationen, vol. iii. pt. ii. p. 327. vol. ii. p. 240. —Cooper, A., above cited. (b) Richter, Anfangsgn'inde, vol. vi. p. (c) Drsault, CEuvres Chirurgicales, vol. 338.—Zang, darstellung blutiger, heilkunst- iii. p. 291. TREATMENT. 183 serves, "remove the contraction, restoring the urethra to its natural diameter. In a case of fistula after gonorrhoea, this is easily accomplished. A few introductions of. a bougie will probably be sufficient to dilate the urethra, and make the fistula heal. In cases of fistula in perinaeo, connected with chronic stricture of the urethra, the treatment is just the same. All you have to do, is to cure the stricture, and in nine- teen cases out of twenty, by the time that is fully dilated, the fistula is healed. It is more easy for the urine to pass along the natural passage, if it be of its proper diameter, than it is for it to pass through the oblique passage of the fistula. The fistula has generally a kind of valvular opening in the urethra, into which the urine does not easily flow; and when you have dilated the stricture in front of the fistula, the urine having a free passage in that direction, ceases to flow in the other." (p. 487)]. 965. When, although the urethra has acquired its usual size, the healing of the fistula does not take place, and this depends on the cal- lous or other condition of the fistula, together with the pus and urine escaping by the sides of the catheter, and collecting in it, the fistula must be opened with a bistoury upon a director introduced into it and connected with the groove of a staff passed into the bladder, so that the wound has a funnel-like shape, and its point corresponding with the internal opening of the fistula. If there be several fistulous passages, each must be divided with the director and bistoury. If the internal fistulous opening be very callous, it may be scarified, or touched with tinct. lyttae. The wound may be either gently filled with lint, fastened with sticking-plaster, and a T-bandage, or merely covered with a sponge soaked in warm water. The wound fills from the bottom by granu- lations, the scarring of which may be promoted by touching with lunar caustic. [The continued in-lying of a gum elastic or silver catheter in the urethra, after the complete dilatation of the stricture has been effected, does not always lead to the healing perinaeal fistula, for however completely emptied the bladder may be kept, a little urine will always flow by the side of the catheter, and dribbling through the fistulous passage, keep it open. But another circumstance also takes place, more especially I think I have remarked it, when a silver catheter has been kept in, and which, as Brodie has well observed, depends on "the catheter acting like a seton, inducing inflammation and suppuration of the mucous membrane of the bladder; and some of the pus which is secreted passes through the fistula and keeps it open just as much as it would keep open by the urine itself. In some cases," he con- tinues, "I have adopted the following method: I have made the patient draw off the water with a catheter three times a-day, so that he should never make water except through the catheter, and thus that the urine should be altogether prevented from finding its way into the fistula. This is a better mode of treatment than the con- stant retention of a gum catheter in the bladder; and yet it will sometimes fail." (p. 488). In cases where a perinaeal fistula is slow in healing, Brodie says, he has with some success, "endeavoured to stimulate the bottom of the fistula, so as to make that heal, whilst he took measures to prevent the orifice from healing prematurely. This was effected in the following manner: he melted a little nitrate of silver in a spoon of platina, and dipped the end of a probe in it; which being repeated two or three times, the end of the probe became covered with a varnish of caustic. Thus prepared, he introduced the probe quite to the other end of the fistula; and when he had done this, just touched the orifice of the fistula very slightly with the caustic potash. The effect of nitrate of silver upon a sore surface is not so much to make a slough as to stimulate it to contract, granulate, and heal, whereas the effect of caustic potash, is to make a slough and prevent healing." (p. 488). Upon the question, if a fistula exist in the perinseum, attended with some little contraction of the urethra, not giving the patient much inconvenience, so that it may not much attract his attention, " Are you to allow him to remain thus because the fistula is not very troublesome 1" Brodie gives for answer, "Certainly not; for 184 periNjEL fistula; you do not know to what mischief it may ultimately lead. The matter on some •occasions may not readily escape; it may burrow and cause sinuses in other direc- tions, and may even do still greater mischief. Mr. Vincent and myself attended a gentleman who had suffered under a fistula in perinaeo, and which he had neglected for a great many years. At last he observed the callosity around it grew bigger and bigger, so that it ultimately extended to the scrotum and penis. When we were called to see him we found him with a malignant disease, either carcinoma or fun- gus hsematodes, which had clearly had its origin in the fistula, and had extended from that to the neighbouring organs, The patient ultimately died in great distress and misery." (p. 489)]. 966. If the narrowing of the urethra be such, that it cannot be got rid of in a space of time in which, by the reaction of the fistula upon the whole constitution, life is to be feared for, there remains nothing else than to introduce a staff into the urethra, down to the seat of stricture, which is to be held by an assistant. A director is then passed through the fistula into the internal opening, and the fistulous passage divided on it to the stricture, and this towards the staff. But if the fistula do not lead to the stricture, all the soft parts in the direction of the point of the staff must be cut into, and the staff thrust forwards into the bladder, into which an elastic catheter may then be passed. If the urethra at the seat of stricture be completely closed and degenerated, a staff must be, as in the former case, introduced down to the stricture, and laid bare by a proper cut through all the covering parts, the hardened part of the urethra must be taken hold of with the forceps, and cut out with the knife or scissors, after which an elastic catheter is to be introduced through the urethra into the bladder, and properly fastened. The wound is either to be lightly filled with lint, or covered with a wet sponge. This operation is always difficult and dangerous ; considerable bleeding, violent inflammation, and wasting suppuration and the like, may be its consequences. . But it is certainly very rarely necessary, as with proper attention and perseverance, the most considerable stricture may be over- come, and by proper division of the fistulous passages, the obstacles preventing the cure may be removed. [The operation of dividing the stricture, wThen it has become so tight that the urine will not pass by it, but only by the fistulous opening, is not, or ought not, to be attended with either difficulty or danger, butshonld never be undertaken with- out the surgeon is well acquainted with the anatomy of the parts. It differs in no respect from the operation in the perinaeum performed constantly, foi*cases of reten- tion of urine from stricture, and which if there be either no extravasation of urine or but little, rarely do otherwise than well, and both retention and stricture are at once relieved. When there is perinaeal fistula, there is more difficulty in the operation than in simple stricture, because the neighbouring parts are always thickened, and their natural character greatly altered ; and also after the stricture has been divided, and a large catheter introduced into the bladder, the sides of the fistula having ac- quired a mucous membranous-like character, are little disposed to heal unless their surface be destroyed and new granulations encouraged. The operation is best performed by introducing the catheter down to the stricture, and then finding its point by cutting straight through the raphe, till the catheter point is exposed, which is to be the guide for the subsequent part of the operation. It is very advisable that the external wound should be free; a large clean cut wound heals almost as readily as a small one, and it is preferable, not only as giving the operator more room to act upon the part specially to be acted on, but also is less likely to slough, because the tearing and pulling commonly necessary with a small wound to make room, which cannot even then be obtained, almost invariably pro- duces sloughing. When the point of the catheter has been found, the dissection is to be prosecuted backwards in the track of the urethra, and from time to time the DIVISION OF THE STRICTURE. 185 wound must be examined with a director or a female catheter, of which the point should be directed backwards and upwards, the patient being at the same time desired to force, so that the flow of urine may direct to the aperture in the urethra. It is also very good practice to introduce the finger into the rectum, so as to prevent the di- rector or catheter being thrust into the rectum or between the bladder and pubes, which I have known done, and produce very serious consequences. With patience and tenderness the under end of the urethra may be generally found, and the cathe- ter from the upper part of the urethra must be pushed through it into the bladder, and there left. I do not approve of cutting away the hardened part of the urethra, as recommended by Chelius, as it is quite needless, for the inflammation and suppu- ration, if not even the slight sloughing which may ensue, will remove this without further trouble, whilst cutting away the urethra is more likely to do harm than good, by increasing the cavity to be filled up, and consequently affording more opportunity for burrowing pus. If the fistula have been of long standing, it may be necessary to brush its surface over with caustic, to destroy its mucous character.—j. f. s.] 967- In a fistula of the urethra or bladder, communicating with the rectum, {Fistula recto-urethralis et vesicalis,) and consequent on wound, as in cutting for the stone, puncturing the bladder through the rectum, in rough catheterism, or long continued in-lying of the catheter in the bladder, from foreign bodies in the rectum, or from suppuration, espe- cially in old persons, and the like, the urine mostly escapes by the rec- tum, which causes inflammation and excoriation, and an evil reaction upon the general constitution ; or on going to stool, some thin faecal mat- ter, often only wind or apple or grape-stones, even cherry-stones, which I have noticed in one case, pass through the urethra. If the fistulous opening be neither large, nor of long standing, and the constitution of the patient not bad, nor himself old, it may be hoped that by the con- tinued in-lying of an elastic catheter unstoppied and properly fastened, by placing the patient on his side with his buttocks raised, by constantly emptying and cleansing the rectum with clysters, by observation of great quiet and a strengthening regimen, the closure of the fistula may be ef- fected. This, however, rarely happens, specially in old persons. If this fistula result from wound of the rectum in cutting for the stone, so is its division from the point of injury to the end of the rectum, its most proper treatment (1). Dupuytren {a) has in recto-vesical fistula ef- fected complete cure, or at least considerable improvement, by applying the actual cautery and caustic remedies; in which he introduces his speculum ani (a metallic ring) well oiled into the rectum, seeks for the seat of fistula, and then introduces the cautery into the fistula, even to the bladder. The lunar caustic is to be used in the same way. After forty-eight hours, the cauterization is to be repeated. In the in- terum, attention must be paid to the removal of the urine and faecal matter by cooling diet, by the careful use of soothing clysters, and by the introduction of an elastic catheter into the bladder. Five or six cauterizations are often sufficient to improve the ailment, so that the escape of the urine is much diminished. The application of caustic may be avoided by cutting the sphincter muscles on one or both sides (Jaeger), (1) Desault and Dupuvtren have employed this mode of treatment with good result. Zang (b) considers it preferable to the division of the gut; I have not, how- ever, seen any cure result from it, I have seen a case in which, after the operation (a) Ammon Parallele der franzOsischen und deutschen Chirurgie. Leipz., 1823, p. 111. (b) Above cited, vol. iii. pt. ii. p. 230. 186 RECTO URETHRAL AND VESICAL FISTULA J for the stone by another surgeon, the fistula withstood this treatment with the in- lying of the catheter, but after a year and a-half, healed of itself. In a recto-urethral fistula Astley Cooper (a) made a cut upon a staff introduced into the bladder on the left side ofthe raphe till he feltthe bulb, then thrusta double- edged knife into the perinaeum, between the prostate and rectum, so as to divide the fistulous opening, between it and the urethra. [I have once operated for recto-vesical fistula with considerable benefit to the patient, and I think, had he allowed the treatment to have been persisted in, that he would have been perfectly cured. The object of my operation was, by dividing the m. sphincter ani from the fistula into the perinaeum to produce perinaeal fistula, which would be much more easily managed; and I had hoped that the circular fibres of the rectum above the divided sphincter would assume the function of a sphincter, and thus retain the stools. How far I succeeded, the following recital will show; and I have been induced to give it at length, as it well shows the distressing circumstances attendant on cases of this kind. Case.—S. B., aged 32 years, a labourer of temperate habits and healthy, but very excitable, and subject to occasional attacks of dyspepsia, was admitted into Isaac's Ward Oct. 3, 1837. Seventeen years before he was cut for the stone by the lateral operation, and the rectum wounded in cutting into the staff. This did not seem to interfere much with his recovery, as a fortnight after the operation he was sitting up in a chair and able to help himself at a pump, but in doing this he found his trowsers wetted by the flow of urine through the rectum. When he got sufficiently well to move about, he could never pass his water, whilst in the upright posture, without wetting himself, as the urine passed more freely by the rectum than by the urethra. Since the operation he has never been capable of retaining his urine beyond two hours, more commonly for not more than one, and occasionally for a still shorter period. At times all the water is voided by the anus, and not more than a drop or two by the urethra. Between five and six months after the operation he first ob- served faaculent matter in small quantities to pass from the urethra, whilst attempt- ing to make water, in the erect posture, and at the same time pressing on the anus to prevent the escape of the urine through it. Ordinarily when he is costive, the motions pass in small bits from the anus, and small pieces about the size of peas, and occasionally longer, on an average, about a tea-spoonful, are daily voided by the urethra; but this rarely continues for more than a day or a day and a-half at a time. Ever since the operation, he has been much troubled with wind of which night and morning he passes considerable quantity, which, collecting in the bulb, produces great pain till voided by the urethra. He always passes much mucus by the rectum, and sometimes also from the pern's. Occasionally after connexion, be has observed a little moisture about the anus, with the usual sensation of water passing by it. The fistulous opening is sometimes sore, especially when the bowels are much relaxed, and then stools and urine mixed pass like pease soup from the urethra. About four limes within the last eleven years there seems to have been a gathering for about a fortnight, during which no wind passed by the urethra, and he suffered great pain till the wind again escaped. This was soon followed by blood and pus, after which he got better and went about as usual. He now never leaves his bed without it being wet, the urine having flowed unwittingly through the anus, as he supposes ; and, in making water he is obliged to sit on a chamber-pot, to avoid the inconvenience of the water streaming down upon him. Occasionally he has heat at the lower part ofthe rectum, hardly amounting to scalding, and he thinks that in the last four years the quantity of stool passed by the urethra has increased. When a catheter is introduced through the penis, the point passes directly into the rectum by a narow slit, about an inch and a-half long, immediately above the m. sphincter ani, unless by the finger previously placed in the gut, the tip of the instrument be lifted up and prevented entering. On consulting with my friend Green, whose patient he was, it was determined that I should perform the following opera- tion on. Nov. 18. Having bound him and placed him on the table, in the same posture as that for the lateral operation for stone, the forefinger was introduced by the rectum into the fistulous orifice above the sphincter, but its tip only could penetrate into the cavity of the bladder, after passing for about an inch seemingly along the opened (a) Above cited. TREATMENT. 187 under-surface of the prostrate part of the urethra. A staff was then passed by the penis, and its tip having been tilted by the finger into the bladder, was held as in the operation for the stone. A curved blunt-pointed bistoury was next passed on the finger into the rectum, and thence into the fistulous opening till its extremity lodged in the groove of the staff, towards which having turned its edge I cut through the sphincter by drawing the knife to the perinaeum, and then removing the staff, the finger readily entered the bladder. For the purpose of obtaining a complete view of the fistulous opening, Weiss's speculum vaginas was passed into the rectum, and the aperture was then found to be an inch long, and half an inch wide, with a rounded and very thin edge; but it was requisite to continue the opening of the urethra still more forward into the perinaeum, before the fistulous opening was sufficiently exposed to permit the paring of its edge. I first, however, separated each side of the wound in the rectum, from its connexions with the neighbouring parts, which on the left side, where the cut in the former operation had been made, was of a gristly hardness. The bleeding from these edges was free, a vessel or two required tying, but they continued oozing freely, and were only checked by repeated bathing with cold water. The upper part of the fistulous aperture was then seized with Lisfranc's tentacles, drawn down, and about half an inch of it cut off, which was followed by free bleeding, probably from the'veins at the neck of the bladder. The sides of the upper part of this wound were then brought together with a single interrupted suture, so as to shut off the communication between the bladder and rectum; but the lower part was left alone, the object being to endeavour to establish a fistulous opening in the perinaeum as the most likely mode of closing that between the rectum and bladder, and to render this more likely, the wound in the perinaeum was continued forward till the urethra was opened as far as its passage through the triangular ligament of the pubes. A female catheter Was then passed by this open- ing into the bladder, but as bleeding continued after he was put to bed, it was with- drawn, and having a collar of sponge wrapped round, it was replaced, in hope that the swelling of the sponge would compress the bleeding vessels. About six hours after the operation, he voided by the catheter some very bloody urine, soon after felt sick and faint, and almost immediately had two gushes of clotted blood, (about half-a-pint), accompanied with air from the rectum. He com- plained of much pain in the loins, and of being distended with wind. As I thought the swollen sponge might have prevented the escape of the air as well also of the blood, and might perhaps be exciting the disposition to bleed, I removed it, and directed that the plug should be removed from the catheter hourly and the water drawn off. He went on tolerably well except being teased with flatulence and a tiresome cough. On the third day the wound began to discharge; he has been passing plenty of clear urine by the catheter, often accompanied with air; but on the day following some was noticed to pass by its side, especially whenever he coughed. On the fifth day a small portion of hard stool was passed, whilst he was emptying his bladder, and a considerable quantity of fluid motion was on the sheet. This was the first relief after the operation, for although he had taken a little confection of senna with the view of expelling the wind, it was thought advisable to keep the bowels as quiet as possible. On the seventh day he was going on well, still passed air with his urine, but in less quantity. An injection was given this evening to clear the lower bowel, but it had not any result. One ligature came away. On the following evening he had a plentiful solid motion which gave him much pain; his cough having become very troublesome, syrup of poppies and mucilage were ordered. On the ninth day the catheter was removed, and having been replaced with a shorter one, four ounces of urine were evacuated without any air, but after- wards both were again passed as usual. On the twelfth day he felt much forcing pain as if the bowels were loaded, though he had a good motion last night, and he has twice this morning passed some stool as well as air by the catheter. In the afternoon the bowels were freely moved, after which no more motion passed by the instrument. On the seventeenth day a fresh catheter was introduced ; and on the twe^eth he complained of much irritation in the perinaeum, which when examined appeared to depend on the shoulder of the catheter having caused a little ulceration in the cleft of the buttocks. As regards the parts operated on, the external wound is healing fast, but the fistulous opening does not seem much altered. The catheter was removed, and an elastic male catheter passed by the penis to encourage the heal- ing ofthe perinaeal wound. This did not answer the purpose so far as the relief of the bladder was concerned; for the urine did not pass through it, but some by 188 RECTO-VESICAL AND its side, through the urethra, the greater quantity however escaped by the rectum. On the evening of the twenty-second day, not a drop of urine having passed through the catheter, the dresser thinking it might be stopped up, and that there might be retention, withdrew it, and introduced a silver catheter; but very little water having been obtained, he replaced the elastic catheter, through which, since the urine flowed freely, and on the twenty-fourth only passed into the rectum whilst he eva- cuated his bowels. On the twenty-ninth day his bowels having become loose, the catheter began to slip into the rectum, and have stools pass by it. This coptinuing for several days, the catheter was entirely removed, after which he began to pass about a table-spoonful of urine, at each watering, by the penis, but the greater part escaped by the rectum. For the first two hours after taking drink, he was making water every two hours, but after that time much less frequently. After two months he began to get up; he now retains his water for an hour and a-half or two hours, but voids it both ways. Four days after the water was held for a longer time, did not pass off as he walked about, but after sitting it oozed from the anus when he got up. He still continued slowly and steadily mending, the quantity passed by the urethra being equal to that from the rectum. In the thirteenth week I examined the parts with a speculum; the fistulous opening is about three-eighths of an inch in extent, its edges perfectly scarred and puckered. For the purpose of inducing con- traction, lunar caustic was freely applied. During the following week more urine passed by the urethra, and the edges of the wound were again touched with the caustic. Subsequently, at intervals of about a week, the edge of the aperture was continually touched with the nitrate of silver, and at the end of six months when I again examined the rectum, the fistulous orifice had diminished to the size of a large goose-quill, but he still passed water by it, though varying in quantity. Soon after he left the house much relieved, but not cured by the operation, and I have since lost sight of him.—j. f. s.] 968. Vesico-vaginal Fistula {Fistula vesico-vaginalis) is almost always the consequence of inflammation and sloughing of the vagina in difficult labour with the head long wedged, or of instrumental delivery, in which the fistula may be produced in from twelve hours to fourteen days after the separation of the slough ; more rarely it occurs from injury of the front wall of the vagina and of the bladder, by instruments or sharp bones in opening the head ; from operations, as lithotomy and puncture of the bladder by the vagina, from ulceration ofthe bladder by the con- tinual pressure of a catheter, or of a rough angular stone, from ulcera- tion of a mucous bag, (Dieffenbach), and the like. The fistulous opening therefore mostly depends on loss of substance. The inconve- niences are very great; the vagina, nymphte, labia, and the inside of the thighs, are considerably inflamed, excoriated, studded with pustular eruption, burn and smart from the urine escaping by the fistula and the vagina. Often a stony mass collects between the labia and nympha, and excites much pain ; on account of the patient's continual wetting and the soaking of her clothes, her position and so on, a very offensive smell spreads about, which cannot be avoided by any precaution, or by the most exceeding cleanliness, renders her neighbourhood, in the highest degree troublesome and unbearable, and banishes her to the most painful isolation. The bladder gradually loses its capacity, and the urethra becomes narrow. 969. The diagnosis of the fistula is always easy, on account of the mode of its origin and the symptoms mentioned, and is most'distutfctly determined by examination. If the fore-finger be introduced into the vagina, a very large opening is most commonly found in the middle of its front wall, from the size of a bean to two inches and more, the direction of which is mostly transverse, rarely vertical; but of the latter at least I VESICO-VAGINAL FISTULA. 189 have never seen an instance. According to the different size of this opening it may be felt merely with the finger, or seen on examination with the speculum vaginae, or it may be penetrated by the fore-finger, or by several fingers into the bladder. With so large an opening it is usual for the fore part of the bladder to protrude as a reddish bladder-like swelling into the vagina or between the labia. The aperture is situated for the most part an inch above the orifice ofthe urethra, but it may be higher or lower; it may correspond to the urethra, in which case the urine will be passed voluntarily, and escape only in part by the fistula. Stones may escape by the fistula, and incrustation form upon the internal surface of the bladder, (Jaeger), as well also as in the vagina. The canal of the vagina above the fistula may be natural, or, as I have often found it, narrowed by adhesions in various ways, and even entirely closed; the neck ofthe wound is often drawn awry, nearly destroyed, and the mouth of the womb itself grown together. 970. The prognosis in vagino-vesical fistula is always very unfavour- able, inasmuch as the continual wetting ofthe fistulous edges with urine prevent it closing; this, however, must always be attempted, especially when the opening depends on considerable loss of substance. Although of late the numerous attempts to cure these fistulas have presented only- some successful cases, yet in the very, sad condition in which the patient is placed by this fistula, and in the inadequacy of palliative remedies by means of receptacles for the urine, and so on, the further perfection of this treatment is to be considered as most highly important and to be desired. The various urinary receptacles which have been proposed by Dzondi, as well as the obturators of Barnes, Schmitt, Burkhard, Earle and Duges, by means of sponge and elastic flasks, by cylindrical or other shaped pessaries, or by means of a piece of gut filled with air, are either of no effect or improve the condition of the patient very little. I have only once succeeded by the aid of an elastic bottle, upon which a sponge was fastened to retain the urine, so that in standing or walking it did not escape, and could be voluntarily discharged. 971. The cure of vagino-vesical fistulas has been attempted in various Ways:—1st, By drawing off the urine, and compression of the fistula ; 2d, by cauterization ; 3d, by stitching ; 4th, by the uniting apparatus ; and 5th, by transplanting slcin. 972. For drawing off' the urine, a sufficiently large elastic catheter should, according to Desault (a), be introduced into the bladder, fixed to an apparatus resembling a truss by means of a moveable silver plate, provided with an aperture for the removal of the catheter; and to bring together the edges ofthe fistula, a tent of linen, or a sort of glove-finger stuffed with lint and smeared over with resin or wax; or a bottle of elastic resin, on the front of which a thin piece of sponge is sown, dipped in oil, and the sponge smeared with cerate, calam. (Baines) (g»); or a sponge, (Guthrie), or an elastic oval pessary, (Rognetta), or a hollow resinous cylinder, (Coxe), introduced into the vagina, which it fills up, but does not stretch. During this treatment the patient must avoid lying on her back ; and the cure is rarely effected before six: or twelve (a) Above cited. ing or ulceration ofthe bladder from injury (b) Case of the succesfal treatment of In- during labour; in Med.-Chir, Trans., vol. vi. continence of Urine, consequent to sldugh- p. 582, Vol. ii.—17 190 VESICO-VAGINAL FISTULA. months. Although by this method several successful results have been obtained (a), in most cases it does not succeed, especially if the fistula be old, callous, and round ; by the frequent removal of the plugs from the vagina the cure is always disturbed, and the length of time it requires, in many cases cannot be borne. Jaeger doubts the cures of old fistulas by this treatment, as mentioned by Desault. 973. On the failure of this treatment, for the purpose of effecting the cure most effectually, and in the shortest time, the cauterization of the edges of the fistula with caustic or with the actual cautery has been practised, in order by the inflammatory swelling, suppuration and granu- lation, to effect its diminution and gradual closing. Dupuytren (6) in- troduces his speculum, open above, into the vagina, with its aperture up- wards, and then with a hot iron, or with a piece of nitrate of silver or caustic attached to a thin rod, touches the orifice ofthe fistula for a minute, after which lukewarm water is to be injected. Often a similar application is necessary in from five to eight days. The position ofthe fistula may be illuminated by a candle held before it (c). Lallemand (d) first takes an impression ofthe fistula with modelling-wax, for the purpose of fully understanding the extent of the opening, and its distance from the en- trance ofthe vagina. Afterwards he carefully touches the edges of the fistula with nitrate of silver, by means of a caustic-bearer fixed on a ring, and thus produces a sufficient degree of inflammation. When the slough is thrown off, and the edges of the fistula have become red, swollen, and suppurating, he introduces his connecting catheter (sonde-airigne), which draws off the urine from the bladder, and at the same time holds hooks, which are fixed in the hind edge ofthe fistula, whereby the two fistulous edges are brought together and kept in contact. If one appli- cation of the instrument be not sufficient, it must be repeated. The changed condition of the fistulous opening, and its progressive scarring, is ascertained by the repeated application ofthe modelling wax. Cau- terization can specially have only a satisfactory result when the fistula is small and surrounded with much harshness, and especially, according to Dieffenbach, if it be high up in the vagina, where the suture is in- applicable, and the neck ofthe womb participating in the burning, and thereby swelling assists the union. Sanson describes a peculiar apparatus for illuminating the vagina after the intro- duction of the speculum. Dupuytren has also a connecting Catheter, projecting wings on both sides instead of hooks. Naegele's- and Laugier's Connecting forceps. 974. Sewing up the vesico-vaginal fistula, after having previously refreshed its edges according to the proposal of Roonhuysen (e), as practised by Fatio {f) and Voelter {g), but not since thought of, and in (a) Desault, Barnes, Young, Guthrie, Archi ves generates de Medicine, April, (Edinburgh Medical and Surgical Journal, 1825, p. 481, pi. i.—Froriep's Notizen, No. 1824, April,) BretsciIler and others. 232, p. 186.—Chirurgische Kupfertafeln, pi. (b) Ammon, above cited, p. 114. civ. (c) Sabatier, Medecine Operatoire.— (e) Heebkonstige Amnerkingen. Amst. Nouv. Edit., vol. i. p. 49. 1663. (d) Reflexion sur le Traitement des Fis- (/) Helvetisch-vernunftige Wehmutter. tules Vesico-vaginales nouveaux moyens Basle, 1752. d'union applicables a celles dans lesquelles (g) Neue eroffnete, Hebammenschule 1st perte de substance est considerable; in Stutt. 1722. TREATMENT BY STITCHING. 191 which Naegele (a) proposed different modes of proceeding, Schreger(6) followed out successfully, has been frequently of late, and with various modifications, performed, but rarely with success. Wutzer (c) has had the greatest success, (of eighteen operated on, three were radically cured and the rest improved), who, by the careful and precise detail of his observations and trouble, accompanied with rare perseverance, has im- portantly contributed to perfecting the operation, and, by the addition of paracentesis vesicae, in order more completely to draw off' the urine, has advanced considerably farther than his predecessors. The performance ofthe operation for vesico-vaginal fistula is always difficult, and maybe even dangerous, from severe inflammation of the bladder and peritoneum. The difficulty of the operation is increased by the high situation of the fistula and by the narrowness ofthe vagina; so also the improbability of its success is in large openings with thin edges, with the whites, with the urine not properly drawn off, and in a bad constitutioned patient. If there be adhesions of the vagina these must be first divided, and any incrustations in the vagina or bladder removed. If the patient still men- struate, the operation must be undertaken two days after it has ceased. The intestinal canal must be cleansed by purging or clysters. According to Wutzer, the operation is only to be undertaken in fine weather. 975. The patient should be placed on her belly upon a table covered with a mattress, so that she may kneel near its edge, with her head and chest bent forwards, and supported with small bolsters. The operator1 sits between the patient's thighs, upon a seat of proper height, so that his arms should not soon tire. To widen the vagina and render it suffi- ciently open, a blind hook should be introduced into it, and the perinaeum raised with it, by an assistant. The labia, together with the sides of the vagina, are to be drawn outwards by other assistants, standing on either side, either with the fingers alone properly applied, or with slightly bent hooks. The position of the patient on her belly is much preferable to that on the back, (as in the operation for the stone), which has been recommended by most persons, as the performance of the operation is rendered considerably easier, although for the patient it is more irksome than on the back. The widening of the vagina with a speculum in the way proposed, is also preferable. (Wutzer). 976. According to Wutzer's method for refreshing the edges of the fistula, the most conveniently situated part should be seized with a long- stemmed slightly curved sharp hook, and brought into a suitable posi- tion ; a line is then to be drawn with the point of a fine pointed scalpel around the fistulous opening, and from three to four lines distant every where from it. The portion ofthe mucous membrane ofthe vagina be- tween the Jine and the fistulous opening is then to be seized with the hook somewhat raised, and gradually removed about the whole extent ofthe opening as thinly as possible, to the breadth of three or four lines, by a saw-like motion ofthe scalpel, and the bleeding which ensues is to be checked by the injection of cold water. (a) Erfahrungen und Abhandlunpen aus (c) Ueber die Heilung der Blasenschieden, demGebiete der Krankheiten des weibl. Ge- fistel; in Organon fur die gesammt HeiU schlectes. Mannheim, 1812, p. 369, vol. i. ii. kunde, vol. ii. pt. iv.—F. Buttgenbach, Dis. (b) Annalen des chirurg. Klinikums auf sert. de variis fistules vesico-vaginalis ope- der Universitat zu Erlangen, Erlangen, randi raethodis. Bonn., 1841, 1817, p. 78. 192 VESICO-VAGINAL FISTULA. By Dieffenbach, the patient is put in the same position as in cutting for the stone, a silver catheter is introduced into the bladder and held by an assistant, and a two-armed speculum vagina passed, in order to see the fistula distinctly. If the fistula be not high up, one of its edges may be seized after another, with a hook, or with a pair of hooked forceps, gently drawn down, and removed with a proper bistoury or pair of scis- sors. If the fistula be high up, Dieffenbach, after introducing Ricord's speculum, passes one pair of hooked forceps into the wall ofthe vagina, above the fistula, and a second pair of hooked forceps beneath it; the speculum is then removed, and the vagina gently drawn with double hooks, if there be considerable tension, by an assistant, to one side, till the edges of the fistula are apparent between the nympha. About the edges little hooks are to be introduced, and both double hooks and one pair of forceps removed; the other pair is held by an assistant, and the little hooks by another person. A small scalpel is now thrust through the mucous membrane ofthe vagina and bladder, distant a line from the fistulous aperture, and a strip, a line broad, is to be removed around the opening, and the hooks again introduced into the bleeding edges. The edge of the bladder is now to be taken hold of with a fine pair of hooked forceps, and a portion, two lines wide, removed with the knife, so that the wounded surface, which was only one line wide, is now four lines. In small fistulas, where the separation of the two walls is not possible, a funnel-like piece should be removed. Hobert (a) refreshed the edges by touching with lunar caustic. Peculiar instruments for refreshing the edges (Naegele's bistoury with a covered edge, Lallemand's hook-shaped knife, and so on) are unsuitable and unnecessary. 977. For uniting the refreshed edges, the twisted, the glover's, the interrupted and the running stitch have been proposed, and with dif- ferent modifications employed ; the twisted and the interrupted are most convenient. The latter is easier of application ; soft threads only and not hard metallic threads being employed, the threads are easily withdrawn; on the other hand the twisted suture renders the union much closer and does not allow the urine to percolate so easily; there- fore Wutzer prefers it, in a quiet intelligent patient, for a narrow vagina and soft fistulous edges. In using the twisted suture, the insect- needles should be fresh sharpened and pointed, just before the opera- tion, but they must not be too fine. The needle in the needle-holder should be introduced at such an angle as suits generally the position of the fistula ; its point should not project farther than necessary. It may be requisite, in order that the movements of the needle be not prevented, to grip it with the needle-holder close to the head. The tip of the fore-finger of the left hand is to be placed near the edge of the fistula, and so directed that the entrance of the needle should be as ad- vantageous as possible. In transverse fistula it is best to pierce the hinder (tipper) lip ofthe wound first, but in longitudinal fistula that next the left side of the pehis. The left fore-finger then presses the corre- sponding lip of the wound against the point of the needle, till it pretty well holds it. The other needles are to be introduced in a similar way, and the distance between the several needles should be no more than two and at the farthest three lines asunder. The tying of the threads (a) London Medical Journal, 1825, Dec. p. 439. TREATMENT BY STITCHING. 193 is to be effected with the two fore-fingers, but if they cannot reach, with the forceps. In the application of the interrupted suture, the curved needle, properly fastened in the needle-holder, and supported by the left fore-finger is to be thrust through both lips ofthe wound at pro- per points ; for which purpose, frequently the edges of the wound must be fixed with a sharp hook, as otherwise they easily give way. As soon as the needle is introduced through both lips up to its eye, an as- sistant frees it by turning back the screw of the needle-holder ; the eye and the thread are then to be oiled, the holder withdrawn, and the point of the needle seized with the forceps, and about eight inches length of thread introduced. Both ends of the thread may be advantageously used for arranging the edges of the wound whilst applying the other stitches. If several threads have to be introduced, it is convenient that they should be of different colour, so that they may be more easily ar- ranged. The needle threads must be first tied and drawn together with the fingers, or if deep, with the forceps. If the first tie loosen be- fore the second is drawn together, it must be kept tight with forceps by an assistant. The threads must be cut off an inch from the knot. In introducing the needle it should be remembered, that the edges of the wound are to be taken hold of so far from the needle, that they may be penetrated without ever piercing the mucous membrane of the bladder. By this treatment the two wounded surfaces are applied to the height of three or four lines, and their free edges at the same time turned in- wards towards the bladder, permit the urine to come in contact with the seam only in the most untoward cases. In this way, according to Wutzer, the very difficult separation of the bladder from the wall of the vagina, which here and there, from the great thinness ofthe tissue, must be quite impracticable, is superfluous. Dieffenbach draws with curved needles seven threads from the hinder to the front end of the fistula when drawn down, of which only one holds the edges of the vagina and the other, those of the bladder. The threads which have been passed are to be properly tied with the fingers, their ends brought out and fastened in the mons Veneris with sticking-plaster. The twisted suture is proposed by Naegele to be made with curved needles; Roux employs the common hare-lip needles; Schreger uses the glover's needles and suture. Ehrmann (a) first introduces on the inner side of the fistula some cross threads, then scarifies, and brings it together by tying the threads. Kilian so in- troduces the needle near the front angle, three lines from the edge, that its convex surface is directed towards the operator, pushes it backwards in the direction of the length of the fistula, and again passes it out at the same place, draws it out with the forceps, and brings back the threads to this side. In this way the threads are introduced on the other side, by which the first thread may be employed for draw- ing down the fistula. The several opposite corresponding threads may then be tied. The conveyance of the needle with the fingers, or, where necessary, with a needle-holder, is preferable to the long stemmed trocar-like needle, from the eye of which the ligature is drawn out with a pair of forceps. (Naegele, Lallemanh, Deuber, and others). The drawing together of the threads, by passing them through several rosary beads, and tying upon them, (Schreger), or with the liga- ture tyer, is improper. For the cases in which, on account of the thinness of the fistulous edges above described, the separation of the vagina from the bladder is not possible, Dieffen. (a) Repertoire Generate d'Anatomie et de Physiologie Pathologiques, vol. v, pt. ii. p. 172, Froriep's chirurg. Kupfertaf. cexxxv. 17* 194 VESICO-VAGINAL FISTULA. bach recommends the running stitch, in which without previously refreshing the edges, a very thick thread is carried by a curved needle circularly around the fistula, some lines distant from its edge, through the cellular tissue connecting the vagina with the bladder, in which the needle must be passed in and out three or four times through the same opening; the thread is then to be firmly tied. (Compare par. 957). 978. For the purpose of carrying off' the urine with greater certainty from the wound thus brought together, puncture of the bladder above the pubes should, according to Wutzer, be performed. The patient must be removed from the position upon her belly to that on her back, and should be allowed some rest. She is then to be brought to the edge of the table, the thighs raised towards the belly, and after the still remaining urine is drawn off'with an elastic catheter, the curved tube of the trocar furnished with a fishbone-plug, and oiled, is to be introduced through the urethra into the bladder; the round head ofthe plug is then placed against the front wall in the direction towards the arch of the pubes, pressed pretty firmly on the hind surface ofthe lower notch ofthe synchondrosis, and there kept some time constantly close to the pubic symphysis, raised along it from below upwards, till at last it can be felt through the abdominal coverings immediately above the pubes, and di- rectly in its middle. The operator then firmly retains the tube in his right hand, in the position just mentioned, places the tip of the fore- finger and thumb of his left hand on either side of the projection artifi- cially made above the pubic symphysis, and endeavours so to assist in fixing the extremity of the tube there pressed up ; an assistant then with- draws the plug, and in its stead introduces a curved stilette into the tube, so far upwards till the two handles completely meet to each other, and the point of the stilette at the same time protrudes through the up- per opening of the tube. At this important moment the operator with his light hand takes hold of the handle of the tube with that of the stilette, and with strong pressure thrusts the stilette in a corresponding direction upwards and forwards, through the front of the bladder and the wall of the belly. The accompanying tube he takes hold of at the same time, with the two fingers of the left hand conveniently disposed, keeps it steady, and then allows the stilette to be withdrawn by an as- sistant, who also immediately carefully removes the handle of the tube, by gently drawing them apart. The operator now changes both hands, draws the tube with his right hand out of the belly till the hinder ex- tremity directed by the left hand enters the cavity of the bladder, be- tween the orifices of the ureters, which can be ascertained by the careful introduction ofthe oiled tip of the finger into the vagina. For the pur- pose of keeping the tube in this position, it must be fixed immoveably by means of wing screws, in the cleft of a previously well-fitted belly-girdle, after which the patient should be carefully conveyed to abed previously prepared, placed on her belly, upon suitably cut out leather cushions, and properly buckled in it with suitable straps. In the gap of the bolster and beneath the point of the tube a basin should be placed to receive the urine flowing from it. For the arrangement of the trocar and bed, see Wutzer, above cited, pi. iv. and v. 979. The after-treatment must have special reference to the pre- TREATMENT BY TRANSPLANTING. 195 vention of inflammation. According to Dieffenbach, besides rest and antiphlogistic diet, injections of cold water every half hour, with a large syringe, through the catheter lying in the bladder should be made, and by an oesophagus tube into the vagina; cold application on the region of the pubes, and according to the state of the constitution, blood-letting ; if pain come on, leeches to the region of the bladder, and even in the vagina; emulsions with aqua lauro-cerasi and castor oil, with mucila- ginous drinks. About the sixth day the ligatures are to be carefully removed with forceps and long scissors, and injections made with luke- warm chamomile tea. If the union succeed and there remain only a little opening in place of the early cleft, or one of the needle-holes, we must endeavour to close it, by touching with tincture of cantharides, and the like, or by the loop suture. According to Wutzer, the symp- toms of inflammation coming on moderately, may be opposed by fre- quently drinking cold water, and careful injections. In more careful examination of the patient, together with the application of leeches, some doses of calomel, rubbing in gray mercurial ointment on the in- sides of the thighs, and the frequent introduction of small pieces of ice into the vagina may be sufficient against severe inflammatory symptoms. The latter remedy employed with a cautious hand, will be especially advantageous and diminish the still burning pain. In increased inflam- matory symptoms, blood-letting, calomel followed with infusion of senna, and injections of luke-warm oil into the rectum are to be employed. When, however, there is no danger of threatening symptoms, constipa- tion for four or five days is rather desirable, and if there be disposition to diarrhoea, it must be checked with opium. If the puncture of the bladder have not been made, or if the tube have again slipped from the bladder, a thin elastic catheter must be introduced through the urethra every hour or two, or even oftener, with frequent pressure to discharge the urine; Wutzer considers it most advantageous when the patient herself can do this; but if not, the introduction ofthe catheter must be carefully performed by an assistant; and only when neither is possible, should the catheter be allowed to remain permanently. When, how- ever, not merely the disposition to inflammation of the bladder is much increased, but also, by the continued irritation, the mucous secretion in the bladder is so great, that particularly after the third day, the catheter is frequently stopped, against which injections are not sufficient, this in- strument must often be changed. The sutures should be first examined three days after the operation ; if about this time a needle or a thread be near cutting through it, must be removed. After the third day, the examination must be made daily, that according as suppuration comes on, the several threads or needles may be removed. In successful cases the scar acquires the desired strength in four days. After the removal of the threads or needles, injections only of luke-warm water, or of weak lead wash should be used. 980. The cure of vesico-vaginal fistula by transplantation, was first attempted by Jobert, in a case where previously two attempts with suture had failed. By means of Museux's forceps or a hook, he drew down the hinder edge of the transverse fistulous opening, pared it, and then did the same with the front edge. He next separated an oval piece 196 VESICOVAGINAL FISTULA. of skin from the mucous membrane of the right labium, so that the flap at the edge of the vaginal aperture formed, by closing the cut, a neck of four lines broad. With a female catheter, he introduced a loop of thread through the urethra, up to the fistulous orifice in the vagina, and drew the one end of the loop out of the vagina, and the other by the catheter, out of the urethra. The turned back flap was so folded, that its mucous surface touched itself, and through its double edge the end of the thread hanging out of the vagina was passed spirally with a needle twice, and so a plug of flesh formed with a raw surface. By drawing the end of the thread hanging from the urethra, the fleshy plug was pulled between the fistulous edges and properly pressed up with the finger. An assistant continued to draw the urethral end of the loop, whilst the operator, after refreshing, drew a thread forwards which had been introduced into the upper edge of the fistula, for the purpose of bringing it into contact with the flap of flesh. An elastic catheter was then introduced into the bladder, the ends of the thread fastened to a T-bandage, (or with sticking plaster on the thigh,) and the wound covered with agaric. The patient was benefited, but not cured. In another case, in which the transplantation was made from the labium, hair subsequently grew upon it, which excited inflation of the mucous membrane of the vagina, and obstructed coitus. Subsequently Jobert made the flap from the fold between the thigh and buttock; after ten or eleven days the patient could pass her water without the catheter, in the usual manner. After four or five weeks the flap was cut through, an inch from its base, whereupon it became black, which, however, it ceased to be, after throwing off a small slough. After two months the successful result is no longer to be doubted. For similar experiments on transplantation see Wutzer, above cited. 981. Dieffenbach endeavoured to close large fistulas by drawing the mucous membrane together. Without introducing a speculum, and after having returned the wall of the bladder through the fistula, and having introduced a sponge into the cleft, to prevent its re-protrusion, he seized one edge of the opening with the hook-forceps, drew it towards him, and supporting it with another hook, cut off a narrow slip from the edge, and also cut. off the edge of the bladder, some lines distant from the edge of the vagina. He then, by means of his own palate-needles, carried two leaden threads through the edges of the vagina, without in- cluding the bladder, and drew them together till there was considerable tension, upon which he thrust the knife in upon the posterior and lateral part of the vagina, and drew it down in a straight line to the nympha, and then treated the opposite side in the same way, so that the breadth of the thus isolated part of the vagina was about a fourth of its whole width. In making this cut the finger was introduced into the rectum to prevent injuring it, and to make the cut sufficiently long and deep. The leaden thread being then drawn tighter till great tension was again pro- duced ; the edge was drawn forward with a hook, or with hook-forceps, and the cellular tissue connecting the vagina to the pelvis cut through with scissors or a knife, first on one and then on the other side, but without coming too near to the bladder. By continuously drawing the leaden threads, the edges were loosely brought together, so that no further tearing apart was to be feared, and the edges ofthe wound were united with the interrupted suture, made with a curved needle, and when the hindmost stitch could not be made with the hand alone, it was made TREATMENT WITH ELASTIC BOTTLE. 197 with a needle-holder. When the whole cleft was closed the leaden threads were drawn close together, and cut off so that only two turns remained. A catheter with large openings on the sides was introduced, and the after-treatment conducted as above described. In moderately large fistulas, when a small neighbouring fold of the bladder lies in the opening, and has already become adherent, Dieffenbach recommends that the edges should be inflamed, by frequently touching with tinct. lyttae, and that the membrane of the bladder should be drawn with a fine hook into the opening. If at last it unite to the edge, its surface should be touched with lunar caustic, to ren- der it more tough and hard. There is still to be mentioned Vidal's proposal of, in complete destruction ofthe vagina and wall ofthe bladder, bringing together the labia, having first pared them; after which care must be taken, by frequent introduction of the catheter, and, in menstruation, by injection, for clearing the urine and blood from the vagina. To the same purpose is Horner's proposal (a) of drawing down the uterus into the va- gina, and so to fasten its front that it may supply the loss ofthe bladder or its neck. [Among the various plans of treating vesico-vaginal fistula, may be mentioned that of introducing a small India rubber bag into the bladder proposed by Dr. Keith of Aberdeen (b), in consequence of the following very remarkable case which came under his care. Case.—J, S., aged thirty years, was admitted into the Aberdeen Infirmary, com- plaining of constant pain in the region of the bladder, and constant distillation of urine from the vagina. She was delivered in 1831 by the forceps, and fourteen days afterwards the urine came away through an artificial opening in the vagina. This: continued for seven or eight years, when she plugged the opening with a pint- bottle cork, and for a time succeeded, and she enjoyed comparative comfort till the cork slipped into the bladder, and was followed by the usual symptoms of stone. For a time the urine flowed again through the fistulous opening, but as the symp- toms of stone became aggravated she regained the power of retaining her water, and this so entirely before the close of the year that she then passed the whole of her urine by the urethra. The irritation of the stone however became so intolerable that it was resolved to crush it by the screw lithrotite. The fistulous opening was then large enough to admit a No. 16-catheter, having once been large enough to admit a pint-bottle cork. When the stone and cork had been crushed, and the particles evacuated the urine again passed freely through the fistulous opening, which, how- ever, had become sufficiently small to allow a button-headed cautery at a white heat to be applied to it, so as to touch at once the edge all around. This was repeated in six days, again in sixteen days, and lastly in twenty-two days, after which she continued quite cured. " Several points of interest attach to this case," says Keith; "first, it affords convincing evidence, from the effect produced on the fistula by the presence of her calculus that were a foreign body of a. smooth and unirritating character, of sufficient weight, introduced into the bladder in cases of vesico-vaginal fistula, the body would act as a bullet valve, and not only keep the patient dry, but actually favour the contraction of the false opening. After seven years, in the above case, the opening admitted a pint cork, with so much ease that it slipped through but after a foreign body was lodged in the bladder, nine months sufficed to reduce the opening to less than one-third of its previous size, and it could only have been during the latter six months of that period that the cork could have acquired density and weight enough to operate as a valve-plug. I would suggest a small thin bulb or bag of Indian rubber filled with mercury. Should incrustation happen in the progress of the cure, a squeeze with a screw lithotrite, or percussor, or a long ossophagus-for- ceps would throw it off", and at last when the opening had contracted to such a size as to admit of its ready cure by the cautery, the thin bag could be easily burst or punctured, and then withdrawn by the urethra. Secondly, If asked why I deprived myself of the bullet valve, while cauterizing in the above case? I reply, that the constant straining kept up by the rough stone, arising from the inflamed state of the mucous membrane of the bladder, kindled and kept up by its presence, obliged me to remove a source of irritation, sufficient to defeat, in more ways than one, any effort of mature adhesion. Thirdly, It is worthy of remark that the application of (a) American Journal, 1839. No. 7. Monthly Journal of Medical Science, vol. iv . (b) Remarks on the Treatment of Vesico- p. 12; also in Braithwaite's Retrospect, vol. vaginal Fistula; in London and Edinburgh ix. p. 164. 198 RECTO-VAGINAL FISTULA. the actual cautery inside the vagina occasions nothing deserving the name of pain, and this observation I have had repeatedly corroborated. The heat of the reflected rays may be felt; but I have never found patients say that they really felt pain. Fourthly, It is advised by high authority to allow long intervals between each ap- plication of the cautery, that time may be afforded for the consequent contraction of the parts : the advice is judicious; but it applies chiefly to cases where the orifice is large, and where there is much to accomplish in the way of closing in. My bullet-valve will, in future, aid the process much in such cases; but I beg to remark that where we have a fistulous opening ofthe size of a female catheter, for instance, and where, as in the preceding and succeeding cases, we are able at once to make the edges approximate, then I would urgently advise the frequent use ofthe hot iron, so as to keep up a raw edge, as well as a complete closure, thereby to ensure adhe- sion and complete obliteration at once." (p. 13). [RECTO-VAGINAL FISTULA, 981.* Still more serious and distressing: to the patient than the vesico- vaginal, is the Recto-vaginal Fistula, (Fistula recto-vaginalis), in which the stools incontinently passing from the rectum, through an unnatural passage in the vagina, convert it into a cloaca, from whence they con- tinually escape by the vulva. When from the discharge of stool by this aperture, it is suspected that a fistula exists between the rectum and va- gina, its situation and extent may be ascertained by the introduction of the finger of one hand into the rectum, and a blunt gorget into the vagina; but if the fistula be very high up, a sound must be introduced instead of the finger; in the latter case, however, Duparcque prefers the speculum vaginae, as by it, every part, even the most minute fold of the vagina, can be thoroughly examined. He also observes, that, "injections are not to be despised, as they point out in the fistula, indications which can- not be so exactly determined by any other means. Thus the injection, which does not return by the vagina in stercoral fistula, otherwise very evident, shows that it is neither with the rectum, nor with the large intestines that there is a communication, but that it belongs to the small intestines. The nature of the matter escaping from the fistula, furnishes also a sign more or less positive ofthe region of the intestinal canal with which it is connected. Thus the matter is liquid and yellowish from the small intestines; thicker and containing portions of formed motions when the fistula is in the large bowels, and more especially when in the rec- tum. * * * If the gas formed in the small intestines differ materially from that in the large, it may also afford some guide to the seat of the fistula; the patient should therefore be put in a bath, and the gas col- lected and analyzed." (p. 315). " The tendency to spontaneous cure which exists in accidental openings, is especially remarkable in tearings of the vagina. As the neighbouring parts converge concentrically to- wards the solution, so does it diminish, narrow, and at last the opening entirely disappears. The development of the cellular granulations, which is a sort of lengthening of the tissue, contributes to fill up the space, and especially to form the scar. Thus fistulous openings, of which the size is so great as to do away with all hope of occlusion, are notwithstanding, more or less immediately closed, either spontaneously after all treatment has been given up as unavailing, or when it has been perhaps more injurious than beneficial." (p. 327). A remarkable in- stance of this kind is mentioned by Duparcque, in which there was one aperture between the vagina and rectum, an inch and a-half above the TREATMENT BY DIVISION OF SPHINCTER ANI. 199 anus, through which the finger readily passed ; and a second between the vagina and urethra, about an inch from the orifice of the latter, of an oblong shape, from seven to eight lines long and two wide. In four months from the delivery, the apertures had diminished to half the size they were of, at the preceding month, when first examined; and at the end of eight months, " nothing escaped into the vagina, and there was merely a slight depression indicating the scar ofthe wounds." (p. 331). The only treatment in this case was great cleanliness, looseness of the bowels, quiet, and generous living. Duparcque observes, that " the passage of the faeculent matter over these accident alfistulas, does not actually prevent their healing, but be- cause the parts on which they are found are not favourably disposed to stretch by their distension, or displacement, to the concentric closing of the opening. Thus the use of sounds, pessaries, and obturators, produce no satisfactory results; but on the contrary, by keeping the walls, of the fistulous organs asunder, they prevent the narrowing of the opening. (p. 331). The passage of the stools over the fistula, is rather advan- tageous than detrimental to the scarring. In reality, their continual con- fact with the edges of the opening, excites an inflammation which prevents their scarring simply of themselves; it causes the development of cellular granulations necessary to fill up the space, and produce consecutive union. * * * But I repeat, the principal and most impor- tant indication consists in putting the perforated parts in a condition most suitable for the approximation of the edges of the opening, (pp. 132-33). The principle here recommended was, however, carried out much more correctly in an operation for recto-vaginal fistula, first proposed and performed twenty-five years ago by Copeland, and it is much to be regretted that he has not given to the public any account of it; for though he is well known as having been the original proposer, yet there have been only a few scattered notices of this operation in the works of other writers (a). He has, however, kindly informed me, that his first operation was for a recto-vaginal fistula consequent on delivery, and that it con- sisted in division of the whole m. sphincter ani, on one side of the anus, so as to produce incontinence of the stools, and quite away from the fistulous opening. The result of this was, that the contraction of the sphincter being destroyed, the parts surrounding the fistula were no longer acted upon by it, and the tendency of the fistulous opening to concentric contraction being not opposed, it gradually drew together till it had completely closed, whilst the divided sphincter uniting more slowly, at last recovered the power of retaining the motions, and thus a perfect cure was effected. He further informs me, that he has operated success- fully five or six times, cutting one or other side of the anus, as might be convenient, but never dividing forwards towards the vagina, nor cutting through the fistula and perinaeum, as the result would inevitably be per- manent incapability of retaining the stools.—j. f. s.] Besides the writers already mentioned on Vesico-vaginal and Recto-vaginal Fistula, there may be also compared Dieffenbach ; in Med. Vereinszeitung fur Preussen. 1836, June. (a) Mayo Herbert, Observations on Injuries and Diseases of the Rectum. London, J833. 8vo. p. 23. 200 OF DISLOCATIONS. Jobert; in Gazette Medicale. 1836,v March. Kilian, Die rein chirurgischen Operationen des Geburtshelfers. Bonn, 1835. Duparcque, Histoire Complete des Ruptures et Dechirures de l'Uterus, du Vagine et du Perinee. Paris, 1836. 8vo. Bendz, H. Ch., De Fistula Urethra; et Vesico-vaginali. Hafniae, 1836; with two plates. Zeis, Handbuch der plastichen Chirurgie. Berlin, 1818. Jaeger; in Handworterbuche der Chirurgie, vol. iii. p. 125. Michon, L., Des Operations que necessitent les Fistules vaginales. Paris, 1841. Le Roy d'Etiolles; in Gazette des Hopitaux, 1842, September. [Barton, J. R., On the cure of Recto-vaginal Fistula by a new opera- tion ; in American Journal of Med, Sciences, vol. xxvi., 1840.—g. w. n.] III.—SOLUTION OF CONTINUITY FROM ALTERED POSITION OF PARTS. A.—OF DISLOCATIONS. First Chapter.—OF DISLOCATIONS IN GENERAL. Duverney, G. J., Traite des Maladies des Os. Paris, 1751, vol. ii. Pott, P., Chirurgical Works, vol. i. p. 373. Edit. 1783. Kirkland, Thos., M. D,, Observations on Mr. Pott's general Remarks on Frac- tures, London, 1770. 8vo. Also ao Appendix to the former concerning the cure of Compound Fractures. London, 1771. 8vo. Aitken, John, M. D., Essay on Fractures and Luxations. London, 1790. 8vo. Bottcher, J. F., Abhandlung von den Krankheiten der Knochen. Berlin, 1796, vol. ii. Boyer, Traite des Maladies Chirurgicales, vol. iv. Bernstein, Ueber Verrenkungen und Beinbriiche. Jena, 1819. 8vo. Cooper, Astley, Treatise on Dislocations and on Fractures in the Joints. Lon- don, 1822. 4to. [And Dr. Warren's Edition of the same work. Philadelphia, 1844, 8vo.—g. w, n,] C aspari, K., Ana torn isch-chirurgische DaTstellung der Verrenkungen, nebst einem Auhange fiber die complicirten Verrenkungen. Leipzig, 1821. 8vo. Cunningham, J. M., Synoptical Chart of the various Dislocations to which the human frame is subjected, comprising their diagnostic symptoms and modes of reduction. London, 1827. fol. Richter, A. L., Theoretisch-praktisches Handbuch der Lehre, von den Briichen und Verrenkungen der Knocken. Berlin, 1828. 8vo,; with 40 folio plates. Hager, Die Verrenkungen und die Verkrummungen. Wien, 1836. 982. A Dislocation {Luxatio, Exarthrema, Lat.; Verrenkung, Germ.; Luxation, Fr.) is the slipping of a moveable bone from its natural articular connexion ; and is distinguished from the separation of bones immoveably connected with each other (Diastasis). 983. The dislocation is either complete {Luxatio completa) when the corresponding joint-surfaces not at all touch, or incomplete, {Luxatio in- completa, Subluxatio), when they are not entirely separated from each other, with which last must be reckoned Wrenching or Distortion, {Dis- tortio, Lat.; Verstauchung, Verdrehung, Germ.; Entorse,Fr.), in which the joint-surfaces are partially separated, but their natural condition is again restored by the strength of the muscles and ligaments (1). Dis- locations are further divided into simple, {Luxationes simplices), when DISLOCATION IN GENERAL. 201 unaccompanied by peculiar symptoms, and compound {Luxationes com- plicatae), which are attended with wounds, bruises, fractured bones, severe inflammation, suppuration and other dangerous symptoms; into recent {Luxationes recentes) and old {Luxationes inveterate^, into primary, {Luxationes primitives), when the displaced head of the bone remains on the spot whereon it had been first thrown, and secondary, {Luxationes consecutivce), when it is dragged up to some other position by the muscles; into congenital, {Luxationes congenitae), and acquired {Luxationes acquisitae). (1) Distortion has various degrees, according as the fibrous tissue, the synovial membranes, the vessels and nerves severally, or altogether, are severely stretched or torn through:—1st degree, Slight pain and gradual swelling ofthe soft parts; 2d degree, Sudden and severe pain, swelling, and effusion of blood; and therewith, in 3d degree, Unnatural motion of the joint in all directions. 984. The diagnosis of dislocations depends on the disturbed function of the dislocated limb, and on the appearances produced by the bone when removed out of its socket. The most remarkable signs are, entire or partial loss of motion of the limb, with altered form and position ; it may be shortened or lengthened according as the head of the bone is displaced in this or that direction, or it may be distorted, which depends on the contraction of the muscles, that, by the dislocation of the head of the bone, are most commonly torn and extended, hence rotation of the limb occurs on the opposite side to that on which the head of the bone is dislocated; the natural form of the joint is changed, the socket is empty, and the dislocated head forms an unnatural projection; the limb is fixed in its position by the stretched muscles, and can only with the greatest pain be moved, and often not at all. To these symptoms are added severe inflammation, pain, swelling, and effusion of blood in the neighbourhood of the joint. The determination ofthe dislocation is therefore more or less difficult, according to the superficial or deep situa- tion of the joint, according to the nature ofthe dislocation and the degree ofthe accompanying swelling. A more remote effect of dislocation is a kind of crackling which depends on the effusion of plastic lymph into the joint and into the mucous bags, and may easily mislead to the presump- tion of fracture. [The limb is not always at once immoveably fixed after dislocation, even when at the hip-joint. I had a case of dislocation into the ischiatie notch several years since, and when I saw the man six or eight hours after the accident, there was so con- siderable motion of the thigh, which could be bent quite up to the belly, that I doubted the nature of the accident. On the following morning, however, the limb could not be bent upon the belly, and the other symptoms of dislocation being present, I made use of the necessary means and replaced the bone. I have also seen other examples of the same kind. Sometimes if a patient be not seen for some hours after a dislocation, it is impos- sible to ascertain the nature of the accident, on account of the great swelling. The surgeon should therefore be especially cautious to make further examination on the subsidence of the swelling, so that the patient may not suffer from his negligence. j. F. s.] 985. The occasional causes of dislocation are external violence or violent contraction of muscles. The former either acts directly on the joint or on the end of the bone opposite, in which case the dislocation is effected more easily ; and generally the bone is obliquely situated in reference to its socket, at the moment when the external violence acts. Dislocation specially occurs the more readily, as the parts about the joint and the muscles are lax and the motions of the joint not confined (1). Vol. ii.—18 202 DISLOCATION IN GENERAL. For the latter reason dislocation ofthe upper arm is more frequent than that ofthe thigh; and dislocations ofthe hinge joints and of such as have broad opposing surfaces to their bones, in which the motion is restricted, are mostly incomplete. Old persons are more rarely subject to dislocation, because the heads of the bones are brittle and easily break; young persons also are rarely subject to dislocation, because their epiphyses easily break (2); in persons of middle age dislocation is most com- mon (3). [(1) Dislocations sometimes happen by mere muscular exertion, some accidental disposition of the bone occurring, by which the ordinary antagonism of the muscles is disturbed, and the efforts of one set become too great for the other. It is in this way that dislocation ofthe lower jaw is produced, most commonly in yawning; the jaw is excessively depressed, the temporal muscle is so twisted over the pulley that it has little power, and then the external pterygoid muscles pull the necks of the jaw forward, and throw the condyles on the articular eminences. Lawrence (a) men- tions a dislocation ofthe shoulder having occurred from muscular action, the patient "had been sitting up in bed to take a dose of medicine, when stretching out the arm to take hold of the cup, without making any exertion, or taking up any particular weight, the humerus became dislocated. Now although the bone came out so easily, yet it did not go back into its proper situation with facility; for it required a pretty strong pull to return it." (p. 477). Dislocations may also result from the laxity ofthe ligamentous capsules of joints. Astley Cooper mentions one of a dancing-girl capable of throwing the knee-cap from the articular surfaces flat upon the side ofthe outer condyle ofthe thigh-bone, in whom this had been produced by violent exertion when a child, (p. 11). And another case in which a young lad had had, whilst on board ship, his foot placed on a small projection on deck and his arm lashed tightly towards the ship's yard, and so kept for an hour, the result of which was that he had the power of readily throwing his arm out of the shoulder-joint, merely by raising it to his head ; but it was re- duced by very slight extension, (p. 13.) He also gives another case, on the au- thority of Brindley, in which a man of fifty years had a dislocation of the thigh which he was capable of producing and reducing at pleasure. (2) My friend, the younger Travers, has informed me that he had in February 1843, a case of dislocation into the ischiatic notch, in a boy of five years old, who, whilst at play in a paved yard, slipped down and was unable to rise. He could neither walk nor maintain the erect posture. All the symptoms of dislocation were present; the head of the bone was resting upon or next to the margin of the ischiatie opening, not having as yet sunk into the eavity of the notch, which Travers con- siders, is always a secondary result of this accident. There was some mobility of the limb. The head of the bone, was almost immediately reduced, by confining the pelvis with a strap upon a firm deal table, turning the child upon his sound (the left) side and making the usual extension, with slight rotation outwards and raising the knee. This is the earliest instance of accidental dislocation with which I am acquainted.—j. f. s. (3) Malgaigne has made an interesting inquiry into the frequency of dislocation in the different joints, and from this it appears, that of 491 cases there were of-— Dislocations of thumb wrist fingers jaw . And also that from the age of two to fifteen years, dislocation of the shoulder oc- curred only once out of four dislocations, but after sixty years about once out of one and a-half (6)]. 986. In every complete dislocation, the capsular and other ligaments, as also frequently the tendons and muscles surrounding the joint are the shoulder . 321 hip 34 collar-bone. 33 elbow . 26 foot 20 17 knee . . 7 13 spoke-bone . 4 7 knee-cap . . 2 7 spine . . . 1 ,(a) Lectures in Lancet, 1829-30, voL ii. (b) Gazette Medicale. TREATMENT. 203 torn; only in great laxity ofthe ligaments of the joint, and large collec- tions of synovia, is dislocation without tearing possible. If the head of the bone be soon returned to its natural position, in general there are not any decided symptoms ; but if it remain any length of time out, of the joint, it acts as a foreign body on the surrounding parts, and the socket is gradually filled up. If it be in contact with the cellular tissue, it so compresses and thickens it, that it, as it were, forms a capsule around the head of the bone, whilst the torn ligaments are still attached to the surrounding parts; the muscles lose by pressure, their structure, their power of contraction, and becomes almost fibrous. If the head of the bone lie upon a bone, it forms a hollow in it, aiound the edge of which bony growths take place, by which the head is more or less perfectly enclosed. In such old dislocations the motions of the joint are always more or less interfered with, the nourishment of the joint suffers, it wastes, and the muscles become lax. 987. The prognosis of dislocation depends on its- complication, seat, duration and cause. Simple dislocation may usually, by early assistance, be reduced, and in general is not dangerous; compound dislocation is, however, on the contrary, frequently accompanied with very dangerous symptoms, and according to the degree of bruising and tearing of the soft parts, according to the constitution of the patient and the like, it is often as necessary, as in compound fracture of bones-, to determine at once on the necessity for amputation, or the possibility of preserving the limb. Dislocations in ball- and socket-joints are commonly less danger- ous than in hinge-joints, although they are more difficult to reduce. In joints surrounded with strong muscles and ligaments, severe symptoms mostly occur. The earlier the reduction of a dislocation is attempted, the more easily is it effected (1); this, however, must often be delayed, on account of the already existing great inflammation and swelling, though not too long, as the dislocated bone is always to be considered as the principal cause of these symptoms (2). In dislocations depending on palsy of the muscles and laxity ofthe ligaments, the reduction is easy, but its recur- rence on the slightest violence is to be feared. In powerful or in old persons the reduction is more difficult than in young and weakly persons, From pressure of the head of the bone upon the nerves and vessels severe symptoms often occur; there may be either partial or complete palsy, or stiffness of the joint, and anchylosis may remain as consequence of inflammation. [(1) My friend, Liston, tells me, that he once reduced, without assistance, a dislocation on the back of the hip-bone, two or three minutes after it had occurred, by the person having been thrown from his horse, simply by putting his hand on the pelvis and pulling and rotating the thigh with the other. This is probably an unexampled case, but it proves, that the earlier the reduction is attempted the less power have the muscles to offer resistance. (2) The necessity for delay in the reduction of dislocation on account of the ac- companying inflammation must be extremely rare, unless violent and unwarrantable efforts have been previously made without success. One such instance I have known, in which suppuration of the shoulder-joint ensued and the patient died,, without the dislocation being reduced. But as a general rule, dislocations should be always reduced, and with the employment of moderate force there is little if any attendant danger.—j. f. s.] 204 DISLOCATION IN GENERAL. 988. The cure of dislocation requires, the reduction of the dislocated head ofthe bone, the fixing it in its socket, and the removal of the symp- toms. 989. The reduction of the dislocated head of the bone into its socket {Repositio, Lat.; Einrichtung, Germ.; Reduction, Fr.) is to be attempted by extension and counter-extension, and by pressure on the head ofthe bone itself, which thrusts it into its socket. The object ofthe extension and counter-extension is to counteract and lengthen the contracted muscles; therefore many recommend that the extension and counter-extension should not be made at the extremities of the dislocated bones, so that there should not be any circular com- pression of the muscles of the limb by which they may be excited to more violent contraction. This notion, however, is rejected by Cal- lisen, A. Cooper, and other surgeons. In certain dislocations, for in- stance those ofthe elbow-joint, the extension and counter-extension can only be effected on the dislocated bones themselves. The extension must always be made in the same direction as that in which the head of the bone was displaced, and with gradually increasing force, so as to tire the muscles; the position of the limb must specially be such as renders the muscles as lax as possible (a). Voelcker (b) effects the same by pressure of the air according to Weber's ex- periments. (Comparepar. 234.) 990. Extension and counter-extension are performed either merely with the hands, or by assistants with twisted cloths, properly applied upon the limb, above and below the dislocation, or with proper machines, among which the pulleys and Schneider's extending apparatus are the best. If the head ofthe bone become more moveable by gradual exten- sion, and approach the socket, it often slips in of its own accord, and with a distinct noise; or it must be drawn towards the socket with the hands, or with cloths, in doing which the limb is brought into a position contrary to that of the dislocation. It must, however, be here remem- bered, that the parts of the joint be not injured by too violent motion, when the extension is not sufficiently made. The perfect reduction is indicated by the natural form and direction of the limb, the cessation of pain, and the freedom of motion. [Dislocations which have existed for some time, although they may not be reduced by ordinary extension for an hour or two, may sometimes be reduced simply by tiring the opposing muscles, by attaching a trifling weight for some hours. The younger Cline in this way succeeded' in reducing a dislocation of the shoulder which had been out for several weeks and coukl, not be replaced by the common method, by fixing the shoulder and suspending a brick, attached to the hand, over the end of the bed. On visiting the patient next day, the bone had returned to the socket. In making extension, caution must be employed, and no more violence used than absolutely necessary, nor ought the surgeon to handle the displaced bone loo roughly, as unfortunately is much more frequently done than should be. I have known a dislocated bone broken by coarse and unjustifiable attempts at its reduction, and cases are mentioned in which an artery has been torn through, all the soft parts laeerated, and palsy of the limb produced. And even when the extension has been very long continued, without great violence, but in a broken constitution, I have (a) Loder's Journal, vol. iii. pi. ix. f. i. tung der luxirten Glieder; in Hamb. Zeits., (b) Worin liegt der Grund der geringen vol. vi. pt. ii. Beweglichkeit und der schweren Einrich. TREATMENT. 205 seen abscess in the joint and hectic fever destroy the patient. Caution, therefore, in making and continuing the extension is most important.—j. f. s.] 991. The obstacles which render the reduction of the dislocation difficult or impossible are, great inflammation and swelling, too small opening in the capsule, the peculiar form of the joint, and the long existence of the dislocation. In the former case suitable extension cannot be employed without occasioning dangerous symptoms; the in- flammation, as in fractured bones, {par. 587,) must be first got rid of by general and local antiphlogistic treatment before proceeding to re- duction. A too small opening in the capsular ligament, is mentioned by many as hindering the reduction, and it is advised that by moving the limb in different directions, the cleft in the ligament should be increased {a). A. Cooper, however, entirely opposes this proposition, and believes only that some ofthe untorn ligaments prevent the reduction. The form of the joint may render the reduction difficult when the edge ofthe head ofthe bone is pushed behind the edge of the socket, as, for instance, at the hip- and shoulder-joint. Old dislocations always require previous blood-letting, baths, move- ment of the limb in various direction, a considerable and continued ex- tension. Dislocations of ball- and socket-joints often after a month are unreducible; reduction has, however, been effected by great force after four and even six months. In hinge-joints, after twenty or thirty days, the reduction is often no longer possible. It is, however, to be remarked on this point, that in old dislocations, if a very violent extension be em- ployed, except in very emaciated, flabby, and old persons, the conse- quences of the extension are more severe than the advantage of the reduction. In young muscular persons, three months may be considered as the longest space of time, at which the reduction of a dislocation should be attempted. If the patient be urgent for an attempt at reduc- tion, he must be made aware of the circumstances already mentioned, and the attempt must be made with caution, so that the muscles and nerves be not damaged. In old dislocations, a threefold obstruction may render it impossible :—1, union of the head of the bone with the surrounding parts, so that even after death, when the muscles are cut through, the head ofthe bone cannot be returned^ 2, the socket may be filled up, in which case the head of the bone, even though reduced, cannot remain in its place; 3, if a new socket be formed in the bone upon which the head lies, so that without fracture it cannot be separated from it (A. Cooper.) (b). [The length of time after the accident, at whieh a bone may be reduced, varies considerably, and depends on the form of the joint and the patient's muscular power. I am inclined to believe, however, they may sometimes be reduced at a longer period than two or three months, and that it is right to make the attempt, but the surgeon should be pressed to the trial rather than press the patient. Of course the more simple the form of the joint, and the more shallow the socket, the easier is the reduction, hence ball and socket-joints are more readily" replaced than hinge-joints, (a) Callisen, Systema Chirurg. hodiern. ationen vom Standpunkte der Chirurgie und vol. ii. p. 684. rried. Polizei betrachtet. Weimar, 1834.— (b) Marx, Jusqu'a quelle epoque est-il Nevermann, Ueber die Nothwendigkeit, possible d'operer la reduction des Luxations ? veraltete Luxationen einzurichten ; in Ham- Paris, 1829.—Von Froriep, Veraltete Lux- burger Zeitschrify. vol.. ii, pt, iii. 18* 206 COMPOUND DISLOCATION. and the shoulder than the hip. Professor Smith, of New Haven, U. S.,- reduced: one dislocation of the shoulder at seven months, and another at ten and a-half months. There is an excellent statistical account (a) of the practice of Dupuytren in the Hotel-Dieu at Paris, in which the twenty-three cases successfully treated by him varied from between fifteen and eighty-two after the accident. Breschet (b) men- tions a reduction of dislocated hip at seventy-eight days, and three of the shoulder at the eighty-second, ninetieth and ninety-eighth day respectively; and in the Memoires de l'Academie Royale de Chirurgie de Paris, vol. v. p. 529, is related a dislocation ofthe hip reduced after, two years.—s. f. s.] 992. As the muscles mostly render difficult the reduction of disloca- tion, in many cases it can only be facilitated or rendered possible by diminishing their contractile power'; This is effected by those remedies which have a disposition to produce faintness, or even fainting, as a smart blood-letting, (according to the slate of the patient's constitution), a warm bath, nauseating doses, of tartarized antimonial wine, tobacco clysters, drunkenness, perhaps also opium.(c), and by frightening {d), or diverting the. patient's attention. 993. After complete reduction the head of the bone has usually no particular disposition to slip out again; this occurs only in violent motions of the joint, or when the dislocation depends on great weakness of the ligaments or muscles. The limb should be brought into a posi- tion, m which the muscles are relaxed, and such bandages applied will prevent its motions, and it should be kept quiet. Cold: applications are employed to prevent or get rid of inflammation. When the inflammatory symptoms, have passed by, careful movement of the limb is to be made, for the prevention of stiffness of the joint, by the long-continued rest. [Sometimes after the reduction has occupied much time, the muscles are so com- pletely tired out and deprived of their tone, especially in persons of lax fibre, that they will not retain the head, of the bone in its place, and consequently the mere weight of the limb will reproduce the dislocation. For this reason, not merely are bandages applied immediately after the reduction, but the joint should be carefully examined without disturbing them, for the first two or three days, to ascertain that the parts are in their proper place. I have known an instance in which a dislocated upper arm after having been reduced and carefully bandaged up, was left undisturbed for some weeks, and on the removal of the bandages was found to have slipped out, and could not be reduced again,^"J. f,.s.] 994. The treatment in sprains is to be the same as for bruises. Cold applications are to be employed, with careful rest of the joint, general and local blood-letting, proportionate to the bruising and inflammation, and subsequently, for, the complete dispersion ofthe extravasated fluids, spirituous and aromatic applications used. There often remains for a long while swelling, weakness ofthe joint, and, in old persons, a crack- ling in the joint, which is removed by volatile rubbing, douche bath, and the like. [The two great auxiliaries in reducing disloeations, are bleeding and nauseating doses of tartar emetic. The bleeding should always be made in a large stream from one or both arms, according to his apparent strength, and whilst the patient stands upright, till he feels faint, which is best determined by his bursting out into a cold, clammvy sweat, and'unless: carefully noticed he drops on the floor before the surgeon is aware. Immediately on the faintness occurring the extension should be made, the bandages and' pulleys having been previously adjusted, if thought necessary; and it should be made steadily and not by jerks.. Frequently the excitement of the (a) Philadelphia Journal of Medicine.. (d) Dupuytren; in Ammon's Parallele, (6) Repertoire G^ntEale^ p.. 170.. , (c) Cooper, A., above cited. CONGENITAL DISLOCATION. 207 pain revives him, and it is then advisable to give him a grain of tartar emetic every ten minutes, so as to keep him in a state of nausea till the reduction is effected. If the dislocation be of long standing it is well to reduce the patient's strength by spare diet and purging for two or three days previous to the operation; and on the same morning to give him nauseating doses of tartar emetic for some hours prior to the extension, so as to put him in the most favourable condition. And the French surgeons are in the habit of applying poultices and other relaxing applications to a dislocated joint, for the purpose of rendering the parts more yielding some days before attempts at the reduction are made.—j. f. s.] 995. Dislocations accompanied with tearing of the soft parts covering the joint and thrusting out of the head of the bon°, belong to those rare but most dangerous cases, in which severe inflammations, weakening suppuration, slough and nervous symptoms are to be dreaded. The danger is greater as the bruising and tearing of the parts of the joint are more severe, the older the patient, and the more out of condition his constitution. According to these circumstances the necessity for ampu- tation, or the possibility of preserving the limb, must be determined. Amputation, however, may subsequently become necessary from wasting suppuration, from sloughing, and the like. If the immediate removal of the limb be not indicated, the head ofthe bone must be returned as soon as possible, and with the least injury ofthe parts ofthe joint; the wound must be completely closed with sticking plaster; the limb surrounded with compresses and with Scultetus's bandage, kept in proper position by the application of splints, and the patient must be treated strictly antiphlogistically, according to the state of his constitution. The wound often heals by quick union and without any particular symptoms. If suppuration ensue, the cure often takes place with an emollient treat- ment f but generally, if it be copious, it is accompanied with severe pain and nervous symptoms, and must be treated according to the rules laid down for wounded joints {par. 559). If gangrene come on, it requires the proper treatment. 996. If the reduction ofthe head of the bone, protruded through the soft parts, be in no way possible, even after proper enlargement of the wound in the skin, nothing remains, but to saw off the protruding bone, by which the stretching and tearing ofthe muscles are relieved, and the joint can be brought to its natural position ; after which the symptoms, in general, soon and considerably diminish. When the reduction of a bone protruding through the soft parts is not immediately possible, it is still less so, when inflammation runs into suppuration; the symptoms continue increasing, and amputation maybe rendered necessary by gan- grene, and by progressive destruction, if the head of the bone have not been removed at the proper time. 997. When dislocation is connected with fracture of a bone, the latter must always be attempted to be set, if it can be done, without extension of the limb. If this be not possible the fraeture must be treated first, and on the length of time requisite for that purpose, depends, whether after union has occurred, putting to rights the old dislocation can be undertaken. 998. Congenital Dislocations, (Luxationes congenitae,) noticed by Hip- pocrates, Avicinna, Pare, Palletta, Sandeforb, and Schreger, at the hip-joint, where they most commonly occur, more carefully de- scribed by Dupuytren, and more recently the subject of numerous ob- servations, have been since noticed in almost all the joints of the ex- 208 CONGENITAL DISLOCATION. tremities. Very different opinions are held as to the causes and origins of these dislocations, principally however with reference to the congeni- tal dislocation of the thigh. Most persons have considered them as de- faults of formation, as the consequence of arrested development of the bones and their sockets (Schreger, Dupuytren, Breschet, and_others). Some have considered them as consequent on distension ofthe capsular ligament, and of misproportion between the bone and its socket thereon depending (E. Stromeyer) (a). Others ascribe them to the position of the foetus in the womb, or to violence operating on them during birth (the Author, D'Outrepont, Cruvelhier). Von Ammon (b) grounds them on default of development; he does not however deny, that there- with in many cases is connected an original deficient condition, or a dis- eased formative process ; and in like manner may the ailment have a purely diseased origin, in certain, though very rare cases, and have no connexion with the fetal development of the hip-joint. Guerin (c) con- siders it as the product of an active or primary retraction ofthe muscles, the remote cause of which is to be sought in the affection of some central part of the nervous system. On the degree and form of the muscular affection, depends the degree of dislocation, as does its development and course upon many secondary circumstances, to wit, prevention of the development of the muscles following on their retraction, physiolo- gical contraction and vertical operation of the tendons. 999. The examination of the joint after death, has explained various changes, in the several tissues constituting the apparatus ofthe joint, as distension, tearing ofthe capsular, and other ligaments ; diminution, flat- tening, distortion ofthe head ofthe bone ; diminution ofthe socket, its filling up with a quantity of fat, flattening or entire disappearance ; a more Or less deep new cavity for the dislocated head; the muscles sur- rounding the joint contracted, shortened, and variously altered in their substance ; considerable wasting in the affected limb. On examination soon after birth, tearing of the ligaments is found, but otherwise the natural form of the socket and head, and the joint especially, is as in ac- quired dislocation. (Palletta). 1000. If the result of these examinations be used for the purpose of clearing up the way in which these dislocations originate, it must only be permitted us to draw conclusions from these observations which have been made soon after birth, as in old dislocations of this kind, still more decided changes must arise from the progressive development of the body, as well in the empty socket, as in the dislocated head, than in old dislocations which have occurred at a later period of life. But in the examination of such congenital dislocations at an early period of life, there are only such conditions ofthe parts ofthe joint as can be ascribed to the position of the foetus in the womb, or to the violence which has operated during birth.' An observation of Cruvelhier's {d) favours the first cause as regards congenital dislocation of the thigh-bone, an ob- servation of Palletta's (e) the second. This is still more decided as regards congenital dislocations in other joints, as resulting from several (a) Ueber Atonie der fibrOsen Gebilde und Recherehes sur les Luxations Congenitals. deren Riickbildung. Wurzb. 1840. Paris 1841. (6) Die angeborenen chirurgischen Krank- (d) Exercitationes Pathologies, p. 88. heiten des Menschen. Berlin, 1842, p. 113. (*) Anatomie Pathologiqus, vokii. faac. i. (c) Gazette Medicale, 1841. No. 7. 10.. DISLOCATION OF THE LOWER JAW. 209 observations. The position of the foetus in the womb, I consider, is the principal cause of this dislocation, and I believe, that the dislocation is effected by it, either directly, in a mechanical way, or that it gives rise to the prevention of the development ofthe parts ofthe joint, and therefore that the latter is not to be considered as a primary cause, but only as a consequence. The observations of D'Outrepont on the origin of this dislocation, from violence during birth, correspond with mine, and I find no contradiction to my long published opinion, in that which Von Ammon (a) has objected to it. 1001. The possibility of reducing congenital dislocation depends on the changes which the muscles have undergone in their dimensions, di- rection, structure, and texture, on the change in the ligaments and cap- sules, the head and surfaces of the joints, on the changes ofthe vessels and nerves, of the cellular tissue and skin, and on the changes of the bones in the neighbourhood of the dislocation. Reduction is to be ef- fected by long continued and gradually increased extension by means of proper apparatus, and by properly fixing the head of the bone, in the socket, after it has been brought into it. If the several shortened muscles do not lengthen, and project considerably, extension should be assisted by cutting them through beneath the skin. Second Chapter.—OF PARTICULAR DISLOCATIONS. L—OF DISLOCATION OF THE LOWER JAW. (Luxatio Maxillae Inferioris, Lat.; Verrenkung der unteren Kinnlade, Germ.; Luxation de la Mdchoire infirieure, Fr.) Binken, Dissert de maxillae inferioris luxatione. Gottingae, 1794. Zertamino, Ueber den wahren Mechanismus der Luxation der unterkinnlade; in von Siebold's Chiron., vol. ii. p. 349. Boyer, Above cited, vol. iv. p. 77. 1002. The condyles of the lower jaw can be dislocated only in one direction, viz., forwards; the spinous process ofthe sphenoid bone pre- vents it inwards, the front wall of the bony auditory passage backwards, the impossibility of inward movement of the opposite side without frac- ture outwards, and the horizontal surface of the temporal bone upwards. Most commonly both condyles, are dislocated together, but frequently only one or other. At the moment when the dislocation occurs, the se- paration ofthe two jaws is very great, but gradually it diminishes to an inch or an inch and a-balf; the incisive teeth ofthe lower jaw project more than those of the upper, the lips cannot be closed, the spittle pours out in large quantity, the pronunciation of the tones, especially of the lip tones is prevented ; a depression is observed in front ofthe ear-passage, on the inner side ofthe cheek a projection caused by the coronoid pro- cess ; the natural prominence ofthe m. masseter is flattened. If the dis- location be only on one side, the chin is drawn in the opposite direc- (o) Above cited. 210 DISLOCATION OF THE LOWER JAW. tion"; on one side only, is the depression before the ear-passage observed, and the lips may be more closed ; the speech, however, is faltering. If the dislocation be not reduced, the jaws often remain fixed in the se- paration already mentioned, but the patient gradually acquires the capa- bility of speaking more distinctly, and of retaining the spittle, and swal- lowing with less difficulty. Chewing remains impossible, and the patient must be fed with fluid food ; but in some cases the capability of chewing hard food has returned. (Boyer), 1003. Dislocation of the jaw takes place in some persons very easily but never in children, on account of the peculiar form and direction of the jaws. Its cause is either external violence, which thrusts the chin downwards and backwards, when, at the same mometit the muscles raising the jaw, especially m. masseter and pterygoideus intetnus con- tract; or violent straining in vomiting or yawning, by which the chin is violently drawn down, and by the simultaneous action of m. ptery- goids externi projected fowards. 1004. Reduction when effected early is easy. The patient should be seated on a low seat and his head pressed by an assistant against his breast. The two thumbs, wrapped in linen, are then to be carried as far back as possible, between the hind teeth, and put upon their crowns, whilst the fingers placed beneath the chin bring it forwards and raise it at the same time. If the dislocation be only on one side, the reduc- tion is to be performed only with one hand, in the way described, but is more difficult than when both condyles are dislocated. For the pur- pose of acquiring great power in this proceeding, the patient may be seated on the floor (Le Cat). If the reduction cannot be thus affected, a piece of cork may be introduced between the hinder teeth and the lower jaw pressed forward against the upper. If the dislocation be only one-sided, the cork is to be applied only on that side. [The readiest mode- of reducing a dislocated jaw is, to set the patient on the floor and fix the back of his head between your knees. Then the handles of a couple of forks, or two round pieces of hard wood of similar size, are to be thrust in, one at each corner of the mouth, between the hind teeth, as far as they can be got. You then place both hands beneath the chin, and drawing it directly and steadily up, the sides of the jaw forming a pair of levers, the-contraction of the temporal muscles, which fix the condyles in their unnatural place, is overcome, and the reduction is easily effected, A little knack is requisite to raise the chin evenly, and keep the fork-handles well fixed, otherwise one condyle-only will slip in, and the attempt to reduce the other, will often displace that first returned*. With inattention to this circumstance* this will occur again and again to the annoyance of both patient and surgeon. If only one condyle be dislocated, it is still best to introduce the fork-handles on both sides.—j. f. s.] 1005. After the reduction is effected, the lower jaw should be fixed by the halter bandage or by a cloth folded together passed beneath it and tied on the head. The patient must for some days refrain from talking or chewing, must only take fluid food, and for a long time use it cautiously, and in gaping support the chin with his hand. 1006. The case may be considered as subluxation of the lower jaw, when from great laxity of the ligaments, the condyles escape over the edge of the inter-articular cartilages in the sockets of the temporal bones, and fix the jaw with the mouth somewhat open. Generally this DISLOCATION OF THE VERTEBRAE. 211 accident is relieved by the natural efforts; it may, however, continue a longer time and yet the capability of moving the jaw and closing the mouth may be recovered. At the moment when this subluxation takes place the patient feels himself incapable of completely closing his mouth ; he feels some pain, and the mouth on the affected side is least closed. Great depression of the jaw directly downwards is required to restore the natural position of the joint. In great laxity of the ligaments, a snapping and some pain is felt in the joint of the jaw, immediately before the ear, when the jaw suddenly returns into its socket, out of which, on account of the looseness of the ligaments, it had escaped forward upon the articular eminences. Young ladies are most subject to this accident; it is best relieved by ammonia and steel, together with shower-bath and blistering, if the disease have existed some time (A. Cooper). 1007. Congenital dislocation of the lower jaw was first noticed by Gueriiv (a), in a foetus with deficient formation of the brain. The stretching and shortening of the depressing muscles, and of the m. pterygoidei externi are remarkably opposed to the lengthening and thin- ning ofthe m. masseteres. Smith (b) observed a congenital dislocation of the jaw on the left side, in an idiot from birth, and considered it as consequent on arrested development in the transverse root of the cheek- bone or of the articular eminence, so that neither socket nor articular process being present, the zygomatic process of the temporal bone was not formed, but that process of the cheek-bone was lengthened, the condyles of the lower jaw were deficient, atrophy of the articular pro- cesses of both upper, jaw and cheek-bones, and the forward position of the orbits were changed. The case differed from dislocation by ac- cident, in the mouth opening and shutting without hindrance, the lower jaw being moveable to a great degree, as naturally, the upper jaw over- hanging it, the coronoid process forming no prominence, and the speech not interfered with. II.—OF DISLOCATION OF THE VERTEBRA.* (Luxatio Vertebrarum, Lat.; Verrenkung der Wirbelbeine, Germ.; Luxation de la Colonne Vertebrate, Fr.) 1008. The connexion of the first vertebra, with the occipital bone is so firm, partly from the ligaments, partly from the muscles, partly from the condition of the joint-surfaces, that a dislocation at the junction of the first vertebra with the head {Luxatio capitis, nuchoe) cannot well be produced, and if it be so by extraordinarily great violence, it is ab- solutely fatal from the simultaneous injury ofthe spinal marrow. 1009. The turning and movement of the head is, for the most part, effected by the connexion ofthe second with the first vertebra, by which the latter, with the head, moves round dhe tooth-like process of the former, as upon a pivot. In forcible bending of the head forwards, the ligament fastening it to the tooth-like process may be torn, so that that (a) Researches sur les Luxations Con- (b) Dublin Journal of Medical Science. genitales. Paris, 1841. May, 1842. * The subjects Fractures and Dislocations ofthe Vertebra are so closely connected that it is almost impossible to separate them; and I have therefore already preferred consider- ing them together under the former title (p. 582, and following).—j, f. s. 212 DISLOCATION OF THE VERTEBRA. process drives directly into the spinal canal. This dislocation always requires very considerable violence, and is not very possible in adults, in which case there is previous fracture of the tooth-like process. In rotation of the head, the lateral ligaments of this process are stretched, and if this motion be carried to a dangerous extent, they may be torn, and the process carried beneath the transverse ligament of the first ver- tebra into the spinal canal. In children in whom the tooth-like process is still low, and the ligaments less firm, they may be torn by violence when the head is drawn directly upwards. The violent circumstances which can produce dislocation of the second vertebra are, a fall from1 a great height upon the head, a violent blow, or the fall of a heavy body on the nape, standing and turning about the head, and lifting up children by the head. By the intrusion of the tooth-like process into the spinal canal, pressure and tearing ofthe spinal marrow are produced, and help is impossible. Cases, however, seem to be known, in which only the lateral ligaments of the tooth-like process have been torn by violence and the patient has lived in this state although the process was still held but by the transverse ligament (a). 1010. The connexion ofthe last five neck vertebrae allows the inclina- tion of the neck forwards, to the side, and a rotatory motion, by which, if carried to a violent extent, the joint-surfaces of the oblique processes get free from contact, are pushed against each other, and cannot be returned to their natural position. Hitherto, this dislocation has been only known on one side, as a consequence of external violence or of strong twisting of the muscles. If at the same time there be severe pain at the seat of dislocation, the head turned towards the opposite side, and fixed in this position, the muscles which move the head are not spasmodically contracted, the spinous processes deviate from their natural position, from the seat of dislocation up to the head. Walther(6) has observed the simultaneous dislocation of both inferior oblique pro- cesses of one of the middle neck vertebrae, and from this case has given the symptoms of such dislocations. The head is turned back, and the neck so bent, that the original line forms a curve, of which .the con- vexity is forwards and the concavity backwards, the front parts of the vertebrae are more separted, but the spinous processes at the same time are pushed one upon another. Such dislocation may, as Walther's case proves, happen without any dangerous effect on the spinal marrow; but there may occur writh it, as well as with every other injury of the verte- bral column, effects on the spinal marrow dangerous to life, as pressure, tearing, inflammation, and the like, and death may be immediate or soon consequent. Dupuytren (c) guards against the possibility of confusing such dislocation with rheumatic affection ofthe neck, which, from some straining or violent motion ofthe head, often comes on with severe pain, impossibility of motion, and the head (a) Delpech, Precis elementaire, &c, vol. [Norris, Case of Complete Dislocation of iii. p. 47. the fifth, from the sixth, Cervical Vertebra. (b) Ueber die Verrenkung der Halswirbel Amer. Journ. of Med. Sci. vol. i. N. S. nacb eigenen Bjobactungen; in his Journal 1841.—g. w. n.] fur Chirurgie und Augenbeilkunde, vol. iii. (c) De la Luxation des Vertdbres et des pt ii. p. 197. Maladies qui la simulent; in Legons Orales, Lawrence,W., On Dislocations of the Ver- vol. i. p. 397. tebre; in Med.-Chir. Trans, vol. xiii. p. 387. DISLOCATION OF THE VERTEBRJE. 213 directed to one side, just as it may occur, under similar circumstances, at any part of the spine (as in the so-called crick in the neck). 1011. If the dislocation of an oblique process be left alone, the pain gradually subsides, and the patient has no other inconvenience than an unnatural position of the neck and restricted motion ofthe head. It is, therefore, held most advisable by some (Desault, Boyer, Richerand* and Dupuytren) to leave this dislocation alone, because in attempting to reduce it, the spinal marrow may easily be so torn as to cause sudden death (a). This opinion is, however, grounded especially upon an im- perfect reason, and various cases are known, in wdiich the reduction of this dislocation has been followed with happy results. Seifert {b) has refuted the reasons against undertaking the reduction of this dislocation, and has frequently performed it successfully. The patient should be placed on a low seat, or sitting on the ground, and his shoulders firmly held back by an assistant. The surgeon then grasps the head, with one hand beneath the chin and the other beneath the occiput, makes ex- tension first in the direction of the dislocation, then in the longitudinal axis of the neck, and when this seems to have been sufficiently made, he twists the head strongly towards the dislocated side. Still the more pressing is the necessity for reduction in dislocation of both oblique processes of the neck vertebrae, and that this may be effected, with care, the observation of Walther proves. The patient is to be put in a hori* zontal position, held up by three assistants, one of whom makes coun- ter-extension on the pelvis, a second draws the shoulders back, and when the trunk is thus properly fixed, a third assistant grasps the head and makes extension, first in the direction of the dislocation, afterwards in the natural longitudinal axis of the neck, that Is, he first pulls the head pretty forcibly back by gradually lengthening the neck, and then turns it backwards. But when the. extension in this direction has attained a certain extent, the head must be brought into its naturally straight posi- tion, by undiminished and still successively increasing extension. Guerin (c) reduced a seventh months' dislocation of the second vertebra of the neck upon the third. 1012. Dislocation of the oblique processes of the back vertebrae cannot happen, nor dislocation ofthe bodies of neck-vertebrae, on account of the breadth of their joint-surfaces, the quantity and thickness of their liga- ments, the strength of the muscles surrounding them, and the slight motion with which each vertebra is endowed. Only when the bodies of the vertebrae are broken can they be dislocated ; but then so great violence operates that symptoms of pressure and concussion of the spinal marrow accompany it. All the cases described as dislocation of the back and loin vertebrae, are fractures of those bones, or simple con- cussion, or some other injury of the spinal marrow. In consequence of the form and connexions of the bodies of the vertebrae, every dislocation must cause death. • Dupuytren has collected several cases in which dislocation Was acccompanied with fracture; in one case separation of the bodies of the vertebras occurred from (a) Petit-Radel, Dictionnaire de Chirur* verrenkungen j in Rust's Magazin, vol' gie; in Encylopedie Methodique. xxxiv. p. 419. (b) Ueber die prognostische Bedentung (c) Revue Medicale, August, 1840, p. 276. therapeutische Behandlung der Halswirbel Vol. ii.—19 « 214 DISLOCATION OF THE PELVIC BONES. tearing of the intervertebral substance, without any fracture. In all these cases death followed the simultaneous injury ofthe spinal marrow. From" what has been said, it may be collected, how those cases are to be thought of, in which with some projection observable after the operation of violence upon the spine, the patient cannot sit upright, and so on, it has been supposed that by laying the body over a tub or any round body, the common dislocation could be reduced. Boyer has also observed on this point, that in violent bending of the spine, the upper and interspinous ligaments of the spinous processes, and the hinder so-called yellow ligaments may be torn. If the tearing be confined to the interspinous and to the upper ligaments, the patient may recover after a longer or shorter period of rest; but tearing of the yellow ligaments causes palsy and death (a). 1013. The ligaments of single vertebrae may be partially or completely torn through, without dislocation, but the injury of the spinal marrow therewith connected may cause death suddenly or subsequently; and to such cases all that has been said in relation to fractures of the spine applies. In every case of distortion and tearing of the ligaments of the spine, only a strict antiphlogistic treatment, with continual rest, and sub- sequently, frequent purgatives to prevent the destructive subsequent diseases, may be employed. III.—OF DISLOCATION OF THE PELVIC BONES. (Luxatio Ossium Pelvis, Lat.; Verrenkung der Beckenknochen, Germ.; Luxation des Os du Bassin, Fr.) Creve, Von den Krankheiten des weiblichen Beckens. Berlin, 1795. 4to. p. 137. ' [Harris, On Dislocation of the Sacro-Iliac Symphysis. N. American Med. and Surg. Journal, vol. 4. 1827.—g. w. n.] 1014. The broad surfaces of the articulations of the pelvic bones, and the great strength of their ligaments, render their separation impossible under natural circumstances, except when acted upon by extraordinarily great violence. The rump-bone may be dislocated inwards, and the hip-bone, upwards. These dislocations are never complete; the effects of violence, however, usually act upon the intestines ofthe pelvic cavity and upon the spinal marrow, and inflammation and tearing of these intestines and effusion of blood, and so on, in the pelvic cavity, ensue; also, palsy of the lower limbs, of the bladder, and rectum; and not un- frequently is fracture ofthe pelvic bones present. The treatment of these dangerous injuries must be precisely the same as has been mentioned (par. 615) for fractures of the pelvic bones. One Case shows that a dislocation ofthe hip-bone upwards maybe produced by a fall from a great height, without symptoms of concussion of the spinal marrow or injury of the pelvic intestines. The share-bone and the spine of the hip-bone of the left side were higher; the left limb was shorter than the other, but the distance from the trochanter to the spine of the hip-bone and to the knee, was the same as on the other side; flexion and extension of the thigh were accompanied with severe pain in the symphysis pubis and sacro-iliaca, with which frequently the whole hip- bone moved. The extension caused only severe pain, without bringing the limb to its natural length. The treatment in this case consisted in strict quiet, and the em- ployment of proper antiphlogistic remedies. When the patient began to walk, he gradually, by the weight of his body, recovered the proper position of the hip- bone (b). (a) Boyer, p. 121. (6) Ibid, p. 135. DISLOCATION OF THE RIBS, &C. 215 1015. Great as must be the violence to produce a separation of the hip-bone, if its articular connexions have their natural degree of strength, just as easily can it be produced if these connexions be lax and yielding. Such is the case in loosening and swelling of the ligaments of the pelvis during pregnancy. Wherefore also frequently from the extension which these bones suffer during delivery, or if the woman get about soon after her downlying, a pretty smart pain is suffered in one or both joints of the pelvic bones, which recurs at every movement, and is accompanied at first with the sensation of a tearing, and subsequently, distinct crepita- tion is felt in the pelvic joints. The gait ofthe patient is then difficult, and on examination, the position of the two hip-bones is not found alike, the one being more or less high than the other. A similar swelling, loosening and laxity of the joint ligaments of the pelvic bones often arises from an internal diseased condition, in which slight violence is sufficient to produce a separation of the pelvic bones. 1016. The principal indication in these cases is, to fix the pelvis as steadily as possible and prevent every movement; for which purpose, a belly bandage, or a leathern girdle, is to be applied sufficiently tight around the hips ; by this the pain is often instantaneously got rid of, and the patient's movements much improved. How far the laxity of the ligaments, depending on general causes, may be relieved by friction, purging, and the like, must depend on the circumstances ofthe individual case. 1017. The coccyx may by violence be driven inwards, or by difficult labour be thrust outwards, giving rise to fixed pain, increased by motion of the lower limbs, but especially in going to stool; frequently it becomes severe and pulsating, when suppuration takes place. The ligaments are not torn in this so-called dislocation of the coccyx, it therefore recovers its natural position ; the employment ofthe hand for its replacement, by the introduction of the finger into the rectum, or by its application ex-. ternally is therefore superfluous. The treatment consists merely in rest, antiphlogistic treatment, and the local application of remedies to effect dispersion and get rid of the inflammatory symptoms. If suppuration take place, a speedy outlet must be afforded to the pus, or otherwise considerable destruction of the loose cellular tissue is produced. IV.—OF DISLOCATION OF THE RIBS AND THEIR CARTILAGES. (Luxatio Costarum, earumque Cartilaginum, Lat.; Verrenkung der Rippen und ihrer Knorpel, Germ.; Luxation des Cotes et de lews cartilages, Fr.) 1018. Dislocations of the hinder end of the ribs have been totally denied by many writers, but admitted by others, who have mentioned a threefold kind of separation, inwards, upwards, and downwards, and complete and incomplete dislocation. So long as the examination of corpses had not shown the existence of these dislocations, it was doubt- ful whether the common dislocation were not fracture of the hinder end of the ribs; examination, however, has proved the possibility of the dislocation of the ribs. 216 DISLOCATION OF THE RIBS. B. Cooper (a) mentions a case of Webster's, in which a man who had died of fever, was, on dissection, found to have the head of the seventh rib drawn upon the front of the corresponding dorsal vertebra and anchylosed to it. Some years previ- ously he had had a sudden and violent fall from his horse, for which the ordinary treatment of fractured ribs had been had recourse to. Donne (b) showed from the examination ofthe body of a child of eleven years old, a complete dislocation ofthe tenth, and a partial one of the eleventh rib; Fimicane one of the eleventh and twelfth rib, Hankel (c) a dislocation of the eleventh rib. 1019. Dislocation of the ribs is only produced by the direct operation of external violence. It occurs most frequently at the eleventh and twelfth ribs, because their front end has no point of support, the trans- verse process is less projecting, and the costo-transverse joint, together with the interosseous costo-transverse ligament are deficient. Disloca- tion of the rib may be distinguished by its greater mobility, when the finger is run along it, and which is still more perceptible the nearer it approaches the hinder end ; by a particular rustling, (which is not to be confused with that from fractured rib or from emphysema), which is per- ceived on the movements ofthe body and ribs by the practitioner, or by the patient himself; by a yielding of the parts covering the hinder end of the rib; by a depression where the head of the rib should be found, and by motion of the hind end on pressure of the front end. It is accompanied with cough, difficult respiration, severe pain, and other symptoms, as in fractured ribs {par. 627). 10$0. To effect reduction, the patient should be placed with his chest upon a firm pillow, so that the front end of the dislocated rib may be pressed backwards, and then the vertebra above and below the disloca- tion is to be pressed down* The rib must be kept in place, by a thick com- press placed at the front end and upon the spinal column, and properly fastened with a chest bandage. If the object cannot be thus attained, it has even been advised to open the cavity of the chest, and with the finger or with a hook to bring the rib into its place. No one should be seduced to such a practice. It is most proper in every case to pro- ceed, as in fracture ofthe ribs, to prevent the motions ofthe chest, with a broad bandage, and to counteract the other symptoms by proper means. 1021. The cartilages of the upper false and lower true ribs may be separated in violent bending backwards of the body, in which the liga- ments are torn where the under cartilage overlaps the upper. At this part projection and depression are observed, the patient feels pain, and the breathing is somewhat disturbed. The natural position of the carti- lage can be restored, if the patient inspire deeply and bends backwards, whilst some pressure is made on the projecting cartilage. The treatment is the same as in fracture of this cartilage {par. 629). Astley Cooper (d) has noticed dislocation ofthe cartilage most frequently at the sixth, seventh, and eighth rib, from the breast-bone and the end of the rib, not un- frequently in children, as consequent on general weakness. (a) His Edition of A. Cooper's Dislocations, q. 520. (6) Gazette Medicale de Paris, 1841, No. 26. (c) lb., 1834, p. 187. (d) Above cited, p. 537. DISLOCATION OF THE COLLAR-BONE. 217 V.—OF DISLOCATIONS OF THE COLLAR-BONE. (Luxatio Claviculas, Lat.; Verrenkung des Schliisselbeines, Germ.; Luxation de la Clavicule, Fr.) 1022. Dislocation of the Collar-bone is much more rare than fracture, and may be of the sternal end or the scapular end of the bone. 1023, It is generally held that the sternal end of the collar-bone may be dislocated forwards, backwards, and upwards. In this dislocation, if the separation ofthe joint-surfaces be only rather considerable, the tendi- nous strengthening fibres, the interclavicular ligament, and perhaps fre- quently the fibres of the sterno-mastoid muscles seem to be torn. In dislocation forwards, which is the most common, and depends on violent pressing backwards or inwards of the shoulders, a projection is observed on the fore and upper part of the breast-bone, which subsides when the shoulder is pressed outwards ; the shoulder stands deeper and more inwards; the head is inclined towards the ailing side ; the move- ment ofthe arm is interfered, with and painful; if the shoulder be raised, the prominence subsides; if the shoulder be depressed, the prominence rises up towards the neck. The dislocation is frequently incomplete, the front only ofthe capsule being torn, and the bone but little projecting. In dislocation upwards, the distance between the two sternal ends of the collar-bones is diminished, and the dislocated end is higher than that of the opposite side. Dislocation backwards, the possibility of which is admitted by most persons, though by others in a manner doubted, but which has been proved by a case of Pellieux's (a), may be caused by violence which thrust the shoulder forwards, or acts immediately upon the sternal end of the collar-bone from before backwards. Its symp- toms are a depression in place of a projection, at the inner end of the collar-bone, only at the opposite end there is decided position and direc- tion of the bone from within outwards, and from behind forwards, severe pain in the region of the collar-bone, and upon the whole side of the neck to the very base of the lower jaw, the mastoid process and occi-. pital protuberance, on sudden movement of the arm, especially in certain opposition to overcome it, as well as with pressure of the hand ; on mo-. tion, a dull rustling is perceptible to the patient, as of rubbing the two, surfaces of the bone together; some pain on rotating the head, henee a degree of stiffneck, so that the head, neck, and chest move together if the patient look sideways ; incapability of the patient raising himself from the bed, except by putting an object before him to serve as a point o£ resistance ; lastly, slight pain in swallowing. As the greater number of writers on this dislocation state that, in it, the wrnd-?pipe and gullet, the vessels and nerves are compressed, and severe symptoms are thereby produced, neither of which was observed by Pej.lieux in his case, and the assump- tion of which depends only on a short notice of Duverney's (b), and a case related by Astley Cooper, in which dislocation in the second way occurred,, therefore Pellieux gives a superficial and a deep dislocation of the sternal end of the collar- bone, taking for the former, the symptoms above described, but for the latter, which can scarcely occur but from direct severe violence upon the collar-bone, and with complete tearing away of the m. sterno-mastoideus, the more important symptoms of (a) Memoire sur la Luxation de 1'extremite sternale dela Clavicule en arriere; inReyus Medicale, 1834, August, p. 161. (6) Traite dea Malaclies des Os, voj. \. p. 201, 19* 218 DISLOCATION pressure on the wind-pipe and gullet, and on the vessels and nerves of the neck. But this statement is unsupported by any reason: for in the case related by A. Cooper, (p. 401), there occurred, during great curvature ofthe spine, a gradual dis- location of the sternal end of the clavicle backwards, in which for the purpose of relieving the severe symptoms of impeded swallowing, the dislocated end of the collar-bone was removed. [In September, 1835, there was admitted into St. Thomas's Hospital, under Tyr- rell, a case of compound dislocation of the collar-bone, backwards which I saw. It had been caused by an earth-slip of twelve feet in height, burying him, whilst employed in preparing for the Southampton rail-road, and driving the sharp end of a pickaxe, with which he was working, into his chest. He reached the hospital three hours after the accident; and on examination, the cellular tissue below the right collar-bone and on the upper part of the breast-bone was found emphysematous. The collar-bone was distinctly dislocated backwards at its sternal end, and there was a wound in the skin opposite the junction of the second rib with its cartilage. When the finger was introduced into this aperture, the great pectoral muscle was found completely scraped from its clavicular attachment, and the finger could pass as far outwards as the coracoid process of the blade bone, and inwards, it followed the collar-bone to the windpipe, on the right and fore-part of which it rested, slightly sunk behind the upper piece of the breast-bone, so that it somewhat interfered with respiration and deglutition. The interarticular cartilage seemed to remain in its proper place, except a small portion which had been torn off with the bone; the ex- treme inner end of the collar-bone could not, however, be distinctly felt; no wound of the intercostal muscles could be ascertained. The pickaxe had probably first passed upwards and outwards, then turned inwards, torn off the pectoral muscle from its origin, and having dislocated the bone, passed inwards above the breast- bone in those directions in which the finger could move; probably it had wounded the pleura and right lung, which appeared the only way of accounting for the emphy- sema. According to his own account, it would seem as if the handle of the tool had penetrated, for he says, the handle was standing upright and he fell forward upon it. But I doubt the correctness of this, as the skin wound was not more than two inches long, and beneath it my little finger would justenter, and no room to spare. He com- plains of a little pain opposite the middle of the second piece of the breast-bone; but he has not any other pain in his chest, and no fracture can be discovered. He seems to breathe easily, although he complains of difficulty of breathing, accompanied with great desire to cough, and a sensation of pressure on the windpipe, which is much increased on raising the skin of the neck when he throws his head back. The shoulder having been brought back with straps attached to a back-board, the board readily resumed its place. The elbow was brought forward and bound to the side. The wound was dressed with sticking plaster, and he was put to bed with the shoulders much raised. He went on without the least unfavourable symptom; in three weeks left his bed, and1 three weeks after went out of the house. The sternal end of the collar-bone still fell a little backwards, and was a little more moveable than natural. He was warned not to use his arm violently. In September, 1839, Velpeau (a) had under his care a ease of simple dislocation of the sternal end of the collar-bone inwards and backwards. The man had been violently squeezed between the wall and a cart, " in such a manner as to thrust the left shoulder forcibly inwards, and break up the ligaments which connected the clavicle of the same side to the first bone of the sternum ; in this way the sternal end of the left clavicle lay upon the superior edge of the sternum, behind the sternal attachment of the sterno-mastoid muscle. The articulating surface of the bone lay close to the junction of the sternum with the clavicle ofthe opposite side. Velpeau considered that in the first instance the force producing the dislocation had operated, so as to displace the sternal extremity of the clavicle upwards and back- wards, inasmuch as the bone lay behind the. sternal portion of the sterno-mastoid muscle, and that it was after this had been effected, that the displacement inwards and across the upper part of the sternum occurred. He considered this was the first instance of this kind of displacement of the sternal extremity of the clavicle which had been observed; in which opinion, however, he was wrong, as the case just mentioned proves.—j. f. s.] 1024. The reduction of the dislocated sternal end of the collar-bone (a) Lancet, 1839.40, vol. i. p. 422. OF THE COLLAR-BONE. 219 is easy ; with one hand the elbow is fixed, and with the other placed on the upper part of the humerus, the shoulder is drawn outwards and backwards, as in treating fracture of the collar-bone (par. 639.) In dislocation forwards, the shoulder should be pressed forwards, in that backwards, backwards, and in the upward dislocation,upwards, so as to prevent the slipping out again of the end of the bone; and the arm is to be kept in proper position with the apparatus already mentioned for fractured collar-bone. According as this apparatus is more or less relaxed, there commonly remains greater or less deformity at the sternal end of the bone, which, however, has no effect upon the motions of the arm. Melier's apparatus, in dislocation of the collar-bone forwards, in which a com- press similar to a truss, and pressing on the projecting end ofthe bone, is connected with Desault's apparatus (a). [It will not be out of place to mention here, the operation performed by Davie, of Bungay, on the case of backwardly dislocated sternal end of the collar-bone re- ferred to by Astley Cooper, in which the bone pressed so upon the oesophagus as to occasion extreme difficulty in swallowing. "An incision was made of from two to three inches in extent on the sternal extremity of the clavicle, in a line with the axis of that bone; and its surrounding ligamentous connexions, as far as he could reach them, were divided with the saw of Scultetus (often called Hey's) ; he then sawed through the end of the bone, one inch from its articular surface from the sternum, and fearful of doing unnecessary injury with the saw, he introduced a piece of well-beaten sole-leather under the bone whilst he divided it. When the sawing was completed he tried to detach the bone, but it still remained connected by its interclavicular ligament, and he was obliged to tear through that ligament by using the handle of the knife as an elevator, and after some time succeeded in removing the portion of bone which he had separated." The case did well (6).] 1025. The scapular end of the collar-bone can only be dislocated upwards, (extremely seldom downwards beneath the acromion), and the separation of the two articular surfaces is not great. The cause is gene- rally a severe fall upon the shoulder, by which it is violently turned backwards. The signs of this dislocation are pain on the top of the shoulder, depression of the shoulder, a great space between the acro- mion and scapular end of the collar-bone, or a projection of the latter ; unaccustomed motion of these two parts, impeded motion of the arm, especially in elevation, diminished distance of the shoulder from the chest, disappearance of the prominence when the shoulders are drawn backwards, but which reappears when it is let go; and if the finger be carried forward upon the spine of the blade-bone it is stopped by the projecting end of the collar-bone. It has been hitherto assumed that the acromial end of the collar-bone can only be dislocated upwards ; at least, experience knew no other kind. Tournel (c), how- ever, saw a case in which the weight of a horse, in a sudden fall, caused separation and driving back of the blade-bone, the collar-bone still remaining fixed at its sternal end, but its outer end, from which the inferior and coraco-clavicular liga- ments were torn, was separated from both articular surfaces, and slipped beneath the acromion. The pivot motions of the arm could be made in the usual directions; the left arm was somewhat longer than the right, the elbow ancf upper part of the arm lay against the side of the trunk; the voluntary motions, especially those up- wards, were impossible, the patient could not bring his hand to his head ; the com- municated motions were free and painless ; the shoulder had lost its rounded form, (a) Archives, generates de Medecine, Jan. (b) A. Cooper, above cited, p. 402. 1829, p. 53.—Froriep's chirurgische Kup- (c) Archives generales de Medecine, 1837. fertafein, pi. ccxxvii. December. 220 DISLOCATION and below the acromion externally was a deep hollow. The shoulder had also two prominences, an internal and upper, formed by the acromion, and an external under by the lower end of the collar-bone. Neither numbness of the fingers nor pain were present; the point of the left shoulder was much nearer the breast-bone than the right; when the finger was carried along the spine of the blade-bone from behind forwards to the acromion it was stopped by the projection ofthe collar-bone. This was perfectly discernible, and disappeared, as well also as the hollow beneath the acromion, when the shoulders were drawn back, the knee being placed between them; but so soort as this was left off, the projection formed by the end of the collar-bones and the depression beneath the acromion reappeared. With Desault's apparatus, and subsequently with that of Plammant, a cure was effected without deformity, and without restriction of the motions of the arm. Melle (a) examined after death, and described such a dislocation of the outer end of the collar-bone downwards. 1026. This dislocation is always easily reduced; the arm is to be raised up against the collar-bone, the scapular end of which is to be depressed. Desault's apparatus for fractured collar-bone is applicable, with the alteration of putting a thick compress upon the scapular end of the collar-bone, and the turns ofthe bandage which are.carried over the injured shoulder and the elbow, to be sufficiently tightened, and further, the arm to be also fixed to the breast with a bandage. The first days the injured parts are to be moistened with cold dispersing applications. As often as the bandage becomes loose it must be tightened. In from four to six weeks it may be removed; most commonly there remains greater or less displacement, which, however, does not interfere with the motions of the shoulder. [The dislocation of the collar-bone upon the spine of the blade-bone is one of the most tiresome accidents we have to do with; at least in all the cases I have had' to deal with, and the injury is not unfrequent, I have never been able by any con- trivance to keep it in place, and have therefore given up attempting to keep it reduced, and only endeavour to keep it at rest, so that it may form new connexions on the scapular spine.—j. f. s.] VI.—OF DISLOCATION OF THE UPPER-ARM. (Luxatio Humeri, Lat.; Verrenkung des Oberarmes, Germ.; Laxation du Bras, Fr.) Bonn, Abhandlung von Verrenkungen des Oberarmes. Leipzig, 1783. Desault, above cited. Warnecke, Abhandlung iiber die Verrenkung des Oberarmes aussdem Schul- tergelenke und deren Heilart. Nurenberg, 1810; with plates. Boyer, above cited, p. 174. Mothe, Melanges de Chirurgie et de Medecine. Paris, 1812. Busch, Dissert, de Luxatione Humeri. Berlin, 1817. Dupuytren, De la difference dans le Diagnostic des Luxations et des Fractures de l'extremite superieure de l'Humerus; in Repertoire General d'Anatomie et de Physiologie Pathologique, vol. vi. part iii. p. 165. Malgaigne, Luxations de l'Articulation Scapulo-humerale; in Journal des Pro- gres des Sciences et des Institutions Medicales, vol. iii. Paris, 1830. Cooper, Astley, above cited, p. 415. Crampton, Philip, M.D., On the Pathology of Dislocation of the Shoulder-Joint; in Dublin Journal of Medical and Chemical Science, vol. iii, p. 42. 1833. 1027. The free motions of the shoulder, the great misproportion be- tween the size of the head of the upper-arm-bone and the flattened (a) Nova Acta physico-medica, 1773, vol. v. p. 1. OF THE UPPER-ARM. 221 hollow of the joint-surface of the blade-bone, the slight strength of the capsule of the joint, and the frequent operation of external violence upon the shoulder-joint, render the dislocation of the upper-arm more frequent than that of any other bone. 1028. The head of the upper-arm-bone may be displaced in three different directions: 1, Upwards (and inwards); the head of the bone rests on the front edge ofthe blade-bone, between the insides ofthe long heads, of the m» triceps and the m. subscapularis. 2, Inivards; the head of the bone recedes between the subscapular pit and the muscle of the same name, beneath the m. pectoralis major. 3, Outwards; between the infra-spinate pit and muscle. [This is the dislocation backwards of English surgeons,—j. f. s.] The dislocation downwards is the most common, that inwards more rare, and that outwards the rarest. The dislocation upwards is impos- sible, partly on account of the acromial process, and the firmness of the joints especially, partly because the upper-arm cannot, on account of the trunk, be driven inwards as much as necessary in order to dislocate it upwards. Astley Cooper (a) speaks of a fourth partial dislocation, when the front of the capsular ligament is torn, frequently only stretched, and the head rests against and on the outer side ofthe coracoid process of the blade-bone {b). 1029. If the head ofthe upper-arm-bone be dislocated downwards, it may be drawn inwards by the contraction of the muscles, (but the m. triceps extensor prevents it being pulled outwards,) and thence gradually upwards towards the collar-bone. In the dislocation outwards such consecutive displacement towards the spine of the blade-bone is not possible. In dislocation of the upper-arm-bone, there may be therefore a fourfold varying position of the head of the bone: 1, downwards; 2, outwards, always primitive; 3, inwards, frequently primitive, usually consecutive, and, 4, inwards and upwards, constantly as consecutive dislocation. A. Cooper, however, does not think that the head is dis- located consecutively, when the muscles have once contracted and no great violence operates. Less change of position may originate in the absorption arising from pressure. Opinions vary in reference to the primitive direction of dislocation of the upper- arm. Many (Hippocrates, Duverney, Fabricius ab Aquapenoente, Desault, Mursinna, Richerand, Mothe, and others) admit only the dislocation downwards as primitive, and that inwards and outwards as secondary. Others (Velpeau, Malgaigne) determine only two primitive dislocations, namely forwards and in- wards, and backwards and outwards. 1030. The several kinds of dislocation of the upper-arm are charac- terized by the following symptoms: In dislocation downwards, the arm is rather longer, can be moved only a little outwards, and motion in any other direction causes severe pain; in old persons, however, the laxity of the muscles often permits more extensive motion ; the elbow stands out from the trunk ; the patient inclines himself towards the side of the dislocation, holds the arm half- fa) Above cited, p. 446. 105.—Hargrave, W.; in Edinburgh Me- (6) Dupuytren, Legons Orales, vol. iii. p. dical and Surgical Journal, October, 1837. 222 DISLOCATION , bent, and supports his elbow on his hip. Beneath the acromion, which seems more prominent, a hollow is observed, the joint has lost its round- ness, the middle line of the arm is directed towards the arm-pit in which is felt a globular protuberance, formed by the displaced head of the bone, only, however, when the arm is separated from the trunk. A kind of crackling is frequently noticed on motion, depending on the exuded matter, or on the effusion of synovia, which disappears on continuance of motion, and is never so great as in fracture. The pressure of the head of the bone upon the axillary plexus often causes loss of sensation, and the sensation of being asleep in the fingers. In dislocation inwards, the elbow stands out from the trunk, and is inclined a little backwards; the direction of the arm corresponds to the middle of the collar-bone, the movement of the arm backwards is not very painful, but forwards extremely so. Beneath the great pectoral muscle is felt the protuberance of the head ; the arm has either its natural length or is rather shorter; the flattening of the shoulder is observed especially at its hinder part; the fore-arm is not half-bent. In dislocation outwards, the arm is inclined inwards and forwards, the flattening ofthe shoulder is most distinct in front; the head of the bone forms a prominence in the infra-spinate pit; the arm may be moved for- wards with the least pain, but every other movement is in the highest degree painful. In imperfect dislocation, where the head is inclined forwards against the coracoid process, a hollow is observed opposite the back ofthe shoulder-joint and the hinder half of the glenoid cavity is perceptible; the axis of the arm is inwards and forwards; the under motions ofthe limb may be completely performed, but the arm cannot be raised, because the upper-arm is thrust against the coracoid process of the blade- bone ; the head forms a distinct protuberance, and if the arm be Totated, the rolling motion of the head is felt. , It is very difficult, and generally impossible, in dislocation of the upper-arm, to determine whether the dislocation of the head of the bone inwards, be primary or consecutive; but inquiry as to how the symptoms have followed each other, and even the treatment in setting, may perhaps afford some clue. 1031. Dislocations ofthe upper-arm are produced by violence, which strikes the arm,'and happens only on that particular direction ofthe arm, at the moment when the violence acts, according to which side the head ofthe bone is driven against the capsule and dislocated. In the occur- rence of dislocation downwards, the contraction of the m. pectoralis major, latissimus dorsi and teres major especially participate. It, how- ever, particularly depends on the m. deltoides, as shown by examples when this dislocation has happened in raising a heavy load. The destruction ofthe soft parts in dislocation ofthe upper-arm, is for the most part restricted to the tearing of the capsular ligament to a tole- rable extent and the bruising of the neighbouring parts. In dislocation inwards, however, a tearing of the m. subscapularis has been observed; as also oftentimes palsy of the arm, cedematous swelling of it: or a palsy of the deltoid muscle is connected with, or subsequently ensues on dis- location. Fracture of the neck of the upper-arm-bone has also been noticed simultaneously with this dislocation. 1032. The inflammatory symptoms which occur in dislocation of the upper-arm, are usually of little consequence, if reduction be soon ef- fected ; but if the dislocation be left alone, considerable interference OF THE UPPER-ARM. 223 with the movements ofthe arm occurs; the dislocated head is kept fixed in its position, the motions of the arm depend only upon the mobility ofthe blade-bone, and often after from four to eight weeks, reduction is no longer possible, even with the greatest efforts. 1033. In reducing dislocation of the upper-arm, the shoulder must be well fixed, the arm extended to a proper degree, and its head brought back in the same way in which it was dislocated. The patient should sit on a common seat, (in difficult cases it is advantageous to lay him horizontally on a couch,) a folded cloth is to be applied above the wrist, its two ends tied and given to an assistant. An oblong, tolerably thick bolster should be put into the arm-pit, projecting beyond the edges of the great muscles ofthe breast and back, and over it a folded cloth, the ends of which are to be carried over the front and back ofthe chest, to the sound shoulder, there tied, and given to an assistant. For the more complete fixing of the shoulder-blade, a second cloth is applied with its middle on the acromion, its ends carried obliquely forwards and back- wards, towards the other side of the chest, and given to an assistant, who dra^ws them properly in this direction towards him. Or the shoulder is fixed by1 a proper bandage, (retractor), through the open- ing of which the arm is passed (a). The surgeon stands on the out- side of the limb, and directs the assistants as to the direction and commencement ofthe extension. In the dislocation downwards, extension must be made directly outwards, and when carried to a proper extent, the arm must be pulled downwards, and somewhat forwards till it be applied to the side of the body, when the surgeon rests his body against the elbow, and with both his hands applied, the one on the upper, and the other on the under surface of the upper arm, carries the head back into the socket. In dislocation inwards the extension must be made outwards and back- wards, the arm brought forwards and downwards, till it lie obliquely across the front ofthe breast, and the surgeon then assists the return of the head ofthe bone, by placing one hand upon the elbow and the other on the inside ofthe arm, and pressing the head outwards. The dislocation outwards requires extension in the opposite direction to the preceding (a). In reduction the following points are to be especially noticed. As every disloca- tion of the upper arm occurs only in a certain position, so must its extension also be made in a corresponding position, and according to the directions laid down. In this position the m. deltoides, supra-spinatus and infraspinatus, which mostly oppose the reduction, are rendered lax. On this account the dislocation is often reduced with ease, immediately after its occurrence, by raising the arm to the horizontal pos- ture, and placing the fingers in the arm-pit. The arm is not to be brought into its natural position, till the head of the bone has been restored to the place from which it has slipped. The head is usually carried back into the socket, rather by the action of the muscles, than by any force applied to it. By what has been said is explained the fitness of La Mothe's (b) proposed mode of reduction. The patient is to be placed on a seat; the shoulder to be fixed by means of a cloth, folded lengthways, applied over it, and held by two assistants sitting on the ground; a third standing (a) Proper retractors are described by Eckoldt (Kosler's Anleitung zum Ver- Pitschel (Anatom. und chirurg. Anmer- bande. Leipz, 1796* p; 299. PI. viii. fig. 8, kungen. Dresden, 1784, p. 66); by Men- 9); by Schneider (Loder's Journal, voh nel (Loder's Journal, vol. iii. p. 300); by ii. p. 466) and by Astley Cooper. (b) Busch, above cited. 224 DISLOCATION on the uninjured side, draws horizontally a cloth laid round the chest. The surgeon, standing on a table near the patient, grips the dislocated arm with both hands, raises it, gently drawing it up towards the patient's head, then pulls more forcibly, and thus almost without pain causes the head of the bone to rise up into its place. Rust (a) simplifies this treatment; the patient being seated on the ground, on a carpet or flat cushion, an assistant, kneeling on the side opposite the dislocated arm, grasps the injured shoulder with both hands locked in each other, the one of his arms being carried before, and the other behind the patient. Whilst he draws the shoulder strongly and steadily downwards, the surgeon standing on the same side as the dis- located arm, grasps it with both hands at the wrist and fore-arm, draws it somewhat towards him, in order to keep it constantly extended, and raises it by a circular movement, above the head of the patient, so that the upraised arm is brought parallel with the long axis of the body. The surgeon then draw s the arm strongly towards him, as if he would raise the patient from the ground, and at the moment this is effected, the head of the bone slips back into its socket. If this do not happen, the surgeon may now give the extension of the arm to an assistant, and kneeling by the patient, places both thumbs under the protruded head, and leads it, by pressing upwards, into its socket. He then fixes one thumb firmly in the arm-pit, with the other hand grasps the elevated arm above the elbow-joint, and draws it carefully down, when, if the head of the bone be not completely carried into its socket, its complete reduction must be attempted, by more firmly sliding it over the opposed thumbs, as if over a roller. 1034. Complete reduction is characterized by the natural form of the joint, the cessation of pain and the free movement of the arm in every direction. To counteract the disposition which the upper-arm always has to become dislocated afresh, its motions should be prevented ; the arm is to be put in a sling, or fastened with some circular turns of a bandage round the body, and some may be carried beneath the elbow and over the shoulder. For the first few days cold applications are to be applied over the shoulder to remove the bruising. If a paralytic state of the arm continue, (which there is always ground to fear if after the disloca- tion there ensue a sensation of cold, of going to sleep, and weight,) stimulating friction, douche-baths, blisters, moxas, and the like must be employed. This may arise from palsy of the deltoid muscle. 1035. In this way the dislocation of the upper-arm-bone may ordi- narily again be put to rights. If violent contraction ofthe muscles occur, we must attempt to diminish it by the remedies heretefore mentioned. A small opening in the capsular ligament is mentioned by many, as the obstacle to reduction in several cases, which may be imagined if the head of the bone return to its place without noise and be directly again dislocated ; in such case the aperture of the capsular ligament must be attempted to be enlarged by moving the arm; numerous observations, however, oppose this notion. 1036. Besides the modes of reducing dislocations of the upper-arm already given, the following still require to be mentioned:— 1. In recent dislocation the patient may be laid on his back upon a table or sofa, in such way that the affected arm may be completely on the edge; a wetted roller is to be applied on the arm above the elbow, and over this a handkerchief is to be fastened. The surgeon, standing with one foot on the ground, places the heel of the other in the patient's arm-pit, so that he finds himself in a half-sitting posture by the side of the patient. By means of the handkerchief he extends the arm for three or four minutes, in which way, under ordinary circumstances, the head is easily reduced. If more power be required, a towel instead of (a) Rust, in his Magazin, filr die ge* &ardt, F., Dissert, de Methodo Mothiano hu- sammte Heilkunde voh x. p> 184.—Leon* merum luxationi reponendi. Berlin, 1820. 8vo, OF THE UPPER-ARM. 225 a handkerchief should be fastened around the arm, by which several persons may pull, whilst the heel is still in the arm-pit. In order to relax the m. biceps the fore-arm must be bent, In this mode of reduc- tion there is less extension of the limb than lateral separation of the head of the arm-bone from the blade-bone. On this account probably has Bertrandi (a) proposed, that the surgeon should place himself be- tween the legs of the patient as he lies in bed, and make use of his left foot if the dislocation be on the right, and his right foot if it be on the left $ide. Sauter's (6) treatment corresponds to this ; the patient being placed on a seat, the dislocated arm is to be drawn down perpendicularly on the body, fixed in this direction by the one hand of the surgeon, at the elbow-joint, and drawn towards the ground, whilst with the other hand the head of the bone is thrust upwards; at the same time an assistant may further the extension, by drawing down the hand, but which is not always, nor ever with violence, to be done. In dislocation inwards the arm is to be inclined more forwards. 2. The patient, being seated on a low stool, the surgeon separates the dislocated arm so far from the body, that he can put his knee into the arm-pit, and whilst he places his foot by the side of the stool, he puts one hand upon the arm-bone, immediately above the condyles, and the other upon the acromion, then presses the arm downwards over the knee, and in this way reduces the dislocation (c). 1037. If in very powerful persons, or in old dislocations, these modes of treatment be unsuccessful, and it be necessary to overcome the muscles by continued and gradually increased extension; the pulleys are to be em- ployed as most convenient. The patient is to be put on a stool, the shoulder fixed with a retractor, and this attached to a hook fixed in the wall on the patient's sound side; the extension-bandage is to be put on above the elbow, and by other bandages connected with the pulley, fastened to the other wall. The direction of the extension is to be similar to that made by assistants; and it must be made gradually, if intended to be kept up for some time. When it has attained sufficient degree, the surgeon puts his knee in the arm-pit, places his foot on the stool, and raising the head of the bone, thrusts it gently into the socket, which, at the moment when the extension is left off, usually happens without any snap. The various contrivances proposed for reducing dislocation of the. upper-arm are in part superfluous, in part unsuitable, because the mechanical violence acts too much on the head of the bone itself; or the extension cannot be made after every one's favourite direction. To these contrivances belong the ambe of Hippocrates, the machines of Oribasius, Pare, Gersdorff, Scultetus, Purmann, Petit ; the reductors of Ravaton, Hagen, Freck, Mennel, Schneider, Brunninghausen, and others. it 1038. If the dislocation have existed some weeks, the arm must, pre- vious to extension, be moved forcibly in every direction, for the purpose of loosening it, and the relaxation of the muscles must be effected by the means already mentioned. After the reduction of these old disloca- tions, an emphysematous swelling is often observed beneath the great pectoral muscle, which soon disappears under the use of dispersing (a) Tnstitutiones Chirurgicse, vol. v. Achselgelenkes; in Homeland's Journal, vol (b) Ueber die Einrichtung des verrenkten xliii. pt. i. July, 1816, p. 39. (c) Astley Cooper, p; 432. Vol. ii.—20 226 CONGENITAL DISLOCATION remedies. Weinhold cut through the tendon of the m. pectoralis major, because it did not yield in an old dislocation (a). The dislocations at the shoulder-joint may often be satisfactorily reduced, even after a long time, especially in relaxed persons; the attempt at reduction, however, is not to be carried too far, as dangerous symptoms may ensue {b). Gibson noticed a rupture of the axillary artery in reducing an old dislocation in two cases (c). ■ Dieffenbach (d), whilst making extension and counter-extension in the usual manner, in a dislocation of two years' standing, divided the tendons of the to. pectoralis major artd latissimus dorsi, the m. teres major and minor, beneath the s* in, and the false ligaments surrounding the new joint, upon which, with the extension made, the head suddenly returned into its socket, and he then applied over it a pasteboard apparatus. 1039. The Congenital Dislocation of the Upper-Arm-bone {Luxatio congenita Humeri) does not, according to R. W. Smith (e), who first noticed it, happen so very rarely. In the early period of life, before the more perfect development of the bones, and before the more powerful action of the muscles, the external appearance of deformity may possibly escape observation; but when the shoulder-bones have attained to their perfect development, when the bony processes about the joints project, and especially when the muscles operating on the shoulder-joint and upper-arm acquire their full activity, then first are the characteristic marks of congenital dislocation, not easy to be mistaken. Smith has noticed two kinds of congenital dislocation, viz., the subcoracoid and the subacromial dislocation. 1040. In the congenital subcoracoid dislocation, the head ofthe upper- arm-bone, when the arm hangs down on the side, is situated beneath the coracoid process, and the outer part of the glenoid cavity can be felt beneath the projecting acromion; if the elbow be drawn forward over the chest, the head of the upper-arm-bone slips backwards over the acromion, and completely leaves the unnatural part of the articular surface, which can now be distinctly felt; the shoulder has not its natural rounded form, but is flattened. The muscles of the shoulder and arm are much shrunk, and also the muscles passing from, the chest to the blade-bone and upper-arm, only the m. trapezius shows the least of this, and seems to be almost the onLy muscle, which still acts upon and moves the blade-bone; the diseased arm is nearly half an inch shorter. The motions of the arm are very much restricted ; elevation and abduction are not possible, and even the forward and backward motions cannot be performed without corresponding movement of the blade-bone. Although the muscles of the fore-arm are not so much shrunk as those ofthe upper, yet flexion is so difficult, on account of the atrophy of the m. biceps, that it can scarcely be brought to a right angle. TElevation is not performed (a) Zwanzig de Luxatione Ossis Humeri, Phys. Sciences, vol. 7, 1823, p. 81, and the et precipue Incisione Aponeuroseos Musculi 3d No. of the New Series of the same, Pectoralis Majoris ad cur. Luxat. inveter. 1828, p. 136.—g. w. n.] Halae, 1819. (d) Vereinszeitung, 1839, No 51. (b) Flaubert, Memoire sur plusieurs cas (e) An Essay upon the original or con- de Luxation, dans lesquels les efforts ont tte genital Luxations of the upper extremity of suivi d'accidens graves; in Rupert. g6n. the Humerus; in Dublin Journal,vol. xv. p. d'Anatomie et de Physiologic Pathologique, 236. vol. iii. fasc. i. Froriep's N. Notizen, July, 1839. No. (c) [Philadelphia Journal of the Med. and 225 and 227. ft OF THE UPPER-ARM. 227 gradually, but with a sudden jerk, in which the blade-bone also is con- siderably raised, the arm pressed to the side, and sometimes even the body bent to the other side, whilst the elbow-joint rests upon the crest of the hip-bone. The deformity exists from birth, but only first at the period of perfect development does it become more apparent. This congenital dislocation may exist on both sides at once. 1041. Examination after death of a case of subcoracoid dislocation on both sides, showed upon the one side scarcely a trace of the natural socket, but, on the contrary, immediately beneath the lower edge of the coracoid process, partially upon the ribs, partially on the axillary edge of the blade-bone, a well-formed socket of an inch and a-half diameter; this reached to the under surface of this process, and was only sepa- rated from the upper-arm by the capsule of the joint. The perfectly formed capsular ligament, extending from the undeveloped glenoid cavity, surrounded these articular surfaces. The perfectly natural ten- don of the m. biceps arose from the point of the latter, and the capsular ligament was also quite natural. The head of the upper-arm-bone va- ried considerably from its rounded form ; it was oval, and its long axis corresponded with that of the bone itself, which depended especially on the hinder part being deficient. The shaft was small and decidedly atrophic ; the position ofthe head on the coracoid process varied, accord- ing to the rotation of the arm inwards or outwards. Upon the other side the deficiency of the articular surface was confined to its inner edge, which was entirely wanting for a thumb's space from above down- wards. The inner edge of the joint-surface was formed by a long ridge, which passed down from the under surface of the coracoid pro- cess ; the tendon ofthe m. biceps and the capsule were perfectly formed. 1042. Smith saw and examined after death congenital subacromial dislocation on both sides. The coracoid process projected considerably, as did also the acromion ; the joint-surface beneath was not, however, to be felt; the projection of the acromion, as well as the flattening of the shoulder, was less decided than in subcoracoid dislocation ; the flattening was confined to the front of the joint. The head of the upper- arm-bone formed a distinct swelling on the back of the blade-bone, beneath and behind the point of the acromion, close on the under sur- face of its spine. The iupper-arm did not stick out from the side, and the fore-arm was rotated invyards. Internal examination of the joint presented no trace of an articular cavity in the usual place, but a well- formed articular pit, surrounded by a capsular ligament, arising from the outer surface of the neck of the blade-bone, which was broader above, and completely reached the under surface of the acromion; the tendon of the m. biceps was perfect, and firmly attached to the upper and inner part of the unnatural joint's surface, the direction of which was forwards and outwards. The head ofthe upper-arm-bone exhibited the same oval form as in the subcoracoid dislocation, only that the fore part of the head was in this case deficient. The little tubercle formed a considerable projection, long and curved, so that it had remarkable resemblance to the coracoid process of the blade-bone. 1043. That these dislocations are congenital and not of accidental occurrencef Smith thinks he has found proof, as regards subcoracoid 228 DISLOCATION dislocation, in the absence of previous injury, in the joint not being the seat of pain, swelling, and the like, but especially in the unhurt con- dition of the capsule and of the tendon of the m. biceps, as well as in the simultaneous existence of apes equinus in the same patient; in the form of the head of the upper-arm-bone being peculiar, and quite dffer- ent from any change which he has noticed as consequent on disease or in old dislocation of the usual kind. Smith is not disinclined to find a resemblance between this congenital dislocation and that described by many writers, as partial dislocation of the upper-arm-bone, as well as that arising sometimes from rheumatic affection ofthe shoulder-joint, (A. Cooper,) or as an unusual atrophy of the upper-arm, (Curling.) He also supposes that in subacromial dislocation, the absence of the natural joint-surface, the complete resemblance of both unnatural articular cavi- ties, the uninjured state of the tendons and ligaments, as well as the peculiar form of the head of the upper-arm-bone, speaks in favour of the congenital existence of this dislocation. With the few examina- tions which have been as yet made of this subject, it is not, however, possible to determine with certainty whether the cause of the disloca- tion should always be sought for in an original deficient formation of the joint surfaces, or whether such dislocations be not produced by the peculiar position of the child, and during birth, and the particular changes subsequently found, on examination, do not depend on the long continuance of the dislocation, and the previously incomplete de- velopment of "the bones, and so on. In support of this opinion at least speaks an observation of Guillarh (a), who reduced a congenital dislocation of the upper-arm-bone by horizontal extension after sixteen years. The reduction was effected after several futile attempts, and when effected it relapsed twice, and was again reduced. After the last reduction, how- ever, the upper-arm for two years and a-half was not displaced, and the move- ments of the limb were almost entirely natural. VII.—OF DISLOCATIONS OF THE FORE-ARM. 1044. These dislocations are distinguished into dislocations of the fore-arm from the upper-arm, and the separate dislocations ofthe spoke- bone and cubit. A.—OF THE DISLOCATION OF THE FORE-ARM AT THE ELBOW-JOINT (Luxatio Antibrachii, Lat.; Verrenkung des Vorderarmes, Germ.; Luxation de PAvant-bras, Fr.) 1045. Complete dislocations of the elbow occur but rarely, on ac- count of the great strength of the joint, and are always accompanied with considerable tearing of the soft parts. The dislocation may be either backwards or lateral, but dislocation forwards is impossible with- out simultaneous fracture of the olechranon. 1046. The dislocation backwards is the most common, and always the most complete. The chronoid process of the cubit gets behind the (a) ReVue Medicale, Aug. 1840. OF THE ELBOW-JOINT. 229 pully-like joint-surface of the upper-arm-bone, and rests in the pit formed for receiving the olechranon. The joint-surfaces of the upper- arm-bone are thrown upon the front of the spoke-bone and cubit, be- tween the coronoid process and the insertion of the m. biceps. If the lateral ligaments are torn, the muscles surrounding the joint, the skiny and even the brachial artery maybe torn. The olechranon forms a con- siderable projection on the back of the upper-arm, whereby the lower part of the m. triceps is twisted, and above the projection of the ole- chranon the upper-arm seems to be somewhat hollowed. On the front of the joint is felt a large hard swelling, beneath the tendon of the m. biceps; the fore-arm is fixed in a half-bent position, except when there is considerable tearing of the ligaments. 1047. If the cubit alone, be thrown backwards, without simultaneous- dislocations of the spoke-bone, behind the upper-arm-bone, the deformity of the joint is considerable, the fore-arm and hand being twisted in- wards, the olechranon projecting, whilst the head of the spoke-bone re- tains its-natural position ; on the outside ofthe elbow-joint a remarkable projection, and on the inner a pit; the fore-arm cannot be straightened except by violence, which will reduce the dislocation, neither can it be bent farther than to a right angle (A. Cooper) ; the arm has been, how- ever, observed motionless in extension, and every attempt at bending was painful and unsuccessful; pronation and supination could,however,. be freely performed, the latter somewhat less than the former. If the fore-arm be but little bent, the annular ligament of the spoke-bone re- mains Uninjured; but on greater bending, this ligament, the upper part of the interosseous ligament, and several muscular fibres are torn, and! the head of the spoke-bone rests against the upper-arm. The distin- guishing marks are, projection of the olechranon^ and the twisting of the fore-arm inwards {a). 1048. The lateral dislocation may be either complete or incomplete; that outwards is more frequent than that inwards. In the former, the internal joint-surface of the upper arm-bone projects more or less, and the joint-surface of the cubit is thrust outwards; the point of the ole- chranon rests on the back of the upper-arm, in consequence of which the fore-arm is fixed in a slightly bent position. In the latter, a part of the sigmoid cavity projects, more or less on the inner, and the joint- surface of the upper-arm-bone on the outer side ; the fore-arm is perma- nently bent. These dislocations cannot happen wkhout tearing of the ligaments of the elbow-joint; even the muscles ofthe fore-arm maybe torn at their origin; hence also frequently, the fore-arm is- not so fixed in its position, as in dislocation backwards. In complete lateral disloca- tion, the projection of the ends of the fore and upper-arm are much jnore decided than in the incomplete, and on account of the great tearing of the soft parts the fore-arm is moveable in every direction. As in dislocations of the fore-arm, the joint-surfaces are mostly still in contact so there may be crackling on moving the joint. 1049. Dislocation backwards of the fore-arm, is mostly produced by a fall upon the outstretched hand, whilst the fore-arm is bent and th& (a) Cooper, Astley, above cited, p. 472.— N. Notizen, July, I839TNb. 228.—Michaelis Revue Medicale, 1830.—Sedillot; in Ga- in von Graefe and Walther's Journal,,vol.. zette Medicale, 1839, No. 24.—Froriep's xxix, p. 296. 20* 230 DISLOCATION upper fixed. If the fore-arm be violently forced to one or other side, lateral dislocation may be produced. 1050. Dislocations of the elbow-joint always produce severe inflam- matory symptoms, and may lead to gangrene and nervous symptoms; generally, however, they are not dangerous. If left alone, they in a short time become irreducible; the dislocation backwards has, how- ever, been reduced after existing two or three months. If in disloca- tion backwards, the joint-surfaces of the upper-arm-bone project through the skin, the case is always very serious, though experience proves that a cure may take place without any particular symptoms. If with this dislocation, there be tearing of the m. biceps, of the brachial artery or of the median nerve, the case is exceedingly dangerous. The com- plete lateral dislocations are more severe than those backwards. The incomplete dislocations are neither great nor difficult to reduce; even if they be mistaken the consequences are less important, if only early motion be used. (1) Astlet and Bransby Cooper (a) effected reduction after three months. Malgaigne and Lisfranc reduced a dislocation of the elbow backwards, of four- teen weeks standing in.a boy ten years old. 1051. The reduction of dislocations of the elbow is not difficult, if undertaken sufficiently early. Extension and counter-extension are performed by two assistants, one of whom grasps the fore-arm above the wrist with one hand, and its upper inner part wilh the other; the second assistant places one hand on the shoulder, and with the other draws back the lower part of the upper-arm. The surgeon, in the dislocation backwards, grasps the elbow with both hands in such way, that the four fingers of the one are upon the front, and the thumb upon the back of the upper-arm, with which, when the extension is suffi- ciently made, he can pfess the olechranon downwards and forwards, Astley Cooper puts the patient on a stool, places his knee on the inside of the elbow, grasps the wrist and bends the arm; at the same time he thrusts his knee against the spoke-bone and cubit, to free them from the upper-arm-bone, and whilst he keeps up the pressure with his knee, he strongly but slowly bends the arm. The arm may also be violently bent around a bed-post. After complete reduction, the elbow-joint is to be surrounded with moistened compresses, a 00 bandage applied and the arm to be put in a sling. The supervening inflammatory symp- toms must be removed by a proper antiphlogistic treatment, and the continual employment of cold applications. The bandages should be removed every two days, so that gentle movements of pronation and supination may be made, in order to ascertain the actuality of the re- duction. The dislocation of the cubit alone, is always easily reduced by one of the prescribed methods; but if, as in the cases mentioned by Sedilnot, the fore-arm be extended, extension must be made, and then the arm bent. If the coronary ligament of the spoke-bone be not torn, that bone retains its proper position on the cubit; but if it be torn, the spoke-bone must be pressed especially into its place, and the recurrence of its displacement prevented by a splint placed along its back. If in dislocation backward, the lower ends of the upper-arm-bone be driven through the skin, the reduction is not thereby rendered difficult; it must be (a) Above cited, p. 441. OF THE ELBOW-JOINT. 231 performed as soon as possible, and the wound closed. If severe inflammation exist, sawing off the projecting ends may alone be sufficient to lessen the symptoms. In tearing of the brachial artery and median nerve, the former must be tied before the reduction; however, the probable danger of gangrene in this case may render am- putation necessary. 1052. The reduction of the lateral dislocation must be effected in the way mentioned, only the joint-ends of the bones must be pressed, with both hands, in the opposite direction to that in which they are dislocated. In these dislocations also Astley Cooper makes extension upon the knee, as already stated. Violent extension of the arm is also often sufficient. The inflammatory symptoms in lateral disloca- tion are always more severe than in that behind; therefore also is a more strict antiphlogistic treatment required. 1053. Though dislocations of the elbow-joint have great disposition to become irreducible, yet if severe inflammation have come on, reduc- tion must not be undertaken till that has been removed. Before attempting the reduction of an old dislocation, repeated motions of the fore-arm are to be made for several days previously. If repeated at- tempts do not succeed, violent extension must be abstained from, because otherwise severe inflammation is to be feared. In dislocation of the elbow-joint forwards, which can only occur with fracture of the olechranon, the same treatment must be adopted as in that fracture, with simulta- neous antiphlogistic remedies. *' 1054. The dislocation backwards of the' spoke-bone is the most common, but occurs more rarely.in adults, than in young persons, in whom it does not take place at once ; but by the habit of pulling the child by the hand a considerable relaxation of the articular connexions of the spoke-bone is produced, which is often manifested by great projection of its end, and painful swelling of its joint, and if the violence be persisted in, dis- location of the radius backwards is produced. At the moment when the dislocation occurs the patient feels severe pain, the arm is bent, and the hand prone; supination is impossible and increases the pain; the hand and fingers are moderately bent; the upper end of thebone forms a distinct projection. -1055. The dislocation forwards of the upper end of the spoke-bone, is the consequence of violent supination. The fore-arm is slightly bent, but cannot be brought to a right angle with the upper arm; if the fore- arm be suddenly bent, the head of the bone strikes against the front of the upper-arm-bone, by which the flexion is suddenly stopped. The hand is prone, but can be brought again perfectly into pronation and supination, although pronation is nearly complete. The head of the spoke-bone can be felt, especially in rotation, which together with the continued flexion ofthe fore-arm are the most decided characters. Boyer doubts the possibility of dislocation forwards without fracture at the same time; in which case the supination necessary to produce this dislocation is prevented by the lesser head of the upper-arm-bone, which thrusts violently against the head of the spoke-bone. This opinion, however, is contradicted by foreign and by my own experience. A. Cooper (a) has seen the dislocation of the spoke-bone for- wards six times; I have seen it twice, and once as an old dislocation in a corpse. The spoke-bone separates from the cubit, at its connexion with the coronoid process*, ^nd its head is drawn back into the hollow above the outer condyle of the upper-arm- bone, and upon the coronoid process of the cubit. Examination shows the head of (a) Above cited, p. 474. 232 DISLOCATION the spoke-bone drawn up into the cavity above the outer condyle of the upper-arm- bone, the cubit in its natural place; the coronary ligament of the spoke-bone, the chorda transversalis, the front ofthe capsular ligament and the interosseus membrane are partially torn, and in consequence of the tearing of the latter the separation of both bones is produced. Rouyer (a), Villaume (b), and Gerdy(c) have also seen dislocation of the upper end ofthe spoke-bone forwards; B. Cooper (d), noticed it once with fracture ofthe inner condyle of the upper arm, and once with a fracture of the spoke-bone an inch and a-half from its head. Simultaneous dislocation of the spoke-bone forwards and of the cubit backwards, have been noticed by Bulley (e) and by Vignolo (/). A longitudinal dislocation of the spoke-bone, in which the head was displaced laterally and above, over the outer condyle of the upper-arm-bone, was seen by Adams (g). 1056. The reduction of this dislocation of the spoke-bone is easy. The fore-arm is extended with one hand "whilst with the other, the head ofthe spoke-bone is pressed into its place, and the fore-arm brought into supination, in the dislocation backwards, and into pronation, in that forwards, and should be kept in place after the joint has been sur- rounded with compresses and circular bandages, by a splint placed on its front or back part. In from twenty to twenty-five days, this apparatus may be entirely removed and careful motion ofthe arm permitted. According to Astley Cooper, the reduction of the dislocation forwards of the spoke-bone, requires much force, and he enumerates cases'in which it was im- possible ; from experiments on the dead body, however, the extension of the hand, in which the spoke-bone alone was acted on, was the most preferable; in this way I have also easily effected the reduction. If the appearances mentioned (par. 1054) indicate the relaxation of the articular connexions of the spoke-bone, all dragging and movement of the hand must be avoided, the fore-arm must be fixed in a half-bent position, and the relaxation ofthe ligaments removed by suitable applications and rubbings in. VIIL—OF DISLOCATIONS OF THE WRIST. (Luxatio Carpi, Lat.; Verrenkung des Handgelenkes, Germ.; Luxation du Poignet, Fr.) 1057. Three kinds of dislocation may take place at the wrist-joint:— 1, the dislocation of. both bones of the fore-arm; 2, the dislocation ofthe spoke-bone; and, 3, the dislocation of the cubit. 1058. Dislocation of the hand from its connexion with both bones of the fore-arm, may be forwards, backwards, or to one or other side; the latter two kinds can only be incomplete, the former two more or less perfect. In the dislocation forwards, the hand is bent much backwards, and there is a great projection upon the inside of the wrist; the fingers are bent as well as the fore-arm. In the dislocation backwards, the very contrary symptoms occur; fracture of the spoke-bone mostly ac- companies it (A. Cooper.) In dislocation on one or other side, there is always distortion of the hand, adduction or abduction, and a projec- tion on the radial or ulnar side. (a) Journal General de Medecine, April, (d) Above cited, p. 457. 1818. (e) Prov. Med. and Surg. Journal, 1841. (6) Froriep's Notizen, March, 1828, No. (/) Revue Medicale, 1841. 429. (g) Dublin Journal of Medical Seience, (c) Archives Generales de Medecine, 1840, vol. xvii. p. 504. March, 1S34. OF THE WRIST. 233 Dislocation ofthe wrist-joint, mentioned from the earliest time, has been doubted by Dupuytren, as he denied its existence, and almost its possibility, and proved the presumed cases of such dislocations were fractures of the lower end of the spoke- bone. This opinion is almost generally received, and by a strict criticism of the previous observations of such dislocations supported, against the opinions of Petit, Desault, Boyer and others. But few observations have excited doubts against the statements of Dupuytren. Voillemier has however shown the existence of such dislocations, by the most careful examination of a complete displacement of the wrist backwards and of the bones of the fore-arm forwards, and has given, as dis- tinguishing marks between this dislocation and fracture of the lower end of the spoke-bone, that in the latter there is a bending in on the outside of the fore-arm near the joint, which is wanting in the former; the hand is abducted, but in dislo- cation, the whole hand is twisted towards the outside of the fore-arm; there is swelling at the fore and under part of the fore-arm, which is wanting in dislocation; but little decided projection of the ends of the fracture forwards and backwards, whilst in dislocation a projection of seven or eightlines backwards is formed by the wrist-joint, and forwards by the bones of the fore-arm; great breadth of the bones on the carpo-metacarpal surfaces, but in the dislocation only the natural breadth; the spoke-bone is shorter, but in dislocation of equal length as in the sound arm; the styloid process ofthe spoke-bone has its natural place at the wrist, but in dislo- cation it is situated on the inside of the wrist, to the inner side of the scaphoid bone; the styloid process ofthe cubit projects upon the back of the fore-arm, but in dislo- cation on the front; it projects as far or farther down than that of the spoke-bone, whilst in dislocation the styloid processes retain their reciprocal position; the po- sition of the hand, usually though not always, is bent backwards, in dislocation commonly bent. Compare par. 653, where is given the literature of fracture of the lower end of the spoke-bone; Voillemier, in Archives Generales de Medecine, 1842, March; Prinz, G„ Ueber den Briich am unteren Ende des Radius, Erlangen, 1842. 1059. The cause of this dislocation is always, a very violent bending of the hand in this or that direction; hence the ligaments are always much torn, and the tendons on the side of the dislocation very severely torn and stretched. Rarely are other of the soft parts besides the liga- ments ruptured. 1060. The reduction of dislocation of the hand is not difficult. Ex- tension of the hand and pressure upon the carpal bones in the contrary direction to which they are dislocated, is sufficient. After reduction, the wrist is to be wrapped up in moistened linen, and fastened with a circular roller. If there be a disposition to re-dislocation, which in the disloca- tion forwards and backwards is generally the case, a splint must be placed on the palmar and dorsal surfaces ofthe hand, and confined with a circular bandage. Severe inflammatory symptoms always arise, which require suitable treatment and cold applications. Subsequently, aromatic applications, spirituous rubbings, and so on must be used to disperse the often long-continued swelling of the wrist-joint. 1061. In dislocation of the spoke-bone alone, which is rare, it is dis- placed on the front of the carpus, resting upon the navicular and great multangular bones. The outside of the hand is twisted backwards, and the inside, forwards; the end of the spoke-bone forms a projection on the front of the carpus, and its styloid process is no longer opposite the great multangular bone. The cause of this dislocation is a fall on the hand whilst turned backwards. The treatment is the same as that for both bones. 1062. In dislocation of the cubit, which is more rare, and in which the sacciform membrane is torn, the bone usually projects backwards. 234 DISLOCATION forming a protuberance on the back ofthe wrist, and although it can be easily pressed into its natural place, the deformity recurs when the pres- sure is withdrawn. The diagnostic sign is the projection of the cubit over the cuneiform bone and the dislocation of the styloid process from the line of the metacarpal bone of the little finger. Pressure restores the bones to their place, in which they are to be retained by splints on both surfaces of the arm and compress on the end of the cubit. IX.—OF DISLOCATION OF SINGLE BONES OF THE HAND. 1063. The great bone (1) alone, can be displaced from its connexion with the scaphoid and semilunar bones, backwards, in consequence of violent bending of the hand; by which a circumscribed swelling is pro- duced on the situation of the great bone, in the direction of the middle finger, which disappears on pressure, but recurs when the pressure is withdrawn. The reduction is easily effected by pressure, upon the pro- jecting head-of the bone, or if this be insufficient, by simultaneous pulling at the fore and middle finger. The hand is to be kept extended, until it be laid upon a flat board, pressure made upon the projection with a compress, a splint applied, and the whole fixed with a roller. If it remain, in a slight degree, it is not accompanied with any incon- venience. (1) Not the trapezial bone as stated by B. Cooper and others. Gras (a) has described a dislocation of the pisiform bone. The great and unciform bones are often thrust somewhat out of their place, in consequence of the relaxation of their ligaments, so that in bending the hand they form a projection on the back of the wrist, and the hand cannot be at all used with- out supporting the wrist. Strips of sticking plaster and a bandage are usually sufficient for supporting the wrist, and the parts may at the same time be streno-th- ened with the douche bath,, and rubbing in volatile ointments and the like. 1064. The metacarpal bone ofthe thumb is alone subject to dislocation from its connexion with the trapezial bone, in consequence of violent bending. The projection which the displaced end of the bone forms above, is very slight, the thumb is bent towards the palmar surface, and cannot be straightened. In reducing it, the extension and counter-ex- tension are made at the thumb and carpus, and the displaced joint-end is to be pressed into its place. To retain it there, the thumb should be enveloped in compresses and a circular bandage, and a thin splint fastened on its hinder surface. If the dislocation be mistaken, which easily happens when swelling exists, the movements of the thumb are permanently prevented. 1065. The phalanges of the fingers may be dislocated forwards and backwards, by violent bending in either direction. In the dislocation forwards, the dislocated bone is bent backwards, the other fingers are bent, the projection of the dislocated joint-surface is on the palmar side ; in dislocation backwards the contrary happens. In dislocation ofthe thumb upwards from its metacarpal bone, the thumb stands almost at a right angle on the metacarpal bone, with the nail-joint bent; and the (a) Gazette Medicale, vol. iii. 1835. OF THE HAND AND FINGERS. 235 head of the metacarpal bone forms a large projection on the volar surface. If these dislocations have existed only a short time, they cannot be reduced. The reduction requires great force, as the edges of the joint-surfaces resist each other, and must be separated. This can only be effected, by means of a clove hitch applied round the phalanx. If in compound dis- location the joint-surfapes project out of the soft parts, and their reduction be not possible, they must be cut off', and their replacement effected; this in one case of compound dislocation of the thumb I performed with the best success. Dislocations of the thumb from the metacarpal bone, most frequently occur, and cause greatest difficulty in their reduction. According to Roser (a), who has col- lected the various opinions upon this dislocation, together with his own observations, the dislocation is always direct, and on the same side on which the violence has occurred. If a person, fall on the ground with his thumbs outstretched, a dislocation takes place on the back, and not in the front of the hand; the thumb is fixed in hyper-extension or dorsal flexion, and forms, often almost a right angle with its metacarpal bone, which makes a considerable projection in the hollow of the hand, and has frequently been mistaken for the dislocated projection of the head of the phalanx, as stated by Fincke (b). I possess an old dislocation upwards of the thumb, in which the position of the two bones corresponds entirely with this state- ment. The difficulty of reducing this dislocation is often so great, that laying bare the old bone, and cutting off the interfering tendons and ligaments has been recom- mended, (Desault, Dupuytren,) and even the removal ofthe projecting end ofthe bone itself, (Evans, Vidal, Norris). In general the jutting against each other of the edges of the joint-surfaces is considered as preventing the reduction; A. Cooper held the interposition of the sessamoid bones to be the cause; Lisfranc and Dupuy- tren place it in the remarkable position ofthe tendon ofthe m. flexor longus, which is displaced'backwards and downwards, so that it lies midway between the phalanx and the head of the metacarpal bone. Hey thinks the cause to be in the lateral ligaments, between which the head of the metacarpal bone, on account of its wedge- like shape, slips out more easily than it can be got back again. Vidal and Mal- gaigne conclude from their observations on the dead body, that the hindrance depends on the locking-in of the metacarpal head between the short muscles of the .thumb. Pailloux, Lawrie, Blechy, and Roser, by their experiments, found the interposi- tion theory confirmed, and the latter could produce the interposition, as often as he pleased, if only the front of the capsule were torn or cut across, and at the same time a little lengthways. In consequence of these various opinions, different proposals have been made to effect the reduction. According to Hey, the bones may be brought into place by pressure without extension; according to Charles Bell, bending the joint with proper pressure. Fincke applies his two forefingers on the back of the metacarpal bone, presses with it against the thumb, whilst his two thumbs are firmly placed against the under surface of the metacarpal bone, and thus easily effect its replacement. Charles Bell's proposal of subcutaneous division of the lateral ligaments with a contaract-needle has been practised by Liston and Reinhardt (c). Roser, from his experiments on the dead body, determines that the reduction can only be effected, when the bone is put into the position out of which it was thrown, and also if the dislocated phalanx be first put in hyper-exten- sion, (dorsal flexion,) and from this be moderately depressed upon the metacarpal head. From all this it appears that the joint must be neither straightened nor bent too much, the direction of the thumb must always be such, that its long axis be directed perpendicular to the rounded surface or the metacarpal head. If this direction be given to the bone, the titling in and interposition, and with them the obstacle, dis- appear. I have, in six cases of dislocation of the thumb from the metacarpal bone, been only once unable to effect the replacement perfectly, in which the dislocation (a) Die Verrenkungen des Daumens von (6) Casper's Wochenschrift, 1838. No.. seinem Mittelhandknochen; in Archiv, filr 18. physiologische Heilkunde, ] 843, pt. 2. (c) Preuss. Vereins Zeitung, 1836. No. 23. 236 DISLOCATION had already existed some days. My practice in this reduction is, to apply a wette<* bandage around the thumb, the ends of which are rolled round my own hand, and whilst with this I pull directly upwards, the left hand is placed on the metacarpus and pressed down, whereupon I bring the thumb into the straight position. I must however confess, that all these cases I had considered as dislocations of the thumb downwards. X.—OF DISLOCATION OF THE THIGH-BONE. (Luxatio Femoris, Lat.; Verrenkung des Oberschenkels, Germ.; Luxation de la Cuisse, Fr.) Boyer, above cited, vol. iv. p. 278. A. Cooper, above cited, p. 37. Travers, B., in Med. Chir. Trans., vol. xx. p. 112. [Warren, A letter to the Hon. J. Parker, containing remarks on the Dislocations of the Hip-Joint. 8vo. 1826.—g. w. n.] 1066. Dislocations of the thigh may occur in four directions:— 1, backwards and upwards upon the back of the hip-bone ; 2, inwards and downwards into the oval hole; 3, backwards and downwards into the isehiatic notch ; 4, upwards and forwards on the horizontal branch of the share-bone. The former of these is most frequent, the fourth more rare than the second, and the third the most rare, and even denied by many writers. The capsule, as well as the round ligament, is torn in every one of these dislocations, though in that inwards and downwards it may remain entire. Astley Cooper (a) gives other proportions in reference to frequency of the several dislocations of the thigh-bone ; he says that the dislocation backwards and upwards is the most frequent, next that into the isehiatic notch, then that on the oval hole, whilst the dislocation on the share-bone is most rare. Besides these four kinds of dislocation of the thigh-bone, some assume a fifth, viz., directly downwards, just as others consider the above four kinds only secondary, in which the head ofthe bone, if there be no fracture of the socket, always leaves the socket at its lower edge, and is first situated between this part and the tuberosity of the haunch-bone, though only for a short time. [Although repeated dislocation of the thigh-bone in the same person is not very common, yet a few years ago there was a woman in St. Thomas's Hospital, under Tyrrell's care," whose hip was dislocated the ninth time. Unfortunately I do not recollect the kind of dislocation.—j. f. s.] 1067. In the dislocation upward and backwards, the head ofthe thigh- bone gets upon the outer surface of the hip-bone, and rests between the external iliac pit and the m. gluteus minimus; hence the foot is an inch and a-half, or two inches and a-half shorter, the toes are turned towards the tarsus ofthe other foot; the knee and foot turned inwards; the limb cannot be separated from the other, but the adduction which exists can be increased, that is, it can be bent obliquely over the other. If there be not any considerable effusion of blood or swelling, the head of the thigh-bone may, by rotation ofthe knee, be felt distinctly upon the outer surface of the hip-bone ; the trochanter projects less and is nearer the spine of the hip-bone ; the rounded form of the hip is lost. Such exten- sion ofthe limb as can be made with the hand does not restore its natural length. If the dislocation be old, the limb retains its position inwards, and the patient can tread only upon the toes; notwithstanding the great (a) Above cited, p. 39 • OF THE THIGH-BONE. 237 shortening ofthe limb, the patient will gradually be able again to walk. Under these circumstances the somewhat flattened head of the thigh- bone lies on the outside ofthe hip-bone, in a corresponding hollow, sur- rounded by a newly formed bony mass. The least and middle gluteal muscles are extended, and converted into a cellular fibrous mass ; the thigh diminishes in size. This dislocation is produced by a fall, or some other violence, which drives the thigh inwards and forwards. It hap- pens the more easily, the farther the violence acting on the thigh-bone is distant from the hip-joint, and if at the same time the gluteal muscles be contracted. 1068. In the dislocation inwards and downwards, the head ofthe thigh- bone gets into the oval hole. Although the condition of the socket seems most favourable for this kind of dislocation, it, however, happens very rarely, because it can be only produced by a fall, when the thighs are far apart. The affected limb is two or three inches longer; the head of the thigh-bone is felt, by pressing with the hand upon the upper inner part of the thigh towards the perinaeum ; the trochanter is less prominent; the body is bent forwards, on account of the extension of the m. psoas and iliacus, but when the body is erect the limb projects; the knee is wide apart from the other, and cannot be brought near it without great pain; the foot is also separated from the other, but cannot be twisted either inwards or outwards. The thigh seems as if united, with the pelvis and has no mobility. If the dislocation be left alone, the limb retrains immoveable, in the position described; it has, however, been noticed (a) that the external obturator muscle is destroyed, and that the ligament of the oval hole is converted into a mass of bone, which sur- rounds the head of the thigh-bone as a socket in which it can move. Ollivier (b) describes a dislocation of the thigh-bone directly downwards, of which he gives .the following symptoms:—the thigh slightly bent at the hip-joint, was a little rotated inwards, and separated from that of the other side; the bent thigh as well as the foot was rotated forcibly outwards; a line drawn from the iliac spine downwards falls upon the inner condyle of the thigh-bone; no sensible lengthening; the m. sartorius and tensor vaginae femoris projected slightly; the outer part of the m. triceps was much stretched; the flank showed a deep fold ; the great trochanter was directed downwards and backwards; the buttock rounded and prominent; the head of the bone was not in the least felt; the extension of the thigh was impossible; the leg might be straightened; adduction, although painful and little, was easy; abduction could be increased. 1069. Dislocation backwards and downwards into the isehiatic notch, happens very rarely, because it can only occur, when the thigh is so near the trunk and the other thigh, that it is scarcely possible. Boyer considers this as secondary, after dislocation ofthe head of the thigh-bone upwards and backwards, when the thigh is much bent and adducted. In this dislocation, the head of the bone lies on the m. pyriformis, between the edge ofthe bone which forms the upper part of the isehiatic notch, and the sacro-ischlatic ligaments, somewhat above the mesial line of this cavity. It is very difficult to distinguish this dislocation, because the length and direction of the limb are but little changed. The extremity is ordinarily half an inch shorter; the trochanter is behind its usual (a) Astley Cooper, above cited, p. 66. (b) Nouvelles Especes de Luxation du Femur"; in Archives generales de Medecine, June, 1824. Vol. ii.—21 238 DISLOCATION place ; the head ofthe thigh-bone can only be felt in emaciated persons, when the thigh-bone is brought forwards as far as possible; the knee and foot are turned inwards, though, however, not so much, as in the dislocation upwards and backwards; when the patient stands he only touches the ground with his toes; the knee is somewhat projected and slightly bent; the limb is fixed in its position. 1070. In the dislocation upwards and inwards the head of the thigh- bone gets beneath Poupart's ligament, upon the horizontal branch of the share-bone; it is rare, and produced by violence which thrusts the thigh backwards and the pelvis forwards ; for instance, a careless step with the foot into a hole, in which case the upper part ofthe body is bent back- wards. The diagnosis is easier than in any other dislocation of the thigh. The limb is fixed in strong extension, abduction, and great rotation out- wards ; it is about an inch shorter, the trochanter is nearer the spine of the hip-bone and less prominent; the head of the bone is felt on the horizontal branch of the share-bone; the buttock is flattened and stretched; the vessels of the thigh are twisted inwards, and pulsate dis- tinctly, and even perceptibly, to the eye. In every attempt to bend the thigh, or draw it inwards, severe pain is produced. In old dislocations of this sort it has been found, that the form of the head ofthe thigh- bone, lying between Poupart's ligament and the share-bone is changed, that it is more flattened, and around the neck a kind of bony collar is produced. Upon the distinguishing characters between the dislocations of the thigh and frac- ture ofthe neck ofthe thigh-bone see par. 671. 1071. As regards the prognosis of dislocations of the thigh, they are usually not accompanied with any unfavourable symptoms like those of the shoulder-joint, as after the reduction is completed, in general, the inflammation and swelling soon subside ; however, in uncommon cases the inflammation runs on to suppuration, and causes the patient's death {a). The reduction of these dislocations is more difficult than all others, especially in robust persons. The dislocations inwards and downwards, and inwards and upwards, are generally more easily reduced than that backwards and upwards. The earlier reduction is attempted, the more quickly is it effected. At what time the reduction of a neglected disloca- tion is still possible, is probably very different, in different persons, as in some cases it can be effected after some months, but in others, after several weeks is impossible. To what degree the movements of the thigh are hindered by an old dislocation, has been already mentioned, In speaking of the several kinds. 1072. As the reduction of dislocation of the thigh always finds con- siderable opposition in the powerful contraction of the muscles, so is it in no dislocation of greater consequence than in this, to lessen these con- tractions by such remedies as effect relaxation in the whole organism. The patient should be bled according to his constitution, should be put in a warm bath, and every ten minutes a grain of tartar emetic given till nausea ensues. It must, however, be determined according to the patient's condition, whether previous to the use of these means, an at- (a) Astley Cooper, above cited, p. 7. OF THE THIGH-BONE. 239 tempt at reduction should be made, and if this attempt fail, then to re- sort to these remedies. 1073. The reduction itself consists in proper extension and counter- extension, which is effected either by assistants or by means of pulleys. Of the former practice in general the French, and of the latter the English surgeons speak in favour. I myself also consider the latter the most certain and most suitable, especially if the dislocation be already of long standing. 1074. In extension and counter-extension by assistants, we proceed in the following manner; the patient lies on a table covered with a mat^ tress: a handtowel folded together (about four fingers wide) is to be placed with its middle on the front of the foot, above the ankle, previously well covered with linen or wool, carried backwards and tied ; and its ends given to an assistant. A similar towel is to be applied on the inner side ofthe sound thigh, also previously defended properly against pres- sure with a roller, and the one end is to be carried over the flank, the other outwards over the buttock, where the ends are tied and given to an assistant. For the purpose of fixing the pelvis still more firmly, a folded cloth is to be carried round it, between the crest of the hip-bone and the trochanter, the ends of which are to be tied together on the sound side, and given to an assistant. The number of assistants must be equal at the points of extension and counter-extension. The practi- tioner places himself on the outside of the dislocated thigh, and di- rects the extension. In dislocation outwards and upwards, the extension must be made obliquely from, without inwards and a little from behind forwards. When it is sufficiently advanced, the practitioner must with both hands press the trochanter downwards and backwards, in order to thrust the head of the bone back into the socket. In dislocation inwards and upwards ex- tension must first be made in the direction outwards, the practitioner then places both his hands upon the upper inner part of the thigh, and presses it upwards and outwards, whilst the assistants, without giving up the extension, incline the lower part of the limb inwards. In disloca- tion upwards and, inwards, the extension must be made nearly in the axis ofthe body, and the head ofthe thigh-bone pressed downwards and out- wards. In the dislocation backwards and downwards, in which Boyer (a) states that it is probably only a secondary displacement in the dislo- cation upwards and outwards, the head of the bone must be first brought to its previous situation, and then treated as a dislocation upwards and outwards (6). 1075. Wattmann, Kluge, and Rust have proposed methods of re- placement, in which, by diminution ofthe muscular contraction, and by rubbing the bones, a less outlay of power is required. 1076. According to Wattmann's (c) plan, the patient, lying on his back, is to be merely fixed by resting the healthy limb against the bed- stead, and by pressure upon the knee to prevent it being bent. Only in great resistance of the muscles, should the pelvis be fixed by a long cloth carried above the hip, and fastened to a rafter between the two (a) Above cited, p. 288. (b) Ibid., p. 302. (c) Ueber Verrenkung am Huftgelenke und ihre Einrichtung, Wien, 1826; with a popper-plate. 240 DISLOCATION bedposts. For the abduction of the thigh, a strap furnished with a roller is sufficient; one or two assistants are employed. In the dislocation inwards and doionwards, the thigh-strap is applied as high as possible, upon the thigh, with the buckle forwards; an as- sistant lays hold of the dislocated foot, in the position in which it is kept by the dislocation, above the ankle, and holding firmly, draws it slightly downwards. The surgeon standing near the patient, rests with. the one hand upon the crest ofthe hip-bone, and with the other hand so seizes on the bandage, that it is directed under the fore and upper iliac spine, and crosses the axis of the thigh at a right angle. He then, with the requisite force, pulls outwards parallel to the direction of a line which may be supposed- to be drawn a hand's breadth behind the an- terior upper iliac spine on the sound side, through the body to the tip of the same process on the ailing side. In this way the extensors and flexors are but slightly stretched, and the rotating muscles first par- ticipate in the flexion, when the head approaches the edge of the socket. By the ordinary flexion of these muscles the head may be lifted into the socket. In dislocation inwards and upwards, an assistant lays hold of the ailing foot above the instep, carries it upwards upon the outside of the sound foot, and keeps it in this position without drawing, whilst the pull, with the bandage, applied as in the former case, is made by the surgeon in a line supposed to be drawn from the tip of the fore and upper iliac spine of the sound side towards the trochanter of the dis- located thigh outwards, and obliquely upwards. So soon as the toes hitherto pointing outwards, become pointed forwards, a slight pull at the ankle in the direction of the long axis ofthe thigh-bone, furthers its elevation into the socket, which is effected by the extended rotating muscles. In the dislocation backwards and downwards, the foot is grasped by an assistant above the ankle, and drawn over the sound limb across and downwards. The bandage, applied as above described, is drawn gra- dually and strongly outwards and forwards, in the direction of a line parallel to one supposed to be drawn two hands'breadth behind the fore and upper iliac spine of the sound side through the body to that of the injured side. The drawing is to be continued, till the thigh itself turns outwards on its long axis, when the head of the bone is pulled into the socket, by the much stretched rotating muscles. In dislocation outwards and upwards, the thigh may either be drawn in its own axis forcibly downwards, and by the thigh-strap outwards and downwards, or an assistant must grasp the dislocated thigh in its axis inwards at the knee and ankle, and slowly lift it forwards, till it forms a right angle with the long axis of the body, and till the fore, still inner edge of the great trochanter, comes directly beneath the fore and upper iliac spine. If the thigh be yet of itself so much twisted on its long axis that the hitherto inwards turned toes are twisted forwards, and even rather outwards, and by this self-twisting of the thigh, which cannot be prevented by fast holding, is the movement ofthe head ofthe bone over the socket declared. The assistant must now gradually let down the thigh till it lies close to the other, upon the bed, whereupon the reduc- tion follows. OF THE THIGH-BONE. 241 1077. In order to properly fix the pelvis, the patient must (according to Kluge) (a) be laid on his back, upon a table covered with a mattress, and between the thighs, covered with a compress, a stout towel drawn, of which both ends must be held by an assistant standing at his head ; a second towel is to be carried round the pelvis, and both ends given to an assistant standing on the uninjured side ofthe patient; a third towel is to be placed around the pelvis, between the spines of the hip-bone and the trochanter carried round the table or bedstead, and tied so as to prevent the elevation of the pelvis. The thigh and leg are now bent by an assistant, to relax the flexors, and at the same time abducted, to re- lieve the stretching of the gluteal, muscles, and the knee should be rotated inwards, by which the head ofthe bone, being set free, resumes its primary direction, whilst the capsular ligament holds it fast above. The head of the bone is guided from its primary direction usually by a slight twist or pull at the knee, or it is lifted up by the surgeon, stand- ing at the injured side, partly with his hands, partly with a cloth em- ployed as a lever. According to Rust's (b) plan the patient being fixed as recommended by Kluge, a folded cloth is to be applied around the upper part of the thigh; the thigh drawn down, and at the same time raised by a strong assistant, who grasps it above the knee, which is to be bent, for the purpose of bringing the head nearer the under part of the socket; then it is to be drawn and abdueted, upon which, by the action of the muscles, it springs into the socket with an audible noise, without ti>e em- ployment of any considerable extension being requisite. Colombat (c) proposes a mode of reduction which he has always successfully employed without assistance and without pain to the patient. The patient stands upright upon the undisloeated limb, his chest bent forwards and resting on a table or high couch, with his hands grasping the opposite sides of the table or couch, to keep his body immoveable during the operation- The surgeon places himself be- hind the patient, on the inside of the dislocated limb, if the dislocation be forwards, but on the outside if it be backwards. He puts first one hand above the tarsus, to bend the leg upon the dislocated thigh ; the other hand, which lies behind the knee, is employed to make gradual pressure from above downwards, for the convenience of extending the muscles. With the first hand he imparts to the limb gentle mo- tions from right to left, and from before to behind, in order to overcome the oppo-' sition of the muscles of the thigh, and to1 render the head moveable, which then moves from the place in which it is, and enters the socket with a noise, 1078. In the reduction of dislocations of the thigh with pulleys, the following mode is to be pursued. In the dislocations backwards and upwards, the patient should be placed upon a table, and a girth carried between the pubes and upper part of the thigh, outwards and upwards, and fastened to a hook be- hind the patient. Above the knee should be applied, around the thigh, a linen pad, and over it a leathern strap, from which other straps de- scend, and are connected with the pulley fastened before the patient. The knee is to be a little bent, but not at a right angle, and directed some- what obliquely over the other limb, The drawing of the pulley is to be slowly continued, till every thing is tight and the patient complains of pain; this degree of extension should be kept up to relax the muscles; then it is to be repeated till the patient complains, and in this manner continued till the head of the bone comes down. When it comes to the. edge of (a) Sich, G. R., Dissert de luxations fe- (c) Ueber die Merotropie bei den Luxa- moris. Berol., 1823, p. 26. tionen des Hiiftgelenkes; in Fboriep's No-.' (b) Richter, above cited, p. 706. tizena Sept, ] 83ft. 21* 242 DISLOCATION the socket, the same degree of extension must be kept up, and the knee and foot rotated outwards without violence. It is often necessary to carry the arm beneath the thigh, near to the joint, for the purpose of lifting the head of the bone over the socket. In the dislocation, inwards and downwards, the patient is to be put on his back, the pelvis fixed with a girth, as in the latter case, the dis- located limb grasped above the ankle and drawn over the uninjured one. In general, however, it is necessary further to fix the pelvis by means of a second strap, which passes around it and crosses the former. If the dislocation have existed several weeks, it is best to put the patient on the sound side, to fix the pelvis'in the manner mentioned, to apply the girth attached to the pully around the thigh, and to raise the thigh when the foot is drawn down ; the foot, however, is not to be brought too much forwards because otherwise, the head of the thigh-bone over- shoots the socket (a). In the dislocation backwards and downwards, the patient must be placed on his side, the straps for extension and counter-extension em- ployed as directed, and the extension carried on, the thigh at the same time being directed obliquely over the middle of the other. Whilst this is doing, an assistant grasps a cloth, applied round the upper part of the thigh, with one hand, and draws it up, whilst wTith the other he presses up on the pelvis (b). In the dislocation inwards and upioards, the patient is laid upon his side, the pelvis fixed, and extension made above the knee. The thigh is drawn in the backward direction, around its upper part a cloth ap- plied, which an assistant draws, whilst with the other hand he thrusts back the pelvis, in order to lift the head of the bone over the edge of the socket (c). The reduction of the dislocation inwards and upwards, is often rendered more easy and quick than in the other way, by Palletta's method, in which the dislocated thigh is suddenly and violently bent towards the belly, when it has been abducted as much as possible (d). [In the dislocation downwards Astley Cooper used to say, in his Lectures, that it might be reduced by interposing the bedpost between the thighs close up to the pelvis, and then making extension. Morgan and Cock, of Guy's Hospital, have reduced several dislocations ofthe hip- joint by placing the foot between the thighs, so that it presses against the upper part of the dislocated bone, and thrusts it away from the pelvis, extension and rotation of the limb being at the same time made by assistants. The principle of the operation is precisely similar to that in reducing a dislocated shoulder by putting the heel in the arm-pit. This practice was first introduced about ten years since by Morgan (e), and by it he has replaced a dislocation upon the^uies, one on the oval hole, and one upon the back of the hip-bone, without difficulty, which he principally attributes to diverting the patient's attention from the operator's efforts by unexpectedly pricking or pinching. Cock has reduced one dislocation on the pubes, and two on the back of the hip-bone, by the foot between the thighs.; but he informs me that the greater number of the persons so treated were weak or elderly. Till making inquiry, I was unaware of so many cases having been thus managed, I do not know that the practice has been elsewhere adopted, but I shall certainly try it, at the first opportu- nity, as it saves all the trouble and inconvenience of pelvis-stians and pullies.— J. F. S.] («) Cooper Astley, pi. viii. fig. 3. Philanthropique de Paris, 1818, p. 285.— (6) Ibid., pi. ix. fig. 3. Ammon, Parallel, p. 170. (c) Ibid., Eg. 4. (e) Guy's Hospital Reports, vol. i. p. 79. (d) Bulletins des Sciences par la Societe OF THE THIGH-BONE. 243 1079. The completion of the reduction of a dislocated thigh-bone is indicated by the audible noise, with which the head returns into the socket, by the natural length and direction ofthe limb, by the cessation of pain, and by the free motion of the thigh. The replaced thigh is frequently longer than the sound one, which depends on the swelling of the ligaments of the joint. In using the pulleys, the head ofthe bone often returns into the socket without any noise, and the reduction is only noticed when the extension is given over. If the extension have not been sufficient, it must be resumed as quickly as possible, before the muscles have time to contract afresh. In order to prevent the recur- rence of dislocation, it is advisable to bind the thighs together above the knees, and to keep the patient at rest, and on his back in bed. He is to be treated generally and locally on the antiphlogistic plan, according to circumstances, and allowed to get up and walk, when the pain has entirely ceased, which usually happens towards the twenty-fifth or thir- tieth day. 1080. Congenital dislocation of the thigh, outwards and upwards, into the external iliac pit, (Luxatio Femoris congenita), mentioned formerly by Hippocrates, and more perfectly described by Palletta (a), was first carefully described by Dupuytren (b), and I have, up to the pre- sent time, had opportunity in more cases, to convince myself of the cor- rectness of his description. It is distinguished from all other dislocations, especially from spontaneous dislocation, in that, 1, it ordinarily occurs in both hips; of the nine cases, however, which I have seen, in four the dislocation was only on one side (c); 2, it is not preceded by any symptoms of coxalgy; and 3, it. is usually first noticed in the first at- tempts the child makes to learn to walk, and if the attempt be continued, till the movements become wearisome. The limb in- this dislocation is shortened, the head of the thigh-bone is upwards and outwards, the great trochanter projects ; almost all the muscles ofthe upper part ofthe thigh are contracted to the iliac crest, where they produce, around the head ofthe bone, a sort of cone, the base of which is formed by the hip- bone, and its point directed towards the great trochanter ; the tuberosity of the haunch-bone is freed from its muscles, and is almost completely uncovered; the limb is rotated inwards, the heel and the bend of the knee stand outwards, and the point of the toe and the knee inwards; the thighs are directed obliquely from above downwards, and from without inwards, and this obliquity becomes greater, the older is the patient and the broader the pelvis; hence arises the disposition of the thighs to cvoss each other below ; the upper inner part of the thigh forms where it is connected with the pelvis, a sharp inward projecting angle ; the whole limb wastes, especially at the upper part. The motions of the limb are very much restricted, especially abduction and rotation ; the lower limbs are very backward in proportion to the perfectly developed upper parts of the body, which is the more remarkable as the pelvis is very broad, and not interfered with in its development. The upper part fa) Exercitationes Pathologies, p. 88. ginelles ou congenitales du Femur. Paris, (6) In Repertoire generate d'Anatomie et 1828. de Physiologie Pathologique, vol, ii. trimestre (c) On the Hip; noticed in Repertoire in. p. 151. Froriep's Notizen, No. 340, p, general d'Anatomie et de Physiologie Chi- 153, and Chirurg. Kupfertafeln, pi. clxxx, rurgioales, 182T, trimestre in. p. 22. Caillaud Billoniere sur les Luxations ori- 244 DISLOCATION of the body inclines very much backwards ; on the other hand, the lum- bar vertebrae project much forward, the pelvis rests nearly horizontally upon the thigh-bones, and these persons touch the ground almost alone with the tips of their feet. When walking they raise themselves on the tips of their feet, bend the upper part of the body very much towards that limb which still supports the weight of the body, raise the other foot from the ground, and bring, with difficulty, the latter from one side to the other. In this case, it is to be observed, that on the side support- ing the weight ofthe body, the head of the thigh-bone rises up into the iliac pit, and the pelvis descends, whilst, on the other side, the dis- placement of the bone is lessened. In running and leaping, which for such persons is very laborious, these appearances diminish from the energy ofthe muscular contraction. When the person lies horizontally on his back, the diseased limbs may, by pulling and thrusting down, be lengthened and shortened, and are hence distinguished from the changed position of the head of the bone. These experiments may be made without pain and with the greatest ease. 1081. In the cases examined after death by Dupuytren, all the muscles appeared pressed against the iliac crest, and drawn up ; some of them were very much developed, others shrivelled, atrophic, and even converted into a yellowish fibrous tissue. The thigh-bones wrere natu- rally formed, and only sometimes the inner upper part of the head varying somewhat from its rounded form. The socket was either entirely deficient, or appearing only as a little irregular bony protube- rance, without any trace of cartilage and ligament, and without any fibro-cartilaginous edge ; and about and over it, the cellular tissue and the muscles attached to the trochanter. Only in one case was the sound ligament lengthened, flattened, and at some parts, as it were, worn out by pressure and friction. The head of the bone was found in a kind of newly formed socket on the external iliac pit, always very super- ficial, and having an undefined edge. Palletta found the under fore- part of the socket covered with ligament, and the upper hinder-part filled with a fat-like mass; the head of the bone round, enclosed in a tough capsule, connected with the fatty mass in the socket by the round ligament, which was so long that it permitted the head to move upwards and downwards, and aside. No hollow in the bone in which the head of the thigh-bone should rest, had been formed in a child who had died sixteen days after birth. Hence, it seemed, that the above-mentioned absence of socket, and so on, was not original, but only consequent, and that this dislocation was, perhaps, simply produced by the peculiar position of the foetus, or by violence during birth. The flattening, or almost complete disappearance of the socket, is explained by the long continuance of the dislocation, and must be so much more distinct in the congenital, as in the progressive development of the pelvic bones it so easily occurs. The opinion, that the congenital dislocation de- pends on an arrested development of the bony parts of the joint (Bre- schet) is very improbable, rests only upon the relations of the socket, after the dislocation has been long existent, and remains refuted by Palletta's and Cruvelhier's cases, till it can be determined by exa- mination at the very earliest period after birth. OF THE THIGH-BONE. 245 Compare par. 998 and the writers there qubted. 1082. Difficult as is the walking, and great as the lameness in this congenital dislocation, especially when on both sides, yet however it may be, in time, considerably improved when the head of the bone is fixed in its new socket (1). Dupuytren recommended rest and a sitting posture to effect the fixing of the head of the bone, and to permit the muscles, as little as possible, to act upon it; for strengthening the parts in the neighbourhood of the joint, daily washing of the body for some minutes in cold water, or salt water, and the constant wearing a padded leathern belt, put on between the iliac crest and the great trochanter, and kept in its place by thigh-straps. Recently, various attempts for the reduction of this dislocation, have been made by long-continued extension, and fixing the thigh with proper apparatus. (Duval, Jalade Lafond, Humbert, Pravaz (2), Gueriiv.) The possibility of a successful result is not, as already said in regard to the origin of this dislocation, to be considered as a thing decided, and must excite us to the early employment of the means of reduction ; although the hitherto known cases do not irrevocably prove the actually resulting reduction, as the lengthening of the limb effect- ed, and the diminished lameness, perhaps, depend on the displace- ment of the pelvis, or the position of the head of the thigh-bone in the isehiatic pit. (1) I have observed one case of dislocation on both sides, in which the walking was at first extremely difficult, but from the fifteenth year and onwards so improved, that now, when the patient is about twenty years old, there is scarcely any trace of peculiar gait to be noticed. (2) Pravaz (a) communicates a case of reduction of congenital dislocation ofthe thigh, in a girl eight years old, by gradual lengthening of the limb, and by violent abduction, assisted by a methodical pressure on the great trochanter. If the reduc- tion be ensured by long-continued rest, various movements of the limb should be performed, the body still being at rest. He believes that even in the cases in which there is not any existing cotyloid cavity, a dislocation of the head of the thigh-bone downwards causes slight halting. A second case happened in a boy of eight years, in whom the reduction was effected by gradual extension, kept up for several months, after which gymnastic exercises were used, which were proper for strengthening the joint and perfecting its coaptation (b). Guerin effected a cure in six cases. H. Joffre (c) refers to the two cases of Pravaz, denies the observations of Hum- bert (d), and thinks that in them no perfect reduction was found, but that merely the head of the bone was situated in the isehiatic pit. Heine, of Cannstadt, has given a very clever apparatus, which, with continued extension, permits every other seemingly necessary movement and direction of the extremity. But notwithstanding all his care and perseverance, he could not, in this dislocation ofthe thigh, effect any result (e). Guerin (f) makes a preparatory and continued extension, by which the shortened muscles are lengthened and are brought to stretch out; cutting through the muscles which do not lengthen; extension of the shortened ligaments, and where this is im- possible, cutting them through; reduction and its preservation by apparatus. Ac- cording to Pravaz (g) every congenital dislocation may be reduced, if it be pos- (a) Revue Medicale, April, 18354 luxations anciennes par cause externe. Paris, (b) Annales d'Hygiene publique; in Fro- 1835; with Atlas of 20 plates. RiEp's Notizen, No. 122. (e) Ueber spontane und congenitale Luxa. (c) Journal des Connaissances Medico- tionen, so wie iiber einen neuen Scbenkel- Chirurgicales, May, 1838, p. 180. hals-Burch-Apparat. Stuttgardt, 1842. (d) P. Humbert and N. Jacquier, Essai (/) Gazette Medicale de Paris,'184l. No. et Observations sur la maniere de reduire les 7-10. Luxations spontanees ou symptomatiques (g) Bulletin de l'Academie Royale de de PArticulation ileo-femorale; methode ap- Medecine, vol. vii. p. 5. plicable aux luxations congenitales et aux 246 DISLOCATION OF THE KNEE-CAP. sible to bring the thighs up to the shoulders, without bending the legs against the thighs (a). OF DISLOCATION OF THE KNEE-CAP. (Luxatio Patellae, Lat.; Verrenkung der Knieschiebe, Germ.; Luxation de la Rotule, Fr.) Le Vacher et Picquet, Theses de variis patellae luxationibus. Paris, 1761. 4to. Boyer, above cited, vol. iv, p. 347. Cooper, A., above cited, p. 178. Malgaigne, Memoire sur la determination des diverses especes de Luxation de la Rotule. Paris, 1837. [Watson, On Dislocations of the Patella, in New York Journ. of Med. and Surgery, No. 2, p. 203.—g. w. n.] 1083. Dislocation of the Knee-cap may happen in two different direc- tions, viz., outwards and inwards; the former kind of displacement is much more common than the latter. These dislocations may be com- plete or incomplete ; in the first the cap leaves the joint-surfaces of the thigh-bone, and rests on one or other protuberance ; in the second it still partially touches the corresponding surface. Diagnosis of disloca- tion of the knee-cap is always easy; the limb is outstretched ; and if it be attempted to bend the leg, the pain is increased ; the knee has lost its natural form. In dislocation outwards the prominence of the inner condyle is felt through the skin, and upon the outer condyle, and if the dislocation be complete on its outside, a considerable swelling is pro- duced by the knee-cap. In dislocation inwards, the outer condyle is felt and the prominence of the knee-cap on the inner condyle. This dislocation is nearly always incomplete. Coze's observation of a dislocation of the knee-cap, in which it was half twisted round itself, has been denied (b). Wolf (c) has noticed a complete twisting round ofthe knee-cap. [Gazzam has given a like case in the American Journ. of Med- Sciences.—g. w. n.] 1084. The causes of dislocation of the knee-cap are mostly, external violence acting on the bone in moderate bending, or complete straight- ening of the leg, and after driving it to one or other side. Also any circumstance by which the foot is turned outwards whilst the knee turns in, may produce this dislocation. If the ligaments of the knee-cap be very relaxed, or the condyles of the thigh little prominent, this disloca- tion may be produced by slight causes. In general, dislocations ofthe knee are not dangerous; but when the violence producing them acts very severely upon the knee-joint serious symptoms may be caused by the contusion. 1085. In reducing this dislocation, which cannot always be effected at the first attempt, the patient should be laid upon his back, the leg straightened as much as possible, and the thigh bent at the hip-joint, the knee-cap is then to be pressed directly forwards, and when its great ridge is lifted over the edge of the condyle, it is drawn into place by the (a) A. Sanson; in Rev. de Specialities, (b) Mem. de la Societe d'Emulation. 1841, Feb.'—Journal de Medecine de Lyon, Paris, 1826, vol. xviii. 1841, Nov. p. 381. (c) Rust's Magazin, vol. xxvii. p. 476. DISLOCATION OF THE KNEE-JOINT. 247 action ofthe muscles. The knee should be enveloped in clotbs dipped in a dispersing wash ; and the patient kept quiet in bed till the pain and swelling have ceased. Should the knee-cap be disposed again to be dislocated, the knee must be supported by means of an elastic knee- bandage. I have seen a congenital dislocation of the knee-cap on both sides, in an aged man. The knee-cap rested entirely on the outer side, so that the middle of the knee-joint was completely void. The knee-cap was so moveable, that in the straight position of the leg it could easily be brought to its proper situation, but on the slightest movement was again displaced. Both knees were very much twisted inwards, the legs and feet very much outwards. The man's gait was very difficult and unsteady. Palletta^o) has examined a case of congenital dislocation of the knee-cap. XII.—OF DISLOCATION OF THE KNEE-JOINT. (Luxatio Genu, Lat.; Verrenkung des Kniees, Germ.; Luxation de Genou, Fr.) von Siebold's Chiron., vol. i. p. 33. Boyer, above cited, vol. iv. p. 365. Cooper, A., above cited, p. 184. 1086. Dislocations ofthe knee are rare, on account ofthe great strength of the joint. The shin-bone may, however, be displaced forwards, backwards, and to one side or other from the joint-surfaces of the thigh- bone. These displacements arev mostly incomplete. The ligaments and tendons which strengthen the knee are always in these dislocations, either much torn or much stretched; even the vessels and nerves may be torn, or the joint-ends of the bones thrust out through the skin. These dislocations cannot be mistaken, on account of the projections which the shin-bone and condyles of the thigh form in opposite direc- tions. 1087. The reduction of these dislocations is not usually accompanied with difficulty. Sufficient extension of the leg is made, and then the displaced joint-end of the shin-bone is pressed into its place, one hand grasping it, whilst the other has hold ofthe lower end ofthe thigh-bone. After the reduction, inflammation must be prevented or got rid of, and the union of the ligaments effected, by strict antiphlogistic treatment, and by keeping the limb quiet, fastening it up in a pair of splints. When all swelling and pain have subsided the limb may be cautiously moved. If the joint remain weak, volatile rubbings must be employed, and a knee-band used for some time to give support. If the inflammation be severe, anchylosis, suppuration, gangrene, and so on, may take place, and the treatment must be guided according to the rules laid down for wounds of joints. If the joint-ends of the bones be thrust through the skin, there may be such destruction, that immediate amputation is re- quisite. Single cases in which the preservation of the limb is possible cannot refute these principles. If the ligaments connecting the semi-lunar cartilages with the shin-bone be re- laxed, they may by external violence, by pushing with the toes of the outward- turned foot and go on, remove the semi-lunar cartilages from their position. At the same time severe pain, swelling, incapability of stretching out the foot, without (a) Exercitationes Pathologic®, p. 91. 248 DISLOCATION OF THE ANKLE-JOINT. much alteration of form in the knee come on. The natural position of the cartilages is most certainly restored, when the leg is bent back as much as possible, by which the pressure of the thigh-bone on the semi-lunar cartilages is removed, and they return to their place, when the leg is extended. The weakness of the joints is to be removed, by volatile rubbings and the like, and the recurrence of this accident prevented, by a properly applied knee-band (Astley Cooper.) Wutzer (a) observed a congenital bending forwards of both legs, depending on dislocation at the knee-joint. Kleberg (b) describes a congenital dislocation of the left knee forwards, where, with the thigh extended, the leg was bent forward at the knee, and lay obliquely upwards in such way, that the points of the toes touched the right side of the belly; the legs could be easily returned to their natural position; they, however, immediately resumed their previous position, whilst the child himself had not any voluntary influence over their movements. Bending the leg back against the thigh to an obtuse angle, and fixing it in this position, by a thin cloth passed round the middle of the thigh and leg, in a short time restored the natural position and mobility of the leg. XIII.—OF DISLOCATION OF THE SPLINT-BONE. (Luxatio Fibulae, Lat,; Verrenkung des Wadenbeines, Germ,; Luxation du Pironi, Fr.) Boyer, above cited, vol. iv. p. 375. 1088. The splint-bone may be dislocated at its upper or lower end, forwards or backwards. This can always be readily distinguished, as the head of the bone can be felt if there be not any considerable swelling. In order to reduce this dislocation, it is only necessary to press the dislocated head into its place, and to fix it there with compresses and bandages. The dislocation ofthe upper end may be accompanied with fracture of the shin-bone, in which with the reduction of the fracture follows also that ofthe dislocation. Not Unfrequently, owing to relaxa- tion of the ligaments, dislocation of the upper end of the splint-bone takes place; its reduction in this case is easy, but just as speedily does the displacement recur. The bone is to be kept in place by rest, and by fixing it with bandages ; the weakness of the joint should be sought to be removed by friction, blistering, and the like. XIV.—OF DISLOCATION OF THE ANKLE-JOINT. (Luxatio Tali, Lat.; Verrenkung des Fusselgelenkes, Germ.; Luxation du Pied, Fr.) Desault, above cited, vol. i. p. 423. Boyer, above cited, vol. iv* p. 375, Cooper, Astley, above cited, p. 238. Dupuytren; in Annuaire Medico-Chirugical des Hopitaux et Hospices de Paris. Paris, 1819. 4to.; with copper-plates. [Baxter, A Memoir on Accidents of the Ankle ; in N. York Med. Repository, vol. vi. N. S. 1821.—g. w. n.] 1089. Dislocations of the foot are frequent, and may occur inwards and outwards, forwards and baclavards; the dislocation inwards is the (a) Muller's Archiv. fur Anatorriie und Physiologie, 1825, pt. iv. p. 385. (b) Hamburger Zeitschrift, vol. vi. pt. ii. DISLOCATION OF THE ANKLE-JOINT. 249 most common; those forwards and backwards are much rarer than those on either side. They are generally complete or incomplete, simple or compound. 1090. In the dislocation inwards, produced by violent turning of the foot outwards, the joint surface of the astragalus is placed beneath the inner ankle, and the lower end of the shin-bone so thrust inwards, that the skin is ready to burst by its pressure; the inner edge of the foot is inclined downwards, the outer upwards, the sole of the foot outwards and its back inwards. This dislocation may be accompanied with con- siderable tearing of the ligaments, with fracture of the outer ankle op,of the middle ofthe splint-bone, or of the lower end of the shin-bone, the soft parts may be torn, the joint surface of the astragalus or ofthe shin- bone be thrust through the skin, or there may be at the same time dis- location of the astragalus from its connexion with heel- and navicular bones. In the latter case, the integuments are often uninjured, and the ligaments between the astragalus, heel-, and navicular bone suffer only considerable extension; often, however, are all these ligaments and integuments so torn, that the astragalus is merely attached at some parts. The dislocation outwards, is consequent on violent inclination of the foot inwards ; the astragalus is thrust beneath the outer ankle, the inner edge ofthe foot is turned upwards, the outer inwards, the sole inwards, the back outwards. This dislocation may be connected with fracture ofthe lower end ofthe splint-bone and of the inner ankle. Usually is there also in lateral dislocation, a more or less decided inclination of the foot forwards or backwards. 1091. The symptoms mentioned of lateral dislocation are so distinct that it cannot be mistaken even when considerable swelling has taken place. But this swelling may render difficult the diagnosis of the dif- ferent complications. 1092. In dislocation of the foot forwards, which arises from violent extension of the foot, and is rarer than that backwards, the joint- surfaces of the astragalus are in front of the shin-bone, the foot fixedly bent, the heel shortened, and the Achilles' tendon nearer the back of the leg. In dislocation backwards, which may be consequent on a fall, with the sole of the foot on an oblique surface, the foot is outstretched and shortened, the heel more prominent, the Achilles' tendon projects from the back of the leg, the joint-surface of the astragalus is felt on the back of the shin-bone, the under end of which forms a hard projection on the middle of the instep and rests on the navicular bone and only on a small portion of the articular surface of the astragalus in front. This dislocation is always accompanied with fracture of the splint-bone of the inner ankle, or the latter is torn off". This dislocation may be incomplete, so that the shin-bone rests half upon the navicular, whilst the other half remains on the astragalus. The foot then seems but little shorter, the heel projects a little, the toes are pointed downwards, so that the patient cannot put the whole sole of the foot on the ground, the heel is drawn up, and the foot to a great extent immoveable; the splint-bone is broken. Vol. ii.—22 250 DISLOCATION OF THE ANKLE 1093. Dislocations of the foot are always important, because they pte-suppose great violence; and severe inflammation, and dangerous symptoms ensue from the tearing of the ligaments and from the drag- ging of the tendons and soft parts. Even in slighter degrees, stiffness of the joint is to be feared. There often remains so great weakness of the ligaments of the joint that the dislocation is reproduced by the slightest effort, if the joint be not strengthened by some mechanical apparatus. The dislocations forwards and backwards, are generally less dangerous, than the lateral dislocations and rarely accompanied with evil complications. Even if the dislocation be not reduced, the foot is not completely unfit for use; but very considerable deformity remains. Lateral dislocations are not always equally dangerous; they often are soon cured without any weakness or interference in the motions of the joint remaining. Dislocation outwards is mostly ac- companied with more injury than that inwards. Simultaneous frac- ture of bones or tearing of soft parts render the case so much more dangerous; though experience shows that, in most cases, the limb may be preserved. 1094. The reduction of dislocation of recent occurrence, is usually not very difficult. The patient lies down, one assistant grasps with both hands the lower part of the shin-bone, and another, or in disloca- tion aside the surgeon himself takes hold of the foot. The former makes counter-extension in the direction ofthe shin-bone, the other ex- tension, (in which the leg is bent at right angle on the thigh), first in the direction which the foot had, and when the ligaments and tendons are sufficiently stretched, he brings the foot into its proper place. In dislocations backwards, the surgeon with one hand presses the heel for- wards, and with the other the shin-bone backwards, and the contrary in dislocation forwards. Complete reduction is indicated by the natural direction and form of thp foot 'and its capability of motion. The ankle- joint should then be enveloped in linen, dipped in dispersing fluid, and fastened with a circular bandage applied in a figure of 00 form. Chaff bags are to be applied on each side of the leg and splints upon them which extend over the ankle-joint as in fracture of the leg. The leg must always be bent at the knee-joint, and laid on a cushion, to relax the muscles. Antiphlogistic treatment must be employed proportionate to the constitution, the dressings moistened with dispersing fluid, and replaced every five or six days. When the pain and swelling have subsided, careful motion must be used, but only after a month, may the patient be allowed to walk gently about. If dislocation of the foot inwards, be accompanied with fracture of the splint-bone, its re-dislocation is most effectually prevented by the apparatus used for fractured splint-bone, which may be also applied in dislocation outwards, the splint with the chaff bag being put on the outside of the leg. In dislocation of the foot backwards, re-displacement may be prevented by placing a* splint and cushion beneath it, (so that both project beyond the heel), and a small cushion on the lower part of the shin-bone, which is here, as well as at the knee, to be fastened with a bandage (a). In dislocations aside, many persons recommend that the limb should be laid on its outside with the leg bent, and the foot enveloped in the many-headed bandage. [Sometimes in dislocation ofthe ankle-joint inwards, the internal lateral ligament is torn through without the malleolar process being broken off. This is a rare acci- (a) Dupuytren, above cited.—Chirurgische Kupfertaf. Weimar, 1820, pt. ii. pi. vi. fig. 5. AND INSTEP BONES. 251 dent, and very difficult to keep in place if there be any disposition to spasm, of which there is an example in a case of Henry Earle's (a). The splints were con- sequently applied more tightly, and perhaps from that cause irritation set up, which terminated in abscess, which was twice opened. The soft parts about the ankle- joint became sloughy, and the patient's violent efforts whilst delirious, thrust the bone through the mortified skin, and it could no longer be at all kept in place. Amputation was performed, but the case terminated fatally.] 1095. If in dislocation of the foot, the joint-end of the shin-bone be driven through the integuments, so soon as it has been properly cleansed, its replacement must be attempted, the wound carefully closed, and the treatment conducted after the general rules. If the narrowness ofthe wound prevent the reduction, it must be sufficiently enlarged ; and if it cannot be then effected, the projecting bone must be sawn off, whereby alone, the natural position ofthe foot can be restored, and dan- gerous symptoms prevented. Amputation is only inevitably necessary, in old weakly persons, in very extensive tearings and crushings of the bones, on the occurrence of mortification and wasting suppuration. If in dislocation outwards, the shin-bone be broken obliquely, near its joint surface, it cannot be kept in place after reduction, and amputation may be indicated. It may also be necessary in cases of continuing very troublesome deformity. [In compound dislocation of the ankle-joint with protrusion of the shin-bone through the wound, most English surgeons saw off the joint end, not merely to render reduction more easy, but also, according to Astley Cooper's opinion, to les- sen the suppurative process, by diminishing the synovial surface. This mode of practice is certainly not commonly followed in reference to other joints, and the younger Cline was always opposed to it being resorted to in dislocated ankle. It must however be admitted, that Cooper's reasoning as well as practice favours the proceeding.—j. f. s.] XV,—OF DISLOCATIONS OF THE INSTEP-BONES. (Luxatio Tarsi, Lat.; Verrenkung des Fusswurzelknochen, Germ.) 1096. The connexions of the bones of the instep are so firm, partly from the strength of their ligaments, and partly from the broad surfaces by which they touch, and their motions are so confined, that their dislocation is extremely rare, and only possible from very great violence, therefore, also commonly accompanied with tearing of the soft parts. 1097. Dislocation ofthe Astragalus may, notwithstanding its situation in the hollow formed by the shin- and splint-bones, and its firm fastening to the heel- and navicular bones, occur in four different directions, in which it may be thrown forwards, inwards, or outwards, from its con- nexion with the navicular, or it may be so twisted onits axis, that its under joint surface is turned upwards. The dislocations forwards and inwards are more common than that outwards (1). These dislocations may be connected with fracture of the shin- or splint-bone, with dislocation of the foot, with tearing of the soft parts and protrusion of the head of the astragalus. The cause is violence, which displaces the foot and leg at (a) Medical Gazette, vol. iv. p. 61. 1829, 252 DISLOCATION its greatest degree of extension, as in a fall from a height, when the sole ofthe foot lights on an oblique surface, and the body falls backwards; or a fall ofthe body backwards, whilst the fore part ofthe foot is fixed, so that the shin-bone is brought into a nearly straight direction with the foot. In this position the lower end of the shin-bone presses on the back of the astragalus, drives it forwards, and tears the astragalo-tibial ligament, and lets go the head ofthe astragalus from the hollow ofthe navicular bone. It is therefore intelligible, why dislocation does not occur when the shin-bone breaks, and this dislocation takes place, espe- cially in powerful, healthy persons, whose bones are strong. In disloca- tion inwards, indeed there is always fracture of the lower end of the splint-bone. Most probably the head of the astragalus is always prima- rily dislocated forwards from the navicular bone, and driven according to the direction of the operating force, inwards or outwards. In twisting round of the astragalus on its axis, it must be driven from behind, for- wards, and from below, upwards, with a very great thrust of the shin- bone upon the foot and leg, whilst extended to the utmost, with which the skin yielding, indeed, though resisting, and the inter-osseous liga- ment must be torn ,through. (1) When Rognetta supposes that dislocation of the astragalus inwards, if not impossible, yet is in the highest degree difficult, because the cleft between the navicular bone and astragalus is filled by exceedingly strong ligaments, the capsule between the two bones in front too weak and extensible, and because the violence causing the dislocation of the head of the astragalus, as the cases, known to the present time, show greater frequency of the dislocation inwards, than of that out- wards. In his experiments, Rognetta has never been able to produce any other dislocation of the astragalus than that forwards. [The dislocation outwards is very rare ; besides James's, of Croydon, case (a), and two other under Guthrie's care (b), I know of none save one now under my friend Stanly's care in St. Bartholomew's Hospital, and which had occurred in consequence ofthe young man slipping off the fourth round of a ladder, the appear- ances of which correspond very closely to the description given by Astley Cooper, but there is not any fracture of the splint-bone. Violent attempts had been made for its reduction before his admission into the hospital some days after the accident, but, as in the other three cases, without success. Reduction was also attempted two or three days after his admission into St. Bartholomew's but they also were quite un- availing, and the displacement still remains. Of these cases James's was the only one in which there was fracture of any bone, and in that the inner malleolus was broken obliquely.—.j, f. s.] 1098. In dislocation of the astragalus forwards, the projection of the head of that bone upon the navicular, is felt on the instep, the toes are depressed and turned somewhat outwards. In the dislocation inwards, the projection is more to the inner side, and the toes turned more .outwards (1); and in dislocation outwards, the prominence of the head of the astragalus upon the cuboid bone, and the foot is so turned inwards, that the outer edge is directed downwards, and its inner, upwards. With much swelling the diagnosis is difficult, and even impossible (Boyer). If the soft parts be at the same time torn, the head of the astragalus either protrudes or may, with the finger, be felt bared. In dislocation of the astragalus with twisting on its axis, it may be so locked in between the shin-bone and heel-bone, that the limb appears (a) Cooper, above cited, p. 359. (b) Hancock's Paper j in Med. Time s vol. ii. 1844, p. 71, OF THE ASTRAGALUS. 253 longer. If, however, this be not always the case, this sign is extremely important, in order to suspect such dislocation, and always to avoid, in such cases, useless and prejudicial attempts of extension and counter- extension (Rognetta). (1) The younger Cline's case of simple dislocation; and Green's case of com- pound dislocation inwards (a). 1099. Every complete, although simple dislocation of the astragalus, is of great - consequence, as its reduction is often very difficult, fre- quently quite impossible, and in that case, a great degree of lameness remains; or by the stretching of the integuments a slough is formed, which only rarely remains superficial, without opening the joint, (Dupuy- tren), but mostly after its separation lays bare the joint, in consequence of which, severe inflammation, extensive suppuration, slough, and dan- gerous symptoms, are produced, and even amputation may be rendered necessary (Boyer). Only when the dislocatipn of the head of the astragalus is not complete, can the function of the foot be gradually to some extent be restored, if reduction has not been effected (Dupuy- tren, Boyer). In compound dislocation the danger is still greater, and depends on the kind of complication. The impossibility of reducing dislocation of the astragalus, even by treatment accompanied with the greatest care and force, as observed by Boyer, Astley Cooper, Dupuytren, myself, and others, depends on the firm locking of the neck of the astragalus between the other bones. In the dislocation inwards, the neck of the astragalus is so locked in between the inner edge of the navicular and heel- bone, that it is completely immoveable, or when the hinder under edge of the upper- joint surface of the astragalus lies under the front edge ofthe shin-bone, as Dupuy- tren once observed. In dislocation outwards, the head of the astragalus may be found beneath and a little before the outer ankle, and its neck pressed on the edge of the hind-joint-surface of the heel-bone, or the head of the astragalus rests upon the cuboid and outer cuneiform bones; the outer edge of the upper-joint surface of the astragalus is placed between the first hinder-joint-surface of the heel-bone, and the shin-bone; on which account it is impossible to free the astragalus by the ordinary methods of reduction. [The simple dislocation outwards, from the cases already mentioned, may be pre- sumed to be irreducible.—j. f. s.] 1100. The reduction of dislocated astragalus, in which it must not be forgotten to diminish the contraction ofthe muscles, in powerful sub- jects, by blood-letting, nausea, and so on, always require bending the leg at the knee-joint. Two assistants fix the thigh, or a folded cloth is for this purpose carried round beneath the knee, and fastened to a hook behind the patient. Other two assistants fix the leg above the ankle. A folded cloth is to be applied round the heel, carried over the instep, and crossed, without covering the projecting bone, and its ends given to assistants to make extension. The extension must be made gradually and strongly, in the direction which the foot has ; the surgeon places the fingers of both his hands upon the sole of the foot, and the thumbs upon the projection of the astragalus, which he presses back. This pressure may be practised with the flat of the hand, or wThilst with the one hand he grasps the leg, and with the other the toes, he places his knee against the projecting astragalus, and thrusts it back (Petrunti). If the reduction be effected, the leg is to be placed half-bent, upon a (a) A. Cooper, p. 364. 22* 254 DISLOCATION OF chaff bag, and retained by the apparatus used for fractured splint-bone, [par. 703), in a position contrary to the direction of the dislocation. The inflammatory symptoms are to be prevented, or got rid of, by strict rest,-cold applications, and so on. 1101. If the reduction be not possible, the attempts to effect it are not to be carried too far, because thereby undoubtedly, severe inflamma- tion, and danger of gangrene will be produced; but the astragalus must be laid bare by a semilunar incision, of which the convexity is directed upwards, the firmly attached parts of the ligaments divided with the knife or scissors, and the reduction then attempted; after which the wound is to be closed with sticking plaster. If the replacement be im- possible, it is best to remove the astragalus entirely, seizing it with the fingers, or with the forceps, and separating its connexions with a bis- toury or curved scissors, in which we must keep on the outside spe- cially for the division of the interosseous ligaments. The wound is to be brought together with sticking plaster, or lightly covered with lint, and the foot and leg kept in a proper position by Sauter's or Eich- heimer's apparatus. The joint-surfaces of the shin-bone are to be brought in contact with the heel-bone. The cure follows, although with shortening, yet with proper usefulness of the foot, so that the patient can gradually walk without difficulty, as I myself noticed in one case. If, after fruitless attempts at reduction, gangrenous inflam- mation, suppuration, and the like ensue, the removal of the astragalus is the only remedy, by which these dangerous unexpected symptoms may be easily got rid of, as thereby both the experience of others, as well as my own, prove the seemingly necessary amputation may be avoided. 1102. If the astragalus be twisted on its axis, and at the same time dislocated from its connexion with the shin-bone, the heel-bone, and navicular-bone, every attempt at reduction is actually useless, and the removal ofthe astragalus is the only way to preserve the foot. Although many observations have been published in which extirpation of the astragalus has been performed with the most perfect success, when the skin had been destroyed by gangrene, or the dislocated bone had been loosened by suppura- tion, the early extirpation of the bone seems most proper, because thereby manifestly dangerous symptoms can be prevented. It is scarcely necessary to remember that in this extirpation the injury of the tendons, nerves, and vessels should be most carefully avoided, and every bleeding vessel tied at once. Upon dislocations of the astragalus compare— Desault, above cited, vol. i. p. 435. Boyer, above cited, vol. iv. p. 388. Astley Cooper, p. 376. Rognetta, in Archives generales de Medecine, 1833, Dec, p. 485. [Morris, in The American Journ. of the Med. Sciences, No. 40. August, 1837.—g. w. n.] 1103. The heel-bone may, as a consequence of a fall on the heel, or other violence, be dislocated outwards from its connexion with the astra- galus and cuboid bone. The great deformity of the heel is the ground of this diagnosis. The bone must be pressed back into its place, and there retained by proper apparatus. As the consequence of an old dislocation of the heel-bone which had been pro- duced in early life by violent dragging off a boot, I have observed degeneration THE NAVICULAR AND OTHER INSTEP-BONES. 255 like elephantiasis and enlargement of the leg which rendered amputation neces- sary (a). [The two cases of dislocation outwards of this bone, mentioned by Astley Cooper, were from my notes. In the simple dislocation, (Martin Bentley), the tuberosity of the heel-bone had nearly disappeared, but the outside of the bone pro- jected on the outer side of the foot much beyond the outer malleolus, immediately beneath which however was a remarkable depression. On the inside there was a remarkable and unnatural projection, caused by the head and inside ofthe astragalus directly below the inner malleolus; the whole foot was displaced outwards and the toes turned out. These appearances must have resulted from the astragalus having been dislocated inwards, from both heel and navicular bone, so that its under-joint surface rested on the inner edge of the heel-bone. The dislocation was easily reduced, having bent the thigh and knee on the body and fixed the leg, by laying hold of the metatarsus and of the tuberosity of the heel-bone, and drawing the foot gently and directly from the leg, during which extension Cline put his knee against the outside of the joint, and the foot being pressed against it, the heel and navicular bones readily slipped into their place and the deformity disappeared. In the com- pound dislocation, (Thomas Gillmore), a wound extended from opposite the middle of the base of the shin-bone, round the upper part of the instep to the outer malleolar process, exposing the head of the astragalus in front, and its outer under-joint-surface for the heel-bone on the outside; the latter and the navicular bone, together with the whole foot, were carried in, so that the toes pointed much inwards towards the opposite foot, whilst the tuberosity of the heel- bone projected outwards. It was reduced by extending the foot and rotating it outwards. In Hancock's case (b) which seems to have been a simple dislocation of the heel and navicular bones outwards, but which was not reduced for a week, the skin which had previously vesicated, sloughed, and as the slough cleared off, the internal calcaneo-scaphoid ligament sloughed also, and the head of the astragalus, which had previously kept its place, twisted round on the heel-bone, till a large portion of its head protruded through the wound, and having lost its articular cartilage and become dead, about three quarters of an inch of it were sawn off, and then the wound healed. —j. f, s.] 1104. The navicular and cuboid bones, though remaining connected with the cuneiform, may be dislocated from the astragalus and heel-bone, which can only be effected by great violence, as the fall of a heavy weight upon the foot. The astragalus and heel-bone remain in their natural place, but the fore part of the foot is always twisted inwards, as in club-foot. Fixing the leg and heel, and extension of the foot out- wards, effect reduction. [A case is mentioned (c) of a bricklayer's boy, aged fourteen years, who fell down a height of forty feet, and apparently struck the extremity of the foot. The ligaments on the dorsal surface of the foot appear to have started, and the scaphoid and cuboid bones projected a little upwards out of their places. The foot was much swelled, was about half an inch shorter than the other, and had a clubbed appearance. Nothing was done in this case.] 1105. Dislocation of the cuboid bone may, as a consequence of great violence, occur upwards, according to Piedagnel, also inwards and downwards. The irregularity and prominence at the situation of the dislocated bone, its form, and the altered direction of the fore part of the foot, give cause for diagnosis, and distinguish it from a dislocation ofthe head of the astragalus upon the navicular bone; as here especially the smoothness and convexity of the head of the astragalus and the three joint-surfaces ofthe navicular bone lead to it. The leg and heel should (a) Heidelb. klinische Annalen, vol. ii. p. the lower ends of the Tibia and Fibula; in 354. Lancet, vol. ii. p. 35. 1844. (b) On dislocation ofthe Astragalus with v (c) Lancet, vol. i. 1839-40, p. 133. 256 DISLOCATION OF THE TOES. be fixed, the extension of the foot made in the outward direction, and the bone pressed into place with both thumbs, after which the foot is to be laid on its side, and protected with a proper apparatus. If the re- duction cannot be effected, destructive suppuration and caries ensue, and the extirpation of the bones is necessary (Piedagnel) (a). 1106. The great cuneiform bone may be dislocated by tearing of the ligaments which connect it with the middle cuneiform, the navicular, and the metatarsal bone of the great toe; it is then projected considerably inwards and somewhat upwards, by the action of the m. tibialis anticus, and does not correspond with the straight line of the metatarsal bone of the great toe. It must be attempted by pressure to return the bone to its natural place, where it is to be kept by compresses, and a bandage applied round the foot and moistened with a dispersing lotion. When the inflammation has subsided, a leathern strap should be bound around the foot, till the ligaments have united, Astley Cooper (b) describes two cases of this dislocation, in both of which the bones were not replaced; there remained, however, only little detriment. 1107. Dislocation of all the metatarsal bones from their connexion with the first row of the instep-bones, in consequence of a fall backwards or forwards, whilst the fore part of the foot was fixed, has been observed by Dupuytren (c). The foot is shortened from four to eight lines by the pushing ofthe bones upon one another; the arching ofthe top ofthe foot is destroyed, the hinder end of the first metatarsal bone forms a projection of half an inch across, behind which is a deep hollow; the concavity of the sole is completely destroyed ; the extensor tendons are to be felt distinctly, and the toes are raised by their stretching; the movements of the foot are impossible. Reduction is effected by fixing the leg when bent, by pulling at the front ofthe foot with a slip knot, and by pressure on the displaced bones. The foot is then to be laid on one side, and when inflammation has ceased, it should be kept steady in a proper apparatus. [A case of dislocation of the outer two metatarsal bones from the cuboid was ad- mitted in 1835 at St. Thomas's, under my friend Green's care. The patient had received a violent blow by the falling of a heavy chest upon the inside of the foot. Upon the top of the foot there was a large swelling before and below the outer ankle, and behind it a cavity in which two fingers could be easily buried, in consequence of the bases of the metatarsal bones having been thrown upwards and backwards upon the top of the cuboid. At the base of the metatarsal bone of the great toe, where the blow had been received, was a swelling as large as a walnut, dependent, however, only upon effusion without displacement or fracture. The dislocated bones were reduced by continued extension with much difficulty, and as they recovered their place a distinct crackling was heard.—j. f. s.] 1108. Dislocation of the Toes rarely occurs, and to it applies all that has been formerly said in reference to dislocated fingers. Dislocation of the great toe from the corresponding" metatarsal bone occurs most fre- quently in consequence of a fall or hanging in the stirrup. It is either incomplete with a painful projection of the lower end of the metatarsal bone, or complete with tearing of the capsule of the joint, of the tendons, of the skin and accompanied with projection of the end of the bone. Its reduction is performed by fixing the foot and extending the toe with (a) Piedagnel; in Jour. Univers. et Heb- (c) Revue Medicale, Dec. 1822.—Heidel- dom., vol. ii. No. 19. berg, klinische Annalen, vol. iv. pt. iv. (b) Above cited, p. 383. DISLOCATION OF THE TOES. 257 a slip knot. If there be also a wound, it must be properly closed with sticking plaster, and inflammation prevented especially by perfect rest, cold applications and suitable treatment. If reduction cannot be effected, the projecting end must be sawn off, and the bone kept in its proper place by a suitable apparatus. Only in splintering of the bone and great destruction of the soft parts is amputation or disarticulation of the corre- sponding metatarsal bone necessary. If an incomplete dislocation remain unreduced, great difficulty in walking, continued pain and inflammation ofthe skin, which it excites, may indicate the laying bare ofthe projecting end of the bone by a longitudinal cut, and its removal, in which the tendon is to be pushed aside. Astley Cooper (a) observed an old simultaneous dislocation of the four lesser toes from their connexion with the corresponding metatarsal bones, by which the functions of the foot were in a great degree destroyed. (a) Above cited p, 385, [ 258 ] SECOND DIVISION. (continued.) III.—SOLUTION OF CONTINUITY FROM ALTERED POSITION OF PARTS. (continued.) B.—OF RUPTURES. 1109. A Rupture {Hernia, Lat.; Bruch, Germ.; Hernie, Fr.) is the protrusion of an intestine from its own cavity into the surrounding cel- lular tissue, or into another cavity. Ruptures are therefore distinguished, according to the three cavities of our body, as ruptures of the belly, of the chest, and ofthe head. I.—Of Ruptures of the Belly. First Chapter.—OF RUPTURES OF THE BELLY IN GENERAL. Franco, P., Traite des Hernies. Lyon, 1556. Gunz, J. G., Observationum anatomico-chirurgicarum de herniis libellus. Lip- siae, 1744, 8vo. Vogel, G., Abhandlung aller Arten von Briichen. Leipzig, 1746. Pott, P., Chirurgical Works, vol. ii. Edit., 1783. Le Blanc et Hoin, Nouvelle Methode d'operer les Hernies. Paris, 1768. Richter, Abhandlung von den Briichen. Gottingen, 1778. Second Edition, 1785. 8vo. Scarpa, A., Sull' Ernie, Memoirie anatomico-chirurgiche. Ediz, Second. Pavia, 1819. fol. Translated into English as A Treatise on Hernia, with notes by J. H. Wishhart. Edinburgh, 1814. 8vo. Lawrence William, A Treatise on Ruptures. London, 1838. 8vo. Fifth Edition. Cloquet, J., Recherches Anatomiques sur les Hernies de l'Abdomen. Paris, 1817. 4to. Irid., Recherehes sur les Causes et l'Anatomie des Hernies Abdominales. Paris, 1819. 4to. Cooper, Astley, The Anatomy and Surgical Treatment of Abdominal Hemia. Second Edition. By C. Aston Key. London, 1827. fol. Hesselbach, A. K., Die Lehre von den Eingeweidebriichen. 2 vols. Wiirz- burg, 1829, 30. 8vo. Key Charles Aston, A Memoir on the advantages and practicability of dividing the stricture in strangulated Hernia on the putside of the sac; with cases and draw- ings. 8vo. London, 1833. Hager, M., Die Bruche und Vorfalle. Wien, 1834. [Parrish, Practical Observations on Strangulated Hernia. Philadel- phia, 1836.—g. w. n.] Jacobson, L., Zur Lehre von den Eingeweidebriichen. Konigsberg, 1837. Hesselbach, A. K., Die Erkentniss und Behandlung der Eingeweidebriiche. Bamberg, 1840. fol. Malgaigne, Lecons cliniques sur les Hernies, recueillees sous les yeux par M. E. Gelay. Paris, 1841. 1110. Ruptures of the Belly {Herniae abdominales) may occur through- out the whole extent of its wall, if this give way or be torn. Most com- DIVISION OF RUPTURES. 259 monly they occur at those parts of the belly where there are already openings for the passage of vessels, nerves, and so on. 1111. According to the various parts at which ruptures are formed, they are distinguished as, 1, Inguinal, which pass through the inguinal canal, 2, Femoral, beneath Poupart's ligament; 3, Umbilical, through the umbilical hole; 4, Thyroid, through the thyroid hole; 5, Isehiatic, through the isehiatic notch; 6, Ventral, through the wall of the belly, the holes already mentioned excepted ; 7, Perinaeal; 8, Vaginal; 9, Rectal, when the rupture protrudes at the perinaeum, in the vagina, or in the rectum (1). Inguinal, femoral and umbilical are the most common ruptures, the others are more rare. [(1) To this list must certainly be added Phrenic rupture (Hernia diaphragmati- ca.) And English surgeons speak also of mesenteric, meso-colic, and meso-rectal ruptures, although strictly speaking they do not resemble true ruptures in leaving their proper cavity, but they burst through parts which have no natural opening for their passage and thus become displaced.—j. f. s.] 1112. Those intestines ofthe belly which on account of their position and connexion are least fixed, protrude most commonly, as the omen- tum and the small intestines, more rarely the large intestines, the sto- mach, the bladder, the internal female generative organs, and the like. Parts may be in the rupture which in their natural place are very far from it. These are either drawn down by the protruding intestines, with which they are connected ; or by the descent of the peritoneum to which they are attached. According to the intestine which ruptures contain are they distinguished as intestinal, {Hernia Intestinalis, Lat.; Darmbruch, Germ.; Enterocele, Fr.,) omental, (Hernia Omentalis, Lat.; JYetzbruch, Germ.; Epiplocele, Fr.,) ventricular, {Hernia Ventriculi, Lat.; Magenbruch, Germ.; Gastrocele, Fr.,) vesical, {Hernia Vesicae, Lat.; Rarnblasenbruch, Germ.; Cystocele, Fr.,) and so on. Several intestines may be contained at the same time in one sac, as for instance intestine and omentum, {Darmnetzbruch, Germ.; Entero-epiplocele, Fr.,) and the like. 1113. When the intestines of the belly are protruded into a rupture, they are usually enclosed in a sac, {saccus herniosus, Lat.; Bruchsack, Germ.; sac herniaire, Fr.,) which is formed ofthe lengthened peritoneum. In rare cases only is this sac deficient; for instance when the rupture is caused by great violence, or after previous wound of the wall of the belly, or after the application of escharotics for the radical cure of the rupture. The sac may also be torn, or destroyed by absorption. If intes- tines protrude, which are not enclosed in the peritoneum, for example, the bladder (1) and c&cum (2), there is not any sac; but if they be much protruded, they draw down the peritoneum connected with them, and thereby form a sac into which other intestines may pass. [(1) In regard to vesical rupture, it is certainly just possible that the bladder may rise to the internal abdominal ring, and thrusting up the peritoneum from that open- ing, may protrude some part of its body uncovered by peritoneum through it, and this may continue to descend through the inguinal canal and form a rupture without a peritoneal or true hernial sac. But such state of things is highly impro- bable, and in the two cases of vesical rupture in the museum at St. Thomas's is certainly not so, for in this preparation it is the fundus of the bladder, that part of the organ most likely to be protruded, with its peritoneal covering which has passed 260 HERNIAL SAC. through the abdominal ring into a distinct peritoneal sac, which from its appearance probably belonged originally to a rupture of the intestinal or omental kind. (2) I do not think that the caecum would often protrude as a rupture without having- a peritoneal sac, more than the bladder, and for nearly the same reasons. There is, however, in the Museum at St. Bartholomew's a caecum carried into the scrotum with a partial sac, and I have also had one case in which I suspect the colon did. But that it does descend into a true hernial sac is beyond doubt, for in the museum of the Royal College of surgeons of England, there is an instance of the lower end of the ileum, the caecum and its appendage, and part of the ascending colon, with a large piece of omentum in the sac of a large oblique inguinal rupture. There is also another preparation, in which the lower end of the ileum, with the caecum and its appendage, are in the sac of an inguinal rupture, and the extremity of the appendage is attached to the bottom of the sac. In St. Bartholomew's museum there is a scrotal rupture (with hydrocele in front) containing caecum and colon. Also a femoral rupture, in which there is small intestine, a portion of the sigmoid flexure of the colon and omentum. A very rare instance of protrusion of the vermiform appendage of the caecum in a strangulated inguinal rupture is given by Taramelli (a); the appendage alone was found in the sac, increased to four times its ordinary size, and an indent at its junc- tion with the caecum showed the seat of strangulation. The patient did well.— j. f. s.] 1114. The cavity of the hernial sac is connected with the cavity of the belly by an opening, the mouth ofthe sac; the narrow part between this opening and the greater extent of the sac is called the neck of the sac; the remaining part the body; and the blind end the bottom of the hernial sac. The sac is furnished with different coverings accord- ing to the difference of place where the rupture exists; on its outer surface it is slightly connected with the surrounding cellular tissue, and therefore the sac remains external when the intestines have been returned. 1115. The hernia] sac is very frequently subject to changes. The peritoneum of which it is formed usually retains its natural condition, and when in old ruptures it thickens, and is found to consist of several layers, the cause of these changes, for the most part, rests on the thickening of the cellular tissue, which covers the outer surface ofthe sac. The substance of the peritoneum itself, however, often thickens and even becomes almost cartilaginized (1). These changes are the result of the irritation and pressure to which the sac is subjected, by the passage forwards and backwards of the intestines; they therefore occur especially in old ruptures which cannot be properly kept up by the truss, and mostly at the neck of the sac. If by contraction of the neck of the sac, or by thickening of the cellular tissue covering it, a narrowing be produced, it may in the gradual increasing volume of the rupture descend, and thus may several strictures be formed in the body of the sac (2). These changes are not always relative to the size of the sac. In large ruptures the sac is often very thin, even so thin, that the peristaltic movement of the intestines can be per- ceived through the external skin. In large umbilical ruptures the hernial sac is often very thin, and in small femoral ruptures very thick. Swellings also may form on the sac from degeneration of the cellular tissue (3). [(1) In the museum at St. Thomas's there is a preparation of a femoral hernial sac converted into bone. (2) I do not agree with Chelius's statement on the causes of stricture in the body of the hernial sac. As regards the descent of the neck, or more properly, the mouth (a) Omedei, Annali Universali di Medicina, vol. lxxv. p. 430. 1835. SIZE, NUMBER, AND KINDS OF RUPTURES. 261 of the sac, into its cavity, so that the stricture is not at the immediate opening into the cavity ofthe belly, but at a less or greater distance below it, so far as I have had opportunity of observing, it is of great rarity. I have only once seen it, and that during last spring, in a case of oblique scrotal rupture, in a young man, which had existed for several years, and in which during the operation an extremely tight stricture was found ve;y high up. This I divided upon a director sufficiently to admit my fore-finger freely into the cavity of the belly; but with all the pains I could take I was unable to return the gut. After many unavailing efforts I cut through the tendon of the external oblique muscle and the other coverings of the upper part of the sac, till I brought its strictured mouth completely into view, which immediately explained the difficulty. The mouth of the sac had descended into its cavity, doubling the neck upon itself, so that a circular blind pouch about half an inch deep, encircled the mouth, which had the same relation to the sac as the mouth of the womb has to the vagina, and its margin had become so firmly and narrowly thickened, that it resembled a ring of whipcord. Into this blind circular pouch the intestine had been thrust at every attempt I had made for its reduction, and thus both escaped, and shut up the mouth of the sac. The finger could be passed into the cavity of the belly, as freely as before; but I thought it best to divide this cord-like edge and the indoubled neck, so as to render the reduction more easy, and such was the result. The patient did well. As to the production of strictures in the body of the sac, I believe that generally these depend much more frequently on bands of adhesive matter having been thrown out under inflammation of the peritoneal sac itself, from some accidental cause or other, rather than from thickening of the cellular tissue external to it, which, how- ever, may take place, as I have seen it do, occasionally producing, not indeed actual bands or strictures, but merely an hour-glass contraction of the sac. (3) Sometimes a hernial sac is contracted in its middle and assumes an hour- glass shape; such a case I have operated on, but it did not produce any confusion. Occasionally, however, it may, as is shown in a preparation at St. Bartholomew's, in which the sac of a congenital rupture has an hour-glass contraction at the ab- dominal ring, and part of it is without, whilst the other part is within the belly, and into the latter portion the gut had been returned, and left.—j. f. s.] 1116. The size of ruptures is very different. Often the rupture contains the greatest part of the intestines of the belly; often is it so small that it can be discovered only with the greatest care. Of the intestine itself there is protruded either an entire loop or only a portion. 1117. Several ruptures often occur in the same subject. Rarely are several, each having its own sac, at the same spot; more frequently, by the protrusion of the urinary bladder, or some other intestine only partially covered with peritoneum, so that the latter is drawn with it, a hernial sac is formed into which the intestines pass. A double hernial sac is very rare, and indeed possible only in inguinal hernia, where a special sac contaiping intestines may drive into the vaginal tunic of the testicle, when its mouth has remained open. Bransby Cooper (a) mentions a case of two inguinal ruptures on the same side; the contents ofthe hinder, larger sac, which remained external, were returnable into the cavity of the belly, but the front smaller sac with its contained intestine had been easily returned into the belly, by the taxis,- he does not, however, explain, how it happened that this thrusting up of the sac and its contents had been effected which is one of the most curious points of the case. [Lawrence says, there is a "kind of double rupture not ascertainable in general, except by examination after death, or in operating, viz :—two sacs passing through the same opening; this may happen in external or internal inguinal or crural hernias. There are instances of even three sacs, particularly in inguinal hernias." (p. 13). As regards the number of hernial sacs, Astley Cooper says:—"Two herniary (a) Guy's Hospital Reports, vol. iv. p. 326. Vol. ii.—23 262 SIZE, NUMBER, AND KINDS OF RUPTURES. sacs have been stated to pass behind the same crural arch; but although I would not be understood to deny their existence, I have not seen an example of sacs having two separate orifices into the cavity of the abdomen; but I have known one hernial sac descending into the sheath for the crural vessels, and crossing the anterior part of these, and another portion of it quitting the sheath and extending in the usual direc- tion upon the thigh." (p. 4). He also gives an example of six hernial sacs:— "Two ofthe sacs upon each side were placed between the umbilical and epigastric arteries; and one on each side is situated between the remains of the umbilical arteries and the pubes. They passed between the tendinous fibres of the transver- salis, which they had separated, and entered the abdominal rings, after which they were covered, as usual, by the fascia, which is extended from the external oblique muscle over the spermatic cord." (Explanation of pi. x. pt. i). And he observes, that after wearing a truss, "although the original sac may be completely shut at its mouth by adhesion or perfect contraction, it is possible that another sac may be formed contiguous to the first." And he gives an instance, in which "two hernial sacs were found side by side, one open and capable of containing the bowels when protruded, the other contracted so much as not to admit a eoose's quill." (p. 23). 4 Morgan (a) had a remarkable instance of a pouch formed at the mouth of the tunica vaginalis, in consequence of partial adhesions of the membrane. The patient had scrotal rupture on the right side, accompanied with symptoms of strangulation. It was reduced with great ease, by gentle application of the taxis. The symptoms, however, continued, and on the following day " a small tumour was perceptible in the course of the inguinal canal." On the third day he was worse, and an opera- tion having been decided on, " after dividing the integuments, superficial fascia, and cremaster, in the usual manner, what appeared to be hernial sac was brought into view; this was laid open, and on the operator introducing his finger, it readily passed through the external ring into the inguinal canal; here an unnatural projec- tion could be felt, but no gut was found, nor could the finger be passed into the abdomen. The inguinal canal was then exposed by slitting up the tendon of the ex- ternal oblique, and the sac before mentioned was more extensively opened, still no in- testine could be found, and no communication appeared to exist between the sac and the abdominal cavity. A substance was felt in the canal which resembled a thick- ening of the cord." Nothing more was done, and he died on the second day after the operation. Upon examination, the part " supposed to be hernial sac, and opened as such was the reflected portion ofthe tunica vaginalis, into the cavity of which the finger had been introduced." The tumour in the course of the inguinal canal was a hernial sac, behind the cord, and containing a portion of slrangulated intestine of a very dark colour, and with a large gangrenous spot. This hernia, had by its pres- sure, prevented the entrance of the finger into the belly. " Just below the opening of the tunica vaginalis into the abdomen, was situated the mouth of a preternatural pouch, which extended downwards and inwards behind the fascia transversalis in the direction of the crural ring. It was into this pouch that a portion of the ilium had descended and had there become strangulated. It seems probable that at the time of the man's admission into the hospital, a large portion of intestine had de- scended into the cavity of the tunica vaginalis, the cavity of which bore all the ap- pearances of an old hernial sac. This, however, was easily returned, while the portion of bowel contained in the other pouch, remained unreduced and suffer- ing under strangulation, caused the symptoms which ended in the patient's death." (p. 83). ■ In the museum at St. Bartholomew's there are two beautiful preparations, one ex- hibiting two inguinal hernial sacs, on the left side, close together and of consider- able length, the mouth of the outer very small; the other femoral, in which there are two distinct sacs and orifices, the outer descends beneath the semi-lunar edge of thejascia lata, but the inner is so small that it scarcely protrudes. Sometimes the sac of a rupture is divided vertically into two, probably by adhe- sive inflammation. I have operated on one such scrotal case. In St. Bartholo- mew s museum there is a common scrotal and also a congenital scrotal rupture of similar kind. r In rare cases, one or other side ofthe sac of a femoral rupture is burst, and a part («) Astlev Coor-ER, above cited, p. 83. STATISTICAL ACCOUNT OF RUPTURES. 263 of its contents are protruded in either direction, so as to form a seeming second sac. I have had three cases of this kind, which will be hereafter noticed, and the case mentioned by Astley Cooper, in which "one hernial sac descended into the sheath for the crural vessels and crossed the anterior part of these, and another portion of it quitted the sheath and extended in the usual direction upon the thigh," (p. 4), I believe to be of similar kind. Neither of these, however, are to be confused with the case described and figured by Bransby Cooper.—j, f. s.] 1118. Ruptures are either free, or reducible, {frei, beweglich, Germ. ; mobile, Fr.,) when they return of themselves, or can be returned by moderate pressure ; or irreducible, {unbewzglich Germ.; immobile, Fr.,) when their return is impossible, the cause of which lies in the adhesion of the intestines together or to the hernial sac, in the strangulation or other change of the parts found in the rupture. 1119. As regards their origin, ruptures may be divided into original (Hernias congenita?, Lat. ; angeborne Bruch, Germ ; Hernie congenitale, Fr.) and acquired, {Herniae acquisitce, Lat.; emcorbene Bruch, Germ ; Ihrnie acquisc, Fr.) ; in the first case the intestines pass through the processes of the peritoneum, which remain open ; in the second, after the processes have closed or at some other place. 1120. The causes of abdomiual ruptures are predisposing and occa- sional. Predisposition to rupture, which may be either original or ac- quired, consists in a relaxation and weakness of the wall of the belly, and in greater enlargement of its natural openings. It may be produced by corpulency, by great extension ofthe wall ofthe belly during dropsy or pregnancy, by quick emaciation, by scars after wounds, especially, when the injury ofthe abdominal wall has been connected with bruising ; by diseased changes of the intestines ofthe belly, by loading them with coarse food, by immoderate use of relaxing drinks and the like. The occasional causes are all kinds of violence which produce great contraction of the wall of the belly and depression of the diaphragm, whereby the intestines are forcibly thrust against the former ; for instance, a violent thrust or blow upon the belly, tight lacing, violent exertion on lifting heavy weights, in breathing, coughing, vomiting, in childbirth, peculiar positions, and so on. The greater the predisposing causes to rupture, the less requisite are the occasional causes ; in great disposition to rupture, they often occur without any assignable occasional cause. In many countries ruptures are very common, and their causes seem to depend on climate, on the mode of living, and on the particular ex- ertions to which the inhabitants are subjected. Ruptures occur more frequently in men than in women, and more fre- quently on the right than on the left side (1). [(1) Lawrence has given the following curious statistical account of ruptures :— " The comparative number of the different kinds of ruptures, and the relative fre- quency of the complaint generally, as well as that of its various forms in the two sexes, and at different periods of life, are exhibited in the following statement, ex- tracted from the register of the patients relieved by the City of London Truss Society within twenty-eight years :— In 83,584 patients, 67,798 were males, and 15,786 were females. Males. Females. 14006 511 left inguinal ) 39419 ino-uinaH 24316 586 right inguinal \ mguinai I . . 45629 single 278 2255 left femoral > com &m««,l 421 3256 right femoral 6210 femoral 264 STATISTICAL ACCOUNT OF 1 24966 286 double inguinal ) .....27029 double 169 1608 double femoral $ 664 2775 umbilical ) ......4063 209 415 ventral ) 1 3 peritoneal.......... £ 1 4 obturator.......... f* 26 46 have undergone operations ..... /2 2289 1401 with umbilical and inguinal hernia have been cured.........3690 446 243 with prolapsus ani....... 689 2196 with prolapsus uteri ) 37 with prolapsus vaginae > .....2392 159 with prolapsus vesica? ) 6 5 with varix of the abdominal veins . . 11 67798 15786—83584 83584 ■ In addition to the above statement, the following varieties in the situation of this malady have been noticed, viz. in 799 Males. 184 left inguinal and right femoral hernia, 82 left inguinal and left femoral hernia, 13 left inguinal and double femoral hernia, 10 left inguinal and ventral hernia, 13 left inguinal and umbilical hernia, 3 left inguinal hernia and prolapsus ani, 3 left inguinal, umbilical, and ventral hernia, 135 right inguinal and left femoral hernia, 27 right inguinal and right femoral hernia, 25 right inguinal and double femoral hernia, 16 right inguinal and ventral hernia, 26 right inguinal and umbilical hernia, 7 right inguinal hernia and prolapsus ani, 1 right inguinal, umbilical, and ventral hernia, 87 double inguinal and right femoral hernia, 54 double inguinal and left femoral hernia, 27 double inguinal and double femoral hernia, 1 double inguinal and double femoral hernia outside of the femoral vessels, 12 double inguinal and ventral hernia, 1 double inguinal aud double ventral hernia, 48 double inguinal and umbilical hernia, 18 double inguinal hernia and prolapsus ani, 2 double inguinal, umbilical, and ventral hernia, 1 left femora] and umbilical hernia, 1 right femoral and ventral hernia, 1 right femoral and umbilical hernia, 1 right femoral hernia outside of the femoral vessels, 799 366 Females. 13 left inguinal and left femoral hernia, 40 left inguinal and right femoral hernia, 1 left inguinal and double femoral hernia, 2 left inguinal and umbilical hernia, 6 left inguinal hernia and prolapsus uteri, 1 left inguinal hernia and prolapsus ani, 20 right inguinal and left femoral hernia, 5 right inguinal and right femoral hernia, 1 right inguinal and double femoral hernia, Carried forward 89 VARIOUS KINDS OF RUPTURES. 265 Brought forward 89 9 right inguinal and umbilical hernia, 3 right inguinal and ventral hernia, 3 right inguinal hernia and prolapsus uteri, 1 double inguinal and right femoral hernia, 8 double inguinal and umbilical hernia, 5 double inguinal and ventral hernia, 1 double inguinal hernia and prolapsus uteri, 28 single femoral and umbilical hernia, 10 single femoral and ventral hernia, 1 left femoral and double ventral hernia on the right side, 1 left femoral and right obturator hernia, 3 left femoral hernia on the outside of the femoral vessels, 14 single femoral hernia and prolapsus uteri, 2 right femoral hernia on the outside of the femoral vessels, 1 right femoral hernia on the inside and outside of the femoral vessels, 2 right femoral hernia, prolapsus uteri, and prolapsus vesicae, 12 double femoral and umbilical hernia, 3 double femoral and large ventral hernia, 8 double femoral hernia and prolapsus uteri, 2 double femoral hernia and prolapsus ani, 22 umbilical and ventral hernia, 5 umbilical hernia and prolapsus uteri, 1 umbilical hernia, prolapsus uteri, and prolapsus vesica?, 1 ventral hernia and prolapsus uteri, 5 prolapsus uteri and prolapsus ani, 109 prolapsus uteri and prolapsus vesica?, 8 prolapsus uteri and prolapsus vaginae, 10 prolapsus uteri, prolapsus vesicae, and prolapsus vaginae 366 " 5448 patients had congenital hernia 7299 patients were relieved with trusses under ten years of age. 4551 between 10and 20 8715 20 — 30 13614 30 — 40 15627 40 — 50 14169 50 — 60 9761 60 — 70 3866 70 — 80 442 80 — 90 23 90 —100 78067 "Of 457 herniae examined by M. Cloquet, 307 occurred in the male, 150 in the female sex; 246 on the right, 187 on the left side, and 24 on the middle line ofthe abdomen. "The numbers ofthe different kinds were as follows :— Males. Females. Ii \l ??' eXtemal ingUinal ! 203 external. > 11 o ■L-\' i ' ' ' \ £ 289 inguinal. 39 8 right internal . . . 86 internal. ) 35 4 left......) 33 « nff-oral . . . j .... 1|tml 3 21 umbilical and linea alba .... 24. 0 3 1eftht°.btU.rat!,r: '. '. \ • • ■ • 10 obturator. Recherches sur les Causes et VAnatomic des Hernies abdominales, p. 9, note."] 1121. The following are generally the symptoms of a reducible rupture 23* 266 SYMPTOMS OF REDUCIBLE RUPTURE. ofthe belly,—a swelling of quick or gradual production, not painful, elastic, of different form according to the opening by which it protrudes, on the surface of which the skin is unchanged, which can be returned by sufficient pressure, which returns of itself when the patient lies on his back, but after any exertion in coughing, sneezing and the like, also after meal-time again protrudes or enlarges. It is accompanied with symptoms of disturbed intestinal functions, as sluggish bowels, rurn- blings in the bowels, belchings, disposition to vomit, dragging pains in the belly, and the like, which symptoms subside if the swelling be re- duced, and afterwards the bowels are usually relieved. If the rupture be small and deeply situated, the diagnosis is often difficult, and must be determined by close examination, by consideration ofthe origin ofthe swelling, and by all the existing symptoms. 1122. Decision as to the parts contained in the rupture is often very difficult, often even impossible, on account of the different changes which the parts themselves and the coverings ofthe rupture undergo. [Chelius's observation, in reference to the difficulty or impossibility of distin- guishing intestinal from omental rupture, is most fully borne out by practical expe- rience, so that few persons are so hardy as to prognosticate the contents of a rupture- sac till it is opened.—j. f. s.] 1123. The intestinal rupture is characterized by a swelling more regular on its surface, elastic, which enlarges when the intestine is loaded, and in returning affords a gurgling noise (1), often felt in the swelling by the patient himself, and by the simultaneous symptoms of stoppage of the passage of the stools. [(1) This gurgling noise is often entirely independent, I believe, of intestine, and caused by the quantity of fluid contained in the sac. And from the same cause arises a symptom which often puzzles a young surgeon; to wit, the seeming reduc- tion of a large portion of the contents of the sac, with a gurgling noise, whilst the remaining contents cannot be returned ; and on the removal ofthe fingers, the rupture reacquires its original size, but admits of the same diminution, by pressure, only again to recover its bulk when the efforts at reduction are given up. This is very easily explained, as the fluid contained in the sac being pressed, squeezes between the sac and its contents into the cavity ofthe belly, although the intestine or omen- tum is so firmly grasped by the stricture that it cannot be returned.—j. f. s.] 1124. The omental rupture feels doughy, irregular, often rope-like, has a more cylindrical form with a broader base, is more slowly deve- loped, is more difficult to reduce, is unaccompanied with any gurgling, and produces a heavy dragging upon the stomach. 1125. Vesical rupture is distinguished by the swelling fluctuating, enlarging, and becoming tense, if the patient retain his urine, and di- minishing when he discharges it; and by pressure on the swelling exciting a disposition to void the urine. Frequently after making water, the tumour does not diminish, but the patient does not feel any disposi- tion to urine, when it is pressed. As the bladder is always more or less dragged or pulled, the patient has a frequent disposition to make water; frequently the urine is completely retained, and in introducing a catheter, it must be observed that it be conducted in a peculiar manner into the bladder. If the vesical be complicated with omental or intestinal rup- ture, the symptoms are confused. Not unfrequently a stone is formed in the protruded part ofthe bladder. 1126. As to the other intestines which may be in the rupture, the position of the rupture, its condition, and the disturbed functions of the CHARACTERS OF DIFFERENT KINDS. 267 contained parts, afford the key. If several parts be together in the rup- ture, these symptoms are confused. 1127. Ruptures are always extremely important diseases. If they be left alone, and their neighbourhood be undisturbed, they always increase; the local and general inconveniences become greater, and the intestines may descend in such quantity into the rupture, that the greater part of them may rest in it. By the changes produced in the hernial sac (par. 1115) and the contained parts, the return of the rupture is rendered im- possible, or strangulation is produced. 1128. The intestines contained in the rupture, may, in consequence of previous irritation, adhere to each other, or with the hernial sac, and the adhesion may be either a mere sticking together with a gelatinous mass, or it may be fibroid, or of a fleshy character, and may take place often only at certain parts, often to a great extent, so that all the parts of the rupture are consolidated into one mass. Omental ruptures grow together more readily than intestinal. The adhesion of the hernial sac with the intestine, must be distinguished from those adhesions with the sac, which have existed before the production of the rupture, between the peritoneum and the intestines, in which the parts lying in the rupture, are, in the same way, attached to the sac, as it was earlier in the belly. 1129. The portion of intestine lying in the rupture, is generally thick- ened, and often considerably narrowed (1). This thickening of the tunics of the intestine may depend on the great development of their muscular coat, consequent on violent straining, for the purpose of driving forward its contents, in the obstructed return of the blood, or in the de- posit of fibrine. The omentum is very frequently very much changed in reference to its structure and form; it is usually thick and hard at the neck of the sac; often rope-like, often rolled up into a hard lump ; often is its bulk very much increased, beset with growths, and often exceedingly hardened. [(1) I do not think that the protruded intestine is often either thickened or nar- rowed. The thickening which is sometimes observed in a strangulated gut, is of two kinds. The less important is when in consequence of strangulation, serum only is effused into the cellular tissue connecting the intestinal coats without other altera- tion, speedily subsides on the division ofthe stricture, and is not to be feared. The other kind, in which the cellular tissue ofthe gut is filled with adhesive matter, the result of a slow inflammatory action, and the intestinal wall acquires a thickness of the eighth of an inch or more, does not subside when the strangulation is removed, has a doughy feel, and is of a dirty reddish white colour, is a very dangerous symp- tom of the disease, and leads to the anticipation of an unfavourable termination of the case.—j. f. s.] 1130. When by a dispropoxtion between the parts contained in the rupture, and the parts containing them, the communication between the belly and the rupture is arrested, strangulation (Strangulatio, Lat.; Einklemmung, Germ ; Etranglement, Fr.) ensues. The causes producing this disproportion are, increased protrusion ofthe intestine in any exertion, overfilling of the intestine in the rupture with stools, intestinal gas, foreign bodies, and the like, consequent on overloading the stomach with food difficult of digestion and flatulent; growth ofthe protruded intestine, inflammatory swelling, degeneration of the omentum, and spasmodic affection ofthe intestinal canal. 1131. The seat of strangulation is either in the opening into the belly, 268 SEAT OF STRANGULATION. through which the rupture has-been produced (the mouth of the rupture, Bruchpforte, Germ.) or in the hernial sac itself. 1132. The aponeurotic parts, which form the abdominal mouth ofthe rupture, produce the strangulation ofthe parts protruded in great quantity, or increased in volume, never by active contraction, but because they do not yield any more, and by means of their elasticity, endeavour to return to their natural condition. Only in (external or oblique) inguinal rup- tures, does a narrowing of the mouth of the rupture, by contraction of the wall of the belly, where the fibres of the internal oblique and trans- verse muscles surround the neck ofthe sac, seem possible to be produced. 1133. In the hernial sac, the confining part is either at the neck, or at various parts of its body, by narrowing and strictures which form in it, (par. 1115,) or it tears, and the intestines escaping through this opening become strangulated. 1134. The determination ofthe seat ofthe strangulation is often diffi- cult, often impossible. The following circumstances may direct the practitioner: Firstly. In a rupture which quickly arises from severe violence, or where, with little extensibility of the opening by which it has escaped, a large quantity of intestine is suddenly protruded, the unyieldingness of this opening is, for the most part, the cause of the strangulation. The hernial swelling does not spread upwards above the external abdominal ring, in inguinal rupture, the inguinal canal is throughout, its whole extent yielding and free from pain ; the pillars of the outer ring are stretched (a). Secondly. That the strangulation is at the neck of the sac, as is most frequently the case, at least in inguinal ruptures, may probably be sup- posed, in ruptures which having been long kept up by a truss, suddenly protrude ; when the aperture through which the rupture protrudes, not stretching, the hernial swelling, although very tense, is reducible, and in the attempt to return it behind the abdominal ring, a swelling is formed. The inguinal canal is full, hard, tense, painful, and presents to the feel a cylindrical swelling. Thirdly. Tearing of the hernial sac, or the inflammatory affection of the parts lying in the rupture, may be supposed to be causes of the strangulation, from the violence with which they operate upon the rup- ture itself; and in tearing the hernial sac, by the changes in its form which the hernial swelling undergoes from the projecting ofthe intestines into the opening ofthe sac (6). Fourthly. The overfilling ofthe intestines with intestinal matter, causes strangulation, mostly slowly, in old ruptures, by its gradual collection, or by overfilling the stomach. According to Malgaigne, never does solid matter, but only intestinal gas collect; the true ground of strangulation is inflammation, which is consequent on such ruptures. Fifthly. The growth of the intestine itself, and the strangulation re- sulting therefrom, cannot be ascertained previous to operation. Malgaigne's supposition, that the strangulation is not produced by the ring, but at the neck ofthe sac, is too general; it is also opposed by Dihay (c). (a) Dupuytren, De l'Etranglement au durch Zcrreisung des Bruchsacbes; in Hei- collect du sac herniaire; in his Legons orales delberg klinischen Annalen, vol. ii. pt. 1. de Clinique Chirurgicale, vol. i. p. 557. (c) Gazette Medicale de Paris. 1841. (b) Breidenbach, Ueber Einklemmung No. 19. INCARCERATION AND STRANGULATION. 269 1135. According to the degree of disproportion between the containing and contained parts of the rupture, is the severity of the symptoms there- on depending. Therefore either merely the communication between the rupture and the cavity ofthe belly is stopped, {Incarceration; Incarceratio Hernia, Lat.; Einsperrung, Germ.,) or the protruded parts are at the same time so compressed, that the circulation of the blood and other juices is prevented (Strangulation, Strangulatio Herniae, Lat.; Einklem- mung, Germ.) In the latter case, the symptoms are dependent on the arrested passage of the intestinal matter, and on inflammation; they become very active, on which account, this kind of strangulation is called inflammatory or acute. In the former case, at least at the onset, the symptoms depend only on the arrested passage of the stools, they are little severe, and may continue longer, wherefore this kind of strangula- tion is distinguished as chronic; but it runs earlier or later into inflamma- tory strangulation, if the disproportion proceed to the above-mentioned extent. It is usually connected with long-continued overloading of the intestine, lying in the rupture, with stools, or with spasmodic affection of the walls of the belly and intestines, in consequence of spasmodic, flatulent or bilious colic, by which the intestines are immoveably retained in the rupture (Spasmodic Incarceration.) Opinions are very various as to the nature of strangulation and the classification thereon grounded. Many assume that strangulation is always, as regards its nature, the same, that is, always inflammatory, and that no actual difference in its form oc- curs, but that it is only acute or chronic according to the degree and severity of the strangulation and the circumstances attending it (Scarpa, Lawrence, Travers, Boyer, Von Walther, Jaeger, and others). Some take in its widest acceptation the divison, proposed by Richter into inflammatory, spasmodic, and that caused by collection of stools, (Langenbeck, Wilhelm, Blasius, and others), and differ only in their description of the symptoms, as they hold them, some as consequent on contraction of the abdominal muscles, especially of the front wall of the inguinal canal, (Langenbeck), some as a consequence of the contraction of the internal muscular inguinal ring, (A. Cooper), and some as resulting from the spasmodic motion and contraction of the tendinous parts, arising from every trifling irritation (Wilhelm). Rust assumes, in referenee to the seat of strangulation, a division active and passsive, according as the parts forming the opening of the rupture contract, and grasp the protruded parts, or according to their morbid condition, and he assumes according to the causal relations of the strangulation, an inflammatory, spasmodic, organic (from the stricture of the hernial sac, loops of omentum or intestine, adhe- sions, and the like) and faeculent division. Sinogovitz (a) considers strangulation as varying only in degree, according as by it the communication is completely cut off or only rendered difficult to a greater or less extent; all the other statements applied to strangulation were only from sympathy of the alimentary canal, namely, from local hindrance of the circulation of the blood and contents of the intestine. This view was already taken by Seiler, and arranged according to this division under imperfect and perfect strangulation and incarceration, and also according to the symptoms, without inflammation, with collection of excrement, with spasm, and with inflammation (b). From these various opinions may be observed, that the views above mentioned differ from each other chiefly in relation to spasmodic strangulation; that in the manner presumed by many, an active spontaneous contraction of the opening into the belly should take place, is just as untenable as the notion of an active strangu- lation in genera]; since a spontaneous contraction of the abdominal ring cannot be admitted, external or oblique inguinal rupture, perhaps, excepted, where the mus- cular fibres forming the internal ring may, as A. Cooper himself admits, contract. (a) Anleitung zu einer zweckmassigen Manual-hulfe bei eingeklemmten Leisten und Schenkel-bruchen. Danzig, 1830. (b) Rust's Handb. der Chirurgie,—Art, Hernia. 270 STRANGULATION. The spasmodic affection in ruptures must be sought not in the containing parts, but in the contents of the rupture; and as the inflammation, although not the cause, is usually a consequence of the strangulation, so must the spasm be considered as an important symptom accompanying the strangulation, by getting rid of which we may hope to be enabled to fulfil the principal indication, namely, to return the protruded intestine or to diminish the relatively too great bulk of the protruded parts. (Seiler). [ The common and indiscriminate use of the terms strangulation and incarceration is very incorrect, for many ruptures are incarcerated which are not strangulated. An incarcerated rupture properly speaking is that, kind of the disease, in which the protruded omentum or intestine, from some cause or other, cannot return or be re- turned into the belly, but does not produce any symptoms of disturbed intestinal functions. This is of very common occurrence, particularly in old and large rup- tures, in which the only inconvenience is the bulkiness of the swelling. A strangu- lated rupture is on the contrary a most serious and quickly fatal disease. The pro- truded omentum sometimes tying down or compressing between itself atid the hind wall of the belly, a portion or portions of the intestines still within the cavity of the belly, so as to prevent the passage of their contents, aud thus causing vomiting and constipation; or a piece of intestine which has descended into the sac, is so girt by its neck, that the contents cannot pass through it, and even its mortification may en- sue by the tightness of the neck "of the sac preventing the flow of blood through it. These observations prove the marked distinction between incarceration and strangu- lation. It must, however, be remembered that every strangulated rupture is incar- cerated till the stricture be removed, and it be rendered returnable; but the relief of the stricture does not necessarily get rid of the incarceration, as there may be other causes, as adhesions or size of the protruded part, which prevent its return. There- fore every strangulated rupture is incarcerated, and a rupture may be strangulated and incarcerated, or it may be simply incarcerated or incapable of return without producing any symptoms.—j. f. s.] 1136. The symptoms of acute strangulation which usually set in after the sudden protrusion of a considerable quantity of intestine, or in a suddenly produced rupture1 after violent exertion and the like, or in those which have been long kept up by a truss, are, more severe pain in the hernial swelling and a sensation, as if a cord were tied round the belly; the rupture is tense, elastic, and cannot be returned ; belchings and vomiting of the contents of the stomach, subsequently, of bile, and at last, of fluid stool and part of the clysters; the vomiting becomes more or less frequent, either of itself, or after the use of every, even of the mildest drink; the pulse, at first, quick and hard, subsequently be- comes small and contracted ; the belly is tense and tender, as is also the hernial swelling, and the skin covering it is frequently reddened ; from the first there is obstinate costiveness, but when there are excre- ments in the large intestines, they can be emptied by clysters (1). In small ruptures which contain only one wall of the intestine, Littre's (a) or lateral rupture,) the costiveness may be deficient or imperfect. If no assistance be afforded, the uneasiness, anxiety, tension and painfulness of the belly and of the rupture increase, the vomiting becomes more fre- quent and painful, the body is covered with sweat, the pulse, quick, small, and thready, becomes irregular, the patient's countenance sinks in. Exacerbations and remissions of these symptoms, however, present themselves, and deceive both the patient and the practitioner. [(1) Although costiveness is generally one of the symptoms of strangulation, it is by no means uncommon for the bowels to be relieved, and not unsparingly, al- (a) Littre ; in Memoirs de l'Academie mit Bemerkungen nbrr Kothfistcln u. wider- drs Sciences. 1700. Rieche, C. F., Ueber naturlichen After. Berlin, 1841 ; with one Darm-Anhangsbriiche (Hernim Liltcriaz) copper plate. INCARCERATION. 271 / though the strangulated bowel be impervious. This depends on the part of the in- testinal canal strangulated ; and the quantity of stool remaining in it below the pro- truded part. I have on more than one occasion heasd surgeons of eminence speak of dilatation of a strangulated rupture on coughing, which I must confess I think impossible, if the rupture be more than incarcerated. Luke, however, as will be hereafter shown (p. 308), when he describes the mode of ascertaining the seat of stricture, in refer- ence to the operation for its division external to the sac, has explained that this dilatation is not ofthe part strangulated, but of that part ofthe rupture immediately above the seat of stricture, whilst that below remains unaltered. Such dilatation may happen when the seat of the stricture is at a distance below the mouth of the sac, but where the mouth itself is strictured, it cannot be possible.—j. f. s. Astley Cooper observes, that " when more than one irreducible hernia exists in the same person, it is sometimes difficult to determine which it is that requires ope- ration;" and he mentions the case of a woman, in which there was a rupture in each groin and another at the navel. Her symptoms not being urgent, the operation was deferred, and she died on the same evening. On examination, "the tumour in the right groin was found to be an enlarged and inflamed absorbent gland, lying over an empty hernial sac. In the left groin was a portion of inflamed intestine, and at the navel was an irreducible, omental hernia*, which had suppurated, and con- tained about a table-spoonful of matter." (p. 36-7.)] 1137. In a slighter degree of inflammation, and when it is long con- fined merely to the seat of strangulation, the symptoms are less violent and come on more slowly. The pain in the belly is not severe, but rather forcing, the belly remains soft, and not painful, the vomiting recurs, at longer periods, and with less violence, the pulse is little or not at all altered. The symptoms first become more severe on the farther extension and increase ofthe inflammation. 1138. The incarceration from overloading the intestines lying in the rupture, or from collection of stools, occurs mostly in old and large ruptures, where the mouth ofthe rupture is wide and has lost its elasticity, after the patient has for some days felt unusual weight and dragging in the rupture, after using food difficult of digestion and flatulent; the rupture is little or not at all painful, not very tense, weighty and doughy to the feel, and requires greater pressure in attempting its reduction ; the belly is indeed full and swelled up but not painful; if pain comes on, it inter- mits ; then follow belchings, vomiting, and costiveness. This incarcera- tion, if it cannot be got rid of by proper treatment, may continue a long time before the symptoms become urgent, but earlier or later inflamma- tion accompanies them. 1139. If there be with this incarceration, spasmodic symptoms, or if they occur in consequence of chilling, (especially in the feet,) or if spas- modic colic exist in sensitive persons, hypochondriacal or hysterical women, and after ailments which produce spasmodic, flatulent, or bilious colic, the symptoms come on more quickly, the rupture although tense is little or not painful, often changes its form, becomes larger, and again smaller ; the pain shifts its place, subsides and returns; the evacuation of the bowels ceases; the patient generally does not vomit often, only after some drinks, whilst others he retains ; the pulse is small, contracted, and irregular ; the urine generally pale ; the respiration difficult; the symptoms often quickly attain a great height, but again subside. Inflam- mation supervenes earlier or later upon the symptoms above mentioned, and it is therefore necessary to be very careful not to be deceived by the symptoms of slight inflammation and to consider it as consequent on spasmodic affection. 272 CONSEQUENCES OF STRANGULATION. 1140. If the strangulation be not relieved, sloughing of the confined part is to be feared, and so much the more as the strangulation and in- flammation are severe. The parts enclosed in the rupture are often gan- grenous, without the external parts presenting any such change. But usually on the occurrence of gangrene the swelling loses its elasticity and painfulness, the skin becomes bluish-black at several places, emphyse- matous, and the epidermis separates; the painfulness ofthe belly and the vomiting cease; the powers sink; the pulse becomes small and irre- gular ; cold sweats cover the limbs and face of the patient; the features are altered ; the ideas become confused ; the swelling bursts and dis- charges very offensive stool. Most commonly gangrene is the forerun- ner of death, the patient, however, may under these circumstances re- cover, the sloughy part of the intestine separates, and its remaining ex- tremities adhering to the peritoneum, form an artificial anus. 1141. If the omentum alone be strangulated, the symptoms are gene- ally not so severe, because it can more easily bear compression in propor- tion, as its structure is not already changed. The inflammation, however, spreads from the constricted part to the other intestines. Although the relief of the bowels be not suppressed, yet belching and vomiting occur. The constricted omentum may pass into suppuration and gangrene (1). Suppuration is an uncommon result; an abscess may form above the constricted part which may empty itself into the belly. Sloughing often occurs without any great effect upon the general condition of the patient; the sloughy part separates, and the remaining part adheres to the opening. [(1) Key (a) makes a very important remark in reference to strangulated omen- tal rupture, which, however, I do not remember to have observed: he says :—" When from the nature of the symptoms the case appears to be merely an omental hernia, the operation must not be hastily proposed, for it is not easy to distinguish between inflammation of omentum which has been irreducible, and strangulation ; for the in- flamed state of the omentum without strangulation, the operation will afford no re- lief; on the contrary, it will aggravate the inflammation. It is highly advisable, therefore, to try the effects of active general depletion, and the application of leeches to the part, under which treatment the symptoms will often disappear. The result of operations on omental hernia which have been attended by acute symptoms, as great tenderness of the part, continued sickness, tense and tender belly, has been such as to induce me to try every means of allaying the inflammatory action before resorting to the operation. The operation in the cases that have come under my notice, has not suspended the symptoms, as it generally does in enterocele, but the patient has sunk within a few hours from the effects ofthe inflammation." (p. 36, note.)"] 1142. The treatment of ruptures differs according to the different cir- cumstances under which they are met with, namely, reducible or irre- ducible, strangulated or gangrenous. 1143. In reducible ruptures the indication is to reduce the protruded parts and to prevent their reprotrusion. This treatment is either pallia- tive by wearing a truss, or radical, by the organic closing of the hernial opening. 1144. The reduction of a rupture (Taxis, Repositio Herniae, Lat.; Zuriickbringung eines Bruches, Germ.; Repoussement de la Hernie, Fr.) is best effected early in the morning, when the bowels are empty, and (a) A. Cooper, above cited. REDUCTION OF RUPTURES. 273 the person is in a position, in which the walls of the belly are as much as possible relaxed, and the place of the rupture is most raised ; there- fore on the back, with the rump raised, the knees drawn up, and the body inclined towards the side on which the rupture is. Previous emptying of the urinary bladder, and of the large intestines with a clyster or purge will facilitate the taxis. The manoeuvre of the reduction itself consists in a sufficiently moderate pressure upon the whole swell- ing, according to the direction in which it has been protruded; or in the greater size and more oblong form of the hernial swelling, the fingers of the right hand are to be applied from the bottom around the swelling, the thumb and the other fingers of the left hand upon the two sides of the abdominal opening, and then it is to be attempted with the right hand to return the rupture according to its direction, whilst with the fingers of the other hand the parts returned are to be kept up. Often the taxis operates very easily, but often a part of the contents of the in- testine must be first returned by a moderate pressure on the rupture. During the reduction the patient must avoid all contraction of the walls of the belly. In proper positions of the body, small ruptures often re- turn of themselves. [In attempting the reduction of a rupture by the taxis, it is always advisable to make gentle and steady pressure over the whole swelling for a few minutes, in order to empty into the belly any fluid Contained in the sac, so that the protruded gut or omentum may be more effectually acted on by the fingers. The same pres- sure should also be employed with the hope of emptying some part or all the con- tents ofthe intestine, if any be down, by which its bulk being reduced, its return is considerably facilitated by the special pressure of the taxis. The fluid of the sac can generally be emptied, so that a very considerable reduction in the size of the swelling is effected, and the Surgeon often fancies he has returned a large portion of the protruded gut or omentum, when in reality not the least part of it has moved, as the exposure of the bowel by the operation proves. The return of the contents of the gut depends on their fluid character, and on the tightness of the stricture, and is far less frequently effected than that of the fluid of the sac. Violence in the use of the taxis is highly objectionable; instances have occurred in which the gut has been burst by it: one such case I have witnessed, and have known of others. Even when the injury is not so fatal, the violent squeezing to which a rupture is very commonly subjected, damages its contents, especially if in- testine be down, by the bruising which results therefrom, and renders the success of a subsequent operation very doubtful. I have seen several instances in which the gut presented large patches of ecchymosis which could have arisen from no other cause; and I believe that to this rough handling is mainly attributable the unsuc- cessful results of operations when the rupture has been long strangulated, and the taxis has been repeatedly employed with an unsparing hand. The reduction should therefore be attempted only with great caution, and with moderate and careful pres- sure. If after the warm bath and bleeding, the rupture cannot be reduced by the taxis applied not beyond half an hour, I think it is best to proceed at once to the operation, as least dangerous to the patient. Occasionally it will happen that, after the surgeon's efforts have failed, the patient himself will succeed in returning the rupture; or he may suddenly become very faint, and the bowel return spontaneously, in consequence of the relaxation of the parts permitting the peristalic action of the in- testines within the belly, or some accidental movement ofthe body, acting upon the portion within the stricture, so as just to shift its place, which effected, the return soon follows, even without the application of ice, or any other remedy to empty the vessels of the part. It sometimes happens in the efforts made either by the patient himself or by the surgeon, to reduce a rupture, that instead of its contents merely being reduced, as in ordinary cases, the whole tumour, sac, bowel, and all, is thrust up into the belly, and the reduction seemingly effected, but the symptoms of strangulation still con- Vol. n.—24 274 REDUCTION IN MASS, tinue,and the patient dies; nor is it till after examination of the body that the cause of the mischief is found out. To this unhappy mode of returning a rupture the French surgeons have given the names Reduction en bloc, or Riduction en masse. It appears to have been first noticed by Le Dran (a),in a man with femoral rupture, Which had been reduced twenty-four hours after its strangulation. The symptoms, however, did not cease, but continued for a week, at the end of which Le Dran saw him; but he was too nearly gone to admit of operation, and died the same evening. The surgeon first in attendance said, " that at the time of the reduction, he did not hear that noise the intestine generally makes when it enters into the belly; and that the parts composing the rupture passed in a heap under the ligament, like a tennis ball. * * * Upon opening the body we found the hernial sac in the belly, about three inches in depth, and eight in circumference, and within it was contained half an ell of the intestinum jejunum." (p. 14). Le Dran directs in such case that "a cut should be made where the rupture was, and that the ring should be dilated or the ligament divided, in order to draw the sac back with the fingers, or a pair of forceps. The sac should then be cut open, its entrance dilated, and the in- testine reduced. The sac cannot be far distant, since it is a part of the peritoneum that lines the inside of the pelvis, (p. 21). De La Faye (b) and Arnaud (c) con- firmed Le Dran's observation by their own experience; but the fact was disputed by Louis (d) on account of the presumed connexion of the sac with the surrounding parts, and its large size rendering its return beneath the crural arch very difficult. Richter (e), however, defended the statement of Le Dran. Another case occurred to Scarpa (/), in a boy of thirteen, in whom the symptoms of strangulation con- tinued after the presumed reduction of the rupture; "in fact, in the dead body of this boy there was not externally the smallest appearance of tumour in the inguinal region; but on opening the abdomen, it was immediately discovered that the intes- tine, Still strangulated by the neck of the hernial sac, had been pushed up along with the sac beyond the ring, where it was seen rolled up between the aponeurotic parietes of the abdomen and the great sac of the peritoneum." (p. 49; Engl. Edit. p. 143). Sabatier, Dupuytren, and Sanson, have also had cases of this kind, and Dupuytren has had not less than six of them (g). It is a very curious circumstance, that although these cases of reduced ruptures in mass, do not seem to have been very rare in France, yet till very lately they have been scarcely ever noticed in this country. Lawrence says:—"I have never seen a rupture reduced in a mass in this manner in the living body; nor have I seen any example of such a reduction in pathological collections." (p. 94). And Key (h) observes:—"I have never known this to take place when the hernia has been re- duced by the taxis." (p. 121). Sir Charles Bell mentions (t) a case of this kind, in which "a tumour was discovered quite within the muscular walls of the abdomen, which proved to be the strangulated intestine wfthin the peritoneal sac; so that the surgeon had reduced the sac and the intestine within it; and the stricture which produced the strangulation being in the mouth of the sac, there was no re- lief, and the patient died." (p. 926). In the Museum of the Royal College of surgeons there is an example of an in- guinal rupture reduced in mass, and pushed between the abdominal and iliac muscles, and the peritoneum, part lying below the crural arch and extending out- wards nearly as far as the external iliac vessels. It forms a considerable swelling inwards towards the cavity of the belly, but is not perceptible externally. The rupture was an old one, and the patient having worn a truss, was not inconvenienced by it, nor ever had difficulty in returning it, till it became strangulated. Another case occurred in consultation to my friends Green and Callaway, in the year 1836, and to them I am indebted for the following particulars. The patient, it appeared, had several years before, whilst in Spain, had symptoms of strangula- tion and a swelling in the scrotum, which having been pushed up completely by a (a) Observations de Chirurgie, &c. vol. ii. (e) Programma, in quo demonstratur her- 12mo. Paris, 1731. niam incarceratum una cum sacco suo (b) Operations de Dionis. Fifth Edit., p. reponi per annulum abdomiualem posse, etc. 324, note A. Paris, 1716. (/) Above cited. (c) Traite des Hernies, vol. ii. p. 96. (g) Dictionnaire de Medecine et Chirur- {d) Memoires de l'Acad. de Chirurgie, vol. gie pratiques,—Art. Hernie, vol ix p 571. iv.p. 299. (A) Above cited. (t) London Medical Gazette, vol. xiii, AND ITS CONSEQUENCES. 275 Spanish surgeon, after a time the symptoms subsided; and he was not farther in- convenienced until the attack now to be mentioned. On this occasion there was a swelling on the left side of the scrotum, irreducible but transparent, and accompanied with symptoms of strangulation. No relief was obtained by medicine, and it was determined to perform an exploratory operation. A cut was made into the swelling, the fluid evacuated, and the finger.being introduced, readily passed in and turned freely about, and the intestines were felt as it seemed, in the belly, and free from strangu- lation. The symptoms, however, continued, and the patient died four days after their onset. On examination it was found that the cavity, opened in the scrotum, did not, as supposed, permit the finger to pass directly into the general cavity ofthe peritoneum, but into a large sac lying between the iMacfascia and the m. iliacus, in which were contained intestines, and these were strangulated in a small aperture at the upper inner side of the sac, where was the communication with the cavity of the belly. The testicle lay behind the scrotal sac, just at the external abdominal ring. Green supposes that the rupture was originally congenital, and that when the patient was in Spain, the surgeon had violently thrust up the whole rupture and the testicle into the belly, the sac doubling on itself; but that the intestine had then partially or completely relieved itself, and that afterwards the sac had lengthened downwards, forming the swelling filled with fluid which existed in the scrotum,and had been cut into. The next case recorded, is that under Bransby Cooper's care in 1839, already mentioned, (par. 1117), in which there were two sacs. The attention of English surgeons was certainly, however, scarcely drawn to the reduction in a mass of rupture, by the taxis, till Luke's paper (a) was read before the Medico-Chirurgical Society, in the spring of 1843; and a perusal ofthe discus- sion thereon (b), clearly proves, that although it was attempted to show the subject had been previously well known, yet none of the speakers produced reference to any other than the few cases which I have already noticed, neither did any one allude to those of Dupuytren or Sanson, It must therefore be admitted, that Luke is fairly entitled to the credit of having brought the subject fairly before English sur- geons, foralthough he has also availed himself of the experience ofthe French, he men- tions not less than five cases which had come under his own notice, three of which were after death, and two he had under treatment, and gives account of; one of which would not submit to an operation and died, whilst the other was operated on and recovered. The possibility of returning a rupture in mass, which had been doubted or denied, was clearly proved by Jules Cloquet (c) in his experiments on the dead subject. He says:—" When the neck of the sac does not adhere very strongly to the apo- neurotic opening, and the latter is also somewhat dilated, which is not uncommon, in pushing violently the rupture towards the cavity ofthe belly, the cellular adhesions of the neck, and of the aponeurotic ring lengthen and break; the two openings which were near, separate from each other; the former sinks, passing inwards, whilst the latter retains its place. Whilst the taxis is employed the cone above the neck ofthe sac on its abdominal side becomes very prominent and much lengthened, is no longer formed as in the former case, (where the neck of the sac adhered closely to the aponeurotic opening), by the whole thickness ofthe abdominal wall, but merely by the peritoneum raised and detached from the muscles, by the sac which endeavours to get between those parts. The sac re-enters successively, and by little and little, through the aponeurotic ring as it dilates; and towards the end of the experiment it esoapes suddenly, and gets behind this opening. It is then easily felt through the abdominal walls, by placing the finger on the spot which the rupture had occupied; it forms a large, hard, round, chestnut-like tumour deeply-seated above the ring. In this case the reduction is complete, the rupture has returned en bloc, and is situ- ated between the abdominal peritoneum and the posterior surface of the aponeurotic ring. The ring contracts sliohtiy, by its elasticity, as soon as the sac has entirely slipped over it, and to a certain point prevents the reappearance of the tumour ex- ternally. This reduction en bloc is sometimes followed by a slight rush in conse- quence of the hasty passage of the bottom of the sac through the ring; but this rush (a) Cases of Strangulated Hernia reduced en masse, with observations ; in Med-chirurg. Trans, vol. ,xxvi. p. 159. (6) Lancet, 1842-3, vol. ii. p. 242-45. (c)Recherches sur les Causes, &c. above cited. 276 REDUCTION IN MASS, never happens when the ring is very loose and wide. * * * When this last condi- tion exists the tumour goes in and out with equal readiness. I have accomplished re- duction in mass in about twenty-five instances, partly of ruptures either strangulated or otherwise irreducible, partly of empty hernial sacs. It is effected most easily in internal (direct) inguinal, then in crural, and lastly in external (oblique) inguinal ruptures. I have never succeeded in umbilical ruptures in adults. When the sac is of considerable size, when it adheres closely to the surrounding parts, when the aponeurotic opening is small, and in the form of a canal, circumstances which are frequently met with in external (oblique) inguinal ruptures, this kind of reduction is almost impossible, unless great force is employed. * * * The replacement m mass of a rupture strietured by the neck of the sac, takes place most easily when the aponeurotic ring is of large size and short; when the sac and its neck are loosely connected to the surrounding parts; and when the protruded viscera adhere together, and to the sac, so that reduction in the usual way is impracticable. In a case of internal (direct) inguinal and in another of crural rupture, I found that the tumour could only be returned in a mass, although the neck of the sac was not narrow, in consequence of close adhesions between the protruded parts and their peritoneal covering." (pp. 113-15). The following are some of the more important of Luke's pertinent observations (a) in reference to the existence of a rupture reduced in mass, when without any tumour symptoms of strangulation are present:-—" The too exclusive reliance upon the ab- sence of tumour as a sign ofthe non-existence of a hernia, may, in certain cases, be highly dangerous. In suspeeted cases, more security will be derived from the in- stitution of inquiries concerning the previous existence of a tumour in the part, and of its conditions when ascertained to have existed, such as its hardness, or the re- verse, its freedom from pain, and also the amount of, and the manner" of applying the force used for its reduction. By such inquiries, not only may the dependence of the symptoms of intestinal obstruction upon hernial strangulation be determined, but also the presumption of a reduction en masse may be raised or removed. Should such a presumption be raised, the surgeon will then be prepared to push his inqui- ries farther, and to seek for indications to direct his diagnosis, which are not usually sought for in ordinary examinations. The mode of proceeding to render these indi- cations available to our use, is twofold. That, however, will in prudence be first adopted which requires mere manual examination without incision, while the second should be had recourse to, provided the first tends to strengthen the presump- tion of a reduction en masse previously raised, * * * It is a circumstance worthy of remark, that the firmness ofthe adhesions of the parts' in which it is embedded, bears no proportion to the duration of the hernial protrusion, as might be, a priori, expected ; for in all the cases (of reduction in mass) related, the hernia had been of some years continuance, yet in each was reduced without the employment of much force. " The presence of sac, even without hernial contents, causes an abnormal fulness in the part, easily ascertainable by examination. The absence of such fulness in a part, when hernia is known to have previously descended, necessarily leads to the conclusion that the sac upon which it depended has been displaced, and probably returned, together with the hernia. The sac in inguinil hernia, below the external ring, becomes united with the spermatic cord, whereby the latter is usually rendered indistinct and obscure. The absence of that indistinctness and obscurity implies the removal of the cause which previously produced them, and, therefore, that the sac has been displaced. The continuance of the indistinctness and obscurity leads to a directly contrary conclusion. When a hernia descends from the abdomen, the aperture through which it desoends is always enlarged and dilated. This fact is ascertainable by the introduction of a finger, a circumstance which becomes avail- able to the diagnosis in these cases. Should a large aperture be detected, a previous hernial descent may be inferred. Under ordinary circumstances of hernia, when the contents are reduced into the abdomen, the area of the aperture is occupied by the remaining sac, while its margins are rendered more or less obscure. If, then, a large aperture be found free and unobstructed, with its margins unobscured, there is raised not only a presumptive evidence of the previous protrusion of a hernia at the (a) Cases of Strangulated Hernia reduced en masse, with observations, in Med.Chir. Trans., vol. xxvi, AND ITS CONSEQUENCES—OPERATION FOR IT. 277 part, but also the farther evidence of the displacement and probable return into the abdomen of the sac by which the hernia had been invested. We are led to a con- trary conclusion by contrary circumstances. These, I believe, are the only indica- > tions useful to diagnosis, resulting from changes caused by the previous descent of a hernia, at or below the abdominal ring. "Nor does the examination ofthe inguinal canal afford any available information, unless a tumour be discoverable in its course; a circumstance which, by the clear- ness of the evidence it affords, renders the diagnosis comparatively easy, and affirma- tively conclusive, but constitutes a description of case not intended to be included in the scope of the present observations, which are directed exclusively to cases un- attended by any external appearance of,tumour. " Yet in conducting an examination of the abdomen, immediately above the seat ofthe internal ring, some corroborative evidence of a reduction en masse may some- times be obtained. Thus it may be expected, that if such reduction has been effected, the inflammation of the hernial contents will cause a circumscribed pain in the seat which it occupies, while a fulness, or even the rounded form of the hernia deeply situated within the abdominal parietes, may possibly be cognizable upon a minute examination; yet the absence both of circumscribed pain, and of fulness or rounded form should not lead to a negative opinion; for, in the first case, neither pain nor fulness existed, yet subsequently a mass of strangulated intestine was discovered at the part. Their presence, however, may be taken as corroborative of an affirmative opinion, founded upon the manual examination previously instituted. " If circumstances justify a suspicion of a reduction en masse in any case, they will also justify attempts to cause reprotrusion of the tumour, that by bringing it into view, the obscurity of the diagnosis may be wholly removed. With this in- tention, as advised by surgeons of authority in such matters, the patient should be placed in the erect posture, and be requested to cough forcibly, to strain and to make exertion. This course of proceeding seems likely to be of use, when the hernial tumour is either in the inguinal canal or at the internal ring; but if it be reduced within the abdomen, as in the cases related, beyond the situation of the ring, the probability of affecting its reprotrusion will be much diminished, and consequently an opinion of the non-existence of a reduction en masse, drawn from the non-appear- ance of a tumour, is to be cautiously avoided." Although, after " the most rigid local manual examination, the indications afforded for our guidance are so obscurely marked," as to afford " a sufficient explanation why surgeons, under these circumstances, are usually unwilling to have recourse to ulterior measures of examination, by submitting the patient to the certain pain and possible danger of an exploring operation, yet such unwillingness may prevent the adoption of the only means of preserving the patient's life. As the doubts and dif- ficulties of such cases can be removed only by the light which an operation of ex- ploration affords, it is the obvious duty of the surgeon to make that unwillingness yield to the pressing emergencies of the occasion. * * * It should be remembered that an unsuccessful attempt is infinitely to be preferred to no attempt at all, and that passiveness on his part may be more destructive to life than any incisions which he may be required to make." (pp. 175-79.) With these observations of Luke I most fully concur, and more especially, be- cause there appears to be pretty good grounds for finding the reduced rupture at a particular spot, as Dupuytren (a) observes:—" When the hernial tumour is reduced in mass it cannot move about in the belly, because it is formed, in part at least, by the peritoneum, which although moveable, remains always in the region to which it belongs, and consequently retains the tumour. The rupture is then permanently behind the opening, by which it has returned and resting on its internal surface. Surrounded by the cellular tissue, which had previously united the peritoneum to the wall of the belly, and which has heen displaced to receive it, the returned tumour is found, besides, to be covered with a second lay ex of peritoneum, which is actually that detached from the hind surface of the belly; so that to penetrate the hernial sac, by cutting through the abdominal wall, the peritoneum must be twice cut, and its cavity opened before reaching the cavity of the sac, unless the operation were per- formed like that for tying the external iliac artery, by raising and detaching the serous membrane. Dupuytren does not, however, advise either cutting through (a) Above cited. 24*. 278 REDUCTION IN MASS—OPERATION. the peritoneum and opening the abdominal cavity, or turning off that mem- brane to get at the hernial sac. " There is fortunately," says he, " a more simple and less dangerous mode of treatment, which consists in seeking for and drawing down the rupture by the opening through which it had passed into the belly, being assured it will be found resting on the internal surface of that opening, where it can be laid hold of with the forceps, and drawn out, with or without cutting the edge of the ring. If the tumour be examined through the cavity of the peritoneum, it will be seen lodged in the iliac pit, a little more outwards in crural rupture, a little more inwards and deeper in inguinal rupture. It presents a narrow, tight opening, in which two ends of the intestine are plunged, forming a loop in the cavity of the sac. It is at this point that the intestines are compressed, narrowed, shrunk, strangulated, and mortified, the upper end more frequently than the lower; the former bulges almost to bursting; the latter, shrunk, empty, and like the intestines of a child." (pp. 592-94). " In conducting operations of exploration," observes Luke, "the indications which are to be sought for, are, for the most part, of a similar nature to those already men- tioned, as useful in the manual examination. They are, however^ more satisfactory and distinct, inasmuch as the parts to be examined are, by our incisions, brought immediately into view, and are not obscured by the interposition of superjacent structures. Thus by the perfect exposure of the inguinal ring, * * * if the size ofthe ring be normal, a hernia has not descended through it; or if it be larger than the normal state, yet occupied by an empty sac, an evidence of the previous ex- istence of a hernia, together with an evidence ofthe reduction of the hernia without the sac being also reduced, is established. But should the ring be found large and free from other obstructions than the cord, and if the cord be distinctand unobscured by the presence of a sac, and a void is found where fulness is to be expected from the previous history ofthe case, a strong presumptive evidence on the contrary side is established, that the hernia, together with its investing sac, is reduced. In proceeding •with the exploration, the inguinal canal is next laid open. * * * I hold a close observance of the condition of parts within the canal to be a matter of very great importance. It will be recollected that the ordinary oblique inguinal hernia, during its passage through the canal, lies anterior to the spermatic cord. The hernial sac, when left empty after the reduction of its contents, occupies the same relative situation, and consequently overlays and obscures the cord after the canal is laid open. If the reverse of this is found in a case where a hernial descent is known to have previously existed, and the cord is ascertained to be clearly and distinctly brought into view, throughout the whole extent of the canal we may justly conclude, that the distinctness and clearness with which the cord is seen are caused by the removal and consequent reduction of the hernial sac from over it, which reduction can be effected in no other direction than into the abdomen. "The condensed cellular capsule (usually found) immediately investing the sac * * * has but little connexion with the sac, and will remain even when the sore has been reduced. * * * If found and ascertained to be empty, the circumstance is of a very conclusive character, and moreoverwill afford a direct clue to the situation ofthe hernia. A finger introduced through an opening made in such capsule, will be conducted towards or through the internal ring, beyond which it will be brought into contact with the hernial tumour itself, having in the introduction passed through the same channel by which the reduction was effected. " The indications to be noticed at the internal ring are of a similar nature to those mentioned as being found at the external ring, and relate to the size of the aperture and the structures by which it is occupied. " It will be observed that up to this period the proceedings of the exploration have been conducted without any danger of importance, and without any necessary dis- turbance to the peritoneum, yet information of the most conclusive kind may have been obtained, and such circumstances brought under notice as could fully justify the operation, even if manifold, more hazardous than it really is. * * *. "The operation may be conducted to a demonstrative conclusion, by ascertaining the existence or non-existence of a hernial tumour, without adding materially to the trifling danger already incurred. This is accomplished simply by the introduction ofthe finger through the internal ring, and by passing it from side to side. Should a hernial tumour be present it will at once be recognised, and found lying externally to the general peritoneal membrane, although within the parietes, and presenting a TRUSSES. 279 rounded surface. Should a tumour be not present, the circumstance may be ascertained by observing the smooth surface of the peritoneum, and the continued ad- hesions which it maintains with the parietes immediately surrounding the ring. If doubt still exists, an enlargement of the internal ring, by division of the adjoining transversalis fascia, will afford a clearer exposition of parts, and a more decisive evidence for either an affirmative or a negative conclusion; and thus an explora- tion may be conducted to its termination without the necessity of any peritoneal section. "When the doubts have been resolved in the affirmative, by the discovery of a hernial tumour, the tumour may be brought into* the inguinal canal, so as to occupy its former situation before reduction, by enlarging the ring to the requisite extent for its passage. It may afterwards be opened, and its contents dealt with according to their condition, as under the ordinary circumstances of common operations. * * * "The sac should in all circumstances be opened, and its neck freely divided, so as not to leave any impediment to reduction of its contents into the general perito- neal cavity. It should be recollected also, that the adhesion of the sac to the'sur- rounding parts has been severed, and that consequently the sac will be liable to be again reduced during the reduction of the contents into the abdomen unless caution be used for its prevention. The danger of this occurrence may be always obviated by the introduction of the finger through the neck of the sac, after the contents have been reduced, for thus the fact of their perfect liberation may be readily ascertained." (pp. 180-85.)] 1145. If the rupture be completely reduced, which can be determined by. introducing the finger into the abdominal ring, its re-descent is to be prevented by continual suitable pressure, which is to be made by proper bandages, Trusses, Bracheria, Lat.; Bruchband, Germ. ; Brayer, Fr.,) upon the hernial opening. Upon the subject of Trusses, see Camper; in Memoires de l'Academie de Chirurgie, vol. v. Javille's Traite des Bandages Herniaires. Paris, 1786. Brunninghausen, Gemeinniitziger Unterricht fiber die Briiche dem Gebrauch der Bruchbander und fiber das dabei zubeobachtende Verhalten. Wiirzburg, 1841; with one Plate. Lafond, J. J., Considerations sur les Bandages Herniaires usitees jusqu'd,, ce jour, et sur les bandages renixigrades ou nouvelles espece de brayer. Paris, 1818. Doring, Art Hamma; in Rust's Handbuch der Chirurgie. Cooper Astley, above cited, p. 21. Cloquet, Art. Brayer; in Diet, de Medecine, vol. v. 1834. [Chase, H. On the Radical Cure of Hernia by Instruments, &c. Philadelphia, 1836. Report of the Committee vof the Philad. Med. Soc. on the construc- tion of Instruments, &c. Philadelphia, 1837.—g. w. n.] 1146. Trusses are either elastic or inelastic. The latter consist of a strap of fustian, leather, or the like, and of a pad. When applied, they may not yield to the movements ofthe coverings ofthe belly, may there- fore be very easily displaced, the intestines slip from them, and if this be prevented by drawing tight, painful pressure is produced. Upon these grounds the inelastic trusses are to be altogether rejected. 1147. Elastic trusses consist of, first, a spring; second, a pad; and third of a circular strap. The spring is a narrow flat piece of well- hardened steel, which bends in a semi-circle around the diseased side. A plate of steel is attached in front to the spring and its inner surface padded with wool or horse-hair, so that it may form a soft but regular arching, this part is called the pad. At the hinder edge ofthe spring is a circular strap, which passes round the other side of the body, and is 280 CURE, SPONTANEOUS AND fastened to a button on the outer surface of the pad. The whole truss is to be covered with soft leather and lined on the inside, so that it may not make any troublesome pressure. 1148. The truss must be made with great care in each of itsparts, and be fitted to every individual case. The strength of the spring must correspond to the resistance which it has to afford, and fit well to that side of the body on which it is applied. The pad must have a size cor- responding to the bulk of the rupture, and the angle at which it stands from the spring correspond to the surface on which it is applied, which it has been also attempted to effect by a moveable pad, in order to suit it to every case. The pad must not be too soft nor too hard, and its con- vexity must be such that it may be regularly over the whole hernial opening; pads of hard wood, ivory, or filled with air, (Cresson and Sanson,) are less certain and suitable. If the circular strap alone be in- sufficient to keep the truss in its proper place, we must endeavour to prevent its displacement by a second strap, carried between the thighs. In order that the truss may be sufficiently firm, it is necessary in every case to take the size, by means of a bandage carried round the body from the seat ofthe rupture and in the direction on which the truss is to lie ; or for the same purpose, a double piece of flexible wire may be used, with which the necessary curve can be given ; about an inch must be added to the size on account ofthe covering of the strap. 1149. The truss is to be applied after the proper use of the taxis for the reduction, whilst with the fingers the intestines are kept up, till the pad be properly applied on the hernial opening, and the strap be fas- tened. The patient should then cough, and stand up, to determine that the truss is not put on too tightly and that the parts are well kept up. The surgeon should always apply the truss the first time ; subsequently the patient may do it himself, but it should be whilst lying on his back and early in the morning ; he should also have several Irusses for the pur- pose of change. The part on which the truss rests should be frequently washed with brandy, till the teguments are accustomed to its pressure. If excoriations occur, the parts should be washed frequently with lead wash, whitelead should be strewed over it, and a thick piece of linen applied beneath the truss. 1150. Various diseases in the neighbourhood of the opening upon which the pressure must be made, and an imperfectly reduced rupture may prevent the use of the truss. Large ruptures are extremely difficult to reduce, and often new ruptures occur afterwards in other parts. In chil- dren the use of an elastic truss is not only accompanied with no injury, as many suppose, but is to be preferred to the use of an inelastic one. 1151. When an adhesion prevents the return of a rupture to such ex- tent that part of it remains external, a truss with a hollow pad may be used ; but in very large irreducible ruptures a suspendor sufficient to en- close it, should be used to prevent the farther protrusion of the intestine. In these ruptures the gradual return is effected by long-continued lying on the back, by slender diet, purging, frequently cold applications over the rupture, and by daily repealed attempts at reduction, which has oc- curred to me in several cases of very large and adherent ruptures. When in large ruptures the walls of the belly are so contracted that the RADICAL, OF REDUCIBLE RUPTURE. 281 parts in the rupture have scarcely any room in the belly, the same treat- ment is indicated. Frequently in such cases, after the reduction and the application of a truss, anxiety, oppression, pain, small pulse, and so on occur, and it becomes necessary to remove the truss, after which the symptoms, as I have observed, subside. 1152. When the intestines are properly kept up by the truss, the hernial sac gradually contracts, and at the same time a slow inflamma- tion arises, consequent on the pressure of the truss, by which perfect ad- hesion ofthe neck ofthe hernial sac takes place, and thus a radical cure is effected. This commonly happens in children, frequently in adults, but never in old persons. On account of this gradual narrowing of the neck ofthe hernial sac, under the continued use ofthe truss, the latter may not be again removed if it be not believed certain that the radical cure is effected; because otherwise, in repeated protrusions of the intestines, strangulation may also arise from the contracted neck of the sac. Whilst the patient wears the truss he must avoid all violent exertion. [Cloquet considers that a hernial sac may be returned spontaneously into the belly in four different ways. First, by the contractility it possesses in common with other tissues, having a constant tendency to retract the sac upon itself, after its distension, and which is, in some cases, sufficient to produce a gentle and gradual return. "The sac then takes a retrogade movement to that of Its formation; the peritoneum passes from the ring towards the parts it had left, that portion of this membrane, which had been drawn towards the ring without passing through it, pulls the neck in every direction, which expands, turns out in some degree, disap- pears, and at last is effaced; the sac unfolds, and again uncovers the wall of the belly, near the aponeurotic opening. The neck of the sac, which was last formed, disappears first, whilst its bottom disappears last, and with great difficulty, so that the reduction is often incomplete." (p. 74.) When a rupture has been thus reduced, the remains of the neck are sometimes observed at a little distance from the ring, in the shape of irregular stygmata, whitish, and more or less opaque. The peritoneum, which formed the sac, is restored to the abdominal wall. * * * Sometimes these sacs are so completely effaced, that no trace of them can be found in the peritoneum co- vering the ring by which they had escaped. The only indication of a rupture having existed at this spot, is a cellular, whitish, empty pouch, arising from the aponeurotic ring." (p. 76.) Second, " by the closing, the gentle and insensible con- traction of the cellular tissue external to the sac. The other tunics may concur also; but their action appears more weak, and less demonstrable. * * * In this case the peritoneum presents at the top of the ring irregular prominent folds, analo- gous to those of the mucous membrane of the stomach during the contraction of its muscular coat." (pp. 78, 9.) Third, by the displacement of the peritoneum from the abdominal wall from various causes, as in two cases of direct inguinal rupture, in which, in consequence of retention of urine, the peritoneum covering the bladder was raised nearly to the navel—by enlargement of the womb by pregnancy, or any other cause—by adhesion ofthe omentum, or intestine to the hernial sac—by a large quantity of fat collecting between the peritoneum and wall of the belly—or by the dragging of another sac which has formed in the neighbourhood of the former. Fourth, by the contraclion of the cremaster muscle; " the two fleshy bundles of which act upon the sac pretty much as the two bellies ofthe digastric muscle effect the direct elevation of that bone." (p. 83.)] 1153. The radical cure of reducible ruptures (especially inguinal rup- tures) was attempted in ancient times in very different and in part cruel and barbarous ways, which had only their corresponding excuse in the ignorance of, or in the bad construction of trusses. Even later modes of treatment have found little favour, on account of the danger there- with connected, and because of the more perfect construction of trusses; and only of late have these objects again attracted more attention, and 2S2 RADICAL CURE less dangerous methods of treatment have been proposed. All the modes of treatment in reference to the radical cure have for their object the organic closing ofthe neck of the hernial sac, or ofthe abdominal ring, or to effect both at once, which has been attempted by a sufficient degree of adhesive or suppurative inflammation, and thereby causing adhesion; or by a plug of skin healed into the abdominal ring. These may be collected together under the following heads '.first, Increased pressure whilst lying constantly on the back, with, or without the simultaneous application of irritating and contracting remedies; second, Caustics and the actual cautery ; third, Ligature of the sac, with or without cutting it off; fourth, Introduction of foreign bodies into the hernial sac; fifth, Healing-in of a detached portion of skin, or of a portion of infolded skin, into the ab- dominal ring. 1154. Increased pressure, whilst the patient lies constantly on his back, heretofore employed by Fabr, Hildanus, Blegny, Winslow and others, has of late been recommended by means of a common pad, (Richter and others,) with a conical linen pad, the point of which is inserted into the abdominal ring by means of an elastic truss; the supine posture is to be continued at least four weeks, till superficial ulceration take place, which should be dressed with lead cerate, and the truss still applied tightly for some time (Langenbeck) {a); at the same time a sponge dipped in turpentine, or a blister, is to be put on beneath the pad (Boyer) ; with a pad of which the power can be increased by means of a compressing screw, with a pressure apparatus moistened with alum wash (Ravin) (b); or with a pad filled with contracting herbs, and sub- carbonate of ammonia (Beaumont) (c). Various irritating and astringent remedies have been mentioned which have been employed in blisters, bags, pads and as washes; to wit, bark, tormentilla, gall nuts, oak bark, rhatany, alum, turpentine, aetherial oils, naphtha, washing with cold water, iron bullets, cold river bathing, and so on. Jalade Lafond (d) employs a pad with a reservoir for holding caustic. 1155. The application of the actual cautery, derived from the Alex- andrian school and first described by Paulus ^Egineta, and of caustic (recommended from early times, from Avicenna up to Kern) closes the hernial opening by destroying the skin and hernial sac, and forming a hard scar connected with the bone. After the rupture has been returned, and the cord drawn aside, the cautery is to be kept so firmly upon the abdominal ring, that it burn deeply through the skin and hernial sac down to the bone. In the same way caustics are to be applied, viz., caustic potash, arsenic or sublimate with opium, lime, sulphuric acid, one part of caustic potash, two of gum-arabic, and some water (Kern). The cautery as well as the caustics have also been applied upon the hernial sac laid bare by incision (Franco, Monro). 1156. Tying up the hernial sac with the ligature {ligatura sacci herniosi, hat.; Zusammenschnurung des Bruchsackes, Germ.) and stitching {sutura, Lat.; JYaht, Germ.) are performed in different ways: first, after the (a) Abhandlung von den Leisten und maniere de les guerir radicalement. Paris, Schenkelbruchen, p. 121. 1827. (b) Essai sur la Theorie des Hernies et (d) Remarques nouvelles sur la cure radi- de leur etranglement, et de leur cure radicale. cale des Hernies sim pies sans operation Paris, 1822. sanglante. Second Edition. Paris, 1841. (c) Notice sur les Hernies et une nouvelle OF REDUCIBLE RUPTURE. 283 already directed reduction, encompassing the sac with a needle and tying together both it and the spermatic cord with a ligature; second, after previously laying bare the sac by an incision, encompassing the hernial sac and the spermatic cord with a needle, and introducing a golden thread which can be so drawn as to close the hernial sac, but the spermatic cord is not to be compressed, (the golden puncture, punctum aureum) (Berard, Franco) ; third, tying the hernial sac and the spermatic cord, and cutting both off below the ligature, or first cutting off both and then tying them (the rupture-cutter ofthe middle ages); fourth, separation of the hernial sac from the surrounding parts, and then tying it with a leaden thread, (Pare,) or closing it with the glover's stitch, the royal stitch, {sutura regia,) (Nuck, Fabr. ab Aquapendente, Guy de Chauliac, and others.) or simple tying with a waxed treble or quadruple thread. (Le Dran, Freitag, Senff, Schmucker, Theden and others,) in modern times Langenbeck and Kern, the latter of whom, in omental rupture, tied the exposed omentum near the abdominal or femoral ring, so that the re- maining part of the omentum, by uniting with the walls of the ring, closed it up; fifth, incision into the integument and hernial sac, and treating as after the operation for strangulated rupture, with simple lint dressing and light pressure with a spica bandage or truss, (Petit, Lieutaud, Le- blanc,) or with simultaneous scarifications ofthe hernial sac, (Freitag, Mauchart, Richter,) or with the introduction of tents of lint (Dionis, Mery, Arnaud, Schreger, von Graefe, von Walther and others.) Here also belongs the injection of red wine, recommended by Schreger, and the inflation of air into the hernial sac, the mouth of the sac being carefully closed with pressure. 1157. The inhealing of a plug of skin, to close the mouth of the sac, is effected in two ways:—1. According to Dzondi's proposal (a), to heal within the abdominal ring, purposely wounded a sufficiently large fold of skin, formed by an incision of the skin ; Jameson (b) made, in a femoral rupture, a fold of skin two inches long, and an inch wide, thrust it into the femoral ring, and united the edges of the skin, with stitches. 2. Gerdy's inhealing of the skin, ensheathed in the inguinal canal (c). After the patient is placed, as in the operation for strangu- lated rupture, a finger of the left hand, smeared with cerate, is to be placed somewhat beneath the hernial opening on the scrotum, and then the scrotum in front of it is to be thrust along the spermatic cord as deeply as possible into the inguinal canal. In this blind sac the finger is to remain, and the skin is to be thrust as far as possible towards the outer wall of the inguinal canal. A curved needle, with two cutting edges, and with a handle, and its eye armed with a double thread, is then to be introduced, on the palmar surface of the forefinger, to the bottom of the ensheathing, and whilst the handle of the needle is de- pressed, the needle itself, its convex surface resting on the palmar surface of the finger, is to be thrust, whilst an assistant presses the external skin against its point, from behind, forwards through the front of the ensheathed part of the scrotum, and the front wall of the inguinal canal, so that the needle projects some lines above the inguinal ring. The one end ofthe (a) Geschichte des klin. Institutes zu (c) Bulletin de Therapie, 1835.—Fink Halle, p. 117. Ueber radicale Heilung der Bruche. Frei- (b) The Lancet, vol. ii. 1829, p. 142. burg, 1837 ; with two copper plates. 284 RADICAL CURE OF thread is now to be drawn out, and given to an assistant, the left finger still remaining in the ensheathing. The needle, in the eye of which the other end of the thread remains, is now again to be passed upon the finger, at some lines' distance from the former stitch, thrust through externally, and the thread withdrawn from it. After the removal of the needle, the threads are to be divided, and a cylinder of plaster placed between them, upon which they are to be tied, and the ensheathed part of the scrotum is firmly retained in its place. If the entrance and canal of the rupture be much enlarged, two other stitches must be applied ; but in general, one is sufficient. The sac formed by the ensheathed skin, is to be then pencilled with caustic liquor ammoniae, to excite inflammation, the part operated on, covered with a pad, spread with cerate, and covered with a compress, and the patient put to bed in such position, that the rump and the head are somewhat raised, and the thighs drawn up. In all cases phlegmon follows, which spreads over the whole ex- tent ofthe stitches, and runs into suppuration, the pus discharges itself through the stitches, along the threads, which, at the same time, also act as guides to it. If the adhesion have taken place in from three to five days, the stitches may be removed. Towards the fifteenth or twentieth day, the suppuration ceases, the ensheathed skin forms a plug, which externally appears like a swelling, but gradually subsides. The patient must, for four weeks, observe the supine posture, and the treat- ment must be conducted according to the inflammatory symptoms which may come on. Signoroni (a) thrusts up the skin, like the finger of a glove, into the sac of the rupture, and fixes it by means of a female catheter, then pierces it with three long hare-lip needles, four lines apart from each other, and twists around each an OO-shaped thread. The needles are left six or eight days. Wutzer {b) retains the skin thrust up into the inguinal canal, by means of a cylinder, on the under part of which is fastened a plate which fits the outer surface of the inguinal canal. A needle is thrust through the upper part of the cylinder, out- wards, and brought out by an opening of the external plate. Here must also be mentioned Garengeot's proposal, according to the experiment once made by Petit, that strangulation existing, if the mouth of the sac were ex- panded with one wound, and the open hernial sac thrust back into the belly, the radical cure followed; this treatment might also apply to the attainment of the radical Cure, as well also as the reduction of the exposed sac according to Hummel and Stephens. [(1) Bransby Cooper (c) has performed Gerhy's operation. The application of the caustic ammonia caused intense pain in the part, for a few hours after the ope- ration, but no pain in the belly. On the fourth day, suppuration having been freely established, the ligature was removed, but the pressure was continued. On the fifth day, there appeared a degree of fulness about the margin of the opening, as if a portion ofthe inverted skin had descended, but without any descent of the intes- tine, and the hardness and swelling about the inguinal canal still led to the reason- able hope that the operation would prove successful. After some days, as the tenderness diminished, greater pressure was made. On the twenty-fourth day, a weak truss was applied, and he continued in bed ten days longer, after which time however he would not be confined, but got up and walked about, and soon after left the hospital. But he had a slight return ofthe rupture]. (a) Bulletino Medic, de BologAa, 1836, (b) Organon fur die gesammte Heilkunde, Dec. Froriep's neue Notizen, vol. ii. p. vol. i. pt. 1. 272> (c) Guy's Hospital Reports, Oct., 1840, pp. 270-75. REDUCIBLE RUPTURE. 285 1158. The most modern practices which may be placed next the former, are those of Bonnet, Mayor, and Belmas. Bonnet {a) employed the same treatment as for varicocele, introducing needles upon the hernial sac, and allowing them to remain. The rup- ture having been reduced, the scrotum is to be grasped with the left hand, as close as possible to the abdominal ring, and the spermatic cord brought into the circle formed by the thumb and forefinger of this hand ; a pin, with a piece of cork on its head, is to be thrust, close to the sus- pensory ligament of the penis, from the point of the finger nearest it, from behind and above, forwards and downwards, through the integu- ments and the hernial sac. A second piece of cork is to be fixed on the projecting point, and brought near the first piece, so that the inter- mediate soft parts are easily compressed ; and in order to keep the second piece of cork in its place, the point of the pin is bent down. The spermatic cord is to be placed between this pin and the tip of the thumb and forefinger of the left hand, and a second pin is then intro- duced six lines distant externally from the first pin, parallel to it, and fastened in the same way. If the spermatic cord have been divided by the pressure of the intestine, into its several parts, a third pin must be passed six lines from the second, so that the other parts ofthe cord may be placed between the second and third pins. Usually, about the fourth day, pain and inflammation come on ; but the pins are not to be removed till the inflammation has acquired a certain degree of intensity, and the hindmost piece of cork has excited ulceration of the skin, which occurs about the sixth, or even at the twelfth day. By this proceeding, not merely is the hernial sac, but also the abdominal ring closed, and united with the neighbouring parts by the effused lymph. Mayor (b) has modified this practice, by forming at the abdominal ring a longitudinal fold of skin varying in size according to the bulk of the rupture and the width of the abdominal ring, to the middle of which corresponds a line drawn over the middle of the hernial swelling; through the base of this fold of skin, held up by the fingers, a needle, armed with a double thread, is to be passed, the ends of which being sepa- rated on each side, are to be tied on a piece of bougie, or on a piece of cotton, or of sponge properly tied together. The number of stitches is determined by the size of the fold. In children the first stitch is to be made over the middle ofthe abdominal ring, at other times, the stitches may be commenced where you please. If the abdominal ring be wide, and the other circumstances unfavourable for contraction and keeping up the rupture, it is then necessary to bring the stitches nearer, and to increase the size of the substances which are held together by the threads. In slight cases, and with quiet, intelligent patients, no ban- daging is used ; slight compression upon a thick layer of wool by means of a fitting truss, or a neckerchief fastened upon the hip, is always re- quisite, especially in children and restless patients, and in large ruptures which are with difficulty kept up. The threads may be removed from (a) Journal des Connaissances Medico- Krankheitsfallen; inBeitragenzurgesamm- chirurgicales, 1836, July.—Gazette Medi- ten Natur und Heilwissenschaft herausgeg. cale, 1836. von Wertenweber, vol. vi. pt. i. Plachetsky, F., Ueber die BoNNET'sche (b) Sur la cure radicale des Hernies. Radical operation der Hernien nebst 8 Paris, 1836. Vol. ii.—25 286 RADICAL CURE OF the sixth to the ninth day, and a truss must be worn for a shorter or longer time afterwards. 1159. Belmas (a) attempts to effect merely adhesive inflammation, by introducing goldbeater's-skin into the hernial sac, which he at first passed in, as an empty, dry bladder, by an incision through the sac, and then inflated it; but of late he has pursued the following plan:—After the rupture is completely returned, the sac and its coverings are to be raised with the fingers ofthe left hand in one fold, in front of and parallel with the spermatic cord, and through its middle, above the abdominal ring, a trocar-like instrument, divisible in the middle, is to be thrust. The operator now allows the hernial sac to slip from between his fingers, so that the fold is formed by the skin alone. An assistant holds this fold, and whilst the hernial sac is fixed by the thumb and forefinger, applied above and below the instrument, the latter is to be thrust forward till the union of the two canals corresponds to the interspace between the walls of the hernial sac. By the peculiar mechanism of the instrument the two canulas, after the removal of the trocar-points, are drawn asunder, and both walls of the hernial sac separated. The assistant lets go the fold of skin, grasps the canula corresponding to the trocar-point, whilst the operator holds the other canula, and through its aperture introduces with a probe four or five thin cylinders of jelly covered with goldbeater's- skin, in various directions, into the neck of the hernial sac. The canulas are then removed, and a truss is put on, the pad of which acts where the cylinders of jelly are placed, and is to be worn at least for four months, constantly. The patient may after the operation follow his business. The cylinders of jelly are soon absorbed. The goldbeater's- skin resists absorption longer, and excites slowly in the hernial sac an adhesive inflammation, which is confined to the parts in immediate con- nexion with the foreign bodies. Walther's proposes to inject animal fluid, the patient's blood, into the hernial sac. Upon the Radical Cure of Rupture, compare also Ran, Dissert, de novo hernias inguinales curandi methodo. Berol., 1813. Pfefferkorn, Diss, de herniis mobilibus radicitus sanandis. Landishut, 1819. Pech, Osteosarcoma ej usque speciei insignis descriptio; adjuncta est de cura her- niarum per ligaturam tractatiuncula. Wirceburg, 1819. Hesselbach, A. K., Die Lehre von den Eingeweidebriichen, vol. ii. p. 214. Thierry, A., Des diverses methodes operatoires pour la cure radicale des Hernies; These de concours; avec des Planches. Paris, 1841. 1160. The decision as to the performance of the radical cure for re- ducible rupture in general, and on the different modes of treatment in particular, must be guided by the following circumstances. In conse- quence of the very greatly improved construction of trusses of late years, the necessity for the so called radical operation is, in comparison with former times, quite another thing, as thereby every reducible rupture can be retained in its proper place, and a cure often be effected by the pro- per wearing of a truss. All the modes of operation mentioned are more or less dangerous, especially cauterizing, tying, and stitching up the hernial sac, and the introduction of tents, as the inflammation thereby (a) Recherches sur un mqyen pour de- 1838.—von Walther, Ueber die Hernioto- terminer des inflammations adhesives dans mie als Mittel zur radicalen Heilung der les cavites sereuses. Paris, 1829.—Clin- Briiche; in Journal fur Chirurgie und Au- iques des h6pitaux de Paris. 21st Aug., and genheilkunde, vol. xxvi. pt. iii. p. 363. (En- 11th Sept. 1839.—Revue Medicale. March, graving of the instrument.) REDUCIBLE RUPTURE. 287 excited quickly spreads over the whole of the peritoneum and the intes- tines. Therefore, also, many of the earlier adherents to this or that practice, have after unfortunate results, given them up entirely; and al- though some, for instance, Kern, have always observed fortunate results, and only one case terminate fatally, yet these assertions are too greatly opposed to the experience of others, to enable us to yield them entire belief. All the modes of treatment at the same time, in reference to their permanent consequences, are uncertain, and the statements of the cures are confined principally to immediately after the operation. Although the external abdominal ring and a part of the neck of the hernial sac be loosed, their remains (in external or oblique inguinal rupture) the open- ing ofthe internal abdominal ring into which the intestines again enter, and by gradual subsequent absorption ofthe effused plastic mass, and the thin- ning ofthe scar resulting therefrom, the rupture enlarges outwardly. In many cases, if the enlargement of the opening out of which the vessels of the testicles and thighs protrude, be the consequence of a bad, lymphatic constitution, apertures are formed in other parts of the belly, and if the rupture be kept up at one part, it will be seen to project at some other part. In gouty, otherwise healthy subjects, in a small rupture of not long continuance, if the sac be not thickened and not united to the neighbour- ing parts, the result may be at first favourable. Increased pressure, with the supine posture, is of all treatment the least dangerous, and may be attempted in all cases, although even herewith, severe inflammation and gangrene (Manget, Richter) and even death (W7ilmer, Schmucker) have been observed. As to this mode of treatment, the methods of Gerdy, Belmas, and Mayor, arranged according to their less danger. Gerdy has up to the present time had the greatest success : I have, how- ever, seen a recurrence of the disease, and according to Breschet (a), the results have in several instances been unfortunate. If, as in old ruptures where the sac adheres to the aponeurotic opening, (the abdo- minal and femoral ring), and consequently a mere inthrusting of the skin be not possible, the hernial sac be thrust in and held with loops, dangerous inflammation may easily occur ; and this is still more likely to occur, if, as in Bonnet's practice, be adopted. In this respect Mayor's treatment is least attractive. I consider as some of the indica- tions for the so-called radical cure those reducible ruptures, which even in the above mentioned supine posture, with the application of a truss, cannot be certainly kept up, especially in young persons, Gerdy's or Mayor's treatment is the most proper; but a truss must always be worn subsequently. The possibility of an unsuccessful, and the probability of a not permanent resulf must not be witheld from the patient's knowledge. The patient's wish to be cured radically, at all hazards, and to get rid of the 'use of the truss must not, according to the hitherto noticed results, determine the surgeon to operate. Opinions in reference to the value ofthe radical operation for reducible rupture, are in modern times much divided, many rejecting it as dangerous and ineffectual, (Boyer, Dupuytren, Lawrence, and others,) and it has been attempted to be ef- fected by continued pressure alone (Richter, Langenbeck, Zang). Few have allowed its general employment (Kern, von Graefe). Some confine it to certain cases (Schreger, von Walther, and others.) Schreger especially lays down (a) Journal von Graefe und von Walther, vol. xxii. pt. iv. p. 657. 288 RADICAL CURE OF RUPTURES. the following indications:—1. To remove certain local conditions and to render the application of a truss possible, for instance, in the complication of inguinal rup- ture with hydrocele, and indeed in a common hernial sac ; in young subjects, with large ruptures, which cannot be properly kept in their place by any truss ; in partial adhesions between the protruded parts and the hernial sac, or the testicle in congenital rupture. 2. In very fat or thin persons in whom the truss always shifts for the purpose of restricting by the operation, the protrusion of the rupture, and thereby to strengthen the effect of the truss. 3. When scarcely any truss will fit; for instance in lame persons, or if the testicle lie completely in the groin. 4 Questionable femoral ruptures, because in these there is little benefit from insecure application of the truss, and the danger being greater in existing strangulation. But in all these cases, the rupture can be kept up by the proper construction of the truss, and its application in the supine posture. If hydrocele exist at the same time, re- peated puncturing answers the purpose better (a). [English surgeons have rarely employed either of the methods proposed for the radical cure of ruptures, except the constant application of a truss, which, however, is admitted to be rarely successful, except in young persons and very recent ruptures. Astley Cooper removed the entire sac in a case of femoral rupture, and " passed stitches through its mouth, so as to bring the edges into perfect contact. * * * On the sixth day the ligatures came away, and the wound was healed on the tenth. A month afterwards I saw the woman," says he, "and was surprised to find that another hernia had formed on the same spot, which was already as large as that for which the operation was performed. * * * It appears, therefore, that the removal of the sac will not prevent, a return of the disease; and, indeed, when it is recollected that the aperture from the abdomen continues ofthe same size after, as before the opera- tion, and that the peritoneum will still remain the only obstacle to the descent ofthe intestine ; it does not appear probable that this highly extensible membrane should succeed in preventing a return of the same hernia, the just formation of which it was unable to resist." (p. 62). Astley Cooper objects to the plan of making a ligature round the mouth ofthe hernial sac, not only that its object, gradually to cut away the sac, is inefficient, as shown in the preceding observation, but also because "it cannot even be securely done; for first, the spermatic cord is often divided by the sae, so that one part of it passes behind, and the other before, or on the side of the sac. When this happens it would be extremely difficult, if not impossible to conduct the operation in such manner as to avoid injuring parts which should never be touched. Secondly, this operation is founded on mistaken ideas of the hernial sac; for a ligature applied as proposed, at the abdominal ring, if it cut through the sac, must leave a hernia above it, with a sac still open as before; and the ligature cannot be employed to the part of the sac lying above the ring, without splitting up the tendon of the external oblique muscle, which would take off so much of the natural support of the parts, as almost certainly to allow of a future descent. Thirdly, the danger of the operation is a principal objection. A ligature applied around a part of the peritoneum must inflame it; and as this membrane is continued without interruption along the sac into the cavity of the abdomen, the inflammation will follow the same course, and expose the patient's life to hazard." (p. 62). In sup- port of this latter objection, Cooper refers to Petit's (b) experience. I opened the tumour," says the latter, " and replaced the omentum; I then detached the sac, and tied it as I had seen done, and dressed my patient. In two hours time I was much surprised at receiving a message that he felt great pain over the whole belly, and severe gripings. I hastened to the patient, fancying that the intestine might have slipped into the ring and become strangulated; but when the dressings were taken off, and nothing was found in the wound, I concluded that the mischief had been caused by tying the sac. I cut the ligature and removed it, and dressed the parts simply; the symptoms were immediately relieved, and ceased entirely in an hour. This is not the only observation I have made on the subject; all I have seen has con- firmed me in the opinion, that the ligature ofthe sac, or in other terms, of the perito- neum, since the sac is formed by that membrane, may bring on symptoms very like those caused by stangulation of the intestine. I cannot doubt that those whom I (a) Compare Hesselbach, p. 245; Jacob- (6) Traite des Maladies Chirurgicales, son, p. 77 ; Sigmund ; uiHufkland's Journal, vol. ii. March, 1841. TREATMENT OF STRANGULATED RUPTURE.---TAXIS. 289 have seen perish after the employment of the punctum aureum, have died from in- flammation ofthe belly, caused by tying the sac." (p. 339). Lawrence also comes to the same conclusion in regard to the proposed operations for the radical cure of ruptures.—" I cannot believe," says he, " that any one of the methods now under consideration is calculated to attain the proposed object. Why does the rupture return after the operation 1 Because the ring has been enlarged by the previous protrusion, and is still further weakened by the incision necessary for removing the stricture, This state of the tendinous openings would not be altered by closing the mouth of the sac, even if we could accomplish that object. We must reject the ligature on account of the danger inseparable from its employ- ment, and we have no sufficient reason for placing confidence in scarification of the sac or in its removal by dissection. In many instances these latter methods would be neither easy nor free from danger. Hence we account for the circumstance that all these various methods have become completely obsolete." (p. 321.)] 1161. The treatment of strangulated rupture must be directed accordr ing to the different character and severity of the symptoms ; in reference to which, suitable remedies must be employed with due circumspection and choice ; too violent attempts, and especially too frequent changes, and again, new experiments which have in so great number been pro- posed and boasted of, are to be avoided. But too frequent is the course of strangulation hastened by improper treatment, and the patient's con- dition rendered worse. The more acute the inflammation the more dan- gerous is it. 1162. Inflammatory strangulation requires blood-letting, especially if the symptoms be severe, if the patient be strong, the rupture and the belly very painful. Small pulse, cold limbs, pale countenance, must not prevent blood-letting, as these are the peculiar symptoms of violent inflammation ofthe belly. The earlier bleeding is performed, and the more blood is taken at once, even till fainting is produced, the better is its effect. Leeches may also be applied about the region of the rupture, and because ihey usually here produce an erysipelatous inflammation of the skin, they may be applied about the rectum, (Birago,) (a) and cold fomentations, at the same time upon the hernial sac or cold sprinklings to the rupture. If the rupture be very tense and painful to the touch, it must be attempted by these means first to produce a favourable change, general and local relaxation, before the taxis is employed, which must be done in the most dexterous manner, according to the above-described rules. If the rupture be less painful we may commence the treatment with the taxis, and if this be not successful, the above treatment must precede subsequent attempts with the taxis. All internal remedies, especially purging, are in this strangulation hurtful ; even calomel, which has been recommended by many, (Rust, Seiler, and others,) I have always noticed as having only an injurious effect. The patient must merely take mild drinks, for example, almond, milk, gum water, and the like, in small quantities. Clysters in severe inflammation, merely soothing, with the addition of castor oil, and in diminished^ inflammation, of infusion of tobacco or tobacco juice, are extremely' efficient. Tobacco clysters are not to be considered as irritants, but as narcotics, and the employment of belladonna or hyoscyamus are similarly circumstanced, only the ope-, (a) Compendio di Osservazioni cliniche carcerate, e sulla potissa caustica applicata sul vantaggio delle Mignate applicate all' in diverse malattie di carattere linfatic'oi Ano nelle ernie inguinale et addaminah* in- Milano, 1821. 8vo. 25* 290 SYMPTOMS OF STRANGULATION ration of the tobacco is less dangerous; from it ensue a disposition to nausea, to fall down, faintness, slow pulse, and diminution of the tension of the rupture. The effect of the tobacco juice and infusion is similar, but the tobacco-juice clysters are very troublesome, the necessary preparations for which are not always at hand. For the infusion, from half a drachm to a drachm of tobacco is used in from twelve to six- teen ounces of water, for two clysters. When injurious effects have been observed, the quantity of tobacco was too large. [Tobacco clysters are very uncertain, and have been occasionally very dangerous remedies ; as the strength of the infusion varies considerably according to the fresh- ness and goodness ofthe tobacco leaves, of which it is scarcely possible to judge. The use of tobacco clysters, which was formerly much urged by Astley Cooper in cases of strangulated rupture, is now much less practised than formerly; indeed I have not known it used at St.Thomas's either by my colleagues or myself for many years. We prefer, in the event of the failure of the taxis, after warm bath and quick full, bleeding, at once to resort to the operation, considering it the most safe practice.—j. f. s.] 1163. If the symptoms be less severe, and if complicated with spasm, warm bathing, rubbing in volatile ointments, with opium or oil of hen- bane upon the belly, tobacco clysters, cold applications upon the rupture, and in powerful persons, a large bleeding in a very hot bath, are most efficient remedies, after which sudden relaxation follows, and the reduc- tion is effected. Here also internal remedies are ordinarily hurtful, as they increase or excite vomiting, as purgatives, with whatever addition, ipecacuanha in repeated doses, and so on. A simple emulsion with aqua laurocerasi is, among these, the most proper* The taxis must here also be at first attempted, and if it do not succeed, must be repeated after the remedies mentioned. 1164. In Chronic Strangulation, when, from collection of stools, but without any inflammatory symptoms or. vomiting, or when these, though rarely, are present, stimulating clysters of vinegar and water, soap and water, solution of salts with castor oil, solution of tartar emetic, infusion of senna, tobacco clysters, cold applications upon the rupture, and inter- nally purgatives, in very chronic cases calomel &lone, or with opium and colocynth extract, (A. Cooper), even with jalap or croton oil, (von Walther), have been directed. But when vomiting has set in, the latter remedies always render the patient's condition worse. With the taxis it must always be attempted to compress the rupture, in order to return part of the collected stool. When inflammatory symptoms have come on, the above-mentioned treatment must be employed in corres- pondence with circumstances. 1165. The taxis must be employed in strangulated, in the same way as in reducible rupture. The patient after having emptied his bladder, must lie in such posture that the seat of rupture be raised, and the walls of the belly properly relaxed ; in inguinal and femoral ruptures with the rump raised, the chest bent slightly forwards, and the thighs drawn up towards the belly, but not separated from each other. The practitioner stands on the right side of the patient, grasps the hernial swelling with the fingers of his right hand, and places the fingers of the left in the region ofthe mouth ofthe sac, and endeavours, by alternately pressing the rupture together, and in the direction of its escape, to press it back into the belly. In small, for instance, femoral and umbilical ruptures, the fingers of both hands may be applied around the swelling to compress and return it. Herewith the rupture must be carefully NOT ALWAYS CEASING AFTER REDUCTION. 291 moved from one side to the other, kneaded between the fingers, and the pressure only gradually increased. Violent pressure is to be avoided, because severe pain, increased inflammation, and even rupture of the bowels or of the hernial sac may ensue, and the taxis must not be too long continued; but it must also be remembered, that without pain scarcely one strangulated rupture can be reduced. These manipula- tions may be continued for from a quarter to half an hour, and in chronic strangulation, even longer, and with greater force. We should endea- vour to withdraw the patient's attention to some object, and forbid all effort and straining. If the taxis be unsuccessful, the patient must be left quiet in the same position, with the thighs supported in the hams; and it must be considered, according to the circumstance, what farther re- medies are to be employed, and whether the attempts with the taxis should be repeated. Nothing is more injurious than excessive violence and rough handling. I have observed not unfrequently, that by keep- ing quiet, after the most careful attempts, at reduction have failed, the rupture returns either of its own accord, or with a slight assistance on the part ofthe patient. 1166. If the reduction succeed, the symptoms usually soon cease, and relief of the bowels ensues either of themselves or by the use of purga- tives and clysters (1). If the inflammatory symptoms continue, they re- quire corresponding treatment. The abdominal ring should always be examined with the finger, in order to ascertain that no part of the rup- ture remain in it, as may be the case, especially in external inguinal ruptures, in which I have several times observed, after a tolerably bulky, and in one case even very large rupture, had returned, and the external ring was free, that there was strangulation of a small portion of intestine at the inner ring, which rendered the operation necessary. But if under the treatment prescribed there be no satisfactory change in the rupture, but on the contrary, it become more hard and painful, the belly tense, and the vomiting more frequent, neither the use of other remedies,, nor attempts with the taxis are to be persisted in, butthe operation must be had recourse to. The treatment proposed for strangulated rupture, in reference to the employment of remedies internally and externally, and of the taxis is very various. Although these several modes of treatment may be grounded on many good results, the above- described method must be considered most preferable, if it be employed with dis- cretion and proper circumspection. The position of the patient under the taxis, with his feet or knees upon a person's shoulders; the vertical position of the body, in order thereby to effect the return of the intestines through their proper tendons, and the application of ice poultices upon the rupture (Ribes) (a), with the pelvis raised and the head depressed; the posture upon the opposite side, with the thigh drawn up on the affected side (Hey); even the position on the knees and elbows. Continued pressure on the rupture with a weight or bladder of quicksilver of from two to five pounds; or by the patient's hand. Shaking the whole body by driving in a wheelbarrow (Preiss); injection of air into the rectum, and drawing it off with a clyster-pipe. The introduction of a thick elas- tic tube through the rectum into the sigmoid flexure of the colon, after O'Beiern's manner (b), who considers the collection of the intestinal gases, and the spasmodic closing ofthe rectum as the most common cause of strangulation. The application of dry cupping-glasses about the hernial swelling, or of a glass bell, out of which the air may be pumbed by some strokes of an air-pump, till the rupture is as high fa) Gazette Medicale, July, 1833. (b) Dublin Jour, of Medical Science,Sept. 1838. 292 OPERATION FOR again, after which it either returns of itself, or is easily reduced'with the taxis (a). Clysters of hyoscyamus and belladonna; a mass of belladonna ointment smeared over the interior of the rectum; or a bougie smeared with extract of opium and of hyoscy- amus, of each two grains, passed into the urethra (Ribieri, Guerin). Purgatives of all kinds; rubbing of croton oil on the belly; galvanism (b); clysters of lead wash (Nember, Rennerth, Preiss); tartar emetic (Church); muriate of morphia (Bell). [(1) It is perfectly true, that in general after reduction the symptoms ot strangu- lation subside; but now and then they do not, which may depend upon the damaged condition ofthe bowel, or simply on the existence of peritonitis. Instances of the latter are not very uncommon, and can scarcely be distinguished from the symptoms of strangulation, except by the absence of the hernial swelling. Of the former I had an example under my care in 1840, which was a source of great anxiety, and terminated fatally. Case.—J. S., aged seventeen years, ruptured himself on the right side whilst lifting hampers into a cart in the afternoon of Nov. 30, and immediately observed in the scrotum a swelling as large and as long as his thumb. Half an hour after he began to vomit, and continued to do so through the night. On the following morning the taxis was unsuccessfully employed, and afterwards a few leeches ; some medicine was given, which was rejected; he con- tinued vomiting during the day, had not any relief from the bowels, and suffered pain in his belly. Next morning the rupture was reduced and a truss applied, but removed two hours after, as it was too large. During the day he was relieved of the pain, but vomiting occurred five or six times, and especially on attempting to take any thing into his stomach. Towards 8 p. m. the swelling reappeared, about half the former size; the vomiting became more frequent, and the pain in his belly increased. Bee. 3, 2 a. m.—He was bled nearly to fainting, and the rupture returned; a cold mixture in a bladder was applied (for what reason did not appear) to the region of the swelling, and replaced continually as it became warm. The vomiting, con- stipation, and pain continuing, he was brought to the hospital at % past 3 p. m.—He was immediately put in the warm, bath, where I examined him, but even when standing up could only observe a slight fulness in the right groin, probably from the leeches, and very deeply a small indistinct swelling not exceeding the size of a small bean, between the abdominal rings; it neither dilated on coughing, nor yielded to pressure. I could pass my finger readily into the ex- ternal ring. His belly was full and and tympanitic, and he complained of pain and tenderness specially about the hypogastric region. The pulse was small and quick; but he had not any anxiety of countenance. I could not feel satisfied of the exist- ence of a rupture, and therefore ordered five grains of calomel and an injection of infusion of senna and salts, which was retained ; but an injection of castor oil in the course of the evening returned immediately. 11 p. m. I made another careful examination, in consultation with my friend Callaway, and I thought I felt a slight gurgling, but very doubtful; it could not be felt again, and we both were satisfied that the swelling was merely the spermatic cord. We therefore ordered a grain of calomel, and half a grain of opium, every hour, with a castor-oil injection immediately; and thirty leeches to the belly, with subsequent fomentations, considering his attack to be peritoneal and enteritic. Dec. 4. The bowels continued obstinately costive throughout the whole day, except a very small quantity of thin watery stool once in the afternoon, and again in the evening, although injections were thrice thrown up. The vomiting did not recur, but he felt nauseated, and the tenderness, and tympany of the belly increased. When I saw him at nine in the evening, his tongue was much loaded, and the gums reddened, but without soreness or mercurial smell. The little enlargement in the inguinal canal still remaining, I fancied I again felt a slight gurgle, but it ceased almost immediately. The calomel and opium were ordered every three hours; half a drop of croton oil directly, and to be repeated two hours hence, if requisite; thirty leeches to the belly, and fomentation. I had scarcely left him when he vomited about a pint of dark-green and very fetid fluid. The croton oil was taken at i past (a) Huaf, De usu Antliae pneumaticse in (b) Archives Generales de Medecine. arte medica. Gardce, 1818.—Kcshler j in 1836. Hecker's lit. Annalen, 1835, April. STRANGULATED RUPTURE. 293 10 p. M.,and after an hour producing only a small thin motion, the second dose was given. Two hours after, his bowels acted again, and he again began to vomit, and vomited and passed thin, but more faeculent motions five or six times before Dec. 5, 7 a. m. when he became quiet, and two hours after took some bread and milk, which he retained till 11 a. m., and then rejected; his countenance is now much shrunk and flushed, but he is cheerful, and wishes something to eat: pulse 100, and small. He has much pain in the belly, but it is less distended. An hour after he had another loose motion. 2. p. m. In consultation with my friends GREENand Callaway, we were satisfied that no intestine was down, and the slight fulness already mentioned had entirely disappeared. The calomel and opium which had been withheld at the last period, was ordered to be resumed, and a mustard poultice applied over the belly. Soon after the application of the poultice, vomiting of thin, yellow, acid-smelling fluid recurred, and continued frequently till evening, when I ordered him effervescing mixture, with large excess of alkali, but without benefit, and the vomiting con- tinued through the whole night and following day, not being at all checked by two minim doses of hydrocyanic acid, with compound spirits of ammonia, every six hours. As his mouth was untouched by the calomel, I ordered on the morning of this day, Dec. 6, that he should rub in a drachm of mercurial ointment, with five grains of camphor, every four hours; a large blister over the whole belly, and a colcynth in- jection. 8 p. m. No motion since noon yesterday; the vomiting continues, and he is much sunk. To take a grain of solid opium every six hours, and have some brandy and arrow-root. Dec. 7, 4 p. m. He died, having continued to vomit since the last report, and not having had any relief from the bowels. Examination.—After raising the tendon of the external oblique muscle from the inguinal canal, the edge of the internal oblique was seen uplifted by a small dark- coloured tumour about the size of a hazel nut, which was evidently a hernial sac and contained dark-coloured fluid. The internal oblique and the transverse muscles were then carefully divided up to the internal ring, to which the sac was easily traced, and the latter having been carefully opened about its middle, about a drachm of serum escaped. The sac was cut up to the internal ring, through which a very small knuckle of dark-coloured but shining intestine protruded. The belly was next opened; it contained no fluid, and little appearance of inflammation, except a thin film of adhesive matter slightly gluing together the intestines in the right iliac pit. The abdominal muscles having been completely turned down, about eight inches of very dark-coloured yellowish green intestines were exposed, distended im- mediately above the portion of gut in the mouth of the sac, with thin faeculent matter like his last stool; an inch of the bowel below the sac's mouth was of the same dark colour, and suddenly terminated by a distinct mark of strangulation, upon which, beneath the peritoneum, fibrin had been poured out. Below this point the gut was healthy but contracted. The portion of intestine in the sac was about two- thirds of its tube, the part nearest the mesentery, being quite above the internal ring. In examining further, this protruded piece of gut dropped out, and there was not found upon it the slightest mark or appearance of strangulation. From this examination, I presume, that the strangulated bowel had been returned by the medical man who last saw him; that the strangulation had been sufficiently long to destroy the vitality of the intestine, which had therefore never recovered itself; that the portion of intestine found in the mouth of the sac, had been forced in by the vomiting but that it had never been strangulated nor incarcerated, nor had probably been there constantly, through the course ofthe disease, though it might have been occasionally, by the effort of vomiting; and that the costiveness depended not on the tube of the bowel being impervious, but on its death having destroyed its functions, and that the stools passed were merely forced by their quantity through the dead intestine,—j. f. s.] 1167. The decision as to the proper time for the operation, especially depends on the kind of strangulation, on its severity and duration, on the constitution of the patient, and on the effects which the previous 294 OPERATION FOR remedies had produced (1). In inflammatory strangulation, in small ruptures, which arise suddenly from external violence, or in those where the strangulation is at the mouth of the sac, (par. 1135), in young vigorous persons, the operation must not be delayed; if by the pre- ceding treatment reduction have not been effected, or if the painfulness of the rupture will permit no further attempt at reduction. It is often necessary within the first eight or twelve hours. In such cases can the advice of Kern and Wattmann be alone applicable, not uselessly to waste time by attempting relief with external and internal remedies, but immediately to employ the only helpful remedy; to wit, cutting into the rupture. In spasmodic and chronic strangulation, the operation may be delayed ; very frequently repeated attempts at reduction should, how- ever, be'avoided, and after the most powerful remedies have been em- ployed, it is better to resort earlier to the operation, than by further delaying it to put the patient's life in greater danger. But the operation is in these cases specially indicated, if an inflammatory condition be superadded, especially in old persons. In general, the longer the opera- tion is delayed, the more unsatisfactory is the prognosis, as the danger is less from the operation itself, if properly conducted, than from the de- gree of inflammation and the circumstances thereon depending. [(1) The invariable rule in all eases of rupture in which symptoms of strangula- tion exist, be they slight or severe, if the taxis, after warm bath and bleeding have been unsuccessful, is without loss of time to proceed to the operation, as the most safe for the patient. For the damaged state of the intestine is frequently not indi- cated by corresponding severity of symptoms, as is well known to every one who has often operated in strangulated rupture. Every hour, therefore, which defers the operation adds to the patient's danger; on which account we cannot operate too early, when satisfied that strangulation cannot be relieved without. Occasionally it happens that patients will not submit to an operation for strangu- lated rupture, and nothing then remains but to persist in the employment of one or other of these remedies which have been proposed. The tobacco clyster is now therefore permissible, and should be resorted to, and the continued application of ice poultice (ice roughly pounded or a freezing mixture, consisting of hydrochlorate of ammonia and nitrate of potash, five ounces of each with a pint of water), in a blad- der upon the swelling, which sometimes succeeds ; but the condition of the skin should be attended to during its use, as it may become frost-bitten, and though the rupture may be reduced, the skin may slough, which happened to a patient of the elder Cline, Sometimes the patient having withheld his consent for many hours, being at last worn out by the vomiting, will submit to an operation; the question then comes, should it be performed under unfavourable circumstances ? I think it should; for, without an operation, he must certainly die, and with it he has a chance, how- ever slight, of recovery. Indeed I think the operation for strangulated rupture should always be performed, if the patient be not in articulo mortis.—j. f. s.] On Strangulated Rupture in particular, the following writers may be consulted :— Zimmermann, Beobachtungen der beruhmtesten Wundiirzte neuerer Zeit zur Er- laiiterung der sichersten Behandlungsarten eingeklemmter Briiche. Leipzig, 1832. folio. Stephens, Treatise on Obstructed and Inflamed Hernia. London, 1829, Rust, Ueber die rationelle Behandlung eingeklemmter Briiche ; in his Magazin, vol. xxix. pt. ii. Singovitz, Anleitung zu einer zweckmassigen Manualhulfe bei eingeklemmten Leisten und Schenkelbruchen. Danzig, 1830. 1168. The operation for strangulated rupture proceeds by the follow- ing steps:—first, The incision of the skin; second, The exposure and opening of the sac: third, The dilatation of the neck of the sac or of the abdominal ring; fourth, The return of the intestine. STRANGULATED RUPTURE. 295 Previously to the operation, the urinary bladder should be emptied, the seat of the rupture if hairy, shaved, and the patient so placed on a narrow table, covered with a mattress, that the rump and chest be raised, and the belly properly relaxed; or so upon the edge of the table, that the feet may rest on and be supported by a stool. 1169. The skin above the hernial swelling is to be raised into a transverse fold, the one end of which is given to an assistant, and cut through with a bistoury (1). By means of a grooved director intro- duced into the angle of the wound, the incision is to be enlarged up- wards and downwards, so that it extend beyond the swelling in both directions (2), if the tension ofthe skin do not permit the formation of a fold, the incision must be made freely, the skin being drawn aside by the thumb and forefinger of the left hand. As there are ruptures with- out sacs, or as the sac may be torn, the incision through the skin must be cautiously made, and the director used as much as possible. [(1) Lifting up a fold of skin over the rupture, and either cutting through it, as here recommended, or piercing it with a bistoury, and cutting out, is, I think, bad and dangerous practice; for it cannot always be ascertained what the thickness qf the coverings of the sac are, or indeed whether there be any other than the skin, and and therefore, in not very dextrous hands the sac may be opened at once, and the gut injured. This mode of commencing the operation may seem smart and flashy, but it is dangerous and improper, and entirely devoid of any good reason for its per- formance. (2) In inguinal, or rather in scrotal rupture, it is better that the cut made length- ways, should not extend below the bottom of the tumour; it should terminate an inch above it, as room in the operation is not wanted there. The cut should extend above the swelling, otherwise the stricture is so inconveniently deep, that it will commonly be necessary to enlarge the external wound after the sac has been opened, and before the division ofthe stricture can be made. In femoral, umbilical, and other ruptures, it is not needful to extend the cut beyond the swelling, because the flaps usually made either by the i or crucial cut, afford ample space for the continuance of the operation.—j. f. s.] 1170. The exposure of the sac requires care, as the coverings are very different, and in old ruptures considerably degenerated. At the' part where protected from any other injury, or where fluctuation is most distinct from the fluid contained in the sac, the coverings must be taken hold of with a pair of forceps, raised up in a heap, and divided with, the bistoury held flat (1); this is to be repeated till the sac is laid bare, which is known by its shining surface (2). The blood flowing from these cuts must be carefully absorbed with a sponge. The hernial sac itself should be raised in a similar manner, and cut into, from this opening a little fluid usually escapes; for though the omentum be fallen over the surface of the intestine, the shinyness and smoothness of the sac show the practitioner that he has penetrated its cavity (3). The edge of this opening is to be raised with the forceps, and enlarged with blunt-ended scissors, till a finger can be introduced into it, upon which the scissors (4), or button-ended bistoury, should be introduced, and the opening of the sac increased upwards and outwards throughout its whole length (5). If on opening the hernial sac, an adherent part be lighted on, the opening must be enlarged at some other part, till the finger can be introduced, to destroy the adhesion, if it be gelatinous, or if membranous, to divide it with the knife. In firmer fleshy adhesions, we must proceed as will be hereafter mentioned (6). 296 OPERATION FOR STRANGULATED RUPTURE. If after these appearances, it be doubted whether the sac be opened or not, the swelling is to be pinched up with the thumb and forefinger into a fold, and that held between them gradually allowed to escape, when it is distinctly felt whether there be merely intestine or the hernial sac also. [(1) In dividing the coverings of the sac, I prefer, after the skin has been com- pletely cut through, scratching with the end of the probe or director, till a layer of the cellular tissue be penetrated, and then introducing the director and dividing upon it; after which a second and other layers are to be divided in similar way, even to the opening of the sac. itself. This is much safer than nipping up with the forceps and opening with the knife laid horizontally, which, however, cautiously used, may, in opening the sac itself, risk the puncture of the intestine; an accident which once occurred to myself when I was a young operator. (2) The hernial sac cannot always be distinguished by its shining appearance, for occasionally it is thick and opaque, especially after long wearing a truss ; and I have again and again seen the sac opened when the surgeon supposed he was far from having reached it. Also if, as in rare cases it happen that the sac and its contents be glued together more or less completely, this distinction does not hold. (3) The most certain proof of the sac being opened, is the escape of the fluid in greater or less quantity contained in it, which is proportioned generally to the length of time the patient has had the rupture, and also of the existence of strangulation. It is a most satisfactory indication of the course of the operation, but the surgeon must not expect always to have it. During the course ofthe last few months I had a case of strangulated rupture, in which not a drop of fluid escaped when the sac was opened. The colour of the fluid escaping, when the sac is cut into, varies considerably; sometimes it is almost colourless, sometimes red as bloody and Callaway told me of an instance in which even a clot of blood was found in the sac; the case, how- ever, did well. (4) I prefer the director and knife to the scissors, and throw aside even the di- rector immediately the aperture is sufficiently large to admit the finger, which is always the best guide for the knife, and the greatest protection to the contents of the sac. (5) There is no need, as already mentioned in regard to the external wound, to open the sac down to its bottom ; but it must be divided up to the stricture. (6) Whenever an artery is disposed to bleed, if divided whilst cutting through the several coverings, it is better at once to tie it, as the bleeding often causes con- fusion.—j. f. s.] 1171. In many cases, when the strangulation is not considerable, or depends on the peculiar position of the intestines, their entanglement, or their circular enclosure by the omentum, the protruded parts may be feturned when they are properly untwisted ; or when the part of the intestine at the seat of strangulation has been a little drawn out, and by a gentle pressure, it has been attempted to return the contents of the bowel into the belly. If the intestine be strangulated in a fold of the omentum, this must be freed with the bistoury, if the intestine cannot easily be drawn out of it. [In the College Museum is a very remarkable instance of strangulation of a small intestine, by a smooth round cord, two and a half inches long, and about a line thick, extending from the end of a diverticulum on the ileum to the mysentery, about an inch and a half from the edge of the intestine. In St. Bartholomew's Museum there is a similar case of diverticulum from the small intestine to the me- sentery, forming a'circular hole, in which the gut is strangulated. The patient was subject of obstinate costiveness, and died in four days. In St. Thomas's Museum there is an instance of strangulation of small intestine by a band from the ascending colon to the mesentery. And at St. Bartholomew's a preparation of the small in- testines of achild of seven years old, strangulated by a narrow thread-like band from the mesentery; he was admitted for constipation, and died fourteen days after.—j. e. s.] 1172. If reduction cannot be thus effected, the seat of strangulation must be dilated, which may be done either by cutting or by stretching. OPERATION FOR STRANGULATED RUPTURE. 297 1173. Dilatation by cutting is effected in the following way:—The intestine is to be withdrawn in the most careful manner by an assistant, from the place where the cut is to be made; the sac should be drawn somewhat outwards with the thumb and forefinger of the right hand, and the tip of the left forefinger is to be introduced between the intestine and the neck of the sac; a straight or curved narrow bistoury, with a blunt end, should be introduced flat upon this finger, its cutting edge directed towards the place where the cut is to be made, and the seat of strangu- lation cut into by raising the handle of the knife, or by pressing its edge up with the finger-of the left hand ; but if the strangulation be so great that the finger cannot be introduced, after drawing down the neck of the sac, a director, curved according to circumstances, and oiled, is to be introduced between the intestine and the seat of strangulation, its groove turned towards the part where the incision is to be made, its handle so held with the fingers of the left hand, that they separate the intestines from the director, and give it such position, that its point rests against the inner surface of the peritoneum ; and then upon its groove the button- ended bistoury should be introduced. If the seat of strangulation be deep, it is more safe to draw the intestines a little down, so as to be able to see the seat itself. The direction of the cut should always be such as to prevent serious injury ; and its size such that the forefinger may, without violence, be introduced at the part where the stricture was situated. It is then to be ascertained by the introduction of the finger into the belly, whether any second strangulation exist which requires a second dilatation. There are peculiar instruments for dividing the strangulating part. Petit's straight and curved fork director; MerY's and Mo.^renheim's winged director; the straight bistoury, with a button or probe end of Petit, Bellocq, Brambilla, Dzondi, the convex one of Le Blanc, Brambilla, Dupuytren, Seiler ; the concave of Per- ret, Heister, Arnaud, Richter, Rudtorffer, Astley Cooper, Langenbeck, and others, merely a modification of Pott's bistoury, the concealed bistoury of Bienase, Le Blanc, and Le Cat. [In the divison of the stricture, the use of the finger, as a guide for the introduc- tion of the blunt-ended bistoury, is far as preferable to the director; and being sure that it is by far the safest, I rarely use any other, however tight the stricture may be. If the finger can fairly reach the stricture, and the smallest part of its tip can be introduced, a very little gentle thrusting will make room for the entrance of the point of the knife. In inguinal rupture I do not recollect to have used a director more than two or three times, and but little more frequently in femoral. The direc- tor is a very unsafe instrument, where out of sight, for however carefully the in- testine may be tended, it will occasionally turn over the director, and be cut in di- viding the stricture, which I have seen happen once ortwice. When it is absolutely necessary to use the director, in consequence of the impossibility of getting the tip of the finger into the stricture, I have protected the intestine by introducing a span- tula between it and the director up to the very stricture. But when this difficulty occurs, it is advisable to lengthen the cut upwards through the skin and coverings ofthe sac, till the stricture is brought completely and distinctly into view, and then to introduce the director.—j. f, s.] 1174. The bloodless dilatation, or that without cutting, which is only. applicable in those cases where serious injuries, not well to be avoided, forbid incision, may be effected either by the introduction of the finger, or with a proper dilating instrument, (Le Blanc's dilator,) or with a small hook, (Le Cat's S-shaped hook and Arnaud's hook;) which is to be carefully introduced between the intestine and the seat of stricture, Vol. ii.—26 289 OPERATION FOR STRANGULATED RUPTURE. and therewith extension made, sufficient to render the reduction possible. Bruising of the intestine is scarcely to be avoided. The bloodless dilatation, first proposed by Thevenin (a), was particularly recom- mended by Le Blanc (b); but although Le Cat, Arnaud, Richter, even Scarpa, and others have conditionally declared, for it, in recent times it has been almost en- tirely rejected, and only applied, by some, (Trustedt, Rust, Seiler,) to femoral rupture, especially, and in a manner to be hereafter described. [I know no circumstances in which dilatation without the knife is permissible. ^ I should consider any forcible expansion of the stricture, by pulling or dragging with instruments, dangerous and unwarrantable, as it would be ineffectual for the required purpose without more mischief than would result from using the knife.—j. f. s.] 1175. When the obstruction to the return ofthe intestines on the part of the neck of the sac, or of the abdominal ring has been removed, it depends on the state of the parts contained in the rupture how their return shall be effected. This is often at once possible, without any difficulty; often must the intestine be carefully unfolded, if filled with stool or air (1). That part of the intestine at the seat of strangulation should always be drawn a little down, to examine its condition. The reduction should be effected with the fingers wetted, those parts first protruded, being carefully first returned ; thus the mesentery earlier than the intestine, and that before the omentum, according to the direction of the aperture through which they have protruded. The forefinger is then to be passed by this opening into the belly, for the purpose of deter- mining that all the parts are returned (2). [(1) Always before the intestine is attempted to be returned it should be emptied by gentle pressure of its contents, whether air or stool, which renders the reduction easy; whilst if this be not attended to, considerable difficulty is often experienced. Not unfrequently after dividing the stricture, the tonic power of the muscular coat of the bowel will itself empty its contents ; or if they be fluid, they will flow back into the intestine canal, the protruded gut become flaccid and be readily returned into the belly. I do not at all consent to the practice of pricking or cutting into the in- testine, if it be indisposed to return, on account of its distension with air. I am sure that after dividing the stricture freely, it is not matter of much consequence whether the gut be returned or not by the operator, as most commonly after a short time the air passes along the freed gut, and the protruded part diminishes in size, and if not restrained by adhesions retracts into the belly. (2) Although there may be little fluid in the sac, yet it is not unfrequent to have it pour forth freely from the cavity of the belly after the protruded parts have been returned. I recollect having a case in which blood-red fluid escaped so largely that I almost feared I had divided some vessel; however, it ceased before the patient was removed from the table. Callaway tells me of an instance in which, after the return of the intestine, a large quantity of honey-like fluid poured forth, he presumes from an ovarian dropsy having been wounded : the patient, however, re- covered.—j. f. s.] 1176. The reduction of the intestine may be rendered difficult or im- possible— 1. By adhesions, 2. By disorganization, 3. By gangrenous destruction. . 1177. If the connexion of the parts with each other depend on a gela- tinous substance, it can be easily destroyed with the finger. Filamentous adhesions having been made tense, may be divided with the knife, the edge of which is to be turned towards the hernial sac, rather than towards (a) Traite des Operations. Paris, 1696. (b) Precis d'Operations. Paris, 1775, vol. ii. chap. vii. TREATMENT OF INTESTINE. 299 the intestine. But if there be a fleshy adhesion between the sac and its contents, the practice is different, according as the adhesion is between the omentum and the hernial sac, or between the omentum and the in- testine. In the former case the omentum must be divided, as near as possible to the adhesion, with the knife or with the scissors. If the omentum adhere to a considerable extent to the sac, it must only be divided at the neck of the sac, surrounded with some linen overspread with cerate, and when the inflammation has subsided, it should be divided near the abdominal ring. (According to Scarpa, it should be tied and tightened daily till it fall off.) The omentum often returns into the belly whilst surrounded wTith the linen (1). In the second case, after the strangulation is relieved, the intestine must be left quiet in its place, covered with compresses moistened in and often wetted with decoction of marsh-mallows (2). It is frequently observed that the piece of intes- tine gradually returns into the belly. If it remain partially in the ab- dominal ring, it becomes covered with granulations and adheres to the integument. The same practice must be pursued in the natural con- nexions between the intestine and the hernial sac, when they render reduction impossible. If the intestine be so considerably distended with stool and air that reduction is rendered difficult, it must be attempted, after sufficiently cutting into the constricting parts and after the intestine has been somewhat drawn down, by gentle kneading, and pressing together, to return partially the contents of the bowel, and to diminish the size of the intestine. In such cases the overfilled intestine has been punctured with a large needle. (Lowe,) with a lancet, (Loeffler,) and with the trocar (Richerand, Jonas, Von Graefe); the latter was successful, and at the same time a loop ofthe mesentery (a) was applied (3). [(1) If the adhesions between the omentum and sac be old and membranous, and easily divided, it is advisable to do so, and to return the omentum. But more fre- quently the adhesions are too short to admit of this; or the surface of the omentum is actually glued to, and so consolidated with, the surface of the sac, that it cannot be set free without cutting through. I have had two cases of this kind, in which, having returned the gut, after freely dividing the stricture, I have left the adhering omentum undisturbed, and no ill consequences have ensued. But there is a pre- paration in St. Thomas's Museum, where this practice was pursued, and the gut, after division of the stricture, returned into the belly, yet the symptoms of strangu- lation continued, and the patient died; and, on examination, it was found that the omentum formed a tight cord upon the intestine as it lay transversely behind it, on the brim of the pelvis, and completely prevented the passage of the contents of the bowel through it. I do not, therefore, feel certain as to which is the best practice in such cases; but I may state, that my cases which were successful happened after the fatal case just mentioned. I certainly should not be disposed to adopt or re- commend the practice proposed by Chelius, of separating the adhesions at the neck of the sac, and passing a piece of linen round the omentum, with the purpose of dividing it at a future time, as I should expect that the presence of such extraneous substance would be likely to excite dangerous inflammation. (2) As to the adhesions between the omentum and gut, if they cannot be easily separated with the finger, they are best left alone, without attempting further sepa- ration or their return, to take their chance together, either to remain in the sac, or return of their own accord into the belly, (3) There is in the Museum of the Royal College of surgeons of England, a preparation of a portion of strangulated small intestine, which not being returnable on account of the great quantity of air it contained, was cut into, to the extent of an inch, and left in the sac, and the patient died. I cannot imagine there is any ne- cessity for puncturing the intestine to compel its return into the belly, provided the stricture be freely divided; for I know by experience, that if strangulation be relieved, (a) Journal von Graefe und Walther, vol. iii. p. 255. 300 OPERATION FOR STRANGULATED RUPTURE, it is of little consequence how much intestine be down. In reference to this point, I recollect the largest scrotal rupture on which I have operated, and in which, before the division of the stricture, there was at least half a yard of bowel down, filled with air; and, after the stricture had been cut through-, at least as much more thrust through, so that I almost despaired of getting any back; yet after a time I returned the whole. To my vexation, however, next morning I found my patient had got out of bed to relieve himself on the chamber-pot, and as might be expected, the bowel had desc'ended, and in such quantity, that the scrotum was at least as big as a quart pot, and the vermicular motion of the intestine was distinctly seen through the stretched skin. Nothing further was done than to keep the tumour raised above the level of the abdominal ring, by placing a pillow beneath it, and by degrees it returned, and the patient never had an untoward symptom. If, however, the bowel be filled with solid matter, as hard stool, or apple or potato skin, and its return thus prevented, as well as the passage through it stopped up, an instance of which latter kind is in the College Museum, then the loaded gut ought to be cut into freely without hesitation, as the only means of perhaps saving the patient's life. But such cases I suspect are exceedingly rare.—j. f. s.] 1178. If the omentum be converted into a tangled lump, it must not be returned into the belly, because it requires a too large dilatation of the abdominal ring, and this degenerated mass may produce inflammation and even suppuration in the cavity ofthe belly. The general advice in these cases, is to tie the omentum above the degenerated part, to cut it off' below the ligature, to return the tied part into the belly, and to fasten the threads externally. The ligature of the omentum, however, causes a new strangulation (1). Experiments on animals, and numerous practices upon man, show that the omentum, cut off and without tying, may be returned into the belly without injury (2), But if the vessels of the cut edge of the omentum bleed they must be tied singly and the threads allowed to hang out ex- ternally, or torsion must be performed on them (3). The recommenda- tion of allowing such diseased pieces of omentum to lie out, (Pouteau, Desault, Volpi, Zang, and others,)'proves the objection, that by fast- ening the omentum in this position, severe disturbance of the stomach and so on may be produced. If the omentum be sloughy, the sloughy part must be removed with scissors, and treated in the way prescribed. In these cases, generally the omentum becomes adherent to the neck of the sac, w-hichit then closes like a plug. [(1) I have tied the omentum, and cut off the part below the ligature several times, without any of the untoward results commonly, and as by Chelius, assigned to this practice. (2) The largest portion of omentum I have known removed was seven ounces and a-half, in a case of scrotal rupture, in a man forty-two years of age, under Cal- laway's care; he reoovered, and the preparation is in the Museum of Guy's Hospital. Key (a) advises, that " the omentum should be unfolded before it is divided by the knife; otherwise the cutting off the omentum in a mass prevents all the vessels being seen, and when returned into the abdomen they bleed profusely. A case of this kind happened to him, in which he cut off "a large portion of omentum with one stroke of the knife, securing the bleeding arteries before returning it to the mouth of the sac. In four hours after the operation, blood of an arterial colour began to ooze from the sac, and soon increased in quantity to alarm the dresser. He used pressure and cold to no purpose. Her pulse began to falter, and her face was be- dewed with a cold perspiration; and in this state I found her, when early on the following morning I was called to see her. It was evident she had lost a very large quantity of blood, and had she not been possessed of an unimpared constitution, she (a) Cooper's Hernia, above cited. TREATMENT OF OMENTUM. 301 could not have supported the loss. I opened the sac, removed the coagulum with which it was filled, and was proceeding to look for the bleeding vessels of the omentum, when I fortunately observed the haemorrhage had suddenly ceased. The only ill effect of the haemorrhage was the disturbance of the adhesive process, and the consequent suppuration in the sac, as she ultimately perfectly recovered." (p. 43, note.) When necessary to remove omentum I generally tear it off as far as possible, and afterwards cut through the part which will not tear. I have rarely had occasion to apply any ligatures. Sometimes if the omentum be left, it sloughs; I have seen this happen two or three times without any inconvenience. Astley Cooper (a) mentions a case in which both omentum and intestine were returned into the belly, and after the operation the patient complained of severe pain in the belly; the ligatures on the wound in the scrotum were removed; on the following day a small portion of gangrenous omentum protruded, more and more gradually descended, till the whole which had been protruded appeared in the wound, sloughed, and the patient recovered. (p. 44.) Hewett has recently (b) given a good account of some cases in which the omentum had formed a complete bag around the intestine in strangulated rupture. Although Richter has been stated to have had cases of this kind, yet it appears. that he merely notices their existence without mentioning any particular instance, and Hey's cases cannot be admitted as belonging to this elass. Hewett states that "these sacs have been found in the three most common forms of hernia; but it is in the umbilical hernia they have been generally observed ; the relative situa- tion ofthe intestine and the omentum in the abdominal cavity will easily explain the^ fact. Complete omental sacs were found in four cases out of thirty-four operations for strangulated hernia, performed at St. George's Hospital in 1842-43 ; of these four cases two were femoral, one inguinal, and one umbilical. The formation of these sacs is attributed by Richter to the firm agglutination of the margins of the omentum which has surrounded the bowel. In this explanation of Richter's which does not appear to be applicable to the majority of cases the two following explana^ tions ofthe manner in which these sacs are in some cases formed have been added; —First, the gut, completely enveloped by the omentum, passes through the ring, and the omentum thus disposed round the intestine becomes attached to the circumfer-< ence of the neck of the hernial sac; this omental pouch is subsequently distended by the intestine, and thus forms a complete lining to the hernial sac. Second, an epiplocele takes place, and the portion of omentum which is protruded becomes al- tered in structure, and its folds firmly united to each other by the effusion of tymph; but within the abdominal cavity, in the neighbourhood of the ring, the fold, into which the omentum has been drawn may not be agglutinated ; they will thus leave spaces into which a knuckle of intestine may insinuate itself, pass through the rings and form for itself a bed in the altered mass of omentum which is in the hernial sac. It may happen that two or three portions of gut may slip into the different spaces left between the folds of the omentum and subsequently form for themselves sepa^ rate pouches. Several separate sacs, with narrow-necks, may be thus found in the omental mass, which is in the hernial sac. Once formed, these sacs may attain an immense size. In one case the sac measured six inches in length, and eleven inches in circumference at its broadest part. The omentum in which a sac has been formed, may in the course of time, especially if it is irreducible, become altered in structure either by the effusion of lymph or by a deposition of fat, which takes place in the walls of the sac. By this alteration of structure the thickened sac may, in an ope-; ration, become the source of very great difficulties. * * * These omental sacs may either lie loose in the cavity ofthe hernial sac, or the two sacs may have contracted more or less extensive and firm adhesions with each other, (pp. 284-87.) The neck of an omental sac may become the sole cause of strangulation, of which an instance is given. " The division of the neck of these omental sacs may be fol- lowed by haemorrhage," of which he also mentions a case ; the external bleeding at the operation was slight, and soon ceased; but after death a large patch of recently (a) Above cited. Hernia; completely enveloping the intestine $ (6) Observations on the Omental Sacs in Med.-Ohir. Trans, vol. xxvii. 1844. which are sometimes found in Strangulated 26* 302 OPERATION FOR STRANGULATED RUPTURE, effused blood was found in the folds of the omentum near the mouth of the sac. (pp. 291, 92.)] . ff (3) If the blood have not coagulated in the vessels ofthe omentum, cutting it on and tying them singly is not only an almost interminable business, but also when apparently all the vessels have been secured, and the patient put to bed, after a few hours secondary bleeding occurs from some little vessel or vessels which had escaped notice, the sac and yielding skin become largely distended with blood, in such quantity as to produce faintness, and require the reopening ofthe wound to remove the blood and tie the bleeding vessels. This disturbance ofthe wound prevents the adhesive process, and very commonly gives rise to abscess in the sac or its immediate neigh- bourhood, by which the cure is much retarded. A case of this kind occurred to me, and a large abscess was the result, although the patient ultimately recovered. It is on this account I prefer tearing through the omentum as much as possible, by which the ends of the vessels are ensheathed in cellular tissue, and do not bleed, or even lying up the omentum together. The occurrence of abscess in the sac, independent of bleeding, and which some- times reproduces symptoms of strangulation, has been noticed by Key, as will be presently seen (p. 309); first in a case which occurred et St. Thomas's Hospital in 1817, which 1 remember to have noted ; and secondly, in a case of his own.— 3. F. S.] 1179. If the intestine have a dark, violet, even dusky colour, and its warmth be diminished, these must not prevent its reduction ; only, according to some, the precaution should be taken of drawing a loop through the mesentery, for the purpose of keeping the returned intes- tine in the neighbourhood of the abdominal ring, and to afford a more free escape to the stool, if a part of the returned intestine be destroyed by gangrene. [It not unfrequently happens, that though an intestine be a dark-chocolate colour when the sac is first opened, yet immediately after the division ofthe strieture, the colour, which has depended only on venous congestion, begins to alter, and the gut becomes florid. This is always a very encouraging sign.—j. f. s.] 1180. If the gangrene be more severe, which is characterized by loss of gloss, by an ashy-gray colour, by a softened condition, by the easy peeling off of the outer membrane of the intestine, if the gangrenous portion be but small, it must be opened with a lancet, and the gan- grenous part fastened in a corresponding position to the abdominal ring. If a loop of intestine be attacked with gangrene, and the continuity of the intestinal canal destroyed, the gangrenous part must simply be cut off with scissors, as by the previous inflammation, adhesion of the rest of the intestine with the hernial sac. has been effected, which prevents ail effusion of stool into the belly. If the excrement will not escape of itself, an elastic sound must be introduced. The enlargement of the mouth of the sac with the knife is dangerous, as the division easily overshoots the boundary of the adhesion and may cause effusion into the belly. Stitching up the intestine after cutting off the gangrenous part, as proposed and performed in various ways, is objectionable, as the stitch not holding the inflamed intestinal membranes, produces extension of the inflammation and gangrene. 1181. If in the protruded bowel any wounding substance be found, it must be removed by the wound ; if the intestine be so narrowed and degenerated that it can no longer allow the passage of the stools, that part must be cut off, the wound brought together, by means of Lembert's stitch; or the intestine must be fixed in the abdominal ring, by a twist WITHOUT OPENING THE SAC. 303 of the mesentery. In very small wounds only of the intestines, may the little opening be tied up with a silk thread (A. Cooper). 1182. If in an old and bulky rupture, it be certain that it is not pos- sible to return the contained parts, on account of the great adhesion and degeneration, the hernial sac must merely be laid bare at the abdominal ring, the strangulation relieved, and the rupture left where it was (1 . That mode of operating in which the hernial sac is not' to be at all opened, but only the abdominal ring dilated so as to return the hernial sac together with the intestine, is, in general, to be rejected, and the not opening of the sac to be most especially confined to those cases in which it is certain that in a recently produced or extraordinary large rupture, or in a rupture entirely adhering to the neck of the sac, the strangulation is seated in the abdominal ring. In most cases the con- nexion between the aponeurotic opening and the hernial sac is so firm that the blunt end of a knife cannot be inserted between them, especially if a truss have been already worn (2). Although Franco and Pare had cut into the abdominal ring and did not open the hernial sac, except when reduction could not be effected, yet the practice was first generally recommended by Petit, in large and adherent ruptures; after him, by Garengeot and Monro, in recent and small ruptures, and more recently by A. Cooper; but especially by Key (a) and Preiss (b) has it been laid down, to a certain extent, as the proper practice (2). The advantages resulting therefrom, are diminution of the danger, as the hernial sac is not injured; as well as that by keeping the air from the cavity ofthe belly inflammation, in any injury of an artery effusion of blood into the belly, and also injuring and tearing the intestine in incipient gan- grene, are prevented; and when it seems necessary, the opening of the hernial sac can always be made. These benefits are, however, sufficiently outweighed by the disadvantages, that without opening the sac no insight can be obtained of the state and condition of the parts, the tightness at the neck of the sac may be caused by the entanglement of the intestine and by the peculiar position of the omentum, and the operation, especially in stout persons, is very difficult, and therefore only to be con- fined to the above-mentioned cases. With this mode of treatment must be placed Guerin's (c) subcutaneous incision of the abdominal ring, which he would employ in all ruptures with recent strangulation from the ring, where, however, no slouo-hy destruction of the loop of intestine is to be feared. In strangulation by the hernial sac it is not applicable. [(1) When a rupture is large and old, surgeons generally follow Astley Cooper's recommendation, of dividing the stricture without opening the sac and leaving the protruded gut in the sac or not, as maybe. For this he assigns the following reasons:—"first, in very large old hernias, the cavity of the abdomen is so much di- minished by the habitual loss" of the protruded intestine and omentum, that it becomes scarcely able to receive them again; and if a reduction is attempted, the force necessary to effect it endangers the bursting of the intestine; second, a large surface of intestine is exposed and handled for so long a time, as to produce, even if it does not give way, the risk of an inflammation which will probably be attended with fatal consequences; third, if by great pains the intestine be returned, it is scarcely possible to keep it in the now over distended abdomen, so that the slightest cough, or effort of any kind, is sufficient to bring it again down into the sac, and thus induce a high and dangerous inflammation; lastly, when great adhesion occurs, so much time is necessarily required in performing the operation, to separate the united surfaces, that fears may be justly entertained of the patient not surviving the operation. * * * Hence, in these cases, I would advise only the division of the abdominal ring; or (a) Memoir on the advantages and prac- (b) Wiirdigung des Bruchschnittes ohne ticability of dividing the stricture in Stran- ErOffnung des Bruchsackes. Wein, 1837. gulated Hernia on the outside of the sac. (c) Gazette Medicale de Paris, 1841. No. London, 1833. 33. 304 OPERATION FOR STRANGULATED RUPTURE, if the stricture is higher up, of the lower edge of the transversalis muscle; but the hernial sac should not be opened, unless the stricture is situated in the sac itself." His mode of performing the operation he thus describes:—" I made an incision three inches in length, immediately over the abdominal ring, exposing it with the knife, as well as the fascia, which it sends off. I then made a hole in the fascia large enough to introduce a director, which I thrust up behind the abdominal ring, between it and the hernial sac; and passing a curved probe-pointed bistoury upon it I divided the ring. I then introduced my finger, and feeling some resistance from the trans- versalis, I carried the bistoury upon the director up to it, and divided this also." (p. 63). It is rather odd, in referring to Cooper's first reason for following this practice, that the case on which the operation just described was performed, "had existed from the patient's (aged fifty-four) earliest years," and that it "was of enormous size, reaching half-way to the knees," yet after the division of the stricture, " it went up with a gurgling noise, as soon as his hand was laid upon the tumour." And as regards the danger of exposing and handling for a long time a large surface of intestine, as laid down in his second reason for not opening the sac, the only case he refers to is Carpenter's, who says :—" It was the largest hernia I ever remember to have seen;" and, having opened the sac "a large quantity of intestine, with a small piece of omentum protruded;" but after dividing the stricture, the adhesions were so great, that he "judged it advisable not to attempt their separation. And from the size of the hernia, it was quite impossible to bring the integuments over the intestine, which was therefore left exposed to the air;" yet nothing untoward ensued; "the intestine soon began to granulate, and gradually shrunk within the wound," and the patient recovered, (p. 64). This is the operation on which Astley Cooper lays so great stress, observing:— "I feel convinced that this operation will be gradually introduced into general practice when it has been fairly tried, and found, if performed early, to be free from danger, and attended with no unusual difficulty." (p. 64). "If we cannot accomplish our object in this manner," says Lawrence, "a small aperture may be made in the sac, near the ring, which will enable the surgeon to introduce a curved director under the stricture; the knife carried along the groove, divides the tendon with ease. When the parts are thus set free, they should be returned into the belly by pressure on the swelling, if adhesions do not prevent this; at all events, they generally admit of being replaced in part." (p. 285.) (2) I do not think it can be fairly stated from Astley Cooper's published state- ments, that he is in the generality of cases favourable to, or that he recommends the practice of dividing the stricture, in strangulated rupture external to the sac, but only lays it down as the general rule in large ruptures. It is quite true that in his great work on Hernia, in the first part of the first edition, when treating of the operation for inguinal rupture, he says :-—" An advantage is derived from dilating the stricture without cutting the sac itself, for, there is no danger of injuring the intestine, &c." (p. 30) ; and in the second edition he speaks more at length on the subject thus :— " I have occasionally practised, and for some time recommended in my lectures the following mode of dividing the stricture without including the sac., The tendon of the external oblique having been divided a little above the external ring, the sac is gently drawn down, while the muscles are drawn up by an assistant. In this way the stricture is brought into view, and can be divided without risk, and without in- cluding the peritoneum," (p. 39) ; and he then enumerates the advantages from this practice, that there is no danger of wounding the intestine, and that if the epigastric artery is cut, as the peritoneum is undivided, the flow of blood would beimmediately perceived, and then the vessel might be secured. But in neither edition of his Surgical Lectures, neither that in the Lancet of 1823-24, nor that edited by Tyrrell in 1827, does he allude to the division of the stricture without opening the sac, except in large ruptures. In both these editions of his Lectures he also expressly directs opening the sac and says in the one (a), after " feeling for the stricture, * # # yOU introduce the probe-pointed bistoury on the director or finger, and divide the stricture without cutting too much;" (p, 478.) and in the other (b), "having thus exposed the contents of the hernial sac, as far as the seat of stricture, the ope- rator should insinuate the point of his finger or a director under the stricture, between the sac and its contents, at the upper part, carefully keeping the latter from turning (a) Lancet, 1823, 24. (b) Tyrrell's Edition of Lectures, vol. iii. WITHOUT OPENING THE SAC. 305 over the finger or director. He should then pass the knife for dividing the stricture upon the finger or director, under the stricture, and by a gentle motion divide this stricture, &c." (pp. 44, 5.) I may also add that I have no remembrance of having seen him operate without opening the sac, in the many operations for strangulated rupture which I saw him perform in the Hospital during the first fourteen years of my professional life. To Key, however, must be justly ascribed the revival of Petit's operation, and of its more extensive application (a). His views with regard to its employment will be seen in the following observations upon fifteen fatal cases. " The majority of the cases," he says, " appeared to have died from peritoneal inflammation conse- quent upon the exposure of an inflamed or strangulated portion of bowel. I say exposure of the bowel; for it is; probably, not so much the wound in the peritoneal sac that disposes to inflammation, as placing the bowel under circumstances to which it has hitherto been unaccustomed. The sudden change of temperature to which it is submitted, the exposure to light, and to a current of air, cannot but have some influence upon the delicate circulation of the part, and be productive of some im- pression on the nerves of so susceptible a surface as that of a strangulated intestine. And if to these influences be added the handling which the gut usually experiences, the reaction that follows these agents, we must regard as a natural consequence and likely (as experience proves) to amount to excessive inflammation. In tracing the inflammation consequent upon an operation for hernia, it is found to spread from that portion of the bowel that has been strangulated over the peritoneal surface of the intestines, and not to have its origin from the incision in the sac, although two wounds are usually inflicted upon it, one for the purpose of exposing its contents, and another, higher up, to divide the stricture. The peritoneum about the seat of stricture exhibits fewer signs of acute inflammation than the investment of the bowels." (pp. 11, 12.) After giving an "outline of these cases," Key observes, " it is obvious that the attempt to relieve the stricture without exposing the contents ofthe sac, could not have been attended with any untoward consequences in any of the cases, with the exception of the two cases of gangrene, Nos. II. and XII.; and in these the symptoms denoting the approach or existence of sphacelus, were suffi- ciently marked to point out to the operator the necessary mode of proceeding. Some of the other cases, in all probability, would have been benefited had the sac been left entire." (p. 26.) Lawrence does not agree with Key in " ascribing the unfavourable state of bowel which was found in so large a proportion of his thirteen cases, (the other two not having been operated on,) and which, I believe, will be met with in the majority of those who die after the operation, to the operation itself and its attendant circum- stances, namely, exposure to air and light, change of temperature and handling. I think it rather owing to the pressure ofthe stricture, which affects the parts, not like the slight violence of the operation, for a few minutes only, but uninterruptedly for hours, and sometimes days, disturbing the circulation, making an impression on the intestine as if it had been tied with a string, and sometimes causing ulceration either of the internal tunics or of the bowel in its whole thickness. That inflammation excited by this kind of injury may cause death is clearly proved by Mr. Key's cases. * * * When we find the intestines at the time of the operation mortified, as in cases II. and XII., distended and discoloured, so that it could not be replaced, and required to be opened, as in case V., so altered that the operator would not venture to return it, as in cases III. and VII., the mischief is obviously independent ofthe operation, and its source is rendered unequivocal when we see the tube marked by the stric- ture, and mortified at the part thus impressed, as in case IX." (pp. 279, 80.) From a very careful consideration of the circumstances attended on strangulated rupture, and frojn observation of the appearance which the bowel too frequently ex- hibits, and the results which follow, I cannot but agree with Lawrence that the mischief is rather owing to the "pressure ofthe stricture," than with Key, that it is "consequent upon the exposure of an inflamed or strangulated portion of bowel." But I think it is impossible to doubt that an additional cause is to be found in the unwarrantably violent and repeated squeezing which the rupture suffers during the use of the taxis; so that one is only astonished that the gut is so rarely burst, and the patient destroyed in a few hours. And then, as Key has well expressed it, " an (a) Memoir, above cited. 306 OPERATION FOR STRANGULATED RUPTURE, operation is often regarded as a forlorn hope, resorted to in the extremity of danger, when the injurious effects of delay and violence combine to preclude a chance of success. The effect of exposing a contused part is seen in a common bruise; if the soft parts are severely contused, the skin remaining entire, the inflammation that follows subsides without injuring the texture of the part. But if a small wound accompanies the injury, the inflammation proves destructive in its effects ; sloughing of the cellular membrane, with copious suppuration ensues, and the process of healing is tedious. Between a common contusion and an intestine, or omentum bruised by the taxis, there is a close analogy; a breach of texture, in the one case, leads to the same effects as exposure in the other. Inflammation is in both the result; and the vitality of the parts being impaired, disorganization in both cases follows as the consequence of inflammatory action. If the contusion he not accompanied by a breach of the surface, no harm is anticipated; and just so if the bruised contents of a hernia are returned without a wound ofthe peritoneal sac, and consequent exposure, inflammation, if it does come on, seldom proves severe, and still more rarely fatal." (pp. 58, 9.) Admitting that "the condition of the bowel, that above all others renders it an imperative duty to open the sac, is that of gangrene," and stating that " it is a remark made by some surgeons of experience that the intestine is occasionally found to be in a state of gangrene when no symptoms had existed before the operation to raise a suspicion of mortification having taken place," Key observes, "it does not, how- ever, appear, that any pains have been hitherto taken to form a correct diagnosis of the circumstances under which gangrene has actually taken place; nor am I prepared to say, that, in all cases, such a certainty of diagnosis is attainable; I think, however, that if the attention of the profession were more closely directed to the consideration of the condition preceding gangrene, a near approach might be made, sufficiently accurate to direct the surgeon's practice in all cases." (pp. 103, 104). I cannot agree with Key that " the ordinary characters of a completely sphacelated portion of bowel are distinct enough," for I am quite sure that I have seen them all existing more than once or twice without any gangrene, but simply depending on the un- warrantable violence used in attempting to return the rupture. But I do agree with him, that "it sometimes happens that no such change takes place in the swelling, and then the evidence of gangrene is much more equivocal." It is by no means in- frequent to find an intestine mortified, although the time it has been strangulated is short, and not the slightest external sign leads to the presumption of its condition; as, on the contrary, it now and then happens that the exterior of the swelling is tender, inflamed, doughy, and crackling, from the causes I have just mentioned, and yet the intestine within be healthy, and the patient recover the operation. As regards the loss of elasticity in the swelling, I believe it a very uncertain sign; the intestine may be gangrenous, but the sac full of fluid, as is commonly the case under such circumstances, and then the elasticity remains. The only sign which 1 think can be relied on, though even that is doubtful, is when the gangrenous intestine has burst; then, indeed, although the redness, doughiness, and crackling still remain, the rounding of the swelling subsides, and when a little pressure is made on it a central hollow is produced, and a sense of yielding beneath, very different from the pitting caused by pressure on cedematous cellular tissue. Key mentions a case which occurred to him, in which "a fetid smell, similar to that described by Sir A. Cooper, was perceptible in the progress of the operation, before the sac was opened," The patient had a femoral rupture, and "a fetid smell arose from the swelling as soon as the fascia propria was opened; it was a smell arising from a decomposed portion of bowel, and the transudation of its faecal con- tents. The intestine proved to be quite gangrenous, being black, devoid of lustre, and lacerable. Such a factor might, I apprehend, be discovered in, most cases of sphacelus before the sac is opened; its absence should be ascertained in every case in which the contents of a hernia are to be returned without opening the sac. Before disorganization of the coats of the intestine takes place, transudation of fluid or of fetid air is probably prevented. In incipient gangrene, therefore, it is not to be ex- pected." (p. 109). One instance of fetid smell before opening the sac occurred to me in the case of strangulated umbilical rupture, (No.X, in my Table,) which had been so for thirty hours; but on exposing the gut at the operation, part of it was quite natural, and part dark chocolate-coloured, but shiny, and did not seem to be mortified; after death, WITHOUT OPENING THE SAC. 307 at forty-eight hours from the operation, it had a dirty clay-coloured appearance, very different from that when first exposed. . Admitting that the presence of the fetid smell is always indicative of gangrene, though it has been rarely observed, yet its absence is no certain sign of the healthy state of the intestine; and, therefore, some still more definite symptoms of this dan- gerous condition of the gut are requisite before it can be decided with certainty pre- vious to opening the sac. Lawrence adheres to the old practice of opening the sac and dividing the stricture from within; he says :—" The mode of proceeding thus recommended by Sir Astley Cooper, and executed by him with perfect facility," which is also fully confirmed by Key's practice and experience, " would be found difficult to those less intimately conversant with the anatomy of ruptures, and in some cases, probably impracticable. It is therefore fortunate that we cannot regard it as a matter of much consequence. When the hernial sac has been freely laid open, we cannot suppose that the addi- tional division of its neck will much increase the chance of peritonitis. If the stric- ture be divided in a proper direction, the epigastric artery is not endangered. Nor can the intestine be wounded if due care is taken to protect it, by using a deeply- grooved director, or by carrying the curved knife along the finger. It may also be carefully held out of the way when the stricture is divided, either by the operator or assistant; or it may be covered at that time by the handle of a scalpel, Let me ob- serve further, that the method of dividing the stricture on the outside of the sac does not necessarily secure the protruded parts from injury. In an attempt of this kind recorded by Pelletan (a), the intestine was wounded. The question of eligibility between the ordinary course of proceeding, and this modification must be determined, like all other practical matters, by experience. Unless unequivocal advantage should be found in the latter, I should not recommend its adoption, being unwilling to in- troduce without absolute necessity, a new difficulty into an operation, always re- quiring consideration and caution, and frequently attended with embarrassing cir- cumstances," (p. 290). From my own personal experience of the division of the stricture external to the sac, I can say nothing, never having performed it. But I do not think so great ad- vantage is gained by not opening the sac, as is stated. From all the cases I have observed, either in the practice of others or in my own, I do not think cutting through the hernial sac, and consequently opening the peritoneal cavity, so serious as generally considered. If inflammation of the peritoneum have not been pre- viously set up, either by the rough usage of the rupture, or by the irritation which a long strangulated or gangrenous gut produces, I cannot understand why making a small opening into the peritoneal cavity should be more dreaded than the long slits, which are now made without compunction, for the removal of diseased ovaries, and so forth. There are* however, some conditions which even those who advise leaving thesac untouched, admit, require that it should be opened, namely* confinement ofthe protruded parts by entangling bands, or by adhesion to the sac itself, and a gangrenous condition of the bowel. "Under all circumstances, therefore I am still disposed to continue the practice of opening the sac, as I have hitherto done believing it to be the most safe. I cannot conclude these observations without stating that I believe much of the fatality attendant on operations for strangulated ruptures, depends on the improper after-treatment. 1 well recollect the time when, as soon as the patient was put to bed, he was dosed with senna and salts, With a view of speedily pro- curing stools, and his already irritable bowels being thereby rendeyed still more irritable, he speedily sunk. Although this practice is probably less followed now than formerly, yet I am afraid there is still too great inclination to employ purga- tives too early. For a few hours nothing more than a clyster should be given, and not even that, unless the patient be very uneasy in his bowels, and puffed up with wind. Not unfrequently they relieve themselves, and only after twelve or eighteen hours is it advisable to give medicine by the mouth, for the purpose of completely clearing the whole intestinal canal. And unless there be any special indication for calomel, I believe that castor oil is the best remedy of all. Luke, who is a great advocate for Petit's operations, observes (b) that " the ope- ration itself admits of a very brief general description. It consists of an incision of (a) Clinique Chirurgicale, vol. iii. p. 102. (b) Operation for Strangulated Hernia; in Med. Gazette, vol. i. 1839-40. 308 OPERATION FOR STRANGULATED RUPTURE. the integuments over the seat of the stricture, followed by a division of the sub- jacent cellular texture and fascia, to which succeeds the cautious division ofthe stricture itself; and afterwards the hernial contents are returned into the abdomen,as by the taxis, without exposure. In femoral and in umbilical hernia, for all practical purposes of the operation, the seat of stricture may be assumed to be at the respec- tive abdominal apertures, although in the former hernia there is occasionally some light variation upon that point. * * * In inguinal hernia the seat of stricture is far more variable, and the range of its variation extends from the internal abdominal ring to the scrotum in the male; consequently, without some previous indica- tion to guide the operator, the external incision may be made over one extre- mity of the range, when the stricture is far away at the other, and a fruitless search may be the probable result. * * * There are several ways of conducting the neces- sary examination to obtain the desired diagnosis, all of which depend for their suc- cess upon the stoppage of the communication of impulse from one part to another by the stricture. Thus, if the body of a hernial tumour be compressed by the hand, an impulse is communicated to all its parts below the seat of stricture; but if the neck ofthe hernia be grasped between the ringer and thumb ofthe other hand, above the stricture, while such compression is made there will not be any impulse felt. When, in the commencement of the examination the neck of the tumour is first grasped, we may be always assured, that if an impulse is felt on compression of the tumour itself, the seat of stricture is nearer to the abdomen,- and by gradually withdrawing the finger and thumb in that direction, while renewed compression of the tumour is made, a point will be soon reached at which impulse ceases to be felt. The point at which impulse first ceases to be felt, is the seat of stricture. In like manner, if an impulse is not felt when the neck of the tumour is first grasped, we may be equally assured that the stricture is situated nearer to the body of the hernia,- and, by a like gradual approximation to it with the finger and thumb, an impulse shortly commences to be felt. That point is the uppermost part of the strangulated contents, which implies that the stricture is immediately above it; and, on inquiry, it will be found to cor- respond with the indications of an examination commenced from below, as just mentioned; and thus the two modes of examination will tend to the correction of errors, to which each separately is liable. The same information may be obtained by attending to the point of cessation of impulse when the patient coughs; but this method is irksome and painful under circumstances of acute peritoneal inflammation, and on that account is not so generally desirable as that detailed. Yet much valua- ble information not otherwise attainable may be afforded by using this method in con- junction with that furnished by compression of the tumour. In some cases the stricture occupies a considerable portion of the neck of the hernia, but in most it is confined to a limited space. In the former case, before performing Petit's operation, it is desirable to be acquainted with those limits, in order that, when extensive, suitable provision may be made for its complete division. The combination ofthe two examinations has this knowledge for its object, which is easily attained by at- tending to the points of cessation of impulse. The point of cessation of impulse on coughing indicates the upper boundary of the stricture, and the point of cessa- tion of impulse on compression of the hernia, indicates its lower boundary of the stricture; and, consequently, the boundaries are the limits of its extent." (pp. 865, 66.) He further observes:—" The probability of the necessity to open the sac to effect a return, is much increased when the stricture is caused by its thick and indurated neck. * * * When the stricture is situated exteriorly to the sac, a director may enerallybe easily introduced under it, and it may be as easily divided with a bistoury; ut when the neck of the sac itself forms the stricture, no such measure can be adopted. In such cases its division should be accomplished by cutting the indu- rated and thick substance on its exterior surface only, taking the greatest care that the knife does not penetrate to the interior of the sac. If this step has been pro- perly performed, the division is only partial, and little amount of relief will ensue. To render the relief effective, the partial division of the indurated neck should be repeated in one or two other situations on the circumference of the stricture, by which, at length, the stricturing substance is so far weakened in its power of resistance, especially when unsupported by surrounding structures, that it becomes susceptible of dilatation by the very moderate interior pressure of the hernial contents during the efforts of the taxis. Success does not frequently attend the first efforts, so that re- TREATMENT OF SLOUGHY INTESTINE. 309 newed partial divisions, and renewed efforts are mostly required; and, however unpromising such cases may be, experience enables me to state that in this way they often admit of relief without the necessity of opening the sac. The proportion of failures in the attempt is, from its nature, greater than that which is experienced in hernias, strictured by the margins ofthe abdominal apertures; yet inclusive of these failures, I have not any reason to consider their general amount large, having sus- tained only five failures out of thirty-two cases, on which I have attempted to leave the sac unopened." (p. 866.) There is much good in the preceding observations, on which account I have so largely quoted them ; but the success resulting from this practice, so very far beyond what usually happens in cases of strangulated rupture, leads to the suspicion that some of the number mentioned, might, perhaps, have been relieved without other operation than the taxis.—j. f. s.] 1183. When the intestine has been properly returned into the belly, and the wound and surrounding parts cleaned, the edges ofthe wound must be brought together either with sticking plaster or with a stitch, covered with wadding and a compress, and this dressing bound on with a suitable bandage. The patient should be put in such position that the belly shall be relaxed, with his chest raised, and his thighs drawn up ; he must observe the strictest quiet, and take only mild mucilaginous drinks. In general some hours after the operation the bowels are re- lieved of themselves ; but if this do not happen, an oily mixture may be given, castor oil, clysters, calomel, and if no inflammatory symptoms exist, an oily mixture, with common salt. The dressing must be re- placed as often as necessary, and a slight Compression made opposite the abdominal ring. When the wound has scarred, a proper truss is to be applied. If inflammatory symptoms occur, they must be treated antiphlogistically. If there be inflammation, consequent on still existing strangulation, or if protrusion of the intestine again happen, and it be painful to the touch, the part must be returned into the belly by intro- ducing the finger. If symptoms of strangulation still continue, on ac- count of entanglement of the intestine within the belly, its adhesion or narrowing, the intestine must be protruded by coughing, or by intro- ducing the finger. If the strangulation still continue several days after the operation, and the intestines be still protruded on account of adhesion, it may then be advisable, in complete obstruction ofthe intestine, to open it with a lancet. Key (a) notices one circumstance in the after-treatment, (especially in inguinal ruptures,) in which symptoms resembling those from strangulation occurred, viz., the transition of inflammation of the sac into suppuration. The scrotum swells up a day or two after the operation, becomes painful, hiccough and vomiting recur, the relief of the bowels is diminished or suppressed, and, from the fulness of the hernial sac, the patient has the sensation as if the rupture were again protruded. Distinct fluctuation is ordinarily not to be felt, on account of the thickening of the mem- branes. At first leeches and evaporating washes are to be applied, subsequently poultices, the closed wound is to be punctured with the lancet, and an escape made for the pus, whereupon the symptoms soon subside. [I have had one case of suppuration of the sac of an inguinal rupture, but it did not cause any peculiar or dangerous symptoms, and after a few days emptied itself, and gave no further inconvenience. I have once seen in a young man, operated on for scrotal rupture, and who was purged violently for some days, after taking five doses of two grains of calomel, with half a grain of opium every six hours, for peritonitis, inflammation extend from (a) A. Cooper's Hernia, p. 58, note. Vol. ii.—27 310 OPERATION FOR STRANGULATED RUPTURE. the sac up to the navel, and round into the loin, which terminated in large slough- ing of the cellular tissue ; but he ultimately recovered.—j. f. s.] 1184, If the intestine be sloughy, it must be merely covered with a light compress dipped in a mucilaginous fluid. When all the slough is thrown off, and the artificial anus or faecal fistula is formed by the union of the destroyed intestine with the neighbouring peritoneum, care is merely requisite for the due escape of the stools, the aperture is to be covered with wadding, and all pressure removed ; the patient should take nourishing and easy digestible food ; clysters and gentle purges should be often given. [In general during the course of strangulation, the gut becomes so adherent to the mouth of the sac, that if it should mortify and burst, or if it be purposely opened by the surgeon during the operation, it rarely recedes, and the stools, passing by the wound form an artificial anus. On the other hand an intestine may be returned into the belly, and slough after- wards. Key mentions a case (a) under Astley Cooper, in which strangulated inguinal rupture was operated on, " and the intestine, though dark-coloured, appear- ing to be merely congested, was returned into the abdomen. In the evening ofthe same day he passed stools per anum, and appeared relieved. On the third day, as soon as the poultice was removed, a quantity of faeculent matter was seen issuing from the opening; the discharge of faeces continued for five days, at the end of which time it altogether healed, and the wound speedily cicatrized." In another case, a strangulated congenital rupture, which occurred to KEYhimself; on the fourth day after the operation "a copious discharge of faeces had taken place at the wound. The abdomen had remained tender since the operation, but he had discharged fasces per anum. The discharge did not cease for several days, and delayed the healing ofthe wound. But at the end of about sixteen days, he became convalescent, and the wound entirely closed." (pp. Ill, 13.) Lawrence mentions a remarkable case of bubonocele, which was operated on by Ramshen :—" The gut, which was much discoloured, wTas returned without difficulty, but seems not to have completely re- entered the abdominal cavity. On passing the finger as high as the incision would admit, if it did not fairly reach the abdomen, it seems as if the intestine, although free from stricture, were contained in a peculiar membranous bag." Clysters, which were ordered, could not be forced up, which led to examination of the rectum, and thence some hardened faeces were removed. She was much exhausted, but, by care, had considerably recovered next morning, and the bowels not having been moved, calomel and colocynth extract were given every two hours, which, in the evening, began to operate, and before morning she had eight or ten stools. She continued for a time in a very fluctuating state, but well-grounded hopes of her re- covery were entertained till " she wras seized, in about six weeksafter the operation, with violent pain in the lower part of the abdomen, which terminated in two days in a discharge of fasces from the wound, and perfect ease. The appetite now failed, the strength decreased, and death took place on the tenth day from the appearance of faeces in the wound. On examining the body, the whole of the intestines were found so strongly adherent to each other, that they could not be separated without laceration. A portion ofthe ilium, the same, probably, which had been protruded, adhered to the abdominal ring. Its coats were greatly stretched, and its canal was much contracted. A small ulcerated aperture was discovered in this part; and led, in a fistulous form, through a substance nearly equal in size to the little finger, to the external wound." (p. 328.) It has been well observed by Key, that, "cases are sometimes met with in which the patient appears to be doing well after the operation, the evacuations being free and natural, and the sickness and pain subsiding ; but after the lapse of two or three days the powers begin to sink, the abdomen, though not very tense, is uneasy under pressure; the pulse small and quick, and the tongue becomes dry and coated. This condition is, perhaps, protracted for several days, and the patient at length dies. A post mortem inspection discovers the cause of death in the dark colour and lacerable condition ofthe strangulated portion ofthe bowel and the vascular state of the sur- rounding parts. This unexpected termination of a case when it does occur, usually (a) Memoir. TREATMENT OF SLOUGHY INTESTINE. 311 takes place in patients of enfeebled constitution, whose powers are unequal to the restoration of the healthy circulation in the strangulated bowel after its release from the stricture; and in whom, therefore, a slight degree of inflammation gradually ends in the extinction of its vitality. At the period of the operation the intestine, when exposed, presents none ofthe usual indications of present or approaching gan- grene; no infiltration of its tissues, no discoloration beyond that which retarded cir- culation in a healthy bowel produces, no lack of peritoneal lustre, and no lacerabi- lity of texture ; it in no point appears to differ from those cases of strangulation, in which an early operation is had recourse to before severe symptoms come on, and in which a favourable prognosis is verified by a rapid convalescence. Exposure of a portion of bowel possessing such feeble powers of resistance to morbid influence cannot but tend to increase, probably to excite, a disposition to inflammation; which though low in degree, is sufficient to destroy its vitality: and it may therefore be fairly regarded as the main agent in the production of gangrene." With this ex- planation I cannot agree; the mischief has been done to the bowel, or at least its foundation is laid, I believe, before the sac is opened, by the disturbance ofthe cir- culation during the strangulation, from which the bowel has not power to recover itself; and according as the stagnation of the blood has existed for a shorter or longer time, and to a less or greater extent, so does the mischief run on subsequently to inflammation and gangrene.—j. f. s. " In cases in which great depression of the powers is observed to precede the ope- ration," continues Key, "death sometimes rapidly takes]place without any other obvious cause than the exposure of the bowel. The condition of the patient is often found to be manifestly worse after the operation, and stimulants are obliged to be plentifully administered, in order to sustain the sinking powers of life. This may happen without inflammation of the abdominal cavity, or gangrene of the bowel; and is attributable solely to the depressing effect of the operation. The pulse, which before the operation was feeble, becomes fluttering, and scarcely perceptible; the countenance which was anxious, now bespeaks the approach of death ; the skin is covered with a clammy moisture, and the whole frame is siezed with a restlessness that gradually ends in the calmness of dissolution." (pp. 51-4.) Astley Cooper mentions the very remarkable circumstance of tetanus follow* ing the operation for rupture, on the eighth day, by which the patient was speedily destroyed (a.)] (a) Above cited, p. 58. 312 TABULAR VIEW OF OPERATIONS Tabular View of Operations Kind. Sex. Right scrotal, not Male . small. Lf ft direct scrotal, (also on other side,) size of pi geon's egg. ;crotaI, large as Male .. child's head of two years. Age. 43 73 Scrotal, left, (also Male on other side,) size of an orange. Femoral,right dou- Female ble sac. Scrotal, right, as large as a pear Male .. Femoral, right, ofFemale, large size and oblong form on Poupart's liga- ment, then bend- ing down and extending into labium. Right scrotal, con- Male. genital; three lin- gers thick, one long. Femoral, (right,) Female. not large, but From child hood, but not congenital 15 vears. 55 19 years. Truss. Worn for last seven years 40 years, (in carcerated.) 9 years. 2 years. 10 years. 43 Says he has only noticed the swelling 12 months. 12 years Strangu- lation. 3 days.. 12 hours. 4 days... None Vomiting. Seven hours, little. Constant. Co n st i pa tiou. Vnt men tioned how long. 3 days... Symptoms not urgent. Fouryeaiscup 3days.. Iruss. Much For some time 36 hours.. Slight..... (Symptoms of strangulation scarce, so that I did not operate for 24 hours.) Truss not fit ting. suspensory. Six weeks ... 10 hours.. 12 hours.. 47 hours. Much throw- ing up of wind, but no vomit- ing. Much Much 4 days. 3 days. 24 hours naturally but since hy clyster 04 hours..! * Upon these cases I operated in St. Thomas's Hospital during the first four and a half years of Subsequent severe illness has twice broken in on me, and prevented me keeping so regular an advantage which accrues from such tables.—J. F. S. FOR STRANGULATED RUPTURE. 313 for Strangulated Rupture.* Tenderness. Of belly little, of rup- ture ditto. Of belly much, with precordial pain and hiccough from first day, which conti nued till third day after operation,and pain in belly ceas'd. Of rupture, probably from attempts at reduction. Of the rupture a lit tie. Of the belly; has had hiccough through out whole day; tenderness ceased on second day. None in belly nor in rupture. At lower part belly, near the swelling. Pain in belly, tender- ness of rupture. A little pain in belly .when pressed. Contents. Eight inches gut on- ly, bright and tur- gid, thickened. Sac divided by verti- cal septum, omen turn before, gut be hind; two inches gut, bright choco late-coloured. Half yard of intei tine, front half of which chocolate & thickened, other un altered; also large mass of omentum. Much adheringomra turn, almost schir rous; a small por tion of colon heal- thy. Bit of omentum, size of a walnut, in lit tie sac; four inches choc, intest., shin ing,but slightly ad herent, and much matted omentum in large sac. Three inches choco- late, with a little patch of adhesive; no omentum. fOmentum in labium soft, but in true sac firm and mat ted; in true sac knuckle of bright gut. Two inches gut dark coloured, bright. Rowels moved. Cured. Died on ninth day; intestine at mouth of sac still dark coloured, little in flammation. Freely within an hour. After 24 hours free mo tion from repeated clys ters; the bowels con- tinued to be moved but though assisted with stimulants and nourishment, he gra- dually sunk. V slight motion from Cured (stricture not clysters after 24 hours; tight.) after same interval, and castor oil and clyster, bowels moved freely. Result. in eight hours after two clysters some scybota came away. Next morning he had calo- mel and castor oil, and the bowels were freely moved. An hour after, the bowels very freely opened, and again three hours af- ter. Within eight hours after twice castor oil, very copious motions. Within first nine hours the bowels thrice spar- ingly relieved by clys- ter. She went on very well, but the bowel were not satisfactorily moved till four days after the operation, al- though she had calo- mel and opium twice a day, with occasional castor oil and senna and salts. Bowels moved by clyster and castor oil freely be- tween 12 and 16 hours afier operation. Cured (stricture none but without dila- ting.) Cured (stricture not very tight.) Additional Remarks. Large quantity of fat between cremaster and sac. I wounded intes- tine in opening sac with knife. Attempts were made to diminish size of rup- ture by application of ice, but without, avail. The dresser had also given tartar emetic. The omentum was left. The gut came down again on ninth day, in getting out of bed, but slowly returned. Ice was applied for three hours before operation without benefit. Di- lated the stricture and left the gut, but tore and cut off" omentum. Probably in this case the colon, together with its peritoneal connex- ion to the iliac pit, de- scended, but I did not notice this at the ope- ration. The larger piece of omen- tum was cut off. Cured (stricture very Cremaster enormously tight.) thickened. Cured, (stricture very The inside of the sac had tight.) | probably burst, and al- lowed the gut to escape into the labium. Healthy, bright, and.Ninn hours after ope- dark-coloured gut. ration bowwls freely moved by clyster. Cured, (stricture at internal ring very tight, and like movable membra- nous ring. Cured, (stricture tight.) my Assistant Surgeonship; and it will be observed that for one whole year I had not a single case. account since; but I hope yet to resume and continue a similar one, as 1 am convinced of the 27* 314 TABULAR VIEW OF OPERATIONS Kind. Sex. Age. Strangu- lation. Vomiting. Constipa- tion. 1840. X. April 18 Femoral, (right, swelling large. Female 24 years. Partially irre due. XL June 15 XII. July 4 XIII. July 30 XIV. Aug. 16 Umbilical,(as large as a half-quart ern loaf,) with cleft, so as to have hour-glass form. Femoral, (right,) always small Scrotal, (left,) size of pigeon's egg. Scrotal, (right,) also on left. Female 12 years. Partially irre-30 hours. due, no truss. 57 20 years. No truss. XV. Oct. 29 Femoral, (right,) size of pigeon's Female. 45 14 years. Has worn 54 years on left Has worn 18 on right after blow. Much, 12 hours. 36 hours. 3 days. 6 hours. 20 years. Has worn till within last three years. 4 days. Much, three days. Much, 5 days. Much. 36 hours. 36 hours, much. FOR STRANGULATED RUPTURE. 315 Tenderness. Contents. Bowels moved. Much pain in belly, and not relieved by the operation; no pain nor tender ness in swelling. Swelling tender. Pain, but not tender- ness, in the belly Much pain in belly. Much pain in belly; after operation complained of pain about navel, which did not subside. Much adhering omen turn, four inches of intestine verydark, but shining. Sac divided by trans verse band; hard muss of omentum adherent in upper portion; 8 inches of dark chocolate bright intestine Very small knuckle of dark-coloured bright gut. A few scybola brought away by clyster 22 hours after operation, but nothing more. Bowels relieved of thin motion 30 hours after operation, not without calomel and opium every two hours seven times; a single dose of calomel and clysters had previously been useless. Large knuckle of dark gut, very tense, and perito neal coat seemed cracked. Half yard of gut, not deep-coloured, but much thickened and slightly ecchy mosed. Much pain in belly, with tympany. Three hours after opera tion a few small scybola after clyster, but after castor oil the bowel were freely moved during the day; purg ing came on on third day. Bowels twice moved within 12 hours by castor oil. Mass of heal thy omen turn adherent, small bit of reddened but not dark gut, size of top of thumb, Result. Died 13 hours, (stric ture very firm.) Within 24 hours his bowels freely moved by clyster; after which they continued tolera bly regular. Calomel and opium were given every six hours, and when his powers began to fail, brandy and arrow-root. Died 48 hours, (stric ture not tight.) Died 65 hours, (stric ture very tight) Additional Remarks. Fetid smell on opening the sac. The adhering omentum was left alone. The vomiting conti- nued after the opera- tion almost to the last. On examination, the intestine* gangrenous, with mark of separa- tion; intestines slightly glued. Fetid smell before open- ing the sac. A deep tnugh band of cellular tissue indented the her- nial sac, which also had a corresponding deep fold. Vomiting conti- nued till death. On ex- amination, the intes- tine dirty clay.colour; no peritonitis. No account of examina- tion. Cured, (stricture very tight.) Died six days after, (stricture not tight, but required divi- sion, as also a band below it.) The bowels were not moved till a few hours before death. Died 36 hours, (stric ture tight.) The scrotum very largp, much reddenpd, proba- bly from efforts and crackling. Much diffi- culty in returning gut on account of its thick- ness. In course of the second day hiccough came on, and some sickness, which sub- sided, but came on next day* and frequently after to the last. Nor was it checked but slightly by hydrocyanic acid. On examination, all the intestines were found glued together; strangulated gut not restored; suppuration between cremaster and sac. She was, when first seen, very much depressed, and the surface cold. Three or four ounces of straw coloured fluid escaped from the belly after reduction, imme- diately on the return of the gut. The omen- tum left in sac. Calo- mel and opium were ordered directly after the operation on ac. count of the pain and tenderness ofthe belly. Egg and brandy, and other nourishment were given without avail, Slight peritonitis; only a portion of intestinal tube, size of sixpence, had been strangulated, and lay just above mouth of sac. [ 316 ] Second Chapter.—OF ABDOMINAL RUPTURES IN PARTICULAR. I.—Of Inguinal Rupture. (Hernia inguinalis, Lat.; Leistenbruch, Germ.; Hernie inguinale, Bubonocele, Fr.) Camperi, P., Icones herniarum inguinalium, edit, a S. Th. Soemmerring. Francof, 1801. Cooper, Astley, The Anatomy and Surgical Treatment of Abdominal Hernia. Part i. Rudtorfff.r, F. X., Abhandlung iiber die einfachste und sicherste Operationsme- thode eingespenter Leisten-und Schenkelbriiche; nebst einem Anhange merkwurdi- ger,auf den operativen Theil der Wundarzneikunst sich beziehender Beobachtungen. Wien, 1805. 8vo. 2 vols.; with eight plates. Hesselbach, F. C, Anatomisch-chirurgische Abhandlung iiber den Ursprungder Leistenbriiche. Wiirzburg, 1806. 8vo. ----------------, neueste anatomisch-pathologische Untersuchung iiber den Ursprungund das Fortschreiten der Leistenund Schenkelbriiche. Wiirzburg, 1815. 4to.; with fifteen copper plates. Wattmann, Ueber die Vorlagerungen in Leistengegend. Wein, 1815. Langenbech, Commentarius de structura peritonaei ,testiculorum tunicis, eorum- que ex abdomine in scrotum descensu; ad illustrandam herniarum indolem. Got- ting., 1817. fol. ----------, Abhandlung von den Leisten-und Schenkelbriichen, enthaltend die anatomische Beschreibung und Behandlung der selben. Gotting., 1821 ; with eight copper plates. Meckel, J. F., Tractatus de morbo hernioso conp-enito sinp-ulari et complicate Berol., 1772. s s Sandifort, Icones herniae inguinalis congenitae. L. B., 1788. 4to. Wrisberg, Observationes anatomicae de testiculorum ex abdomine in scrotum de- scensu, ad illustrandam in chirurgiadeherniis congenitis utriusque sexus doctrinam; in Comment. Soc. Reg. Scient. Gotting., 1778. Sinogowitz, Anleitungzu einer zweckmassingenManualhiilfe bie eingeklemmten Leisten und Schenkelbriichen. Danzig, 1830. 8vo. [DaHrach, W. E., The Anatomy ofthe Groin. Philadelphia, 1830. folio.--G. W. N.] Zahner, ChirurgischeAnatomiederBriickstellenamUnterleibe; inaug. Abhandl. Erlangen, 1833. Hammond, William, Anatomy and Surgery of Inguinal and Femoral Hernia. London, 1834. fol. Also the writers before mentioned. 1185. Inguinal Rupture passes through the abdominal ring {annulus abdominalis); it may be either Scrotal, (Hernia scrotalis, Lat.; Hoden- sackbruch, Germ.; Oscheocele, Fr.) when descending into the scrotum, or Labial, {Hernia labii pudendi externi, Lat.; Bruch der ausserer Schaamlippe, Germ.; Hernie des grandes levres, Fr.) when passing into the labium. 1186. The front or outer abdominal ring is the external opening of the inguinal canal, (canalis inguinalis), and is formed by the tendon of the external oblique muscle stretching from the upper front spine ofthe hip- bone to the pubic symphysis, (Poupart's ligament or the external ingui- nal ligament of Hesselbach), where the fibres separating, attach them- selves by one part (the inner pillar of the ring) to the pubic symphysis, ANATOMY OF INGUINAL RUPTURE. 317 and by the other (the outer pillar of the ring) to the spine of the share- bone. A triangular opening is thus formed, of which the share-bone is the base, and the point inclining upwards and outwards is the junction ofthe two pillars. By the splitting ofthe muscular fibres of the internal oblique abdominal muscle, the junction of its tendon with that of the transverse muscle, forms the other part of the inguinal canal. The in- ternal opening of the inguinal canal {hinder or inner abdominal ring) is formed by an aponeurosis, (the fascia transversalis of Cooper, the internal inguinal ligament of Hesselbach, the external layer of the peritoneum of Langenbeck), commencing from the hinder edge of Poupart's ligament, which seems to twist itself upwards and backwards. This aponeurosis loses itself above in the cellular tissue which overspreads the inner sur- face of the transverse muscle, and is continued to the under surface of the diaphragm. Internally it arises from the outer edge of the tendon of the straight muscle, which unites with it, and therefore at this part it is strongest. Where the strong fibres of this aponeurosis ascend obliquely outwards over the femoral vessels, they form an oblong aperture for the passage ofthe spermatic cord (which, according to Cloquet, is covered by this aponeurosis, to the testicle, where it is connected to the vaginal tunic) (1). The inguinal canal is directed from without and above, inwards and downwards, as it passes from the hinder or inner to the front or outer ring, and is from one inch and a quarter, to an inch and a half long. Its front wall is formed by Poupart's ligament, and a small part ofthe internal oblique muscle; its hind wall inwards and upwards by the delicate fleshy bundles of that muscle, and below and without, by the fascia transversalis. In the male the spermatic cord passes through the inguinal canal, and is surrounded besides by the process ofthe transverse fascia, by cellular tissue, and covered by the cremaster muscle, (the lengthened fibres ofthe internal oblique muscle), the general vaginal tunic, (tunica vaginalis communis, according to Langenbeck), a process of the external layer of the peritoneum. The external surface of the external oblique muscle is covered with a delicate aponeurotic expansion considered to be a process ofthe m. fasciae latae femoris, and which spreads over the front inguinal ring and the spermatic cord {tunica dartos, fascia super- ficialis of Cooper) (2). The epigastric artery arises from the external iliac above Poupart's ligament, ascends between the transversal fascia and the outer layer of the peritoneum, inwards and upwards, on the inside of the hinder or inner inguinal ring, there crosses the spermatic cord, reaches the edge of the straight muscle about an inch and a half from its origin, and runs upwards on its hind surface. If the region of the groin be examined on the peritoneal side, the trace of the obliterated vaginal tunic is seen at the point which corresponds to the hinder in- guinal ring, and in many cases there is a depression in the peritoneum, which indicates the upper part of that tunic remaining open; on the inner side of this spot lies the epigastric artery. Between this and the umbilical artery, opposite the front or outer inguinal ling, is seen a slight depression, (inguinal pit, fovea inguinalis of Hesselbach,) where the peritoneum, towards the external ring, is covered only by the weaker parts of the transversal/ascza, and by the delicate bundles of the internal oblique muscle. 318 KINDS OF [(1) The description of that most important part in ruptures, both inguinal and femoral, namely, the fascia transversalis, is not given by Chelius so clearly as might be; for it is far less difficult either to dissector describe than commonly considered. At the onset it must be remembered that it is not a tendinous, bnt merely a cellular membranous structure, much condensed, and connecting the whole hind surface of the abdominal muscles with the front of the peritoneum. It is not part nor process of Poupart's ligament, but simply attached to it by one of its processes, whilst the other descends behind it, the former commonly called the iliac, and the latter the pubic portion of the fascia transversalis. The iliac portion commences by a sharp angle at the outside of the pubic spine, and ascends outwards, closely attached to the back and upper edge of Poupart's ligament to the upper front spine of the hip-bone, gradually increasing in width, and having a scythe-like shape, with the edge up- wards and inwards, to the middle of that ligament, where it suddenly spreads upwards and is interposed between the back ofthe abdominal muscles and the front ofthe peritoneum, and is said to be lost on the diaphragm, which, however, is not really the case, for it continues as the connector of the peritoneum with that muscle, and then descending upon the front of the loins connects it with the lumbar muscles, and runs down upon the iliacus muscle on either side, between them and the peri- toneum, and having attained those regions assumes the name of fascia iliaca, where for the present it must be left. I have said that the iliac portion of the fascia trans- versalis" was scythe-shaped to the middle of Poupart's ligament, and it is there, about an inch in depth. It then runs inwards and descends behind the lower part of the straight muscles, is fixed to the back of the pubic bones, as far as their spines, spreads out on either side beyond them, behind and connected but slightly with the scythe-like portion, up to the upper front spine ofthe hip-bone; this from its attach- ment is called the pubic portion of the fascia transversalis, and its shape is more sickle-like, with the concavity upwards and outwards. The sudden turning inwards and downwards, and afterwards outwards and upwards of the pubic portion uncon- nected, or but loosely connected with the iliac portion of the fascia transversalis, leaves a gap about an inch and a half above Poupart's ligament, the hinder or inner abdominal ring, which has a sort of oval shape, or rather like the periphery of the vertical section of a pear. That part of the pubic portion from below the inner ring to the spine of the share- bone, and behind the scythe edge ofthe iliac portion of the fascia transversalis, alone forms the floor or back ofthe inguinal canal, down to the upper edge ofthe external ring, but between this and its connexion to the spine, and symphysis of the share- bone, it is strengthened by the lower ends of the conjoined tendons of the internal oblique and transverse muscles, which descend in front of and closely connected with it, to be fixed from the spine to the symphysis of the share-bone, and thus to- gether they shut like a window-shutter against the back of the external ring. A little shallow triangular groove extends from the internal to the external ring formed by the scythe edge of the iliac portion in front, and the pubic portion of the fascia transversalis behind, and in this as in a gutter lies the spermatic cord or the round ligament. It must not be supposed that the inner ring is an actual aperture, except during the descent of the testicle, and then indeed it is only the orifice of a cellular pouch thrust down below the pouch of the peritoneum, which subsequently forms the vaginal tunic ofthe testicle; and when, after the arrival of that organ in the scrotum, the peritoneum upon the cord gradually closes and thins, so likewise does the pouch of the transversalis facia, forming the fascia of the cord, described by Astley Cooper long before Cloquet's account of it. In addition to this fascia from the inner ring a similar funnel of cellular tissue from the outer ring is given off as the cord passes through it, and the two fasciae so called become confounded into one below, between the external ring and the testicle. (2) The superficial fascia or aponeurosis of the external oblique muscle is not tendinous, but merely the cellular tissue which connects the skin with the front of the abdominal muscles, and descends upon the spermatic cord and testicle to connect them with the skin of the scrotum.—j. f. s.] 1187. At these two points inguinal ruptures are formed, and upon the difference in their origin depends their division into external and in- ternal, or oblique and direct of English surgeons). INGUINAL RUPTURE. 319 1188. External or Oblique Inguinal Rupture {Hernia inguinalis externa, Lat.; AiXssere Leistenbruch, Germ.; Hernie inguinale externe, Fr.) com- mences at the seat of the obliterated canal of the vaginal tunic, or the intestines pass into the canal itself, which remains partially or completely open. This rupture proceeds from above and without inwards and downwards, in the direction of the spermatic cord, as a cylindrical swelling; the spermatic cord lies on its inner hinder side, and the epi- gastric artery passes under the neck ofthe hernial sac and upon its inner side ; if it be returned, a peculiar gurgling is heard. 1189. Internal or Direct Inguinal Rupture {Hernia inguinalis interna, Lat.; Inner e Leistenbruch, Germ.; Hernie inguinale interne, Fr.; Ventro- inguinal Hernia of Cooper) passes out of the inguinal pit directly from within outwards through the external inguinal ring; it has a peculiar rounding, a short neck ; it raises the inner pillar of the abdominal ring considerably; the spermatic cord lies on the outer side of the swelling; no gurgling is heard on its return. 1190. The symptoms by which external and internal inguinal ruptures are distinguished from each other, are only certain at the commencement of their existence, and whilst they have yet no great size. When the external inguinal rupture has become very large, it completely loses its cylindrical form, its oblique narrow neck, and passes directly out of the cavity of the belly. The position of the spermatic cord in old ruptures is equally various; not unfrequently are the vessels separated from each other by the pressure of the swelling. 1191. External or oblique inguinal rupture passes through the hinder (inner) inguinal ring into the general vaginal tunic, and may descend to the testicle, the proper vaginal tunic of which it touches. Its own coverings therefore are, 1, the skin of the scrotum; 2, the fascia super- ficial; 3, the tunica vaginalis communis, upon the upper surface of which spread the fibres of the cremaster muscle ; 4, the hernial sac itself, an unnatural lengthening of the peritoneum, covered on its outer surface with loose cellular tissue. In old ruptures these layers are often of consider- able thickness. Sometimes the external inguinal rupture does not pass through the front inguinal ring, but remains lying in the inguinal canal; it is then called imperfectly developed inguinal rupture (Rupture in the inguinal canal of English surgeons.) It forms in (above) the middle of Poupart's ligament, above (before) the crural artery, a round or obliquely oval swelling, which becomes larger by coughing, is accompanied with an unpleasant sensation of pressure and dragging, and easily thrust back on application of the finger. The external inguinal ring is free. If the rupture increase, it descends obliquely inwards and downwards, towards the external inguinal ring, and passes through it. But it often exists as an undeveloped inguinal rupture, and spreads upwards and outwards. Besides the coverings already mentioned, this is covered with the front wall of the inguinal canal; to wit, the tendon of the external oblique, and the muscular fibres ofthe internal oblique muscle (1). [(1) It is not covered by the muscular fibres of the internal oblique, for as soon as the rupture is formed by protruding through the upper or internal abdominal ring, the muscular edge of the internal oblique and transverse muscles slips back, and rests upon the upper and back part of the swelling.—j. f. s.] 320 CONGENITAL INGUINAL RUPTURE. 1192. The internal or direct inguinal rupture projects at the inguinal pit, either between the fibres of the fascia transversalis, and the thin bundles of the internal oblique abdominal muscle, or protrudes with it the fascia transversalis; it drives down external to the vaginal tunic into the scrotum, and if it sink lower than the spermatic cord, the testicle rests upon the fore or outer part of the body of the hernial sac. The coverings of this rupture are, 1, the skin of the scrotum; 2, the superficial fascia; 3, sometimes some bundles ofthe cremaster muscle (a); 4, some- times the transverse/asaa {b); 5, the hernial sac, with its external sur- face covered with loose cellular tissue. (a) As long as internal inguinal rupture is not far from the abdominal ring, it is not covered with the cremaster; but in great protrusion it can incline farther out- wards, and then it is possible that some fibres of the cremaster may appear on it, beneath which it simultaneously slips down. (b) This usually appears to be the case, and the cause why the internal inguinal rupture can never attain the size of the external. 1193. It must be considered as a strong disposition for inguinal rup- ture if there be only a partial remaining open of the upper part of the vaginal canal for the outer, and a great elevation of the duplicature of the peritoneum, in which the umbilical artery lies, for the inner inguinal rupture. 1194. The ileum is the most common intestine in inguinal rupture, next it the caecum and its wormlike process. If the caecum or colon protrude, the ligaments are lengthened which connect them to the peritoneum, and also that part of the peritoneum which is connected with the intestines is drawn down, so that between the hernial sac and the intestines there is the same natural connexion as existed in its previous position. In these ruptures of the caecum and colon, part lies externally to the sac, as in the belly it had lain external to the peritoneum. In general the hinder or under part of its calibre is protruded ; as it drops down however the in- testine often twists, so that its bare part lies in front, in which case the rupture seems to have no hernial sac. The omentum commonly passes into an inguinal rupture, especially on the left side. With the internal inguinal rupture a portion of the urinary bladder sometimes protrudes, which cannot be drawn from the sac. In rare cases, in women, the in- ternal generative organs are contained in inguinal rupture. Inguinal ruptures are much more frequent in men than in women. The frequency of internal to external inguinal ruptures is as one to fifteen. 1195. If the intestine pass into the still open canal of the vaginal tunic ofthe testicle, it is called a Congenital Inguinal Rupture (Hernia inguina- lis congenita seu processus vaginalis, Lat.; angebomer Leistenbruch, Germ.; Hernie inguinale congenitale, Fr). The origin of congenital inguinal rupture depends, in addition to the vaginal tunic remaining open, upon special causes:—first, on the long continuance of the testicle in the ex- ternal inguinal ring, because then the vaginal canal has less disposition to be obliterated; second, after birth the protrusion is always favoured by respiration and by the action ofthe abdominal muscles; third, by adhe- sion of the testicle with the omentum, or with the intestine, previous to its descent, or if the intestine be connected with the peritoneum, as the caecum on the right side, it may be drawn down with it. 1196. Congenital inguinal rupture has the same relations as external DISTINCTION OF INGUINAL RUPTURE FROM HYDROCELE. 321 or oblique inguinal rupture, but is distinguished by the following cir- cumstances,,/^, the common external inguinal rupture does not descend over the place where the general vaginal tunic is connected with the testicle ; in congenital rupture the intestines touch the testicle, and can thrust it upwards and backwards; second, congenital rupture develops itself more as the hernial sac is not formed by the early gradual elongation of the peritoneum. 1197. The coverings of congenital inguinal, are the same as those of external or oblique inguinal rupture, except that the hernial sac1 is formed by the tunica vaginalis propria. In rare cases a second lengthening of the peritoneum may descend into the still open canal ofthe vaginal tunic, by which the intestines descending into this sac are separated from the testicle (a). The congenital inguinal rupture is mostly intestinal, be- cause the omentum is very short; it may however contain a portion of omentum if it have been adherent to the testicle in the belly (1). Narrowing ofthe hernial sac occurs most frequently in congenital inguinal rup- tures, and consequently often several nearly perfectly closed hernial sacs are formed (b). [(1) This is Astley Cooper's Encysted Hernia of the Tunica Vaginalis, in which " on opening the tunica vaginalis, instead of the intestine being found lying in contact with the testicle, a second bag or sac is seen enclosed in the tunica vaginalis, and enveloping the intestine. This bag is attached to the orifice ofthe tunica vaginalis, and descends from thence into its cavity; it generally contracts a few adhesions to the tunica vaginalis, whilst its interior bears the character of a common hernial sac." Cooper considers that in this case "the tunica vaginalis, after the descent of the testicle, becomes closed opposite the abdominal ring, but remains open above and below it. The intestine descends into the upper part, and elongates both the ad- hesion and tunica vaginalis, so as to form it into a bag, which, descending into the tunica vaginalis below the adhesion, and becoming narrow at its neck, though wide ati its fundus, receives a portion of intestine. * * * The disease does not appear like hernia of the tunica vaginalis, as the testis is not involved in it, but can be dis- tinctly perceived below it. * * * The strangulation arises from the contracted state of the mouth of the hernial sac." (pp. 79-80.)] 1198. Various swellings which occur in the inguinal region must be distino-uished from ruptures ; such are hydrocele, varicocele, inflammatory sioelling ofthe spermatic cord, arrest of the testicle at the abdominal ring, collections of fat in the cellular tissue ofthe spermatic cord, collection of pus. 1199. It is hardly possible to mistake a collection of water in the tunica vaginalis propria for a rupture. If the hydrocele be large, it may extend up to the abdominal ring and seem to penetrate within it, but if the swelling be drawn a little down, it will be seen that it does not lie in it, and that the ring is in its natural condition. In hydrocele the swelling ascends gradually towards the abdominal ring. The functions of the intestinal canal are undisturbed ; lying on the back and coughing have no effect on the swelling. Congenital hydrocele, where indeed water is collected in the canal of the vaginal tunic, has greater resemblance to rupture; however, the consistence of the swelling, its transparency, its (a) Hey, Practical Observations in Sur- Brucbsackes bei angebornen Briichen; in gery. London, 1814, p. 226.—Cooper neuen Chiron, vol. i. pt. i.—Liman, Beobach- Astlev, above cited. Meckel, Handbuch tungen uber das normwidrige Verhalten des der Pathologischen Anatomie, vol. ii. pt. i. Brucbsackes; in Journal von Graefe und p. 379, von Walther, vol. v. pt. i. p. 97. (b) Chelius, Ueber Verengerung des Vol. ii.—28 322 INGUINAL RUPTURE FEIGNED BY more easy or more difficult reduction, its quicker or slower reprotrusion, give the explanation (1). The diffused collection of water in the cel- lular tissue of the spermatic cord (Hydrocele tunicae vaginalis communis) has the greatest resemblance to an omental rupture. The swelling which originates along the spermatic cord is broader below than above, seems to diminish on slight pressure, though it recurs immediately the pressure is withdrawn on lying down and standing up. If there be fluctuation, it is only at the bottom ; if the bottom of the swelling be pressed, the fluid gently rises towards the apex, and expands it. If the swelling be within the abdominal ring, it stretches it; the patient often feels a pain at some part, and a dragging in the loins. As a distinctive character from omental rupture, it must be remembered that hydrocele of the cord has less consistence and a less irregular surface than omental rupture; it is also usually somewhat broader at the base, whilst in omental rup- ture the contrary occurs (a). [(1) Although hydrocele ofthe common kind, namely, that in the vaginal cover- ing of the testicle itself, cannot, without great carelessness, be mistaken for scrotal rupture, as its slow formation, its commencement from below instead of above, and its transparency sufficiently characterize it; yet if the hydrocele be situated in the cord itself, it may, at first sight, be thought to be a hernial swelling, especially as it seems to begin at the top instead of the bottom of the scrotum, and the patierlt's account of its origin is often very confused. I have seen three or four cases of this kind, and the last which I had under my care presents a very good example ofthe usual occurrences in this complaint Case.—W. H., aged thirty-five, a healthy carpenter was admitted May 30, 1845, and says he had never any swelling in his groin till three weeks since, when, as he was lifting a heavy weight, he suddenly felt something snap in the left groin ; but he suffered neither pain nor uneasiness, and continued his work during the rest of the day without further noticing it. On rising next morning, how- ever, he observed a small tumour about the size of a filbert, in the left groin, which he says entirely disappeared when he was lying down on his back, and was capable of reduction when he stood upright. He was told the swelling was a rupture, and advised to wear a truss, for which he applied to a maker, who being unable to re- turn the swelling, applied the truss upon it five days ago ; from which to the present time he has continued to wear it, but the swelling increasing in size and becoming painful he applied to a practitioner, who considering the disease to be an irreducible rupture sent him to the hospital. The swelling was in the course ofthe left sper- matic cord, about the size of a hen's egg, and extended up to the external ring and down to the testicle; above it the cord could be grasped, the finger and thumb almost meeting; it was firm and elastic ; very tender to the touch (probably from the irritation ofthe truss) ; and a portion of it about the size of a walnut, was trans- parent. From these circumstances I was led to believe it a hydrocele of the sper- matic cord. Some, however, might suppose, as it arose so suddenly, that the swelling was caused by tearing of one or more lymphatic vessels whilst he was exerting himself. Nothing further was done than applying hot flannels to the swelling, keeping him in bed, and giving him a dose of opening medicine. In the course of six days it had diminished to the size of a nut, and at the end of a fort- night had entirely disappeared. A boy aged six years, was brought to the hospital May 5. 1838, considered to have strangulated rupture. He has worn a truss for several years. His bowels have not been moved for the last three days, and he has vomited several times, but not since yesterday morning; neither has medicine, which he then took, been rejected, although it has not operated. The right side of the scrotum, as far as the raphe, is distended with fluid, semi-transparent and cede- matous; its shape flat, and much the form ofthe testicle; it is firm, but indents on (a) Scarpa, Sull' Ernie Memoire Anato- Notes by Wishart Edinburgh, 1814. 8vo. mico-chirurgiche. Milan, 1809. fob—Ib., p. 97. A Treatise, on Hernia translated; with AND ACCOMPANIED WITH HYDROCELE. 323 pressure of the fingers, and reaches up to the abdominal ring, where it narrows. I could not satisfy myself as to the existence of any rupture, but thought it had the appearance resembling what I should suppose a burst hydrocele might assume. His mother took him away, promising to bring him back; but he never returned. Very recently a similar case to the first was received into the hospital, and as in it, the cord could be grasped between the swelling and the external ring; but some doubt of its nature being entertained, a cut was made into it, some straw coloured serum escaped, and the cyst found to be closed and quite free from the belly. Sometimes these hydroceles of the cord may result from the patient having worn a truss sufficiently long to produce adhesion of the mouth of the sac and shut off the lower part from the belly without its cavity being obliterated. Sometimes after the adhesion ofthe mouth ofthe sac, it may be again thrust down, either par- tially along the cord, in which case there may be a collection of water in the old sac, between the new one and the testicle; or the newly protruded sac may descend before the vaginal covering ofthe testicle, and carrying down with it the old sac, the latter may become situated between the new sac and the vaginal coat of the testicle. This appears to me to be the case in two preparations in the rich collection of rup- tures at St. Bartholomew's Museum; and these cases are further interesting, as both also have hydrocele of the vaginal coat of the testicle itself. Sometimes a rupture is accompanied with a common hydrocele below it; but in more rare cases the hydrocele is in front of the rupture, and generally is not dis- covered till the operation is performed, when it is Hable to produce confusion, and make the operator suppose he has mistaken the case. Thomas Blizard appears to have been the first person who observed hydrocele in front of an inguinal rupture. His patient had been subject to bubonocele on the right side upwards of six years, and he had almost constantly worn a truss. During the last two years of this period, a swelling of the testicle on the same side, which seems to have been hydrocele, occurred, but after a few months disappeared, and left the testicle wasted and drawn up to the groin. " When first called to him," says Blizard (a), "I found a small bubonocele on the right side, and could dis- tinctly feel the testis of the same side, but very small, lying at the bottom of the hernia, having an inclination forwards, * * * Twenty hours after the descent I performed the operation. Having dissected down to a membrane, which I considered to be the hernial sac, I punctured it at the upper part, and then laid it open its whole length. It extended within the ring, which to obtain room for examination, I dilated. Upon further inquiry, I found the hernia was situated more deeply, and that the membrane which I had laid open was the tunica vaginalis testis, extended by the hydrocele, which had entirely disappeared. I then of course dissected through this tunica vaginalis at the posterior part, and laid open the hernial sac, which contained a portion of intestine nearly black from strangulation." The stricture was at the mouth of the sac. " In this case the hernia must have been behind the cord." (p. 66). Another example of this kind occurred to the younger Cline shortly after, and is mentioned by Astley Cooper (b). I witnessed this operation. " On making an incision, into that which was supposed to be the hernial sac, a fluid similar to that of hydrocele escaped, which it afterwards proved to be, for it was the tunica vaginalis which had been opened; on dilating this opening a little, a tumour presented itself, which was afterwards found to be from'J-th to ^th of an inch thick, which being dis- sected through, a fluid resembling the first in colour, but of a fetid smell, came out. This tumour was found to be the tunica vaginalis of the cord, but much altered from the natural appearance by a quantity of lymph that had been effused, which gave it the appearance of India rubber; the intestine had adhered firmly to the adjacent parts, and the stricture was divided with (on) the finger. Mr. Cline thought it not ad- visable to attempt to break through the adhesions, so as to return the intestine, lest it might bring on a dangerous degree of inflammation." (p. 17). He did well. These cases are not so uncommon as formerly supposed, and many of our Museums in London possess two or more examples.—j. f. s.] 1200. Varicocele, when it has attained considerable size, has indeed some resemblance to omental rupture, the abdominal ring is not, how* *■ (a) Astley Cooper, above cited. (b) Above cited, 324 FAT-RUPTURES. ever, stretched ; the several strings of the swollen vessels are felt; if the swelling be compressed for a few moments between the fingers, without thrusting it back towards the belly, it almost entirely disappears; the whole mass of the testicle seems expanded into varicose vessels. In doubtful cases, let the patient be laid on his back, return the swelling, and press with the finger on the abdominal ring; this pressure will, when he rises, be sufficient to prevent the protrusion of the intestine, but not to suppress the flow of blood into the spermatic vessels. 1201. If an inflammatory swelling ofthe spermatic cord be developed spontaneously, the diagnosis is doubtful, so much the more, if injuries, as violent strains, blows, and the like, which equally cause ruptures, produce this inflammation. Such inflammatory swelling passes through the abdominal ring, descends to the testicle, which seems as it were confused with the swelling ; it is elastic, painful, and manifestly enclosed by the inguinal canal. Fever comes on, the bowels may be drawn in to participate, suppression of their relief, disposition to vomiting and the like are produced. In such cases the diagnosis is more difficult, if pre- viously there were a rupture which has become strangulated by the injury which has excited the inflammation ofthe cord. 1202. When the testicle only, at a late period, descends through the inguinal canal, or when, on account of the shortness of the spermatic cord, it remains in the canal, it may by the opposition which the walls of the canal offer it, become inflamed. If in examining the scrotum, only one testicle be found, the diagnosis is thereby determined. An imperfectly developed external inguinal rupture may exist at the same time with one testicle lying in the groin, the protrusion of which may cause the severest pain, by its pressure on the testicle, as I myself have noticed in one instance. [(Key (a) mentions a case of strangulated inguinal rupture, in which the testicle had never descended lowrer than the external ring, in consequence of which "the shape of the swelling was peculiar; the hernia, instead of passing downward into the scrotum, turned, after emerging from the inguinal canal, over the tendon of the external oblique muscle, and appeared somewhat like a femoral hernia." (p. 25). There is also an example of this kind in the Museum of the Royal College of surgeons; and at St. Bartholomew's there is an instance of a congenital rupture in the inguinal canal, in which the testicle also is still remaining.—j. f, s.] 1203, Fat may be collected in the cellular tissue of the spermatic cord, project from the abdominal ring, or may exist along the cord in the scrotum, and form a swelling, which otherwise is accompanied with scarcely any inconvenience. But a collection of fat may arise upon the front or hind surface of the peritoneum; in this enlargement the fat de- scends through the abdominal ring into the scrotum, and drags the peri- toneum with it. These so-called Fat-Ruptures, which may be formed on different parts of the belly, have the greatest resemblance to omental ruptures, especially if they, as is frequently the case, can be reduced. Collections of fat upon the surface of the peritoneum may protrude through the white line, through the interspaces of the muscles, or through the natural apertures of the belly. If these swellings be situated at or upon the white line, they rarely attain any considerable size; usually their size is from that of a nut to that of an egg. Some fatty granules, deposited on the outer surface of the peritoneum, are gradually received into one of the little openings or clefts formed by the fibres of the (a) Memoir. DIVISION OF STRICTURE. 325 tendinous aponeurosis, where they by degrees grow and enlarge, become converted into a swelling with a neck, the root of which is attached to the peritoneum, the neck surrounded by the fibres of the aponeurosis, and the bottom spread beneath the skin. They are usually firmer when small, and penetrating through a small opening; on the contrary, of looser texture when large, and increasing without restraint. Often they seem to be reduced and got rid of, but often they are immoveable. The con- tinual dragging to which they are subject not unfrequently produces a funnel-shaped projection of the peritoneum at that part where they arise, and trTus they present a sac-like extension, surrounded by a fatty swelling, which, according to Velpeau, may cause a real rupture ; this danger, however, Pelletan states, does not happen when a considerable quantity of fat is found around the soft swelling, for the purpose of preventing the entrance of intestine or omentum into this elevation of the peri- toneum. These swellings are frequently surrounded with membranes which present perfect coats, and sometimes also contain cysts. The fatty ruptures usually produce neither pain nor other inconvenience, and often remain unobserved throughout the whole life; but if they lengthen deeply into the duplicature of the sickle-shaped ligament ofthe liver, they may produce great inconvenience, by actually tearing the liver and the peritoneum in the movements ofthe abdominal muscles. Fat-ruptures cannot with certainty be distinguished from omental ruptures, for if, as Scarpa affirms, they be usually tougher and less compressible, this character, however, loses all value in old and adherent omental rupture. Pelletan first pointed out the mechanism of the fat-rupture, when it descends through the inguinal canal. In three cases he found the fatty mass doubly enveloped in peritoneum, when the fatty swell- ing was attached entirely to the peritoneum, like the testicle in its descent; and in the protrusion of the fatty swelling into the scrotum, the peritoneum was drawn over it like'a sheath. The fatty swelling in the scrotum has the same relations as the testicle in its vaginal tunic, being doubly covered by the peritoneum, to the one part of which it is firmly and to the other loosely attached. This some- times also occurs when the fat-rupture passes out by any other of the natural open- ings in the belly. Although, however, fat ruptures be found in the scrotum without any peritoneal covering, the peritoneum is more or less withdrawn or not at all connected with them, if they be merely collections of fat in the cellular tissue of the spermatic cord. Although the cavities formed by the double lengthening ofthe peritoneum do not close, but communicate with the cavity of the belly, as does the cavity of the vaginal tunic in congenital rupture, yet the fatty mass usually fills the sac so completely, that very rarely does intestine of omentum descend with it and complicate the case. The distinction of this fat-rupture from true rupture is often very difficult. Its gradual growth, and its freedom from pain on pressure, even when very considerable, are characteristic symptoms; but their resemblance to omental ruptures has even deceived the most experienced practitioners. If severe oolic or the like accompany such swelling, a mistake is the more easy, and is only first dis-i covered in the operation (Scarpa, Cruvelhier, Ollivier). Compare also on this subject Morgagni, De sedibus et causis Morborum, Epist. xiv. art. 10. Epist. 1. art. 34. Pelletan, Clinique chirurgicale, vol. iii. p. 33. Bigot, Dissert, sur les tumeurs graisseuses exterieuses au peritoine, qui peuvent simuler des Hernies. Paris, 1821. Coates, R.; in Cyclopaedia of Pract. Medicine and Surgery, edited by Isaac Hays. Philadelphia, 1834. vol. i. 1204. Collections of pus which pass along the spermatic cord, out at the abdominal ring, may diminish or disappear in the supine posture, and increase on coughing and any other exertion ; the fluctuation, the presence of symptoms of psoas abscess or of caries ofthe vertebral column may, however, guide the practitioner. 1205. Inguinal ruptures must be returned in the same direction by which they have protruded, that is, the external or oblique from below upwards, and from within outwards; and the internal or direct, from below upwards and directly from before backwards. 1206. For the purpose of keeping the rupture up, a truss with a semi- . 28* 326 DIVISION OF STRICTURE IN INGUINAL RUPTURE. circular spring which closely surrounds one half of the pelvis is best. In the external or oblique inguinal rupture with a long neck, the pad must press upon the whole length of the inguinal canal; but in internal or direct rupture it must merely press on the external inguinal ring in the direction from before backwards. For the external inguinal rupture with a short neck the truss should be the same. 1207. The strangulation of inguinal rupture maybe situated at the external or internal inguinal ring, in the neck ofthe sac, or in strictures of the body of the sac. If it cannot be removed by the general treatment above-mentioned, the operation must be performed with the following special objects : — 1208. The cut through the integuments should always be made, espe- cially in large ruptures, in the mesial line ofthe swelling, on account of the possible displacement of the spermatic cord, and carefully, because there may be a rupture without a sac (1). In every very large external or oblique rupture the cut should be commenced above the abdominal ring, where the swelling is narrowest, and not further continued till it has been ascertained, by feeling with the finger, whether the spermatic cord do or do not lie upon the hernial sac. When there is much water in the sac, the opening may be made boldly. In addition to the signs already mentioned, {par. 1170,) of having laid bare the hernial sac, this circumstance still serves, that as the hernial sac is always connected with the pillars of the abdominal ring, the ring cannot be penetrated before the opening of the sac with the point of the forefinger. If the hernial sac be thin, it can be torn, by seizing it with the forceps ; but if it be very thick, frequently a superficial layer only must be divided, by which it is rendered more transparent and rather bluish. In dividing the stric- turing part, in well determined external or oblique inguinal rupture, the cut must be made outwards, towards the iliac spine, but in the internal or direct inguinal rupture, upwards and inwards; in those cases where it is doubtful of which kind the rupture is, directly upwards, parallel with the white line, so that the cut may form a right angle with the body of the share-bone. After the complete return of the intestine, the forefinger should be carried through the inguinal canal, into the belly, to ascertain that it is clear and that no portion of intestine remain in it. In imper- fectly developed external inguinal rupture, if the strangulation be at the internal ring, the skin, the superficial fascia and the tendon of the ex- ternal oblique muscle must be divided in the direction of the inguinal canal, outwards and upwards, and the seat of stricture cut into outwards and upwards. (1) On account ofthe circumstances already mentioned, (par. 1192,) it is always cf importance before operating on an old scrotal rupture on the right side, to consider whether the rupture be formed by the caecum or the beginning ofthe colon. Besides the size and long continuance of the swelling, its knotty condition excites suspicion, which is probable, if the rupture have been slowly produced. So long as it was in the groin it was returnable, but no longer; at least it cannot be perfectly returned so soon as it has descended into the scrotum, when the patient, after digestion is ended, and a short time before the bowels are relieved, feels dragging and pressure in the rupture, as well as frequently colicky pains, which subside after going to stool, and if there be in the right iliac region a hollow corresponding to the size of the rupture. In this rupture the stricture only is to be divided, and the adherent intestine covered with compresses, dipped in a mucilaginous fluid, by which in general it gradually returns into the belly. CONGENITAL RUPTURE IN THE FEMALE. 327 The various opinions upon the most proper direction for the cut into the stricture, in inguinal rupture, in order to avoid injuring the epigastric artery, have only by the correct anatomical knowledge of its different origin, attained the proper explanation. The direction of the cut obliquely upwards and outwards, as proposed by Louis, Morand, Sharp, Gunz, Pott, Bell, Sabatier, and others, is so far the most proper, as in external or oblique inguinal rupture the artery cannot be injured, and it is by far the most common, (par. 1194). As in the direction of the cut obliquely upwards and inwards towards the navel, according to Heister, Garengeot, Le Dran, Richter, Mohrenheim, Mursinna, and others; or inwards towards the symphysis, after Ludwig and Seiler, only in internal or direct inguinal rupture can the artery be avoided, but in external rupture it can and must be wounded, if it be not granted that thereby really only the internal pillar of the external inguinal ring shall be cut into. The direction of the incision directly upwards, proposed by Franco, Dionis, Petit, Camper, Rougemont, and others, was for that occasion the safest, and Astley Cooper (above cited,) still considers it the most proper and safe in all cases. Chopart and Desault gave the most important advice, always to make the cut towards the side opposite the position of the spermatic cord, advice, which the know- ledge of the corresponding relative position of the spermatic cord and spermatic artery, and a presumption of the various kinds of inguinal ruptures, renders clear (2). [(2) I do not think Chopart and Desault's counsel is the best that can be taken, if it mean any thing more than a caution not to divide the spermatic vessels, which no one would do but by the most gross carlessness. Practically speaking, however, I can say that I do not recollect having had or seen a single instance of operation interfered with by the position of the spermatic vessels, presuming that no pupil of Cline or Cooper would think of dividing the stricture in strangulated inguinal rup- ture in any other direction than directly upwards, and neither to the right hand nor to the left. For whatever may be said, it is impossible, I believe, to distinguish, without actual dissection, whether an inguinal rupture be oblique or direct, and therefore any deviation from the directly upward division is hazardous.—j. f. s.] 1209. Congenital inguinal rupture, in regard to its treatment, agrees entirely with that of external or oblique rupture. The radical cure here takes place earlier, by the constant use of a truss, as the canal of the vaginal tunic has a natural disposition to close ; on which account stran- gulation mostly occurs from a stricture of this canal. The sac is often so contracted, even at its lower end, that the cavity ofthe vaginal tunic is entirely closed from the rest ofthe hernial sac. If a portion of intes- tine protrude with the testicle, it must be attempted carefully to draw down the testicle into the purse, and to keep up the rupture by the truss ; if the testicle remain at or in the external or inguinal ring and will not descend, a truss, with a concave pad, must be carefully applied. Pressing back the testicle, recommended by many persons, is very painful and dangerous, as degeneration of the testicle may be caused by the pressure ofthe truss. If the rupture adhere to the testicle, and keeping up the former be very painful, an operation and division of the adhesion is in- dicated. If strangulation be present and the operation necessary, (which even in the first days after birth may happen,) it must be performed with particular caution, that the testicle be taken care of. Any adhesion be- tween the testicle and the protruded parts must be divided. If water as well as intestine be contained in the congenital rupture, it can be determined, after having returned it with the intestine, and putting the finger on the ring by raising the patient, when the water first, and then by coughing or the like, the intestine protrudes. If in these cases a truss be applied, in most, the water is gradually absorbed. 1210. After completing the operation for inguinal rupture, and cleans- ing the wound, the edges of the skin should be brought together, with 32S FEMORAL RUPTURE. some interrupted stitches, and between them strips of plaster applied, and covered with wadding; to the region of the inguinal canal a many- folded triangular compress is to be applied and kept in place with a T bandage. The patient should lie in bed on his back, with his thighs drawn up towards the belly, and supported by a bolster beneath the knees. The after-treatment is to be conducted by the rules already laid down. 1211. In the operation for inguinal rupture, without opening the her- nial sac, after making the proper cut ofthe skin a small aperture is to be made in the tendon of the external oblique muscle, a little above the external inguinal ring, and a director introduced, with which it is sought to find the seat of stricture, and then it should be directed towards the outer or inner inguinal ring and the stricture divided with a knife intro- duced upon the director (Key); or the hernial sac is to be drawn a little down, whilst the muscles are raised by an assistant, and then the stric- ture being rendered visible in the opening of the tendon, should be divided (A. Cooper). 1212. External inguinal rupture may originate, in women, in the lengthening of the peritoneum, which sometimes accompanies the round ligament of the womb, and is comparable to congenital rupture in the male sex. [This lengthening of the peritoneum was first described by Nick (a) who called it a diverticulum, and said it was about half an inch long and not constant. Clo- quet (b) speaks of it by the name of Nuck's canal, as "a cylindrical tube termi- nating in a point or in a rounded cul-de-sac, of which the length and size varies; sometimes, on the contrary, it is a little flask with a narrow neck which communi- cates with the belly," and that he has "found them not only in female foetus, but also in young girls and women of all ages." (p. 41). As to the frequency of congenital rupture in the female, Allan Burns says (c) that he has seen seven cases, in six of which he "found the anterior side of the inguinal canal deficient. * * * In one of the subjects with congenital hernia the sac did not escape from the canal; in five it had, from the peculiar state of the canal, descended along the thigh, assuming to a great degree the resemblance to crural hernia. * * * In congenital inguinal hernia the risk is that we must take the disease for crural hernia." (pp. 514, 15.)] II.—OF FEMORAL RUPTURE. (Hernia cruralis, femoralis, Lat.; Schenkelbruch, Germ.; Merocele, Hernie crurale, Fr.) Vrolyk. G., Arbeelding der vatern, welke in de operatie der dye-breuk by man- nen behoven vermyd te worden. Amsterdam, 1800. 8vo. Translated into Ger- man as Abbildungen, welche man in der Operation eines mannlichen Schenkel- bruches zu schonen hat. Amsterdam, 1801. 4to. Monro, A., Observations on Crural Hernia. Edinburgh, 1803. Hey, W., Practical Observations in Surgery. London, 1803. Chapter III. Cooper, A., Anatomy and Surgical Treatment of Crural and Umbilical Hernia, Burns, A., Observations on the structure of the parts concerned in Crural Hernia; in Edinburgh Medical and Surgieal Journal, vol. ii. p. 265. de Gimbernat, A.. Nuevo Metodo de Opera en la Hernia Crural. Madrid, 1793. 4to. Also translated as A new Method of Operating for the Femoral Hernia, by Dr. Beddoes. London, 1795. . 8vo. (a) Adenographia curiosa, cap. x. de pe- (c) Monro, A., Jun., M.D., Morbid Ana- nton»i diverticulis novis. tomy of the Human Gullet, Stomach, and Co) Recherches Anatomiques. Intestines. Edinburgh, 1811. 8vo. ANATOMY OF FEMORAL RUPTURE. 329 Hull, Ueber den Schenkelbruch in von Siebold's Chiron., vol. ii. pt. i. Breschet, Considerations anatomiques et pathologiques sur la Hernie femorale, ou Merocele. Paris, 1819. Liston, Robert, Memoir on the formation and connections ofthe crural arch, and other parts concerned in Inguinal and Crural Hernia. Edinburgh, 1819. 4to. Langenbeck, Anatomische Untersuchung der Gegend, wo die Schenkelbriiche enstehen ; in his Neue Bibliothek, vol. ii. pt. i. Schreger, Chirurgische Versuche, vol. i. p. 171. Scarpa, Antonio, Sull' Ernie, Mem. Anatomico-chirurgiche. Ediz. nuova, 1819. The new articles translated into French by Ollivier under the title Supplement au Traite pratique des Hernies, &c. Paris, 1823. 8vo. Walther, W., Commentatio anatomico-chirurgica de hernia crurali. Lipsiae, 1820. Manec, Recherches sur la Hernie crurale. Paris, 1826. The writings of Scarpa, Hesselbach, Cloquet, and Langenbeck, already quoted. 1213. Femoral Rupture passes through the femoral ring, {annulus cruralis), usually on the inner side of the femoral vessels, (internal Fe- moral Rupture); in rare cases on the outer side {external Femoral Rup- ture. The division of femoral rupture, into external and ^internal, is grounded on the ob- servations of Cloquet (a), and Hesselbach (b), and is proved in opposition to the doubts of Boyer, Lawrence, Langenbeck, and others. Logier (c) describes a new kind of rupture, which passes obliquely through Gimbernat's ligament, and the mouth of which is separated by a portion of that ligament, and by the umbilical artery from the femoral ring. The epigastric and obturator arteries originate from a common trunk. 121,4. Poupart's ligament stretches like a cord from the upper front iliac spine, to the pubic symphysis, where it is fixed, as already de- scribed {par. 1186). Just as this ligament approaches the share-bone, it increases in breadth, so that by this broader portion, it is attached along the spine of that bone. This insertion runs inwards to a point; outwardly it is broader, and bounded by an edge, concave towards the femoral vessels, (Gimbernat's ligament). The space beneath Pou- part's ligament outwardly, namely, the hollow between the upper and lower front iliac spines, and the ilio-pectinean eminence is filled up by the m. iliucus internus, and m. psoas magnus, so that only in the middle of Poupart's ligament, between the ileo-pectinean eminence, and the sharp edge of Gimbernat's ligament, there remains an oblong opening, the femoral ring, {annulus cruralis, Lat.; Schenkelring, Germ.; anneau crurale, Fr., the inner aperture for the femoral vessels of Hesselbach), which contains the femoral vessels, nerves, and lymphatic ganglions. The m. iliacus internus, and psoas magnus, are covered with a thin apo- neurosis, (fascia iliaca), which arises imperceptibly from the surface of the former, and lies immediately upon those muscles ; the iliac vessels, and peritoneum, lie upon and are connected with it by loose cellular tissue. This aponeurosis is attached to the linea innominata, to the inner edge of the iliac pit, and to the hind edge of Poupart's ligament. Opposite the latter insertion, it terminates running into a point near the passage for the femoral vein. Another portion of this aponeurosis passes over the share-bone, behind the femoral artery and vein, towards the thigh, where it forms the hind part of the sheath in which the (a) Above cited, p. 85. (b) Der aussere Schenkelbruch; in Neue (c) Archives Generales de Medecine, May, chiron., vol. i. p. 91. 1833. 330 ANATOMY OF femoral vessels are enclosed, and is fixed to the fascia lata. From this slate of parts, the protrusion ofthe intestines is very difficult; however, the part between the inner concave edge of Poupart's ligament, and the femoral vein, is not entirely closed, but only filled up by a lymphatic ganglion, or by thick cellular tissue. This space is bounded above and before by Poupart's ligament; below and behind by the share- bone; inwardly by the concave edge of Poupart's ligament; and out- wardly by the femoral vein. The thigh-sheath (fascia lata) has two distinct insertions at the front upper part of the thigh ; it is firmly at- tached to the upper part of the share-bone, above the origin of the m. pectineus, which it overspreads, and further to the front part of the fe- moral ring. The former portion proceeds with the iliac fascia behind the femoral vessels; the second attaches itself to Poupart's ligament, though not throughout its whole length, for its insertion terminates at the inside of the femoral vessels, which it covers externally. In this region then the femoral vessels lie between the two layers of the fascia lata; the upper layer is connected below with the under, by which one opening is formed the external opening for the femoral vessels of Hessel- bach ; the oval cavity of Lawrence, which, at the outer edge, presents a semilunar edge; the femoral ligament of Hey; the falciform process of Burns.) In this outer hole the vena saphena passes. This aperture is larger in women than in men where it is entirely closed by a tendinous bundle of net-like tissue. Besides this aperture, there are still several little openings in the upper layer for the passage of vessels. A thick cellular tissue, or a thin aponeurosis, spreads over the fascia, and covers the vena saphena. [This description ofthe parts concerned in femoral rupture does not accord with that usually received in England, nor is it correct according to our dissection. It is a curious circumstance that the tendinous and cellular parts connected with femoral rupture seem to be a general repetition of. those of inguinal; in both an aperture exists in the tendinous expansion over the parts, and in both a cellular funnel, less or more perfectly shut up and guarded by peritoneum exists. Poupart's ligament, or the lower margin of the tendon of the external oblique abdominal muscle, has been already mentioned as stretching from the upper front spine of the hip-bone to the spine and symphysis of the share-bone, its two latter attachments or pillars being separated by the external abdominal ring. But on further examination, it is found that the attachment of this tendon is still more ex- tensive, its connexion with the pelvis being continued outwards from the pubic spine about half an inch, and finishing by a half oval concave edge facing outwards, thus forming a triangular tendinous space, known as Gimbernat's liga- ment, which diminishesi by its own breadth the opening from the belly to the thigh between Poupart's ligament in front and the pelvis from the pubic spine to the lower front iliac spine, which is also still further lessened upon the outer side by the conjoined mass of the m. iliacus internus and psoas magnus, as they pass from the pelvis into the thigh, to their insertion in the little trochanter. The space then actually left is scarcely more than an inch wide to the inner side of the junction of the hip and share bones, and consequently before and above the inner half of the acetabulum or hip-socket and a little to its inner side, and through it the femoral vessels pass. But this aperture, the crural ring, has further boundaries. As from Poupart's ligament, or the crural arch, as it is often called, is expanded above, the tendinous covering of the belly, below the upper front iliac spines, and of the m. recti upwards to the pit of the stomach having in it the external abdominal ring, so from the lower edge ofthe ligament descends an extensive tendinous expansion which encloses all the muscles of the thigh and is lost about the knee-joint, and commonly called the fascia lata. This sheath seems to begin by a sharp angle from the lower edge of Poupart's ligament, where Gimbernat's ligament ends above; FEMORAL RUPTURE. 331 as it continues outwards it deepens, assuming a crescent or sickle-like shape, form- ing the falciform process, till it stretches down the whole length ofthe thigh. But before doing this, and at the distance of about an inch and a half from Poupart's liga- ment, corresponding also to the same distance from the oblique crease in the skin, which separates the belly from the thigh, it curves suddenly inwards and upwards, spreading as it rises in front of the m. peclineus, above the origin of which it is fixed » into the pelvis as far as the pubic spine. A large opening of an irregular oval form is thus left in the otherwise complete tendinous sheath of the muscles of the thigh, and to it is given by Lawrence the name of lower or anterior opening of the crural canal; over the inner lower edge of which the great saphenous vein is seen mount- ing to enter the inside of the femoral vein, which with the great artery it accom- panies, are here uncovered by tendinous sheath, but still covered in a peculiar manner. It will be recollected that when speaking of the transversal fascia in the desciption of the parts of inguinal rupture, that its lower part at the bottom of the belly was mentioned as consisting of two portions, the front and outer or iliac portion con- tinued along the margin of Poupart's ligament to the upper iliac spine, forming the outer half of the internal abdominal ring, then bending round behind the peritoneum and spreading over the front of the m. iliacus internus and psoas magnus, as they fill the ventral cavity of the hip-bone, and there assuming specially the name fascia iliaca. The hinder inner, or pubic portion of the transversal fascia was also men- tioned as forming the back of the inguinal canal, and the inner half of the internal abdominal ring and then stretching away outwards in a sharp edge up to the spine of the hip-hone, behind the front portion, there terminated, and might with equal propriety be called fascia pudica, it being remembered, however, that neither it nor the so-called fascia iliaca are other than continuations or processes of the trans- versal fascia. In the angular track between Poupart's ligament in front, and the m. iliacus and psoas magnus behind and on the outer side, and the edge of Gimber- nat's ligament and the angle of the share-bone, behind, and on the inner side, these the iliac and pudic portions of the transversal fascia unite in a kind of seam on each side, but separated in the middle at the gap formed by the crural arch for the passage of the femoral vessels. Thus far completes the description of the trans- versal fascia in the belly; part of which only, namely, that immediately connected with inguinal ruptures, had been described. It remains now to speak of this fascia as connected with femoral rupture. The aperture behind Poupart's ligament or the crural arch, and called by Hey the femoral ring, gives passage to the femoral vessels, which, whilst in the pelvis, lie upon the iliac portion of the transversal fascia, between it and the peritoneum, but reaching the crural ring, escape from behind the peritoneum, and then are placed between the just mentioned iliac portion of the transversal fascia behind, and its pudic portion in front. Here the iliac and pudic fasciae, having joined so as to form a corresponding opening to the femoral ring, are continued down into the thigh, in the shape of a wide, but much flattened funnel, behind the fascia lata, but uncovered by it, as the funnel descends behind its oval opening, and containing within it the femoral vessels, is called the femoral sheath, the hinder or iliac portion of which descends only to the origin ofthe deep branch ofthe femoral artery; whilstits front or pubic portion, extends along the trunks of the femoral vessels till they penetrate the tendon of the m. triceps adductor femoris. A process passes from the front to the back ofthe sheath, along its whole length, dividing it into two distinct canals, in the outer of which is contained the femoral artery, and in the inner the femoral vein. Immediately above the lower edge of the oval opening of the fascia lata is an open- ing on the inside of the femoral sheath, through which the great saphenous vein penetrates to empty itself into the femoral vein. Above the former, the absorbent vessels penetrate, as Astley Cooper (a) describes, " through the inner side of the sheath, near the pubes. In the male subj-ect 1 have seen them enter the sheath in a cluster, through a single hole in this fascia,- but in both sexes the fascia is generally rendered cribriform, by these vessels passing through a variety of small openings." (p. 9). He also further states, what I must confess I bave never observed, that "if the sheath be opened, the contents will be found separated by two membranous septa, one passing between the artery and vein, and the second equally distinct be- ta) Hernia, part i. 332 COVERING OF FEMORAL RUPTURE. tween the vein and the absorbents. * * * The contents of the sheath differ in their attachments to the bag ; the artery and vein are seen completely filling up the space in the sheath which is allotted* to them ; while the absorbents are loosely connected by means of cellular membrane and fat, which, not affording sufficient resistance to the pressure of the abdominal viscera occasionally allows the descent of a hernia." (p. 10). This portion of the sheath is commonly in health, called the cribriform fascia, and it is between it and the femoral vein that femoral rupture first enters the sheath, and then, protruding its inner side, has been called by Astley Cooper the fascia propria ofthe rupture, a most inappropriate name, as it might lead to the sup- position of a new formation instead of the simple protrusion of an old structure in these cases. In regard to this covering of the femoral sac, Cooper says :—" A thinfascia naturally covers the opening through which the hernia passes and descends on the posterior part of the pubes. When the hernia, therefore, enters the sheath, it pushes this fascia before it, so that the sac may be perfectly drawn from its inner side, and the fascia which covers it left distinct. The fascia which forms the crural sheath, and in which are placed the hole or holes for the absorbent vessels, is also protruded forwards, and is united with the other, so that the two become thus consolidated into one." (part ii. p. 2). Cloquet alsodescribes the closure ofthe top crural sheath in a very similar manner. "The upper orifice of the crural canal (sheath) is closed," says he, "by a membranous partition, which opposes the formation of crural rupture, as well as the entrance of the finger when pushed from above down- wards, above the crural arch. This partition forms above the arch a sort of dia- phragm-cellulo-fibrous. whitish, thick, and very resistarjt in some subjects; simply cellular, weak, and readily yielding in others. I propose giving it the name crural septum. It arises completely around the upper opening of the crural canal, is thick- ish, and its fibres are most commonly transverse in front, towards the crural arch. Within it proceeds from the cellular tissue behind Gimbernat's ligament; or, rather, from the concave edge of that ligament itself, conjointly with the inner wall ofthe crural canal (sheath) itself. Externally it is blended with the femoral sheath, and the laminar tissue encircling the epigastric artery, on the outside of which cellular tissue fills the space between the crural arch and vessels. Its upper abdo- minal surface is concave; its lower, towards the crural canal convave; but some- times both surfaces are flat. It always presents one or more apertures for the passage ofthe lymphatic vessels, and sometimes the upper part of the crural canal seems merely closed by a fibro-cellular net-work. One of these openings larger than theiothers, is central, and penetrate^d by an oblong lymphatic gland, and will admit the finger." (pp. 73, 4.) Lawrence says that he has not found, on dissec- tion, either Cooper's "thinfascia," or Cloquet's » membranous partition," and is " disposed to refer the origin of this fascia propria to the condensed fibrous sub- stance, which completes the crural sheath on its inner or mesial side." (p. 478.) And with his views in this respect I fully concur.—j. f. s.] 1215. Although the femoral ring is a larger opening than the abdo- minal, yet femoral is more rare than inguinal rupture, because the intes- tines do not press so directly upon this part; it is not originally open, nor does any organ descend through it. Femoral rupture is more fre- quent in women than in men. 1216. Femoral rupture commences with a little roundisii deep-seated swelling beneath Poupart's ligament, which as it enlarges spreads aside, so that its base increases in breadth, and its greatest diameter corre- sponds to the oblique direction ofthe groin (1). The swelling never attains the size of inguinal rupture; it may, however, spread over the femoral vessels and nerves, and produce a sensation of numbness, or cedematous swelling of the foot of the affected side. In men, the dis- tinction between femoral and inguinal rupture is easy, because the latter closely follows the direction of the spermatic cord ; but in women it is more difficult, because the cord does not exist, and the abdominal is nearer the femoral ring (2). Femoral rupture is easily distinguished from a bubo, and from a collection of pus; the diagnosis is, however, MODE OF REDUCTION. 333 more difficult when the rupture is accompanied with a swelling of the glands (3). [(1) Femoral rupture commonly after descending a little down and protruding the sheath inwards, turns upwards upon Poupart's ligament, so that the bottom of the sac is above the mouth. Astley Cooper, however, states that " it sometimes happens that instead of crossing the thigh in the direction of the crural arch, it ex- tends downwards along the edge of the crural vein and the vena sapheena major. (p. 1). The tumour does not quit the sheath for the crural vessels. The appearance of this disease is that of a general swelling of the fascia on the inner side of the femoral vein, but without its producing any circumscribed tumour. The part swells whenever the patient coughs or uses any considerable exertion, but the swell- ing diminishes though it does not entirely subside, when he stands at rest. * * * I believe it to be not an unfrequent variety, as I have met with it three times in the dead body, and it existed on both sides in each. * * * It is continued downwards within the sheath, passing anteriorly to the femoral vein, and descends as far below the crural arch as the sheath will allow, the distance being in general from two to three inches." (p. 25). Callaway tells me one such case occurred under his care, and was at first supposed to be varix of the femoral vein, its true nature was, how- ever, discovered, and a truss was applied with advantage. (2) In ordinary cases I have never seen any difficulty of distinguishing femoral from inguinal Tupture in women; and cannot conceive it possible, except whilst the latter is in the inguinal canal, or on the point of passing through the external abdo- minal ring, but even then it is not difficult to determine, as the swelling of femoral rupture can be pushed down into the thigh, and Poupart's ligament either thereby exposed or the fingers passed between the rupture and it, which cannot be done by pressing down inguinal rupture, as thereby Poupart's ligament is more hidden. (3) Besides thdse here mentioned, there are other swellings in the upper part of the thigh or groin liable to be mistaken for femoral rupture. Astley Cooper men- tions an enlargement of the crural vein, which dilated when the patient coughed, (in consequence of the return of blood into the belly, made by the pressure of the bowels upon the iliac veins,) disappeared in the recumbent, and reappeared in the erect posture. * * * It was easy to detect the nature of the case, for although it disappeared in the recumbent posture, it was immediately reproduced, although he continued in that posture, by pressing on the vein above the crural arch, and retard- ing the return of blood." (p. 4). Tumours also, either fatty or encysted, may occupy the seat of the rupture, and be mistaken for it. Of the latter there is an example in St. Thomas's Museum.—j. p. s.] 1217. The coverings of femoral rupture are,first the external skin; second, cellular tissue and glands; the layer of the former is often very thick and loaded with fat; third^ the superficial layer of the fascia lata (1); and fourth, the hernial sac, the protruded part of the peritoneum, which is covered on its surface with a layer of loose cellular tissue. These coverings are not the same in all cases; a rupture of increasing size may protrude through the aperture by which the vena saphena has entered, so that it is then for the most part covered only with skin and subjacent cellular tissue. Most commonly a portion of the ileum is in- cluded in femoral rupture, more rarely the omentum, and extremely seldom a portion of the bladder. [(1) This is erroneous; the fascia lata never covers femoral rupture, which passes, as already mentioned, through the oval opening, and the third covering is the pro- truded sheath of the femoral vessels, as I have already described. I recollect seeing Green operate on a case in which, when the so-called fascia propria was exposed, it had a nodulated form, and gave some idea of intestine covered only with its peritoneal sac; but on carefully cutting through, a mass of soft fat was found beneath it, under which was the sac. In another case under my own care, having cut through the fascia propria, as seemed, I thought I had reached the peritoneal sac, and dividing it, a small quantity of fluid was discharged, which led me to suppose I had opened the sac, but what I Vol. ii.—29 334 OPERATION FOR supposed to be intestine remained very immoveable, and led me to doubt. Upon examining what was thought to be mesentery I found the vessels running in all directions, and the part itself semi-transparent; I therefore carefully cut through it, and immediately about a table-spoonful of fluid escaped, and a knuckle of intestine was exposed.—j. f. s. A very remarkable case of femoral rupture is mentioned by Berard (a), which contained the Fallopian tube, and a large quantity of fluid. It had commenced two years previously in a small tumour, which was reducible, but she neglected wearing any bandage. In December, 1837, the growth had become more rapid, and the swelling, which was in the right groin, larger than a hen's egg, stretched some- what towards the abdomen and right labium, with a broad base, and smooth surface, ex- cept on the inner upper side, where a nipple-like process, as big as the top ofthe finger protruded, and the skin covering it was thin and bluish. The tumour fluctuated, and was transparent, and she says returns into the belly when she lies down. It was presumed to be a serous cyst developed in the part, or an old hernial sac closed by adhesion at the neck, and become dropsical. She had also a hard round body, as big as a turkey's egg, protruding above the pubes, which on examination, by the vagina was found to originate from the womb. The first-mentioned swelling was punctured with a trocar, and six or eight ounces of citron-coloured frothy serum dis- charged, which coagulated with heat, A round body, as large as a small nut, and irreducible, was felt in the femoral ring and ceased to be felt behind the crural arch. On the fifth day after the operation the sac suppurated, and she died on the seventh. On examination the interior of this cavity was found lined with albuminous exuda- tion, and it communicated by a free opening with the peritoneal cavity behind Poupart's ligament. It contained nothing but the Fallopian tube in a state of con- siderable hypertrophy, without adhesion to the interior of the sac, but closely united to the anterior part of the circumference of the sac. The tissue of the womb was healthy, except being distended by an enormous fihrous tumour.]* 1218. The epigastric artery is on the outer side in internal femoral rupture, and ascends on the outer side of the hemial sac, where it crosses the spermatic cord, which runs on the upper and inner side of the rupture. The variations in the course of the epigastric and obtu- rator arteries are here' of the greatest importance. If the obturator artery arise from the external iliac or from the epigastric, or both from the crural artery, when it has passed below Poupart's ligament, the obturator artery runs along the inside of the hernial sac, down into the pelvis. In the same direction, frequently passes a not inconsiderable branch of communication from the epigastric to the obturator artery. The observations on the frequency of these different origins do not always precisely agree ; the origin of the obturator artery is, however, almost more common from the epigastric, than from the internal iliac artery (b). 1219, The spermatic cord surrounds the upper part ofthe neck ofthe hernial sac, describing a semi-circle inwards, so that the neck of a fe- moral rupture lies between the epigastric artery and the spermatic cord, at an equal distance from both. 1220. Femoral rupture is often very difficult of reduction owing to its depth. The taxis must, in a small femoral rupture, be applied directly from before backwards ; but in a large one, first from above downwards, and then from before backwards, the thigh being also much bent at the ■mi^f^TS £pr"' !83?—Brintish "einer Schrift; Ueber die sichcrste Art des MlS"Medl,cl1 Revie7> vol. x. p. 267. Bruchschnittes in der Leiste. Bamberg und (b) Cloo-uet, above cited.-HEssELBACH, Wurzburg, 1819, 4to.; with six Engravings. A. K., Ueber den TJrsprung und Verlauf der -Tiedemann, Erkhirunjr seiner AbWldiS un eren Bruchdecken Schlagader und der gen der Pulsadern, p. 288-298 HUflbeinloch Schlagader. Nachtrag zu STRANGULATED FEMORAL RUPTURE. 335 groin. The fingers of both hands are to be applied on the swelling, and attempts made gently, but continuously, to return the parts. In order to keep the femoral rupture up, a similar bandage to that used in inguinal rupture 16 employed, only with a shorter neck, because the femoral ring is nearer the rliac spine, than to the front inguinal or ex- ternal abdominal ring. The direction of the neck of the bandage must correspond to that of Poupart's ligament to wit, from the side towards the share-bone. The edge of the pad must not descend over the bend ofthe groin. 1221. Femoral rupture may be strangulated in the external or in the internal aperture for the vessels ; the strangulation is generally very severe, and if reduction cannot be effected, the operation is soon indi- cated. The strangulation may also be situated in the neck ofthe sac, especially if a truss have been worn for a long time. Jaeger's assertion (a) that no case of strangula- tion by the neck of the sac is known, I must deny. I would add, that in two cases the reduction of the intestine was impossible, although the femoral ring was so considerably cut into that the finger could be readily passed into it, and turned about in every direction. In both cases the strangulation was in the neck of the sac, after the division of which the bowel was easily reduced. [Key considers the usual seat of stricture in femoral rupture to be " a tendinous band, which joins the fascia transversalis to the posterior margin of Poupart's liga- ment, and which is quite distinct from Gimbernat's ligament, upon which so much stress is laid by some as constituting the stricture." (p. 14, note, part ii.)] 1222. The cut through the skin in the operation for femoral rupture should have an oblique direction, corresponding to Poupart's ligament, and should extend half an inch over the swelling towards the iliac spine and;the pubic symphysis. The cellular tissue is then to be divided as described (par. 1170) in the direction of the cut in the skin. The sub- jacent fat, which in stout persons is often very considerable, has a pe- culiar consistence, and often a resemblance to a piece of omentum, must be carefully separated from the bands, and the upper layer of the fascia lata cut through (1); the hernial sac is then to be exposed and opened. A case may occur in which the rupture protrudes through the opening of the upper layer of the fascia lata, in which instance, by cutting through the skin and cellular tissue, the operator comes at once upon the hernial sac. The opening of the hernial sac requires the greatest care, as there is always but little fluid, and frequently only a small loop of intestine uncovered by omentum. The oblique cut, corresponding to the great diameter of the swelling, (Scarpa, Zang, and others), is in general most suitable, because by dividing the upper layer of the fascia lata, Poupart's ligament is at the same time relaxed. In large swell- ings, or in stout persons, a T-shaped (Cooper, Lawrence, and others) or a trans- verse incision (Pelletan, Dupuytren) may be made. The directly vertical inci- sion is objectionable. , [(1) It must not be forgotten that what Chelius here and elsewhere calls the upper layer of the fascia lata is really the femoral sheath.—j. f. s.] 1223. If the strangulation be caused by the outer aperture of the femoral vessels, or by the opening of the external layer of the fascia lata, the tendinous edge of this aperture must be carefully cut into. If the strangulation be in the femoral ring, different modes of treatment are proposed. (a) HandwOrterbuch der Chirurgie, vol. iii. p. 591. 336 EXTERNAL FEMORAL RUPTURE. (a.) In women the point of the forefinger or the director should be introduced between the neck of the hernial sac and the intestine, the button-ended bistoury passed upon it, and the inguinal ligament cut into inwards and upwards. (b.) In men the button-ended bistoury should be introduced upon the director which has been passed on the inside, to protect the spermatic cord, and the inguinal ligament should be divided horizontally inwards, or rather a little obliquely upwards, two or three lines deep (Scarpa). Dupuytren cuts obliquely from below upwards along the edge of the outer inguinal ligament, in the direction by which the spermatic cord descends. (c.) For the purpose of more surely preventing the injury of the epi- gastric or obturator artery, Arnaud's hook should be introduced under the inguinal ligament, so as to draw it obliquely up towards the navel, whilst the power of the pull should be kept up by the finger introduced beneath Poupart's ligament, and the intestine pressed back. If the in- guinal ligament be not thereby sufficiently stretched, some slight cuts, only a line deep, must be made in its edge, and then it must be raised up with Arnaud's hook (Schreger). In the same way Le Blanc's dilator is to be used. Also by introducing the forefinger between the inner surface of the hernial sac and the edge of Gimbernat's ligament, the latter may be stretched, or even torn (Rust and others) (a). For an account of the numerous modes of proceeding in the operation for femoral rupture, see Schreger, Grundriss der chirurgischen Operationen, vol. i. p. 254. Third Edit, 1224. The danger, which, in the above-described course of the obtu- rator and epigastric arteries, is run from the practice a and b, on account of the injury of these vessels, the favouring of the recurrence of a rupture by the bloodless expansion, according to c, further, the circumstance that the parts suffer considerable bruising, and fhe*mere extension in many cases is not sufficient for the removal ofthe strangulation, have decided Hesselbach to the practice (which in a manner resembles the earlier practice of Bell, Else, and others) of seizing the exposed lower edge of the inguinal ligament with the foroeps, and cutting into it layerwise, from below upwards, two lines deep, and to introduce the forefinger between the intestine and the seat of strangulation. If the cut be in- sufficient, it must be lengthened through the fibres of the aponeurosis of the external oblique abdominal muscle above the spermatic cord, which is raised by an assistant, and the inner inguinal ligament should be cut into in the same way (b). 1225. This practice, although safer, on account of the deep situation of the femoral ring, especially in stout persons, is accompanied with great difficulty. That proposed by Scarpa and Dupuytren seems perferable to all other, if attention be paid to the following circumstances; the point of the forefinger is to be so introduced between the protruded part and Gimbernat's ligament, so as to bring the nail behind its sharp edge; Cooper's hernia-knife with the probe point, is to be passed upon (a) Trosteht, Ueber die Vorzuge der (6) Hesselbach, A. K„ die sicherste Art Ausdehnung vor dem Schnitte bei der Ope- der Bruchschnittes in der Leiste. Bamberg ration des eingeklemmten SchenkelbrUches; u,nd \Vurzbwg, 1819, in Rust's Magazin, vol. iii. p. 227, FEMORAL RUPTURE WITH TWO SACS. 337 the finger, behind the sickle-shaped edge of Gimbernat's ligament, so that the edge does not extend above it. The edge is then to be pressed by the front of the finger against the ligament^ so as to effect its division by pressure, and not by drawing. A smaller cut of one or two lines' extent is often sufficient for the reduction of the protruded parts, by slightly pressing in with the finger. If this be insufficient, the incision must be repeated {a). [The division of Gimbernat's ligament is useless; the stricture in femoral rup- ture is almost invariably in the neck ofthe sac itself, which must be divided, or the rupture will not return. In operating on femoral rupture, without opening the sac, Key observes:—" It may be as well to disturb the subjacent cellular membrane as little as possible, as inflammation is less likely to follow, and to assume the form of erysipelas. For this reason the inverted T incision, usual in the operation for femoral hernia, may be in most cases reduced to a single incision, either at right angles to Poupart's ligament, or in a transverse direction across the tumour. In patients who are spare, and in whom the neck of the sac lies at no great depth from the surface, it is unnecessary to disturb the cellular membrane by turning aside the flaps of the integuments. This will diminish the suppurative inflammation, and in such cases will afford ample room for the operation. I have not made trial ofthe perpendicular form of incision, but a single transverse one I have found sufficient when the integuments have been loose and the tumour not large. The superficial fascia adheres firmly to the common integuments, and is usually turned aside with them, especially when the latter are pinched up for the purpose of making the first incision. The fascia propria is there- fore quickly exposed, and forms the first distinct covering of the tumour, being darker than the more superficial cellular investment. It is under the outer layer of this fascia that the adipose structure is formed, and which often assumes the ap- pearance of omentum. The director easily makes its way under this fatty matter as far as the neck of the sac, which lies deeper than the operator at first supposes. The point of the director should be applied rather to the inner than to the outer part of the neck of the sac, as it will be found more easily to pass under the stricture at this part. It should not at first be attempted to be thrust under the stricture, as the firmness ofthe parts forming the stricture would resist it. But the seat ofthe stric- ture being felt, the operator should depress the ends of the director upon the sac, which will yield before it, and then, by an onward movement, the director slides under the stricture." (pp. 143, 44.)] 1226. The return ofthe intestine, the dressing and the treatment after operation are to be conducted in the same way as already described in inguinal rupture. , 1227. The external femoral rupture, which consists in the protrusion of the peritoneum and of the fascia iliaca on the outside of the femoral vessels, between them and the front upper angle ofthe hip-bone, and is gradually developed, forms at the place mentioned a moderately raised swelling, which, becoming narrower below, ascends, however, obliquely inwards, and terminates with a blunt point in the region of the lesser trochanter. The finger cannot in the least be brought under either of its edges. If in its further growth the rupture overcome the anterior iliac fascia, the form and direction of the swelling is changed; a new one is developed beneath the old swelling, which always extends further be- tween the fascia lata and.the muscles of the thigh. The mouth of the rupture is formed by the outer part of Poupart's ligament and the iliac spine ; on its inner side lies the femoral artery, and upon it the circumflex iliac artery. The neck of the sac is the widest part of it lying within (c) Scarpa, above cited.—LANGENBECK,above cited, p. 80.—Richerand, Histoire des Progres recens de la Chirurgie, p. 62. 29* 338 FEMORAL RUPTURE the belly; its inner wall lies under the semi-lunar bridge of the posterior iliac fascia, its outer on the m. iliacus internus and psoas magnus. The body of the sac lies behind the anterior iliac fascia, near it outwardly lie the m. rectus and vastus externus femoris, near it inwardly the femoral vessels and nerves, partially covered by it, and upon or before it the m. sartorius and part of the fascia lata. The bottom of the sac, its narrowest part, lies on the trochanter minor. The coverings of this rupture beneath the skin are, first, the femoral ligament upon the inner greater half, and the m. sartorius upon the outer lesser half of the hernial sac; second, a layer of tough cellular tissue, in which small blood-vessels and nerves run; third, the anterior iliac fascia; fourth, the posterior iliac fascia, which is very delicate, and allows, fifth, the hernial sac, which it com- pletely envelopes, to show through. Hesselbach considers a weak con- stitution, and the existence of the m. psoas minor, by which a cup like hollow is formed, as disposing to this rupture. As long as this rupture is enclosed in the anterior iliac fascia, it cannot well be strangulated, because the neck is the widest part ofthe sac ; but if that fascia be torn by great violence, then, according to Hesselbach, strangulation may follow. The taxis is to be applied from below upwards ; and if the operation be necessary, it is only possible, according to Hesselbach, to avoid wounding the circumflex iliac artery, which always lies in front of the neck of the sac, by the division layer-wise of the strangulating parts (a). [Astley Cooper observes, that "it is by no means common to meet with devia- tions from the usual structure of crural hernia," and describes three varieties ; first, that in which "the fascia usually covering the hernial sac has given way so as to allow a portion of the tumour to pass before it; thus dividing the tumour into two parts, witti a sort of hourglass contraction between them," (p. 25, part ii.) very similar to which appears Hesselbach's case, quoted by Key, where " the sheath had given way in different parts so as to give the sac an appearance of five small tumours, which was probably owing to the apertures thr'ough which the ab- sorbents pass having yielded, while the general texture of the sheath had resisted pressure." (p. 25, note, part ii.) Second, " when the tumour does not quit the sheath for the crural vessels." Third, "that in which the hernia is formed in part within the sheath, and also in the common way." (p, 25,. part ii.) I have had three cases of femoral rupture which seem distinct from either of those mentioned, and were furnished with a secqnd sac, produced, I presume, by rupture of the original one. Case, 1.-—S. B., aged fifty-six years, a stout, healthy, but flabby woman, was ad- mitted into St. Thomas's Hospital on the afternoon of Sept. 23d, 1837, having been subject of rupture on the right side for the last nine years, during the latter four of which she has worn, though irregularly, a cup-truss, as the protrusion could not be entirely returned. Within the latter period the rup- ture has descended so largely five times as to cause severe vomiting, but has been relieved. Qn the 20th ult. her bowels were moved, and not since. Next afternoon she was attacked with severe vomiting, and yesterday the taxis was employed severely, but without relief, and the symptoms continued up to the period of hei admission, when she was immediately put in the warm bath, which produced com- plete prostration, and attempts at reduction were made, but without success. In the evening I saw her, and she had then recovered the effects of the bath, but she was vomiting stercoraceous matter, had continual eructations, and hiccough, which had been through the whole day, otherwise she was tranquil, and her coun-> tenance cheerful. The belly was tender, but not much distended. A large oblong tumour extended from the pubic spine to within an inch of the (a) Hesselba,ch above cited, apd his Lehre den Eingeweidebriichen, vol. i. p. 172.— Z*is, Dissert. Hernias cruralis externoe historia. Lipsia>k 1832* WITH TWO SACS. 339 upper front iliac spine, about three fingers in breadth, covering Poupart's ligament, and having the appearance of an enlarged mass of inguinal glands, very firm and unyielding, and the skin covering it very livid, from the previous severe handling. A second swelling occupied the place of femoral rupture, not exceeding the size of a walnut, separated from the former by the crease of the groin, and rather nearer the pubes than usual. This seemed without doubt a femoral rupture, and gave a sense of indistinct fluctuation when the swelling on the groin was pressed. I was in much doubt of the character of the larger swelling, whether it were a mass of enlarged glands further swollen and inflamed by the handling, or whether an en- cysted tumour, or whether a rupture; but neither its history nor situation led to the latter supposition. As the swelling had been so severely mauled, I thought it best not to make any violent or long-continued efforts to return the rupture, and, not succeeding, proposed to her an operation, to which, however, she would not consent. The symptoms continuing throughout the night, and her countenance becoming anxious, she was at last persuaded to submit; and after consultation with my colleague Green, on the following day, Sept. 24ih, noon, I proceeded to operate on the smaller tumour, in the same way as for femoral rupture. Nothing unusual occurred except that, on opening the sac, no fluid escaped; a portion of omentum, about as large as a walnut, turned out, but no intestine could be found. I then passed my finger up towards the mouth of the sac, into the aperture of which I could just introduce it. No alteration having taken place in the tumour on the groin, and the omentum, in the sac just opened, seeming scarcely sufficient to account for the severity of the symptoms of strangulation, we determined on narrowly examining the sac, to ascer- tain whether it communicated with the large swelling. In carrying my finger round the hernial cavity for this purpose, it suddenly passed into an aperture on the outer side, and, being pushed onwards, entered the large swelling, and passing along it nearly as far as the iliac spine, could be readily felt, and not deeply, beneath the skin, which was then slit up on my finger, and thereby a large mass of healthy omentum exposed, which, being raised, about four inches of small intestines, choco- late-coloured and bright, but with a few patches of adhesive matter beneath its peritoneal coat, which also adhered slightly to the omentum, came into view. The mouth of the sac was speedily found, and my finger with little difficulty passed into the belly; but the gut would not return till the aperture had been enlarged with the knife. About four ounces of omentum were cut off, and the wound dressed ; she recovered without an untoward symptom. I presume in this case that the hernial sac had burst, but how or when, the history of the case gave no information, and that the protruded bowel and large portion of omentum had no proper sac, but had merely formed themselves a cavity in the cellular tissue. Case 2.—A. B., aged fifty-five years, a healthy, stoutish woman, of loose texture, was admitted Feb. 24th, 1842, having been the subject of femoral rupture on the right side for twenty years, the latter half only of which she has worn a truss. On the morning of the 2lst ult. her bowels were last moved, and, having exerted herself more than usual during the day, the rupture increased beyond its ordinary size, and could not be returned as previously. She was constantly vomiting during the night; and H3xt day was bled, put in the warm bath, and had the taxis applied for two and a half hours without relief. The vomiting ceased in the course of the day, and nothing was done for her yesterday except giving some sulphate of magnesia in the evening, which, not operating, castor-oil was given this morning, but without relief. She has now (noon) a little hiccough, and frequent fetid eructations, but has not vomited since the 22d ult. The belly is generally tender, and the pulse small; but the countenance is little distressed. In front of Poupart's ligament there was a large swelling, extending to within two inches of the iliac spine, but not much elevated, and from its inner extremity a second swelling descended in the usual situation of femoral rupture, but pyriform rather than globular, and passing down lower in the thigh than usual. A distinct indentation existed between the two swellings, as if they were separated beneath the skin; and at this part was a scar, the result of an abscess five years ago. The fingers could be passed behind both swellings, especially the inner, which was tender; but neither were inflamed,.nor appeared to have been much handled. The general resemblance to the former case was very strong. The taxis was employed 340 WOUNDS OF EPIGASTRIC both before and after the warm bath, but without avail, and with her consent the operation was performed, at 2, p. m., upon the inner swelling. After cutting through, and turning off the skin and superficial fascia, an absorbent gland was found on Poupart's ligament, sending inwards a neck to join another below it; and three absorbent vessels were seen entering the former gland, having risen up from the femoral sheath, and by their tightness produced the depression between the two swellings already mentioned. The neck of gland was divided, and the fascia propria, which was very tough and almost fibrous, slit up on a director, ex- posing the hernial sac, which was so much larger than seemed at first, that I was Obliged to widen the opening in the skin by cutting it inwards. The sac was then opened, and a small quantity of fluid escaped, followed by protrusion of omentum, and the cut, having been completed with a bistoury upon the finger, a knuckle of intestine, about three inches long, was found on the inner side of the swelling. I then passed my finger down to the stricture, and could enter just the tip within it; but the size of the other swelling rendered it so deep that I found, it necessary to enlarge the external cut upwards previous to division of the stricture, which was made sufficient to admit the finger readily into the belly. The gut being congested, but bright, and, having examined the strictured part, and emptied it, I returned the bowel without difficulty into the belly. On carefully examining the hernial sac, in reference to the remaining swelling, I found an aperture in its outer wall close to Poupart's ligament, through which my finger readily passed into the tumour, the extent of which outwards was ascertained by the finger being buried up to the knuckle. The cavity contained nothing but soft omentum, which, having in vain attempted to withdraw, I thought best left alone. That omentum, however, in the opened sac, though healthy, being large in quantity, I cut off, having previously introduced a double ligature, and tied it on each side, which prevented any bleeding. She was then put to bed, and recovered without any hindrance. Case 3.—A. W., aged fifty-five years, a spare, healthy woman, was admitted in the afternoon of Nov. \th, 1828, having ruptured herself on the right side ten years ago, since which time she has worn a truss constantly, which, however, has not fitted, and the rupture has been so much incarcerated five or six times as to need assistance for its reduction ; but it does not appear certain, from her account, that its entire contents have- been always returned. Yesterday evening (her bowels having been twice relieved during the day,) whilst engaged in her usual occupation, mangling, the rupture came down beneath the truss, which she took off, and, having returned the protruded parts, felt no farther inconvenience till 11 o'clock this morning, when it again came down, and, having attained larger size than usual, became painful, and made her sick and faint. She could not return the rupture, nor could her medical attendant, who twice employed the taxis during the afternoon, and then sent her ou that evening to the hospital, where the warm-bath and taxis were resorted to, but without avail. When I saw her, at 6, p. m., she had been constantly retching for the last five hours, and so continued, raising, however, nothing more than a little transparent, colourless fluid. She had frequent eructations, increased by any pressure on the swelling; the belly is full, but not tender, and she complains only of pain at the lower part, near the rupture; pulse small; countenance pallid and anxious; the bowels have not been relieved since yesterday. Upon Poupart's ligament was a large tumour Of an oblong shape, extending from about three fingers' breadth to the inner side of the upper iliac spine, into the right labium pudendi. It was more prominent, bulky, and rounded, at its outer end, gra- dually narrowed as it proceeded inwards, and reaching the lower part of the mons Veneris, bent dovvrt at an angle, and descended for the distance of an inch into the labium. The upper outer part of the swelling was firm and unyielding, but the labial portion soft and fluctuating on pressure. The appearance ofthe tumour, which was such as might be supposed to depend on inguinal and femoral rupture existing simultaneously, rendered the diagnosis puzzling. But finding it possible to get my fingers under both ends of the swelling, although I could not pass them behind its centre, I concluded that the case was one of femoral rupture,accompanied with variety. * This view was supported by the patient's statement, that till this morning, although often very large, the swelling had always been in the thigh alone, and not in the labium, where it first appeared only to-day. As the case was one of which I knew none like, I gladly availed myself of my friend the elder Travers's OR OBTURATOR ARTERIES. 341 kind opinion, which, concurring with my own, it was determined to operate as for femoral rupture. At 9, p. m., a transverse cut was made from the middle of the firm swelling inwards, nearly to the spine of the pubes, and a second at right angles with and below it. The other coverings were then divided in the usual way, and on opening the hernial sac, a little dark-coloured serum escaped ; and when it was fully divided, forthwith a quantity of omentum burst through the aperture, and the swelling in the labium at once subsided. This portion of omentum was very soft and loose in texture, and had been, doubtless, that last descended; but the remainder, forming the bulk of the swelling, was firm and matted together, and upon raising it a knuckle of intes- tine was seen, dark-coloured but bright and cedematous. Having introduced my finger into the sac, I could not at first pass it down to the stricture, as it was intercepted by a band, which I supposed to be an old adhesion ; but having drawn the omentum and gut to the outer side, I was enabled to reach, and found the stricture very tight, and admitting only the tip of the finger, but sufficient to allow the entrance of the blunt-ended bistoury, with which I divided, till my finger would pass into the belly, up to the second joint. I then readily emptied the gut, and attempted to return it, but could not succeed. It was thought that the difficulty depended on the stricture not having been sufficiently freed, and I therefore prepared again to intro- duce the bistoury, by drawing the omentum and intestine to the outer side. This, however, being done, a broad membrane was seen descending from the upper part ofthe sac, behind which the finger could be passed. It was, this, doubtless, which first prevented the introduction of my finger into the stricture, and subsequently ob- structed the entrance ofthe gut into the belly by dropping against the mouth ofthe sac. We determined on its division ; and this done without further dilatation of the stricture, the intestine easily returned. The omentum was partially adherent to the mouth of the sac, and being in rather large quantity, and its matted part rather bruised, the greater portion of it was removed, and three little vessels in it disposed to bleed were singly tied. The sac having been thus emptied, was found to be of large size, extending rather more outwards than usual; and on its inner side, the finger being pressed, readily passed inwards, and for an inch and a half downwards into the right labium ; but whether this part of the cavity had any peritoneal lining, I did not observe. She recovered without any drawback. In January, 1842, she again came under my care with symptoms of strangulation. She had constantly worn the truss, but not to much purpose, as the rupture has come down four or five times a week. The original femoral swelling had now increased to the size of a large fist, and filled up a considerable part of the inguinal region both below and above Poupart's ligament. On its inner side, the part which had descended into the labium was also enlarged, and its fore and upper part had as- sumed a remarkable form, exhibiting the appearance of the appendix auriculae of the heart, with its loose extremity projecting upwards and forwards. This labial part of the swelling was very hard and firm, and its contents seemed solid, whilst the outer and larger portion was evidently filled with intestine, which could be readily felt, as the skin alone appeared to cover it, and pressure caused much gurgling. The rupture was returned, after the Warm bath, by emptying the smaller into the larger swelling, which having been done with some difficulty, the aperture between the two was grasped tightly, so as to prevent any escape, the larger swelling being thrust into the thigh by an assistant. I again employed the taxis' upon it, and the rupture was slowly but completely returned into the belly. The mouth of the sac was large enough to admit the entrance of two or three fingers, and through the in- side, the fingers could be readily passed into the appendicular swelling, and to the bottom of the labium.—j. k. s.] 1228. Wounding the epigastric or obturator artery, or one of their branches, in the operation for inguinal or femoral rupture, may cause a fatal or alarming bleeding, the more, as the blood is commonly poured into the cavity of the belly. By proper consideration of the points mentioned in the several kinds of these ruptures, this injury may indeed always be prevented. For stanching the bleeding, compression with oak agaric, plugs of lint moistened with styptics, with peculiar instru- 342 WOUND OF EPIGASTRIC OR OBTURATOR ARTERIES. ments, (Desault, by means of broad compressing forceps, Schindler, with forceps having a hinge, Hesselbach, with a peculiar compressor, Hager, with a compressor for the middle meningeal artery,) the passing a needle around the bleeding vessel, the enlargement of the incision, and special tying the vessel, have been proposed. Hesselbach's in- strument (a) seems to have the preference ; with its spoon-shaped part we must endeavour to find the seat ofthe bleeding, as when it is passed into the belly, the blood in that cavity externally, which, however, is better done by introducing the forefinger. The spoon-like part is then to be placed on the wound of the vessel, the other broad part, on the front wall ofthe belly, and by means of a screw, the two parts are to be pressed together. A cold application assists the operation of this remedy. [Although it cannot be doubted that wounds of either the epigastric or obturator arteries are very dangerous accidents, yet it is very remarkable that with the fre- quent variety of their origin and in the great number of operations for strangulated rupture, such cases are exceedingly rare, the number collected by Lawp.ence being not more than twelve or fourteen. In one of these, " the epigastric artery had been completely divided at three quarters of an inch from its origin, and it did not ap- pear that the smallest quantity of blood had escaped from the divided vessel;" in another, in enlarging the stricture, " the wound immediately filled with arterial blood, which rose again almost directly to the edge ofthe incision when removed with the sponge. * * * The patient lost about a pint of blood, fainted, and the bleeding ceased, nor did it come on again." (p. 271). In other cases, however, the patient died ofthe bleeding, either with or witnout the mischief having been discovered. If there be reasonable ground to suppose that either artery is wounded, the proper proceeding is to seek for and tie it, which was done by Mackay with suc- cess (b). It is also remarkable that the bleeding does not always come on immediately at the operation ; but from the two following cases it appears that this may arise from other arteries than either obturator or epigastric. Lawrence mentions a case of strangulated bubonocele in which "noblood was shed during the operation; haemor- rhage, however, took place on the same evening, but yielded to the application of cold cloths." There was no further bleeding till " the morning of the eighth day, when a profuse haemorrhage took place from the wound; it consisted of arterial blood, and did not cease till two pints at least had been lost. He survived this occurrence about a week," The vessel which had been divided was "the arterial branch, which the epigastric sends to the spermatic cord ; but its size did not seem adequate to the suply of so profuse a bleeding." (pp. 273, 74.) Everarh Home (c) also relates a case of strangulated scrotal rupture, in which suppuration of the testicle having followed the operation, "a haemorrhage took place in the evening (ofthe tenth day), which made the removal of the testicle necessary in order to secure the vessel. He lost a pound of blood; but ultimately recovered. (p. 109.)] .(a) Hesselbach, F. K., Beschreibung und Schenkelbruche. Wiirzburg, 1816 ; with Abbildung eines neuen Instrumentes zur two copper plates. sichern Entdeckung und Stillung einer bei- (b) A. Cooper, p. 41. dem Bruckschmitte entstandenen gefahr- (c) Cases and Observations on Strangu- lichen Blutung. Ein Anhang und Beitrag lated Hernia, in Trans, of a Society for the zu den neuesten anatomisch pathologischen improvement of Med. and Surg. Knowledge, Untersuchungen iiber die Leisten und vol. ii. UMBILICAL RUPTURE. 343 III.—OF UMBILICAL RUPTURE. (Hernia umbilicalis, Exomphalas, Lat.; Nabelbruch, Germ.; Hernie ombilicale, Omphalocele, Fr.) Desault, QDuvres Chirurgicales, vol. ii. p. 315. Cooper Astley, Anatomy and Surgical Treatment of Abdominal Hernia, part ii. p. 29. Oken's Preisschrift iiber die Enstehung und Heilung der Nabelbruche. Lanshut, Soemmering, S. T., Ueber die Ursache, Erkenntniss und Behandlung der Nabel- bruche. Frankfurt, 1811, Thurn, Ueber die Ursachen der Nabelbruche, bei Kindern und deren Heilung besonders durch Abbinden; in von Sikbold's Chiron., vol. ii. part ii. p. 3. Muller, H., Inaug. Abhandl. uber den Nabelbruch, mit einem neuen Vorschlage zu seiner Behandlung. Enlangen, 1841. 1229. The True Umbilical Rupture passes through the opening of the navel, and is thereby distinguished from the so called false umbilical rupture, which is formed in the neighbourhood ofthe navel. Umbilical rupture is either congenital, or arises accidentally after birth. 1230. Congenital Umbilical Rupture is the consequence of an arrested development of the foetus, of a backward formation of the abdominal muscles, the fixtus remaining in that earlier stage of development, in which the intestines have not yet entered into the cavity of the belly. This rupture is situated in the spongy cellular tissue which connects the vessels of the navel-string together. It is therefore on this account opaque, where covered by the integuments of the belly, but transparent over the rest of its extent where surrounded by the cellular tissue ofthe navel-string. Besides this cellular tissue, this rupture is also enveloped in a hernial sac, and lies in a triangular space, which is produced by the separation ofthe vessels of the navel-string from each other. The veins are always above, the two arteries below and on the sides. The size of this rupture varies according as it contains a larger or smaller quantity of intestines. Several portions of the small intestines are usually con- tained in the swelling; frequently also the colon, omentum, stomach, liver, and spleen. [In tying the umbilical cord after birth, care should be taken to ascertain pre- viously whether there be any protrusion of viscera into it, which sometimes having, from the small size of the rupture been overlooked, intestine has been included in the ligature, and wounded; instances of which are mentioned by Mauriceau (a), Sabatier (b), and others.—j. f. s.] 1231. Umbilical rupture afterbirth occurs, from the time ofthe sepa- ration of the navel-string to the third or fourth month. If circumstances, as violent screaming, restlessness of the child, and the like, then ope- rate, which force the intestines violently against the walls of the belly, a portion of peritoneum, and of intestine, is easily thrust through the still open navel-ring, or the scar, not yet firm, gives way. As the navel after the proper obliteration of the annulus umbilicalis, must be considered as the firmest part of the abdominal wall, it is pro- bable that in the cases where true umbilical rupture has been* observed (a) Traite des Accouchemens, vol. i. p. 497. (b) Dela Medecine Operatoire, vol. i. p. 152. 344 UMBILICAL RUPTURE. in adults, it had already formed in childhood, but, on account of its small size, had been overlooked; or that the navel-ring is enlarged, as a consequence of great extension of the abdominal wall, in fat persons, or after frequent pregnancies. Umbilical rupture, in adults, is, therefore, more frequent in women, who have been often pregnant, after great ex- tension of the belly from dropsy, and in very fat persons. Umbilical rupture occurring after pregnancy, has a round, sometimes cylindrical, sometimes conical form, and a circular base; in large swelling, the scar of the navel is more or less smoothed. The coverings of this rupture are:—1, the external skin ; 2, the delicate aponeurosis, which spreads over the external surface of the abdominal muscles; 3, the peritoneum lengthened into the hernial sac. The latter is often very thin, and more often, adherent to the coverings and to the intestines, especially.at the point of the swelling; it seems also deficient, and is sometimes torn. The neck of the sac is always very short, and connected internally with the aponeurotic navel-ring ; in old and large umbilical ruptures it is tough, and often cartilaginous. In such ruptures, very considerable adhesions exist between the protruded intestines, themselves, and the hernial sac, so that they form an inseparable, mass, and the contained intestines can only be returned with difficulty. Collections of stool may therefore occur in that part of the intestine between the rupture and the navel, vomiting, and the like. Actual strangulation is rare in umbilical ruptures; if, however, it occur, the symptoms are more severet han in other ruptures, and more rapid mortification is to be dreaded. [Astley Cooper mentions "an example of the sac having been either absorbed or burst, by which openings have been formed, and portions of omentum protruded through the sac of the larger one. Sometimes an umbilical rupture forms two tumours, of which Astley Cooper mentions an instance operated on by the elder Cline, who, " after returning the intestine from the hernial sac, on putting the finger into the abdomen, an opening could be felt about half an inch from that by which the finger passed, which led into another tumour by the side of the former." (p. 31). On dissection, in the tu- mour that was most inferior "I found," says Cooper, "a small portion of the ileum, and part of the caecum. In the other tumour there was a portion of colon, and which adhered to the sac." (p. 47). I have had a case (No. XI. in the Table) somewhat similar, in which the rup- ture, about the size of a half-quartern loaf, had somewhat the shape of the figure 8, the head of which was rather smaller, and bent over to the left side. In the course ofthe operation a deep tough band of cellular tissue was found thrusting down the middle ofthe hernial sac, which retained the indentation after the cellular band had been cut through. The sac contained a large quantity of hard impacted omentum, and some inches of intestine.*—j. f, s. Umbilical Ruptures sometimes acquire " enormous size in women, whose bellies are pendulous, from bearing a great number of children. In three such instances," says Cooper, "I have seen the hernia extending so low from the navel as entirely to cover the pudendum;" the largest he ever saw "measured across twenty inches by seventeen." (p. 34.)] 1232. In congenital "umbilical rupture, it depends on its size and on the condition of the walls of the bellly, whether any thing can be under- taken for its cure. If that part ofthe intestine, external to the belly, be not large, and be reducible, its return must be carefully effected and re- protrusion prevented, by graduated compresses, which should be fastened with strips of sticking plaster and a body-belt. This practice is prefer- able to that followed by Hamilton, who after returning the intestine, TREATMENT. 345 applied a stout bandage around the base of the swelling, and brought the^edges of the abdominal coverings together, with two silver needles and sticking plaster, and the cure was effected in a few days (a). If the congenital rupture be considerable, and its return in a gentle manner not possible, the child usually dies soon after birth, in which case, the external covering of tire swelling is thrown off and the intestines are laid bare. Experience, however, proves, that if the swelling be properly protected from all external pressure, granulations may be produced after separation of the external covering, and thus the whole part be gradu- ally covered with firm skin and a tendinous expansion (6). 1233. The treatment of umbilical rupture occurring after birth, is easy. The parts are returned without difficulty, and are kept up with a convex pad of wood, wax, or the like, applied close to the navel-ring, and properly fastened with sticking-plaster, and a broad bandage. In changing the dressings, especial care must be taken that the protrusion ofthe intestine be prevented, by pressure of the finger on the navel-ring, till the pad be again properly applied. Usually, in children, a radical cure vefy soon takes place, on account of the natural tendency of the navel-ring to obliteration. In adults, elastic trusses, which yield to the motions of the abdominal muscles, are employed. Of the many, and some very complicated umbilical trusses, an elastic truss of a similar kind to that for inguinal rupture is preferable, of which the spring should be well fitted to the fulness of the belly, and its pad project directly from the spring; or a somewhat Concave metallic plate, to which is attached a spring, with a pad, and kept in its proper place by an elastic bandage attached to both sides of the plate ; or a plate of horn is applied, in the middle of which is screwed a pad, and fixed with a large, tight, sticking- plaster, and a belly-band, by which the rupture can be most certainly kept up. If the rupture cannot be returned, a large hollow pad must be used, by which the increase ofthe rupture is prevented. Rothmund (c) after completely replacing the contents of the hernial sac,"presses the external coverings and the hernial sac through the mouth of the sac into the belly, and thrusts a round plate, corresponding in size to the extent of the aperture, into the pouch thereby formed. On this plate, which can be kept steady by a stem projecting in its middle, a contrivance is to be attached, which can increase it from two to four lines at the greatest part of its periphery. By drawing the stem, the enlarged plate, which no longer can escape out of the mouth of the hernial sac, is firmly applied against the inner hinder wall of the latter, A somewhat larger plate, with an opening in its middle, corresponding to the inner plate, is applied on the cover- ings of the belly, and then the projecting stem of the first is to be passed through the opening of the second, and fastened by a contrivance attached to it. In this way the ensheathed hernial sac may be firmly compressed, at pleasure, at the whole hinder extent of the mouth, to the extent of some lines; and by this gradually in- creased pressure, after some days, adhesive inflammation is excited, by means of which the mouth of the hernial sac is closed, the compressed parts of the ensheathed sac at the hind surface of the navel-ring becoming adherent to it, and to the umbilical canal. This compressor cannot generally be borne more than three, and at most, five days. If the ensheathed hernial sac look livid, the compressor must at once be removed. The compressors are made of wood and metal (d) ["The presence of the intestine and omentum in the tumour keeping the navel open, oppose," says Desault, " its continual tendency to close; a tendency, how- fa) Cooper, above cited, p. 32. decken begriing deten Nabelbruckes; in \b) Ribke, Heilung eines in der ersten Rust's Magazin, vol. viii. pt. i. p. 130. Bildunund im Mangel der aiisseren Hant- (c) MiiLLER, above cited, p. 53. (d) Muller, pi. v. Vol. ii.—30 346 OPERATION FOR STRANGULATED UMBILICAL RUPTURE. ever, which sometimes becoming greater than the resistance of the escaped parts, compels their return into the belly, obliterates the aperture which has given them passage, closes, consolidates it, and hence spontaneous cures of infantile umbilical ruptures occur." (p. 317). He gives two instances of this fact. The one, a female child of two years of age, with a rupture the size of a large nut, which had occurred soon after birth, and for which nothing had been done. He proposed applying a ligature, but the parents would not permit it. In the following year he saw the child again, and the rupture had disappeared. Nothing had been done, but the tumour°had gradually subsided. In the other case the rupture had existed from birth, and at five years of age it was determined on applying the ligature. It was however deferred, in consequence of an attack of small-pox. After the child's re- covery the swelling was found much diminished, and Desault, presuming it might be cured by nature, left it alone* He was right; at the end of eight months it had entirely disappeared. Soemmering (a) and Brunninghausen (b) have mentioned several similar instances.] 1234. If the operation be necessary in strangulated umbilical rupture, the opening must be carefully made into the swelling, because the cover- ing, are often very thin, and the hernial sac adherent to the skin, or intestines, or torn. The cut through the coverings should be made per- pendicularly. If after opening the sac, and the proper disentanglement of the intestines, and so on, reduction cannot be effected, a director must be introduced between the neck ofthe sac, and the navel-ring cut into downwards with the button-ended bistoury. If previous to the operation, the impossibility of returning the rupture, on account of the existing adhesions, should be perceived, if the parts of the rupture be not gangrenous, a semilunar incision is to be made at the bottom of the swelling, on the right or left side, through the skin, the thin aponeurosis carefully divided, and a director attempted to be introduced at the upper or under part ofthe navel-ring, between it and the neck of the sac, and upon it the button-ended bistoury for cutting into the navel-ring; or if this be not possible the point of the left forefinger with the nail turned down, is to be placed between the neck of the hernial sac and the under edge of the navel-ring, and upon it a cut with a straight bistoury is to be carefully made from without inwards with a gentle motion of the hand. But if the parts in the rupture be gangrenous or self-strangulated, the sac may be carefully opened at any convenient place. The further treatment is to be guided according to the ordinary rules. ' [Astley Cooper mentions " one circumstance of danger which is peculiar to the umbilical hernia, which is, that when the skin has become very thin over the tumour, the pressure simply of ihe protruded parts, under strangulation, will sometimes very early destroy the life of that portion of the integument by stopping the circulation through it. It first turns green, the cuticle then separates from it, and that portion of the skin becomes dry and of a brown oolour; and in the instances in which this circumstance came under my observation the patients have died." * * * "Suppu- ration," he also observes, " now and then takes place in the omentum of an irredu- cible umbilical hernia." (p. 35.) As pregnancy is not an unfrequent cause of umbilical rupture, it is rather curious that strangulation at this period so rarely occurs. If it cannot be overcome by the usual remedies, the operation may be resorted to without the patient's condition rendering it less hopeful. Astley Cooper mentions one case operated on success- fully in the eighth month of pregnancy (c); Lawrence one in the seventh or eighth month (d); and Clement another in the fourth month (e)]. (a) Above cited. {d) Above quoted, p. 560. (b) Loder's Journal fur Chirurgie, vol. (e) Observations on Surgery and Patho- iii. p. 1. logy p. 123. (c) Above quoted, part ii. 347. RADICAL CURE OF UMBILICAL RUPTURE. 347 1235. The radical cure of reducible umbilical rupture, in yoang persons, by the application of a ligature, after the reduction ofthe intes- tines, around the integument covering the rupture, by tying which tightly the parts taken hold of are destroyed, and a tough scar formed (1), is generally exceptionable; because, firstly, umbilical rupture is very com- monly cured in children by the mere powers of nature ; secondly, because the cure can certainly be effected by continued moderate compression; thirdly, because the operation is very painful, even dangerous, (as a small part of an intestine may be included in the ligature,) and after the scarring of the suppurating parts, compression is necessary for a much longer time; fourthly, because no decided radical cure can be effected, as a part of the neck of the hernial sac always still remains, and the scar produced is not sufficiently firm to prevent the dragging ofthe intestine. In female children, it must also be remembered that in pregnancy the scar may be torn {a). But in all the umbilical ruptures, which are several inches long, and purse-shaped, if the firm application of a truss be.pre vented by the great lengthening of the skin the ligature may be proper; and if it do not effect the closing of the navel-ring, the close application of a truss may be rendered possible {b). (1) In former time this was recommended and practised by Paulus jEgineta, Albucasis, Pare, and others; objected to by Guy de Chauliac and Dionis, and again recommended, especially by Desault (c), von Graefe, and others.' [Scarpa, Astley Cooper, and others, are much opposed to the ligature. Bene- dict of Breslau has also abandoned it on account of the serious, if not dangerous, symptoms resulting from its use. He says (d):—" In all the cases, pain in the belly came on about the third day, with great tenderness to the touch, especially near the navel, and considerable fever, so that the presence of peritoneal inflammation could not be mistaken; in one instance there was also vomiting. All the patients recovered under antiphlogistic treatment; but the symptoms were so formidable for two days, that a surgeon would not be justified in employing this treatment unless all other measures had failed." And its my opinion he would not be justified even then; for it is asserted by Richerand (e) that many of Desault's cases, supposed to be cured, returned. A case is also mentioned (f) in which a child of seven and a-half years old died in consequence of such treatment, the operation being thus performed; " the patient was placed on her back, the contents of the hernia were returned, and the sac was raised and twisted to ensure the reduction. A flat buckskin ligature, three-fourths of an inch wide, was applied close to the abdomen, not so firmly as to strangulate the parts, but sufficiently to retain the viscera and excite ad- hesive inflammation in the sac. A strong silk ligature was then applied with suffi- cient firmness to interrupt all circulation. When the mortified part was cut away, it was found that a portion of omentum had adhered to the sac, and of course had been included in the ligature. The patient died on the tenth day. The ring was perfectly closed by adhesion and granulation, which sprung from its tendinous margin; the colon adhered to the inner surface of the granulations; no inflammation could be detected in any part," (p. 368). It must be admitted that in this case cir- cumstances were not very favourable as to the success ofthe operation. "The mouth ofthe sac presented a diameter of three inches, and the enormous tumour extended to the knees. The swelling measured at the neck twelve inches in circumference; six inehes lower it was fifteen inches; it was seventeen inches in length; and two extensive ulcers existed on its posterior surface" (g).—j. f. s.] (a) Scarpa, above cited.—Girard, Me- (d) Rust's Magazin far die Gesammte moire sur la Hernie ombilicale chez des en- Heilkunde, vol. xliv. p. 176. fans; in Journal General de Medecine, vol. (e) Nosographie Chirurgicale, vol. ii. p. xli. July, 1811. 453. (b) Guincourt ; in Journal de Medecine (/) Fahnestock ; in American Journal of par Corvisart, &c, vol. xxi. 1811.—Wal- the Medical Sciences, vol. xvii. ther ; in Salzburg Med.-chirurg. Zeitung, (g) For the above quotations I am indebt- vol. i. p. 426.1814. ed to Lawrence's work on Hernia,—j, f. s, (c) Above cited, p. 324. 348 OF VENTRAL RUPTURE. IV.—OF VENTRAL RUPTURE. (Hernia ventralis, Lat.; Bauckbruch, Germ.; Hernie ventrale, Fr.) Garengeot, Sur plusieurs Hernies singulieres; in Memoires de l'Academie de Chirurgie, vol. i. p. 699. _ Pipelet, Nouvelles Observations sur les Hernies de la Vessie et de 1 Estomac; in the same, vol. iv. p. 188. La Chausse, B. J., Dissert, de hernia ventrali. Argent., 1746. Klinkosch, Progr. quo divisionem herniarum novamque hernia ventralis speciem proponit.. Prag., 1764. Soemmering, S. T., Ueber die Briiche am Bauche und Becken, ausser der Nabel- und Leistengegend. Frankfort, 1811. Cooper Astley, above cited, part ii. p. 49. 1236. A Ventral Rupture is that which protrudes through an unnatural opening on the front or side of the belly. This rupture is much more rare than either of those already mentioned. It takes place through openings in the abdominal muscles, and their aponeuroses; most com- monly in the space between the two m. recti, more rarely on the sides of the belly, from the hip-bone to the last rib. and in the lumbar region {Lumbar Rupture) (1). The causes of this rupture are the ordinary occasional causes of rupture, with existing relaxation of the abdominal walls, especially of the white line, after many pregnancies, in quick emaciation after previous stout- ness ; or it is caused by tearing of the muscles and aponeurosis, at the parts where scars have formed (2). Or the entire walls of the belly often spread into a sac which contains intestines (3). These ruptures are generally provided with a hernial sac, except when they are consequent on previous wounding of the peritoneum. [(1) Of this very rare form of Ventral Rupture Cloquet gives an instance in a man of seventy-five years, who, whilst lifting a heavy mattress, felt a violent pain, with a sense of tearing in his loins, whioh gradually subsided in course of six weeks. But about a fortnight after, whilst getting up in his bed, he had a fresh attack of pain at the same spot. When seen next day he was much agitated, had violent colic, some nausea and vomiting, and his bowels were costive. The skin in the right lumbar region, without being discoloured, was raised slightly by a rounded swelling about five inches from the spines of the vertebras. It was little tender, and when grasped, was found to be somewhat elastic, crackling, deeply situated, or at least separated from the skin by a layer of fat. It had a broad pedicle, increased in bulk, and dilated on coughing, sneezing, and making water. He had severe and constant pain deep in the right lumbar and iliac regions in the course of the caecum and ascending colon. The swelling was much larger when he stood up than when lying down, and when he turned on his face it disappeared, and left a hollow readily distinguishable by the touch. He was treated by putting a pad upon the seat of swelling, after its contents had been returned, and confining it with a circular ban- dage, (pp. 5, 6, note.) (2) I have seen two or three cases in which, after pregnancy, the linea alba has been torn to the extent of several inches; and in one of them below the navel I well recollect I oould, without diffioulty, bury my whole hand in the cavity of the belly, thrusting in the skin as a large pouch before it. In neither of these cases, however, was the protrusion of the bowels very considerable. There did not seem to be any thing remaining but the skin alone.—.j. f, s. Lawrence mentions a very interesting case of a woman who strained herself by lift- ing a heavy table, and died from inflammation of the chest. She had complained only of pain in the loins. But on examination both m. recti abdominis were torn through about one-third of their thickness, and there was a small quantity of coagulated blood STOMACH RUPTURE, SO-Calkd. 349 about the torn fibres; but the sheath was not ruptured, (p. 583). Probably, had she lived, this would have become a ventral rupture. In reference to wounds of the belly, which are sometimes followed by ruptures, he mentions, as an example, that this does not always occur. The case of a boy who had been largely gored by the tusk of a boar, and had the greater part ofthe stomach distended by a hearty dinner recently taken, the omentum, the transverse arch of the colon, and some small intes- tines protruded through the wound; they were returned with difficulty, and having been retained by the uninterrupted suture the case did well, and no rupture followed. (p. 584). (3) Of the latter kind, in which a portion of the entire abdominal wall seems to yield, various instances are mentioned. Richter describes a broad swelling, as large as a woman's breast, in each groin of the same person (a). And Siebold describes one equal to a loaf gf bread in size, between the cartilages, of the ribs and navel (b). 1237. These ruptures may happen through the whole length of the white line {Herniae lineae albce); but they are more commonly observed in that part above the navel, than in that below it. They for the most part contain a portion of omentum ; if they be below the navel there usually lies in them a small piece of intestine, frequently the bladder or the womb. They often protrude so near the navel as to be easily mis- taken for umbilical rupture. They have always an oval form, and have little prominence in comparison with their size; iheir neck is always oval, like the cleft through which they have passed; the neck of the sac is always very narrow in comparison to its size. If quite close to the navel-ring, they are distinguishable from true umbilical rupture by the oval shape of the neck of the sac, and by the navel being seen on one or other side of the swelling. Ruptures in the white line happen most frequently in women ; their coverings are the same as those of um- bilical rupture. They are kept up by the same trusses as the latter; but their radical cure is by far more rare than that of umbilical rupture. If there be strangulation, and the operation be necessary, it is the same as that for umbilical rupture ; only the opening into the belly is best en- larged on one side or other. 1238. From these ruptures of the white line must be distinguished, those swellings formed by a portion of fat which has penetrated through a cleft in the white line, and have great resemblance to the omental ruptures of the white line. These swellings feel hard, are insensible, irreducible, and produce no inconvenience. If such swelling be acci- dentally accompanied with colic^ a mistake is very easy, (Compare par. 1203.) 1239. At the upper part of the white line, and on the left side ofthe ensiform process, little ruptures not unfrequently arise, which, on account of the severe irritation of the stomach connected with them, may be called Stomach Ruptures, {Herniae ventriculi, Gastrocele), but they usually contain a part of the transverse colon (c). They are often so small as to be scarcely perceptible, have usually the size of an olive, and are rarely larger. They produce, without being strangulated, pain, dragging at the stomach, great tenderness of the pit of the stomach, vomiting, hiccough, nausea, especially after eating; and these symptoms diminish (a) Abhandlung von den BrQchen. Second Chirurgie, vol. iv.—Littre; in Mem de Edit., translated into French by Rouge- l'Acad. des Sciences. 1714. mount, p. 7. Bonn, 1788. 4to. (c) In Loder's Journal, 1797, vol. i. p. (b) La Peyronie; in Mem. de l'Acad. de 215. 30* 350 ISCHIAT1C RUPTURE. in the supine posture. The swelling is only felt when the patient stands up, or when the body is bent forward. The cleft through which the rupture protrudes may be, perhaps, felt in coughing. For the purpose of keeping up this rupture, it is best to wear stays made of whalebone, which, at the part corresponding to the rupture, are furnished with a pad of sufficiently large size. 1240. The treatment of the other Ventral Ruptures agrees, except in some slight modifications, with that for ruptures of the white line. If strangulation render the operation necessary, the dilatation of the stric- turing part must be made in such direction that no important vessel shall be injured, and as much as possible directly upwards. V.—OF ISCHIATIC RUPTURE. (Hernia ischiatica, dorsalis, iliaca posterior, Lat.; Hufibeinbruch, Germ.; Hernie ischiatique Ischiocelt, Fr.) 1241. Isehiatic, Dorsal Rupture, passes through the notch of the haunch-bone, above the sacro-ischiatic ligaments and pyriform muscle, below the gluteal muscle, and appears externally near the lower part of one of the lateral edges of the rump-bone, or coccyx ; it attains often a considerable size, extending more either upwards and backwards, or outwards, towards the perinaeum. It contains, either merely intestines, urinary bladder, or both small and large intestines, the womb, and the like, together. It is undecided whether the male or female sex be more subject to this rupture. It is more frequently noticed on the right than on the left side. It may be congenital, or may occur subsequently. The various cases of this rupture described are those of— Papen, C. H., Epistola ad. illustr. virum Alb. de Haller de stupenda hernia dorsali. Gotting., 1750 ; in Haller's Disput. Chirurg., vol. iii. p. 314. Verdier ; in Memoires de l'Academ. de Chirurgie, vol. ii. p. 2, note a. Camper, Demonstrationes anatomico-pathologicae, lib. ii. p. 17. Rose, Progr. de Enterocele'ischiatica. Lips., 1792. Lassus, Pathologie Chirurgicale, vol. ii. p. 103. Cooper, Astley, above cited, p. 66. Schreger, Chirurgische Versuche, vol. ii. p. 156. Berzold; in Siebold's Samml. chirurg. Beobact., vol. iii. p. 292, pi. iii. Monro, Anatomy of the Gullet, Stomach, and Intestines, Edinb., 1811, p. 380. Hager, above cited, p. 275. Roubein, Annales cliniques de Montpellier, vol. viii, p. 354. 1242. The diagnosis of this rupture is very difficult. Whilst it is small and covered by the great gluteal muscles, it cannot be discovered. In making the diagnosis, we must first remember the seat of the swell- ing ; the suspicion of a rupture is so much the greater when it is con- genital, and has a form, namely, a globular form, which other swellings generally have not. It can only be determined when the intestine can be felt in the rupture, which may be returned, and again protrude. In small ruptures the Convolutions cannot be at all felt; and even without adhesions, the return of this rupture may be impossible, on account of the small size of the aperture by which it has escaped. In large rup- tures, an emptiness of the belly is noticed. Congenital isehiatic rupture first begins with a broad base from the THYROID RUPTURE. 351 body, but in larger ones the neck is narrower than the bottom. As the urinary bladder can alone lie in dorsal rupture, so must the symptoms of vesical rupture be remembered in the diagnosis. The distinction of this rupture from a fatty or encysted swelling is difficult; it may be easily mistaken for an abscess when it proceeds to suppuration. Spina bifida is distinguished from this rupture by its seat in the middle of the rump- bone, by its fluctuation, and, in most cases, by its transparency. 1243. As in this rupture the pelvic aponeurosis is ordinarily torn and not displaced with it, it is covered only by skin, and by the outspread, or divided fibres of the m. levator ani. The sac of the rupture lies be- tween the under inner edge of the great gluteal muscle and the side of the rectum. On the inner side of the hip-bone, the neck of the sac is immediately surrounded by the obturator artery, both above and below. Upon the outer side of the hip-bone, the isehiatic nerve lies before and below, and the gluteal artery behind (A. Cooper) (a). 1244. Small dorsal ruptures may be .easily reduced ; they return of themselves into their proper place. Large and more long-continued rup- tures are capable of a slow reduction by a continued suitable position and external pressure. Reduction may be impossible on account of adhesion, or if the greater number of the abdominal organs be contained in the rupture, on account of the contraction of the walls of the belly. According to Astley Cooper, if isehiatic rupture render the operation necessary, and the extension ofthe mouth ofthe sac cannot be effected with a blunt hook, it must be divided forwards. Seiler considers it absolutely necessary in dividing the mouth of the sac, to cut layerwise from without inwards, and to tie the divided arteries immediately. Hager (b) distinguishes an upper and lower isehiatic rupture; the one should descend above the m. pyriformis, the other between it and the isehiatic nerve and the upper of the m. gemini; the one has at its escape from the isehiatic hole, the upper gluteal artery above and behind, and the nerve below it; the other has the lower gluteal artery, the pudic artery and vein, and the nerves below it. It is best not to open the hernial sac, and in the superior isehiatic rupture, to divide its mouth forwards and outwards, but in the inferior, forwards and upwards. Scarpa (c) considers this in women as enlarged pudic rupture, and in men as large perineal rupture, and therefore treats them as such. This opinion is perhaps right as regards some of the above-described cases, for instance, those of Papen and Bose ; but it is contradicted by other cases in which there has been sufficient ana- tomical examination. VI.—OF THYROID RUPTURE. (Hernia Foraminis ovalis seu thyroidei, Lat.; Bruch des eirunden Laches, Germ ; Hernie du Trou ovalaire, Fr.) Garengeot, above cited, vol. i. p. 709. Heuermann, Abhandlung der vornehmsten Chirurg. Operationen. Copenhagen, 1778, vol. i. p. 578. Eschenbach, C, Observata quaedam.anat.-chirurg. medica rariora. Rostoch., p. 265. Gunz, De herniis, p. 96. Vogel, B., Abhandlung aller Arten der Briiche. Glogau, 1769, 8vo. p. 204. t (a) Above cited, pi. xxiii. (b) Above cited, p. 272. (c) Supplement, above cited, p. 150. 352 THYROID RUPTURE. Camper, Demonstrationes anat. pathol., vol. ii. p. 17. Cloquet; in Journal de Medecine par Corvisart, etc., vol. xxv. Bulletin de la Faculte de medecine, No. 8, 1812. p. 194. Buhle, De herniS. obturator^. Hal., 1819. Gaderman, Ueber den Bruch durch das Huftbeinloch, nebst einem seltenen Falle hieriiber. Lanshut, 1833. 8vo. Cooper, Astley, above cited, part ii. p. 61. Cloquet, J., Pathologie chirurgicale. Paris, 1831. pi. v. 1245. In Rupture of the Thyroid Hole, the intestines pass through the opening in the ligament by which the obturator nerve and vessels, pass. The share-bone is in front ofthe neck ofthe sac, and its under, inner, and outer part, is surrounded by the obturator ligament. The base of the rupture is between the m. pectineus and adductor brevis, or between the front heads of the adductor. The obturator vessels are upon Its inner hinder part, and large branches of the obturator nerve are be- fore it. Differences however may occur, especially if the obturator and epigastric arteries arise in common, of which a case was seen by Gader- mann where the artery passed first on the inner, and then on the front of the hernial sac. This rupture is at first very apparent, if a large quantity of intestine be protruded. It may have a different form, be- cause it penetrates through different interspaces of the muscles. It occurs more commonly in females than in males, and may contain intes- tines, omentum, and even the urinary bladder; and not rarely does it occur at the same time on both sides. [Cloquet says (a), that "Ruptures of the subpubic (thyroid) hole are much more frequent than generally supposed, and that they are more commonly met with in women than in men. They have distinctive characters when they have attained a certain bulk; are capable of being operated on, especially in thin persons; and that the bladder may displace itself, through the subpubic hole" (p. 87.) In a case, however, which he has given an account of (b), the tumour produced no visible ex- ternal swelling, although of the size of a small hen's egg; but it was covered by the m. peclineusand adductor longus. And in Duverneys case (c), in which there was rupture through both thyroid holes, although each of the swellings was as large as an egg, yet no external tumour was observed. Neither was there*any swelling in Smith's, of Manchester, case (d). It must, therefore, be taken as a rule, that these ruptures are not usualty discoverable, although in Garengeot's patient it was ; the tumour, which was distant about a finger's breadth from the pudendum, descending six inches down on the inner and upper part of the thigh (e); it was reduced. Lawrence considers that " the m. pectineus, the long and middle heads ofthe m. triceps, and the m. gracilis, so completely close the space into which the sac protrudes, that they must by their pressure prevent it from increasing to any great bulk." (p. 619.) Frantz relates (/) the case of a woman forty years old, who, with many symp- toms of strangulated rupture, bad severe pain at the upper inner part of the left thigh, which came on suddenly, and recurred every ten minutes. No swelling was observable, but pressure high up between the m. triceps and the adductor muscles produced severe pain. There was neither tenderness nor pain in the belly. Three years previously she had had the same symptoms, but was suddenly relieved, whilst pressing on the part, when something seemed to go back with a noise into the belly. This had occurred more than once since, though less severely. When Frantz at- tended her, the symptoms were much more violentand less manageable; bleeding, purging, pressure, and other means were useless. Stercoraceous vomiting occurred on the ninth day, and the symptoms of strangulation increased up to the fourteenth, (a) Recherches Anatomiqnes. (d) Lancet, 1829-30, vol. ii. p 735. (b) Journal de Corvisart, above quoted. (e) Mem. de l'Acad., just cited, p. 708. (c) Mem. de l'Acad, Roy. de Chirurgie, (/) Allgemeine Medicinische, Central vol. i. p. 711. Zeitung, April, 1842. VAGINAL RUPTURE. 353 when she seemed dying, but a free discharge of stool then took place ; and ulti- mately she recovered. The only two examples of this disease I know of, are one from a male subject in St. Thomas's Museum, and another in the collection of the Royal College of Sur- geons.—j. f. s.] . 1246. The diagnosis is founded on the seat of swelling at the upper inner part ofthe thigh, on its peculiarly elastic tension, on the mode of its origin, on the possibility of its reduction, on the sensation of gurgling, or of different kinds of contents in the swelling, and on the gastric symptoms which usually accompany ruptures. This rupture may be strangulated, and the strangulation is usually at the mouth of the sac, but is more rarely caused by the neck ofthe sac or by the muscles. 1247. If the rupture be reducible, it must be returned to its proper place, and there retained by means of a graduated compress and an inguinal spica bandage, or with an inguinal truss, of which the neck is more lengthened downwards, and the pad comes directly below the transverse branch'of the share-bone, at the origin of the m. pectineus. If there be strangulation, if the remedies employed be ineffectual, and the operation be indicated, the enlargement ofthe stricture, when pos- sible, must be effected in the bloodless way, with the blunt hook from within outwards, and downwards. The dilatation with the knife, if necessary, must, according to Astley Cooper, be made inwards. If the rupture be concealed beneath the muscles, the diagnosis is rarely so certain that the operation can be undertaken. According to Gadermann (a), the cut must be made through the skin and femoral ligament, an inch below Poupart's ligament, and as far from the pubic symphysis, and continued rather inwards, about four inches in length; the pubic muscles must be cut through obliquely, and also the long and short heads of the m. triceps. VII.—OF VAGINAL RUPTURE. (Hernia vaginalis, Lat.; Scheidenbruch, Germ.; Hernie vaginale, Fr.) Garengeot, above cited, p. 707. Hoin, above cited, p. 211. Christian, On a species of Vaginal Hernia occurring in Labour; in the Edin- burgh Medical and Surgical Journal, vol. ix. p. 281. Stark, Dissert, de hernia, vaginali et stricturU uteri. Jena, 1796. Cooper Astley, above cited, part ii. p. 56. 1248. In Vaginal Rupture the intestines pass down in the fold of the peritoneum between the womb and the rectum, or between the former and the bladder, in consequence of which a swelling takes place on the hinder or front wall of the vagina, but for the most part more on one than on the other side, which, as it enlarges, passes between the labia, and attains considerable size. The rupture usually contains the urinary bladder when it is on the front wall of the vagina, or the womb, when it is on its back wall. There may be also a portion of the small intestine, more rarely of the colon or of the omentum. The swelling is elastic, and free from pain ; when pressed it recedes, but recurs on coughing, and so on; it increases in the upright, and diminishes in the supine posture. The mouth of the womb is completely free. If the swelling occur at (a) Above cited, p. 29. 354 PERINEAL RUPTURE. the hind wall of the vagina, it is generally deeper than in front; in the • latter case it is also usually accompanied with great inconvenience, in consequence of displacement of the bladder. With a large rupture at the hinder wall of the vagina there is most commonly prolapse of the anus. If the rupture be caused hastily, by violent straining and the like, the patient feels as if something were torn in the vagina, and severe pain, which subsequently is converted into a remitting colicky pain. If the vaginal rupture contain the bladder, it causes great disposition to make water, itching in the urethra, retention of urine, tension and painful disten- sion ofthe belly, sometimes agitation, restlessness, dragging at the sto- mach, and sundry«disturbances of the nervous system. In the protruded part ofthe bladder a stone may be formed. 1249. The predisposing causes of vaginal rupture are, relaxation of the vagina from previous delivery; whites, improper use of coitus, warm bathing, fire-pans, relaxed state of the body, inclination of the pelvis backwards, so that the intestines sink more deeply into it, and also wide pelvis. This rupture generally occurs soon after delivery, from straining ; it rarely happens in unmarried women. 1250. The replacement of vaginal rupture is usually easy. The patient being placed on her back, pressure is made with the fingers upon the swelling, and continued, if it return upwards with the fingers, even to the entrance ofthe womb. If the reduetion be difficult it should be favoured by relaxing clysters, and by continuing the supine posture. The reprotrusion of the rupture is best prevented by a cylindrical pessary, which can be fixed with a T-bandage. The patient must avoid all straining, and if the rupture protrude in spite of the pessary, that in- strument must be removed, and after the reduetion of the rupture re- placed. A radical cure may perhaps in many cases be effected by the continued use of the pessary and of astringent injections into the vagina. If this rupture protrude during childbirth, it must be kept back by continued pressure, till the child's head have descended, and then delivery is quickly completed. Vaginal rupture may be strangulated (although rarely, on account ofthe yieldingnessof the parts surrounding the rupture) by the enlarged womb during pregnancy, or by the collec- tion of faecal matter. The return is effected by the use of suitable means, at least no Case is known in which the operation was necessary, which also is only possible when the rupture is low down in the vagina. The midwife Rondel (a) recommends a ring-pessary of watch-spring and Indian rubber for keeping up this rupture. VIII.—OF PERINEAL RUPTURE. (Hernia Perinsei, Lat.; Mittefleischbruch, Germ.; Hernie du Perinee, Fr.) 1251. Perinaeal Rupture occurs by the descent of the intestines be- tween the rectum and vagina in women, and between the rectum and bladder in men. The external swelling in the perinaeum is different; (a) Me moire sur la Cyslocele vaginale, et sur les meilleurs moyens d'y remedier. Paris, 1835. PERINEAL RUPTURE. 355 it presents itself in the male generally in the region of the neck of the bladder; in women between the vagina and anus, usually on one or other side, and at the bottom of the labium. This rupture may contain a part of the intestinal canal, of the omentum or of the bladder. Iri women it must always be complicated with vaginal rupture (1). In men it causes various urinary inconveniences. (1) Chopart and Desault (a) believe that perinaeal rupture in women is not pos- sible as a vaginal rupture is more easily formed. Its existence in women has, however, been proved by the observations of Mery (b), Curade (c), Smellie (d), and Schreger (e); and many examples of it have been given by Chardenon (/), PlPELET (g), BROMFIELD (h), SCHNEIDER, SCARPA (i), JACOBSON (k), and SCHOTT (/); also A. Cooper (m). 1252. Perinaeal rupture is rare, and only possible in violent driving of the intestines downwards; in great resistance ofthe coverings of the belly, great relaxation of the peritoneal fold between the vagina and rectum, or between the rectum and bladder, and in slight inclination of the pelvis. Perinaeal rupture which contains the bladder, occur espe- cially in pregnancy, when the bladder is thrust downwards and outwards by the distended womb {n). In men, perinaeal rupture has a round or pear-shaped form; the swelling is in the perinaeum, on one side of the anus, so that the raphe is pressed somewhat aside. In women, so long as the rupture remains in the perinaeum, the swelling is roundish, and bluntly conical-pointed ; as it extends into the labium it becomes oblong, egg-shaped. Generally perinasal rupture is small, or up to the size of a hen's egg ; but it may attain considerable bulk. 1253. The return of this rupture is usually easy, and it may be kept back by a bandage, consisting of a spring surrounding the pelvis, from the hinder part of which a curved spring descends, and attached to its extremity a conical pad, which being applied directly upon the seat of the rupture, the latter is kept up by the strength of the spring and by an elastic bandage around the thigh. If this rupture be strangulated, and its reduction by suitable remedies impossible, the operation is neither difficult nor. dangerous, as the opening of the hernial sac is almost always external to the bottom of the pelvis. After opening the sac, a button-ended bistoury is to be introduced between the intestine and the tough edge of the hernial sac, and the strangulation may be relieved by a slight cut from below upwards, obliquely towards the side (kScARPA). The opinion, that by pressing back the external swelling, the rupture cannot be completely reduced, is disproved by Scarpa's observations. The Pudendal Hernia of Astley Cooper (o), the posterior labial rupture of Sei- (a) Traite des Maladies Chirurgicales, (h) Chirurgical Observations, p. 264. p, 292. (*) Olliver's Translation, Memoire sur (b) Memoires de l'Acad. de Chirurgie, la Hernie du Perinee; at the end of his Sup- vol. ii. p. 25. plement, p. 118. (c) Memoires de l'Acad. des Sciences, (k) In von Graefe und Walther's Jour- n\3, nal, vol. ix. pt. iii. (d) Srmmlung besonderer Falle in der (I) Nosologisch therapeut. Betrachtung Hebammenkunst vol. ii. pp. 147, 148. drerier interessanter Krankheitsfalle, above (e) lb., p. 181.' cited, p. 59. Frankfurt, 1827. 8vo. (/) Hoin, above cited, p. 135. (m) Above cited, p. 59, (g) Memoires de l'Acad. de Chirurgie, (n) Kosch, Dissert, de Cystocele pen- vol. iv. p. 182. naeali Regionmont, 1826. (o) Above cited, p. 52. 356 OF RECTAL AND PHRENIC RUPTURES. ler, is to be considered merely as a variety of the perinaeal rupture in women. The intestines descend along the vagina, between it and the m. levator ani, and form a swelling on the under half of the labium. It is distinguished from inguinal rupture, by the upper part of the labium and the abdominal ring being quite free. It is felt on introducing the finger into the vagina, pressing on the side of that passage, high up. See Scarpa, above cited, p. 139. Cloquet, J.; in Nouv. Journ. de Medecine, vol. i. p. 427. Bompard; in Dictionnaire des Sciences Medicales de Bruxelles, vol. vii. p. 448. IX.—OF RECTAL RUPTURE. (Hernia Intestini recti, Lat.; Mastdarmbruch, Germ.; Hedrocele, Archocele, Hernie du Rectum, Fr.) Schreger, above cited, p. 136. 1254. In Rectal Rupture there is a prolapse ofthe rectum, which con- tains the portion of protruded intestine. The predisposition to this rupture seems to be slight inclination of the pelvis, slight projection of the promontory, and slight curving ofthe rump-bone. 1255. A rectal rupture may perhaps be inferred, firstly, from the long continuance of the prolapse and its size ; secondly, especially if the position ofthe body show slight inclination of the pelvis; thirdly, if the flatness of the upper part of the belly indicate an unnatural deepness of the small intestines; and fourthly, if the swelling of the prolapse be upon the one side of greater size, and at the same time, firmer, more elastic and fuller, than on the other. The diagnosis is determinable only by examination ; the attempt to return the prolapse gives oppor- tunity for seeing whether there be any motion of the contents, whether, in coughing and so on, the swelling reprotrude; whether the patient experience any colic in the prolapse. These experiments maybe with- out satisfactory result, if there be adhesions in the rupture. An old prolapse of the rectum, in which there is thickening, enlargement, and so on, has great resemblance to such adherent rupture. Rectal rupture may inflame ; there maybe even strangulation, by the contraction of the sphincter muscle. 1256. The treatment consists in the return of the rupture, and when this is done, in preventing its reprolapse, as will be mentioned in speak- ing of the rectal prolapse. If the replacement be impossible, the case must be treated as a prolapse of the rectum. X.—OF PHRENIC RUPTURE. (Hernia phrenica, Lat.; Zwerchfellbruch, Germ.; Hernie diaphragmaiique, Fr.) [Protrusion through the diaphragm occur in different wavs. First, Through the natural apertures by which the aorta, vena cava inferior, oesophagus and intercostal nerves pass. These are very rare, and Astley Cooper says he has never seen an instance. Morgagni mentions one, in which the omentum, the duodenum, and jejunum, with part of the ileum, ascended by the side of the oesophagus, and com- pressed the heart and lungs into a very small compass (a); also another, (a) Epist. liv. art. xiii. OF PHRENIC RUPTURE. 357 in which part of the colon, a large portion of the omentum and the pan- creas passed through the hole for the intercostal nerve. Fantoni also mentions a case, in which the stomach and part of the omentum had entered the chest by the side of the oesophagus {a). Second, From malformation of the diaphragm, which is more frequent, and is more common on the left than on the right side, and in the mus- cular than in the tendinous portion ofthe muscle (1). Macaulay men- tions one case, in which the stomach and greatest part of the pancreas had passed into the cavity ofthe left pleura; and another, in which the whole liver had entered the right pleura {b). If the protrusion and the aperture be considerable, the child dies soon after birth. But if the aperture be small, the patient may live for some years; and in the case mentioned by Astley Cooper (c), the following symptoms were ob- served. Oppression in breathing from childhood ; and as she increased in years the least hurry in exercise, or exertion of strength, produced pain in the left side, a frequent cough, and very laborious respiration. After great exertion an attack of pain in the upper part of the abdomen, with vomiting, and a sensation of something dragging to the right side, and always referred to the stomach. The cessation of these symptoms was as sudden as their accession ; after suffering severely for a short time all pain and sickness ceased. These symptoms were of longer continuance as she became older. At twenty-eight years she died, having had symptoms of strangulated rupture for some days before. On examination, eleven inches of the great arch of the colon was found to have passed through a hole, two inches in diameter, in the left side of the diaphragm into the chest, together with a considerable portion of omentum (2). These cases generally are unprovided with any hernial sac, the peritoneum and pleura both seeming to terminate at the margin of the hole. Cooper, however, relates a case, in which there was a sac considerably larger than a tennis-ball in the right side of the chest, consisting of the pleura and peritoneum united, with its orifice at a small distance from the right side of the ensiform cartilage, where there ap- peared a deficiency of fibres in the large muscle ofthe diaphragm. The sac contained the right extremity of the stomach and beginning of the duodenum, the arch of the colon, and part of the omentum (3). Third, From wounds or laceration ofthe muscle, which remain during life. This may happen from penetrating wounds with the sword, or by broken ribs being thrust through the diaphragm. Sometimes even a blow on the belly, received in a fall, will rupture the tendon of the diaphragm. The patient lived five days, and on examination the stomach and part of the duodenum were found protruded into the left pleura (4). (A. Cooper.) (1) In St. Thomas's Museum there are two specimens of Phrenic Rupture through the left side of the muscular part of the diaphragm; in the one small intes- tines, and in the other part of the stomach has passed into the chest. (2) This preparation is in the Museum at St. Thomas's. Two other cases are mentioned; one by Clark (d), and the other by the younger Monro (e). (a) De Observ. Med. et Anat. Epist. 1714. (c) Medical Records and Researches. Epist. xxiii. (d) Transactions of a Society for the im- (6) Medical Observations and Enquiries, provement of Medical and Surgical Know vol. i. p. 25. ledge, vol. ii. p. 118. (e) Treatise on Crural Hernia. Vol. ii.—31 358 MESENTERIC AND MESOCOLIC RUPTURE. (3) An instance of protrusion of half the pyloric extremity of the stomach, the whole arch of the colon and the omentum, through a hole, two inches in diameter, in the left muscular portion of the diaphragm, near the vertebras, is mentioned by Leacock (a), in a man of forty-nine, who had severe pain of the belly, especially at the pit of the stomach; constant vomiting, with rigors and disposition to syn- cope on the slightest movement. He died within thirty hours of the symptoms coming on. (4) A case of aperture through the tendon of the diaphragm, by which the stomach, transverse arch of the colon, and omentum passed into the left side of the chest, is related by Macfayden (b). XL—OF MESENTERIC AND MESOCOLIC RUPTURES. (Hernia mesenterica et mesocolica, Lat.) It might at first sight appear incorrect to describe these as ruptures, because they do not leave the cavity of the belly; but they are as truly ruptures as if they did, inasmuch as they escape from their proper cavity, the reflected peritoneum, and are found on its external surface. The mesentery and mescolon, each consisting of two layers of perito- neum, may have either of these layers naturally deficient, or torn by violence, and thus an opening may be formed, through which the intes- tines entering, separate the peritoneal layers and form a hernial pouch between them. Astley Cooper says (c) that he is unable to determine which of these is the cause of the disease, but is disposed to believe its source is in an originally defective structure. Whether these cases ever present symptoms of strangulation may be questionable. Of the two cases mentioned by A. Cooper, nothing was known, and his pre- sumption of what the symptoms might have been is of little consequence. In the mesenteric rupture, all the small intestines, except the duodenum, had passed between the mesentery by a small aperture in its hinder layer. In the mesocolic rupture, the aperture was in the front layer of the mesocolon on the right side, and it contained all the small intestines, except the duodenum, a small part of the jejunum, and the termination of the ileum. Lawrence says (d) he has seen an instance of mesocolic rupture in that portion of the mesocolon belonging to the sigmoid flexure of the colon; and also refers to Jobert's case (e), in which the intes- tine having passed through Winslow's hole had become strangulated in an opening ofthe mescolon. It may also be here noticed that Lawrence has seen the broad liga- ment of the wound separated and forming a sac similar to those just mentioned, (p. 630). As the disease is necessarily fatal, it has been proposed to open the belly near the presumed seat of the obstruction, and if possible ascer- tain it. This was done, though without success, by Dupuytren ; but his failure is attributed to his own wishes in the conduct of the operation having been overruled. The examination after death proved however that his proposal was the correct one. (f). {a) A. Cooper, above cited, p. 72. (d) Above cited, p. 630. (6) Edinb. Med. and Surg. Journ. vol. xix. (e) Traite des Maladies Chirurgicales, vol. p. 362. i. p. 522. (c) Above cited, part ii. p. 73. (/) Jobert. p. 581. STRANGULATION WITHIN THE PERITONEUM. 359 XII.—STRANGULATION OF INTESTINE WITHIN THE PERITONEAL CAVITY. The bowels may become strangulated within the peritoneal cavity, according to Astley Cooper (a), by passing through apertures in both layers of the omentum, mesentery or mesocolon; by adhesions con- sequent on inflammation leaving an aperture in which a portion of intestine becomes confined ; and by a membranous band forming at the mouth of the hernial sac, lengthening by the repeated protrusion and return of the intestine, and at last accidentally entangling and confining it. To these may also be added the adhesion of the omentum to the bottom ofthe hernial sac, which sometimes becoming tense, presses the bowel passing behind between itself and the hind wall ofthe belly, and preventing the passage of its contents, produces strangulation. Of the two latter forms notiee has already been taken (par. 1171 and 1177, note 1) as being connected with the ordinary descent of ruptures. Lawrence observes {b), " the violence of the symptoms and their fate of progress vary very much in different instances. They sometimes come on gradually, and advance very slowly, the case appearing to be one of mechanical obstruction, and being attended with an almost indo- lent enlargement of the abdomen. In other instances the close pressure ofthe stricture excites active peritonitis and enteritis; the inflammatory symptoms are strongly marked, and the case proceeds rapidly to a fatal • termination. ' As the exciting cause of the mischief is not indicated in these cases by any characteristic symptoms, they are considered and treated as examples of ordinary peritonitis and enteritis. The real nature of the malady is not suspected until it has lasted for some time and more especially from the combination of obstinate constipation with faecal vomiting. * * * The disease if left to itself is inevitably fatal," (p. 630). The subject of Internal Strangulation has occupied the attention of Rokitansky of Vienna, and he has divided it (e) into three species. First. The narrowing or complete obliteration of the canal of a piece of intestine, resulting from the pressure exerted on it at one or more spots, by a smaller or larger portion of intestine or its mesentery, so as to compress it against the opposite side of the abdomen. Second. The rotatory species, which consists of the rotation of one part round an axis farmed by some other part; it includes three subspecies; a, the rotation of a portion of in- testine round its own axis; b, round an axis formed of the mesentery i c, where a portion of intestine forms the axis round which another larger portion with its mesentery turns, so as to touch the periphery of the axis at every point. Third. This is caused by some peculiar arrangement of parts, the result of original mal- formation, or of previous disease. These strangulations of the intestine occur in circular or fissured spaees formed, a, by fibres or bands of cellular membrane run- ning from one organ to another; b, by adhesion of the free end of the vermiform appendix to some spot of the walls of the abdomen, or to a portion of intestine or mesentery; c, by adherent diverticula,- d, by the adhesion of two convolutions at a single point; e, by perforations in the mesentery, or by fissures in an omentum altered by disease. The conclusions which Rokitansky draws from the numerous cases with which his paper is illustrated are, First. That though no age precludes the possible occur- rence of internal strangulations of the intestines, yet they are most frequent in the (a) Above cited, p. 75. St, vol. xix. 1836.—Also in British and (b) Above cited. Foreign Medical Review, vol. iii. p. 495, (C) Medicinische Jabrbiicher des Oesterv. 1837. 360 RUPTURES OF THE CHEST. middle and advanced periods of life. Second. That for a longer or shorter period before the fatal termination, the patient is attacked by symptoms indicating a stran- gulation of the intestine. These generally commencing with a sudden cutting pain in the bowels (in some cases proceeding from a determinate point) followed by more or less rapid visible distention of the belly, tympany, constriction of the chest, anxiety, nausea, and vomiting, according to the violence and duration ofthe strangu- lation, sluggish bowels and long continued costiveness oecur, with or without the previous symptoms. Rest, gentle aperients, and favourable positions of the body, mitigate or dissipate these symptoms, but they reeur from the original cause, and terminate fatally. Third. The course of the affection is not generally very rapid; it seldom destroys the patient before the second day, and frequently runs on for six, eight, or ten days; rarely extends to the third week, and is then interrupted by re- missions and seeming improvements. Fourth. The disease may be distinguished mostly by the appearance of the patient; by the succeeding attacks; their origin from a determinate cause, and their course; by the intervals of ease between the attacks; by their suddenness, and progressive increase after a certain period; and finally, by insurmountable costiveness. Rokitansky rejects all medicine, especially purgatives, and proposes the knife as the only means of relief.—j. f. s.] II.—Of Ruptures of the Chest. Chaussier; in Journal de Medecine, par Leroux. March, 1814. Vergne, sur les Hernies des Poumons. Paris, 1825. 1257. Ruptures of the Chest are very rare and no other part than the lungs can easily be contained in them (Hernia Pulmonum, Lat.; Lung- mhruch, Germ. ; Hernie des Poumons, Fr). They are either congenital, and resulting from imperfect development of the walls of the chest, or they occur subsequently, by destruction ofthe walls ofthe chest, without wound of the general covering; for instance, by extensive fractures of the ribs, by tearing of the intercostal muscles, by severe cough (1), by destruction of the ribs, and so on. After such injuries, the lungs, on account of great extent and mobility, more frequently form ruptures, if they are not adherent to the surrounding parts (2). [(1) Gratelup (a) describes a protrusion of the lunp; between the sixth and seventh rib on the left side, whieh occurred during coughing. The swelling was soft and elastic, an inch and a-half long, and three quartes of an inch wide, and was painful at every inspiration. Gratelup returned it, and applied a pad with a ban- dage; after which the patient had no more inconvenience, and recovered. (2) Richter says, that " Sabatier told him of a soldier who at the battle of Rosbach was wounded in the chest. The corresponding portions of two ribs which had been shattered by the ball were lost. The opening however closed, but the broad soft scar soon yielded after the cure, and formed a bag which at every breathing alternately sunk and rose again." (p. 4, 5.)] 1258. If a pulmonary rupture occur after any of the just-mentioned occasional causes, a soft elastic swelling is produced, which gradually enlarges, often brings on a painful dragging, which ceases when the swelling is returned. Its enlargement corresponds with the movements ofthe chest in respiration. 1259. Such rupture may be easily kept back, by means of pressure, but no radical cure is to be hoped fOF, because the disease is grounded in a solution of continuity of the ribs or intercostal muscles, which cannot be restored. (a) Richter's Abhandlung von Bruchen. Edition, 1785. RUPTURES OF THE CHEST. 361 [As the lungs are occasionally found out of their proper cavity in consequence of deficient formation of the chest and other causes, so is also the heart; and this con- dition, whether it be simply unnatural position within the chest itself, or actual re- moval from it in a greater or less degree, is called displacement of the heart (Ectopia Cordis, Lat). When the congenital displacement is within the chest, the heart may be situated either, a, horizontally, which is very rare; b, vertically in the centre of the chest, as quoted by Breschet (a); c, vertically with its apex upwards and be- tween the lungs, and its base with the large vessels as low as the navel, as in De Torries' case (b); or d, the heart may be more or less to the right side, and its apex pointed in the same direction, or it may be placed completely on the right side, with or without transposition of the viscera of the belly, as in Breschet's four cases (c). Similar examples have also been noticed by other writers. When the heart is congenitally displaced without the chest, it may be either on the surface ofthe body, or beneath the skin. Ofthe former kind Breschet speaks of cases " connected with deficiency in the diaphragm and abdominal muscles, in which the heart, liver, and stomach, sometimes also the lungs and all the abdominal viscera are contained in a sac, sometimes covered only by peritoneum, sometimes by an extension of the common integuments, and sometimes occupying the sheath ofthe umbilical cord, forming a variety of umbilical rupture." (p. 25). O'Bryen has also given an account (d) of partial displacement of the heart, consequent on absence of the ensiform cartilage, and part of the recti muscles and diaphragm, in which a portion of pericardium, containing the tip of the left ventricle, preternatu- rally lengthened, protruded, together with part ofthe arch of the colon immediately beneath the integument. The child lived three months, and the heart appeared to be insensible to the touch. Or the protrusion may depend on fissure, or deficiency in the ribs or breast-bone. Of the latter kind of displacement Rami l (e) mentions a case in a girl of ten years, in whom the heart was placed below the diaphragm in the situation ofthe stomach. Deschamps (/) relates the ease of an old soldier, in whom the heart was found in place of the left kidney. Brescbet gives an account of three cases in which the heart was found in the neck. Displacement of the heart after birth may occur at any period, most commonly by various kinds of diseases; but Stokes has related (g) a "case of probable dis- location of the heart from external violence," in which the person having been crushed between a water-wheel and the embankment supporting it, had two of the lower ribs on the left side, the fifth, sixth, and seventh on the right side, and the right clavicle and humerus broken. Fdr the first three hours he was completely in- sensible. He afterwards felt great pain in the right side of the chest, with a sen- sation as if a foreign body preventing respiration had been introduced into the right lung; the pain was accompanied with violent throbbing and heaving, and it was soon discovered that his heart was'pulsating at the right side of the sternum. The person himself is quite positive that before the accident his heart beat on the left side, and was the first to notice its altered position. He recovered, and was sub- sequently able to follow his usual habits of hunting and shooting. Actual protrusion of the heart (Hernia Cordis, Lat.; Her,zbruch, Genm; Hernie du Cceur, on Cardiocek, Fr.) is very rare, even congenitally. Chaussier gives the- account of one case, a female infant in whom there was a soft roundiish swelling about an inch high, and two and a quarter inches broad at the upper and fore-part of the belly, in which on the slightest inspeotfon, the form and various movements of the heart and the dilatation and contraction of its ventricles were^ observed. Its size varied according to the different states of respiration; when the child inspired, the heart rose and seemed partially retracted into the ehest, but when she expired the heart was driven forwards and downwards and the motions of the ventricles were very manifest. The swelling gradually increased in bulk, and enlarged when the child cried, especially when she was held upright; but it became- softer and (a) Sur l'Ectopie du Cceur; in Repent. (d) Transact, of Provinc.Med. and Surg. Gener. d'Anatomie et de Physiologie Putho- Assoc., vol. vi. p 374. logiques, &c, vol. ii. p. 9. Paris, 1826. 4to. (e) Journal de Medecine, vol. xlix., p^ (6) Philos. Trans., vol. xli. p. 776, 1741. 423. (c) Memoire sur l'Ectopie du Cceur; in (/) Journal Gener. de Med., vq). xxvi. p„ Repertoire General d'Anatomie.. 275. (g-1 Edinburgh Medical and Surgical Journal, vol. xxxvi. p. 44. 31* 362 RUPTURES OF THE BRAIN. smaller when she was quiet and laid down. Gentle pressure also ^mimshed the size of the swelling. As far as could be ascertained there was a large opening on the left side of the chest, below theedge of the fourth rib: some of the ribs below, were deficient at the aperture. The child was well and healthy. Chaussier also men- tions the case of a soldier, twenty-seven years old, in whom all the breast bone was deficient below the first pair of ribs. The five following pairs of ribs had no carti- lages, but the seventh pair had cartilages, and united with each other at the mesial line. The interspace thus left on the front of the chest was large oblong, and seemed covered only by skin, and all the movements of the heart could be perceived through it: but there was not any protrusion. The man was perfectly healthy, had served several years, and sustained the ordinary fatigues of a soldier's- life (a).] HI.-—Of Ruptures of the Brain. Corvinus, Dissert, de hernia cerebri. Argent, 1749; Siebold, C, Collectioobservationummedieo-chirurgiearum. Fasc,i, art. i. De hernia cerebri. Wijizeb., 1769. Ferrand, Memoire sur l'Eneephalocele ; in Memoires de l'Academie de Chirur- gie, vol. ii. p. 61. Oehme, Dissert, de morbis reeens natorum chirurgicis. Lips., 1773. Held, Dissert, de hernia cerebri. Giess., 1777. 4to. Sallneuve, Dissert, de hernia cerebri. Getting., 1792. 8ve. NiemeyrJ De hernia congenita. Halae, 1833. Thiemig, Dissert, de hernia cerebri. Gotting., 1792. 8vo. Earle, Henry, in Med.-Chir. Trans., vol. vii. p. 427. Lipschitz, Encephaloceles aequisitae cum abseessu cerebri observ. Regimontii. 1828. Otto, A. W., Lehrbuch der pathologischen Anatomie, vol. i. Berlin, 1830. Beck; in Busch, von Graefe und and. Encyclopa)disehes Worterbuch, vol.xvi. p. 169, 1837, Article Hernia Cerebri (b). 1260. Cerebral Rupture (Hernia Cerebri, Lat.; Hirnbruch, Germ.; Hernie du Cerveau, Encephalocele, Fr.) is a swelling, depending on the protrusion of the brain through an opening in the bones of the skull, and overspread by the external coverings. It is either congenital, or may anse accidentally after birth; in the former case, the brain protrudes through some place corresponding to the sutures; in the latter, through an open- ing caused by loss of substance. [The definition just given of this ailment, whieh is the true one, shows that the term hernia cerebri, as used by English surgeons, is most improperly employed, inas- much as the disease which they so name has no resemblance to a rupture or protru- sion of the brain from its proper cavity and enveloped in its natural coverings, but is consequent on a tearing through of its investing membranes, and a luxuriant granulating process of the brain itself, for the repair of a direct injury, resulting from external viiolenee, by which that organ has been wounded ; or to fill up the defi- ciency which the ulceration exeited by irritation and subsequent suppuration, conse- quent: on inflammation and' ulceration of the dura mater, set up by ?iecrosis of the neighbouring skull-bone, has produced. The hernia cerebri of British surgeons, upon which the best paper is that of Stanley (c), is in fact, no brain-rupture at all; (a) I have extracted these cases from H ufk- (b) I have freely availed myself of this ex- land und Harles' Neues Journal, der pruk- cellent article, which is the best 1 have met tischen Arzneikunde, &c., who quote them with on a subject little attended to in this from a paper of Chaussier's in LhRoux's country.—j. f. s. Journal dp Medecine, March, 1814;. but I (c) Cases of Hernia Cerebri, with Obser- cannot find it there, or in the neighbouring vations-;. in Med.-Chir. Trans., vol. viii. p. 12. volumes.—j. f. s. CONGENITAL CEREBRAL RUPTURE. 365 it is merely a luxuriant, or so-called " fungous" growth of a brain-ulcer to fill up its cavity, and is nothing more than a neglected active healing ulcer, of which the at- tempts for its self-cure being too vigorous, assume effectually an unnatural condition, and thus prevent the reparation of the injury they were intended to cure. This state of the brain has been already noticed (par. 450, vol. i. p. 425); and it must not be confused with that now under consideration, of which a very excellent account has been given by Beck (a); nor with the blood-swellings of the heads of newly-born children, which will be noticed hereafter.—j. f, s.] 1261. Congenital Cerebral Rupture is the consequence of an incom- plete or retarded formation of the skull-bones, the interspace being filled only by fibrous membrane, through which the brain, when in a diseased state of expansion, as in hydrocephalus, protrudes (1). It occurs most commonly in the middle of the occipital bone, in the region of the great occipital hole, or at the posterior fontanele; it may be, however, at any other part of the- skull, where the bones are still separate. It is character- ized by a swelling of various size, covered by the integuments of the skull, which are thinned on the top of the swelling, and deprived of hair. The aperture, by which the brain protrudes, is irregular, and the swelling usually fluctuating, can rarely be much diminished by pressure, and recurs when left alone ; the edge of the bone is felt at its base, and the swelling has usually some pulsation. The symptoms vary according to the size ofthe rupture; if it be small, there is generally no particular disturbance, when the swelling is properly protected from external violence. In large cerebral ruptures, there arises from the weight of the swelling, tearing of the brain, and so on, pain which the child shows by slight moans and sighs, and which may be relieved by proper support and covering of the tumour. Children, with large cerebral ruptures, commonly die early, and pass their short life in continual stupefaction; are often sick, badly nou- rished, and are frequently convulsed. The swelling may inflame and burst, and the patient then soon dies. Several cerebral ruptures may exist at once. Those affected with cerebral rupture often live long, and frequently, without any disturbance of the bodily or mental powers being thereby caused. Held (b) saw a cerebral rupture, in a girl of twenty years; Guyenot (c), in a man of thirty; Richter (d), in a man of sixty; Lallemand (e), in an imbecile girl of twenty-three years; Wedemeier (/), in a young man of eighteen, who was small, imbecile, and almost speechless. On examination of congenital cerebral rupture, the galea aponeurotica and dura mater, are found tolerably united together beneath the external skin. In the sac formed by them is a large or small portion of brain, covered by the tunica arach- noidea and pia mater; the entire surface is moistened with serous vapour; and fre- quently there is a considerable quantity of serous fluid. No adhesions have been hitherto observed in this rupture. The condition of the displaced brain is similar to that within the skull, but surrounded at its base with a groove. A part of the ventricle, expanded with water, may be contained in the rupture. Not unfrequently is cerebral rupture accompanied with spina bifida. [(1) Otto observes (g) on this point, that it (Watery Rupture of the Brain; Hirnwasserbruch, Germ.; Hydrocephalocele, Fr.) " seems to depend rather on a dis- eased partial enlargement of the brain, which, if not in all, certainly in the greater number of instances, depends on hydrocephalus, rather than on deficient development ofthe skull-bones, which seems only to be consequent on that condition." (p. 409.) (a) Above cited. (e) Boyer, Traite des Maladies Chirurgi- {b) Ibid. cales, vol. v. p. 201. (c) Ferranh, above cited. (/) Von Graefe und von Walther's Jour- (d) Comment. Soc. Goetting, vol.. xv„ p. nal, vol. ix. p 126. 21. (g), Above cited. 364 CONGENITAL CEREBRAL RUPTURE. And " although in some cases, perhaps, a simply hypertrophy of the brain may cause cerebral rupture, yet hydrocephalus is usually its cause; therefore almost all the well-observed cases of cerebral rupture have distinctly shown this; and I have also noticed it in the cases which I have observed. In Penada's case (a) much water constantly trickled from the cerebral rupture; and in Earle's case (b) the water again collected after having been drawn off. Baron (c) has related an instance of a female child who was born with a remarkably large head, which at the end of a month measured twenty-nine inches in circumference. " The circumference did not farther enlarge, but a swelling began on the top of the head, over the posterior fon- tanels, which, in the space of another week acquired the magnitude of a goose's egg. At this period of the disease the mother, on going one morning to take up the child, was very much surprised to find that the swelling had become much smaller, and perfectly soft. She observed likewise a constant dribbling of water from the urinary passages, and that the bed was soaked with the discharge. It continued in- cessantly for three days and three nights. By this time the swelling had entirely disappeared, the head was considerably smaller, and the integuments which before were very much distended, now fell in large wrinkles over the child's forehead, so as actually to cover the eyes," (pp. 51, 2.) After two months the discharge by the urinary organs diminished, the head acquired greater size than before, " having on this occasion extended itself over the whole of the head and face. * * * A watery discharge, tinged with blood, was seen to ooze from the nostrils and mouth. It con- tinued without ceasing for three days, when the swelling on the top ofthe head had vanished, and the head itself was much smaller. The fluid never again accumulated in the sack on the outside of the head, nor did the head ever gain its former magni- tude, because the discharge from the nostrils was kept up, with slight intermission, til] the time of its death," (pp. 52, 3,) which occurred about eleven months after. Baron observes in explanation, that " the expansion of the brain, its membranes, and of the cranium, seems to have gone on till the parts would stretch no longer, when the rupture took place which caused the first swelling and established a free and large communication between it and the interior ofthe brain." (p. 55.) In very rare cases the fluid is contained between the brain and its membranes, and protruding, the latter forms its only contents as in Textor's (d) and Thomp- son's (e) cases. Sometimes a portion of the cerebrum, sometimes a part of the cerebellum is con- tained in these ruptures, and an instance is given in which the whole cerebellum was found in a rupture through the occipital bone (/). There is also usually fluid on which account the disease has been named hydroencephalocele. Congenital cerebral rupture is considered by Meckel (g) to arise either from col- lection of fluid in the brain, or on its surface, in which case a portion of the brain and its membranes are protruded. And as to its more frequent occurrence on the occipital bone than elsewhere, Otto sa3rs, that this happens because "the occipital bone consists of several pieces of bone, which only at a more advanced period unite, and that the water collected in the posterior horn of the ventricle can act more powerfully upon the four pits formed by the dura mater in the occipital bone than upon the other parts, which rather form an inclined plane." (p. 412.) And he sa)^s, that in this case "the brain penetrates through the enlarged occipital hole, and the cleft upper vertebrae of the neck, or through special holes in the shell ofthe occipital hone, or at its upper angle." (p. 410). Among the more rare positions of this rupture must be mentioned the cases mentioned by Moreau (h) and Rich- ter (i) in which the swelling appeared at the root ofthe nose and still more rarely, where it protrudes into the orbit, the nostril and the sphenoidal sinus. These swellings sometimes are much larger than the head itself, of which a case ■ 'a) S.igjrio d'Osservazioni e Mcmorie, vol. (e) London Medical Repository, vol. ii. p. i. p. f5. Padova, 17D3. 8vo. 353.1824. (b) Medic, ("hir. Trans., vol. vii. p. 427. (f) Kolbmanx in Siebold's Journal fiir (c) History of a case of Rupture of the die Gcburtshulfe, vol. iv. p. 150. 1>23. Brain, and its Membranes, arising from the (g) Handbuch d r Pathologischen Anato- accumulation of fluid in a case of Hydroce- mie, vol. i. p. 301. Leipzig, 1812. 8vo. phalus Internus; in Med. Chir. Trans, vol. (A) Dictionnaire de Medecine, vol. viii, viii. p. 51. p. 5!. (d) Neue Chiron., vol. i. p. 463. (i) Comment. Soc. Gotting, vol. xv. p. 29. 1804. ACCIDENTAL CEREBRAL RUPTURE. 365 has been recently mentioned by Forgemol (a); in this instance the circumference of the head above the ears was only 26 centimetres, whilst that of the tumour was 30 centimetres. Congenital cerebral rupture sometimes appears to be double, either in consequence of the little yielding of the falciform process of the dura mater, and of the longi- tudinal sinus; or by a tendinous band dividing it into two halves, as in Wepfer's case (b), which lived till six years old. These, however, must not be confounded with the actual duplicity of the hernial tumour, "twice noticed" by Otto "at its commencement in one case, and perfectly formed in the other, where the one was again divided into two halves. And in Billard's case (c) the scar above the her- nial rupture appeared to have been a second rupture." The cure of these ruptures has been denied, but Otto cites two instances, Bil- lard's, just noticed, and one of Meckel's (d),in which it occurred; "scarred spots being found where in the foetus the water had escaped, and the brain seemed to have fallen together." (p. 412.)] 1262. In Accidental Cerebral Rupture, the brain protrudes gradually, by means of its alternating pressure, at the spot where a previous injury of the skull has formed an opening, which is only closed by a cellulo- fibrous substance. As the scar has not the extensibility of the cover- ings in congenital rupture, so accidental rupture never acquires its size. The swelling always pulsates, increases somewhat during expiration, and lessens somewhat during inspiration. If the swelling can be returned, the edge ofthe opening in the bone may be felt. ["The acquired cerebral rupture is," says Beck, "so rarely observed that nothing decided can be mentioned as to its progress. If the case mentioned by Lipsius be considered as hernia cerebri acquisita, it may be concluded from it, in reference to other cases, that the danger of this condition depends on the disposition of the brain to ulcerative destruction, formation of abscess, and secondary fungus." (p. 176). This, truly, is not saying much, and indeed Chelius's observations are not more to the purpose. I do not know of any instance where, after the filling up of the opening in the skull which has been consequent on the loss of bone, either by the violence itself which has broken it, by the surgical operation which has removed it to relieve the brain from pressure, or by exfoliation, the result of direct injury or constitutional disease locally affecting the skull bone, the protrusion of the brain with its cellulo-fibrous covering has taken place. Indeed, when from either of these causes an aperture has been formed in the skull, and the corresponding wound of the soft parts around it has scarred by its edges inosculating, if the term may be permitted, with the exposed dura mater, of which the surface first granulating, either itself becomes converted into a thin skin, or is covered with skin shooting from the surrounding scalp; in such cases, instead of any protrusion of the brain and its covering membranes, there is a seeming depression, which, however, is really only correspondent to the thickness of the bone lost, and not an actual drop- ping into the cavity of the skull of the cellulo-fibrous substance, which fills up the hole left by the deficient bone. The edge of the bony aperture in these cases is almost invariably thin, scaly, and sharp,as if there had been an unsuccessful attempt to convert the cellulo-fibrous substance into bone. The pulsations of the brain are, when the patient is unexcited, sometimes, though not always, distinctly per- ceptible through this substance for some little time after the scarring has been per- fected; but sometimes, even whilst the dura mater is granulating, little or no beating ofthe brain is observable. As, however, the scar becomes older and tougher the pulsation becomes less and less perceptible, and at last entirely ceases. But though such is the case under ordinary circumstances, yet if, from any cause, the patient be agitated and the circulation quickened, the throbbing of the brain against the cel- lulo-fibrous scar is distinctly visible, and subsides only as the agitation passes off. (a) Bulletin de l'Acad. Roy. de Medecine, (c) Traite des Maladies des Enfans nou- vol. x. p. 1024. 1845. veauxnes, &c. Paris, 1828. 8vo. (6) Obs. de Affect. Capit., p. 46. Scaohusii, (d) Descript. monstrorum nonnullorum, p. 1717. 57. Lips., 1826. 366 ACCIDENTAL CEREBRAL RUPTURE. This I have frequently observed, as every one must, who has seen large apertures in the skull, from whatever cause resulting, scarred over. The cellulo-fibrous scar has a very smooth and highly polished surface, at first of a reddish colour, but subsequently as white or whiter than the surrounding skin; and more or less small blood-vessels are seen meandering upon it, which often re- main after the general vascularity of the scar has diminished, and it has become white. Like all other newly-formed parts, its vitality is not great, and consequently, it not unfrequently ulcerates superficially, heals up slowly, and again and again ulcerates and heals up in like manner. Although tough and resisting, it is not suf- ficiently stout to protect that part of the brain it covers from pressure ; and therefore, if the fingers be applied on it sufficiently firmly, the brain being pressed, its func- tions are disturbed, and convulsions, with the ordinary symptoms of compression, are produced. On the other hand, a sudden and large impulse of blood may so in- crease the bulk of the brain as to drive it against the cellulo-fibrous scar with suf- ficient force to burst through it. A very remarkable instance of this kind is men- tioned by Jamieson (a) in a girl of thirteen years, who, having fallen from the roof of a house, " broke and shattered her cranium at the place where the sagittal and coronal sutures meet, making a depression of the bone of about four inches in dia- meter;" for which she was trepanned, and "the depressed pieces of bone being all found separated from the neighbouring sound bone, were all brought away, and so left a terrible chasm in the cranium." (p. 217). In three months the integuments were cicatrized, but she continued to wear a plate of lead which had been applied over all the dressings on the fifth day after the accident, for five months, " but then, thinking herself secure, she laid it aside, and continued well seven months more, when the kink-cough, (whooping cough,) then epidemic in the place, seized her, and was so violent one night when she was in bed, that the cicatrix in her head was lacerated, and the brain was pushed out at the teguments. Being instantly called for, I found above two ounces of the brain lying on the scalp." (p. 218). Entire paralysis of the limb ensued, but she had still the use of her reason and tongue; was much inclined to sleep, had a low depressed pulse, anxietas cordis, and involuntary discharge of urine. After continuing in this state for five days, she died; but unfortunately no examination of her body was permitted.—j. f. s.] 1263. Accidental cerebral rupture is distinguished from the so-called fungus of the dura mater, by its origin ; further, by its usually only oc- curring in more advanced age, and is preceded by pain, stupor, and the like. The congenital cerebral rupture may be distinguished from the blood- swellings of new-born infants, especially by the latter, in general, being seated on the sides of the head, and being unaccompanied with any symptoms of disturbed cerebral functions; whilst congenital cerebral rupture always arises on the region of the suture. Both cerebrum and cerebellum may be protruded (b), and the greater part of the brain con- tained in the swelling (c). Trew (d), Le Dran (e), and others, have described cases of cerebral rupture occupying the right parietal bone, but they are the less to be relied on, as in neither case was there any anatomical examination. The occurrence, however, of cerebral rupture in other parts than the sutures, is proved by anatomical examination (f). Cerebral rupture is distinguished from watery cysts on the head of newly-born children, with which it agrees in reference to its seat, and by (o)The Brain forced, by coughing,through (c) Isexflamm ; in Archives Generales do the cicatrice of a wound of the head, &c.; Medecine, vol. iv. p. 229—Gaz. Med., 1834, in Medical Essays and Observations, pub- p. 667. lished by a Society in Edinburgh, vol. ii. p. (d) Sanson; in Sabatier, Medecine Ope. 217. ratoire, vol. iii. p. 403. (6) Lallemand andBAFFos; in Richer- (e) Commerc. lit. Noric, an 1738, p. 412. and, Nosographie Chirurgicale. Fourth (/) Observations de chirurgie. Paris, Edition, vol. ii. p, 318.—Boyer, above 1771, vol. i, obs, i. cited. DIAGNOSIS AND TREATMENT. 367 pressure on it causing cerebral symptoms, by its pulsation and great firmness; the diagnosis, however, is difficult when, as frequently, a col- lection of water occurs with cerebral rupture {a). 1264. The treatment of congenital and accidental cerebral rupture, consists in returning and retaining the swelling within the skull, for which purpose a sufficient degree of compression is employed by ban- dages dipped in astringent fluids, or by apparatus of leather, or less suitably, of metal, to such extent, as not to produce any symptoms. Small congenital cerebral ruptures may thus be radically cured, which is not to be expected with those arising from accident (b). If the cere- bral rupture be large, and the reduction impossible, the swelling must be supported and protected from external pressure. In such cases the puncture of the swelling has been proposed in order to discharge the fluid and lessen the bulk of the swelling. This practice is always very dangerous, although it has been practised with success. The puncture should be made with a fine needle or lancet, and after emptying, the aperture is to be closed to prevent the entrance of air. Punctures have been made very frequently with successful result (c) (1). Tying the swelling (Schneider) (d), and incision with the view of extirpation, under incorrect diagnosis (Lallemand) (e), and the removal of part ofthe protruded brain (Stanley) (/) (2), have had fatal results. Opening the swelling has sometimes first discovered the incorrectness of the diagnosis, and a dry dressing, with slight pressure, has been employed till the brain has returned, and complete scarring of the hole in the skull (g) has taken place. [(1) Henry Earle mentions (h) the case of a female child born with transpa- rent globular tumour at the back of the head which in eight days had increased to the size of a billiard-ball; it "appeared to be in its nature similar to the disease termed spina bifida, and to consist of an expansion of dura mater, containing serum, in con- sequence of a deficiency of bony or other support at this part." He made three punctures with a common needle, and let out three drachms of fluid. The punctures had not healed two days after, and pressure again discharged the same quantity of fluid. Two days after, the punctures had healed, and the sac was again full; it was then pricked with a very fine trocarrmade needle and canula, and an ounce cf serum drawn off. Five times after, at intervals of from two to four days the puncture was repeated, and at the last little fluid was evacuated, and the sac, having collapsed, thickened. . For sixteen days the case went on well, but then the sac inflamed, patches of skin came away, and a thin ichor discharged from the whole surface. Three days after, the tumour was as large as ever, but opaque and very vascular; it was then punctured with a lancet, and half an ounce only of fluid discharged. Twice afterwards, the tumour was again emptied with the lancet; but two days after the last puncture, the surface ofthe swelling inflamed, and on the day follow- ing, the flap of the last opening began to ulcerate, and in two days more extended do°wn to the cavity ofthe sac by a small aperture through which the serum continued to ooze. Three days after she died, without any symptoms of inflammation or ef- fusion on the brain. Adams mentions a case which was punctured seven times, the skin gradually thickened, the secretion of fluid diminished, but protrusion, probably a small portion ofthe cerebellum, remained. The child recovered. Puncture is not, however, free from danger. Corvinus mentions a, case (i) in (a) Hoefling, Zwei Falls von Hirnbruch; —Compare Gazette Medicale, vol. iv. p. in Casper's Wochenshrii't, 1835. No 23. 299. y Compare also Naegele. Ueber den ange- (d) Richter's chirurg. Bibliothek., vol. bornen Hirnbruch und die Kopfblutge- viii. p. v!69. schwulste Ncugeborner in diagnosticherHin- (e) Boyer, above cited. sicht; in Hufeland's Journal, 1822, May, (/"> Above cited, p. 24. p. 1. (g) Richter's chirurg. Bihliothek., vol. iv. (b) Sallneuve, above cited.—Martini; p. 55 i; and Stanley, above cited. in Froriep's Notizen, vol. xi. p. 222. (A) Above cited. (c) Froreip's Notizen, vol xx.wi. p. 346. (i) Above cited, p. 336, 368 OF PROLAPSE OF THE WOMB. which the large swelling was opened by Fried, and death ensued. Seiler (a) performed this operation, and the child died comatose on the third day. Von Graefe (b) punctured with a trocar and canula, and left in the latter to allow the escape of the fluid; but the swelling becoming painful, and assuming a dusky colour, it was withdrawn, convulsions ensued, and the child died. Pitschaft (c) relates two cases of suppurating protrusions in children, in which some ofthe brain oozed out, and which were cured by the application twice a day of linen spread with honey, with large compresses dipped in decoction of oak bark; and the internal exhibition of acorn coffee and cooling diet. The children's intellect was uninjured, (2) Stanley's cases are improperly introduced here; they were all fungous growths of the brain, soon after the removal of portions of the skull which had been depressed. Two ofthe boys died and one lived.—j. f. s.] C.—Of Prolapses. 1265. A Prolapse (prolapsus, Procidentia, Lat.; Vorfall Germ.; Chute, Fr.) is the partial or complete protrusion of an organ out of its cavity, so that it comes into immediate contact with the external air; in which consists the difference between prolapse and rupture. 1266. The common causes of prolapse, are tearing or relaxation of the natural attachments, or ofthe openings, and diseased changes ofthe organ itself. 1267. As the prolapse of the brain, lungs, and bowels have been already considered with their respective wounds, there remains only to be here considered, prolapsus of the vagina, of the womb, and of the rectum. I.—OF PROLAPSE OF THE WOMB. (Prolapsus Uteri, Hysteroptosis, Lat.; Vorfall der Gebdrmutter, Germ.; Chute de la Matrice, Fr.) Chopart, Dissert, de uteri prolapsu. Paris, 1722. Sturm, Dissert, de procidentia uteri. Erf., 1744. Sabatier, Sur les Deplacements de la Matrice et du Vagin; in Mem. de l'Acad. de Chirurg., vol. iii. p. 361. Klinge, Commentatio de uteri procidentia usuque pessariorum in hoc morbo. Gotting., 1790. Foehr, Dissert, de procidentia, uteri. Stuttg., 1793. BachmanN, Dissert, de prolapsu uteri. Duisb. 1794. Meissnerj Die dislocationen der Gebarmutter und der Mutterscheide von Seiten ihrer Entstehung, ihrer Einflusses, und ihrer Behandlung dargestellt. Leipz. 1821, vol. i. Cruvielhier, J„ M.D., AnatomievPathologique. Paris, 1828. fol. Clarke, Sir C. M., Bart., Observations on those Diseases of Females which are attended by Discharges. Part I. Third Edit., 1831. Large 8vo. Boivin, Madame, et Duge's Maladies de 1'Uterus. Paris, 1833; 2 vols. 8vo., [a) Rust's Chirurgie, vol. viii. p. 411. (c) Hufeland und Osann's Journal fur (b) von Graefe und von Walthkrs Jour, praktischer Heilk. 1832, Oct., p. 56. nal, vol. xix. p. 162. PROLAPSE OF THE WOMB. 369 and translated by G. O. Hemming, M. D., as On the Diseases of the Uterus; with Notes. 2 vols. 8vo. London, 1834. RamsbothAm, F. H., M.D., Lectures on the Morbid Affections of the Puerperal and Pregnant States, IheOrganic Diseases of the Uterine System, &c.; in London Medical Gazette, vol. xvi. p. 529. 1834-5. Blundell, James, M.D., Observations on some of the more important Diseases of Women. Edited by Castle, T., M.D. London, 1837. 8vo. Wybrand Hendrikst, Descriptio historica atque critica variarum uteri prolapsum curandi methodum. Berol., 1838 ; with three copper-plates. Richter, A. G. Chirurgische Bibliothek, vol. iii. Ulsamer, M.D.; in Busch, von Graefe und and. Encyclopaedisches Worter- buch. Article, Gebdrmutter Dislocationen, vol. xiii., p. 557. [Geddings. Observations on the Operative Procedures employed for the relief of Procidentia Uteri. American Journal of the Medical Sciences, vol. 26, p. 357. Philada. 1840.—g. w. n.] Besides the works on Diseases of Women by E. v. Siebold, Jorg, Dewees, and others. 1268. Prolapse of the Womb designates that displacement of the womb in which it descends more deeply into the vagina. According to its greater or less considerable descent, is it called complete or incom- plete prolapse. It may also be accompanied with inversion of the womb. [" The descent of the womb," says Sabatier, " has three different stages, to which have been given the names relaxation, descent, and fall or precipitation. When it is only in its first, or even in its second stage, the womb descends more or less in the vagina; a pear-shaped tumour is felt,'around which it is easy to carry the point of the finger, and which is pierced at its extremity by a transverse aper- ture. This tumour is situated higher in relaxation, and lower in descent of the womb. When, on the contrary, the disease has arrived at its third and last stage, the womb is precipitated completely out. It carries with it then the vagina, doubled upon itself, and a part of the bladder which is very adherent. Many even of the floating bowels of the lower belly sometimes sink into the kind of cul-de-sac formed by the vagina, and render the tumour monstrously large." (p. 362.) To the same effect are Blundell's observations. " There are three varieties," says he, " of this complaint, relaxation, prolapsus, and procidentia. When the womb protrudes beyond the os externum, the disease is called procidentia; when it remains at the outlet, prolapsus; when it scarcely subsides below the brim, it then constitutes what is denominated relaxation." (p. 33.) It will be readily perceived that Blun- dell's procidentia is our Author's Complete Prolapse, and that his prolapsus and relaxation are included under Incomplete Prolapse.] 1269. In Incomplete Prolapse of the Womb, {Prolapsus Uteri incom- plete,) that organ descends more or less into the vagina, and forms a pear-shaped swelling, which protruding only whilst the patient stands, can, on examination, be swept round by the finger, and at its lower part a transverse cleft, the mouth of the womb, is felt (1). Or the womb, with its neck, descends between the external generative organs, in which case the vagina is at the same time inverted, and descends with it (2). The symptoms presented by incomplete prolapse are, dull but constant pain in the rump, loins, and flanks, a weight and pressure in the vagina, frequent need of going to stool, often violent urgency, and difficulty in discharging the urine (3). All these symptoms increase if the patient standing long, have Exerted herself; and diminish or disappear entirely if she continue for a long time in the horizontal posture. If the neck of the womb have descended between the external generative parts, the movements of the body are hindered, and all great exertion rendered Vol. ii.—32 070 KINDS OF PROLAPSE impossible. The irritation which under these circumstances affects the womb, and the other organs of the pelvic cavity, may be participated in by the bowels; and the functions of the alimentary canal are often disturbed (4). At the time of menstruation all these inconveniences increase; it becomes irregular; considerable flooding frequently occurs, and is accompanied with a copious discharge of the whites. [(1) "Of the descents of the uterus, the most common, perhaps the most ob- scure and the most troublesome, is, says Blundell, "that variety in which the uterus descends but a little way, an inch or two into the pelvis, technically called relaxation of the uterus." The symptoms attending this condition, he observes, often lead the woman, if married, to suppose herself pregnant. If the medical attendant have any doubt of the case, " that doubt is to be set at rest by making a careful examination. If the disease exist, you will observe the upper part of the vagina to be very relaxed, and the womb to protrude; and were you to introduce a catheter, you would find there is a tendency to an obstruction and distortion of the urethra." (pp. 39, 40.) (2) The more advanced form of incomplete prolapse Blundell speaks of as " a more frequent disease than procidentia, complete prolapse,) and therefore still more important to be known; in which the womb comes down to the external parts, but not beyond them, and called prolapsus uteri." The symptoms, he observes, "are worse at night, because the womb comes down in the evening, the patient having been about all day;" this observation may indeed be also applied to relaxation. " On the whole, I should say," he continues, " that there are few diseases which are better characterized than prolapsus uteri" by its symptoms. If examinations be thought necessary^they "are better made in the evening than in the morning, for in the morning the womb is almost always in its place, whereas, in the evening, it is considerably descended, so that the displacement is easily recognised. To this character may be added, first, the laxity of the vagina, which, in its upper half, is much more capacious, so that, perhaps you might put a pullett's egg into it there, though the lower part of it may be tenser; secondly, a bearing on the rectum, pro- ducing irritation ; and, thirdly, if you introduce a catheter into the bladder, you will find the passage more or less distorted, the instrument moving about, and perhaps turning round completely by being thrown out of the ordinary line." (p. 37-9.) (3) The disposition to frequent voidance of the urine may arise either simply from the irritation produced by the displaced womb pressing against the neck of the bladder, or from the pressure preventing the complete emptying of that organ, or from the womb dragging it down and bending the urethra upon itself backwards and downwards to a greater or less extent. Upon this point Ramsbotham observes: —"The more vehement the woman's efforts to accomplish the relief of the bladder, the more perfect does the obstruction appear. Nor is this difficult of explanation; because, under these forcible endeavours, the diaphragm and abdominal muscles both being called into strong action, propel the uterus even lower; and in this man- ner the pressure before existing is increased." (p. 530.) (4) The irritation of the rectum is in either of the two stages now under conside- ration merely attributable to the pressure ofthe womb, and not to any dragging. 1270. In Complete Prolapse, or Falling out of the Womb, (Prolapsus Uteri completus), the organ projects entirely out of the external parts of generation; the vagina is thereby drawn afterit and doubled; the organs connected with the Womb are entirely dragged out of their place; the intestines sink into the sac produced by- the inversion ofthe vagina, and therefore a void is always noticed in the lower part of the belly (1). All the symptoms mentioned in complete prolapse here exist in a greater degree; voidance ofthe urine is specially attended with conside- rable difficulty, and often entirely prevented (2); qualmishness, sickness, spasm in the belly, sometimes fainting, severe febrile symptoms often occur, especially when the prolapse has taken place suddenly. The swelling formed by prolapsed womb has an oblong, nearly cylindrical OF THE WOMB. 371 form (3), terminates below in a narrower part, on which is found a transverse opening, (the mouth ofthe womb), from whence during men- struation blood flows, and into which a probe may be introduced not more deeply than two inches (4). The base ofthe swelling is attached to the inner skin of the labia, by which the introduction of the fingers, near the swelling, is prevented. The tumour has at first a reddish colour, and is sensible; but by contact with the air, friation, and the moisture of the urine, and so on, it becomes inflamed; a copious secre- tion of mucus takes place on its surface, and it becomes gradually insen- sible, and overspread with a thick skin, like other parts (5). The in- flammation may be severe, and run on to ulceration, and even to morti- fication (a). (1) In reference to the size of the prolapsed womb and vagina and the contents of the sac formed by the latter, Blundell observes:—" I have seen several cases in which the vagina has been forming a large tumour lying forth between the limbs ; this cyst containing not merely the womb, but in part the bladder, the small in- testines, the ovaries, and perhaps the rectum,-for where you have procidentia, it very rarely happens that the womb only descends, generally the other viscera come with it, in a larger or smaller mass. A case of this kind if you are incompetent, you may mistake for polypus, inversio uteri, not to mention a large descent of the bladder only; but when you examine the tumour with eare, you will frequently discover, first, that on the surfaee ofthe tumour, the rugae of the vagina are more or less conspicuous; secondly, that you can introduce a catheter into the tumour, pro- vided the bladder be come down; thirdly, that on passing a finger into the rectum, it may perhaps descend into the back of the cyst; lastly and above all, that at the lower part ofthe cyst, the os uteri may be found. Sometimes the os uteri is so con- spicuous that you can see it at the first glance; but at other times it appears under the form of a very minute aperture, the usual tuberele being wanting." (pp. 33,4). Cruveilhier says he has seen onecise of prolapse in the living subject in which the bowels descended into the inverted vagina, but has never met with it after death. He also observes that in consequence of the peritoneal doubling or pouch between the vagina and bladder being much shallower than that between the vagina and rectum, the vagina may be completely inverted in front, whilst it is scarcely ever so behind; and that, consequently, the vertical extent of the swelling is greater before than behind. [This observation seems to me the very contrary of what might be expeeted.—j. f. s.] For the same reason, he says also, that the front pouch is too slight generally to receive intestines into it, whilst the hind one may receive a large quantity, and that under such circumstances the prolapse may become as large as a roan's head (b). (This does not appear to me a more satisfactory statement than the former, for did the hinder pouch still remain, the protruded swelling would have the form of a double sac, separated by a cleft, the front one formed by the womb itself, and the hind one by the peritoneal sac containing intestines, and thus in fact becoming a vaginal rupture. But this is not the case, at least in the few cases I have seen (as they generally fall to the lot ofthe man-midwife, rather than the sur- geon); for in them the prolapsed part was smooth and regular, the whole circumfe- rence of the vagina having been included in the protrusion, and thus forming a common funnel into which the bowels descend.—j. f. s. "Many months, or even years, may elapse," says Clarke, "whilst the uterus is making this descent; for when the uterus has descended so far that it can rest upon the perinaeum, there it not unfrequently remains, resting upon it as upon a shelf, the ' violence of the symptoms abating, the parts which suspend the uterus above, although much lengthened, being no longer put upon the stretch. From this circumstance it should appear that the greater number of the inconveniences attending this complaint depend less upon the pressure ofthe uterusin the vagina, than upon the dragging of the parts above." (p. 68). (a) Hausmann, Dissert, de Uteri Proci- Viteb. 1728.—Saviard, Observ. chirurg. dentia. p. 58.—Sabatier, above cited, p. Paris, 1784, Froriep's chirurgische Kupfer. 362. tafeln, PI. lxi. (b) Livr. xxvi. p, 3. 372 PROLAPSE OF THE WOMB. (2) Although difficulty in voiding the urine and frequently even retention are consequent on prolapse of the womb, yet Cruveilhier has given (a) instances in which incontinence has ensued. And in the case above mentioned, in which the rectum was displaced, he states that there was involuntary discharge of the stools. (3) Clarke says that "after some time the breadth of the tumour increases, so that it becomes of a globular form." (p. 71). And farther that " the vagina, when dragged down by the uterus, sometimes undergoes such a degree of distention that its diameter will be greater than that of the pelvis itself. In the case of Watkins, who died in Kfcisington workhouse, the tumour measured more than fifteen inches in circumference, and its length was six inches and a half." (p. 125.) (4) Cruveilhier confirms Blundell's observation in reference to the altered form ofthe mouth ofthe womb, its front lip being sometimes effaced whilst the hind one is very prominent. Its direction also is sometimes changed, the long axis of its aperture being from before backwards, instead of from side to side; and occasion- ally it is so small as to seem scarcely large enough to permit the escape of the men- strual fluid (b). Cruveilhier states (c) that he has invariably observed in prolapse of the womb an elongation of that organ, accompanied with great contraction and narrowing, which occurs principally at the junction of the body with the neck. Cloquet also gives (d) an instance of the same kind. Cruveilhier farther notices (e) that some- times this elongation and at other times the descent of the womb is greatest. In some instances he found the lengthening so great that when seen within the pelvis, the womb appeared to occupy its proper position; and under these circumstances he considers that the disease commenced with the inversion of the vagina. " The lengthening of the womb," he observes, "can only be effected by previous soften- ing, in consequence of which the organ becomes in some degree ductile; this soft- ening may be perhaps, purely and simply the result of the slight pull upon the womb" (/). (5) Ramsbotham observes:—" It is worthy of remark, however, that although the local inconvenience is much more distressing when the womb protrudes without the labia than when it is still retained within the pelvis, yet the system in the former case does not suffer so much ; and the reason is obvious. While the vaginal mem- brane is protected from the external air, its secretion is kept up, and sometimes in an extensive degree; but when exposed to the atmospheric influence it ceases to secrete, and a proportionate quantity of power is therefore saved." (p. 531.) "It seldom happens," remarks Clarke, "that the vagina remains long exposed to the action of the air without ulceration taking place upon its surface. This ulcer- ation does not attack the whole of the exposed surface at once; small spots or patches inflame and ulcerate, and these sometimes run into each other, but the whole surface is seldom covered by them. The ulcerations are generally not deep, and they have the appearance of healthy sores, which readily heal upon the replace- ment of the prolapsed parts. Whenever ulcerations are met with, the os uteri seldom escapes being attacked by one of them." (p. 83.) Sometimes it happens after displacement of the bladder, consequent on prolapse ofthe womb, that stones form either in the fundus, of which Cloquet mentions (g) two instances, and Cruveilhier, one; but the latter pathologist has found a stone in that part of the bladder which had not been dragged down (h). Although the rectum is less likely to be pulled from its place than the bladder, yet this has also happened. Cruveilhier, relates (i) an instance in which the rectum, dilated and filled with stool, was drawn forwards a little above its extremity, and formed a funnel-like lengthening. And Cloquet figures (k) a case in which, with great enlargement of the rectum, a considerable finger-like process descended into the cavity of the inverted vagina."] 1271. The Causes of prolapse of the womb are predisposing and oc- casional. The former consist in relaxation of the natural attachments of the womb by copious, long-continued flow of mucus, by frequent de- (o) Livr. xxvi. p. 3. (/) Livr. xvi. p. 2. (b) Ibid. (g) Pathologie Chirurgicale. (c) Livr. xvi. p*2. (A) Livr. xxvi. p. 3. (d) Pathologie Chirurgicale (i) Livr. xvi, p. 3. (e) Livr. xxvi, p, 2, (le) Pathologie Chirurgicale. causes. 373 liveries, specially if they be very quick, or difficult, and require artifi- cial aid (1). The occasional causes are severe exertion, by which the abdominal muscles are violently contracted, raising heavy weights, violent pressure in going to stool, long-continued standing, and so on. They cause the prolapse the sooner they operate after delivery; and therefore the disease occurs most commonly in women of the lower classes who have often borne children (2). In those who have not borne children it is but rarely observed, and then severe violence must always operate, or the attachments of the womb be relaxed by great previous flow of mucus (3). During pregnancy the womb cannot easily protrude, and a considerable prolapse is itself removed by the ascent of the womb., Cases are mentioned {a) in which prolapse has occurred during preg-; nancy, and even during delivery (4); in such, violent straining must have operated, and the diameter of the pelvis have been of great size. Any diseased change of the womb which increases its weightr for in- stance, polyps and so on, or swellings which press upon it, may favour its prolapse (5). [(1) Among the causes of prolapse of the womb, Blundell notices especially, a large pelvis,- and he observes, that "this descent of the uterus, to which alt females may be subjected, when the parts are relaxed, occurs certainly most frequently where the pelvis is capacious, and not only in the earlier but sometimes in the later periods of gestation." (p. 116). (2) Ramsbotham observes, that "in the higher circles, indeed, these (last) causes do not obtain; and in them, therefore, we more often find it consequent on miscar- riage or accompanying a broken state of health. All women are aware of the ne- cessity of confinement after delivery of a mature foetus, and consequently if they have it in their power, they willingly follow the course prescribed for them. But when they have passed an ovum of only two or three months' age, as they have suffered but little pain and less discharge, and as they had scarcely been sensible of any e/largement in their person before the miscarriage commenced, ttiey con- sider the occurrence of little import; they think confinement to the horizontal posture for two or three days quite sufficient, and feel a longer restraint irksome, and in spite of advice and remonstrances will busy themselves about their domestic affairs, while still the uterus is much too bulky and heavy to be sustained by its natural supporters." (p. 530). He also states that "a violent fit of coughing occurring soon after labour or abortion, or an attack of sneezing, although the woman may still retain the re- cumbent posture, is likely to produce prolapsus,- and it may be occasioned by a rupture of the back part of the vagina and perinaeum." (p. 530.) (3) A remarkable instance of prolapse of the womb in a young woman (a virgin) was under Elliotson's care in St. Thomas's Hospital, in 1828 (b). She stated that " whilst lifting a person out of a coich, she suddenly felt intense pain in her back, and the uterus descended and protruded beyond the os externum,- its de- scent was accompanied by profuse hemorrhage. She was immediately placed in bed and a surgeon sent for, who replaced the womb. In a month afterwards, feel- ing herself quite well, she married, and ever since (five months) that peroid has suffered exceedingly from pain in her back, and from repeated descents of the uterus* accompanied with hemorrhage." (pp. 733, 34). Samuel Cooper states (c) that he has seen two. instances of prolapsed womb in maidens, in. the course of seven or eight years. Ramsbotham has known it twice in unmarried girls about twenty (a) Harvey, Exercitationes de Partu, p. vol. xiv. p. 2.'i2.—Mullner, Wahrnehmung 518.—Fabricios, Proo-r. de foetus vivi ex- einer sammt dem Kinde ausgefallenen Ge- tractione, utero prolapso. Helmst, 1748. barmutter. Nurnberg, 1771.. —Haller's Disput. chir. sel., vol. iii. p. (6) Lancet, 1827-28, vol. ii„ 434.—Saviard, above cited, p. 66.—Ducreux (c) Surgical Dictionary, Seventh Edition,, and Portal; in Sabatier, above cited, p. p. 1838. 368.—Journal de Medecine, vol. xliik p. 366. 32* 374 TREATMENT OF years of age. And other cases are related by Mauriceau, Saviard, Monro, and Cruvelhier. (4) Ullsamer (a) mentions, that he had observed "prolapse of the womb to be in one village, as it were, endemic, in almost all the women who had borne one or two children; and when its cause was subsequently ascertained, it was found that the midwife of the place, who had never been instructed, put all the women, as soon as they had the slightest labour pain, into the labour-chair, which was her only mode of assistance, and let them go on and strain, till either the birth were effected or the woman could go on no longer." (p. 561.) This cause of prolapse is not likely to occur in this country, our women being put in the recumbent posture in- stead of on the labour-chair; but the fact is worth observation. (5) Degeneration, accompanied with increased size of the neighbouring organs within the belly may, although rarely, cause prolapse of the womb, as dropsy, or hardening of the ovaries, of which an interesting example is mentioned by Kuhn (b). Clarke observes that " procidentia uteri and separation between the bones ofthe pelvis may exist together in the same patient," and mentions an instance of a young lady who, after her second confinement, was thus affected. "During and after this labour there was a considerable discharge of blood, but in other respects she was well. At the end of a fortnight she found herself incapable of standing,.and all the symptoms returned, as after her former labour," (pain in the back and groins, un- easiness in the region of the stomach, and impaired digestion, hysteria, and mucous discharge from the vagina, which were diminished by the use of a pessary, astrin- gent injections, sea bathing, and tonio medicines.) By the use ofthe means above mentioned, the fresh water bath being used of necessity instead ofthe sea bath, the symptoms all left her, excepting the pain in the back, and the incapability of stand- ing for half a minute unless supported on each side. Whenever she made the at- tempt to stand she placed her hands upon the sides of her hips. This led the author to make a firm pressure there with his own hands; and as long as this was firmly applied the patient could stand, but as soon as this support was withdrawn she was in danger of falling." (pp. 78-80.) She was cured by wearing for some time a leathern belt, an inch and a half wide, applied as tightly as she could bear it with- out pain. Clarke states that he has met with many similar cases, which recovered, but that the "progress of such cases towards health is always exceedingly slow."] 1272. The prognosis of prolapse of the womb depends on its degree and causes; it is, however, always doubtful in reference to a radical cure. The symptoms may be- very dangerous, especially if the prolapse have occurred quickly. 1273. The treatment consists in the return of the prolapsed womb, and in. the prevention of its reprolapse. 1274. In incomplete prolapse the return is unaccompanied with diffi- culty ; the womb usually returns of itself, when the patient is in the re- cumbent posture. But if this do not take place, the womb, after empty- ing the bladder and rectum, must be pushed back with the fingers, which are to be placed upon it, in the axis of the pelvis. In complete prolapse the reduction is generally more difficult, especially in fat persons, and may be impossible if the womb be considerably swollen and inflamed (1). In these cases the attempts at replacement must be made in the horizontal position, with the rump raised; warm bathing, bleeding, relaxing applica- tions, and the use of cooling remedies, having been previously resorted to; and the reduction must always be carefully made, so as not to increase the symptoms. If the womb prolapse during pregnancy, it must be returned as quickly as possible (2). If this cannot be done without efforts which may be dangerous to mother and child, it is to be feared that in the in- (a) Cited at head of this article. (b) Allgem. Medic. Annalen, part ii. p. 841. Altenburg, 1812. PROLAPSE OF THE WOMB. 375 creasing size ofthe womb its circulation may be so prevented as to cause gangrene; in which case nothing remains but to diminish the size ofthe womb by breaking the membranes, and drawing off the waters; or the womb remains lying in front of the external genitals till the completion ofthe delivery, which in many instances (which happens also in those prolapses occurring during delivery) is effected merely by the natural powers, in some by artificial assistance, and even by cutting into the mouth of the womb (a). After delivery the bulk of the womb dimi- nishes, and the reduction is easy. [(1) "Ruysch forbids the reduction ofthe prolapsed womb when it is ulcerated; but," observes Sabatier, "as this complication is only accidental, as it is only caused by the continual rubbing to which the tumour is exposed, and by the acridity of the urine with which it is bedewed, no danger is to be feared from this practice. We perceive, on the contrary, that as that which causes and sets up the ulcers with which the vagina and womb are affected ceases by its reduction, the, ulcers will heal of themselves, when the womb is in its natural place; and experience supports the truth of this reasoning." (p. 365). (2) "When prolapse occurs during the course of pregnancy," Sabatier says that "its reduction must be attempted, which is sometimes tolerably easy, the preg- nancy being but little advanced, if the reduction ,be made at once, and care have been taken previously to empty the bladder and rectum by the catheter and by clysters, and by putting the patient in a proper position. If, on the contrary, preg- nancy be far advanced, or if the prolapse have existed some time, the reduction be- comes very difficult and in this case it is more prudent to leave, the part hanging out rather than to weary the mother and child by unavailing efforts. The womb, how- ever, must not be left to itself; it must be supported by proper bandages, and the patient even kept in bed-to the ordinary termination of pregnancy. If the prolapse happen at the time of delivery, reduction becomes useless, and even dangerous. We must then occupy ourselves with the delivery of the child by gradually dilating the womb, which must be carefully supported during the operation, which though troublesome,, presents no greater difficulty than when the womb is in its natural position. The extraction, of the placenta requires much care. It is easy to perceive this must not be left to nature, and still less that the cord should be pulled in the usual way. The hand being introduced into the womb, the placenta must be de- tached according to Levket's method. After which the womb gradually contracts, and the reduction is tolerably easy." (pp. 369, 370.)] 1275. When the prolapse has been returned, the ailment is only of slight extent; and if it have not long existed, the patient requires to be kept several weeks on her back; in passing her motions, she should avoid all straining and sitting up, and she should use local and general strengthening remedies, as volatile frictures of the belly, astringent in- jections into the vagina, strengthening baths, especially tan baths, and so on (1). In this lesser degree ofthe disease, sponges moistened with astringent remedies may be introduced into the vagina (2). In com- plete prolapse the womb must, after proper reduction, be retained in its place by a mechanical contrivance, the so-called pessary. [(1) Clarke says that " in procidentia uteri, cold water ought to be applied to the female parts, to the belly, and to the back, by means of a sponge, three or four times a day; and the water for this purpose should be used as soon as it has been drawn from the spring. The water may be rendered still colder by the addition of some matter which is passing from a solid to a fluid state, as ice or salt. Cold water may also be thrown into the vagina by means of a syringe, or a piece of ice may be introduced into the vagina and suffered to dissolve there. In very slight cases of the disease, when the symptoms are just beginning, and when they are (a) Ephemerid. Natur. Curios., dec. ii. an iii. p. 375.—Jalouset ; in Journal de (Vlede- cine, vol. lxiii. 376 PESSARIES AND known to proceed from the causes which have been mentioned, they will be re- moved by attendance to these rules, assisted by the horizontal posture." (p. 95). "In procidentia ofthe uterus," Clarke farther observes, "astringent applications to the vagina become very serviceable, by diminishing its diameter, and thus rendering it less disposed to receive the displaced uterus; and also by restraining the mucous discharge." (p. 98). "A mixture of alum and sulphate of zinc, in such proportions as the nature of the case may seem to require, will sometimes fulfil the intentions of the practitioner better than either employed alone; and so of all the other mineral astringents which have been in use." (p. 101). Of the vegetable astringents, " cortex quercus, cortex granati gallae, possess a great degree of astrin- gency. They give out their astringent properties to water more readily by boiling than by infusion, and therefore the decoctions of them are to be preferred; they may be used alone, or some of the mineral astringents may be dissolved in them. By these means are procured astringent fluids of such strength, that the vagina may be so much contracted as to even render the introduction of the pipe of the female syringe difficult. Astringent injections should be thrown into the parts twice or thrice a day, or oftener, and they should be used cold." (p. 103). Upon the subject of injection, Clarke states, that "whenever it is found neces- sary to inject fluids into the vagina, and important that they should remain there for any time, the operation should be performed when the woman is in a recumbent position; and if a pillow is previously placed under the hips, in order to raise them a little, the fluid will be less likely to escape. The syringe to be employed should be capable of holding as much fluid as will fill the vagina." He objects to the mode in which the holes are generally made in the syringe, by which either the fluid passes out too quickly, or little or none reaches the upper part of the vagina, " but if the holes are all placed at the extremity of the pipe, the injection will be thrown to the upper part of the vagina, and will be sure of return by the sides." (pp. 95-7). _ _ " When ulceration has attacked the vagina, in consequence of exposure to air and pressure," Clarke recommends that "a small quantity of some warm ointment be applied to the parts affected by it, such as the following:—?* bals. Peruv. 3ij., ung. cetacei §j. M." (p. 103), (2) Clarke objects to the use of sponge, as " the worst material which can be employed for pessaries ; it is porous, and will very quickly imbibe the moisture of the parts. The piece of sponge must be large, compared with the size of the vagina, or it will be useless ; and if it is large, the vagina (the dilated state of which was one of the causes of the disease) will be still farther dilated; and although whilst the sponge is warm, the uterus will rest upon it, and the symptoms may be relieved, yet when it is removed the disease will return in an increased degree." (p. 112.)] 1276. Pessaries, {Mutterkrdnze, Germ.; Pessaire, Fr.,) in reference to their form and substance, are very various; they are oval, round, globu- lar, cylindrical, furnished with a stem, and so on; they are made of wood, or cork, caoutchouc, and covered with wax or var-nish (a). 1277. The oval pessary, made of cork overspread with wax, and provided in the middle with an opening not too large, is the most serviceable., It keeps its place whilst the two ends of the oval thrust against the sides of the vagina and pelvis. It is to be applied in the following way. The patient, her rectum and bladder having been pie- viously emptied, lies on her back, with the rump raised, her thighs apart, and bent towards the belly, the labia are to be separated with (a) Hunold, Dissert de Pessaries. Marb., Paris,1833.—Zimmermann, Erfahrungen und 1779.;—Bernstein, systematisohe Darstell- Mitheiltmgen bewahrter Aertze .und Wund- ung des chirurgischen Verbandes, p. 352.— aerzte neurer Zeit fiber Prolapsus und Car- Meissner, above cited.—Herrez de Che- cinoma Uteri nebst einer grOndlichen Be- goin; in Memoires de l'Academie de Made- leuchtung der Pessarien. Leipzig, 1834. cine, vol. ii. p. 319.—Mad. Rondet, Memoire fol. No. 148.—Gemeinsame Zeitschrifl fur sur l'emploi des Pessaires de caoutchouc, die Geburtskinde, vol. vi. pt. i. ii. SUPPORTING BANDAGES. 377 two fingers of the left hand, and with the right hand the pessary, held flat, is to be thrust so high into the vagina, that the mouth of the womb may meet its aperture when it is brought horizontal, and its two ends jut on both sides against the pelvic bones. The patient mu$t remain in the horizontal posture some hours after the introduction of the pessary to ascertain if it still keep its proper place. A large pessary must be chosen if the womb again prolapse; and a smaller one, if that intro- duced cause too much pressure. At the same time the strengthening remedies, already mentioned, {par. 1275,) must be used. If pregnancy occur, the pessary should be removed about the third or fourth month. The patient must then keep herself quiet, avoid all exertion, and, in de- livery, all pressure and excitement of labour-pains. [When the prolapse is so great that the globular pessary, which Clarke thinks is the best, will not be retained, neither can be kept in the vagina by any common bandage, he recommends " a pessary to be chosen of the size which the case requires, and a small slip of brass to be attached to it by its two ends, leaving a space between the instrument and the centre of this piece of brass; a belt of leather, long enough to go round the patient's body, is also to be prepared; to the centre of which behind, a brass wire, as thick as a common quill, is to be attached by a screw. This wire is now to be properly bent, and the pessary being introduced into the vagina, the wire is to be passed between the pessary and the piece of brass attached to it; and being brought up between the thighs, it is to be attached to the fore part of the circular strap. The reduced parts are by this means supported by a pessary, and this is kept in its place by the unyielding piece of metal." (p. 127.)] 1278. The use of the pessary is frequently accompanied with much inconvenience, as it causes pain, inflammation, stinking discharge, sup- puration, and even degeneration of the generative organs; in many cases it cannot be worn, and in many the prolapse cannot be kept up for any time (1). In such cases the only help consists in anorganic narrowing of the vagina with or without excision of its walls, by means of the suture, Elythroraphy (Hall, Berard,) Colpodesmoraphy, (Bel- lini,) or by junction of the labia by means of the suture, Episioraphy, (Fricke,) or by the introduction of a ring (2). [(1) The use of pessaries has of late years gone much out of fashion, on account of the many inconveniences which they cause; and in their stead many of our lead- ing accoucheurs prefer the use of a modified T-bandage upon the belly and perinaeum. Among these, Dr. Hull's utero-abdominal supporter is perhaps the most known and commonly used in "this country; and I have seen it employed very successfully several times in my own hospital patients, for whom it has been prescribed by our obstetric physicians. It does not appear certain that Hull was the real inventor of this bandage; at least, one very similar to it had been long previously made by Sheldrake of Leicester Square, and another and more simple had been invented many years before by King, a Surgeon at Clifton. I am not aware, however, that any good explanation of the way in which such bandages act had been given, till Hull brought Out his apparatus. He considers " Prolapsus Uteri, not as a displace- ment of the womb merely, but as a loss, of that perfect equilibrium between the upper and lower portions of the abdomen which is essential to the preservation of the relative situations of the viscera it contains, and also a dislocation of the uterus and bladder; and in some cases, as especially dependent upon a pouch-like relaxa- tion of the whole perinaeal region. His method of cure consists in giving the weakened and relaxed portions of the muscular walls of the abdomen adequate me- chanical support, which directly replaces the viscera, and gives back to the weakened walls their lost tone." (a). (a) This extract I have taken from " A Published by Weiss, of the Strand, who is brief account of the application and uses of agent for these bandages. The original the Utero-Abdominal Supporter, for relief pamphlet, published in America about ten and cure of Procidentia and Prolapsus Uteri, years ago, I have in vain endeavoured to patented by A. G. Hull, M. D." London, procure.—J. F. s. 378 OPERATIONS FOR The apparatus consists of abroad soft elastic pad, covering the whole hypogastric region, upon the middle of which the front end of a spring, like that of a common truss, acts, and from the hind end a strap passes round the opposite side of the body, and fastens on the pad. "The effect of this pad is to give the weakened lower portion of the abdominal muscles a congenial support, which, at the same time that it diminishes their labour, stimulates them by the well-known power of me- chanical pressure upon muscular tissue, to a permanent renewal of their vigour. It reduces the distended hypogastrium, aids the upward forces of the belly, and by its direction, upwards and backwards, directly relieves the pelvic viscera from the unna- tural pressure ofthe downward forces." That portion of the apparatus above described, is not always "competent to the entire relief of all cases of this species of uterine displacement; the perinaeum sometimes losing so much of its muscular and organic contractility, as not to resume its natural dimensions and situation, even when the downward forces are stayed by the hypogastric pad. In cases of this character, al- though the abdominal support of the apparatus does certainly relieve many of the distressing sensations of the patient, yet the distended floor of the pelvis remains a cul-de-sac for the reception of the viscera, whenever that apparatus is removed for a length of time. To obviate this liability, as also to give tone to the vagina by the stimulus of mechanical pressure, thereby to diminish its calibre, and restore it to its natural situation, the doctor applies against the perinaeum, externally, a prism- shaped pad or cushion, made of sponge, firmly encased in cloth, which is held in its place by a strap passing between the thighs, and over the perinaeal region, in the manner of a T-bandage. This perinaeal cushion, with its rising and sinking in perfect accordance with the respiratory motions of the diaphragm and abdominal walls, keeps up an equal, firm, and, to the patient, agreeable pressure upwards, is a good substitute for the intervaginal pessaries." Sheldrake's bandage is very similar to Hull's, but without the spring. King's bandage is very simple, and I am informed very efficient; it is, in fact, a T-bandage, of which the circular part is in two pieces, one passing round the back of the pelvis from below, the upper front spine of one hip-bone to the other, and its ends connected in front by an elastic strap, rather wide in the middle, to which is attached a perinaeal strap, also elastic, and padded more or less thickly in the peri- naeum, according to circumstances. (2) Phillips (a), in a case of prolapsed womb, for the relief of which the patient could not bear the use of any pessary, attempted to produce a scar of the vagina by destroying its mucous surface with caustic, for the purpose of causing such con- traction of the passage as would prevent the descent of the womb. Having intro- duced a three-pronged speculum vaginas and freely expanded it, he liberally applied lunar caustic upon two of the exposed surfaces, and afterwards washed out the vagina with warm water. The application gave very little pain, but its effect did not extend beyond the epithelium, and when this peeled off there was not any appear- ance of granulating surface. Six weeks after he "used the fuming nitric acid, brushing it over a larger surface by means of a camel's-hair pencil. The pain it occasioned was greater than that which followed the use of the nitrate of silver, but still it was not severe nor long-continued. The inflammatory action was much more decided, the whole thickness of the mucous tissue sloughed, and a fair granu- lating surface, yielding a considerable purulent secretion, was established." (p. 495.) The descent of the womb did not at first appear to be much checked, and it was thought of bringing the sides of the vagina together with suture, to which however the patient would not assent. Gradually the descent of the womb diminished, and for eight months had entirely ceased, the capacity of the vagina having diminished to that of a woman who had never borne children. If pessaries be used, they should be occasionally removed to cleanse them of any acrid or gritty substance which may have become attached and be likely to excite inflammation and ulceration. Clarke also remarks, " that instances too have oc- curred, where parts of the instrument have been destroyed by a spontaneous change taking place in it, and angular portions of it having been left, which have produced similar bad effects ;" of which he gives an instance. And he also mentions a re- markable case, in which "a supposed schirrous tumour surrounding the os uteri was found to be a cork pessary, introduced many years before, and rendered very (a) London Medical Gazette, New Series, 1838-39, vol. ii. PROLAPSE OF THE WOMB. 379 rough by calculous matter deposited on its surface. It was withdrawn, and all the symptoms subsided in the course of a week." (pp. 116, 17.)] 1279. According to Hall {a), after the womb has been forced down by the patient's efforts as much as possible, two parallel cuts should be made along the whole length of the vagina, from the neck of the womb to its entrance, through the mucous membrane, which is to be separated, so that an interspace of two and a half inches is laid bare between the two incisions. A stitch is then to be put in through both edges of the wound near the neck of the womb, the womb itself to be returned, and the threads tied firmly together. Several ligatures may in the same way be gradually applied (1). Ireland (b) has successfully practised Hall's method, which he has only modi- fied with the view of avoiding more certainly the bladder and rectum, by making the incisions on the sides nearly parallel, but converging at their extremities, by removing the flaps above and below, and applying all the sutures before returning the womb. Velpeau and Berard have performed Ireland's modified operation, but they also removed a third slip from the front of the vagina (c). [It has been a dispute with whom this operation originated. Velpeau, in his Clinical Lecture just cited, says, that " the first idea of this operation is due to Ge- RARDmwho described it in a memoir which he presented to the Societe de Medecine de Metz ou de Nancy, which however was never published. He proposed to con- tract the vagina, and if necessary even to obliterate it, in women in whom the cata- menia had ceased. He found many opponents to his ideas, which were rejected." (p. 276.) Velpeau does not mention in what manner it was proposed to effect the contraction ofthe vagina, neither does Gerardin himself in his letter to the Academie (d), in which he says, that "before 1823 he had proved that the pessary might be replaced by and the cure of prolapsed womb radically effected by a surgical opera- tion." It is therefore just possible, though not very probable, that Marshall Hall might have been aware of Gerardin's suggestion before he proposed and had his operation performed by Hemming (e) in the autumn of 1831.—j. f. s. (1) Dieffenbach (/) made use of the actual cautery for the cure of prolapsed womb; but not being satisfied with it, has laid it aside. Lawrie of Glasgow, how- ever, mentions (g) the case of a girl of eighteen, who had prolapsed womb sud- denly produced by carrying a heavy tub ; nitrate of silver was freely applied, astringent injections and other remedies used, and strips of the mucous membrane dissected off the sides and back of the vagina, but without benefit. He then, having dilated with Weiss's speculum, applied the actual cautery on either side of the vagina, nearly as high as the womb. The operation was very painful, the external parts became cedematous, she had retention of urine, some pain in the belly, and hysterical symptoms, which readily yielded to mild treatment. She was kept in the recumbent posture for six weeks; and left the hospital nine weeks after the operation, without the least tendency to the renewal of prolapse ; but having a cir- cular contraction of the vagina, just below the womb. Nine months after, the pro- trusion recurred, after long standing and unwonted exercise. The actual cautery was again applied, the same symptoms produced, but subsided, after one bleeding, aperients, fomentations, &c. She was kept in bed for nine months; then allowed to get up, wearing a compress in the perinaeum, and a T-bandage, and was perfectly cured. Ker (h) mentions a case of prolapsed womb, which would not yield to the usual means for its return, but was treated effectually with ergot of rye. The woman (a) London Medical Gazette, vol. ix. p. (/) Medicinische Vereinszeitung, 1836, 269. 1830. No. 13. (6) Dublin Journal, vol. vi. p. 486. 1835. (g) Medical Gazette, vol. xxviii. p. 757. (c) Archives Generales, vol. viii. p. 515, 1841. Second Scries.—Journal Hebdom., vol. iii. p. (h) Efficacy of the Secale cornutum in a 275. 1835. case of Irreducible Prolapsus Uteri; in Lon- (d) Gazette Medicale, vol. iii. p. 533. don Medical Gazette, vol. xiv, p. 604. 1834. (e) London Medical Gazette, 1835, vol. i. p. 266. 380 OPERATIONS FOR PROLAPSE OF WOMB. had had external prolapse for three years, which returned when she lay down,' but at last a complete prolapse of the uterus took place, which could not be returned. " Sixteen hours after, the uterus was considerably enlarged, little if at all, below the size of the foetal head ; indeed, in a condition decidedly cedematous." Attempts at reduction, mild aperients, warm fomentations and injection, all failed; and after having been persisted in for twenty-four hours, it was determined to give the Secale cornutum in scruple doses every three hours. After taking the first dose she com- plained of a great deal of grasping grinding pain in that which was down, very much resembling labour, and these pains increased on each succeeding dose. On examination, a material diminution in the size of the prolapsed womb was found to have occurred, so much so that the rugae of the vagina were perfectly manifest, and without any great effort the reduction was effected.] kg 1280. Bellini (a), with a pair of hook forceps, grasps the upper seg- ment of the externally-protruded vagina, draws it down, and giving the forceps to an assistant, begins at the outer edge of the vaginal commis- sure, upon the left side of the swelling, with a flat curved needle armed with two threads, to unround it, and with the thread form a half-circle, in the form of a horse-shoe, or an CS, and thrusting the thread in and out at intervals of two lines. To prevent injury to the rectum, the forefinger of the left hand must be introduced, for the careful direction of the needle, which should be passed no deeper than the walls ofthe vagina, and with every stitch only one line of it is to be taken hold of. When the upper part of the swelling is reached, it must be surrounded with four stitches, and the needle carried in the same way downwards, to complete the horse-shoe. The ends ofthe threads are now to be drawn together, so as to fold up the prolapse, and then fastened with a loop knot. The after-treatment consists in rest, blood-letting, cold fomenta- tion, and diet. After two or three days, the threads may be drawn tighter. A portion of the mucous membrane of the vagina, separates after ten days, a scar forms in the vagina and prolapse never recurs. 1281. Episoraphy is performed, according to Fricke (b), in the fol- lowing manner:—After the patient has been properly placed, the sur- geon takes hold of one labium with one hand, thrusts in a pointed bis- toury about two fingers from the upper commissure, and a full finger's breadth from the edge of the labium, and carries it down to the fraenulum, where he brings it out again in a small curve, so that a portion of the labium of a finger's breadth width is separated, and then the upper still attached part of this portion of skin is to be completely cut through in an oblique direction. The same proceeding is to be adopted1! with the other side, and so carried on to the fraenulum that a part of the latter is removed, and both cuts brought together at an angle, at a finger's breadth from the fraenulum. After the bleeding from the spouting arteries has been stopped by torsion, and from the little vessels by cold water, both edges of the wound are to be brought together with from ten to twelve stitches. It should be previously con- sidered whether the prolapse can be kept up merely by quiet position or not; and in the latter case, previous to putting in the stitches, a piece of oiled sponge, upon which a thread is attached, should be introduced into the vagina. The patient, after the operation, is to be laid on her side, with the rump somewhat raised, and the knees tied together. Ap- (a) Bulletino delle Scienze Medica. Nov., (b) Annalen der chirurg. Abtheilung dee Dec., 1835. Krankenhauses zu Hamburg, vol. ii. p. 142. OPERATIONS FOR PROLAPSE OF WOMB, 381 plications of cold water or lead wash should be made to the wound, and the urine drawn off by the catheter, for the first few days. Though, however, no perfect union ensue, yet usually the prolapse is partially kept up. The vaginal mucus and the menstrual blood escape, and coitus can be effected by the opening remaining at the upper part. Should pregnancy ensue, the adhesion may be divided, or cuts on the sides made at the time of delivery (1). (1) Kock (a) uses the quill-stitch in episioraphy. Plath (b) gives the account of a birth after episioraphy. A bridge still existed; in delivery the lower opening dilated, and was still farther enlarged by three cuts on the sides. The result was completely satisfactory. [Gi:ddings of Maryland (c) has performed successfully the operation of episiora- phy four times in the following manner. The patient being placed in the ordinary position for lithotomy, and the prolapsus reduced, one labium was put on the stretch by an assistant, and an incision was commenced, with a common scalpel, about a finger's breadth from the upper commissure, and the same distance from the edge of the labium. The incision was carried downwards with a bold sweep, and ter- minated by a slight curve inwards, and at a little distance behind the fourchette. A slip of the labium, of a finger's-breadth in thickness, was thus severed from the external parts, taking care not to cut through the mucous membrane of the vagina. Making traction on this slip downwards and inwards, the mucous membrane of the lateral portion of the vaginp, was then dissected up to the extent of an inch and a half, and detached with the excised labium. The same was repeated on the opposite side, the incision being so directed as to intersect the first cut at an acute angle, and remove the fourchette with the other parts. After the slight haemorrhage had ceased, an oiled sponge was introduced into the vagina, and the two raw surfaces brought into apposition by the quilled suture of five stitches. A compress of lint, and a T-bandage were applied, and the parts kept cool with cold water. The sponge which had been introduced to keep up the womb till adhesion had taken place, was generally removed about the fifth or sixth day ; and the sutures were taken out, as the parts seemed to have united.] 1282. For the purpose of holding the labia together, and thereby pre- venting prolapse, a hinge ring, about the size of a large ear-ring, should be used; it is to be drawn through the lower part of both labia and closed, so that it may lie iri the region of the fraenulum (d). 1283. An old prolapse oftentimes cannot be returned without causing anxiety, pain in the belly, costiveness, and other symptoms (e). In this case, the womb must be supported with a bandage, and care must be taken for the proper emptying of the bladder and rectum (1). If the completely prolapsed womb be so changed by disease, as for example, by schirrhus, that its removal is indicated, this must be effected by the ligature (2) or by incision; the latter at least has been done successfully, by Langenbeck (f) (3). [(1) When, in consequence ofthe altered position of the bladder often attending prolapse of the womb, the urine cannot be voided, and it becomes necessary to in* troduce a catheter, the altered direction of the urethra must not be forgotten; and according to the directions of Cruveilhier, the instrument must be directed down* wards and backwards with its concavity downwards, and thus it " first enters th© (a) von Graefe und von Walther's Jour- nal, vol. xxv. p. 667. (6) Hamburger Zeitschrift, vol. ii. pt. ii. (c) American Journal of Medical Science, vol. 26, p. 364, 1840; also Braithwaite's Retrospect, vol. iii. p. 151. 1841. Second Edition. (d) Kraus ; in Medicinischen Correspon* Vol. ii.—33 denzblatt" des Wilrtemb, arzth Vereines., July, 1843, Nov. 20.—Hevfelder, Das chi* rurg. und Augenkranken Clinicum der Uni- vers. Erlangen, 1843, p. 45. (e) Riciiter's Chirurg. Biblioth. vol. iii, p. 141. (/) Neue Biblioth. fur die Chirurg. und Ophthalm., vol. i» p. 551. 382 PROLAPSE WITH INVERSION displaced part of the bladder and is afterwards raised by a lever-like movement into that portion of it still remaining in its natural situation" (a). ..... (2) The removal of a prolapsed schirrous womb was effected with the ligature by Recamier and Marjolin; but the woman died from some cause independent ofthe operation. Cruveilhier, who mentions this case (b), objects to the treatment as being accompanied with great risk of including a portion of the bladder in the liga- ture. He recommends, in preference, cutting through the back of the vagina,[into the doubling of peritoneum between it and the rectum, then drawing the womb through the aperture and detaching it from its cellular connexions with the bladder. (3) In Langenbeck's operation, the womb, after cutting across the vagina, was drawn down, separated from the peritoneum without opening its cavity, and cut off, excepting a small portion of its fundus, which being healthy, was left undisturbed.] IL—OF PROLAPSE OF THE WOMB WITH INVERSION. (Prolapsus Uteri cum inversione, Lat.; Vorfalle der Gebarmutter mit Umstulpung, Germ.; Chute et Renversement de la Matrice, Fr.) Sabatier, above cited, p. 375. Fries, C. F., Abhandlung von der Umkehrung oder eigentlichen, in version der Gebarmutter. Miinster, 1804. Herzog, E. B., Dissert, de inversione uteri. Wirceb., 1817. Newnham> W., An Essay on the Symptoms, Causes, and Treatment of Inversio Uteri; with a history of a successful extirpation of that organ during the chronic stage of the disease. London, 1818. Crosse, John Green, An Essay, literary and practial, on Inversio Uteri; in Trans, of the Prov. Med. and Surg. Assoc, New Series, vol. i. p. 285. 1845. 8Vo. 1284. Under the term Prolapse of the Womb with Inversion is under- stood the dropping down of the fundus of the womb into its cavity, and the sinking down of the fundus and body into the mouth of the womb, into the vagina, and even its protrusion at the external generative parts. It is, therefore, distinguished as incomplete and complete inversion; in the former case the fundus of the womb protrudes more or less through its mouth, and forms a semicircular swelling, which is encompassed by the mouth of the womb ; in the latter the whole womb is protruded, from its fundus to its neck, through its mouth, and lies in front of the external generative parts in shape of a pear-formed swelling. [Crosse observes:—" Inversion of the uterus is either partial or total; the latter can exist only in one degree, and admits of no subdivisions. Partial inversion, on the contrary, comprises very many degrees; and there are both physiological and practical reasons for noticing and describing three, by way of classification; namely, depression, introversion, and perversion. Depression, the first division and slightest degree of partial inversion, is present, when any portion of the entire thickness of the walls of the uterus becomes convex towards its cavity or interior, without going to the extent of being invaginated, or brought within the grasp of the rest of the uterus, supposing it to. contract by the action of its muscular coats. The interior convexity is answered by a concavity of the same extent on the exterior surface of the womb. The posterior, lateral, or even perhaps the anterior part of the body of the organ, may be thus displaced after par- turition ; but usually the fundus is the part affected. * * * The palpable evidence of this degree of inversion is obtained by examination through the parietes of the abdomen, or by the hand in utero meeting with a convexity of more or less firmness according to the atonic or contracted state of the part, and giving the idea of a pla- centa still remaining, after the entire placenta has been removed. If the placenta be (a) Livr. xxvi. p. 2. (b) Livr. xvi. p. 4. OF THE WOMB. 383 still adherent, its attachment is to the inverted portion, and any attempt to remove it by traction will increase the inversion. Introversion is when so great a part of the fundus is displaced, as that it comes within the grasp of the portion of the uterus, into which it is received. The great- est degree of this displacement consists in the fundus and continuous part of the body of the uterus being received into the remainder of its body and cervix, th& convexity of the fundus being palpable at the os tineas. The inverted portion is in a situation to be resisted, supported, compressed, and otherwise acted upon, by the uninverted, by which it is always surrounded. In proportion to the degree of intro- version is the depth and extent of the peritoneal pouch opening towards the abdomen. The uterine ligaments are in part drawn into this pouch, and the ovaria approximate, the marginal circle corresponding to the angle of inflexion. On examining above the pubes, the circular margin of the uterus can be felt forming the boundary of the inversion, and the uterus and part of the body of the organ are wanting; in a thin patient, and where the abdominal parietes are relaxed and yielding, the fingers ofthe accoucheur may even enter the orifice of the peritoneal pouch, pressing those pa- rietes before them. If the placenta be still attached, it is felt at the ostincse, or in the cavity ofthe uterus, and judged to be of unusual size; if partially detached it allows of great haemorrhage, which may cease on its removal, if the inverted fundus contract, and be felt firm to the touch ; but haemorrhage continues if the inverted mass be soft, indicating that it is still in a state of inertia. Perversion is when more or less of the inverted portion of the uterus projects through the os tineas; in its greatest degree the whole body of the uterus as well as the fundus, passes inverted through the os, the cervix only remaining in situ, encir- cling the contiguous or highest part of the inverted portion, all the rest being un- compressed and unsupported by the uterus. The peritoneal pouch is lengthened, and the proper uterine cavity nearly obliterated. Where " the inverted part is sur- rounded by the cervix, it may constrict it, producing congestion and even strangula- tion in all the rest of the inverted organ below. The angle- of inflexion (so first named by Radford of Manchester) is always below the middle of the body of the uterus. In considering the successive steps of the inverting process, we trace the descent of the fundus through the uterine cavity until it projects at the os, fills the vagina, and reaches the external labia; and the process may go on in the same direction to its completion, the invertedfundus and even body of the uterus prolapsing externally, until the encircling cervix descends, under expulsive efforts, to a level with the labia, andbecomes apparent under ocular examination. But if the labia-iesist sufficiently the farther descent of the fundus, and part ofthe body ofthe uterus remains still un- inverted, may not the process be carried to its completion by ascent of the cervix ? No author has hinted at this view of the subject, and yet its correctness must be ad- mitted, in order to explain the well-established fact, that where the inverted fundus and body of the uterus are still in the vagina, the cervix is felt high above the pubes, even near to the navel, sometimes taking the situation the fundus would normally occupy, the vagina being proportionally stretched and carried upwards,—changes which can only be explained by supposing that, at a eertain stage, the inversion ceased to progress by descent of the fundus, and was continued and -completed by ascent ofthe cervix. If'the placenta be still adhering, it precedes the fundus, is felt in the vagina, or observed at the external labia, giving the attendant an impression of its being firmer than usual, and of greater size. * * * If the placenta be already away, a convex tumour occupies the vagina, of a greater or less size, according to the proportion of the body of the organ inverted, having a soft, slightly nodulated surface, bleeding easily under the touch, its highest part encircled by the cervix. If the cervix only remain uninverted, the fundus and body of the uterus maybe so large as to fill the bony pelvis, distend the vagina and render it difficult, if not impractica- ble for the accoucheur to reach the cervix; but as often as the inverted mass pro- lapses at the vulva, the encircling cervix can be felt. * * * Examination above the pubes may enable the accoucheur to detect the orifice leading to the peritoneal pouch, formed by'the inverted fundus and body of the uterus, or in the case of external pro- lapse at the vulva, to convince himself of the absence of the organ from the abdo- men, (pp. 283-99.) "In all degrees of inversion," says Crosse, "there is a concavity or pouch lined with pertioneum, and open toward the general peritoneal cavity. In simple depres- 384 PROLAPSE WITH INVERSION sion the intestines rest in the concavity; and as the pouch or cul-de-sac increases, the intestines may, if the opening into it be large, occupy this pouch, so that in total inversion, with prolapse, they may actually descend beyond the external labia, still resting in the peritoneal bag, which the inversion has occasioned." (p. 308.)] 1285. The inversion of the womb occurs either suddenly, or gradu- ally; the former is possible only during delivery, when it quickly fol- lows if the woman be in the upright posture, and strain very violently at the moment when the child is forced out; or it may occur from pull- ing at the navel-string, from too short or coiled up navel-string, and so much the more as the pelvis is wide (1). The inversion may be pro- duced gradually by polypous growths at the fundus of the womb (2), by .a slight inbending of the fundus, which remains after previous de- livery, and gradually increases; in which case there is generally only imperfect inversion-(3). (1) According to Hachmann, fa), there may be spontaneous inversion dependent on spasm, probably from deficient contraction of the womb, analogous to partial contraction, which is observed in stricture of the womb, in which case, for instance, the relaxed and toneless fundus, sinks inwards, is grasped by the contracting body, and descends completely down to the mouth ofthe womb. [(2) On this point Clarke observes:—"It is said that inversion maybe pro- duced by the weight of a polypus attached to the fundus ofthe uterus. This cause may, of course, render unmarried women the Subjects of this disease; but it will be rarely met with, first, because polypus itself is infrequent; secondly, because the polypus must be very large and heavy, that it may have the power of drawing down the uterus; thirdly, because an unimpregnated uterus is unyielding and firm; and fourthly, because the polypus, to produce that effect, must be attached to the fundus of the uterus." (p. 150). Crosse, however, says:—" Next to pregnancy, the most frequent cause of en- largement ofthe uterus is a polypous tumour, which, when attached, as often hap- pens, to the internal fundus ofthe organ, may occasion its inversion in all the different degrees that have been referred to. Any of the various tumours that progress to- wards the uterine cavity, and take the polypoid form, may induce inversion; but the vesicular polypus, being softer and of less density than others, and having usually a narrow neck, is less likely, in the progress of its growth and of its expulsion, to cause uterine inversion, whilst the polypus of great density, and with a broad basis, and particularly the fibrous, is not unfrequently followed in its later stages by the displacement in question." (p. 321). Inversion of the womb from polypus is as various as from any other cause. "At first so partial," says Crosse, "that the polypus is still situated in the uterus, and next it descends into the vagina, bringing the inverted fundus to the os,- then the polypus protrudes at the labia, the displace- ment being carried to the greatest degree of partial inversion, and filling the vagina, whilst the cervix alone continues in situ, or is itself inverted with part of the vagina. A farther stage remains, in which the uterine inversion is total, and prolapses ex- ternally, bringing with it the vagina, also inverted, (p. 331). If the polypus be attached to any part of the fundus, at the terminating opening of either ofthe Fal- lopian tubes, or in the interspace between those openings, it may determine a partial and limited inversion, whilst still remaining wholly or chiefly within the uterus.. The symptoms are the same as a polypus produces, without inversion, and cannot be considered characteristic, although generally more severe, such as un- easiness in the uterine region, forcing pains, leucorrhcea, and menorrhagia." (p. 324). (3) "In addition to what has been already stated, we may," says Crosse, "enu- merate coagulated blood accumulated in the uterus, and an hydatidous growth, or mole, occupying its cavity, each of which has been known to cause uterine inver- sion." (p. 338). Of the majority ofthe cases referred to the former cause, Crosse has considerable doubt.. '*Some," he says, "are unsatisfactory, others evidently (a) Einige Falle von krankhafter Lage- zin der Ausland Literatur. Nov., Dec, 1834, veranderung des Uterus;. in Hamb. Maga- p. 352. OF THE WOMB. 385 stated in error, the epoch of the inversion having manifested itself to the unsuspect- ing or uninstructed observer, (perhaps some seven or ten days after delivery,) not being the commencement of the displacement, which was coincident with the ter- mination of the labour. With more correctness may we regard distention of the uterus from blood as a cause of the relapse of inversion." (p. 339). As to the cases uncomplicated with pregnancy, "where blood was the primary cause of enlargement ofthe uterine cavity," he says, "I cannot quote any so objectionable as the case related by Mr. Watkinson (a), in which a woman of fifty years of age had inver- sion take place under protracted and very severe menorrhagia, in which, as Wat- kinson supposed, in a relaxed state of the os uteri, and perhaps of the uterus itself, owing to protracted haemorrhage, the organ became inverted on the expulsion of coagula. At the expiration of four or five years the inverted womb hung half way down towards the knees, with a neck formed by the inverted vagina, about the size of one's wrist. The patient was reduced to imminent danger of life by sloughing and abscess, when the uterus Was removed by incision below a ligature placed on the vagina with a fatal result. Of inversion following the expulsion of hydatidous masses, he mentions the case recited by Dr. Thatcher, of Edinburgh, in his lectures, in which the woman acknowledged that she had pulled away a protruding mass, which consisted of an immense accumulation of hydatids, firmly cemented by nearly cartilaginous bands, and had thus produced the same result as from in- judiciously pulling the umbilical cord for the extraction of the placenta after deli- very. There was "every diagnostic mark of the inverted uterus, with the os uteri clear and defined, surrounding its upper base." Attempts to return it were fruitless, and "at midnight the uterus was close down on the os externum. Next morning it was found fully protruded at the vulva, in shape and size like the largest caout- chouc bottle for injection." It could not be returned, and therefore, on the third day "a ligature of silver wire was applied close to the os uteri, with the double canula as for polypous. The ordinary means for supporting strength and preserving cleanliness were used. On the third day from the application of the ligature sepa- ration was nearly effected, and the slightly remanent portion was divided with the scalpel." (pp. 340-42.)] 12S6. The quick-formed inversion of the womb is commonly accom- panied with severe pain, bleeding, inflammation, and swelling of the prolapsed part, and if it be complete, with sickness, fainting (1), con- vulsions, depressed powers, small and scarcely distinguishable pulse, and with danger of mortification and death; in a complete inversion, however, all the symptoms may be absent (Hachmann). The slowly- forming inversion ofthe womb prevents the discharge of the urine and stools, causes irregular menstruation, bleeding, inflammation of the womb and neighbouring parts, pain in the belly, hsemorrhoidal incon- veniences, whites, hardening, excoriation and ulcers of the womb (2), bad nourishment, dropsical swellings, hectic fever, and so on. [(1) Upon these symptoms Dailliez (b) makes the following interesting ob- servation:—"A loop of intestine may follow the fundus of the womb, insinuate itself into the cavity, of which the entrance is at first very large, become strangu- lated, as has been observed after bursting of the womb, and give rise to new symp- toms, which have hitherto been merely regarded as sympathetic. The intestinal pains, the swelling of the belly, the sickness, vomitings, hiccough, so frequently attributed to reversion of the womb, may actually depend in some women only on, this strangulation." (p. 80). (2) " Whilst the inverted uterus remains in the vagina, the discharge (excepting at the periods of menstruation) will be of a mucous kind," observes Clarke ; " but if the uterus falls lower, so as to protrude beyond the external parts, the exposure of that surface, which, in a natural state, lined the cavity, to air, as well as to occa- sional injuries, may induce inflammation and ulceration over a part, or the whole of its surface; and th© mucous discharge may be changed to one of a purulent kind, so considerable in quantity as to debilitate the constitution, and to cause all thecommoa (a) London Medical and Physical Journal,, vol. vii. p. 435* (b) Theses 33* 386 PROLAPSE WITH INVERSION OF THE WOMB. symptoms of weakness. If there are any ulcerations upon the surface of the upper part of the tumour, formed by the inversion ofthe vagina, they will be circumscribed, and rarely cover its whole surface." (p. 155.)] 1287. Inversion is distinguished from prolapse of the womb by the pear-shaped swelling, broad below, on which no opening is found (par. 1269). The distinction from a polyp of the womb is always difficult, and depends on the following circumstances ; in the complete inversion,, the form of the swelling resembles indeed that of the polyp, but it is enclosed at the upper part by a fold, and neither the finger nor a probe can be passed up between the swelling and this fold, as it can in polyp; the completely inverted womb has also at its upper part, from being hollow, a soft and yielding character. But this distinction is especially difficult in an incomplete and slowly produced inversion. When the inverted womb still lies in the vagina, it is broader above than below,- but the polyp has the directly contrary form; the swelling of the pro- lapsed womb has a more definite feel than the polyp, which last is more moveable and its surface smoother than that of the prolapsed womb. The simple inbending ofthe womb may in some degree be felt through the skin of the belly. The diagnosis is considerably assisted by the origin of the ailment after previous deKvery. But all these circum- stances may, in certain cases, lead to no definite results; for the form of polyps as well as their sensibility and mobility varies; both swellings may present a smooth or uneven surface; the polyp may appear soon after birth ; the examination of the belly in stout persons gives no result. It seems to deserve particular attention that the polyp, when it has once penetrated the mouth of the womb, grows remarkably quick. 1288. The first indication, in inverted womb, is to return it to its place as soon as possible because otherwise by the quickly ensuing in- flammation and swelling, its replacement is difficult and impossible. If the inveision be incomplete and recent, it is sufficient to thrust up the bottom of the womb gently through its mouth with the fingers of the right or left hand collected in a conical form. If the inversion be com- plete, if it have continued some hours, or days, the fundus must be grasped with the whole hand, and whilst gently compressed, should be pushed up in the axis of the pelvis. In difficult cases the object may perhaps be attained, if two fingers be passed by the side of the protruded fundus of the womb into its mouth, enlarging it and then first returning that part next the mouth and afterwards the bottom of the womb. After the reduction, is completed, the hand is to. be kept in the womb till, by simultaneous rubbing and sprinkling the belly with cold water, it have perfectly contracted, and the after-birth, if still retained, have been thrown ofl'(l). Quiet in the supine posture with the rump raised, and the avoidance of all exertion, are favourable to keeping the returned womb in place (2). If the replacement be impossible, from the inflammation and swelling, or if on account of the increase of dangerous symptoms, especially of convulsions, it cannot be undertaken, then, after the womb has been gently thrust into the vagina,it must be attempted to diminish the swelling by suitable antiphlogistic treatment, and by simultaneous empty- ing of the bladder and rectum, before proceeding to its return (3). At- tempts at replacement must not be continued too long, nor too violently, because thereby the most dangerous symptoms arise; but should be re- TREATMENT OF— 387 peated after a suitable pause. In one such case the womb has been seen to return by the ensuing contraction,(a.). (1) If the placenta remain still attached to the prolapsed womb, its separation must be first effected, before any attempt at replacement, because the reduction to- gether with that of'the placenta is considered impossible; but as this is contradicted by experience, the removal ofthe placenta renders the reduction doubtful, and dan- gerous bleeding may be easily produced ; so the greater number of modem accou- cheurs agree to attempt its reduetion, together with that of the placenta, and only to remove it when it adheres very slightly. (2) In chronic inversion, it becomes more difficult to preserve the womb in its place, because it has lost its power of contractility. To effect this, some have re- commended the introduction of pessaries, (Rousset,) of several pieces of sponge, (Jorg,) of a caoutchouc bottle, (Fries,) and of peculiar supports for the womb, (L6EFFLER, SlEBOLD). ["In a case where the uterus has been long inverted, and lies in the vagina, (the latter cavity having undergone no change, except from distention,) it will not be advisable," says Clarke, " to recommend any other remedy than the injection of some very mild astringent fluid three or four times a day, into the vagina. Some restraint will thus be placed upon the quantity of the discharge, and the parts will be kept clean by it. Pessaries are useless; the vagina being already so completely filled that nothing more can be retained in it." (p. 156). (3) In the treatment of recent inversion, Clarke lays down, that " the uterus is to be first returned to its usual state and natural situation ; and the case then becoming simply one of a retained placenta is to be treated as such; but if, neglecting this order of proceeding, the placenta should be first removed, a number of bleeding ves- sels will be exposed before the uterus can contract, so as to restrain the haemor- rhage ; and the chance is, that the patient may die from its effects." (p. 152). Inversion of the womb "is occasionally met with in the chronic state," says Clarke, attended by a mucous discharge. The symptoms ofthe chronic state re- semble those of procidentia uteri; and, an examination being made, a tumour is found either in the vagina or hanging out of the external parts. Such a tumour may be mistaken for polypus; but in the latter disease, the os uteri encircles the tumour; in inversion ofthe uterus, the os uteri forms a part ofthe tumour itself. Moreover, the inverted uterus is sensible; polypi of the uterus, on the contrary, are void of feel- ing." (p. 153.)] 1289. If the return of an inverted womb be impossible, dangerous symptoms must be prevented by properly emptying the bladder and rectum by the avoidance of all effort and so on, and by the introduction of a pessary to prevent, if possible, the farther descent of the womb. But if the inversion be accompanied with threatening symptoms, if the replacement be in nowise possible, if the womb be in a state of cancer- ous or other kind of degeneration, then may the cases related {b) of suc- cessful removal ofthe womb, determine us to its removal with the knife, after previously applying a ligature; or with the ligature, in which it is best to apply two ligatures with a single needle and to tie them on each (a) Saxtorph's gesammelte Schriften ge- burtshiilflichen Inhaltes; translated into German by Scheel. Copenhagen, 1803, p. 305 (6) Berengarh Carpi, Comment, ad Mun- dini Anatom., p. 225.—Dietrich, C M., Rede von einem Vorfalle und glucklich unter- nommener Absetzung der Mutter. Niirnb., 1745. 4to.—Faivre; in Journal de Mede- cine, vol. iv.—Wrisberg, Commentatio de Uteri rnox post partum naturalem resectione no3j, lethali. Gotting. 1787.—Ricuter's. chirurg. Biblipthek., v*l. viii. p. 671.—Newn- ham, above cited.—Windsor, J., Some Ob. servations on Inversions ofthe Uterus, with a case of successful extirpalion of that organ ; in Med.-Chir. Trans., vol. x. p. 358.—von Siebold's Journal" fur Geburtshulfe, u. s. w., vol. v. pt. ii. p. 406.—Bottger, in von Graefe und Walther's Journal, vol. xxiii. pt. ii.— Kettler, in Oester. Medicinischen Jahr- biichern, vol. xi. pt. iii.—Cook, J. C, Case of Loss of the Uterus and its appendages soon after delivery; with remarks on the propriety of removing that organ in cases of Inversion or. Scirrhus. London, 1836. 388 TREATMENT. side to prevent slipping; it must, however, be borne in mind that the in- testines may have descended in the place of the inverted womb. [When the inverted womb falls out of the body, drawing with it the vagina, and increasing weakness is produced by the quantity of the discharge, " if this case is left to itself, the woman," observes Clarke, "either drags on a miserable existence for a number of years, or her life is cut short by the constant drain. Cases of this kind can receive very little benefit from external applications; and it is obvious that not much is to be expected from internal medicines. Powdered chalk or lapis calaminaris, sprinkled upon the part, may check the discharge a little; the oxide of zinc may in some measure abate its quantity; but it will not remove it altogether; and the same observation will apply to astringent applications generally. The fol- lowing application may have a beneficial effect:—^ Hq- calcis giv. mucil. sem. cydon. 3vj. M. * * * It may be considered more prudent, if the discharge diminishes in consequence of such applications, to persevere with them, rather than to risk any danger which may arise from an operation. In those cases of inversion of the uterus, where the woman has passed the menstruating age, where her comfort is de- stroyed by the disease, and where the profuseness of the discharge threatens her with death from the debility which it produces, it may be advisable to recommend the performance of an operation, which has been in many instances attended with success, and frOm which the author has known a patient recover after she has at- tained the age of sixty; this operation is the removal of the inverted uterus itself. Although it is not expedient to subject a patient labouring under a chronic inversion of the uterus during the menstruating portion of her life, under ordinary circum- stances, to the danger of the removal of the organ, the system of a woman may be so drained by the excessive discharge as to warrant the performance of the opera- tion." (pp. 157, 58). It does not appear that the removal of the inverted womb by ligature is danger- ous; the cases treated by Clarke himself, as well as those he quotes, did well; so also Blundell's case, and he observes:—" Indeed I have not heard even of any cases in which the operation has been followed by fatal consequences ; though such cases must, I presume, occasionally occcur." (p. 145). In one of Clarke's cases, "a strong silken ligature was used, and although nearly three weeks elapsed be- fore the uterus was separated during which symptoms of inflammatory action pre- sented themselves in full force, with vomiting and diarrhoea, the result was most successful, and perfect health was restored, (p. 159). In another, in which the operation was performed by Chevalier, "a ligature was applied round the con- tracted part of the tumour, that is, where the uterus terminated, and the vagina began. It was tightened daily, until about the eleventh or twelfth day, when the parts included in the ligature were absorbed, and the uterus fell off. During this time the patient complained of very little pain." (p. 163). Blundell "applied the ligature with Hunter's needle, as in the case of polypus, and in eleven days the uterus came away; it sloughed, and softened down, so as not to separate bodily, in the form of uterus, and the recovery of the patient was complete." (p. 144). In Dr. Joseph Clarke's case (a), " the pressure by ligature, which the partially in- verted uterus bore for many days, not only with impunity, but with decided benefit to the future health, constitutes the leading feature of this case. When the uterus became completely -inverted, its amputation became an easy operation, and the patient's previous good health suffered no diminution." (p. 161). Dr. Symonds of Oxford (b) applied a ligature in a case of inverted womb in a young woman, eighteen years of age, two years and a half after the delivery of a living child. The placenta had been long retained, and was brought away with great violence. The ligature was tightened every other day, and the patient did not suffer much pain till this had been several times repeated. The tumour sepa- rated on the fifteenth day; three or four days after, dangerous symptoms appeared; and on the sixth day after, she died. On examination, about a quart of pus was found in the peritoneal cavity ; the bladder and omentum were adherent; and there was a free and open passage between the vagina and the abdominal cavity; of a circular form, capable of admitting the finger, and consisting of the ring of the os (a) Edinburgh Medical Annals, vol. ii. p. (b) North of England Medical and Surgi- 419, and also quoted as above by Clarke. cal Journal, vol. i. p. 149. PROLAPSE OF THE VAGINA. 389 uteri, and about three lines of the cervix, close upon it were the ovaries, of natural appearance, and the remains of the Fallopian tubes. III.—PROLAPSE OF THE VAGINA. (Prolapsus Vaginas, Lat.; Vorfall der Muterscheide, Germ.; Chute du Vagin, Fr.) Schrager, Dissert, de prolapsu vaginae uteri. Lips. 1725. Strochlin, J. G., Dissert, de relaxatione vaginae, prolapsu et inversione uteri. Argent., 1749. Sabatier, above cited, p. 390. Loder, J. C, Prog, i.-iii. de vaginae uteri procidentia. Jen., 1781. Meisner, above cited, p. 212. Clarke, Charles, above cited, part i. p. 142. 1290. When the canal of skin which forms the vagina protrudes wholly or entirely from the labia, it is called Prolapse ofthe Vagina. It may consist either of the internal membrane alone, or of all the mem- branes of this canal; in the former case only is it possible for the womb not to descend at the same time. The prolapse is either complete or in- complete; in the former, the whole of the vagina descends; in the latter, only a part at one or other side, and usually on the front. [The prolapse which Chelius treats of more especially, must be considered as the anterior prolapse ofthe vagina, and differs decidedly from the form described by Clarke, who says, " the term procidentia vaginae is here meant to imply a relaxa- tion of the posterior part of the vagina, so that this part is lower than the natural defined edge of the perinaeum." (p. 142). From this description, it may be fairly distinguished as the posterior prolapse ofthe vagina. John Burns (a) says, that " the rectum, in every degree, is more or less drawn down, and brought forward, sometimes so much so as to form a kind of pouch in the protruded vagina." (p. 78.)] 1291. The Complete Prolapse is at first characterized by a soft bluish red, slightly wrinkled or smooth ring which, by its gradual lengthening, acquires a cylindrical form, and, at its lower end, has an aperture into which the finger may be introduced, and the mouth of the womb felt. The prolapse is increased by standing, and generally returns in the hori- zontal posture. If it have existed for some time, the condition of the skin is changed, it becomes dry, and similar to the common tegument; it may inflame, pass on to ulceration, and so on. Inconveniences are con- nected with prolapse of the vagina similar to those accompanying pro- lapse ofthe womb, only in a slighter degree ; the patient feels, especially if the prolapse have occurred suddenly, a pressure in the vagina, a con- stant disposition to void the urine and stools; she is subject to a copious flow of whites, the menstruation becomes irregular, and on every violent exertion prolapse of the womb is to be feared. Imperfect Prolapse forms a blind sac, at the under end of which there is not any opening, and at the side of which the finger may be passed into the canal of the vagina. The prolapse which depends on vaginal rupture, has been already mentioned (par. 1248). The diagnosis between prolapse of the vagina and that of the womb is easily determined by the symptoms mentioned, by the excrescences in the vagina^ and by examination. (a) Principles of Midwifery. Ninth Edition. 390 PROLAPSE OF THE VAGINA. ["Very few symptoms attend this complaint," says Clarke; "some pain in the back is present, but this is not considerable; some transparent mucus comes away from the vagina, and the woman complains of a relaxation in the parts, and of some- thing projecting from them." (p. 145). "In the earlier stage," Blundell (a) ob- serves, "the tumour is very small,,perhaps not larger than the ball of the apex of the fore-finger, forming at the back or front of the vagina, or laterally, or in all three positions at once, protrusion by no means uncommon. These protrusions, if small in size, maybe looked upon as natural to the part; but they often show a disposition to increase, and then begin to attract attention." (p. 29.)] 1292. The following circumstances predispose to prolapse of the vagina; relaxation, and slight cohesion of the vagina, and its surround- ing cellular tissue in cachectic subjects after a violent flow of whites, after frequent deliveries, especially if the perinaeum be torn, after too, frequent coitus, onanism, and the like. The occasional causes are, violent exertions in lifting heavy weights, in violent vomiting, shriek- ing, and the like ; violent efforts in delivery, especially in improper pos- tures, in going to stool and so on ; also pressure from the parts sur- rounding the vagina, for instance, from large stones in the urinary bladder, from retention of urine, dropsy of the belly, and so on, may produce prolapse. It arises in general suddenly or slowly. [Clarke's form of prolapsed vagina is considered by him to arise from the habi- tual constipation of the bowels, to which women subject themselves, in consequence of which "the lower part ofthe intestinal canal becomes so distended sometimes as to make the posterior part of the vagina approach near to the anterior part of the pelvis, and in this way the diameter of the vagina may be much diminished. This extreme distention of the gut at length diminishes, or takes off the power of con- traction upon its contents, and the strength of the sphincter muscle is increased by its frequent resistance to the contraction of the intestines and abdominal muscles; at length, when, by the operation of purgative medicine, or by the natural strong ef- forts of the intestines, or by manual assistance, (which is sometimes required,) the lower bowel is emptied of its contents, the pouch formed by it, and the posterior part of the vagina continues, so as to form procidentia vaginas. If the fore-finger of the surgeon is passed into the anus, under such circumstances, and carried forwards, it will be directed into the pouch so formed. This disease appears sometimes to be produced by piles, acting in the same manner as habitual costiveness. * * * The complaint may also be produced by cysts belonging to diseased ovaries, falling down into the hollow between the rectum and the posterior part of the vagina. In one case where this happened in labour, it was only " terminated by opening the child's head, by means of which operation the life ofthe woman was saved. After the labour, the cyst went up again into the cavity of the abdomen ; and the vagina being no longer pressed down, regained its natural situation." (pp. 143, 44.) Clarke farther observes, that " when the patient is in the horizontal posture, the tumour made by the prolapsed vagina is somewhat smaller than when she is erect; but it never goes away altogether. Its size is sometimes as large as a hen's egg. Very few symptoms attend the complaint." (p. 145,)] 1293. A small and recent prolapse of the vagina is easily returned if the patient being put in the horizontal posture, on her back, with the rump raised, the protrusion be pressed back with the finger well oiled, and the skin of the vagina als/> pressed every where on the sides. If the replacement be prevented by inflammation and swelling, or the pro- lapse be of long standing, luke-warm baths, softening applications, a longer continued supine posture, and attention to the free voidance of the urine and stools must be employed. [For curing the posterior prolapse, Clarke says:—" The practitioner is to direct proper means to keep the rectum empty, and thus to remove one of its causes; after- wards he is to endeavour to restore the tone of the gut. Without attending to the (a) Above cited. PROLAPSE OF THE BLADDER. 391 first of these objects, the second cannot be accomplished ; and unless the tone ofthe bowel is restored, the mere emptying of it will be useless. Purgatives given by the mouth, and clysters thrown into the rectum, are the means by which the first of these objects is to be attained. If piles are present, the class of resinous, purgatives is to be avoided. * * * As in some instances, the gut is so much distended as en- tirely to have lost its power of action; neither clysters nor purgatives will be of any avail; the clyster-pipe, as it passes into the rectum, will be blocked up by fasces; and purgatives will only bring a large quantity of faeces down, which will add to the bulk, already too great. Nothing remains in this case but to empty the rectum by manual operation. * * * The patient being placed on her left side on a bed, her knees being drawn upwards, the fore-finger of the right hand of the surgeon, covered with oil, is to be introduced into the vagina; a marrow-spoon, or the small end of a common table-spoon, covered with oil, and warmed, is then to be introduced into the rectum; and by means of it, assisted by the finger in the vagina, the faeces are to be scooped away. A large clyster is then to be thrown up; and if any faeculent matter should be lying in the sigmoid flexure of the colon, it will be brought down into the rectum, where it may be easily removed. For the purpose of giving tone to the rectum, the same means are to be employed as are calculated to produce similar effects in other parts of the body. Bandages are not applicable to this case. The object is to give support to the posterior part of the vagina and to the weakened rectum. A globular pessary answers both of these purposes very well, and it should be carefully adapted to the size of the vagina. * * * Costiveness in future is to be carefully prevented." (pp. 146-48.)] 1294. To prevent the reprolapse of the vagina, the introduction of pads filled with astringent substances, and steeped in red wine, or sponges cut in conical form, moistened with astringent fluids, should be used previous to employing the pessary. The patient must for a long time observe rest and a horizontal posture; and employ the remedies advised (par. 1275) for strengthening the relaxed parts. In old pro- lapses, which cannot in any way be kept up, the operation already men- tioned in prolapse of the womb, {par. 1278,) by narrowing or closing the vagina, can alone get rid of the evil. *IIL—OF PROLAPSE OF THE BLADDER. (Prolapsus Vesicae, Lat.; Harnblasenvorfall, Germ.; Chute de la Vessie, Fr.) Clarke, C. M., above cited, part. i. p. 130. Blundell James, M.D., above cited, p. 31. [Prolapse of the Bladder may be easily mistaken for prolapse of the vagina, and has been confused, though with less cause, with that of the womb, although some of the symptoms are common to both. The pro- lapsed bladder falls back, just behind its neck, carrying with it, into the cavity ofthe vagina, the front of that passage, and the twO together de- scend less or more completely, and appear at the os externum in form of a convex or hemispherical swelling, which fills up the orifice, and sometimes protrudes between the labia, the transverse folds of the vagina being less or more distinct upon it, according as the bladder is full or empty. The sensation of bearing down is less great than in prolapsed womb; but it is in some women greatest in the horizontal posture; in the night, therefore, the patient is much annoyed with this sensation, which is fre- quently accompanied with a perpetual desire to make water. The dis- comfort and protrusion is greatest when the bladder is full; but it rarely 392 PROLAPSE OF THE BLADDER. happens that that organ can be completely emptied, the muscular fibres forming the pouch or tumour not appearing to have the power of con- tracting completely. The peculiar symptom of prolapse of the bladder is a pain referred to the navel, with a sense of tightness there; the pain greatest when the bladder contains the largest quantity of urine, dimi- nishing as the water is voided, and ceasing when the bladder is nearly or entirely emptied. This symptom is especially noted by Clarke, who thinks it may be accounted for, perhaps, by a stretched state of the um- bilical ligament, (the remains of the umbilical arteries,) or by the drag- ging upon the navel itself. The pressure of the back of the bladder on the front of the vagina lengthens the cellular tissue, connecting it with the front of the cervix uteri; but, as it does not yield readily, it drags down with it the anterior lip ofthe os uteri, and lengthens it very much. Hence, "the os uteri," says Clarke, "instead of being found in the centre of the pelvis, opens directly backwards, and lies in contact with he posterior part of the vagina; so that the space between the elon- gated anterior lip of the os uteri, and the posterior part of the vagina is very small;" and sometimes, indeed, the as is patulous. There is often a discharge of mucus in these cases, and rarely it is profuse. Prolapse of the bladder is distinguished from prolapsed womb, by the absence of the stomach symptoms, which rarely, if ever, occur when there is mere displacement of the bladder (Clarke). There is not any aperture in the protruded part, as in prolapsed womb; but the swelling has a regular fo/ra, filling up more or less completely the cavity of the vagina, but admitting the finger to be passed up between itself and the hind wall of that passage, to the mouth of the womb. Clarke says that, on tracing the tumour in the vagina "to its origin, it may be felt lying between the os pubis before, and the uterus behind ; and a practi- tioner can hardly fail to discover that it is formed by fluid." The latter part of this observation is correct; but its relative condition with regard to the womb will depend upon the extent of the dropping down of the bladder, and the position of the womb is rather above than behind the tumour^ The diminution of the size of the swelling when the bladder is emptied, is also another characteristic, and distinguishes the disease from the encysted or other tumours which occasionally, though rarely, form in the neighbourhood of these parts. If the catheter be introduced, it can be easily felt within the cavity of the swelling, (an excellent indication of the disease,) and, under volun- tary urging, the swelling is found to increase considerably in size. By these two marks the disease may be readily known (Blundell). If the prolapse occur during labour, care must be taken not to mistake it for the descending portion of the membranes, by which irreparable mischief has been inflicted (Castle). The treatment consists in keeping the bladder constantly empty, in the injection of astringents, and in wearing a pessary, either globular, or egg-shaped. The latter is, perhaps, the most preferable, "particu- larly," says Clarke, "where the diameter of the vagina is but little increased by relaxation." All exertion which might force the bowels down upon the bladder should be avoided, and the patient should be kept quiet; and, perhaps, if confined to the recumbent posture upon OF THE BLADDER. 393 her face, with a catheter in her bladder, so that the urine might pass off without being retained in the bladder, and thus the disposition of that organ to contract encouraged and kept up till the vagina had recovered sufficient tone to resist the pressure of the protruding bladder. The use of the pessary and astringents is said to be generally sufficient for the cure of prolapse of the bladder; but sometimes the instrument cannot be borne, and the downward pressure of the swelling is so great and inconvenient, that the woman is incapable of any exertion, or even of moving about without much distress. Under such circumstances, it will be advisable to take out a portion of the front wall of the vagina, and thus diminish its disposition to yield to the pressure of the bladder. Cases of prolapse of the bladder do not often fall under the surgeon's care, in this country, except when the ordinary treatment with pessaries and injections fail, and it becomes a question whether the patient can be relieved by an operation. One such instance has come under my care, and been considerably relieved; for, al- though not entirely cured, the patient has been enabled to resume her ordinary occu- pation. Case.—M. A., aged twenty-five years, a fair-haired, hysterical, well-formed, but not stout single woman, came under my care, Oct. 24, 1837.—She began to menstruate when sixteen years old, and for the first year had good health ; but since that period has been continually ailing, and suffered" very much at her monthly times. The menstrual discharge has been scanty, and not lasting more than two days, when she has been so unwell as to be quiet; but, when engaged in her occupation as housemaid, and able to be about, it has been plentiful, and lasted four days. She has always had much bearing down, and, within the last three or four years, has suffered much from leucorrhcsa, and the bearing down has so increased, that, for the last twelvemonth, she has been unable to follow her usual employment, and been compelled to give up her place. Five months ago the protrusion was as large as a cowrie-shell, and, when she exerted herself, it became much larger. She did not usually void her urine for twelve or sixteen hours, and then the protrusion disappeared. MicturitiQn was always accom- panied with sharp smarting pain; it was long before she could void any water; sometimes not for eighteen or twenty hours. By repeated efforts, however, she was at last enabled to empty her bladder, and never required the introduction of a catheter. Last spring she attempted wearing an Indian-rubber pear-shaped pessary; but it was useless, as, whenever she walked about, it immediately dropped out. For the last three months she has kept in bed, used astringent injections, and worn a sponge pessary, which has kept the swelling up, but without any actual im- provement. Nov. 11.—I made an examination with the view of ascertaining the feasibility of removing some horizontal slips of the front of the vagina, as suggested to me by my friend Dr. Locock. As she had not made water for three hoiJrs, the bladder was partially filled, and a swelling, about the size of a cowrie, protruded through the os externum vaginae, and just appeared in front of the furcula. Some of the rugae of the vagina were very distinct, and the swelling began a full inch behind the orifice of the meatus, which canal was not at all displaced, and allowed the ready entrance of a catheter into the bladder. Slight pressure returned the tumour, and the os uteri was then found depressed to within an inch of the os externum. On expanding the vagina with the speculum, it was seen to be so drawn off from the front of the neck of the womb, that no appearance of neck remained; but from the plane of the os uteri to the front wall of the vagina, was one continuous and very open curve; but the cul-de-sac, behind the neck, was, on the contrary, very deep. Having withdrawn the speculum, I could, without difficulty, nip up an inch and a half of the vagina from the back of the bladder; and having ascertained this, it was determined to remove a slip or two of the lax part. Nov. 12.—Having bound her, and put her in a position for lithotomy, as there was but little protrusion, and her efforts failed of driving the swelling down, I com- menced the operation by pinching up the front of the vagina, and passing a tenacu- lum through, drew it down; I then introduced a needle and ligature, about an inch Vol. ii.—34 394 PROLAPSE below the os uteri, and half an inch above the tenaculum, for the purpose of draw- ing down the vagina after the removal of the proposed slip, and to prevent difficulty from its retraction. The portion of the vagina included on the tenaculum was then drawn down, and having been felt to be separated from the bladder, I made a hori- zontal cut, about an inch and a half in length, carefully separated the vagina from the bladder, first with the blade, and after with the handle of the knife, till I could hold the slip with my thumb and finger, and withdrew the tenaculum. I then sepa- rated the flap till it was an inch in depth at the middle, but tapering to a point at each end, and cut it off horizontally below with a pair of scissors. There was pretty free bleeding,, but only one small vessel could be found to tie, and it ceased after sponging with cold water for about a quarter of an hour. I then introduced three platina sutures upon very small needles, the middle one first, and having brought the edges of the wound close, twisted them together. She was then put to bed upon her face, a catheter introduced, and the urine directed to be withdrawn hourly. The operation was not difficult, nor very painful; but there was a little awkwardness in getting the sutures through, perhaps from the small size of the needles. Nov. 13.—Last evening there had been a little oozing of blood; but during the night a considerable quantity; one sheet having been soaked through, has been re- moved, a second is in much the same state, and there is about eight ounces of clot in the hair of the pubes. She feels rather faint, but her face is much flushed. She has passed plenty of water, both through and by the side of the catheter; but she complains of much pain in the chest and loins, with great tenderness of the belly. As it did not seem well to permit the continuance of the bleeding, I removed the catheter,.cleared away all the clot, and introduced the speculum. No clot was found in the vagina, but there was a free oozing from between the lips of the wound. Failing to find any vessel, I removed the right suture, upon which the wound gaped, and seizing its upper lip whilst she strained, I drew it down, and carefully examined the whole surface, from which the oozing was very free. After considerable trouble, I found and tied three small bleeding vessels, which, however, I believe to be veins, and the bleeding being checked, I passed a silk suture, and again introduced the catheter. Nov. 15.—She has not had any more bleeding, and the pain and tenderness of the belly have diminished, but the latter still continues about the region ofthe bladder. There is a little fetid discharge from the vagina, and some small thin flakes of ad- hesive matter in the urine. On examining with the speculum, I found all the sutures had begun to ulcerate, and therefore removed them; the metallic ones with some difficulty, as they did not readily untwist. The wound did not gape, but the extent of the union could not be ascertained. On the front of the vagina, near the neck of the womb was a seemingly ulcerated spot, perhaps where the first thread for drawing down had been passed. She had a tolerably good night, and next morning drew off about half a pint of very ammoniacal urine, with much adhesive flakes ; this evacuation was followed with great pain in the bladder and pudendum, for about half an hour, and then gra- dually subsided. In the course of the day, the quantity of water drawn off in- creased, and became quite clear. She had not any febrile excitement, but still complained of much pain in the left breast, across the pit of the stomach, and over the whole belly, which is probably only hysterical. She had an increase ofthe throbbing in the wound, which has been constant since the operation. Nov. 17.—The throbbing has diminished, and the discharge from the vagina has increased, and is distinctly purulent. She has still much pain in the region of the bladder, and the urine is much loaded with adhesive matter. Nov. 19.—Is better, and has passed plenty of urine, which yesterday was scanty, and the sediment in it mucoid. Less throbbing in the vagina, but the discharge increased. Complained of pain and soreness, with beating in the umbilical re- gion, and some tenderness on pressure, as also about the region of the bladder; and also pain in the upper part of the thigh. Her bowels are kept regular with castor oil. In the course of the evening she became very hysterical, and it was necessary to give her some aether and tincture of henbane, with camphor mixture. But next day she had recovered herself, and her bowels having been freely moved, the ab- dominal pain almost entirely ceased. Nov. 22.—The speculum was intrrduced to examine the state of the parts, but being inefficient was withdrawn, and the os externum being held widely apart with OF THE BLADDER. 395 the fingers, she was desired to bear down. This brought the wound into view, which had not yet united, but was healing by granulation. There was a free leucorrhoza. Jan. G, 1838.—Up to the present time she has been kept in bed, and the wound has healed. The discharge continues very profuse, and she has much pain in the loins. On examination the bladder was found still falling back as previous to the operation. A fortnight after, she was allowed to get up and walk about; the descent of the bladder soon became as at first, and protruding between the labia when she exerted herself. The operation had therefore been unavailing. In the middle of March, after going about moreihan usual, the bladder protruded to the size of an egg, and on the following day still more ; but a few days rest in the recumbent posture re- stored the old condition. As she continued very delicate, it was determined she should go to the sea-side for the improvement of her constitutional powers, and she went to Brighton in April, wearing a globular pessary, which kept the bladder up; hut after a month as it caused much pain in the region of the bladder, it was thought advisable to remove it, which was done with much difficulty, and in course of the following week the protrusion returned. For some weeks she used a cold salt water hip-bath daily, and the recumbent posture; and afterwards, sea-bathing three or four times a week, but without diminution ofthe discharge, and with no benefit to her health. The vagina was then cauterized with the caustic potash thrice, at intervals ofa week; from the first application there was little sloughing, the second caused much, and the third less, but more than the first; and during the separation ofthe sloughs, she used injections of cold sea water continually, and took forty drops of the tincture of muriate of iron twice a day. She left Brighton in September without any material im- provement and returned home to her usual employment. Soon after, the dragging pain in her loins and the protrusion increased, and if she walked a short distance, these became worse, and were accompanied with pain in the upper part of both thighs. In December, a ring pessary was introduced to relieve the protrusion, but its pressure upon the rectum was so great, that she could not pass her motions, and after having been worn three days, it was necessary it should be removed. She came under my care again in January, 1839, much out of health and spirits ; nothing therefore was done but to improve these, and I did not make any examina- tion till the middle of April. The bladder was then still fallen, but less than be- fore, merely appearing at the os externum, and returned with the least pressure with the fingers; the scar on the front of the vagina, of which the shortening was very decided, was quite visible, and though nothard was tender; the position of the womb and the state of its lip was nearly the same as at first. Thinking, as little pressure kept the bladder in place, a small oval pessary might be useful, I introduced one; but the next day the bladder had slipped down between it and the pubes, and she had so much pain that it was necessary to remove it. Although kept in the recumbent posture, she still had severe dragging pain in the loins, equally as when she was about; and as she objected to the application of caustic again, but was willing to submit to an operation, I determined on removing a vertical piece ofthe vagina, which was done May 18.—She was now placed standing with her body bent at right angle with her legs, and resting upon a table, with the pelvis rather higher than the shoulders. A pewter speculum, slit lengthways and the edges widely opened, was introduced into the vagina, with the gap towards its front; a catheter was introduced ; the labia held apart by assistants, and the perinaeum pressed up with the speculum. I then seized the front ofthe vagina with Beaumont's needle and drew it down till I could con- veniently pass a tenaculum through it, which done, the needle was withdrawn. Pulling up the vagina with the tenaculum as far as I could, I cautiously made two simi-ellipticle cuts about an inch and a half in length, from half an inch below the neck of the womb to about the same distance behind the urethra. The right cut was made freely with a common scalpel, but the left required a little more care and was made by short portions, cutting upwards, with a phimosis knife which was very convenient; and the insulated piece was then dissected off the bladder, leaving a gap about half an inch wide, which was increased to an inch by paring the edges of the wound. There was as in the former operation, very free oozing of blood, and it became necessary to tie two small arteries. Three sutures were put in very 396 PROLAPSE OF THE BLADDER. readily with Beaumont's needle, and the speculum having been withdrawn they were tied and the operation completed. She was put to bed on her face, an elastic male catheter introduced, so that the urine might escape as soon as it entered the bladder; and twenty drops of laudanum, thrice a day in mint water, were ordered for the pur- pose of keeping the bowels costive. May 23.__Excepting a little discomfort from position, she has been tolerably well. There is now a little purulent discharge, and on gently separating the parts one suture was found separated, but there was little inflammation about the Wound. May 26.—She was rather flushed and feverish, and had not passed water for some hours; the catheter was withdrawn, found to be clogged, and when introduced again, a pint of high-coloured urine passed, which greatly relieved her. Another suture and one of the ligatures came away in the evening, and on the following day the remaining suture and ligature. June 7.—The catheter having caused some irritation to the bladder, was removed, and a common female instrument given her to pass frequently, so as to prevent dis- tention of the bladder. Up to this time the urine has been more or less turbid, with flakes of adhesive matter, as after the first operation. June 18.-—Having now been on her face for thirty-one days, latterly without much inconvenience, she was allowed to lie on her side. July 22.—An examination was made ; there was less protrusion, but the bladder still falls back into the vagina. The wound is perfectly healed ; but there is ten- derness about the neck of the bladder. The discharge continuing, a small bag partially filled with powdered oak bark was introduced into the vagina. The bark swelled so much with the moisture that it was necessary to diminish its quantity. Jug. 5.—The discharge is materially diminished, but the vagina slips below the bag. ,Aug. 25.—Was allowed to dress herself, but still kept in the recumbent posture. The bark bags were left off, and a saturated solution of alum in elm bark was ordered to be injected frequently during the day. Sept. 5.—She has not gained much advantage by the injection; the bladder is just visible at the furcula. Sept. 20.—She returned home, being able to walk about much better than pre- vious to the operation, and had but little pain in the loins ; the discharge, however, continued. She was directed to wear a pad in the perinaeum, supporting it with a T-bandage, and to use the oak-bark bags. On the whole I was fearful that she had not derived any material benefit by the operations to which she had been subjected, but was agreeably surprised on seeing her in November, 1840, to learn that soon after her return home, she had been able to stand whole days at the ironing-1able without any protrusion. For some months she has been able to go about without difficulty, and do any thing she has to do; but she says there is some protrusion. I examined her, however, and found little or none. In the following January she married, and was confined in the ensuing December. She was taken in labour on the 16th, and delivered after forty-eight hours. She got up at the week's, end, and a week after there was protrusion about the size of a walnut, which continued increasing till at present, March 20, 1842.—The bladder again protrudes between the labia, about the size of a crown piece ; after standing up, the mouth of the womb descends behind; but both easily return when she lies down. Her health is now tolerable, and she manages with a little weariness to get through the usual occupations of a labourer's wife. As with all the disadvantages which her continual standing whilst at the ironing- board, the protrusion had been materially checked, and she was capable of exertion which for some years before she was incapable of making, it may be inferred that the latter operation was advantageous to her, and that probably had she kept quiet at first for some months, she would have recovered completely. I should not hesitate therefore to perform this operation in a similar case.—j, f. s. Lightfoot of Newcastle-on-Tyne (a) has performed successfully Fricke's ope- ration of episioraphy in a case of prolapsed bladder which descended through the (a) Lancet, vol. i. p. 322. 1841. PROLAPSE OF THE RECTUM. 397 labia to the size of a fist. Six strong hempen sutures were put in; the limbs tied together, and the woman put on her side; a catheter was introduced, and not re- moved for two days; but the urine being found to escape by its side, and cause irritation, it was removed, and passed occasionally for the following five or six days. Cold water was applied, and the vagina now and then cleared and washed by'in- jecting cold water. Opium was given to constipate the bowels. Two of the sutures were taken out on the fourth, and the others on the sixth day, at which time union by the first intention was complete. Three weeks after the operation she left her bed, and walked about; and in a week after, she was able to resume her usual oc- cupation of household work. On examining her three weeks after, there was not the slightest prolapse; and when she was desired to strain violently, the rugae of the vagina were seen, but did not protrude.] IV.—OF PROLAPSE OF THE RECTUM. (Prolapsus Ani, Lat.; Vorfall des Mastdarmes, Germ.; Chute du Rectum, Fr.) Schacher, Dissert, de morbis a situ intestinorum naturali. Lips., 1721. Luther, Dissert, de procidentia ani. Erf., 1732. Heister, Dissert, recti prolapsus anatome. Helmst., 1734. Monteggia, Fasciculi pathologici. Turin, 1793, p. 91. Jordan, Dissert, de prolapsu ex ano. Gottingen, 1793. Hey, William, Practical Observations on Surgery. London, 1810. Second Edition. 8vo. Copeland, Thomas, Observations on the Principal Diseases of the Rectum and Anus. London, 1814. Second Edition. 8vo. Howship, J., Practical Observations on the symptoms, discrimination, and treat- ment of some ofthe most common Diseases of the Lowerlntestines and Anus, &c. &c. London, 1820. 8vo. Chap. iv. Bushe, George, M.D., A Treatise on the Malformations, Injuries, and Diseases of the Rectum and Anus. New York, 1827. 8vo. Syme, James, On Diseases of the Rectum. Edinburgh,. 1828. 8vo. Salmon, Frederick, Practical Observations on Prolapsus of the Rectum. Lon- don, 1831. 8vo. Dupuytren, Le Baron, Lecons Orales de Clinique Chirurgicale. Article,—Chute du Rectum, vol. i. p. 157. Paris, 1831. Mayo, Herbert, Observations on Injuries and Diseases ©f the Rectum. London, 1833. 8vo. Brodie, Sir Benjamin C, Lectures on Diseases ofthe Rectum; in London Medical Gazette, vol. xv. p. 845. 1835. Velpeau, Lecons Orales de Clinique Chirurgicale.. Article,—Procidence de PAnus, vol. iii. p. 128. Paris, 1841. 8vo. 1295. Prolapse of the Rectum appears under three forms; it may be either the rectum with all its membranes, or simply the internal mem- brane, or an inverted' upper portion of the intestine {Volvulus Intussus- ceptio). Although the rectum is pretty firmly fixed in its place, its prolapse, with all its membranes, has been improperly doubted; it occurs rarely under this form, but I have distinctly noticed'it (1). [(1) The opinion here disputed is Copeland's, who says :—"In almost every case of prolapsus ani, xt is the- internal membrane of the intestine only which de- scends through the sphincter muscle. The connexion of the external surface of the rectum is so firm with the surrounding parts, that it is almost impossible the whole should be protruded together; a separation or elongation of the union between the coats of the intestine must therefore precede the disease, and forms its essential cha- racter ; whether it be produced by the effusion of blood between them, or by corr- tinued tenesmus, or efforts to pass the faeces, or peculiarity of structure, or any other cause, (pp. 74, 5.) 398 PROLAPSE Syme does not agree with either Chelius or Copeland, as to what he calls pro- lapsus ani. He says :—"Such tumours consist either of the gut in its whole thick- ness, or of the mucous membrane alone in a state of morbid development. Being thus differently constituted, they should not be confounded together, as they usu- ally are, but carefully distinguished, since they have no resemblance to each other, either in the nature of their production, or the treatment which they require. In makin? this distinction, it is fortunately unnecessary to employ any new names, since if the title prolapsus be confined to denote those protrusions in which the whole thickness ofthe gut is concerned, the other forms ofthe disease may all be referred to the head of Haemorrhoids." (pp. 88, 9.) Bushe describes only " two forms of this disease. In one the mucous membrane is alone prolapsed ; whereas, in the other, all the coats of the rectum come down. The first is by far the most common, in consequence of the great extent and loose connexion of the mucous tunic ; while the firm union of the intestine itself, with the surrounding parts, the longitudinal direction of its strongest and most numerous fibres, together with the action ofthe levatores ani muscles, offer much resistance to the descent of the entire gut." (p. 201.) That cases do occur in which the whole gut is prolapsed, is put beyond all doubt, as Velpeau mentions that the younger Berard dissected a tumour formed by invagination of the rectum through the anus of a female. The inversion of the in- testine was complete, for the peritoneum was included in the swelling." (p. 128.) He also mentions Paillard's case (a) and others eited by Nelaton.] 1296. In the prolapse of the internal coat of the rectum, consequent on relaxation and lengthening, merely a little reddish swelling first ap- pears, which gradually enlarges, increases in size, becomes wider, is rounded below, but narrowed above by the sphincter muscle, and at its free extremity has an aperture by whieh the stools escape. The surface of the prolapse is, according to its different duration, and the degree of its girting by the sphincter, red, bluish, more or less tense or soft, covered with bloody mucus, and often divided into several lobes (1). In prolapse of the rectum, with all its coats, which I have only noticed in children, a more cellular swelling, which terminates pretty pointedly, projects directly, as in protrusion of the bowel from artificial anus; and if the finger be introduced through the opening, the contraction of the intestinal walls is distinctly felt (2). The symptoms which prolapse of the rectum especially produce, are various, according to its degree and duration, but generally they are not severe, because the rectum is not so very sensitive to the contact of air. If, however, the prolapse be considerable, it may inflame or become strangulated by violent contraction of the sphincter muscle, in which case even gangrene may occur (3). [(1) "When the mucous membrane is alone prolapsed in the child, it assumes," says Bushe, "the appearance of a small pyramidal, red and coiled tumour; while in the adult it is less red, and generally takes the form, either of the two lateral flaps, or of a circular fold. In some of these cases, the portion of membrane thus protruded comes from the pouch of the rectum, while that within tbe sphincters re- mains in situ. When this is the ease, we can pass the extremity of the little finger between that portion of the membrane whieh adheres to the internal sphincter and that which is protruded." (p. 204). (2) Syme's prolapsus ani, in which the whole thickness of the gut is involved, "consists of a tumour generally round or oval, but sometimes cylindrical, varying in size from that of a small egg to that of the largest orange, exhibiting the slimy surface of a mucous membrane, and affording a copious secretion of very similar ap- pearance to red currant jelly. It is obvious that the connexions of the lower part of the rectum must prevent it from descending, so as to present these appearances, which can be accounted for only by supposing that the higher part of the gut be- (a) Revue Medicale. OF THE RECTUM. 399 comes invaginated in the portion below it, so as to project beyond the anus. In short, the derangement will be the same as that which is named intussusception, with this difference, that, in the latter case, the invagination occurs higher up the intestine, beyond the reach of sight and touch." (p. 89). (3) "The symptoms of the prolapsus," observes Syme, "vary with the size of the part protruded, and the degree of vigour with which the intestine resents its unnatural position. They are, therefore, in general, more urgent in young persons, and less so in old people. There is always more or less uneasiness in the protruded part, and obstruction to the evacuation of the bowels; and, if inflammation com- mences, the sufferings of the patient become extreme, terminating even in his death, or mortification of the invaginated portion of intestine. Though the' bad conse- quences are not always very rapid in their progress, the disease, if left to itself, can never be regarded as free from danger, and should, therefore, always be remedied as soon as possible." (pp. 91, 2). Bushe also remarks that, "when the protrusion is allowed to remain down, it becomes, engorged with blood from the pressure which the sphincter exercises on the veins, as is manifested by its increase in size and livid colour. If it be not soon reduced, inflammation sets in, and is attended not only with great local pain, but fever, and, in some rare cases, death ensues, in con- sequence of extensive peritoneal inflammation. In some other, and yet more rare cases, the protruding portion sloughs off, and a cure follows." (pp. 204, 205). A case ofthe latter kind is related by Sauveur and Ansiaux (a). Prolapse of the rectum is liable to be confounded with hemorrhoidal tumours, and with intussusception. Copeland says " the prolpasus ani has so many points of analogy with haemorrhoids, that it may, in some measure, be considered as the same disease in a more chronic and advanced state, (p. 73). And Syme thinks that the protrusion of the mucous membrane alone should be referred to the head of haemorrhoids. Bushe observes, as to its diagnosis from haemorrhoidal tumours, that "the semilunar form of the flaps, the extent of their base, our ability to glide the folded membrane between the finger and thumb, as well as their freedom from erection and haemorrhage, are characters so opposite to those which pertain to hae- morrhoidal tumours, that a very cursory examination enables us to distinguish them." (p. 162). In reference to intussusception, he says :—"In protrusion of the rectum, we are not able to insert a probe or the finger higher than the border of the internal sphincter, in consequence of the doubling ofthe mucous membrane; while, in intussusception, no resistance is offered to the ascent of either one or the other." (pp. 205, 206.)] 1297. The causes of this prolapse are either injuries which weaken the sphincter muscle and the natural attachments of the rectum, as in- frequent hard evacuations from the bowels, the improper use of relaxing clysters or strainings, which drive the intestine down, as severe and continued bearings down in long-continued diarrhoea, ascarides, hsemor- rhoidal inconveniences, organic changes of the membranes of the rectum, stone in the bladder; farther, violent screaming and attempts at raising heavy weights, and the like. Rectal prolapse occurs most commonly in children, especially from diarrhoea during teething, and in old weakly subjects. 1298. Prolapse of the rectum is always a painful ailment. In chil- dren, it is for the most part, soon cured, if the causes of irritation ofthe rectum be removed, and more power obtained by the continued develop- ment of the sphincter muscle. In grown persons the disease is always more severe, and easily returns upon every occasion. In old prolapses considerable changes occur in the structure of the rectum, continued discharge of mucus, and the like, occur (1). [(1) "When the descent of the bowel is often repeated," says Bushe, "the mucous membrane becomes indurated, loses its villous surface, and, in some in- stances, even ulcerates. This is more likely to be the case when the sphincter has (a) Ansiaux, N., Clinique Chirurgicale. Second Edition, p. 179. 400 PROLAPSE OF THE RECTUM. become relaxed, from the repeated dilatation it has suffered, and there is a con- stant nisus, causing the bowel to contract, and force out the mucous membrane." (p. 205.)] 1299. The treatment consists in the reduction and keeping up of the prolapse and upon the removal of its causes. For its replacement, if the prolapse be recent and small, slight pres- sure with the flat of the hand is sufficient; but if it be considerable and have existed many hours, the patient must be placed, after having voided his urine, upon his belly, with the rump somewhat raised, and the thighs separated; or he must be put upon his knees and elbows, and then with the finger smeared with oil, placed near the opening of the rectum, it must be attempted to press back alternately the part of the bowel nearest the opening, during which the patient should refrain from all forcing and shrieking. If in this way the prolapse be returned into the cavity of the rectum, it must be attempted by the introduction of the finger to carry it higher and into its original situation (1). If the pro- lapse be large, of many inches length, and consisting of all the coats, especially in children, the practice just recommended for its return is insufficient. The fore-finger of the right hand must be introduced into the opening of the prolapse, with which the prolapsed part is to be thrust in and then kept up with the fingers of the left hand, placed at the edge ; the fore-finger is to be somewhat withdrawn, and again intro- duced deeper, so as by repeated thrusting inwards to return the pro- lapse. If the reduction be very difficult, in consequence of spasmodic forcing, relaxing antispasmodic applications, opium internally and in clysters, are useful. If the prolapse be girt by the sphincter muscle, and much inflamed and swollen, its return must be attempted after the use of blood-letting and cold applications. Some persons recommend also slight cuts (2). If this do not succeed and symptoms of danger ensue, the sphincter muscle must be divided at that part where the stric- ture is greatest, by means of a director introduced into it, and a button- ended bistoury, which is advantageously preceded by the use of a speculum ani. If the bowel still cannot, on account of the great swell- ing, be reduced, it must be only gradually returned, as it is diminished by the use of proper remedies. [(1) The plan recommended by Brodie for the treatment of prolapsed rectum in children is the following:—"Purge him with calomel and rhubarb occasionally; be very careful about his diet, that he does not eat a great quantity of vegetable sub- stance, which tends to fill up the cavity of the bowel, while it affords but little nourishment, and every morning let some astringent injection be thrown up. That which I have generally used is a drachm of tinct. ferr. mur. in a pint of water, and two or three ounces or more of this, according to the age of the patient, may be in- jected into the rectum every morning, the child being made to retain it as long as possible. I never saw a case of prolapsus of the rectum in a child which was not cured in this manner." (pp. 845, 46). The treatment of prolapsed rectum in children, in whom it is frequently of con- siderable length, is a very troublesome matter. The attempt to reduce it gives the child pain, and causes him to cry, and thus force the bowel down repeatedly al- most directly after its return, the relaxation of the sphincter being so great, in gene- ral, that it affords little opposition to the descent of the gut. I have not been in the habit of using injections ; but have merely kept the child as much as possible in the horizontal posture, and, having returned the bowel, have applied a pad either of, linen alone, or of cork covered with linen, and of corresponding size to the breadth of the protruded gut, fastening it with a T-bandage. If the protrusioii can be only TREATMENT. 401 a little restrained at first, it is pretty certain that continuing the same remedy will ultimately be effective, although but very slowly. Attention to the bowels, so that the stools should be thin, and passed with little effort, is a very important part of the proceeding; and for this purpose I prefer a tea-spoonful of castor oil occasionally, which I think better than calomel, as less likely to produce the tenesmus so fre- quently following the use of that medicine. The nurse, however, must be taught how to return the gut, and strictly enjoined to return it immediately after the motion has been passed, and not to allow the child to sit straining on his chair, as is too com- monly permitted.—j. f. s. (2) Dupuytren, with great propriety, objects to this practice. He says:—" Some persons recommend scarifications; but, as they cause wounds, and consequently in- flammation of the large bowel, they should not, as far as possible, be employed. The same objection applies to leeches, which may produce internal or external bleeding, and ulceration of the gut." (p. 159.)] 1300. In order to prevent the reprolapse, it must be endeavoured to get rid, as far as possible, of the causes upon which the disease depends, to diminish the irritation of the rectum, the bladder, or neighbouring parts, to extirpate the haemorrhoids and the like (1), and to restore to the rectum its natural powers by cold bathing, by cold or astringent clysters of red wine, and the like. To prevent the reprolapse, a piece of sponge dipped in cold water, is fastened with a T-bandage, or the application of large strips of adhesive plaster, from the region of the pubes, near to the aperture of the anus up to the region of the rump- bone, so that merely a space is left for the passage of the stools {a); the bandages of Juville {b) and Gooch (c), are to be preferred as most suitable; as also the application of a pad of lint, in such way as not to prevent the discharge of the stools, a hollow cylinder of ivory or of caoutchouc, by which it is hoped to keep the relaxed walls in their proper place, but which generally cannot be worn, and still farther weakens the sphincter. In women, the prolapse of the rectum may be kept back by a pessary introduced into the vagina, only it must not press either too much or too little upon the rectum. Klein (d) recommends, as a very efficient remedy, even in very old prolapses of the rectum, sprinkling a powder, consisting of equal parts of gum arable and colo- phonium,- by the use of which the prolapse returns, and this is to be repeated as often as the prolapse recurs. I have not, however, noticed any particular benefit from it. Schwarz (e) recommends the extract of mux vomica, as a very efficient remedy in all cases of prolapsus ani, one to two grains dissolved in two drachms of water, of which from six to ten drops are to be given every four hours to children; and to older persons, even fifteen drops; frequently he gives it in connexion with some grains of extract of rhatany. [(1) When an adult labours under prolapse of the rectum, "consequent on a pro- trusion of piles, the first thing to be done," says Brodie, "is to destroy the piles. Let the patient sit on a pan of hot water, and the sphincter muscle being relaxed, and the parts distended with blood, the piles and rectum will all protrude together. You must then tie the piles, which you can easily do, your assistant holding the rectum on one side, while you apply the needles and ligatures on the other. Having tied the piles, you return the rectum into its proper place; and you will probably find that, in curing the piles, you have also remedied the prolapsus of the bowel; but, if the patient neglects himself afterwards, as the piles return, so the prolapsus returns with them." (p. 846.)] (a) Niemann, in Knescke's Sammarium, (c) Hofer, Lehrsatze des chirurgischen vol. x. pt. vi. Verbandes, vol. ii. p. 384, pi. xvi. fasc. 100. (6) Abhandlung, ueber die Bruchbander, (d) Heidelberger klinische Annalen, vol. u. s. w. p. 102, pi. xii. ii. pt- i- p. HO. (e) Hufeland's Journal, 1835, Feb. No. 4. 402 PROLAPSE OF THE RECTUM, 1301. All these modes of treatment are, for prolapse of long stand- ing, really fruitless, and accompanied with considerable inconvenience to the patient (1). In these cases, the treatment prescribed by Dupuy- tren (a) is most effective; the patient is put upon his belly, his head and shoulders low, but his pelvis on the contrary much raised by one or several pillows, for the purpose of rendering the aperture of the anus more distinct. Two, three, four, five, or six, of the radiating folds sur- rounding the anus, which are either level, or more or less prominent, are to be seized with a pair of pincers, with somewhat flattened points, one after another, right and left, and even before and behind, and each fold, as raised, is to be taken off with scissors curved towards the surface, and the cut is then to be continued to the anus, or even higher into it; but it is ordinarily necessary only to continue the cut some lines Upwards. In less relaxation, two cuts, in greater relaxation, several cuts are to be made on each side. Bleeding and other symptoms do not come on ; but usually during the operation there is violent contrac- tion of the sphincter. The wound is to be simply treated, and after scarring, the opening of the anus has proper firmness, and the prolapse does not recur (2). The application of the actual cautery, according to Phillips (b), corresponds in its operation to excision; according to the state of the case, from one to four appli- cations must be made; and, indeed, if the disease be recent, it may be merely ap- plied to the edge of the anus, without touching the mucous membrane of the rectum; but if the case be old, the white-heated iron must be carried over the mucous mem- brane. The length of the slough should be half an inch. Scarring produces such con- traction of the anus, that reprolapse is thereby prevented. [(1) The difficulty, and even impossibility, of returning the bowel sometimes occurring in old prolapse of the rectnm, does not depend on the contraction of the sphincter, as might be supposed. This was first noticed by Hey, who observes:— "Although the prolapsed part of the intestine consisted of the whole inferior extre- mity of the rectum, and was of considerable bulk, yet the impediment to the reduc- tion did not arise from the stricture of the sphincter ani, for I could introduce my finger with ease during the procidentia; but it seemed to arise from the relaxed state of the lowest part of the intestine and of the cellular membrane which con- nects it with the surrounding parts," (p. 424.) (2) It has been disputed whether Dupuytren is to be considered as the originator of this operation, or whether it is merely a modification of Hey's. There can be no doubt that the principle was the same, that of diminishing the aperture of the anus; but the two operations differ from each other as much as Copeland's pre- sently to be described, and far preferable to either, differs from both. Hey's account of his operation will show its total difference from Dupuytren's ; and that able French Surgeon is fully entitled to the merit of whatever credit belongs to its pro- posal ; although I must confess I think Copeland's operation is best of the three recommended. Hey says :—" The relaxed state of the part which came down at every evacuation, and the want of sufficient stricture in the sphincter ani, satisfied me that it was impossible to'afford any effectual relief to my patient, unless I could bring abonta more firm adhesion to the surrounding cellular membrane, and increase the proper action of the sphincter. Nothing seemed so likely to effect these purposes, as the removal ofthe pendulous flap and other protuberances, which surrounded the anus. I hoped the inflammation caused by this operation would produce a more firm adhesion of the rectum to the surrounding cellular substance; and I could not (a) Above cited, p. 163.—Journal General methode, den Mastdarmvorfall zu beseitigen; de Medecine, vol. lxxxi.—Von Graefe und in Hecker's Annalen, Mirch 1829, p. 261. von Walther's Journal, vol. v. pt. iii. p. —Macfarlane, J., Clinical of the Surgical 524.—Von Ammon, Erfahrungen und Be- Practice. Glasgow, 1832. p. 151. merkungen liber Dupuytr*en's Operations'- (b) London Medical Gazette, vol. xi. p. 384. OPERATIONS FOR. 403 doubt that the circular wound would bring on a greater stricture in the sphincter ani." (pp. 443, 44.) It is not out of place to remark in reference to these operations, that Velpeau ob- serves:—"Very frequently a portion of the fleshy coat of the intestine is found ac- companying the mucous coat in prolapsed rectum. There is no inconvenience in removing with the mucous membrane a portion of the muscular tissue; on the contrary, the cure will be more complete, and I have some disposition to believe that the want of success which has occasionally followed the operation has depended on the1 omission of this precaution." (p. 135). The only means of "restoring the disturbed union between the inner membrane of the intestine and its external surface," is, according to Copeland, " by exciting a degree of inflammation on the external surface of the inner membrane, sufficient to produce a union and consolidation of the parts together." He objects to the use of stimulating injections, as inflaming the mucous surface, causing great pain and dis- tress, "without any material benefit to the disease; for the inflammation is,propa- gated along the mucous surface, without extending to the deeper seated parts or external coat of the intestine." Having shown that the inner coat of the alimentary canal loses a considerable portion of its villous nature as it approaches its extremi- ties, that wounds at such points are less serious than when inflicted on the more interior portions ofthe canal, and that "the degree of pain is beyond all comparison, less in proportion as the part wounded or tied is more removed from the anus and the cutis surrounding it; an operation or ligature which would be violently painful at the circumference ofthe anus if it involve the smallest portion of the skin, being spoken of as little more than uneasiness, or not calling forth any expression of pain, when performed on a part of the membrane more removed from the seat of external sensation; and the consequent fever and inflammation having the same relation to the part," he proceeds to observe, that "the only effectual means then of producing this desirable union between the coats ofthe intestine, is by a wound, or a removal of a small part of the inner membrane which protrudes at the anus, and constitutes the disease." * * '* That the removal of the (entire) protruded portion is not very essential to the cure of the disease, I think will appear evident, if it be con- sidered how very small a part of the inner membrane being cut or tied away, in proportion to the whole bulk, will be sufficient to prevent the remainder from pro- truding. I have, in some instances, been obliged to repeat the operation on the opposite side ofthe gut, when the adhesion formed by the wound was not sufficient to support the whole circumference of the canal. But in one case I removed the ligature immediately after it had been very tightly applied, and returned the in- testine. The cure was complete; but I do not know whether the part sloughed or hot to which the ligature had been applied. This injury done to the inner mem- brane of the intestine, then, is the most certain mode of producing that degree of inflammation, and consequent adhesion, which produces the cure of the disease, and in which, in fact, the cure consists. "The mode of performing the operation which I think is most advisable, and which I have very frequently performed without any one unfavourable circumstance, is, the bowels, being well emptied previously, and the time chosen when the pro- jection is considerable, to pass a tight ligature round a very small portion of the inner membrane, at-a part not immediately in the vicinity ofthe anus, that is, above the union of the cutis with the mucous membrane, and to return it, together with the ligature, into the gut. This is not, for the most part, a painful operation; but it is advisable that a grain of opium, or a few drops of laudanum, be given to pro- cure ease, and also that the bowels may be somewhat confined for a day or two after the operation; for an evacuation during the active stage of the inflammation would give considerable uneasiness, and interrupt the adhesions which we depend on for the cure. Nevertheless, the cure has not been less complete, because the parts have come down in a more swelled and painful state for several days after the operation. The patient must be directed to keep his bed, should live very sparingly, and cloths dipped in Goulard water, or laudanum and water, should be applied when the pain or inflammation require it. In two or three days, if the bowels have not acted spontaneously, some mild aperient should be given. In about five or six days the ligature comes off, and shortly afterwards the part will heal, and cease to come down, or come down, only in a much less degree than be- fore the operation." (pp. 77-84). 404 TREATMENT OF OLD PROLAPSE OF THE WOMB. This mode of treating prolapse of the rectum is now pretty commonly employed ; and from my own experience, I may add that Copeland has very faithfully and truly described its simplicity, its almosfr entire freedom from pain, and its great ad- vantages. I have never had occasion to perform Hey's operation, or its modifica- tion by Dupuytren ; and I believe that in almost all cases Copeland's method will be found amply sufficient, amHnfinitely less painful.—j. f. s. M'Cormac says (a), that " reflecting on the procedure in question, (Dupuytren's operation), it occurred to him that the same result might in a measure, at least, whilst the child went to stool, be secured by careful manual traction. * * * Ac- cordingly when the child went to stool, the skin, anterior to the anus, was drawn to one side by means of the fingers extended around. The little girl submitted to this with some reluctance, and complained that she could not evacuate her bowels. She was encouraged, however; a stool was obtained ; from that day and date, now a month since, the bowel has not once descended. * * * The little girl requires comparatively little attendance, her mother, in fact, is only required to stand by, and in a short time, it is to be hoped, her onerous and anxious ministry will wholly cease." (p. 417.)] 1302. In an old prolapse of the rectum, a considerable enlargement? and at last hardening of the prolapsed part, is often gradually produced by the contact of the air, rubbing, and so on. If in such case the return be not possible by continued supine posture, by keeping up pressure and the use of cold applications, or if doubtful symptoms arise, the pro- truded part of the rectum must be cut off at its base. In doing this considerable bleeding is always to be feared, for which plugging, em- ployed in the way prescribed, (par. 939,) is no certain remedy, as it is easily thrown off, or displaced, by violent forcing, and, as I have seen, fatal bleeding ensues. It is preferable, after the removal, to touch the bleeding part with the actual cautery, by which the bleeding is more certainly stanched, and the elastic power of the rectum increased. In order to meet the danger of bleeding in cutting off a degenerate prolapse ofthe rectum, Salmon (b) has proposed the following proceeding, which he has found by experience to be sufficient. The patient being pro- perly placed, and the buttocks separated from each other by an as- sistant, he thrusts one or more stout straight needles from above down- wards, through the base of the swelling. As the needles penetrate the muscular coat, they prevent its return after the tumour is cut off". He now takes hold with the hook, or with forceps, of a portion of the swell- ing, draws it gently towards the opposite side, and cuts it off with one stroke ofthe scissors, as deep as the line between the mucous and mus- cular coats, which must be spared, as otherwise there will be slight difficulty in going to stool. In the same way all the other portions are to be removed. After the removal, the bleeding is to be stanched by the usual means; cold water is usually sufficient; most commonly it stops of itself. If the vessels are to be tied, it may be done easily, as the wounded surfaces are kept out by the needles. The needles are to be left in for an hour; and the wounded surface should be anointed with oil. In irreducible prolapse, which causes severe and dangerous symptoms, the appli" cation ofthe actual cautery was early recommended by Leonidas, Severinus, Tul- pius, Levret, and others. [The use of the actual cautery to produce sloughing of an obstinate prolapsed rectum was recommended by Ansiaux (c) in consequence of the cure he had noticed (a) Dublin Journal of Medical Science, vol. (b) Practical Observations on Prolapsus of xxiii. 1843. the Rectum. London, 1831. 8vo. (c) Above cited. RELAXATION OF THE ANUS, OF THE RECTUM. 405 to result after a natural slough ofthe protruded gut; he operated on three women at the different ages of sixty-two, thirty-five, and sixty years, with success. Dupuy- tren objects (a) to the cautery, that "independent of the severe pain it causes, it may produce violent and more or less serious inflammation of the intestine and of the neck ofthe bladder." (p. 161.)]. 1303. The prolapse of an unsheathed upper intestine, of the lower end of the colon, ofthe cacum, even ofthe ileum,is usually distinguished by its having some inches of length, and by its condition. The only aid consists in the return of the prolapsed part into the rectum, and in keeping it up. If the finger be insufficient for its return, an elastic tube, and even the dashing of cold water (Boyer) must be used. A very large portion of ensheathed intestine of considerable length has been observed to separate and to be thrown off. [In connexion with prolapse of the rectum it may be well to notice here two con- ditions mentioned by Bushe. 1. Relaxation of the Anus, which "depends upon a want of contraction in the sphincters the causes of which are:—disease or injury of the brain or spinal cord, exhaustion attending weak health, sedentary habits, protracted diseases or old age, excessive or repeated dilatation of the anus, produced by straining in chronic dysen- tery, the introduction or extraction of foreign bodies, and the growth of tumours from within the intestine, and finally operations performed for fistula, fissure, &c. The consequences of this affection are proportionate to the want of power in the sphincters; thus, when they are completely paralyzed from disease, or injury of the brain or spinal cord, the faeces are discharged involuntarily; whereas in that dimi- nution of tonicity in their fibres, which depends upon constitutional exhaustion, the discharge of mucus attended perhaps with slight excoriation of the verge of the anus, is the most troublesome symptom. It not unfrequently happens that the mu- cous membrane is protruded, and should the dilatation be considerable and prolonged, especially in elderly persons, the surrounding skin will lose its elasticity, which it is not very apt to recover, even though the sphincters be restored to their primitive condition, The treatment will depend upon the cause; if the brain or spinal cord be at fault, these must be looked to; if there be haemorrhoidal or other tumours, they must be removed ; and if the general health be impaired, it must be improved. " The best local remedy," says Bushe, " is the injection of half a pint of cold wa- ter, three times a day." Stimulating vapours and compresses dipped in astringent washes are recommended by some practitioners, (pp. 213, 14.) 2. Relaxation of the rectum with invagination of the mucous membrane " is dis- posed to by repeated distention of the bowel with faeces, or injections. When the rectum is empty or relaxed, and the individual,strains violently to effect a motion, the mucous membrane maybe forced into the inferior part of this intestine, and thus partially obstruct it, so that the faecal matter lodged above can be but imperfectly discharged. If the finger be introduced, the nature of the case will be easily disco- vered. The bowels are confined; the calls to defecate are frequent, urgent, and generally ineffectual, nothing being voided but mucous or puriform matter, often streaked with blood ; finally, the pain is always considerable, but occasionally vio- lent. A well-regulated diet, gentle aperients, emollient followed by astringent in- jections, and the use of the inflated gut, or bougie, will generally suffice for its re* moval. If, however, the nature ofthe case be not detected, one of two things must follow: either a complete prolapsus will ensue, or what is worse, the displaced membrane will, from irritation and inflammation, become thickened and indurated, and the opening through it contracted, (pp. 215, 16.) The case quoted by Salmon, and which was under the care of Somme (b), ap- pears to me to have originated in this relaxation, though the young woman is stated to have been " long affected with a contraction of the rectum, three or four inches above the anus ,■ and the bridle forming the ring, hard, callous, and so contracted, that it only allowed liquid matters to pass, whence arose obstinate constipation and colic ;" for Somme continues:—*" I tried dilatation with bougies, which had momen- (a) Above cited. (b) Etudes sur Pinflamraatiom Paris, 1830. 8vo. Vol. ii.—35 406 CHANGED DIRECTION tary success." Now if a stricture had formed, the bougie would not have passed, but if, as seems probable, the obstruction was caused by the descent and ensheath- ing of the mucous membrane, the introduction of the bougie would carry it up and unfold it, and thus the obstruction be got rid of for the time. That this was really the case seems to be proved by her becoming attacked some time after with severe constipation, which lasted three weeks, accompanied with vomiting, swelling, and pain in the belly, violent colic and fever. She was treated for enteritis, the consti- pation overcome with clysters, which were followed by copious sanguineous diar- rhoea. Subsequently the evacuations became free, the fever ceased, and some days after "apiece of membrane protruded by the rectum, which being slightly pulled, brought away a portion of intestine about a foot long. This was not false mem- brane, but wholly intestine; internally the villous coat was black, externally the surface was smooth, and there was a groove upon it indicating the attachment of the mesentery." Salmon makes a very good observation in reference to the incautious use of clys- ters, which have been noticed as one cause of relaxed rectum. " Many persons," says he, " are daily in the habit of throwing immense quantities of fluid into the rectum, by which it is forcibly distended and irritated ; thus, instead of the enema affording relief, it is productive of serious irritation ; but a far greater evil resulting from this practice is, that the rectum, from the immoderate distention thus induced, is rendered unsusceptible of the natural stimulus arising from the ordinary accumu- lation of faeculent matter;" and in support of this statement he relates a case of supposed stricture of the rectum, in which he passed number eleven bougie without difficulty, to the great surprise of the patient, who for some time had lost nearly all power of relieving the bowels which never acted without the assistance of medicine or an enema, " he having been in the habit of pumping a couple of quarts of thin gruel into the intestine once, and occasionally twice every day. (pp. 23, 24.) D.—OF CHANGED DIRECTION OF THE WOMB. Medical Observations and Enquiries, vol. iv. London, 1771. Saxtorph, in Collectan. Soc. Med, Havniens., vol. ii., 1775. Desgranges ; in Journal de Medecine, vol. lix. Wall, A,, Dissert, de uteri gravidi inflexione. Hal., 1782. Baumgarten, Dissert, de utero retroverso. Argent., 1785. Melitsch, Abhandlung von der sogenannten Umbeugung der Gebarmutter. Prag., 1790. Lohmeier, Von der Zuriickbeugung der Gebarmutter; in Theden's neuen Be- merkungen und Erfahrungen, vol. iii. Berlin, 1795. Murray, Dissert, in uteri retroversionem animadversiones. Ups., 1797. Merriman, S., On retroversion of the Womb, including some observations on extra uterine gestation. London, 1810. Naegele, Erfahrungen und Abhandlungen aus dem Gebiete der Krankheiten des weiblichen Geschlechtes. Mannheim, 1812, p. 341. Schweighaeuser,, J. F., Aufsatze iiber einige physiologische und praktische Gegenstande der Geburtshiilfe. Niirnberg, 1817, p. 251. Schmitt, W. J., Bemerkungen und Erfahrungen fiber die Zuriickbeugung der Gebarmutter bei nichtschwangeren, nebst einigen Beobachtungen iiber die Vor- wartsbeugung. Wien, 1820. Eichorn, H., Von der Zuriickbeugung der nichtschwangeren Gebarmutter; with one copper plate, 1822. Svo. Meissner, F. L., Die Schieflagen und die Zuriickbeugung der Gebarmutter, nebst einer Zugabe, iiber die neuerlich bekannt gewordene Umbeugung derselben. Leipzig, 1822. Mende, L., Von der Zuriickbeugung der Gebarmutter in geschwangerten und un- geschwangarten Zustande; in his Beobachtungen und Bemerkungen aus der Ge- burtshiilfe und gerichtlichen Medicin, vol. ii. p. 150. Blundell, James M. D., above cited. OF THE WOMB, 407 Rigby, Edward, M. D., on Retroversion of the Unimpregnated Uterus; in his Reports on Diseases of Females ; in Medical times, vol. xiii. 1845. 1304. The womb is subject to various changes of direction, inasmuch as its axis may deviate backwards, forwards, or to either side, from that of the pelvis. The former two states only will be here specially con- sidered. 1305. If the long axis of the womb vary so much from that of the pelvis, that cutting it at a more or less acute angle, its base be directed towards the rump-bone and the mouth of the womb towards the share- bone, this displacement is called Retroversion of the Womb {Retroversio Uteri, Lat.; Ruclcwdrtsbeugung der Gebarmutter, Germ.; Retroversion de la Matrice, Fr.) but if its base drop towards the share-bone, and the mouth of the womb be inclined towards the rump-bone, it is called introversion {Antroversio Uteri, Lat.; Vorwdrtsbeugung, Germ.; intro- version, Fr.) The former position is more frequent than the latter, and' both may occur to a greater or less extent. 130b". Retroversion of the Womb occurs more frequently during preg- nancy, especially in the third and fourth months, than in women not pregnant; it is, however, in these often enough, and (according to Schweighaeuser and Schmitt (a) even more frequent than during pregnancy; and my own observations on this point concur with that opinion. [Rigby is also of this opinion, and observes :—" I am sure I have the confirming testimony of Dr. Simpson and Mr. P. Smith, when I state it to be one of the mosv common displacements to which the uterus is liable in the unimpregnated state, and that this form of it occurs far more frequently than the ordinary retroversion d uring pregnancy," (p. 124.) There is, however, a difference between the retroversion which occurs whilst the woman is pregnant, and that when she is not so ; for Rigby observes :—" The case now alluded to is where the fundus is bent downwards and backwards; so that it can be felt close behind the os and cervix uteri, which, instead of being forcibly dragged upwards and forwards behind the symphysis pubes, is little, if at all, removed from its natural situation. This state of retroflexion (a term which Rigby prefers to retroversion, j. f. s.) is chiefly met with in the unimpreg- nated uterus, although it sometimes occurs during pregnancy, (p. 124.) " In different women," observes Blundell, " the womb varies very much in its virgin size; for in some it is three times-as large as in others. Now if it so happen that the womb is very small, and. that retroversion has taken place without impreg- nation, the pressure which it occasions may be so inconsiderable, that the nature of the case may remain unsuspected; but when the womb, though unimpregnated, chances to be of large size, especially if the pelvis is small, or contracted, considera- ble pressure may be produced, and we are first led to investigate its nature, in con- sequence of the irritation and obstruction of the rectum and the bladder, when the accident is soon recognised by the characteristics before given." (p. 19.) 1307. It is probable that retroversion of the womb in pregnant and not pregnant women is not produced at once; but by degrees, under fa- vourable circumstances, a complete retroversion is gradually formed from a simple reclining of the womb. The following may be noticed especially as predisposing causes, slight inclination and great capacity of the pelvis, low position of .the intestines, perhaps also Douglas's (a) Richter'3 chirurgische Bibliothek, sen ; in von Siebold's Journal fur Geburts. vol. v. p. 132, vol. ix. p. 310.—Stark's Ar- hiilfe. Frauenzimmer und Kinderkrankhei- chiv. fur die GeburtshQlfe, vol. iv. p. 637.— ten, vol. iii. p. 59.—Schweighaeuser and Osiander ; in Salsburg. Med. Chirurg. Zei- Schmitt, above cited. tung, 1808, vol. iv. p. 170.—BrQnninghau- 408 RETROVERSION folds, peculiar deviation of the original formation (a), relaxatiou of the broad and round ligaments of the womb. The occasional causes are, pregnancy, overfilling of the urinary bladder, stools unfrequent or ac- companied with great effort, constant lying on the back, increased weight, swelling, or other degeneration of the hinder wall ofthe womb, violent straining, and so on. Retroversion cannot occur in a perfectly healthy state ofthe womb ; were it even possible, it could not readily produce such severe symptoms. The chronic inflam- matory state of the womb, which most commonly gives rise to retroversion, causes pain and dragging in the back and loins, difficulty in walking, difficulty in voiding the urine and in going to stool. On examination, a lower position of the womb, swelling and sensibility of its vaginal portion are observed ; most commonly, also, is there a flow of mucus from the generative organs. The two last symptoms dis- tinguish it from pregnancy (b.) 1308. The symptoms which indicate retroversion of the womb de- pend on the obstructed or completely suppressed discharge of the urine and stools, and on the diseased changes which arise in the displaced womb. These symptoms in general occur suddenly in retroversion during pregnancy, which greatly prevents and often entirely suppresses the voidance of the stools and urine; severe and extremely painful dragging come on with a feeling of pain, weight, and fulness of the belly, also distention and painfulness, disposition to vomit and actual vomiting, fever, extreme restlessness, abortion, and even death from tearing of the bladder, and inflammation and gangrene of the intestines of the belly.(c) The. seeming retroversion of the womb, mentioned by Mende, must be noticed, in which case at the later periods of pregnancy, its hinder wall expands like a sac, producing similar symptoms to the true prolapse, usually terminates in abortion, and is distinguished by the mouth and neck of the womb not at all deviating from their natural position (d.) [(1) Blundell observes that " the patient often tells her adviser that she has been placed in some situation of restraint, and that afterwards, on retiring, and try- ing to evacuate the contents of the bladder, not a drop of the secretion would pass away, and this has occurred perhaps for hours before you see her, the accumulation having continued ever since ; so that there is a great deal of pain of the abdomen and heat, with forcing and fluctuation, which may be felt as distinctly as in a case of ascites. I wish it to be understood, however, and very important it is that this should be known, that in the retroversion of pregnancy, you have not always, nor I think generally, these complete retentions of urine; for often, where the uterus is re- troverted, the retention is partial. In a case recorded by Van Doeveren, although the woman passed her urine every day, still she died from a ruptured bladder. * * * Day after day the fluid is sparingly emitted, but never in such quantity as to empty the bladder completely, till by-and-by, perhaps, the secretion begins to steal away involuntarily, or she may have strong efforts to pass the urine, even against her will, (a) Schreger; in Horn's Archiv. 1817, March and April, p. 311. (6) Robertson, Cases and Observations on simple chronic inflammation of the Uterus, in which state its organ may become retro- verted ; in Edinburgh Med. and'Surg. Journ. 1822, Oct. p. 520. (c) Linne and Hunter ; in Med. Observ. and Enquiries, vol. iv.—Saxtorph, above cited.—Wilmer, Cases and Remarks in Sur- gery, London, 1779;—Henschel ; in Lo- PER's Journal, vol. iii. p. 536.—Natjmberg ; in Stark's Archiv. vol. vi. p. 381.—Van Doeveren, Specimen observationem acade- micarum ad monstrorum historian], anato- men pathologicum et artem obstetriciam speatantium. Groning ; 1765.—Reid's Fall einer Ruckwartsbeugung der Gebarmutter in funften Monate der Schwangerschaft; in Froriep's Notizen, September, 1838, p. 304. (d) On Retroversion of the Womb after birth, with tearing of the hind wall of the vagina and prolapse of the fundus uteri.— See Dubois ; in Presse Medicale, May, 1837. No. 20.—Schnachenberg ; in Casper's Wo- chenschrift, 1838. No. 34, 35. OF THE WOMB. 409 and with every effort a small gush only may be produced, or there may be a con- tinual dripping, and yet, notwithstanding all this, an accumulation of water may go on very gradually, so that several pints, nay, several quarts, may be gradually ac- cumulated, as in the following example:—'A woman labouring under symptoms like ascites, a practitioner proposed, I think, the operation of tapping. There was, however, some obscurity about the case—a great deal of pain more especially— and, an obstetrician being called in, in consequence, a catheter was introduced, and water drawn to the amount of seven quarts, which had been accumulating in the bladder for two or three weeks, in consequence of a retroversion of the uterus.1 "— (pp. 7, 8.) (2) Lacroix remarks (a) that, whether hy sympathy or direct irritation, is not so evident; but it is often seen, nevertheless, that when the retroversion is sudden, either in the virgin, or pregnant female, hiccup, flatulence, vomiting, fainting, &c, commonly show themselves; and, even when the displacement is more gradually produced, analagous symptoms of less intensity are present.] 1309. On examination with the finger in the vagina, the mouth ofthe womb is found behind or above the share-bones; often scarcely, some- times not at all reachable, and on the hind wall ofthe vagina is the fun- dus of the womb, descending against the rump-bone like a lump, which on examination is felt through the rectum. [" In examining a ease of retroflexion of the unimpregnated womb during life, the finger," says Rigby, " can frequently reach a firm globular mass like a walnut, situated behind the cervix uteri, and evidently posterior to the vagina. At the first touch, or to one unacquainted with this condition of the womb, it seems like a lump of scybalous matter in the rectum,- for in many, perhaps most instances, the finger can- not reach sufficiently high up to distinguish the continuity of this mass with the cervix, the point of flexion being usually in the body of the uterus, close above its junction with the cervix. This, however, varies considerably, both in different cases and in the same individual, and at different times. In some cases the curve is much higher, so that the whole of the uterus seems to be in the natural position except a sharp bend or double at its uppermost portion. In others, the point of flexion is so low down that it can be easily reached, and the fundus is felt much lower than the os uteri. " On examination per rectum we feel the same hard lump through the anterior wall of the intestine; and by being able to reach higher up in this direction than with the finger per vaginam, we can frequently verify or correct our first impression. But it is by the uterine sound, invented by Professor Simpson, that we obtain such pecu- liarly valuable and interesting results in this form of uterine displacement. On passing the instrument in the. usual direction upwards and forwards, it becomes almost immediately arrested ; but on turning its point backwards, exactly in the con- trary direction, it will pass readily along the cervix, and then glide downwards and backwards, until the measure mark of two and a-half inches, having reached the os uteri, shows us that it has entered to the natural extent of the uterine cavity; the point is now evidently in the centre of the tumour between the rectum and vagina, as may be felt through either of these passages, thus proving it to be the fundus uteri in this unnatural position. By carefully turning the instrument round, and carrying its point upwards and forwards in the natural direction of the uterus, we shall also carry up the fundus upon it and restore the uterus to its proper position. On exami- nation either by the vagina or rectum, we now find the tumour has entirely disap- peared ; and as far as the finger can reach through the latter passage, the uterus will be felt in a direction upwards and forwards, and held in that position by the sound within it. In some instances, the uterus, when once replaced, maintains its natural position either permanently, or at least for some little time afterwards; but in many, especially those of long standing, and where the fundus has been forced very low down, the handle of the sound requires to be held firmly so as to keep the uterus in citu,- and the moment we loose our hold of it, (the handle,) it will turn round, rising at the time upwards and forwards towards the symphysis pubis, showing that its point has turned downwards and backwards. In other words, the uterus has returned (a) Annales de la Chirurgie, vol. xiii. p. 457, 1845, April. 35* 410 RETROVERSION. to its former state of displacement, carrying the sound along with it; we shall now again feel the tumour in the recto-vaginal sac, containing the point of the sound within it. " On examination per vaginam we shall find that pressure on the retroflected fun- dus seldom produces pain until we try to push it up against the ovary; the sound will pass into the fundus without causing much uneasiness, but if we carry the finger to the upper parts of the vagina into the vicinity ofthe ovary we shall excite severe pain. The same will be observed in examination per rectum.- the instant we press up the uterus the patient complains greatly, but per se the uterus is not painful, and we can ascertain that the intensely painful spot is distinctly above the tumour formed by the retroflected uterus. These and other symptoms resulting from ovarian irrita- tion or inflammation cannot, therefore, be looked upon as a necessary accompaniment to retroflection, although there is no doubt that they are frequently present; but the two affections are sufficiently often associated to justify a careful examination ofthe position of the uterus in every case of chronic oophoritis. " In some cases the canal ofthe cervix is so closed at the point of flexion as to re- sist every attempt to introduce the sound, and the dilator must be carefully premised until a sufficient passage has been obtained. I have reason, however, to think that when the canal is so closed as to require the dilator, it is rather owing to a congenital formation than to the effects ofthe bent state of the uterus, which last is, however, sufficient not only to obstruct the free discharge of the catamenia, but also to pre- vent conception." (p. 125.)] 1310. The symptoms do not occur so quickly in retroversion of the womb in women who are not pregnant, and vary according to the de- gree of retroversion and the condition of the womb. Only with slight reclination and little sensibility of the womb do no symptoms occur; if there be much sensibility, dull pain occurs in the bottom of the pelvis, dragging, painfulness on examination, sometimes difficulty in the dis- charge of the urine and stools, and gradual organic changes in the womb. In a greater degree of reclination, swelling up of the whole womb is ob- served, but especially of its hind part with increased sensibility to the touch; increased Weight and difficulty in moving about. The sensation of constant pressure in the region of the rectum, with difficulty in void- ing the stools and urine. In completely retroverted womb, dragging pains, swelling, weight, immobility ofthe womb, often inflammation and great painfulness on examination, suspended or irregular menstruation, and difficult voidance ofthe urine and stools occur. If the retroversion take place after delivery, it may cause continued and dangerous flood- ing (a). It is self-apparent that these symptoms must be variously mo- dified by the simultaneous changes, in the structure of the womb, and that examination must demonstrate a different relative position of the mouth and base of the womb, according to the different degree of dis- placement. If the womb be fixed in its unnatural position by adhesions, the retroversion may even be fatal from the inflammation of the intestines lying in the pelvis (b). ["The presence of this displacement is not necessarily indicated," says Rigby, *'by any peculiar symptoms ; indeed, in some instances, I have found it existing without a single circumstance to make the patient suppose that she was otherwise than in a state of the most perfect health, even as regards the catamenial periods. Generally speaking, however, there is a dull pain and sense of pressure about the sacrum, verging to one side or the other, according to the direction which the fundus has taken. In some instances she has pain and numbness down the thigh of that side, with difficulty or inability to move or stand upon, and probably arising from (a) Brunninghausen, above cited. (b) Sch weigh abuser, above cited, p. 253—Schmitt, above cited, p. 16. TREATMENT. 411 the fundus pressing on some of the sacral, nerves, since the pain is instantly re- moved by the replacement of the uterus, and the numbness or lameness ceases in an equally striking manner. At times this pressure increases to a severe bearing down, which after a while again subsides, and which is probably connected with the passage of faeces along the neighbouring intestines, and more or less depressing the fundus. "In a considerable number of cases there are distinct marks of ovarian inflamma- mation on the side to which the uterus inclines ; or at any rate I may say that, in a large majority of cases, as it is the left side to which the uterus inclines, so is it also the left ovary which is most frequently painful. These are, in fact, the ordinary signs of oophoritis" (p. 125.)] 1311. As to prognosis, the bad symptoms have been already men- tioned which especially occur in retroversion. It must be especially observed in not pregnant women, whether the organic changes of the womb be preceded by retroversion, or whether they be consequent on it; in the former case the restoration of the proper position of the womb is the most perfect cure, but in the latter not. [" With respect to the prognosis of retroversion," Blundell remarks, " that where the womb is replaced, the patient, in general, does well enough, provided you proceed on the principles prescribed ; yet it is not impossible that miscarriage may take place after reduction; for in two or three instances I have known this take place. Inflammation of the bladder of the acuter kind may occur, and you may have a chronic disease of this organ. Where there is a good deal of inflammation, your patient may die of exhaustion. You may find that some officious hand has thrust a ca- theter through the back ofthe bladder into the peritoneum, and that the escape ofthe urine into the peritoneal sac has destroyed the patient. The bladder in some rare cases may be burst open, of which I possess a very beautiful preparation. The uterus is as large as a child's head ; above the retroverted uterus is the bladder which has been ruptured. It is remarkable that in this rupture of the bladder, which has arisen from its over distention, it is not the front, that surface of it, I mean, which has no peritoneal covering, but it is the posterior surface, invested by the peritoneum, the back part of the body, which is the region of the rent. Now it was this which first led me to propose, that where a rupture of the bladder takes place in any case, but especially in a retroversion of the uterus, we should not give the patient up for lost; for if there is reason to believe that the bladder is burst into the peritoneal sac, we might make an opening into the peritoneum,—say above the symphysis pubis,—by which we might discharge theurine, and then injecting distilled water ofthe tempe- rature of 98°, we might wash the viscera, so perhaps as to prevent a general peritoni- tis ; this done, we might draw the bladder up to the opening, and close the rent by ligature. This operation I have performed on several rabbits; in one or two experi- ments I brought the bladder out, tied it up, and took away about one quarter of it, viz., the whole of the fundus, and the animal did perfectly well. This operation I have never had occasion to try on the human subject; but in a case otherwise des- perate, I should be inclined to recommend it. I may here remark, that since I have suggested this method of closing the bladder by ligature, Mr. Travers (a) has per- formed the operation on the stomach ; there was a slight wound in the organ; he boldly tied up the aperture; the thread came away, and the case did perfectly well." (pp. 19, 20.) It must not be supposed that Travers made the ligature on the wounded stomach from Blundell's suggestion; Astley Cooper had long before tied up the hole in a gut, wounded during the operation for strangulated rupture, and the case did well. Travers himself had also, some years before Blundell's proposal considered the matter, related experiments on the subject, and laid down rules for the application of the ligature. But Benjamin Bell had mentioned this question even long before Travers (J)]. 1312. The treatment of retroversion of the womb consists in emptying the bladder and rectum, and on the restoration of the natural position of the womb. (a) This case is cited in the first volume of this work, p. 476. (6) Ibid., p. 4 63. 412 RETROVERSION OF THE WOMB. 1313. Emptying the bladder is effected by the introduction ofthe ca- theter, which is rendered easy if with two fingers of the one hand, that part of the vagina, opposite the pubic symphysis, be smoothed and pushed upwards, or if its more elevated position forbid this, if it be merely pressed backwards. This manipulation is not without advantages even if the entrance of the urethra be so much drawn inwards, that it cannot be seen, or if any other obstacle to the use of the catheter exist (a). When drawing off the urine is completely impossible, puncturing the bladder above the pubes has been proposed {b). Emptying the rectum is to be attempted with clysters (which can often only be done with difficulty) of decoction of barley and grass roots, with the addition of salt. Experience shows that in many cases, after this previous treatment, the retroverted womb of itself recovers its position (c). Hence by many, the replacement is considered unnecessary, and the dis- tentions of the bladder and rectum held as the special cause of the retroversion. If inflammatory symptoms be also present, they must be attacked with suitable treatment. 1314. The modes of proceeding for the replacement of the retroverted womb are very various. The patient being placed on herknees and elbows, the base of the womb is to be pressed forwards and upwards towards the navel, with two fingers introduced into the rectum {d); which ma- noeuvre may perhaps be assisted by two fingers passed into the vagina, and attempting to draw down the mouth of the womb. Some recom- mend the replacement to be effected by the fingers (e) introduced into the vagina, and in difficult cases, even the whole hand (1). The diffi- culties which have occurred in certain cases have led to the use of ele- vating instruments (f), to the proposal of puncturing the womb {g) (2), of cutting through the pubic symphysis (h), and of opening the belly (i). (1) Bellanger (k) advises, when, on account ofthe elevated and forward direc- tion of the neck of the womb, it is not possible to employ the fingers through the vagina, to introduce a flattened catheter into the bladder, and therewith to bring down the neck of the womb, whilst with the fingers in the rectum, its base is lifted upwards. This object was effected in a case where attempts at replacement had been vainly made in different ways. See also Lallemand (/). (2) Puncturing the base of the womb through the hind wall of the vagina has been successfully performed by Jourel ef Rouen. Baynham (m) has performed it successfully, by a curved trocar passed through the rectum into the most projecting part of the swelling. Halpin (n) effects the replacement, by inflating a bladder introduced into the vagina in the following manner. " I attached," says he, "a small recent bladderto (a) Naegele and Schmitt, above cited. obstetricae, Mosq. 1810, p. 69.—Schmitt, (b) Cheston; in Medical Communications, above cited. vol. ii. p. 6. (g) Huntkr, Wm , above cited.—Bellan- (c) Vermandois ; in Journal de Medecine, ger, above cited, p. 235. vol. lxxxviii.—Croft; in London Medical (A) Richter; in Chirurg. Bibliothek, vol. Journal, vol. xi.—Denman, T., Introduction vii. p. 729. to the Practice of Midwifery. London, (i) Callisen, Systema chirurg. bod., vol. 1801. v ii. p. 670.—Fiedler, in Rust's Magazin, vol. (d) Hunter, W., Saxtorph, Richter, and ii. p. 243. others. (k) Memoire sur la Retroversion de 1'Ute- (e) Lohmter and Naegele, above cited. rus; in Revue Medicale, 1824, Feb. jh 229. (/) Salzb. med.-chirurg. Zeitung, 1791. (I) Ibid., May, 1824, p. 191. vol. i. No. 1.—Osiander, above cited.— (m) Edinburgh Med. and Surg. Journal, Richter, G. M., Synopseis praxeos medico- vol. xxxiii. p. 256. (n) Dublin Journal, vol. xvii. 1840. No. 49. TREATMENT. 413 the tube of a stomach-pump, with an air-tight piston, and, having immersed it a few moments in warm water, to bring it to the heat of the body, I introduced it, empty, into the vagina, between the fundus of the uterus and the rectum. Retaining it within the vagina, by holding my hands firmly across the orifice, it was then slowly and steadily inflated. After a time she complained of a sense of tension or bursting, but no pain. We then ceased throwing air into the bladder, allowing what was in already to remain, keeping up as it did a steady, equal, well-directed pressure on the tumour. After the expiration of five minutes, we threw more air into the bladder, when the patient exclaimed, slowly, "Oh! now you are forcing something up to my stomach." I retained the bladder some time longer in its situation; and then, previous to withdrawing it, permitting the escape of some air, I introduced my finger, and had the satisfaction of finding that the tumour was no longer in the pel- vis, and that the os uteri lay within reach of my finger, pointing downwards and backwards. * * * The retroversion having been rectified, I would introduce, as a pessary, a gum elastic bag, constructed on this principle, and inflate it to a pro- per state of distention." (p. 76.) 1315. If the fitness of these different modes of treatment be compared, the preference must, from the result of experience, be given over all other to the replacement through the vagina, as a far greater number of successful cases to have been ascribed it than to that by the rectum, which has been often unsuccessfully attempted, even with the whole hand, and with the employment of great force (a). As to the more heroic pro- posals for realizing the replacement, none indeed, except puncture of the bladder, is permissible, as in the cases where, after emptying the rectum and bladder, the symptoms are not diminished, and the proposed manipulation is insufficient, such fixing of the womb in its unnatural position may occur, that the replacement is impossible in any way, as Hunter found on dissection of a person who died from this dis- ease (b). 1316. In reference to the retroversion of the womb in women not pregnant, these rules apply, which have been given for the removal of the symptoms caused by the retention of urine and stools. As to the re- placement, Schweighaeuser considers it unnecessary, in which opinion Schmitt also concurs, as by emptying the bladder with the catheter, and the intestinal canal with opening clysters, and the previous use of neu- tral salts, with carefully observed position on the side, the rump being raised, and the upper part of the body bent down, nearly always the ef- fect is produced, and the womb gradually resumes its natural position, whilst also the swelling gradually subsides. This may be assisted, if with two fingers introduced daily into the vagina, the base of the womb be raised gradually but carefully. If the symptoms be inflammatory, merely mild remedies, emulsions of linseed <% almond oil, fresh castor oil, lukewarm bathing, steaming, by means of a sponge laid on the ge- nerative organs, relaxing poultices upon the belly, and even general and local blood-letting, and copiously rubbing in mercurial ointment on the insides of the thighs. When the most pressing symptoms have been removed or lessened, then the replacement is to be especially attended to. Only when retroversion of the womb exists without any appearance of acute inflammation, may the replacement be at once attempted, but it (a) Vermandois, above cited. (b) Einige medicinische und chirurgische Beobachtungen u. Heilmethoden. Aus d. Engl, gesammelt und mit vielen Zusatzen herausgegeben von K. G. Kuhm. Leipz., 1784, vol. i. 414 RETROVERSION OF THE WOMB. must not be too long continued. As to the manipulation of the replace- ment, all that has been said heretofore applies. 1317. When the womb is returned to its place, it has rarely a dispo- sition to be displaced anew, and the continued position on the side, is sufficient to prevent it. And besides as the womb enlarges during pregnancy, its retroversion is no longer possible. If there be a special disposition to retroversion, a round or oval pessary, with a pretty large aperture, or a sufficiently large piece of sponge introduced into the vagina fastened with a T-bandage, will prevent it. This applies also after the and replacement of the unimpregnated womb. The patient should very carefully avoid keeping on her back (a). ["In some few instances," says Rigby, "the displacement has been permanently removed by once rectifying the position of the uterus with the uterine sound; but this favourable result is rather the exception than the rule, and some mechanical means is therefore required to retain the uterus in situ. The supporter used by Pro- fessor Simpson is excellently adapted to this object, and has answered well. It con- sists of a pin the length of the uterine cavity, (two and a-half inches), fixed in a disc or button on which the 'os uteri can rest, connected with, and kept in proper position by a little frame resting on the mons Veneris, which is fixed and properly adjusted by tapes. Another and equally ingenious mode of supporting the uterus he has obtained by means of a species of pessary, to which he has fixed the pin by a spring hinge, like that of a knife-blade. I have never tried this last, but to the other I can bear most favourable testimony, having applied it in a considerable number of cases with which I propose to illustrate this subject. I have lately altered the form of the pin which is passed into the uterus, making it flat, instead of round, and broader, so as to adapt it more exactly to the shape of the cavity. The pressure which it exerts on the internal surface of the uterus is thus more equable, and over a large space, and consequently does not produce so much irritation, whieh, especially at the catamenial periods, is occasionally troublesome, producing also a profuse discharge, and for a longer period than usual. To obviate the chemical action which takes place in an instrument made of German silver, I have had this portion of it made of ivory, at the suggestion of my friend Professor Retzius, of Stockholm, to whom I showed it, and in two cases it has been worn with much more comfort than with the ordinary pin; the objection, however, to the chemical action on the uterine secretion upon the German silver Professor Simpson had already remedied by electrotyping it with gold. " The length of time during which these instruments require to be worn varies a good deal, and I have reason to believe that in cases where the displacement has re- turned, it has been owing to my having removed the support too soon. I believe that a month is the minimum period, and that in most instances our chances of suc- cess will be much greater if the period be extended to two months, or even longer." (pp. 125, 26.)] 1318. The introversion oftheWomb is more rare than its retroversion, and occurs in both the uppregnated and unimpregnated state (1). In the former case it is consequent on violent exertion, on vomiting, on a false step, and so on, with violent pain in the region of the stomach and belly, febrile symptoms, and frequent urgency to void the urine. The region of the stomach is somewhat tender on pressure, the whole belly, full, puffed up, especially the hypogastric region. The stress upon the pubes is very troublesome; the forcing of the urine very painful; in which, however, but little is discharged, and only in drops; therewith usually is their great urgency to going to stool, with thin and small motions. A swelling as big as the fist, seems to lie in the depth, behind the pubic symphysis; it can, however, only slightly be felt. The drag (a) Hunter, William ; in Medical Observations and Enquiries, vol. iv. ANTROVERSION OF THE WOMB. 415 upon the bladder becomes exceedingly severe, without a drop of urine being discharged, a violent attack of fever takes place, disposition to vomiting, and the hypogastric region will not bear the least touch; the distended urinary bladder may so cover the swelling of the womb that it can no longer be felt. On examining the vagina, its entrance is narrow; the finger more deeply introduced, strikes immediately behind the pubic symphysis, upon a semilobular swelling, which drops into the little pelvis, feels smooth, elastic, and soft, and somewhat tender. The vaginal part is either not at all felt, or only with difficulty, in the more free hinder space of the pelvis above, pressed against the rectum in the hollow of the rump-bone, and otherwise forming a continuation with the swelling, so that the finger cannot be carried round between the two. Neither the vaginal portion nor the swelling are moveable by pressure. The symptoms of antroversion of the impregnated womb differ according to their degree, the period of its origin, and the sensibility of the patient. In the above described way as Hachmann (a) noted it in antroversion, occurring suddenly in the third month of pregnancy, from a false step. Baudelocque (b) mentions a case of antroversion in the second month of pregnancy after an emetic. Nolde (c). [(1) Blundell seems to think antroversion of the womb scarcely to be a diseased condition. " It is said," he observes, " that sometimes a change of position may take place, in which the fundus comes forward, and the mouth recedes, and which altered position writers have denominated antroversion of the uterus'; but the truth is, that the womb is almost anteverted, frequently the fundus is pushed down below the symphyis pubis. Repeatedly, in making examinations, have I perceived it in this position, between my fingers, so that, in my opinion, these anteversions of the uterus can scarcely be looked upon as extraordinary and morbid. I might say, with truth, that they are perfectly healthy." (p. 21). John Burns (d) says :—"Of this accident I have never seen an instance during gestation, and from the nature of the case, it must be very rare; but I have met with it, from enlargement of the fundus uteri, in the unimpregnated state." (p. 260). Boivin and Duges say they have had frequent occasion of observing, after parturition, a decided inclination of the fundus uteri forward, the condition of the womb being intermediate between obliquity and retroversion. This form of displaced womb is mentioned also by Gray, of New York (e), as "a dislocation of the womb downward, and slightly backward, the os tineas tending towards the coccyx. The ano-perinaeal region of Velpeau, or the perinaeum posticum of the older anatomists, from relaxation of the levator and sphincter ani, becomes enlarged, and the triangular space between the point of the coccyx and the tubero- sities ofthe ischian bones, forms, in consequence, a broad deep cul-de-sac, into which the uterus sinks in the line of its own axis, and rests against the anus and rectum. This posterior dislocation of the womb often takes place in pregnancy, particularly during the first four months; but it also takes place under other circumstances, I have no doubt, and that much more frequently than is commonly supposed. * ■* * The posterior displacement will be readily recognised by examination per anum. The finger will have to pass very much more backward than usual to get around the os tineas, which lies hard against the rectum, just above the sphincter ani, and is very perceptible to the feel- of the surgeon. In passing the finger per vaginam, the neck of the womb is first encountered, occupying the situation of the os uteri. The os uteri is found lying against the rectum, its aspect being backward and downward toward the point oftheos coccygis, will have to be carried back in a curved form to reach it. The space between the os uteri and the posterior termination of the vagina appears much larger than natural." (pp. 221, 22.)] (a) Einige Falle von krankhafter Lage- (c) Beitrage, p. 220. veranderung der Gebarmutter; in Hamb. (d) Principles of Midwifery. Mugazia der aiisland. Literatur. Nov., Dec, (e) On External Pressure in Prolapsus ]834 p.'352. Uteri: in London Med. Gaz., vol. i. New (6)'L'Artdes Accouchemens, p. 255. Series, 1838-9. 416 TREATMENT. 1319. In treating antroversion of the pregnant womb, if the swelling be firm and immoveable, blood-letting, clysters (of an infusion of bella- donna, according to Hachmann) should be first employed, and the urine drawn off with the catheter. If the swelling be thereby rendered more moveable, or if it be moveable from the beginning, and unconnected with any particular symptoms, its replacement is to be attempted. The patient must be placed on her back, with the pelvis properly raised, the four fingers of the right hand being passed into the vagina are carried up to the deepest lying part of the swelling, and this is to be forced by a gra- dually increased pressure upwards, and in its slow yielding, somewhat backwards, whilst the left hand fixes the hypogastric region immediately above the pubic symphysis. In Hachmann's case, very considerable, and for the patient, extremely painful force was employed, in order to lift the swelling out of the little pelvis. When this was effected, and the mouth of the womb removed from the rump-bone into the axis of the pelvis, the hand was withdrawn, and the pain ceased as by enchantment. Continuance on the back for some time is sufficient to prevent the recur- rence of the displacement. [Boivin and Duges mention a case in which the fundus uteri inclined forwards, lower down than the cervix, and in which reduction seemed impracticable; yet, nature alone, during the progress of gestation accomplished the cure. Godfrey, of Rennes, relates (a) two instances in which the natural position of the womb was restored simply by position. The first case he was unable to see ; but directed that the woman should be put on the side of the bed, with her head and hands on the floor, and with the front of the thighs and legs only resting on the bed. In this position, he says, that the intestines, being drawn towards the diaphragm, the pelvis is emptied, and the womb, being no longer pressed on, resumes its natural position. After the patient had been in this posture fifteen minutes, all pain ceased. In the second case the woman was thirty-three years of age, had been pregnant be- tween three and a-half and four months of her first child. She was attacked with weight in the pelvis, and frequent disposition to make water. Nothing having been done, excepting that she went to bed, and the symptoms continuing next day, an examination was made, and the neck of the womb was felt behind, and towards the curve of the sacrum, while the fundus was in front and behind the os pubis, the blad- der not being very full, the catheter was not passed, but she was placed in the posi- tion just mentioned, upon the side of the bed, for twenty minutes. The feeling of weight in the pelvis diminished, and the desire to void the urine ceased.] 1320. The antroversion ofthe womb in its unimpregnated state, occurs either suddenly or slowly. In the former case, it produces violent pain, fever, great difficulty in voiding the urine and stools; in the latter, the difficulty of passing the urine and stools is less. The patient has, when she walks, the sensation as if a hard body fell upon the bladder, causing urgenc-y to void the urine, which body again falls back when the patient lies on her back. Thence the possibility of confounding this condition with that of a stone in the bladder (6). Oftentimes there arise hBemor- rhoidal affections, severe pain in the belly, suppressed or too frequent menstruation, and the whites; conception may be prevented. In exami- nation with the fingers through the vagina, the base ofthe womb is found in front above the share-bones, its mouth situated opposite the rump-bone, and frequently, so high that it can scarcely be reached. Siebold (c) has found the vaginal part connected with the rectum. (a) Annals d'Obstetrique des Maladies (6) Journal de Medecine, vol. xi. p. 269. .des Femmes et des Enfans, Jan. 1842 ; and (c) Handbuch zur Erkenntniss und Heil- London and Edinburgh Monthly Journal of ung der Frauenzimmerkrankheiten. Second Medical Science, vol. for 1842, p. 313. Edit. Frankfurt, 1821. vol. i. p. 737. ' CURVATURES. 417 1321. The causes of antroversion ofthe womb are much inclined pelvis, loose connexion of the womb with the bladder, high position of Dou- glas's folds, too early getting up after delivery, continual costiveness, organic changes in the base ofthe womb, and bodily exertion of various kinds. 1322. The restoration of the natural position of the womb is easy. With two fingers introduced into the vagina, it is to be attempted to bring down the mouth of the womb, whilst with the other hand above the share- bones, the base of the womb is to be pressed backwards and upwards. The patient must continue a long while upon her back, a bandage should be applied round the belly, close above the pubes, and if this be insuffi- cient to keep the womb in its place, it must be supported with a ring pessary. If the vaginal portion be adherent, it may be divided with the knife, and its reunion prevented, by a sponge put in it for a long while {a). ["The pessary in this case," says Gray, "does no good whatever; it is thrust into the ano-perinseal region, already rendered a sac by relaxation, and by the presence of the dislodged womb, and there, as a really foreign body, excites the same sensa- tion, and keeps up the same irritation and discharges which the womb had done, and generally, as may readily be supposed, the latter are of a very aggravated character; whereas the new instrument of Dr. Hull, (his utero-abdominal supporter,) by press- ing the ano-perinaeal region upward and inward, directly opposes the descent of the womb, and, at the same time, diminishes the capacity of this region, whilst the hy- pogastric support of the apparatus prevents the descent of the abdominal viscera into the pelvis." (p. 222.)] E.—OF CURVATURES. 1323. Curvatures {Curvaturce, Lat; Verkriimmungen, Germ.; Cour- bures, Fr.) are remarkable deviations of certain parts of our body from their natural direction, depending either on an actual bending in the con- tinuity ofthe bones, or on their bending-and distortion in the neighbour- ing parts, that is, in the joints. 1324. Curvatures are either yices of the primary formation and con- genital; or they arise later, and are ordinarily developed without pain. The bones are not divided as in fracture, nor completely displaced at their joints as in dislocation. Only in a great degree of curvature, if the joints be also distorted, deviations gradually occur in the joint-surfaces ofthe displaced bones; just as in long continuance ofthe ailment, single bones are differently changed in their form, diminished by absorption, or united by callus. 1325. The erect posture of our body, and ofthe several organs, depends on the, equal antagonizing operation ofthe muscles, and on the firmness of the bones. The causes of their curvature are therefore disturbed abolished antagonism ofthe muscles, or changes in the structure ofthe bones, whereby they lose their proper degree of firmness. 1326. The antagonism of muscles is disturbed when either one part (a) Kyle, Beobachtungen iiber Antroversio Uteri in 'nichtschwangeren Zustande; in von Siebold's Journal, vol. xvii. pt. i. Vol. ii.—36 418 CURVATURES. possesses an absolute excess of activity above the other, or when one part is so weakened, that it opposes no obstacle to the natural activity of the other. This may be effected by palsy, wounds, weakness ofthe muscles, continued rest of certain muscles, tonic spasm, ordinary exer- tion of certain parts, especially in particular positions, by which they are wearied especially in children still under development, by diseased changes in the muscles, as from gout, rheumatism, inflammation, ulcera- tion, ossification, and so on. The activity of the flexor muscles natu- rally, especially in the foetus, exceeds that of the extensors; hence also the greater number of congenital and original curvatures arise in the course of the flexors. 1327. The muscles which produce the curvature, suffer always a more or less considerable degree of contraction and shortening, so that they are capable only of little extension, or of none at all. In long con- tinuance of this condition, various changes occur in the tissue of the muscles, they lose their fulness, become thinner, even cord-like, and at last are converted into a fibro-cellular, or fatty mass (1). Whatever be the causes which have produced the contraction of the muscles, these changes are always the same, and their common origin lies in the con- tinual rest, in which such muscles are found. Muscles, and, through them, their tendons and aponeuroses, must be kept in their constant and proper motion and activity if their vitality and organization is to remain natural, and a harmonious relation to exist between the voluntary influence which depends on the brain and the irritability which originates in the spinal marrow. If the activity of a muscle be damaged by one of the above- mentioned causes, and the muscle be kept in constant rest, it gradually diminishes, and at last all voluntary influence over it is lost, and its irrita- bility and tone increase correspondently ; by longer continuance of this condition, the tissue shrivels up, becomes unyielding, is to a certain degree atrophied, according to the same law that the intestine below an artificial anus, or a vessel which no longer contains blood, shrivels up, grows together, and at last wastes away. The rest of a muscle, when its contraction has once taken place, is therefore continual, because all voluntary motions which the patient attempts with the curved part, can occur only in such one way and direction, that thereby no outstretching and extension, but only a greater shortening ofthe contracted muscles, can be effected. A close observation ofthe motions in curvatures, especially in the feet, shows this remarkably. It is clear, that under such circum- stances, the nervous influence and nourishment must be diminished in the muscles, and the diminution of the nervous influence may increase up to actual palsy, although the contraction of the muscle continue. In this way also is explained the reason why in palsy, which originates from , the brain, and loss or diminution of the voluntary influence depending on the muscles, the muscles are contracted, whilst in palsy, proceeding from the spinal marrow, they are lax and atonic. Spasm, produced by topical causes in the muscle itself, or by reflected activity of the spinal marrow, may be the first origin of contraction ofthe muscles, and ofthe curvature thereon depending; but the continued contraction ofthe muscle is not to be considered as a consequence of continual spasm, but of the sustained rest of the muscle, and its diminished voluntary action. The CURVATURES. 419 same is observed in inflammation, and in all painful affections when certain muscles are kept in a continued quiet state. The most direct proof of this opinion is given by the bearings of the limb, if its natural direction be restored, in which case the recapability of motion, and the voluntary influence again gradually returns, and in the same measure, the nutrition of the muscles is increased, and their bulk enlarged, as I have especially observed, after the cure of curvatures by cutting the tendons. (1) Guerin (a), who, in all contractions assumes a convulsive retraction of the muscles derived from the brain, whence ensues an indispositiou to the growth of the skeleton, change of bulk and fibrous degeneration disturbed functions, supposes that muscles, which by other causes have been relaxed and shortened, do not exhibit the hardness and fibrous degeneration, as the former contract, but these are disposed to fatty degeneration. 1328. The natural connexion of bones may be disturbed by rickets, osteomalacy, scrofula, venereal, cachectic diseases, inflammation, suppura- tion, and so on. The softened bones are then exposed to the action of the muscles, and drawn according to the direction of the force acting upon them ; or the weight of the body is sufficient to curve them; from which latter cause such curvings most frequently happen in the trunk and the bones ofthe lower extremities. Frequently do the just-described causes occur at the same time, and in inverse proportions ; the curvings, however, most commonly arise out of unnatural activity ofthe muscles. 1329. As to the prognosis of curvatures, all depends on their extent and how long the curvature has existed, and in how far the causes origi- nating them may be got rid of. The younger the subject, and the less the curvature, so much the more favourable is the prognosis. In older subjects, and long-continued curvature, the treatment is always protrac- ted, and in many cases, often only an aggravation of the disease can be prevented. When in curvatures at the joints, organic changes ofthe bones, destruction, anchylosis, and so on exist, the disease is incurable. Curvatures depending on muscular contraction, generally allow a better prognosis than those from diminished connexion of the bones. But if the muscles have become so wasted by long-continued curvature that their lengthening can be of no use, which is however difficult to deter- mine, they are incurable. 1330. The cure of curvatures depends on the removal of the causes, and the restoration of the natural direction of the curved parts. When the firmness of \the bone is altered, such remedies must be employed as therapeutics have pointed out as fitting to the special diseases which cause the changed coherence of bones, together with the simultaneous employ- ment of suitable contrivances and apparatus by which the straight direc- tion may be restored. Mere mechanical treatment is entirely useless if the diseased state ofthe bony system be not removed. 1331. If the origin of the curvature depend on the disturbed equili- brium ofthe muscular activity, the treatment must be directed according to the different causes. Usually rubbing suppling remedies into the shortened and contracted muscles, and spirituous rubbings into the stretched and lengthened muscles are recommended; but from these remedies there is really less benefit than from the motion and extension (a) Gazette Medicale, April, 1838. No. 14. 420 TREATMENT. of the contracted muscles which arises from their application. As with long-continued curving, the nervous influence is diminished in the con- tracted and shortened muscles, and a lessened activity of the nerves of motion is accompanied with a certain degree of curvature and wasting, so may sharp irritants, vesicatories, and even moxas, act beneficially in quickening and increasing the vitality, which remedies are especially in- dicated in actual palsy. In reference to this object, kneading, rubbing, and stretching the muscles, are very serviceable; but above all, suitable gymnastics, (with careful regard to the somewhat necessary improve- ment ofthe general state of health,) as first introduced by Delpech (a). Slighter degrees of curvature may be got rid of by these remedies alone ; but if the curvature be greater, they must be accompanied with the appli- cation of suitable machines and apparatus. 1332. If with long-continued curvature from shortening of the mus- cles, such change of their tissue have been produced, that by the treat- ment proposed it can be removed either with extreme difficulty, or not at all, the subcutaneous cutting through the shortened muscles, or their tendons anfd aponeuroses, (myotomia, tenotomia,) if possible, is the most proper remedy. Between the two ends .of the divided tendon which retract, the upper more strongly than the lower, blood is effused, which coagulates and unites with the whole internal surface ofthe wound, and especially with the ends of the tendon. Exudations of plastic lymph soon occur, particularly from the ends of the tendon, presenting whitish thread-like streaks, running from one to the other, and gradually from mass resembling fibrous tissue, which is capable of due extension, and sufficiently strong to answer the function of the muscles. This operation is therefore especially indicated under the above-mentioned conditions, if there do not at the same time exist such considerable changes in the bones, and from the long continuance of the disease, such a degree of wasting in the muscles, and the whole limb, that by the mere lengthen- ing of the muscles, the restoration of their natural position cannot be effected, which however it is often difficult previously to determine, and when the causes giving rise to the contraction, gout for instance, still exist. The various objections made to this operation, the repeated shortening of the tendons by the gradual contraction of the newly formed intersubstance, as observed in every scar, as well as the injury to the natural direction and motions of the part from excessive activity of the antagonizing muscles, are without foundation, and contradicted by the large experience of modern times. The pain and wound are in this operation usually slight, and no particular symptoms occur. If in rare cases such be observed, as violent inflammation, with destruction ofthe cellular tissue, exfoliation of tendons, and so on, they must be ascribed rather to the peculiar relations of the constitution of the patient, or to the proceedings in the operation and the after-treatment, than to the opera- tion itself. The straightening ofthe part, and the stretching of the ten- dons by proper apparatus, is most properly commenced some days after they have been cut through, when the external wound is healed, to which time a light bandage covering the part keeps it in a proper position. The (a) De POrthomorphie par rapport a l'espece humaine, &c. 1828. Paris and Montpellier, 2 vols. 8vo. atlas, 4to. WRY NECK. 421 employment of extension immediately after the division is improper, as thereby the two ends ofthe tendon are too far separated, and bad symp- toms may be brought on. Too late use of extension when the interme- diate substance has a trained firmness, renders the lengthening difficult, and even impossible. The division of shortened muscles and tendons, early employed on the m. sterno- cleido mastoideus in wry neck, (Roonhuysen, Meeckren, Ten Haaf, and others,) and then forgotten; again revived by Sharp, by Tilesius, and Sartorius, upon the Achilles' tendon in club-foot, by Michaelis extended to other tendons also, were subsequently little thought of, and only employed in certain cases of contraction, by Dupuytren and Dieffenbach in wry neck, and by Delpech employed in horse-foot as a subcutaneous division. But more recently, it has been first brought into practice as a subcutaneous division by the large experience and observation of Stromeyer; and by Dieffenbach, Stoss, Duval, Scoutetten, Bouvier, Pauli, myself, and many others has it been variously practised and extended to different muscles, as more attention has been paid to the special treatment of curvatures. The mode of cure of tendons thus divided, Delpech formerly, and in modern times more espe- cially, von Ammon (a,) Duval, Bouvier, and others (b,) have explained by experi- ments on brutes. I.—OF WRY NECK. (Caput obstipum, Cervix obstipa, Obstipas, Torticollis, Lat.; schiefe Hals, Germ. Torticolis, Obstipite, Fr.) Mauchart, Dissert, sistens caput obstipum. Tubing., 1737. Rettig, H. X., Dissert, sistens caput obstipum. Budae, 1783, 8vo. Gruve, G., Dissert, de capite obstipo. Traj. ad Rh., 1786. 4to. Clossius, C. F., Ueber die Krankheiten der Knochen. Tubing., 1798, p. 254. Richter, Anfangsgrunde, vol. iv. p. 256. Jorg, J. C. G., Ueber die Verkriimmungen des menschlichen Kdrpersund erne, rationelle und sichere Heilart der selben. Leipz., 1816; with six plates. Stromeyer, L., Beitrage zur operativen Orthopaedic. Hannover, 1838. Phillips, Benjamin, Lectures on Surgery; in London Medical Gazette, vol. xxvi. p. 244. 1840. Dieffenbach, Die Durchschneidung der Sehnen und Muskeln. Berl., 1841, p. 17; with twenty lithographed plates. Phillips, Ch., M. D., De la Tenotomie sous-cutanee, ou des Operations qui se pratiqueut pour la Guerisondes Pieds-bots, Torticollis, &c. Paris, 1841. 8vo. Bonnet, A., Traite des Sections tendineuses et musculaires,etc. Paris, et Lyons, 1841, p. 581. 1333. Wry Neck consists in such distortion of the neck, that the head is inclined forwards, aside, downwards, frequently even to the shoulder- and the face turned more or less to the opposite side, and at the same time forwards and upwards ; the chin raised proportionally higher, as the head is in a greater degree drawn down. The patient can, under these circumstances, move the head either not at all, or only in a slight degree; often can it be done only by the assistance of another, and fre- quently it is not in any way possible. This disease may originate in an irregular activity of the muscles of the neck, especially of the m. sterno- mastoideus, in a large unsightly scar, or in a distortion of the neck itself. When long continued, there is always dissimilarity in the two sides of the face. (a) De physiologise tenatomite experimen- dung der Achilles'sebne als Operativ-ortho. lis illustrat. Dresden, 1837. padisches Heilmittel., Dorpat, 1843; with (b) Pirogoff, N., Ueber die Durchschnei- seven copper plates. 4to. 422 CAUSES. Distortion of the neck, as consequent on inflammation and suppuration of the joint-surfaces of the vertebrae of the neck, has been already considered (par. 263.) 1334. The most frequent cause of wry neck is unnatural muscular activity. It is either congenital and depends on irregular position of the child in the womb (1); or it arises from violence during delivery, which affects the m. sterno-mastoideus (2); or it comes on later from the habit always hanging the head to one side, especially in children, if they*be constantly carried on one arm ; if, on account ofthe continuance of any pain in the neck it be inclined to one side (3), by spasm and or- ganic change in the structure of the m. sterno-mastoideus. If the cause lie in the unnatural activity of this muscle, it is always found, on fbe side to which the head is drawn, stretched like a cord, hard and un- yielding ; in attempting to bring the head into its proper position, the muscle becomes more tense and prevents it (4). It is really only the m. sterno-mastoideus which is primarily shortened, and most commonly on the right side ; rarely, also, the m. cleido-mastoideus and cucullus; the m.platysma myoides, may also be shortened. Frequently is the m. ster- no-mastoideus of one side palsied, and the natural contraction of that of the other draws down the head. In this case the dissimilarity of the two sides of the face and the distortion of the features are not so great, as in wry neck from unnatural muscular contraction; the head is drawn only towards the shoulder, but the chin is not raised (5). That the cause of the evil is in the bones is known, when no change can be observed in the muscles, and the general symptoms of softening of bone be pre- sent. The head is also usually more moveable than in the former cases (6). (1) Stromeyer (a) remarks on the coincidence of congenital shortening ofthe m. sterno-mastoideus with the irregular position of the child, so that a breech-birth takes place, or turning is necessary. (2) After difficult delivery, and after the application of forceps, a little round bluish doughy swelling above the collar-bone, corresponding to the course of the m. sterno-mastoideus, is frequently observed, which, after subsiding, leaves to be felt a hard thick substance, depending on partial or complete tearing ofthe muscle. (Stro- meyer, Dieffenbach.) (3) I have noticed a wry neck which arose from the application of a blister behind the ear, and in a short time became considerable. [(4) Although generally in wryneck the muscle or muscles causing it are felt contracted like a cord, yet this is not always so. Syme (b) mentions an instance of this kind in a boy with lateral curvature. " Observing that his head inclined to one side, I examined the sterno-mastoid, and found it, not tense and rigid as I had expected, but soft and yielding. I perceived, however, that when an attempt was made to raise the head, the muscle resisted and became tense, and therefore con- cluded that it was the seat of the evil." (p. 273.) (5) Brodie mentions (c) a remarkable example of wry neck alternating with in- sanity, among the instances he gives of persons " labouring under some disease in the brain, in whom a particular symptom, referred, perhaps, to a distant part of the body, is so severe, or so distressing*, that they regard it as the original disease. * * * In many of these cases, the cause of irritation seems to operate always on the same part of the sensorium, and there is little or no variety in the local indications by which it is rendered manifest. At other times it has no determined seat: it may affect at first one portion of the brain to which a certain function belongs, and then (a) Above cited, p. 131. _ Monthly Journal of Medical Science, vol. iii' (6> On Lateral Curvature ofthe Spine and 1843. the cases in which it may be remedied by (c) Lectures illustrative of certain Locai operation; in London and Edinburgh Nervous Affections. London* 1837. 8vo. WRY NECK. 423 it may affect another portion, whose function is entirely different, and the symptoms vary accordingly. * * * A lady became affected with a spasmodic affection of the sterno-cleido mastoid muscle, producing what is commonly called a spasmodic wry neck. This symptom continued unabated for a year, and then suddenly left her; but as the spasm in the muscle ceased, she fell into a state of mental depression, amounting to insanity; and in this she continued during the whole of the second year. At the end of this period she recovered of the disordered condition of her mind, and the spasm of the muscle returned, continuing from that period up to the time of my being consulted three or four years afterwards." (pp. 7, 8.) (6) Syme remarks:—" It may be well to warn against mistaking for wry neck depending upon muscular contraction, the distorted position of the head which pro- ceeds from caries between the occiput, and atlas. The latter disease, like the for- mer, usually occurs in young persons, presents to a careless observer similar symp- toms, and if confounded with it, leads to a treatment not only useless, but extremely dangerous, (p. 273.)] 1335. The prognosis in wry neck depends especially on the cause and duration of the ailment. In young persons, if the cause be in the muscles, the prognosis is always favourable; and this applies also, under similar conditions, from curvature of the bones. But, if by long con- tinuance of the ailment, the vertebrae of the neck have undergone a change of form, or have become united by adhesion, which may be as- certained by careful examination with the fingers, and simultaneous movement of the neck, the ailment is incurable. 1336. The cure of wry neck varies according to its causes. If de- pendent on unnatural activity of the muscles, it must be attempted to relax the contracted, m. sterno-mastoideus, by rubbing in suppling reme- dies, as well as by exciting contraction of the relaxed muscles on the other side by volatile, strengthening rubbings of aromatic spirit, arrack, rum, and the like, and even by the employment of electricity or gal- vanism. After rubbing, attempts must be made to stretch the shortened m. sterno mastoideus, and at the same time, to bring the head straight, which manipulation must be continued fqr a quarter or half an hour, during the day, till the head have been brought to its natural place, and even bend somewhat to the opposite side. The patient must also be permitted frequently to turn his head aside. For the purpose of keeping the head straight, various apparatus and machines have been proposed, for instance that of Le Vacher, with alteration by Delacroix {a), Kohler's cap, and others. Jorg's (b), apparatus, however, seems to answer the purpose best; it consists of a head-band and stays, on the front of which is attached a spring, from whence a strap carried round the neck and fastened behind the ears in the region of the mastoid process, is fastened to the head-band. This apparatus may be worn day and night, and the manipulation may be also continued. As the head, though thereby straightened, is still how- ever held somewhat forward, towards the end ofthe cure the band must be carried beneath the arm ofthe ailing side, go, up through a ring, and be fastened at the place mentioned. The apparatus must be worn (latterly only for some hours in the day) till the antagonism between the two sterno-mastoids is perfectly restored. Delpech (c) recommends a stretching apparatus, when in bed, and drawing the head by means of a loop fastened to the head and to the side of the bed. (a) Gerdv, P. N., Traite des Bandages et Appaieils de Panseraent. Paris, 1826. 8vo. et atlas 4to.—von Froriep's Kupfertafeln, pi. clxix. (6) Above cited, pi. ii. (0 Orthomorphie, vol. ii. p. 209. 424 TREATMENT. 1337. But if, when the disease have already existed for some time in a certain state, this treatment have no result, it is extremely irksome.and tedious; the division of them, sterno-mastoideus then leads more speedily to the object, and is, indeed especially, the only cure in all cases where, by the continuance of the ailment, organic changes occur in the structure of the m. sterno-mastoideus, which render all lengthening by the pro- posed treatment impossible. The reasons which have been brought against this operation, rejected unconditionally by Jorg, are quite un- tenable; the operation is free from danger, accompanied with little pain, and the result is quick, even after the disease has existed twelve or sixteen years, or even longer. Roonhuysen (a) and Ten Haaf (b) cut through the m. sterno-mastoideus from without inwards, with a fold of the skin raised. Von Meeckren (c) effected the division with a pair of scissors ; Minnius (d) first destroyed the skin over the muscle with caustic, and then cut it through with scissors. Sharp (e) made a transverse cut through the skin, and divided the muscle from within outwards with a knife intro- duced behind it. This treatment was recommended by all the later writers, till Dupuytren and Dieffenbach (/) proposed the subcutaneous division of the muscle, in which manner the operation has been performed with the most successful results, by many surgeons and by myself. 1338. The subcutaneous division of the m. sterno-mastoideus is per- formed in the following manner. The patient sitting on a stool, one assistant draws the head to the opposite side, and another pulls down the shoulder of the ailing side, in consequence of which the muscle pro- jects strongly at its shortest part. The skin above it is then taken hold of with the thumb and fore-finger ofthe left hand, well'drawn away from the parts beneath, and a narrow, slightly convex, straight knife, held flat, is to be thrust an inch or two above its lower insertion, through the skin, and carried close behind the muscle, to the other side beneath the skin, but without piercing the latter. The edge is then turned towards the muscle, and the thumb of the left hand being placed on the muscle, to fix it against the edge, the muscle is divided, without cutting the skin, in drawing out the knife. At the commencement of the division of the muscle, a dull and sometimes tolerably loud crack is heard, upon which the head is almost immediately drawn straight by the contraction of the m. sterno-mastoideus on the other side; but sometimes the old position is retained, and even more strongly. At the moment when the knife is drawn back, if pressure be made with the thumb upon the part divided, and no blood be poured out beneath the skin, a firm compress of lint is to be applied, and fastened with sticking plaster, and a bandage carried obliquely over the neck and breast. Two cloths carried round are suf- ficient to support the head; they do not, however, keep it straight, but leave it in its early oblique position. The choice of place for dividing the m. sterno-mastoideus (fixed by Latta at half an inch, and by Dieffenbach at two inches above its insertion) is indifferent, and (a) Heilkuren. Nurnberg, 1674, vol. i. (c) Wahre und wunderbare chirurgisch No. 22, 23.—Blasii, G, Observat. Med. rar. und geneeskunstige Anmerkungen. Nurn- Amstelod., 1677, pi. ii. No. 1. berg, 1675. (b) Abhandlungen aus der Naturge- (d) Tulpii, Observationes Medic. schichte, praktischen Arzneikunde und Chi- (e) Treatise on the Operations of Surgery, rurgie; aus den Schriften der Harlemer London, 1740, chap. xxxv. und anderer Hollandischen Gesellschaften (/) Rust's Handbuch der Chirurgie,— gesammelt. Leipzig, 1775, vol. i. p. 262. Art., Caput obstipum. TREATMENT OF WRY NECK. 425 must be guided by where the muscle can be isolated safely; however, the deep division at the tendinous part is more preferable, because it is liable to less reaction than the division ofthe muscle. I use a straight, narrow, slightly convex knife, because it acts more surely and correctly than a knife with a concave edge; and, like Dieffenbach, I make only one thrust, in which he uses a narrow sickle-shaped knife, much curved at its point. Stromicyer, who has frequently performed the division of the m. sterno-mastoideus from before backwards, employs for the purpose a narrow curved knife, with its convexity cutting, which he thrusts through a fold in the skin, an inch broad above the collar-bone, and by the entrance of the knife divides the muscle. For those cases where the muscle cannot be sufficiently isolated, he has proposed a peculiar forceps-like instrument (a). 1339. Ordinarily the division ofthe m. -sterno-mastoideus is sufficient; but if the m. cleido-mastoideus, or a cleido-mastoideus secundus, (Stro- meyer,) or the clavicular portion of the m. cucullaris be shortened, the division must be effected with a straight or convex narrow bistoury, or with Stromeyer's instrument, according to the rules given above. 1340. If the patient be kept quiet, in the horizontal posture in bed, and on antiphlogistic diet, generally no farther symptoms occur. After some days the external wound is healed. The muscle, at the place of its division, usually presents a slight swelling; frequently also a slight fluctuation of blood is felt in which case, according to Dieffenbach, sticking plaster should be applied anew somewhat tighter, in order to promote its absorption, which is usually effected in a few days. Appli- cations of warm lead wash, and rubbing in warm oil to get rid of the last tension^are generally superfluous. If pus be formed, it must be dis- charged by a puncture, and the wound treated simply. A pasteboard cravat of half the usual height, folded in a cloth, and applied on the side of the division is, according to Dieffenbach, more serviceable in pre- serving the straight posture ofthe head than all violent extension, on which point I, from experience, entirely agree with him. Stromeyer (b) considers that only by a stretching apparatus (pi. vii.) are we in a position to obtain all the advantages of the operation which can be attained, because only in the horizontal posture can the muscles of the neck be completely extended, and it is only possible to stretch the head towards the diseased side for the purpose .of giving the m. sterno-mastoideus its whole length, and enabling it again to extend itself. He therefore puts it as a question whether, in very bad cases, it be not advisable to begin the extension directly after the operation, in order to avoid a repe- tition of the division. If after perfect replacement, the freest motion of the neck be again given, and com- plete similarity of the sides of the face obtained, yet is it observed in some cases, that at the moment when the muscular system is not in action, the head is somewhat disposed towards the ailing side, manifestly because there the turgor vitalis is less. Stromeyer does not know whether this be entirely lost in age. Spirituous rubbing seems to him to contribute somewhat to the diminution of this relaxation, but above all, the continued use ofthe stretching apparatus, some time after the subsidence of all resistance. 1341. If the cause of wry. neck be spasm of th*e m. sterno-cleido mas- toideus, in which case the ailment is always more or less painful, accom- panied with radiation of the pain, according to the branchings of the nerves, and often alternating, it must be inquired whether or not any internal cause be in play, against which the treatment should be directed, and antispasmodics employed both internally and externally. But if the contraction have at once become permanent, in general all internal and (a) Above cited, pi. viii. f. 1, 2. (6) Above cited, p. 130. « 426 CURVATURE OF THE SPINE, external treatment is fruitless, and cutting through the muscle is the only means whereby not merely the straight direction ofthe head is restored, but also the painful and spasmodic affections are removed. Compare the interesting observations hereto belonging of Stromeyer (a) and Amussat (b). A spasmodic affection of the m. platysma myoides, with radiation on the face and ear of the affected side, was perfectly cured by Gooch (c) by a transverse division of the muscle beneath the jaw, after he had laid it bare with a transverse incision of the skin across its breadth. 1342. If large scars be the cause of wry neck, their mere division is usually of little use, and the evil may thereby be even increased. The whole scar, together with the thickened and adhering cellular tissue must be removed, and where possible the quick union of the edges of the wound brought ahout. During and after the treatment, the head must be kept in a proper position. With slight superficial scars only, its straight direction may be often given to the head, by suppling reme- dies which are to be rubbed in, and by the bandages prescribed. 1343. If the cause ofthe wry neck be in a bending ofthe neck-verte- brae, and if it be unaccompanied with anchylosis, or change of structure, the above-mentioned apparatus must be used for the gradual straighten- ing ofthe head. II.—OF CURVATURES OF THE SPINAL COLUMN. (IncurvationesseuDistortiones Columnss Vertebralis, Lat.; VerkriimmungenderRtick- Cnsdule, Germ.; Courbures de la Colonne vertebrale, Fr.) Coopman, G., Dissert, de Cyphosi. Franeq., 1770. 4to. Le Vacher de la Feutrie, Traite du Rakitis, ou l'art de Tedresser les enfants contrefaits. Paris, 1772. 8vo. Wantzel, Dissert, de efficacitate gibbositatis in mutandis vasorum directionibus. Francof., 1778. 4to. Venel, Description de plusieurs nouveaux moyens mecaniques propres a prevenir et meme corriger dans certains cas les Courbures laterales et la Torsion de l'Epine du dos. Lausanne, 1788. 8vo. a Roy, C. H., Commentatio anatomico-chirurgica de scoliosi. Ludg., 1774. 4to. Wedel, G. W., Dissert, de gibbere. Jen., 1781. 4to. van Gesscher, D., Bemerkungen fiber die Einstellungen des Riichgrathes und fiber die Behandlung der Verrenkungen und Briiche des Schenkelbeines. Trans- lated into German from the Dutch, by J. C. Wemeyer. Gottingen, 1794. 8vo. Sheldrake, T., Essay on the various Causes and Effects ofthe Distorted Spine, and on the improper methods usually practised to remove the distortion. London, 1783. 8vo. Portal, Observations sur la Nature et le Traitement du Rachitisme ou des cour- bures de la colonne vertebrale et de celles des extremites. Paris, 1797. Wilkinson, C. H., Physiological and Philosophical Essays on the Distortion of the Spine. London, 1796. Reynders, J., De scoliosi ejusque causis et sanatione, observatione et propriis experimentis confirmatia. Groning., 1787. 8vo,- Feiler, J., De spinae dorsi incurvationibus earumque curatione. Noremb., 1807. Jorg, above cited. Chouland, J. L., De cas pelvium spinarumque deformatarum, i. ii. Lipsiffi, 1818-20. Ward, Practical Observations on Distortions of the Spine, Chest, and Limbs. London, 1822. (a) Above cited, p. 137. (?) Gazette Medicale, December, 1834, 829. (c) Cases and Practical Remarks in Surgery, vol. ii. p. 83. Norwich, 1767. ITS KINDS. 427 Wengel, C, Ueber die Krankheiten am Riichgrathe. Bamberg, 1824. fol.; with four plates. Shaw, John, On the Nature and Treatment of the Distortions to which the Spine and the Bones ofthe Chest are subject. London, 1823. 8vo. Ibid., Further Observations on the Lateral and Serpentine Curvature ofthe Spine, and on the Treatment of Contracted Limbs. London, 1825. 8vo. Ibid., Engravings illustrative of a Work on the Nature and Treatment of the Dis- tortions to which the Spine and the Bones of the Chest are subject. 1824. fol. Dufour, Memoire sur l'Art de prevenir et de corriger les Difformitps du Corps, designes sous le nom d'Orthopedie; in Revue Medicale, 1817. Jan.-June. Delpech, Considerations anatomieo-medicales surl'art appelle Orthopedie et sur les Difformites qui en sont l'objet; in Revue Medicale, 1827. April. Heidenreich, F. W., Orthopadie, der Werth der Mechanik zur Heilung der Ver- krummungen am menschlichen Leibe. Berlin, 1827. Beale, L. J., A Treatise on Deformities, exhibiting a concise view of the principal distortions and contractions of the limbs, joints, and spine; illustrated with plates. London, 1830. 8vo. Stafford. A., A Treaties on the Injuries, the Diseases, and the Distortions of the Spine. London, 1832. 8vo. Maisonabe, C. A., Orthopedie clinique sur les Difformites dans l'espece Humaine. Paris, 1834. 2 vols. 8vo. Mellet, F. L., Manuel Pratique d'Orthopedie, ou traite elementaire sur les moyens de prevenir et de guerir toutes les difformites du corps humain. Paris, 1835; with eighteen plates. Guerin; in Gazette Medicale, vol. v. 1837. No. 34. Humbert, P., et Jacquier, N., Traite des Difformites du Systeme osseux ou d'emploi des moyens mecaniques et gymnastiques dans le traitement de ces mala- dies. Paris, 1835. 8vo. Atlas of 174 Plates, pi. iv. Pauli, F., Ueber den grauenStaar und die Verkrummungen. Stuttg., 1838. 8vo. Stafford, R. A., Two Essays on Diseases of the Spine. 1. On Angular Curva- ture of the Spine and its Treatment. 2. On the Treatment of Lateral Curvature by Gravitation, Lateral Exercise, &c. London, 1844. 8vo. [Mitchell, J. K., On Lateral Curvature ofthe Spine in North Ameri- can Medical and Surgical Journal. Philadelphia, 1827.—g. w. n.] 1344. The spinal column may be curved at any one part, and accord- ing to the direction in which this occurs, are distinguished, first, the lateral Curvature (Scoliosis); second, the posterior {Humpback, Bucket, Germ.; Gibbus, Cyphosis); third, the Anterior Curvature (Lordosis). The spine never deviates according to either of its natural directions, but always in an opposite one. At the same time it is therewith more or less twisted, and this again in a contrary direction. It is evident that the intestines contained in the chest and belly, must consequently have their natural position variously altered, and only the successive origins of these curvatures render it comprehensible, how these intestines are often so considerably displaced, without great disturbance of their functions. The curvatures of the spine have no effect on the transverse diameter of the pelvis, if unfounded in general disease, especially rickets or osteomalacy (a). This opinion, advanced by Meckel, and supported by numerous facts, which, in consequence of careful observation, I hold to be correct, has been denied by Jorg (b) and Choulart (c) in so far as they assume, without any general disease of the bones, a decided influence of the curvature of the spine upon the form of the pelvis, only that in general disease, or, if the curvature have existed from youth, it is more decided. According to their view, as the spinal column has four natural curves, (a) Meckel, J. F., Handbuch der mensch- (b) Above cited, p. 8-26. lichen Anatomie, vol. ii. p. 740.—Wenzel, (c) Above cited, p. 15. above cited, p. 9. 428 CURVATURE OF THE SPINE, (at the neck convex forwards, at the back convex backwards, at the loins convex forwards, and on the rump-bone convex backwards,) in all cases where the natural curve increases at any one spot, the other natural curves should also be increased; just as, on the contrary, when the curve takes place in the opposite direction, the other parts ofthe spine also have their natural curve assume a contrary direction; in consequence of which the rump-bone becomes more curved, or more flattened. In lateral curvature the pelvis is always narrowed obliquely by the inclination of the rump-bone toward the one or other side. See also on this subject Rokitansky (a). 1345. The inclination ofthe spinal column to one side, {Scoliosis,) pro- duces at first a different condition of the shoulders, and one becomes higher than the other; the body is disposed towards the side opposite the curvature, the one side of the back is full, the other concave, and more hollow; and upon it, between the last false rib and the hip-bone, is observed a small fold ofthe tegument, which increases proportionally as the curvature of the spine increases. With such increased inclination toward the side, distortion of the spine also occurs; the spinous pro- cesses are twisted toward the side of the inclination. The whole trunk is gradually bent, the ribs follow the distortion of the spine, are flatter on their concave surface, but upon their convex hinder surface are more strongly arched, are very widely separated from each other, and broader, whence a projection backwards is produced. The breast-bone is mostly oblique, and drawn towards the concave side of the curvature. If the curvature be at the upper part ofthe spine, the position ofthe shoulder- blades is much changed. Curvatures at the lower part of the spine affect the carriage of the body less than at the upper. Lastly, curvatures are produced in opposite directions, in which case one is, as it were, equalized by the other. In the highest degree the direction ofthe bones of the pelvis is changed, the one hip-bone stands higher than the other, and, under the circumstances mentioned, (par. 1344,) the promontory of the rump-bone may project inwards towards the one or other side, and narrow the entrance of the pelvis. The higher position of one shoulder is always present in scoliosis, but it occurs alone, and without simultaneous curving of the spinal column, as high shoulder (Humerus elaius). Raising up one shoulder, usually the right, by which the ele- vating muscles ofthe shoulder-blade become gradually stronger, is the result of bad habit;' the lower angle of the blade-bone is raised higher than that of the other side; the hinder edge, however of the bone remains in the same position, and only after long continuance does the shoulder-blade project especially at its angle. If both shoulders be high, which occuts from bad carriage, as a consequence of correspond- ing straining of both arms, in bending forwards the head, in short-sighted and old persons, the back is considerably arched, and the head in the same proportion pro- jecting. In a higher degree always, at the same time, some inclination of the spinal column occurs. [The most common cause of a high shoulder is to be found in the abominable practice of undressing girl's necks, as low as the hanging on of their clothes will permit. Instead ofthe shoulder straps of their dress being as they should be, fairly above the root of the acromial processes, they often, indeed most commonly, either only skirt the extreme end of those processes, and rest on the rounded upper part of the deltoid muscles, or are actually far down on the arms; in consequence of which, the dress having little or no suspension on the shoulders, is constantly dropping, and the girl to save her clothes dropping down, or at least to keep them in place, is con- tinually hitching up the shoulder from which the shoulder-strap most easily slips, and thus the elevating muscles becoming stronger on that side, pull the shoulder (a) Beitrage zur Kenntniss der Ruck- Brustkorbes und Beckens; in Oester-Med. grathskrummungen, und der mit denselben Jahrbilchern, vol. xxviii. pt. i. ii. zusammentreffenden Abweichungen des ITS KINDS. 429 permanently up, and produce a very ugly appearance. But the mischief does not stop here, for though there be really no disease in the spine, yet this constant hitching up of the shoulder, causes the head and neck to be thrown to the other side, whilst the chest is drawn out to the same side, and thus a lateral curvature of the spine is produced, and a girl's figure spoiled, for the simple purpose of uncovering her neck and shoulders as far as possible, which, as well for decency, as for the preservation of the child's health, ought to be covered. Many parents have been thus the real cause of their daughter's distortion, if not of more serious consequences ; and there- fore, in growing girls who have the least disposition to slip their shoulder out of their dress, most especial care should be taken to prevent the possibility of keeping up this habit, by having the dress made so high, that it cannot slip down, and then the sensation of its slipping being lost, the child no longer continues to hitch up her shoulder, and by a little attention to her proper carriage, the mischief, if not of long standing, may be got rid of.—j. f. s.] 1346. The intestines of the chest and belly are variously displaced by the higher degrees of scoliosis, in consequence of which the circula- tion of the blood in the lungs is hindered, difficult respiration, narrow- chestedness, disturbance of the digestion, and so on, arise which thus explain the usually weakly form of the body in persons affected with such curvatures. 1347. In Cyphosis the spinous processes form a convex projection, and the bodies of the spinal column a curve, the concavity of which is forwards, and, as they drop together, the upper approach the lower. At first, the head of the patient inclines forwards; in the supine posture no change is observed, except after very considerable exertion. In the second degree, the inclination of the spine remains, and is always in- creasing ; it projects into a blunt, and, subsequently into a sharp angle. If the cyphosis be in the vertebrae of the neck, breathing and swallowing are especially affected ; if the vertebrae of the back be curved, the ribs are lengthened forwards, the breast-bone raised, and the transverse diame- ter ofthe chest lessened, from which difficulty of breathing ensues. By the dropping of the spine, the bowels are driven down into the pelvis, and frequently cause difficulties in digestion. The bodies of the verte- brae shrink in a high degree of the disease, and they may be fixed by anchylosis in their unnatural position. Inclinations in other directions may at the same time accompany cyphosis. Only in the cases where the cyphosis depends on caries of the vertebrae (Pott's disease) does palsy of the limb occur. 1348. The inclination forwards is the most rare of all the curvatures ofthe spine. The vertebrae project forward in a convex arch, and the spinous processes are thereby approached together in a concave curve. Whence follows, that the lordosis can never attain so great an extent as the cyphosis, because the spinous processes touch. It occurs always in the vertebrae of the loins, and the inconveniences they excite are those ofthe pendant belly. It has been observed, but very rarely, in the ver- tebrae of the neck. 1349. What has been said upon the etiology of curvature in general, applies also to that of the spine. There is either a disturbed antagonism of the muscles, or a diminished strength of the bones. The occa- sional causes which especially favour the various inclinations of the spine are :— First. In scoliosis, careless carriage of the body in various employments, hanging on one side in writing, sitting, especially in the hand-work of Vol. ii.—37 430 CURVATURE OF THE SPINE, ladies, increased exertion of one side, the habit of doing every thing with one hand, constantly carrying children on one arm, which acts very prejudicially, as one hip-bone is always more raised and pressed than the other. The younger the patient is, the more prejudicially do the above-mentioned causes operate. If the cause of the curvature depend on unnatural activity of the muscles, they are more firm and contracted on the concave side of the curvature (which, in by far the greatest numberof the cases, is the left;) if the cause ofthe curvature depend rather on an altered state of the bones, the difference of the muscles is not so remarkable (1). Second. In cyphosis the cause, for the most part, is in the bones, and the weight of the body itself is sufficient to increase the bending back- wards already existing in the vertebrae of the back, where the cyphosis most commonly occurs ; often is there accompanying weakness of all the muscles, which should keep the spine erect, as is frequently the case in children and old persons. Third. In lordosis, in their natural state, the external muscles of the loins are more powerful than the internal; whatever therefore increases the strength of the former, increases also the natural bending inwards of the vertebrae of the loins, as long standing with the upper part of the body bent back, great bending back ofthe upper part ofthe body in the usual carriage, bearing heavy burdens. Lordosis is therefore more frequent in men than in women. (1) Stromeyer (a) supposes that scoliosis arises, if not in all, at least in most cases,, from one-sided palsy ofthe inspiratory muscle, viz., the m. serratus magnus. The muscle, although still capable Of voluntary motions, takes no part in those of breathing, which is especially observable if the motions of the diaphragm be re- strained by pressure on the belly, and the external muscles of inspiration be excited to increased activity; as then the muscles of the palsied side remain quite quiet. This imperfect palsy is derived from the palsy of Bell's respiratory system, from an incapacity of the affected nerves proceeding from the periphery to re-excite re- flected irritation, in which case they still obey the stronger stimulus proceeding from the will. The greater number of cases produced in support of this opinion, permit ajso another explanation, and according to what has been already said upon the aetiology of curvatures in general, is this state of palsy ofthe muscles of inspiration to be considered, not as a primary, but as a secondary state. According to Gunther's (b) observations in snake-like scoliosis the muscles neither of the concave or convex side are much wasted, nor are they changed in form, al- though it so appears as long as they are attached to the body. They are only either stretched where passing over the projections, or folded when lying in the concavities. On the contrary, there appears a decided difference in the strength and weight of the corresponding muscles of the two sides, and that muscle increases which has an un- favourable position, and is therefore required to act with more power. So, for in- stance, the m. cucullaris of the concave side exceeds that of the convex about 90 grs. in a weight of 1550 grs.; the m. latissimus _dorsi of the convex, that of the other side about 120 grs. in 1160 grs. If the relations of one muscle be so dispro- portionate that, in its natural circumstances, it either act not at all, or irregularly, its circumstances change, so that it detaches itself from some places, attaches itself to others more suitable, or forms new heads. [According to Zink's opinion (c) scoliosis generally commences from the fifth to the eighth year of age, and between the third and fifth dorsal vertebrae, and the de- viation is almost always towards the right shoulder-blade; that shoulder exhibiting (a) Ueber Paralyse der Inspirations- (c) Verhandl. der K. K. Gesellschafl der muskeln. Hanover, 1836. Aerzte zu Wien, 1842-43; and British and (fc) Pfaff's Mittheilungen, 1836,'pt. ix* Foreign Medical Review, vol. six. p. 370, p. 10. 1845. ITS KINDS. 431 an excess of nutrition over the left, which is especially apparent in the blade-bones themselves. Such children have a remarkable tendency to lean towards the weaker side, while on every occasion requiring muscular exertion, they prefer the stronger hand. " From repeated observations," says Zink, " I am convinced that the greater part of the mischief here detailed, is effected during sleep, and consequently, is in operation during one-third of the patient's daily existence. The heart then leans down towards the left side, and the lung on that side is compressed, one lung only (the right) performs its full office, and the muscles of respiration on that side are in a state of activity, greatly exceeding that of the left. I have also ascertained that the convexity of the deviation of the spine accords exactly with the insertion of those muscles which are most active in the process of respiration. This deviation from the perpendicular, so high up in the spinal column, is often overlooked, and the in- ferior and secondary contortion to the left side in the lumbar vertebrae is often re- garded as the primary affection." And he farther observes:—"This disease is more frequent among the wealthy, and more commonly in females than males." Syme (a) observes:—"There is one particular condition of lateral curvature cer- tainly not common; yet, judging from the number of cases that have fallen within my own observation, I should.say not extremely rare, in which complete, relief may be afforded by the division of a muscle, and in no other way. I allude to spinal curva- ture depending upon wry neck, caused by contraction of the sterno-mastoid. This muscle is liable to contraction both spasmodic and permanent. The former does not, so far as I have seen, affect the shape of the spine, and in two cases treated by division, did not yield to the operation. But the latter is apt to produce lateral cur- vature in every degree and may be remedied with no less ease than certainty by subcutaneous incision" (p. 271)1. 1350. The special diagnosis of curvatures in regard to their cause, is now to be considered. Great muscular weakness, resulting from pre- vious disease, disturbed digestion, disturbed sexual development, and the like, by which gradually the joints ofthe spine are left to the unaided and inadequate strength of the ligaments, is characterized by weakness ofthe muscles, pain, and weariness of the spine, speedy tiring after every movement, dropping of the spine to one side or other, or forwards, and great mobility of the spine; so that, on examination in various positions ofthe body, alterations appear ; when lying down, the deformities disap- pear, if they be not very great. In children who are very stout, and have a large head, whose muscles are too weak for the weight of their body, and especially of their head, there appears commonly at the time when they should begin to walk, incapability of so doing ; and, when sitting, a great dropping forwards ofthe head, by which the spine pro- jects backwards in a large curve ; in lying down, this is diminished, but with carelessness, it becomes permanent, and always more considerable. 1351. The swelling of the fibrous intercartilage has been considered by Delpech {b) as no rare cause of spinal curvature; it proceeds gene- rally from one point to all the vertebrae in various degrees, or all may be at once attacked. In the former case sometimes severe, sometimes slight pain occurs at any one part of the spine, which consequently is deformed. This pain has not, however, always a definite and precise place: the patient points out the seat of pain in a vague manner, frequently on one or other side of the body, frequently at the epigastrium. A curvature appears, which, at first, is inconsiderable, and forms a pretty large curve. The direction of the inclination is determined by the greater or less thickness which one or several fibro-cartilages have obtained at any one part of their extent. Hence may arise curvatures backwards, forwards,. (a) Above cited. (b) Orthomorphie, vol. ii. p. 53* 432 CURVATURE OF THE SPINE. and especially sideways. If a complication exist at the same time, for instance, a too short lower limb, a deforming scar, long continued pain, a forcibly-continued position, and so on, they may determine the direc- tion of the inclination. This is, at first, slight, indefinite, and even tran- sitory ; it subsides, at least partially, in the horizontal posture, in the morning, immediately on getting up, and so long as the principal func- tions, especially digestion, are carried on satisfactorily. The curvature extends to the neighbouring vertebrae. These new curves disappear in the horizontal posture, and when the body is supported on the hands, whilst the primitive curves still exist. Subsequently these successive curvatures become permanent, and no longer subside in the experiments just mentioned. Sometimes walking and standing are rendered difficult by the curvature; the patient resorts to particular attitudes to keep himself upright, and, in a short time, new deformities are observed in the oppo- site direction, for the purpose of restoring the equilibrium of the body. These new curvatures may also subsequently become permanent. The curvatures form, at least before they are yet very old, more or less open, but regular arches. If the swelling attack the fibrous inter-cartilages all at once, (cases which have been noticed by Delpech only in lymphatic and weakly per- sons,) the patient is not capable of standing upright; he always seeks a resting place, loves repose, is apathetic, but yet restless; he avoids all exercise and all enjoyments of his age ; the slightest walking tires him. Generally there appear disturbance of the digestive organs, palpitation ofthe heart, and oppression ofthe chest, which, however, are transitory. The patient avoids bending himself in any one direction; and in the most simple, and shortest walks, has frequent falls, accompanied with pain, which ceases as quickly as it came on, and the seat of which the patient cannot accurately determine. If sufficient pressure be made successively on the spinous process of each vertebrae, violent pain is excited in each and an epileptic attack, accompanied with convulsive movements ofthe upper and lower limbs. If the examination be made whilst the patient stands, epilepsy follows, with the painful sensation produced by pressure. On examining the spinal column, it is easily perceived that a greater or less mobility exists in almost all the vertebrae, but especially in those in which the pressure causes the symptoms mentioned. There still, how- ever, appears no permanent deformity ; but if the patient be carefully sus- pended by the head or by the arms, all appearance of deformity subsides, and it is clear that all are possible, but none yet exist which may become permanent. If the ailment continue to permit it, successive and alternate fixed curvatures occur, which quickly increase, but always retain their fundamental character, to wit, a greater or less large arch, generally of pretty large extent, but regular, and free from all angles. These cur- tures very readily increase. 1352. In the curvatures of the spinal column from softening of the bones, the spine usually projects backwards where one or several bodies of the vertebrae have sunk in, and a vertical flattening of the body of a vertebra takes place. The bending backwards is frequently connected with, a slight disposition towards the side. At some distance from the original curvature, large curves and almost regular arches are formed. In rickets there are accompanying swellings of the condyles of the tubu- TREATMENT. 433 lar bones, which also bend in various parts, disturbance of digestion, distended belly, and so on. In osteomolacy, the whole constitution is much affected for a long while before the curvature takes place, severe, com- monly wandering pains, spreading over the breast and belly, frequently fixed in the spine, which increases at every movement, even on turn- ing round in bed, precede and accompany curvature; febrile symptoms frequently appear; digestion and all the functions become more and more affected; the weakness is always greater, partly on that account, probably on account of the pain at every movement, the patient keeps one position in bed, which determines the direction of the inclination of the spine. In these curvatures the ribs especially,, and the bones of the pelvis, are decidedly changed in their form and direction. 1353. The prognosis in curvatures of the spine, is directed generally according to the age of the subject, the duration, the cause, the degree, and complication of the disease. Many curvatures which, as yet, have not become permanent, and are connected with general disturbance of the health and weakness ofthe muscles, may, indeed, in rare cases sub- side, form favourable change of the constitution during the period of development, or from accidental improvement of the general state of health; but reliance on this self-assistance of nature is always dangerous; for, in most cases, experience commonly shows the case getting worse. The younger the patient, the slighter the degree of curvature, so much the easier is it of cure; in persons advanced in years, and in adults,, the progress of the disease may be arrested by careful treatment, but no perfect cure is effected. If the cause of the curvature be a diseased condition of the bones, the prognosis is always more unfavourable than if it were in misproportions of the muscles. If inclinations of the spine, in different directions, exist, the treatment is more difficult than if there were merely one single inclination. In long-continued curvatures of the spine, such changes occur in the vertebrae that a cure is rendered im- possible. It is therefore an important observation^ in reference to this point, that the curvature remain without increase some two or three years, and still more important, that for an equally long time, all the vague symptoms of inexplicable injury of functions, which accompany the completion of the deformity, are progressively and completely stopped (a). In these cases the curvature is connected with anchylosis of the vertebrae, and the cure is impossible. In order to. ascertain this, the patient, having stripped, should be laid flat on his belly, and rubbed with spirituous remedies on the extended muscles, but with relaxing remedies on those of which are contracted, and attempts should be made to restore the spine gradually to its natural direction. If the patient then feel a stretching and stress upon the curved part of the spine, and not at the insertion ofthe muscles, it may be decided that there is anchy- losis. This condition of the curvature is more surely indicated, if pre- vious or continued extension of the spine show no change in the curva- ture. On the other'side, if changes in the spine be observed on care- fully lifting the body by the head (1), so that the feet do^not support the weight of the body, or in extension whilst in the horizontal posture, there is more hope of restoration. Anchylosis, however, is not very (a) Delpech, a£ove sited.: 37* 434 CURVATURE OF THE SPINE. common, and usually only accompanying a long-continued great degree of curvature, and in persons of advanced age. The scoliosis, when it first occurs in adults, rarely attains the first degree. The lordosisis most easy, the cyphosis the most difficult of cure. [(1) This practice of lifting by the head, to which Chelius very frequently recurs in these diseases, I think very objectionable and dangerous, especially in weakly children, who may be entirely free from disease, as the longitudinal ligaments of the spine maybe insufficient to bear the weight ofthe lower part ofthe body. Astley Cooper, in his lectures, was accustomed to inveigh bitterly against the foolish trick of showing children the way to London, as it is called, which consists in lifting them up by the chin and back ofthe head. Chelius's proposal is of the same kind, and equally objectionable.—j. f. s..] 1354. The treatment of curvature of the spinal column must be vari- ously conducted, according to the different cause and nature of the deformity, that is, such remedies must be employed as counteract the causes in which it originates, and at the same time, or immediately after the- straight direction must be restored by mechanical apparatus and other means operating on the spine. In former times the first indication was almost completely neglected; the treatment was, for the most part, purely mechanical, and partly thence, partly from the inadequacy of the mechanical apparatus, was imperfect, and in mosf cases, even hurtful. Only in modern times has this treatment become the object of careful inquiry, and employed on right principles, according to the difference of the causes of curvature. A survey of the various machines and contri- vances which have been proposed for the treatment of the spinal curva- ture, give proof of this. 1355. The apparatus which have been proposed for cure of spinal curvature, act either by pressure or extension, or both together. 1356. To the apparatus, acting by pressure, belong First. Heister's iron cross {a), which consists of two flat iron rods connected together in form of a T. On the transverse piece are two rings, by which the shoulders can be'drawn back; at the extremity of the vertical piece descending along the back is a strap, by which it is attached to the body. B. Bell (&) has added to this machine a padded neck-band, connected to the cross by an iron rod, which may be fixed higher or lower, in order to keep the head more or less up. Second. Van Gesscher's apparatus consists of a stirrup bound around the pelvis, on which two rods are attached with screws running upon the sides of the spinous processes, and rivetted above to a shoulder- piece, on the two ends of which are straps to draw the shoulders back. 1357. To the apparatus operating by extension, belong, first of all, the extending beds and stretching apparatus of Venel and Schreger (c), Lafond {d), Shaw (e), Maisonabe {f), Blomer (g\ Langenbeck {h), Delpech {%), Heine, and others, in which the patient is fastened, by (a) Institutiones, Chirurgicse, pi. viii. f. 13. (/ ) Journal Clinique des Difformites, Dec. (b) Lehrbegriff, vol. v. pi. iv. f. 5, 6, 7. 1825, No. ii. (c) Versuch eines Streckapparates zum (g) Journal von Graefe und von Wal- aachtlichen Gebrauche far Ruckgrathsge- tiier, vol. ix. pt. iv. Compare Froriep's krttmmtei Erlangen,. 181ft.. 4to.; with copper- Chirurg. Kupfertafeln, pi. clix. clxxxii. plates. (k) Muhrv, Dissert, de spinte distortioni- (d) London Medical and. Physical Jour- bus et pede equino. Getting., 1829. »al, Dec. 18:26, p. 497. (i) Orthomorphie, pi. 40, 41. (e) Above cited. TREATMENT. 435 means of padded straps applied on the feet and head, above and below to a bed or chair, and the extension of the whole body is kept up by sufficiently strong springs. In some of these machines it is attempted simultaneously to employ pressure, by means of solid pillows thrust be- neath the back, or as in the stretching apparatus of Delpech and Lan- genbeck, by elastic traces carried around the body from one to the other side of the bed. The same object is effected only momentarily, by the so-called neck-swing {escarpolette) of Clisson, in which a broad cloth is applied around the patient's neck, and to its two sides is attached, be- hind the ears, a bandage which is carried through a pulley attached to the ceiling, wherewith the patient draws himself up as long as he can bear it. Here also belongs Le Vacher's machine which consists of stays, laced in front, and having a plate attached to its hind part. An iron rod passes into a groove upon this plate, which ascends straight up the middle of the neck, and thence curves, over the head to the forehead. In the notch at the upper end of this rod is hung an apparatus which is fastened around the head and beneath the chin of the patient. Pelug {a) has improved this machine by attaching, instead of the head-apparatus, at the end of the iron rod which reaches only to the upper part of the neck, a neck-band, by which the chin and occiput can be held up. Sheldrake altered Le Vecher's machine; he took away the stays and fastened the iron rod on a plate which descended from the middle of the back and fitted closely to the rump-bone. Delacroix also altered this machine, making its point of support on the pelvis {b). Guerin (c) has proposed an apparatus for the simultaneous extension {extension sigmoide) ofthe vertebral column in contrary directions of the curvature. Hereto also must be referred Darwin's (d) advice, to keep the patient, at the onset of the curvature, for a long time in the horizontal posture, and if this be insufficient, to let him sit on a particular kind of seat, in which, by a special contrivance, the shoulders can be raised and the head supported. Bloimer and Lafond's stretching chair (e). 1358. The apparatus acting by extension and pressure, are— First. Schmidt's apparatus (f), consisting of two semicircles connect- ed together, which lie upon the hip-bones, and from whence rise up two sheaths, or the reception of two rods, which at their upper part have a semicircular sweep outwards for supporting the shoulders, and are move- able higher or lower.) At the upper part of each sheath is a semicircle, to which two rods are attached, their upper ends thrown round the half circles, like hooks, their lower ends curved round the half circles, en- compassing the pelvis and ascending within it. These processes, covered with leather, form long pads, which are brought close to, or separated from the rods, by screws. Well-fitting stays surround the front of the chest. The apparatus of Langenbeck (g) and von Graefe (A) are con- structed on the same principles. (a) Bernstein, Systemat. Darstellung des (e) Froriep's Chirurgische Kupfertafeln, Chirurgischen Verbandes, p. 259. pi. exxxiv. clix. clxix. clxxxii. ccxl. ccxlvi. (6} Gerdy, above cited. Chirurg. Kup- (/) Beschreibung einer neuen Maschine fertafeln pi. clxix. zur Verminderung und Heilung der Buchel. (c) Gazette Medicale, Nov. 1835, p. 732. Leipzig, 1796. 8vo. (d), Zoonomia, or the Laws of Organic (g) Bibhothek fur die Chirurgie, vol. iii. Life. London, 4to. 2, vols. 17,94-96. pt. ii. pi., n. f. 3. (h), Malschj GL Dissert de nova machina 436 CURVATURE OF THE SPINE. Second. Jorg's apparatus {a) consists of a firm and an elastic part; the former is made of linden wood, covered with soft leather; the latter consists of several springs laid close together and covered, connected at the one end with the firm part and at the other end fastened with a buckle. In scoliosis the firm part is applied to the concave side of the trunk, below it rests upon the hip, and above, just against the shoulder: The. elastic half is carried round the other side (for the first degree of scoliosis, Jorg employs an elastic brace, which is attached to the breeches usually worn, before and behind, in the middle by a button, and passes over the shoulder of the projecting side, where a pad is placed beneath it). In cyphosis this apparatus is applied with the alte- ration, that the firm part is always applied where the trunk is concave, and the elastic half on the seat of the projection. A. Portal had already proposed to a certain extent a similar apparatus, consisting of a double fork, which is fastened on the sides-to a pair of stays, so that the arm above and the hip below serve for its application (b). The Graefean apparatus is composed—1. Of a loin-girdle, which by means of a pair of semilunar plates rests upon the crests of the hip-bones. The hinder ends of this girdle may be introduced into each other, and fastened with a screw. The front ends are connected with a buckle. Upon the semilunar plates are studs on both sides, on which is fastened a strap, destined to support the belly. All this part of the machine is stuffed with hair and covered with leather. 2. Of a breast- girdle, which like the lower one consists of two semicircles, connected behind in the same way as the lower one; and in front, in males, fastened together by a strap and buckle; but in females, segments are-applied around the breasts. 3. On the loin and chest-girdle there are, on both sides, two rods firmly connected with the former, and with the second by a steel plate. These rods form beneath quadranguT lar sheaths, which terminate in quadrangular capsules, on the outside of each of which is a quadrangular prominence. In the interior of these sheaths is an endless screw, which can be raised up or depressed by means of a roller fixed on the quad- rangular projection. The rest of the sheath above the quadrangular process is formed into a cylinder, in which is a spiral spring. Into the upper opening of this cylindrical part of the sheath is the rod received, having upon it the support for the shoulder, which is properly padded, and so attached to the rod that it can be differ- ently placed, according to the different form of the shoulder. For the purpose of connecting pressure on the spine with this extending apparatus, cushions are applied, by means of screws on the breast or loin-girdle, according to the difference of place to which pressure is to be applied. I have made the following alterations in this apparatus to render it more simple and less costly. A case of iron plate, properly padded, and enclosing the pelvis up to the upper spine of the hip-bone, is fastened in front with a broad strap and buckle. On both sides of this pelvis case are two buckles, in which two rods connected with each other are inserted. At the upper end, these rods are connected with an iron plate, through the middle of which a screw passes, quadrangular at its lower end, and at the upper, the properly padded supports are attached, which may be placed higher or lower, by means of a key fitting the quadrangular end of the screw; thus- the apparatus acts like Graefe's. For the purpose of making graduate pressure I do not employ cushions, but elastic bands, (after Joerge's plan,) which in cyphosis lie upon the back, and are attached to brass studs on both rods; but in scoliosis, to the studs on one rod over the projecting side of the trunk, between it and the ascending rod, for the purpose of surrounding the whole body, and again is attached. to the stud of the first rod. In inclination in two opposite directions, this yoke may be applied, also in contrary directions. If the shoulder-blade particularly project, I carry an elastic band over the more elevated shoulder, and fastened behind and be- fore to that going around the body. I allow this apparatus to be worn day antf/ Graefiana. distorsiones spinas dorsi ad sanan- («) Above cited, pi. v. f. I. das nee non disquisitio deformitatum istsu (6) Precis de Chirurg. rjrat, vcL i. Paris,. rum. Berol., 1818. 4to.; with copper- 1761. plates. TREATMENT. * 437 night over a close shirt. From its careful employment I have derived the happiest results (a). 1359. It were superfluous to enter on a special criticism ofthe several apparatus. Those contrivances only which at once effect extension and pressure can act efficiently. Of the portable apparatus of this kind, those only answer the object which have their point of support on the pelvis, and are so constructed that they cause no painful pressure, nor too great compression of the chest, and so on. With proper considera- tion ofthe points still to be mentioned in reference to special treatment, the cure may indeed be effected with these apparatus in incipient and slight degrees of curvature, and specially in lateral curvature produced by un- equal muscular activity, as I have so frequently had opportunity to observe in the use of my above-described apparatus, which is distinguished from that in which pressure is made by the cushions, by the lateral elastic bands. Such favourable result is, however, only possible with close and careful attention, and when, especially, all the circumstances ofthe patient are properly regulated. When this is not the case, the disease becomes really worse, or at least all the time is lost which could have been best employed for the cure of the deformity. For all great degrees of curvature, such treatment is insufficient; a continued employment of the extending apparatus is necessary, the operation of which is not equally certain as that of the portable apparatus, and among which that is best, in which, at the same time, bands are attached, to operate on the oppo- site sides of the trunk, as, for instance, in the extending apparatus of Delpech, Langenbeck, and others. 1360. Such treatment can only in reality be carried on with suitable care in special institutions for the purpose; and this is the reason why of late these (orthopedic) institutions have become so very numerous. There is, however, a well grounded complaint, that in many of them the entire treatment is conducted in a too mechanical manner; and that by too long-continued use of the extending apparatus, with constant rest, the greatest injury is caused to the whole constitution of the patient; so that, as I unfortunately have seen in several cases, with slight Or merely transitory improvement of the curvature, disorder of the health difficult to be got rid of, and even incurable, has been thereby produced. Those cases are not to be now considered where the disease of the spine is of a completely different kind, and not to be thus treated. 1361. Delpech has the great merit, by combining a regular course of gymnastics with the use of the extending apparatus, of getting rid of those disadvantages which have been properly objected to on account of the above-mentioned causes, by the usual employment of the latter, and especially by the proper estimation ofthe operation of such gymnastics, of having opened a new and very successful path in the treatment of this deformity. 1362. These gymnastics have the especial object of relieving the vertebrae from each other's weight for several hours daily; of supporting the weight of the body, without condemning it immediately to rest and its ill consequences; of exciting the activity of the muscles to sufficient continuance and power, so that it may be advantageous to the nourish- ed) Gruber, S. P. G., Dissert, de nova ma- tern, cui accedit hujus morbi descriptio. china Chelius'iana ad'sanandam gibbosita- 1825. 4to.; with copper-plates. 438 CURVATURE OF THE SPINE. ment of these organs, and to the improvement ofthe whole constitution; to employ all the muscles, without exception, in increased exertion, and by means of motion, extension, and pressure, employed in all directions, to reach the affected parts of the spine. These exercises are to be used daily for two or three hours, and then, according to the state of the deformity, the necessary extension in the stretching-bed, or some special apparatus is to be employed. Delpech considers swimming as very proper, but otherwise he does not use bathing, if no special reason call for its use; neither does he employ friction and the like, because by the exercises the muscles are acted on far more properly and more power- fully than by those means. These exercises, which are undertaken gradually, and extended to all the muscles, are, movements upon the swing, exercises and games on the spiral ladder, exercises on the knotted rope, games on the loose rope and climbing pole, games on the obliquely-stretched rope, on the straight and obliquely-stretched ladder, games on the tight rope and flying bridge, the use of a windlas, games with the horizontal pole, and so on. The atlas accompanying Delpech's work gives a sufficient repre- sentation of these different exercises. Where no special institution is at hand, apparatus for these exercises must be introduced into every room, yard, or garden. I have for several years (in my private practice) employed such appropriate gymnastic exercises, in connexion with other remedies in the treatment of curvatures, with the desired results. 1363. If the cause of the curvature be in an unequal contraction of the muscles, in which ordinarily the left side sinks down, the right shoulder-blade projects, and the right shoulder is raised, it must be treated according to the general rules laid down. It is usually attempted by rubbing in suppling ointments, or oily remedies to relax the con- tracted muscles of the sunken side, and by rubbing opodeldoc, spiritus serpylli c. liq. ammon. caust., tinct. canthar., with some volatile additions, to excite the muscles of the protruding side to action. For these cases the employment of electricity, repeated blisters and the douche upon the side of the extended muscles, have been also recommended. In the rubbings, which are to be performed night and morning, the patient should be stretched on his belly, and they should be continued from half to a whole hour, and attempts are, in the meantime, to be made to press the spine inlo its natural direction. These rubbings operate certainly less through the substances rubbed in, than from the pressure, knead- ing, and stretching of the contracted muscles. If the nervous activity be in these cases diminished, the rubbing should be more active; spirituous remedies, and even the application of stronger irritating reme- dies are indicated. In incipient scoliosis, if care be taken that the patient carry himself properly, that the two halves ofthe body be equally exerted, that all faulty posture in writing and the like be diminished, that he often hang by his hands, and keep the horizontal posture in bed, upon a hard mattrass, a perfect cure may be effected. Here also well-fitting stays, with whalebone or elastic springs, will be of much use, as they properly support the body (1). In more considerable curvature, regulated gym- nastic exercises, the use of a properly constructed portable apparatus, or better, the employment of a stretching apparatus, is most suitable. In these cases, the scoliosis does not usually affect the general state of health, and we see that the mechanical means are best endured. If the con- stitution be at the same time affected, corresponding remedies and suit- able dietetic care must be employed. TREATMENT. 439 (1) The prejudices which have been very properly made to the stays (a), has no reference to this determination of their employment. 1364. For the quicker cure of curvatures of the spine, depending on muscular contraction, Guerin (b) has proposed the division of the con- tracted and shortened muscles, and practised it in several cases. The muscles which he cut through were m. cucullaris, rhomboideus, levator anguli scapulae, sacro-lumbalis, longissimus dorsi, and semi spinales. He has performed the division in persons of both sexes, and of different ages: the youngest was thirteen, and the oldest twenty-two years of age. All the curvatures were in the second and third degrees, with distortion ofthe spine and corresponding humps. In some a single division ofthe shortened muscle was sufficient; in others a second and third was under- taken. In all he obtained, immediately after the operation, a very striking degree of straightening of the spinal column; and in a man of twenty- one years of age, whose curvature had been subjected to a ten months1 mechanical treatment, he effected an immediate straightening by cutting through the m. longissimus dorsi, and the corresponding m. semi-spinales. In other subjects he carried on the treatment by mechanical means with decidedly good effect. Although the subcutaneous division of the muscles of the back has been undertaken by other persons, I cannot, from the practice in question, give so decided judgment of its fitness, as the numerous and careful observations upon tenotomy in other curva- tures have allowed. [In regard to the division of the muscles for the cure of curvature of the spine Robert Hunter of Glasgow (c) says :—" In no instance has the operation of itself produced a cure; but in all the cases on which I have operated, with one exception, it manifestly placed the patient in a more favourable state for the performance of a cure. The operation itself appears to me to effect no more than to take off, either in part or whole, the power of muscles that are interested in maintaining the curva- ture, and thus placing the spine in a condition to be more easily influenced by me- chanical and physiological causes. The cages which have been treated by me have all been of long standing, none less than seven years, and some ten, sixteen, and twenty years, and all with considerable torsion and gibbosity, as well as lateral cur- vature. * * * In some instances the section of the muscles was instantaneously followed by an obvious improvement in the state and appearance of the back; in other instances I could discover no change whatever. "I perform," says R. Hunter, "the subcutaneous section of the dorsal muscles at four different places ofthe back. 1st. I weaken the tension ofthe deepest-seated layer of muscles—that formed by the multifidus spinas by dividing the thickest part of that muscle, as it lies comparatively superficially upon the dorsum of the sacrum, opposite the posterior superior spinous process of the ilium,- 2d and 3d, I remove the tension of the middle layer of spinal muscles, that formed by the longissimus dorsi and sacro-lumbalis, by cutting these muscles across, sometimes in the lumbar region, and sometimes in the costal region, according to the circumstances of the case; but more'frequently in the lumbar region, near the origin of these muscles; 4th, to destroy the tension of the flat and more superficial muscles, I divide these muscles by a longitudinal incision, close to the spinous process of the vertebrae, at the place where the tension of the muscles appears to be the greatest. In one instance I cut through, with considerable effect, the latissimus dorsi at the side of the chest, and consequent- ly at some distance from the spine. The muscle crossed the contracted and concave side ofthe trunk, and appeared to be accessory in huddling in the ribs of that side. When the patient attempted to elongate that side, a cord, as thick as the little finger, was seen stretching from the crest of the ilium to the scapula; as soon as this rigid (a) Soemmering, S. T., Ueber die Schad- (c) On the Section of the Muscles in Spi. lichkcrt-der Schnurbruste. Berlin, 1793. nal Curvature; in London Medical Gazette, (b) Gazette Medicale de Paris. 1840. No. vol. xxxii. 1842. 14,15. • 440 CURVATURE OF THE SPINE. cord of muscle was cut through, the ribs became less huddled together, and that side could be elongated to a much greater degree, and the spine materially affected. The cutting of the dorsal muscle is only the first, though an important step in the treatment of spinal deformities. The means that are afterwards employed in con- ducting such cases to a successful issue, are both mechanical and physiological. The first consist in the application of pressure, made in various ways, and by various means, to assist in the gradual return of the parts to their natural places; and the second, without which the first would be useless and unavailing, consists in infusing power into the muscles which have become weak or dormant from disease, by simply calling these muscles frequently, and in various combinations into ac- tion, (p .) In reference to the division of " certain muscles of the back, on the contracted state of which it was alleged the distortion depended," Syme observes, " nothing could be more erroneous than this view of the case, since the muscles throughout its production and existence are entirely passive. They, from the first, do not draw the spine away, but allow it to bend, their fault being weakness, and not undue con- traction, so that those requiring to be connected are seated on the convexity of the curve, instead of its concavity, and it is needless to add, could not be strengthened by division of their substance." (p. 271.) I have not had any experience upon the subject, but am rather disposed to agree in opinion with Syme.—j. f. s.] 1365. In curvatures dependent on great muscular weakness, internal tonic remedies must be employed, as bark, acorn coffee, and the like; a strengthening succulent diet, the use of generous wines, chalybeate mi- neral waters, rubbing in volatile, aromatic, and spirituous remedies, steel, salt, or aromatic bathing, river bathing, and so on. In these cases the gymnastic exercises are especially effective, and, by their pro- per arrangement, the injuries are more certainly prevented, which other- wise are necessarily produced by rest and inactivity of the muscles, ac- companied with the use of the stretching apparatus. In children who begin to walk, it is usually sufficient to rub the back and lower limbs with spirituous remedies, to prevent sitting, and to let them sleep upon a hard mattrass. In the high shoulder attempts must be made to relax and continually depress the too violently acting muscles, by proper rubbing, proper carriage and exercise, for which purpose the one-sided breeches brace, recommended by Jorg, is most suita- ble. In high back, if there be at the same time a bowing forwards of the head, the machine recommended by Shaw (a), is best, by which the muscles of the nape are put in greater activity, and drawing back the head is effected. 1366. If the curvature of the spine depend on softening and thicken- ing of the fibrous inter-cartilage, the readiness with which, by extension, the direction of the spine can be changed, renders it in the highest de- gree proper. If, by pressure, movement between the several vertebrae can be brought about, there is no need of making any attempt at exten- sion, nor of employing any other means which act forcibly on the verte- brae. The altered joints must first acquire more firmness. If, at the same time, there be pain, which, although not symptomatic of inflammation, leads to the belief of a passive gorging of the blood-vessels, a condition which by neglect passes on to inflammation and suppuration, leeches and cupping are to be first employed, though not to excess; afterwards rubbing in volatile camphor liniment, blisters, issues, cold douche bath, warm douche bath of salt water, of water containing sulphuretted hydro- gen, even moxas, especially on the principal seat ofthe deformity. The patient should observe a quiet posture on the back, and afterwards cau- [a) Engravings, pi. vii. f. i. and described in his Essay on Distortions, already quoted. • CURVATURES OF THE LIMBS. 441 tiously use the easiest gymnastic exercises; for instance, the motions with the barrow and rope. The patient's powers must be supported by a nutritious diet and proper medicines. If the nature of this aliment be ascertained only by the horizontal posture, or by careful attempts at extension, if no other pain exist than that caused by careful extension, if it be not increased by pressure on the painful spot, and if it decrease by resting quietly on the back, the gym- nastic exercises may be at once begun, with caution; then followed by the employment of extension; and lastly, the lateral bandages (a) may be also employed. 1367. In curvature of the spine depending on rickets, the treatment must be especially directed towards the improvement of digestion and chylification, by tonic remedies and strengthening diet, aromatic and spirituous rubbings, strengthening baths, lying in the open air upon a sand-bank, warmed by the sun, or to be employed ; horizontal posture upon a hard mattress, and subsequently, gymnastic exercises and the extending apparatus are to be carefully made use of. The treatment is similar in osteomalacy; bark with phosphoric acid is here especially efficient, as I have repeatedly observed. The very severe pain often occurring in these cases, must not lead to the application of leeches, and so on. Besides proper position, and support of the body in gene- ral, nothing farther can be done in these cases against the curvature. 1368. If the curvature be connected with rheumatism, a correspondent treatment must be employed; and the complication having been got rid of, the treatment ofthe curvature must be thought about. Palsy of one or several muscles often occurs from rheumatism ; in such cases, moxas, douche baths, purgatives long continued, and the like, are very efficient. Curvatures of the spine, from contraction of one side of the chest, after the cure of an empyema, or abscess in the lungs, are incurable, and every attempt at their treat- ment inadmissible and dangerous. Curvatures from shortening of one ofthe lower limbs, may, in many instances, be prevented by a peculiar shoe and the like, by which the proper length of the limb is attained. HI.—Of Curvatures of the Limbs. [The several portions of the lower limbs are occasionally and variously curved and contracted upon each other, either as original imperfect de- velopments, or resulting at any period of life from different causes, which may be eithef inflammatory, or from paralytic affection of one set of muscles, whilst their antagonists still possess their contractile power, and, being unopposed, draw together more or less completely those portions of the limb to which they are attached. The fixedness of the limbs from either of these causes must not be confused with that depending on an- chylosis, already considered {par. 224*) (b) in which, after more or less complete destruction of their cartilages, the joint-ends of the bones are fixed in any position they may have acquired, during the progress ofthe disease, by a fibrous or bony union. The cases now to be considered depend entirely upon the condition of the muscles, their tendons, and (a) DELr-ECH, Orthomorphie, vol. ii. p 238. (b) Vol. i. p 267. Vol. II.—38 442 CURVATURES OF THE HIP. tendinous sheaths, whilst the joints themselves have their structure en- tirely changed, or but very little altered; and in such only can surgical treatment be of any avail. l._OF CURVATURES OF THE LOWER LIMBS. Curvatures of the lower, are more frequent than those of the upper limbs, although the bony and muscular fabric of the former are much more strong and powerful, partly because the weight of the body resting upon them more readily produces curvature, under the existence of fa- vouring circumstances; and partly because in most cases, in incipient and even in advanced curvature, walking produces an injurious effect upon the lower limbs. Of the several joints of the lower extremity, curvature is least frequent at the hip, and most common, and, indeed, not infrequent, at the ankle, at which also it was most generally an origi- nal malformation. A.—OF CURVATURES OF THE HIP. Curvature or contraction of the thigh upon the belly {Scelocampsis, Lat.; Angezogensein des Oberschenkels an den Unterleib) may originate in the continued action of the flexing muscles of the thigh, whilst their antagonists are palsied from any cause, or from sympathetic affection of the former muscles, with disease of the vertebrae, which is sometimes consequent on metastasis, or from inflammation in the m. psoas. The treatment of these cases consists in relaxing the contracted mus- cles by'supplying applications, and in exciting the inactive or palsied muscles to action by the use of irritating remedies; and if these fail, the division of the flexion muscles, to wit, the m. pectineus and sartorius has been proposed and performed by Stromeyer (a), but which, as far as I am aware, although successful, has not been repeated by any one else. In a case of metastatic inflammation of the spine following measles, in a child of ten years, in which the thigh, at first drawn close up to the belly, by yielding ofthe lumbarmuscles after the use of tartarized antimonial ointment, blisters and rubbing inmercurial ointment, could be drawndown to a right angle, Stromeyer divided them. pectineus and sartorius with success. The division was made in the following man- ner :—One assistant fixed the pelvis, whilst another stretched the contracted thigh, which raised the m. pectineus so that the finger could be passed behind it from its outer side, an inch and a half below its origin. A strong phimusis-Vnife was then introduced upon the finger through the upper half of the muscle, dividing it, and pe- netrating the skin. He then cut through one half of its breadth beneath the skin, and afterwards divided the second inner and under half; and only a few drops of blood followed the four little punctures made in the operation. The m. sartorius was divided, by adducting the knee so as to make the muscle prominent; and having raised it with the thumb and finger of the left hand, he thrust a phimosis-knife through, about two and a half inches below its origin, and divided the muscle be- neath the skin, the ends of which separated rather more than half an inch. The leg immediately straightened without the least difficulty, and having been kept on an ex- tending apparatus for a fortnight, was allowed to get up, and in the course of three months walked about well. (pp. 119, 20.) (a) Above cited. CURVATURES OF THE KNEE. 443 B.—OF CURVATURES OF THE KNEE. Curvature of the knee may be either congenital or acquired, and de- pending on imperfect development of the muscles, tendons, and fascia, or on their shortening consequent on inflammation, either of the struc- tures themselves or of the cellular tissue around or in the neigbourhood of the joint, or simply from inaction. This condition is to be distin- guished from the curvature which almost invariably accompanies anchy- losis following ulceration of the joint-cartilages, and which has been al- ready considered. One knee may curve or bend inwards, producing the deformity called In-knee {Genu valgum, Lat.; Ziegenbein, Schemmelbein, Germ.; Genou en dedans, Fr.) or Knock-knees, when both knees are in like manner af- fected. It is characterized by a projection inwards ofthe inner condyle of the thigh-bone, with a less or great divergency of the leg and foot outwards, so that in standing the feet are far apart from each other, and the thigh-bones, overhanging the inside of the heads of the shin-bones, are, together with the weight of the body, supported mainly by the in- ternal lateral ligaments' of the knee-joints. The knees also, instead of being against the same imaginary plane, are placed one behind the other. When this deformity is great, walking is very awkwardly performed, as it is necessary, in bringing the leg forwards, to abduct it considerably, to avoid striking the knees together; and in consequence of the oblique direction of the leg, the inner ankle also bends inwards and the person treads upon the inside of the foot. This is a very common ailment in labouring persons who carry very heavy weights, but is generally worst in those accustomed to wheel heavy barrows. It, however, is by no means unfrequent in young peo- ple who grow quickly, but is often recovered from, as their bodily strength improves, unless occupied with hard labour. Little can be done for this distortion, which I have in one or two per- sons known to incapacitate from following any laborious employment, besides supporting bandages and cold douche baths. Although irons are recommended, I have not seen much benefit from them. The knee may also be curved outwards {Genuvaram, Lat.; Sdbelbein, Germ;) this is, however, rare, and must not be confused with the so- called bow leg, which depends principally on outward curving of the shin-bone, and to which the slight outward bend of the knee is only consequent. Toe knee is, however, most commonly bent forward, {Contractura Genu, Lat.; Vorwdrtsbeugung des Kniees, Germ.;) and this may occur from original shortening of the bending muscles of the leg, or of the fascia covering the thigh, an account of which last was first published by Froreip {a), who found in a corpse, that although the flexing muscles were cut through yet the knee could not be straightened. Very fre- quently the knee is'bent at a later period of life, and the most common causes are rheumatic inflammation of the tendinous structures about the joint independent of disease of its interior, or scrofulous inflammation (a) Chirurg. Kupfert, No. 346. 444 CURVATURES OF THE FEET. running on to suppuration, around or even in the joint itself. Palsy of the extending muscles may also give rise to this kind of bending of the knee. The treatment of these cases consists in rubbing and in the application of extending apparatus and the use of passive motion, from patiently persisting with which for a long period, considerable benefit and occa- sional cure results; but in those cases which cannot be managed, it has been recommended to divide the hamstrings, an operation, I believe, first practised by Michaelis (a), who had performed it three times pre- vious to October, 1810, and it has since been occasionally performed with varied success. The operation is performed, either by division of the hamstring tendons at once, or by partial and repeated cuts till they are completely divided, using at the same time an extending apparatus as the patient can bear it. Objections, however, have been made to the operation, that in consequence of the often long-continued bent po- sition of the leg, the joint surfaces in the knee are so much altered in form that they cannot retain their reacquired natural position, and con- sequently dislocation ofthe shin-bone backwards occurs (1). The ope- ration is performed by passing a phimosis-knife between the hamstring and the bone, or between it and the skin, taking care to avoid the pero- neal artery and posterior tibial nerve (2). (I) Fergusson, of King's College, informs me, that in two or three instances he has seen dislocation at the knee occur after division of the hamstrings for contracted knee, and has been obliged to amputate the limb. (2) Stanley (b) operated on a case of contracted knees two years after paraplegia consequent on sleeping on a damp bed. " Each knee joint was immoveably fixed in the state of extreme flexion; the ham-strings were contracted and rigid; and the cellular tissue around them had become indurated, and firmly agglutinated to the tendons, whereby their outline could not be distinctly traced. * * * To avoid all risk of injuring the popliteal or peroneal nerve, he deemed it prudent to divide the rigid hamstrings, and the surrounding indurated cellular tissue, by small subcuta- neous incisions many times repeated in both limbs, applying after each operation the apparatus for extending the knee-joint." By this proceeding, after many months, the joints slowly straightened, and became moveable; but, the action of the ankle- joints being impeded by the rigidity of the Achilles' tendons, Stanley divided these, and afterwards the extensor tendon of each great toe, as it was rigid, and kept the toes constantly raised. Warm baths and friction were employed for sup- plying the limbs, and, at the end of eighteen months, the case was perfectly cured. —J. F. S.] C—OF CURVATURES OF THE FEET. 1369. The feet may be curved in various ways; thus, they may be turned inwards {Vari) or outwards, (Valgi,) or the sole of the foot and the heel may be inclined so backwards and upwards, that the entire sole shall have the same direction as the leg, or the foot may be so drawn forwards and upwards towards the shin-bone, that the point of the heel alone touches the ground. The first kind of curvature is called Club- foot; the second, Splayfoot; the third Horse-foot; and the fourth, Heel or Hook-foot {Pied-bot calcairen of Scoutetten.) (a) Ueber die Schwachung der Lehnen durch Einschneidung; in Hufeland and Humby's Journ. der. prak. Heilk., vol. vi. (b) London Medical Gazette, vol. xxxv. p. 98. 1844. club-foot. 445 Duval (o) includes the various curvatures of the foot under the general name strephopodie, and distinguishes varus as strephendopodie, valgus as strephexopodie, horse-foot as strephocatopodie, its highest degree as strephypopodie, and heel-foot as strephanopodie. c—OF CLUB-FOOT. (Varus, Lat.; Klumpfuss, Knollfuss, Germ.; Pied-bot, Fr.) Sheldrake, Thomas, Observations on the Causes of Distortions of the Legs of Children. London, 1794. s Ibid., A Practical Treatise on the Club-foot. London. 1798. Bruckner, Ar., Ueber die Natur, Ursachen und Behandluno- der einwarts ge- kriimmten Fiisse. Goath, 1796. 8vo. Numburg, J. S., Adhandlung von der Beinkrummung. Leipzig, 1796. 8vo. Wantzel, J. M., Dissert, de talipedibus variis. Tubinga?, 1798. Scarpa, A., Memoria Chirurgica sui Piedi torti congeniti dei Fanciulli, e sulla Maniera di corregere questa Deformita. Pavia, 1817. Third edition. 8vo. Jorg, Ueber Klumpfusse und eine leichte und zweckmassige Heilung derselben. Leipzig und Marburg, 1806. 4to.; with copper-plates. Delpech, Considerations sur la difformite appelee Pied-bots; in Clinique Chi- rurgicale de Montpellier, p. 147. Held, Chari.ks, Dissertation sur le Pied-bot. Strasbourg, 1836. Little, W. J., Symbolae ad talipedem varum cognoscendum. Berlin, 1837. Ibid., A Treatise on the Nature of Club-foot, and analogous Distortions, including their treatment, both with and without surgical operations; illustrated by a series of cases,and numerous practical instructions. London and Leipzig, 1839. 8vo. Stromeyer, L., above cited. Scoutyetten, H., Memoire sur la Cure radicale des Pied-bots. Paris, 1838; with plates. Bouvier, Memoire sur la Section du Tendon d'AcmLLE, dans- le traitement des Pied-bots. Paris, 1838. Dieffenbach, above cited, p. 73. Bonnet, above cited. Phillips, above cited. Duval, V., I'raite pratique du Pied-bot. Paris, 1839. [Mutter, T. D. A lecture on Loxarthrus, or Club Foot, Philadelphia, 1839. See also an elaborate essay on Club Foot and some analogous diseases, in the New York Journ. of Med. & Surg., for January, 1840, by Dr. William Detmold. Bigelow, H. J., Manual of Orthopedic Surgery, Boston, 1845. 8vo.—g. w. n.] 1370. Club-foot is that deformity in which the foot is so twisted on its long axis, that its inner edge is raised, the outer turned downwards, and the sole of the foot with its back brought more or less vertical. The toes are strongly bent, the back of the foot more convex, the sole more concave, and the heel raised, and inclined inwards, so that it does not touch the ground. The whole foot is unnaturally turned inwards. Upon the back (instep) ofthe foot, a considerable prominence is formed by the head of the astragalus; the Achilles' tendon is much stretched. Walking is more or less interfered with; the patient cannot tread upon the sole of his foot, but only on the middle of its outer edge, and, often only on the outer part of the back ofthe foot, where commonly a large calosity, or mucous bag, is enlarged or newly formed. The patient is never able to bend his foot by muscular power; but, in making the at- tempt, he rather adducts the foot already inclined inwards. (a) Revue Medicale, Dec. 1818. 38* 446 CLUBFOOT. 1371. Club-foot has various degrees. When slight, the curved foot may be brought back to its natural position, and the prominence on its back then disappears; but the foot again treads in its unnatural posture, when walking is attempted. In the higher degrees, the foot can never be at once brought to its natural position, and often can scarcely be moved in that direction. In these motions ofthe foot, the fibres of the m. gasfrocnemii and tibialis anticus, and the plantar aponeurosis, which are always more or less stretched, oppose the straightening of the foot. 1372. This malformation, which has been noticed as hereditary, is either congenital, or occurs subsequently. In the former case, which is the most common, the club-foot arises as consequence of arrested de- velopment; of a continuing, excessive activity of the bending muscles of the foot, as has been often observed in a three months' feet us; or as consequence of peculiar position of the foot during pregnancy, and therewith also deficient innervation depending on diseased activity of the brain, and nervous system. After birth, club-foot may be developed by wounds, palsy of muscles, by spasm or neuralgia, and if the foot have been kept a long while in a particular posture by an ulcer, or any other painful circumstance, by which shortening of certain muscles is produced. The disturbed antagonism of muscles (contraction of those attached to the sole, and to the inner edge, extension of those to the outer edge, and back ofthe foot) is the special cause of this malforma- tion ; all the changes which therewith occur in the ligaments and bones are merely secondary symptoms. The shortened muscles are m. tibi- alis anticus, and posticus, gasUocnemii, soleus, and plantaris, the plan- tar fascia, m. flexor longus digitorum pedis-, abductor pollicis, transver- salis pedis, flexor brevis minimi digiti, flexor longus, and brevis pollicis. The lengthened muscles are m. peroneus longus, tertius, brevis, extensor longus and brevis digitorum pedis, abductor minimi digiti. All the liga- ments on the plantar surface, and on the inside of the foot, are short- ened, as, on the contrary, those on its back and outer edge are length- ened. The tarsal bones are herewith, according to the degree of curving, more or less removed from their mutual contact, without en- tirely leaving the sockets or hollows, in which they had been received. The navicular, the cuboid, the heel-bone, and astragalus, especially change their position, and are twisted on their small axis. If club-foot exist long, the bones are fixed in their unnatural position, and more or less changed in their form. Opinions as to the cause of elub-foot are very various. The notions of Pare and others, who held it to be the consequence of long sitting during pregnancy, with the legs twisted over each other, or from pressure of the feet in washing and carry- ing children, are merely to be mentioned. Duverney (a) fixed the cause of these curvatures in the museles, and derived it from the unequal stretching of them and of the ligaments. Scarpa, as well as Bruchner and Naumberg, believed that vicious twisting of the foot first exists, and thereby is caused an approximation of the points of insertion of some muscles, and the distancing of others from their fixed points; consequently, a shortening of the former, and an elongation of the latter. Wantzel considers club-foot as great adduction, accompanied with violent exten- sion, whence necessarily are the corresponding consequences ; and Jorg holds it as a continued adduction, become habitual to the foot. Delpech (b) has of late with- (a) Traite des Maladies des Os, vol. ii. c. 3, (6) Ortliomorpie, p. 117. CLUB-FOOT. 447 drawn his previous opinion that the cause of club-foot is in the form of the bones, because the muscles do not oppose a contrary direction of the foot, which is espe- cially distinct in those cases where the shortening is accompanied with atrophy, and with a sort of palsy. He considers the congenital, or accidental shortening of the muscles, as the peculiar cause of club-foot, and, at the same time, has pointed out the retraction of the plantar fascia. Rudolphi, who has several times seen this de- formity in the fectus of from three to four months, derives it from arrest of the ner- vous influence, contrary to the opinion put forth by Camper and Glisson, that the club-foot arose from vicious position of the child in the womb, by which the foot was pressed on, and its development prevented; an opinion in which Cruvel- hier (a) has participated, and Martin (b) has sought to ground in pressure of the womb from deficiency of the waters. Scoutetten holds the following as the causes of congenital and postgenital club-foot. 1. Unequal division of power be- tween the extending and flexing muscles ; 2. Vicious condition of the joint surfaces of the tarsal bones; 3. Vicious position of the foetus in the womb ; 4. Compression of the flexible joints by contraction of the womb; 5. Convulsions of the child in the womb; 6. Convulsions in early childhood; 7. Chronic inflammation of the muscles of the. leg; 8. Vicious innervation, dependent on disease of the brain, or spinal marrow, without previous convulsions; 9. Contraction of the plantar/ascuz ,• 10. Contraction of the muscles, without discernible cause. Duval (c) assumes as causes of congenital club-foot, (as well as of the other curvatures,) vicious position of the foot in the womb, and disturbance of the functions of the brain and spinal marrow. Consecutive or accidental curvatures he derives from wounds, fractures, dislocations, bad holding of ihe foot, from inflammation, abscess, and so on. With all these causes, unequal activity ofthe muscles exists. Blasius (d) puts forth the congenital club-foot alone as the true one; in it the above-described symptoms are found. That occurring after birth, which usually is not so great, and- is produced by wounds, ulceration, palsy of the muscles, dyscrasy, and neuralgy, is a natural extension of the foot, caused by too violent contraction of the muscles of the calf, in which the turning around the long axis of the limb follows only secondarily from walking. This he calls the seeming club-foot. Club-foot is, according to Little, easily distinguishable from that deformity of the tarsus which is caused by rickets. The participation of the parents in the dis- ease, the usual complication which accompanies rickets ; above all, the curvature of the bones of the limbs, serve as sufficient diagnostic marks. The pathognomonic signs, retraction of the heel, stretching of the tendons of the muscles of the calf and the adductors, concavity of the sole of the foot, and the curvature of the inner edge of the foot are wanting. On anatomical examination the bones appear in varus to be brought out of their position, without prejudice to their natural firmness, from muscular activity, and the weight ofthe body ; in false varus, which arises from rickets, the bones are not only brought out of position by the weight ofthe body, but also compressed and inisformed, in consequence of their softening. [The following interesting case of club-foot was under my care some years ago, in which the cause was at first very doubtful, and led to several operations; but subsequently I think there could be little doubt that it was hysterical. Case.—S. P., aged seventeen years, a stout, healthy girl, was admitted April 9, 1837. She has been irregular for several months, and has had three fits, but of what kind cannot be ascertained. About a month ago she went to bed seem- ingly quite well, and with perfect use of her limbs; but, when she awoke in the morning, her right foot was immoveably fixed, with the sole turned upwards and inwards, so that when put to the ground, the limb rested on the whole length ofthe outer margin of the foot. This was accompanied with great pain along the course ofthe m, peronti. At the present time the foot is firmly fixed at right angle with the leg, and the sole faces directly inwards, the m. tibialis anticus is in strong action, and its tendon raising the skin in front of the ankle-joint. No other tendon or muscle is unnatural. (a) An.-tomie Pathologique du Crrs Hu- (c) Re"vuc M::clicile, Nov. 1838. main. Paris, 1828-30. lb. liv. ii. (d) Klinische Zeitschrift filr Chirurgie (bl Bulletin de l'Academie de Medecine und Augenlieilkunde, pt. i p. 60. de Paris- 15 Nov. 1836. 448 CLUB-FOOT. Any attempt to restore the proper position of the foot causes great pain in the course ofthe contracted muscle. In the course of the two following months, a moxa was thrice applied on the calf of the leer, with the hope of stimulating the antagonist muscles to action, but without benefit. May 18. She was attacked with pain on the inner edge of the calf ofthe leg, fol- lowed by a little swelling, as if the to. gastrocnemii were in action at that point, and accompanied with slight tenderness. These subsided in the course of a few days, and her condition otherwise remained unchanged. June 15. A stream of cold water was ordered tobe poured on her leg, from a height of five or six feet, for a quarter of an hour every morning. This was persisted in for three weeks, occasionally followed by pain; but then given up, as there was an erysipelatous blush about the ankle, which, however, soon subsided. July 10. A moxa was put in opposite the origin ofthe sciatic nerve. July 14. Complains of pain on the outer side of the calf, but more severe than before and accompanied with swelling of the muscle; these have been coming on for the last three days, and the swelling is about the size of half a walnut, tender, but not firm though very distinct. On the following day she was electrified in the whole length of the m. peronei, and from them across to the m. tibialis anticus. This was continued daily for a short time and she fancied she could move her great toe a little. July 21. One or two electric shocks were also passed through the region of the womb, in hope to excite it to action; but, after repetition for two or three days, was given up as it produced great pain in the pelvis, without other effect. Aug. 9. The electric shocks having blistered the front of her leg, sparks were ordered to be taken daily instead. About a fortnight or three weeks after, the ante- rior tibial muscle certainly had yielded, and she was able to get the sole ofthe foot flatter upon the ground, and walk a little better. This, however, lasted only a fort- night, and the foot then gradually reverted to its old position, if not worse. The electricity was therefore given up, and nothing more was done till Oct. 21, when the tendon of the m. tibialis anticus was divided two inches above the ankle-joint, with a phimosis-knife, and snapped with a sharp report. Motion was immediately restored, and the sole could be placed on the ground, but returned to its old position when left alone, and she then suffered great pain in the instep, and up the front ofthe leg, which continued for three hours. It therefore was necessary to preserve the natural position, by applying a foot-board to the sole, on the sides of which the branches of a stirrup were attached, and from its crown a rod, with a screw for adjusting its length, was carried upon the front of the leg, and fixed by a circular bandage below the knee. This apparatus did not answer the purpose, and therefore, on the following day, I put Boyer's splint on the outside of the limb with a foot piece. This was continued for more than a week, but every day the foot was found returned to its old posture, and for the greater part ofthe time the pain in the leg continued. At the end of the week a back-splint was put behind the length of the limb, and the top of the long splint fastened to it, to prevent it turning forward, in which position it had been daily found. This at first seemed to do very well,but it failed, though carefully attended to in the same way for a fortnight. Nov. 15. Still nearly as great inversion of the foot as at first, but it could be restored to its proper place by the hand as easily as at first, and when let go again became distorted. The peroneal muscles do not seem to have the least power. Flexion of the foot upon the leg is much restricted, and it seems probable that the Achilles' tendon will require division. Wishing to try whether any advantage would be attained by her attempting to walk, an apparatus was applied on the outside cf the leg, consisting of an iron rod, jointed at the ankle and knee, and extending half up the thigh, with some straps round the leg and thigh, and a foot-piece at right angle with its lower end, upon which the solo, of the foot was firmly bound with a roller. She was directed to move about with this, and upon crutches. The sole bears well on the ground, but the great toe turns inwards, and she has pain along the back of the leg. This plan was persevered in for ten days, the bandages being adjusted as was found necessary. Nov. 25. On consultation with Dr. Little he thought the m. tibialis posticus was at fault, and I therefore divided it with a phimosis-kn'ife, from behind forwards—to wit, entering the knife between the tibial and long flexor muscles of the toes, about three CLUB-FOOT. 449 inches above the ankle, and carrying the point down to the bone, cutting with it inwards. The inversion immediately subsided, and the foot recovered its natural position; a slip of plaster and a narrow roller were applied, but nothing more done. In the evening she had pain along the inside of the shin-bone, which increased during the night, and subsided on the following morning, but came on again towards evening with severe burning, and a sensation of stretching along the front of the leg, but which entirely subsided next day. Nov. 29. On visiting her this morning, the foot was again found a little turned in the old direction, which she herself had noticed when she first woke this morning. She complains of "a shrinking pain along the inside of the leg, very different from the stretching which she first felt on the night of the 26th; but which has now entirely ceased." The foot can be restored to its natuial position without the least difficulty, but, when left alone, has still the disposition to turn in. The jointed iron rod and foot-piece were therefore reapplied, and answered well. From this recurrence of the distortion, and the continued absence ofthe menstrual discharge, accompanied with headach and pain in the loins, it became questionable whether it might not really be an hysterical affection, of which indeed there had been a suspicion when she was first admitted. It was therefore determined that she should take mist, ferri comp. %jss. ter die, which was continued till Dec. 16, without any benefit. It was therefore left off, and five grains of ergot of rye three times a day, with a warm foot-bath every night, were ordered. Two days after, the headach and pains in the loin were much relieved, and had ceased entirely on Dec. 23; but no change or improvement has occurred as to the menses, or the inversion. The medicine was suspended for three weeks. Jan. 28, 1838. The ergot resumed for a week. Feb. 7. The ergot again. Ordered for the same period. Feb. 24. No alteration. The foot continues turned in, but there is no disposition of elevation of the heel. It was therefore determined to excite the action of the m.peronei by blistering along their whole length. March 3. A second blister has been applied, but there is no improvement; indeed, the heel is more elevated. A third blister was then put on, and the stirrup readjusted to the foot and leg. On the following day the menstrual discharge appeared sparing- ly, the first time for thirteen months, and continued only a couple of days. March 31. She took a dose of the ergot, and next day the menses appeared, and continued for three days; but no recovery of the foot followed, and she left the house in April, with the sole still turned inwards and upwards. I saw nothing of her for several months, till I accidentally met her; and, observing she was walking well with the sole of the foot to the ground, which she informed me had recovered itself, without any farther treatment, a month or two after she had left the house, and that she was menstruating regularly. From this account, I was led to believe that the contraction of the muscles, which had'successively occurred, was hysterical, and that the operations I had performed were superfluous. Varus sometimes occurs as consequence of palsy of the muscles ofthe leg during teething. I operated, in 1839, on a case of this kind in a girl, between eleven and twelve years old, in which the foot first dangled from the ankle ; but, as she grew up, and began to walk, inversion commenced, and, when I first saw her, whilst standing upright, the foot rested on the whole dorsum pedis, except the great meta- tarsal bone, which faced outwards; the tuberosity ofthe heel-bone was raised about an inch from the ground, and its under surface faced inwards ; before this bone nearly the whole sole faced directly upwards. When lifted from the ground, the foot nearly recovered the natural position; but there was still a little disposition to inversion, and the weight of the front of the foot pointed the toes. When the knee was straight, the foot could not be flexed at all on the leg; but, when the knee was much bent, the sole could be almost entirely applied to the ground. The gastroc- nemial muscles were little developed, and the muscles generally did not control the foot. The Achilles' tendon was divided, and extension made; after five weeks, a steel rod, jointed at the angle and knee, and attached to a boot, was put on, soon after which she got up, and, in rather more than seven weeks, began to walk with the sole flat on the ground, with the assistance of a stick, which, in the following week she threw aside of her own accord, and walked slowly without assistance. 450 TREATMENT. She would probably have improved more quickly, but that a slough formed on the skin of the tuberosity of the heel, in consequence of the foot-piece of the first ap- plied apparatus having pressed unduly. At the end of six months she walked very well, and the treatment had perfectly succeeded. Shortly after, I had another case of the same kind in both feet of a child, three years old, in which the same proceeding was adopted with success, as the child walked upon the soles tolerably at the end of six months, whilst wearing boots with jointed steel leg-rods. But he could not do without these, as the paralytic muscles had not recovered, although galvanism had been employed.—j. f. s.] 1373. As to the prognosis of this ailment, all depends on its degree and complication. If there be simply disproportion between the muscles, if the twisted bones have neither their form changed, nor are fixed in their unnatural position by anchylosis, a favourable issue may be hoped for; and the more if the patient be young, far distant from manhood, have no accompanying dyscrasic disease, and the nutrition of the curved foot have not suffered much. The time in which the cure of this ali- ment may occur is not determinable, and depends upon the mode of its treatment, in addition to its degree and duration. In adults who have walked long on their crooked feet, in which the bones are anchylosed, or considerably changed in form, their complete cure is impossible. 1374. The treatment of club-foot consists in the restoration of the natural antagonism of the muscles, and of the straight direction of the foot, which is effected either by lengthening the shortened muscles by means of gradual extension and mechanical contrivance, or by cutting through the tendons ofthe shortened muscles, and subsequently straight- ening the foot by the mechanical means. The first (mechanical) mode of treatment is always tedious and difficult, especially in a greater degree and longer duration of club-foot, in which case frequently it is of no service. It is indicated in slighter degrees of club-foot, when the foot can, without much trouble, be brought straight, and a constant careful over- sight of the patient is possible. The division of the tendons is in all cases the most fitting, when the first mode of treatment has been without benefit, or where the greater degree and duration of the curvature has led to the expectation of its being baffled, or, from external circumstances a speedy termination of the cure is required. 1375. The treatment, by gradually lengthening the shortened muscles, is divided into the periods of. rightly directing, steadying the foot, and of wallcing. In order to bring the foot gradually into the straight direction, it is recommended to use a warm bath, in which twice daily, the foot is to be immersed up to the knee, for about half an hour, and during this time attempts made to bring the foot into its natural position, holding it with one hand, so that the thumb lies upon the back, the forefinger on the inner edge, and the other fingers upon the sole of the foot, and with the other hand placed round the heel, by which the foot, and especially the heel, is turned outwards, the front of the foot raised, and its hind part depressed. These manipulations must be carried on slowly, and for some time. When the foot has been taken out of the bath, and properly dried, lard or goose-fat is to be rubbed on the inner and hinder part of the leg and on the inner and plantar surface ofthe foot, and any spiritu- ous fluid should be rubbed on the fore and outer part of the leg and foot. For the purpose of keeping the foot drawn towards its natural direction, CLUB-FOOT. 451 a triangular piece of cloth is used, folded to the breadth of two fingers, and about three-quarters of an ell long; it should be placed beneath the calf, carried around both ankles, from without inwards, over the back, and over the middle of the inner edge of the foot, under the sole out- wards, and, by proper drawing, it bends the foot outwards. This turn being repeated, the tip of the cloth is carried from the outer, obliquely upwards toward the upper edge of the foot, and both then connected by a packer's knot upon the back of the foot, are carried around the ankle, and tied together (Bruchneu's bandage.) This cloth must be applied once or twice a day ; but, as it nevertheless is easily displaced, strips of sticking plaster may be applied on the same plan, much more efficiently, for the purpose of bringing the foot into place (a). In children born with club-foot, we are restricted for the first two or three months, on account ofthe delicacy of their skin, to frequent daily manipulation, by which it must be attempted to bring the foot gradually to its place; and subsequently the mode of treatment proposed is to be employed. Success is frequent in these cases, on account of the slight degree of the evil and the yieldingness of all the parts. A club-footed patient who has already walked, must from the very onset of the cure be carefully restricted therefrom. Scarpa has recommended a peculiar spring for gradually bending the foot out- wards ; it is applied on the outside of the foot, and fastened with two straps. Re- peated experience has decided me on giving up this practice, and giving preference to the sticking plaster. [As far as I have had opportunity of observing, little real benefit is derived be- yond straightening the foot, whatever bandage or apparatus be used, before the child can be put on his feet, and the weight of his body counteract the unnatural contraction, or disposition to contract, of the gastrocnemial muscles. I therefore rarely do more than, as Chelius recommends, fix the foot with sticking plaster, and, perhaps, put on a light tin shoe, with a back, to render the bandage more firm, but with little expectation of flexing the foot.—j. f. s.] 1376. When the foot has been so far managed, that it can be brought with the hand to its proper place, it is best retained there by the so- called Scarpa's second machine (1), which is applied over the stock- ing and worn day and night. The patient may then be permitted, gra- dually and upon even ground, to stand and walk. After some time, when the foot retains of itself its natural position, the apparatus may be left off during the day, but still worn at night. It is best to let the pa- tient wear a laced boot, which should lace to the toes and have a thin steel plate at its back. (1) Scarpa's machine consists of a shoe, the front of which is made of a thin padded shoe sole, and the back part of a steel plate (a parabolic spring) which en- closes the whole heel. On the inner part of this parabolic spring is a padded strap which is drawn over the back of the foot and fastened to a stud on its outside. A horizontal spring is continued from the outside of the parabolic one to the tip of the foot, around which it is fastened by a padded strap. At the hind end of this spring is a strap fastened to a stud on the inside ofthe parabolic one; and from the outside of the latter a moderately curved spring, with its concave surface towards the leg, ascends up to the region of the knee, and is connected with the parabolic spring by <\ rivet in form of a T. Two padded straps serve for fastening it to the leg above the ankle and below the knee, which, by means of pieces of tin and screws, can be variously attached to the vertical spring. Scarpa's machine is similar to that pro- posed by Delpech (b). To it must be given merited praise and preference above all others (c) (2). («) Giese. Salzb., Medic.-Chirur. Zeitung, 1814. vol. iv. p. 75. (J) Above cited, pi. v. vi. vii. Orthomorphic, pi. xlii. (c) Meinhausen; in Gott. gel. Anzeig., 1799, p. 713; 1807, p. 2019; 1801, p. 1321. 452 DIVISION OF TENDONS. Besides these mentioned, a number of machines and apparatus have been pro- posed, of which mention can only be made. Hippocrates' laced boot; the appa- ratus of Pare, Hildanus, and Haar; the machines of Venel Brunninghausen (a), of Autenrieth, of Blomer (b), of Delacroix, and others. 2. Scarpa's shoe is a very good instrument when the varus is not great, but it will effect no benefit in a bad case; nor will any other; and division of the tendon, or tendons, will be requisite to produce a cure. I may mention, that where I have Been it used, the child walks on his heels, and in spite ofthe spring, the gait is that which is so well known as resulting from what is called pigeon toe.—j. f. s.] 1377. The subcutaneous division of the tendons for the more speedy restoration of the position of the foot especially applies to the Achilles' tendon, the tendon of the m. tibialis anticus, and the plantar^/ascia. The Achilles' tendon generally offers the greatest hindrance to the proper direction of the foot; its division alone is in many cases sufficient, or only in the after-treatment is the necessity for the division of the other tendons declared ; often, however, on first examination the necessity for the simultaneous division of both is shown by the great stretching which the other tendons present. Besides those mentioned, I have, even in the most severe degree of club-foot, never found it necessary to divide any other, although the division of the tendons of the m. tibialis posticus and ofthe m. flexor longus pollicis have been considered neces- sary and performed by others; and Stromeyer, who has frequently cut through the tendon of the m. tibialis posticus, himself admits that from the result of his observations on the division of this tendon no decisive influence upon the restoration of the form and function of club-foot is to be ascribed to it. 1378. The division of the Achilles' tendon is performed most simply and effectually in the following manner. The patient is laid upon his belly, the leg held by one assistant and the foot pressed in its natural direction by another, so that the Achilles' tendon may be tightly strained and very prominent; the thumb and fore-finger ofthe left hand are then to be placed on both sides of the tendon to fix it and the skin covering it, and then a narrow slightly convex and pointed bistoury (1), held flat, is to be thrust in at the inner side of the tendon and directly behind it, about two inches above the heel, beneath the skin, without penetrating it on the outer side, and then the edge of the knife being turned towards the tendon, cuts it through (whilst the flat of the thumb of the left hand placed upon the tendon presses it against the edge) with one or more strokes, without injuring the skin. At the moment of the complete division of the tendon a crack is heard, the two ends of the tendon separate more or less widely asunder, and the foot inclines in the same proportion to its natural position. As soon as the knife is withdrawn slight pressure should be made with the thumb against the little wound, to squeeze out the blood and to prevent the entrance of air; the wound is to be covered with some strips of sticking plaster and wadding, which are fastened with some turns of a lightly-applied roller. The patient is then to be carried to bed, and the foot placed in a suitable position. (a) Richter's Chirurg. Bibliothek, vol. (6) B. Bruns, Dissert, de talipede varo. xv. p. 566, pi. i. f. 1, 2, 3. Berol, 1827. CLUB-FOOT. 453 Thilenius (a), Michaelis (b), and Sartorius (c), cut through the tendon simul- taneously with the skin. Delpech thrust the blade of a bistoury behind the Achilles' tendon, so that on both sides a skin wound is produced about an inch long ; a con- vex knife is then introduced, with the edge of which towards the tendon he divides it transversely, without wounding the skin above it. Stromeyer thrusts in a nar- row curved fistula-knife about two inches above the heel, behind the Achilles' ten- don, and out at the other side, and cuts through it in withdrawing the knife. Stoess makes with a narrow double-edged bistoury, which he thrusts in flat behind the Achilles' tendon, a wound two and a half inches wide, without perforating the skin on the other side, draws the bistoury back, and introducing a button-ended one, slightly curved, and cutting on to a slight extent, with which he divides the tendon. Bouvier (d) makes a slight puncture in the skin with the point of a lancet, a few lines before the tendon, where it is thinnest and strongest, and introduces through this puncture a straight narrow button-ended tenotome between the skin and tendon, and cuts through from before backwards. Guerin brings his narrow tenotome, slightly rounded in front, through a previously made small skin-wound beneath the tendon. Scoutetten stretches the skin with the fingers of the left hand, at the same time drawing it somewhat inwards and thrusts in the tenotome at the inner side of the .tendon, carrying it from behind forwards and from within outwards, without penetrating the skin on the opposite side; he now depresses the handle, draws the knife backwards and forwards, and the tendon is divided. Dieffenbach and others practise in the above-mentioned way. [(1) I never use any other than a common phimosis-knife, which I pass flat before the tendon, till I can feel its point against, but without penetrating the skin on the outside of the leg; then turn the edge to the tendon, which being made tense by an assistant, and pressed against the knife with the left thumb, I cut through with the end of the knife as I withdraw it.—j. f. s.} 1379. When after from three to five days the little wound has closed, the return of the foot to its natural position is to be set about with a machine, which gradually effects the necessary apparent change of posi- tion. Stoess' apparatus best answers this purpose. The return of the foot to its natural place ensues more quickly or more slowly according to the degree and duration of the curvature; all violence must be avoided, and by the gradual reinforced degree of extending the foot and proper soft pads, all painful pressure and excoriation are to be avoided. When the foot is brought to its natural position, Scarpa's apparatus may be applied and the patient allowed to walk. The move- ments of the foot are at first uncertain and stiff, but they improve by exercise, and in similar proportion does the atrophic condition of the muscles diminish, to which end rubbing at the same time with spirits may somewhat contribute. Delpech's apparatus, (e), Stromeyer's (/), Scoutetten's (g), and Pauli's (h) ate also used for this purpose. Pauli, when after two or three days the little wound is healed, surrounds the foot with a mould of plaster of Paris, which he makes in a sort of jointed wooden boot, and leaves to harden. If the proper position of the foot cannot be at once effected, he renews it frequently(l). In not very o-reat curvature, the foot often at once, after the division of the Achilles' tendon, can be restored to its natural position, and in these cases the ex- tending machine may be at once applied. In most cases, however, this is impos- sible, or pain, inflammation, and so on, are too easily excited by the extending force; (a) Medicinische und chirurgische Be- serlesener chirurgischen Beobacthungen,vol. merkungen. Frankf., 1789. p. 335. iii. P- 258. .,„.,..,,.,,. (b) Ueber die Schivachung der Sehne (d) Bulletin de l^cademie de Medecine durch Einechneidung, als einem Mittel bei de Pans December 1836. manchen Gliederverunstaltungen; in Hu«. (e) Above cited, pi. ix. land's and Himly's Journal, vol. vi. Nov. (/) Fl. ni. 1831 d 3 ^ V1* (0 Siebold's Sammlung seltener und au> 1. Vol. ii.—39 454 DIVISION OF TENDONS. it is therefore best to commence the setting straight first when the little wound has healed, (Stromeyer, Dieffenbach, Stoess, myself and others,) (2), and not im- mediately after the operation (Thilenius, Michaelis, Sartorius, Delpech, Bou- vier, Pauli, Duval, Blasius.) [(1) When 1 first began to operate on cases of varus, I had not any opportunity of either being acquainted with or seeing Stromer's apparatus, which I think is by far the best instrument for treating these cases I know of, and I used Boyer's splint for fractured thigh, with the shoe, whieh I first fastened on the foot, and then having fixed it upon the projecting bar, gradually from day to day, drew down the upper end of the splint to the plane of ihe thigh-bone as the patierit could bear it; for although when the shoe was firmly fixed, the length ofthe splint was so great, that it produced such powerful leverage -as to overcome every resistance to placing the foot immediately in its proper position, yet I was afraid of attempting it at once, on account of the violence which would have been needed, and the pain the patient would have suffered ; for even in the way I used it, the patient suffered considerably, from the stress of the shoe-straps, and constantly sought to relieve himself, so that almost daily the foot was found more or less displaced, however well it had been ar- ranged on Che previous day, and therefore the progress of the cure retarded. I therefore altered my plan, and instead of at once attempting to turn the sole down and flex the leg upon the foot, I first endeavoured to get the foot straight with the leg, leaving the toe pointed, and the heel raised, or in other words, to convert the club-foot into horse-foot, and afterwards gradually to flex the foot on the leg from day to day. The first part of the proceeding was affected by Boyer's splint and shoe, with the simple alteration of making the foot-bar, upon which the shoe was -iixed, round instead of square, so that when the bar was entered into its socket, the sole of the foot was readily turned down without making any flexion upon the lev, the socket moving on the bar as the toe pointed, which it is always first disposed to do after the division of the Achilles' tendon. After a few days, when the patient had become accustomed to this new position, I began gradually to flex the foot on the leg, by slipping the foot-piece into the foot-piece of the stirrup apparatus for fractured knee-cap, the circular bandage of which was fixed above the knee, and then gradually shortened the screw rod as the patient could bear the stress upon the ball of the great toe, which was considerable. This answered the purpose, but it was a very clumsy contrivance, and I soon managed to contrive a more simple and efficacious instrument, which consisted of a pair of long narrow splints, like Boyer's splint, one for the outside, and the other for the inside of the leg and thigh, which were connected at bottom by the circular bar on which the foot-piece moved, and upon the leg and thigh, by three or four straps and buckles. For flexing the foot, a stud was placed on each edge of the foot-piece, near its toe end, upon each of which a leather strap fastened, by which the toe end of the foot-piece could be drawn up, and, the foot flexed on the leg, to such extent as might be wished; and this being determined, the other end of each strap was fastened on a stud in the side of the corresponding splint upon the thigh. This apparatus I have used very frequently and successfully, and with children it serves every purpose required, if the surgeon be content to restore the straight po- sition of the foot first, and afterwards to flex it. The instrument has the advantage of being easily made by a common carpenter and smith, and with little expense, even if a new one be made for every case treated. I do not presume to put it in competition with Stromeyer's excellent apparatus, which cannot always be ob- tained when required, is expensive, and needs some little practice for its proper em- ployment. It is, however, a most capital instrument, and effects at the same time the flattening ofthe sole and the flexion ofthe foot with little more than a feeling of confinement to the patient, if it be properly adjusted. (2) I fully agree with those who prefer leaving the limb atrest for a few days after dividing the tendon ; as the patient then bears the extension with less pain. I first began by putting the limb in place at once after the operation, but finding it often necessary to slacken the bandages, I gave it up, and pursued the other practice with greater satisfaction.—j. f. s.] 1380. If there be present with club-foot, considerable bending of the toes, and great concavity of the sole of the foot, in which case the plantar fascia is stretched like a cord in attempting to extend the foot, the divi- DIVISION OF PLANTAR FASCIA. 455 sion of that fascia is necessary (1). If the foot be strongly drawn in- wards, and the curving of its outer edge be so considerable that the great toe and the inner edge of the foot are much contracted, then the tendons ofthe m. tibialis anticus and extensor proprius pollicis must be divided. In greater bending inwards of the foot, so that it can only with the greatest force be moved towards the horizontal axis of the shin-boney the tendons of the m. tibialis posticus and extensor proprius pollicis must be cut through. In dividing the plantar/ascia, the heel and toes should be strongly drawn asunder by an assistant, by which the fascia is still more stretched and projected, the knife is to be introduced, flat on the inner edge ofthe foot under the fascia, its edge should then be turned and the fascia cut through as it is withdrawn, without injuring the skin on the opposite side, which I have often- done with ease. The tendon of the m. tibialis anticus may in this way be divided at the lower end of the shin-bone, where it projects very greatly beneath the skin ; also the tendon of the m. extensor pollicis proprius, to the outer side of which the anterior tibial artery lies, and may be easily avoided. The division of the ten- don ofthe m. tibialis posticus is made half an inch above the inner ankle ; the nail of the left fore finger is to be placed over the posterior tibial artery, and the point of a curved knife carried to the bone, and forwards upon it, divides the tendon (2). A cut three-fourths of an inch long is made more conveniently along the course of the tendon above the inner ankle ; the foot is then turned outwards, and the exposed tendon divided with the point of a knife- (Sisromeyer.) The tendon, of the m. flexor pollicis longus is cut through near the inner edge of the foot, where when violently stretched, it projects between those of the m. flexor pollicis brevis and ofthe m. adductor pollicis, beneath the skin, without thrusting the knife out at the other side. [(1) Shortening ofthe inner portion ofthe plantar fascia producing great diminu- tion in the length, with considerable elevation of the inside of the arch of the foot, in which case, the great toe generally stands almost upright, instead of resting hori- zontally on the ground, I have seen several times, independent of any disposition to club-foot. I have usually cured it without difficulty, by thrusting a phimosis-knife on the inside ofthe foot, opposite the base of the great metatarsal bone, between the skin and fascia, and dividing, the latter in withdrawing the knife. No apparatus is requisite, but after three or four days, when the weight of the body can be borne, the patient is to be directed to walk about a little, so that the newly-formed con- necting matter is gradually lengthened, and the arch of the foot drops to its natural level; the great toe also at the same time recovers its place. (2) The division of the tendon of the m. tibialis posticus is the only one whichi requires much anatomical knowledge or, care, on aecountof the close neighbourhood of the posterior tibial artery, which I once divided in performing this operation on a child; it bled very smartly for a few minutes, and having enlarged the wound, I at- tempted to take it up, but the ends had retracted so much, that I could not succeed, and therefore thought best to bring the edges of the wound together and apply a compress. Union took place, and no haemorrhage occurred. I have been told that such accidents are not very unfrequent, and that no inconvenience follows; but there can be no doubt it were better avoided.—j. f. s.] 1381. If the patient be kept quiet, ordinarily no important symptoms come on; I have not, at least, observed any in my own practice; and if they occur, they would depend rather on the patient's constitution than on. the operation itself, if properly conducted. Should inflammation ensue, and if it be not dispersed by cold applications,.the pus must be early 456 SPLAY-FOOT. evacuated, and by proper treatment the extension ofthe suppuration and exfoliation of the tendon prevented. If unfavourable symptoms occur after this operation, and if in some cases of old and very considerably curved club-foot the result of this operation be not perfect, or even not considerable, and which indeed cannot be previously ensured, yet they do not damage the value of this operation. Even in the earliest child- hood it may be employed. Blasius supposes that the operation, when applied to true club-foot, that is, to severe cases, where it alone can be preferred, effects little or nothing; that it rather only applies tp spurious club-foot, and especially to slight cases. Club-foot is a complication of anomalies: and that the inversion is the most important point; but the operation is directed against only one anomaly, and not at once against the most important. Many groups of muscles participate in the vicious position; the opera- tion is only directed against the muscles of the calf,—at most against the m. tibialis anticus or some one of the others. Atrophy of the leg is always present, and against it can the operation be of no use. This opinion is contradicted by what has been already said, and by the experience both of others and myself. Against Bla- sius's opinion of the propriety of amputation in such states of club-foot, compare Stromeyer (a). b.^OY SPLAY-FOOT. (Valgus, Lat;; Plattfuss, Germ.; Pied-plat, Fr.) Buchetmann, Inaug. Abh. iiber die Plattfuss. Erlangen, 1830 ; with plates. Nevermann, Ueber den Plattfuss und seine Heilung; with a plate; in Ham- burger Zeitschrift, vol. iv, part ii. 1837. Stromeyer, above cited, p. 99. Dieffenbach, above cited, p. 127. 1382. Splay-foot, the reverse of club-foot, is a frequently occurring deformity, in which there is not any actual twisting, but rather only such inclination of the foot outwards that the inner ankle projects very much and descends lower than natural, that beneath the outer ankle is a more or less deep depression, the natural arching of the back of the foot and the cavity ofthe sole and ofthe inner edge ofthe sole are lost, and the foot touches the ground at once with the whole sole, and is widest at the tarsus. Generally the foot is unusually cold, dusky-red or bluish, as if frost-bitten, but, however, much disposed to sweat, so that it is always moist; the skin of the sole is soft, and without the usual hardness and callosities. In walking, splay-footed persons direct the knee inwards and the. foot outwards, so that they mostly tread on the inside of the foot. 1383. The inconveniences in splay-foot are, speedy fatigue in walk- ing, swelling of the foot around the ankles, and soreness of the soles of the feet, on which account persons so affected are not fit for military service in the infantry. From the continual straining of the feet, even chronic inflammation of the ligaments and synovial membranes arises, by which not merely pain but also serous exudation among the tarsal bones takes place. This requires rest, by which the transition to caries is prevented (Stromeyer). It is remarkable that affections of all kinds arising on the feet or legs of splay-footed persons, especially inflamma- tion and ulcers, are always remarkably stubborn. (a) Gasper's Wochenschrift, 1836. Nos. 34, 35. SPLAY-FOOT. 45? Splay-foot must be distinguished from .Broad-foot which is simply an enlargement ofthe natural form of the foot dependent on the extension ofthe lateral ligaments, attached to the metatarsal bones, caused by their frequent use (a); 1384. Splay-foot is either congenital, and shows itself in different degrees directly after birth, as I have several times noticed, in which there is unyieldingness of the m. peronei, especially of the m. peroneus- longus, and the ailment is certainly caused by the position of the child in the womb; or it is developed later, rarely in the female sex and in children under ten years. There is probably a congenital disposition in the position of the tarsal bones, or atony of the plantar fascia and tarsal ligaments, where first, at a subsequent period, and from straining in standing, walking, and so on, splay-foot is developed, and the heel-- bone is so twisted inwards that its outer surface inclines more upwards, and the inner more downwards at the same time. The position of the other tarsal bones and their joints is little changed; the head of the astragalus and cuboid bone often project rather more inwards. In many families, especially among Jews, splay-foot is hereditary. Con- tinual standing, especially with bare feet upon the damp ground, and' much work influence its development. In the higher classes splay-foot very rarely occurs. As to the causes of splay-foot, which have, however, only recently been atten- tively noticed, opinions are different. According to Liston (b) the ailment arises from a thickening (exostosis) of the distal end of the first metatarsal bone, in conse- quence of blows, rheumatism, gout, and scrofula, in opposition to which Froriep (c) correctly observes, that this is only an accidental complication of splay-foot.. Rog- netta (d) holds congenital splay-foot consequent- on deficient development of the heel-bone, and the acquired; as consequence of relaxation ofthe ligaments of the tarsal bones. Thune (e)1 lays the cause in a twisting round of5 the heel-bone* 90 that its outer surfaee is turned upwards, and its inner, one somewhat inwards. The firm connexion between the heel-bone and astragalus by their unyielding ligamentous- apparatus, cause a similar, change in the position ofthe astragalus. If deformity be added, it is accompanied with subluxation between the articular su faces of the head of the astragalus and the navicular bone, in which case the tuberosity of the latter sinks lower than the front part of the head* of the former, which is itself* sunken. The ligaments, especially.the dorsal ligaments, between the astragalus' and navicular bone, but still more, the plantar ligaments, and most of all, those be- tween the two bones are very much stretched. The front fibres of the deltoid liga- ment and ligamentum fibulare tali anticum, are also considerably stretched, as the shin-bone rests only on the hindermost part of the upper joint-surfaces of the astra- galus, and thereby the navicular bone is removed mere forward and the splint bone- more outwards from the navicular bone. Stromeyer places the cause of splay- foot in atony of the plantar fascia and .of the tarsal ligaments. As these yield to pres- sure, the foot loses its arch, and contrariwise inclines outwards, because the action of the tibial muscles and of those ofthe calf, "which properly press the outer edge of the foot and the ball of the great toe against the ground, in less stiength of the ankle-joint, urge the shin-bone inward, which at the same time is accompanied with a driving forwards of the'same bone. Atony of the leg is not to be considered as one ofthe causes in splay-foot; for in some degree of bad cases all the muscles are in such stretched condition that it cannot be ascribed to atony. Thune (/) distinguishes primitive and secondary valgus. The former is already fully developed at birth, and accompanied with a stretching of the muscles on the (a) The Circular to the Prussian military (b) Lancet, March, 1835. physicians, showing the difference of Broad (c) Chirurg, Kuptert. pi. 339. and Splay-foot, in reference to the examina- (d) Archives generales de Medecine, 1834^ tion of recruits; in Rust's Magazin,.vol. (e) Nevermann, above cited. - D 1 (/) Never mann, above cited* 'P'" 39* 458 TREATMENT. fore and outer part of the leg, which increases and becomes painful if it be attempted to put the foot straight; but the foot itself is not deformed. Secondary valgus occurs long after birth, after the patient has been accustomed to walk, and is constantly accompanied! with a change in the form of the foot. Thune has endeavoured to ground this distinction on the different appearances in the one or other form. In secondary valgus the axis of the foot is on its outer edge, concave externally. The inner ankle and the navicular bone form a projection, which, in walking, always more nearly approaches the sole, so that the valgus is in the highest degree talipes; the heel and the outer edge of the foot are away from the ground; the Achilles' tendon lies concealed behind the fold of the skin, and is felt removed somewhat to the outer side; the heel is drawn upwards; the outer malleolus lies concealed in the ankle-joint; the leg, in consequence of wasting, is equally thick below and above, so that the knee appears as if deformed ; the back of the foot (instep) is very much arched; and walking is performed generally not with bended knees. In splay-foot the axis of the foot is not changed, the ankle is very prominent, is lower than usual, and touches the ground; the whole sole of the foot touches the earth; below the outer ankle a cavity is formed, the depth of which depends on the degree ofthe deformity; the heel cannot be drawn up; the outer ankle is distinctly felt; the muscles ofthe calf are not greatly wasted ; the back of the foot is not properly arched, but has at the tarsus an unnatural flattening and breadth; walking is gene- rally performed with the knees bent.. This distinction, however, depends on no actual difference, but is only consequent on simultaneous contraction ofthe muscles, that is, those of the calf, and on shortening of the Achilles' tendon; therefore, in such cases, the division of that tendon may be sufficient (a). 1385. In slighter degrees of splay-foot, and in young persons, the foot may be rubbed twice a-day with spirituous fluids, then wrapped up in a bandage, moistened with spirits, of wine ; cold baths are to be taken from time to time, or a laced leather stocking worn, which equally en- closes the foot and leg, and a shoe, with a strong tin plate, which is convex from behind' forwards to the metatarsal bones. According to Dupuytren, a shoe, with a flexible elastic sole, and raised in height from half to three-quarters of an inch ; according to Rognetta, a raised shoe, together with swathing the foot in a bandage moistened with cam- phorated spirit, which is to be looked to and tightened twice a-day; ac- cording to Stromeyer, a boot, in the middle of which a piece of leather is fastened, confining the middle of the foot from below, upwards, and from within, outwards, then runs pointed, and is fastened by a slit in the upper leather at the outside ofthe foot, to a buckle. In weakly persons an internal strengthening treatment'is at the same time proper. In old persons, and in a high degree of splay-foot, exutories are to be kept long to the sole of the foot, blisters upon its inner edge and on one part ofthe sole, and suppuration kept up by acrid ointment, for the protec- tion of the foot-swathing, and a laced boot (Stromeyer.) Liston recommends a plaster of mercury and iodine to the swelling of the front end ofthe first metatarsal bone, and if this be insufficient, the head ofthe bone is to be removed with cutting forceps. If the splay-foot be great and dependent on diseased contraction of the muscles, against which mechanical assistance is fruitless, Held (b) proposes dividing the m. peronei and indeed the tendons of the longus and medius. The peronei contained in a common sheath are most prominent from four to six lines above the outer ankle; a double-edged bistoury is to be introduced flat beneath them from behind forwards, and the edge turned against them. The tendon of the m. peroneus medius has here still some muscular fibres. The tendons of these muscles are enclosed in proper sheaths from four to six lines under or before the ankle, but they lie so close together that they can be divided at the same time, as the knife is introduced between them and the heel-bone, from above downwards, and somewhat from before, backwards. (a) Strom, yer's case, above cited, p.,95. (b) Above cited, p. 63. HORSE-FOOT. 459 The tendons of the m. peroneus medius may be divided also four or five lines from the base of the fifth metatarsal bone. [In the cases of splay-foot which I have seen, the cause ofthe mischief appears to have been principally in the inner plantar, or calcaneonavicular lio-ament; and it is generally accompanied with tenderness in this neighbourhood. I have usually directed repeated leeching till all tenderness had subsided, and perfect rest; but the relief has only been temporary.—j. f. s.] c—OF HORSE-FOOT. (Per equinus, Lat.; Pferdefuss, Spitzfuss, Germ.; Pied equin, Fr.) Jorg, Ueber die Verkrummungen, p. 77. Zimmerman, Der Klumpfuss und Pferdefuss. Leipzig, 1830. Dieffenbach, Bonnet, and Phillips, above cited. 1386. Horse-foot is that malformation in which the whole splay-foot has one and the same direction with the leg; the heel is considerably drawn up, so that in walking the patient only treads with his toes, and especially with the ball of the great toe. The Achilles' tendon is very tense, the foot at the same time so arched that the convexity of the back and the concavity of the sole are increased. In the greatest degree so complete a turning about of the foot may be produced, that the tip of the foot is turned backwards, and the patient walks entirely on the in- step (a). 1387. The cause of this ailment lies in an unnatural contraction of the muscles of the calf; subsequently also the m. plantaris and plantar fas- cia, the m. tibialis posticus and peroneus longus shorten, and the curva- ture is increased. In a very high degree of this ailment the joint sur- faces of the astragalus are so far pushed forward, that they are nearly out of contact with the shin-bone, which rests almost entirely upon the back part of the heel-bone ; however, it is frequently observed that in long continued and severe horse-foot, the tarsal joints are not particu- larly changed, but that there is a considerable removal ofthe front ends ofthe metatarsal bones from their connexion with the toes, inasmuch as they bear the chief weight in walking, in consequence of the toes being so much turned upwards. Horse-foot is congenital or acquired ; the latter is most common, be- cause, if at a time when the Achilles' tendon is shortened the ankle- joint have not yet attained sufficient firmness, partly from the deficient development of the ligaments, partly from that of the ankles, and espe- cially of the inner, club-foot is quickly produced by the simultaneous shortening of the m. tibialis anticus and posticus. Some inclination of the foot inwards is, however, frequently observed in horse-foot. Dis- eased change in the tarsal bones may also give rise to similar displace- ment. 1388. In reference to the causes, all that has been said in general, and on club-foot applies here (1). The treatment consists in the employment of baths, relaxing rubbings ofthe contracted muscles of the calf and their tendons, in manipulations, (a) Stolz, Memoire sur une variete parti- ciete des Sciences de Basklim. Strasboui culiere du Pied-bot; in the Journal de laSa- 1826, vol. iii. p. 458. 460 HORSE-FOOT. for the purpose of bringing down the heel and raising the front of the foot, which position must be maintained by the apparatus of Jorg (a), Stromeyer, Stoess, and others. In a great degree and long continuance of horse-foot, no perfect cure is effected by this treatment, even though it be long persisted in ; and the only division of the Achilles' tendon and the subsequent application of proper apparatus, as in club-foot, in a short time can restore the straight position of the foot. If the back of the foot (instep) be very much arched and the plantar fascia stretched like a cord, its division is mostly necessary. Stromeyer also cut through, in some cases, the tendons of m. flexor longus and extensor pollicis, on account of a permanent improper position ofthe great toe. Jorg's apparatus consists of a shoe like that of Scarpa's for club-foot; on the outer side of which an iron rod ascends to the knee and is fastened round the leg with a strap. At the lower part of this rod is a spring furnished with a stop-wheel, to which an iron rod is attached, which runs forwards along the foot. A strap carried round the front of the foot is affixed to the end of this rod, by which the foot is always drawn up (2). [(1) Among the causes which produce permanent contraction ofthe gastrocnemial muscles and consequent horse-foot, may be enumerated ulceration, of which I had a good case in 1837, in a strumous girl, whose heel was raised four inches from the ground, the muscles being much shrunk in the calf, and the scar of the skin closely connected with them. The motions of both knee and ankle being perfectly free when the knee was bent, I divided the Achilles' tendon, and she was cured completely. I had also, in the same year, a case of horse-foot under my care, which followed a palsy of the left arm and leg during teething, first at ten months, and next at two years of age, from which, however, when three years old, the patient had recovered so far as to walk about with the aid of a stick or crutch; and when about sixteen, he was able sometimes, to walk even without a stick. Towards the end ofthe fol- lowing year the heel began to leave the ground, and slowly rose still higher till he was twenty years old, when it was at least four inches from the ground, and had so continued when I saw him a twelvemonth after, (Sept. 1837,) the tarsus and meta- tarsus being then on the same plane as the front of the leg,and the foot resting only on the ball of the great toe. The foot was livid and pappy, and when lifted off the ground, dangled at the ankle-joint, both flexor and extensor muscles appearing to be paralysed. Although, under these circumstances, relief from division of the Achilles' tendon seemed to be very doubtful, I thought it worth while performing the operation, so that the sole might be brought to the ground, and then that attempts might be made to excite the muscles on the front of the leg, to action. The tendon was therefore divided in the usual manner on Sept. 30, which brought the sole again flat, its position was preserved by the stirrup and rod attached to a circular knee-strap, and the foot was gradually more flexed by shortening the rod as he could bear it. After wearing this apparatus six weeks, the foot, on its re- moval, was found still to drop, but not to the same extent. He was directed to try to move about on crutches, and to throw some of the weight of his body upon it; but the attempt produced severe pain in the muscles ofthe inside of the leg, which lasted a few hours, and then subsided. On the following day the muscles in the anterior tibial region were electrified for about a quarter of an hour. The foot how- ever still dropping, the stirrup was reapplied; and five days after he was able to bear upon the foot, wearing the stirrup, without pain. About a month after he left the house, the sole of the foot was then flat on the ground, and the foot itself at right angle with the leg; but the muscles in the anterior tibial region were still wanting in tone. I have seen him several times since; the operation has succeeded so far as recovery of the position of the foot is concerned, but the muscles have not re- gained their power, and he is obliged to walk with a stick or crutches. The result of this case, as well also as of those vari already mentioned as following palsy from teething, led me into two or three instances to try the effect of dividing the Achil- (q,) Above cited, pi. vi. HOOK-FOOT. 461 les' tendon where horse-foot was just beginning in children so paralysed, but no benefit was gained. (2) The apparatus I have described for the treatment of club-foot, (par. 1379, note,) or even the fractured patella stirrup, will answer very well for drawing and fixing up the foot in a proper position. Indeed, this distortion of the foot is the most easy of treatment, and might be managed by a careful person merely with a shoe having tapes or straps fixed to its front, and fastened above on either side of a circular bandage above the knee.—j. f. s.] d.—OF HOOK-FOOT. (Talus, Lat.; Hakenfuss, Germ.; Pied-bot calcarien, Fr.) 1389. Hook or Heel-foot consists in the tip of the foot being directed upwards and its back towards the front of the shin-bone, so that the foot forms an acute angle with the leg, often even rests on the shin-bone, and in stepping, the heel only touches the ground. This deformity is always congenital, and manifestly consequent on the position of the foetus in the womb. Often immediately after birth, when the foot is very much drawn up, even if, as I have frequently noticed, it lie upon the shin-bone, it may be brought, by slight force, into its proper place. The contracted muscles are the m. tibialis anticus, extensor proprius pol- licis, and frequently the m. extensor communis digitorum pedis, the ten- dons of which form cord-like projections beneath the skin when the foot is properly placed. The joint connexion between the heel and cuboid bone, and the astragalus and navicular bone appear to suffer most; but the cuneiform bones are also drawn back and their joint-surfaces sepa- rated from each other in the sole of the foot. The point of the foot is also at the same time often turned outwards if the m. extensor communis act violently. 1390. In all the cases which I have hitherto seen soon after birth, it was easy to bring the foot straight, and by means of a curved splint, fastened with a bandage on the front ofthe leg and back of the foot, to keep it so, and in a short time to effect a cure. If the ailment be per- manent and the contracting muscles opposed, this treatment, or the application of a suitable splint, in which case a more considerable atrophy of the leg shows itself than in other curvatures, the division of the stretched tendons, where they project most considerably under the skin, is more certainly efficient. [Of this disease in an incipient state, I saw the following example under my late colleague Tyrrell, originating in accident and accompanied with severe and con- stant pain. Case.—E. G., a tall bony spare widow of forty-six years was admitted Oct. 24, 1835. A twelve month since she had thrown down a table, the edge of which struck her right foot across the heads of the metatarsal bones, and caused violent pain and swelling. Leeches and poultices were used without relief of the pain, and six weeks after the accident all the toes began to stand upright, which disposition increased; and when she left her bed a fortnight after, she was unable to put the whole sole to the ground, and could walk only on the heel, as she suf- fered acute pain along the middle of the sole, with pain in the instep, as if a cord were stretched over it, and shooting pain up the front of the leg as high as the knee. For the last six months the pain has been so severe that she has not been able to put her foot to the ground, but has walked on crutches; and once came into the 462 CURVATURES OF THE SHOULDER. hospital with the purpose of undergoing amputation, which however the surgeon who attended her did not think justifiable. At present the foot is fixed at right angle with the leg, and all the toes raised at nearly right angles with the instep; all the tendons of the muscles in the tibial region have started and are very tight. She has great tenderness on the inside of her sole and heel, and across the under surface of the heads of the metatarsal bones, but no pain on. the outer edge of the sole. There is great pain in the great toe, but not in the others. Pressure along the course of the anterior and' posterior tibial and outer cutaneous nerves, to within a hand's breadth of the tubercle of the shin-bone, causes great pain which shoots up into the knee. As it was thought that these symptoms were produced by the injury which the branches of the anterior tibial nerve had received, at the time of the accident, and that she was probably in a condition similar to that of a horse with lame foot, foT which Sewell of the Royal London Veterinary College had some years since cut out successfully a portion of the nerve going to the foot, by which its sensibility had been destroyed, and the foot again rendered fit for work, it was determined to perform a similar operation, and accordingly, on Nov. 6, a cut was made about a hand's breadth above the ankle-joint between the m. tibialis anticus and m. extensor proprius pollicis, and the nerve being found and carefully separated, an inch of it was removed. She suffered extremely whilst the nerve was being disturbed, but after its division the pain ceased, and the instep felt numb. The edges of the wound were brought together with plaster. She passed a good night, and on the following day was entirely free from pain, except slight pain in the great toe. On the third day, the toes had partially dropped towards their natural position, and on the following day were still straighter, and the great toe was numb. As there was a slight erysipelatous blush about the wound, the dressings were removed and a poultice applied. On the fifth day, a smart arterial bleeding, said to be to the amount of twelve ounces, followed the removal of the poultice, but stopped by pressure for ten minutes, and afterwards a compress of lint was bound on the wound. A slight oozing, however, continued, and on the follow- ing evening, bleeding recurred, and a similar quantity of blood was lost; it was temporarily restrained by pressure and the wound having been cleared by blood, an aneurysm-needle was passed beneath the anterior tibial artery, which was then tied with a single ligature. Unfortunately after this time my notes fail, and I cannot get any satisfactory in- formation, except that the woman did not undergo any second operation, and that she left the house four months after still upon crutches, but under what circumstances I cannot ascertain.—j. f. s.] II.—OF CURVATURES OF THE UPPER LIMBS. [These curvatures, excepting the fingers, are much less frequent than those ofthe lower limbs. A.—OF CURVATURES OF THE SHOULDER. These are of very rare occurrence, the weight of the arm constantly preserving its position close to- the side, and antagonising any of the larger muscles by the contraction of which, alteration of its ordinary situation could be effected. In the contraction of the shoulder the arm is therefore pinned to the side, and the treatment consists merely in the application of blisters, or other irritating remedies for the purpose of in- ducing absorption of the interstitial deposit originating in rheumatic, or other inflammation ofthe soft parts about the joint; and the cautious use of extending apparatus, or passive motion, as the case may be. i OF PERMANENT BENDING OF THE HAND. 463 The division ofthe tendons, as performed by Dieffenbach for the replacement of a long unreduced dislocation at the shoulder-joint, might certainly be applied to cases of contracted shoulder, but I should think little advantage could be hoped from it. B._OF CURVATURES OF THE ELBOW. Curvatures at this joint, although very commonly resulting from an- chylosis, or inflammatory deposit in the soft parts about the joints, are, in rare instances, consequent on contraction ofthe m. biceps flexor cubiti, and m. brachiahs anticus. If arising from the former muscle, any attempt at extending the arm throws its tendon up, as it passes over the front of the elbow-joint, in form of a cord; by which the nature ofthe ailment is distinctly indicated. If rubbing and passive motion, and the extending apparatus be un- availing, it will be necessary to divide the tendon of the m. biceps beneath the skin in the same way as the Achilles' tendon is divided, and'after- wards to apply either a simple splint on the front of the whole fength ofthe arrn, and with a bandage to straighten it gradually, as the patient can bear it, or to make use ofthe extending apparatus.—j. f. s.] C—OF CURVATURES OF THE HAND. 1391. Curvatures of the hand are more rare than those of the foot, and mostly depend on unnatural activity of the muscles. There is either permanent bending of the wrist-joint, with simultaneous pronation or supination, or permanent straightening, or the fingers are permanently bent. a.—OF PERMANENT BENDING OF THE HAND. 1392. In permanent Bending, the hand forms with the fore-arm a more or less right angle, and is at the same time in a state of increased prona- tion and adduction, or of increased supination. In both cases the fingers are strongly bent. The bones and ligaments of the carpus are separated from each other and outspread behind, but in front (volar surface) are contracted, and form a depression. The hand and fore-arm are more or less atrophic. Lode (a) distinguishes these two kinds of curvature of the hand, Talipomanus flexor pronata seu Talipomanus vara and Talipomanus flexor supinata seu Talipo- manus valga. All the muscles which bend the whole hand and fingers, and increase the concavity ofthe hand, in the one case, the pronators, and in the other, the supi- nators, are contracted at once. 1393. This curvature of the hand may be congenital or acquired. As to its causes, all that has been said upon club-foot applies. • I have noticed curvature of the hand as a congenital deformity, once accom- panying club-foot and once with horse-foot on the same side. The (a) Above cited. 464 OF PERMANENT BENDING OF THE FINGER. treatment must be conducted entirely according to the rules laid down for club-foot. A proper apparatus for straightening the hand is found in Lode, fig. 3. b.—OF PERMANENT STRAIGHTENING OF THE HAND. 1394. Permanent Stretching of the Hand, in which his back is re- tracted, in a greater or less degree, towards the fore-arm, and is at the same time in a state of increased abduction or adduction, occurs rarely; and in reference to its aetiology and treatment, all that has been pre- viously said applies. Lode calls this curvature Talipomanus externa. All the extending muscles ofthe hand and fingers, as well also sometimes those muscles which flatten the hand, some- times the adductors, are contracted. c—OF PERMANENT BENDING OF THE FINGER. Dupuytren, Retraction permanente des Doigts; Lecons Orales de Clinique Chi- rurgicale, vol. i. pt. i. p. 117. 1395. A permanent Bending of one or more Fingers may depend on various causes, namely, on diseased changes of the phalanges, on division of the tendons or palsy of the extensors, on a contracting scar in the palm, on destruction of the tendons and sheaths, or contraction of the bending muscles ofthe hand, and contraction and unyieldingness ofthe palmar fascia. The diagnosis of these various causes is really unattended with any difficulty, and depends on the kind of origin, or the perhaps existing scar, or the possibility of moving some ofthe finger-joints, or on violently straightening the finger and so on. In this respect the curva- ture of the finger is most important, as consequent on contraction of the palmar fascia, because, with definite diagnosis, the cure may be more surely effected. 1396. The curvature consequent on contraction of the palmar fascia shows itself especially at the ring finger, mostly in persons who are sub- ject to hard labour, as resulting from inflammatory affection. After violent exertion of the hand, pain frequently comes on, which, however, soon subsides. The fingers are gradually straightened with difficulty, and the ring-finger begins to curve into the palm, at the onset only the first joint bends, but the others follow its movements. In proportion as the ailment proceeds the ring-finger bends still more. At this period no knotty swelling is yet felt on the palmar surface of the ring-finger; its last two joints are straight and moveable. The first joint is bent at a more or less right angle, it is moveable in its connexion with the meta- carpus, but the greatest violence cannot straighten it. If the ring-finger be considerably bent, the skin in the palm presents a fold in the direc- tion of the concavity, towards the ring-finger, and the convexity towards the wrist. If the palmar surface of this ringer be felt, a stretched cord is found, the point of which is directed towards the first joint, and which may be followed to the upper part of the palm. If the finger be bent, this disappears; but, if its straightening be attempted, the tendon of the TREATMENT OF BENT FINGERS. 465 m. palmaris longus is brought into motion, which extends to the upper part ofthe palmar fascia, and the cord is more tightly stretched. According to Goyraud (a) the retraction of the tendinous cords depends on new formations, which pass from the fascia to the sheath of the tendon, from it to the lateral parts of the phalanges, and even from one phalanx to another. These bridges are, however, merely growths of the bridges existing in the natural state. Sanson (b) also believes that this is the usual cause, and the contraction of the palmar fascia only the exception. If the bending of the finger depend on contraction of the bending muscles, a thick cord is felt, in attempting to straighten it, under the fascia,- the m. palmaris remains immoveable, but the bending muscles on the fore-arm are stretched. In a scar, with the muscles attached to it, stretching movements cause pain in the same part; if the hand be bent towards the fore-arm, then the patient can straighten his finger. In palsy, or in division of the tendons of the straightening muscles, the finger is kept permanently shut into the hand, but it may be straightened with a little force, no tight cord is felt, and all the joints are free. In diseased changes in the joints, the finger is more or less bent; the anchylosed phalanges are immoveable; but the others can be moved, and no tight cord is felt in the palm. Many occupations give rise to deformity of the joints of the phalanges without anchylosis, but with perma- nent bending; thus is the little finger in knitters and seamstresses; so the ring- finger, and often several fingers of the right hand, in tailors; and in lace-makers the four last fingers of both hands are curved and so on, as consequence of habit; no cord-like stretching is, however, noticed in the hand, and the finger may still be somewhat straightened. Scars may be easily distinguished by their tension in attempting to straighten the finger. 1397. That the cause of this crooking of the finger is an excessive tension ofthe palmar fascia, which has arisen from pressure, and bruising in hard handiwork, Dupuytren has proved by careful observation, and by the successful division of this aponeurosis. Rubbing, bathing, me- chanical apparatus, and the like, have usually no result, or only transient benefit. The latter I noticed in a considerable curvature of the ring- finger from this cause, in which, by continued use of gray mercurial ointment, and animal baths, the proper position and mobility were re- stored ; but shortly after these remedies were given up, the finger again became as strongly crooked as formerly. The division of the palmar aponeurosis is most effectual. A transverse cut is made through the skin opposite to the junction of the first phalanx with the metacarpal bone, and then the stretched aponeurosis divided in the same direction. If the finger cannot then be straightened, a transverse cut must be made at the joint of the first and second phalanx, or in the middle of the first phalanx. If all the fingers be curved, a transverse cut must be made an inch and a quarter below the former one in the palm of the hand, and the aponeurosis divided. The wound is to be covered with lint, and upon the back of the hand a flat piece of wood attached; on the front part, which has divisions corresponding to the fingers, the latter must be kept in the straight position, by means of nooses, till the scars are completely formed. If the palmar aponeurosis be narrow and stretched like a cord, it is best to determine on its subcutaneous division (c). Goyraud does not divide the skin transversely as Dupuytren does, because, in straightening the finger, the cut in the skin gapes too much; but he cuts through it longitudinally, and through the bridge transversely. (a) Schmidt's Jahrbucher, 1835. p. 248. on Dislocations and Fractures. London (b) Gazette Medicale, 1835. 1 8 August. Edition, 1842. p. 511. (c) B. Cooper; in A. Cooper's Treatise Vol. ii.—40 466 KINDS OF ANEURYSM. 1398. If the cause ofthe finger crooking be a scar, it must be treated according to rules to be hereafter mentioned. In contraction of the bending muscles, relaxing rubbings must be used on the side of flexion, and irritating rubbing, blisters, and so on, upon the side of extension, and also a corresponding mechanical apparatus. Crooked fingers, from destruction of tendons, or organic changes of the joint-surfaces, and the like, are incurable. Tenotomy has been variously employed in contraction ofthe bending tendons and muscles, by which the finger has been perfectly straightened, but the movements of bending were forever lost: the division may be performed on the phalanges or in the palm. 1399. As to the other curvatures, which are seated in the bones them- selves, of the extremities, or in their joints, as for example the bending of the fore- against the upper-arm, or of the leg against the thigh, the oowing of the bones of the leg, the inward or outward turning of the knee-joint, and so on, what has been already observed generally, and the circumstances mentioned in the several kinds of curvature, applies to them. Their treatment must also be by internal and external reme- dies, as well as by the construction of suitable apparatus, which must always act by spring-power, and, if these be useless, and the cause be in the shortening ofthe muscles, if their tendons be accessible, the divi- sion of the stretched tendons and aponeuroses are easily effected. In such cases, the m. pectineus and sartorius, the tendons of the m. biceps femoris, semitendinosus, semimembranosus and gracilis, the fascia lata in the region of the intermuscular aponeurosis and the m. biceps brachii have been cut through. Andry, Orthopaedia, or the Art of preventing and correcting Deformities in Chil- dren. Translated from the French. 2 vols., 12mo. London, 1743. Jorg, above cited. Winter, Beschreibung verbesserter Vorrichtungen zur Heilung schiefer Kniege- lenke und ihrer Anwendung; in Rust's Magazin, vol. ii. p. 163, and pi. i., and most ofthe already quoted writers. Stromeyer, Pauli, Dieffenbach, Bonnet, and Phillips, above cited. IV.—SOLUTION OF CONTINUITY FROM UNNATURAL EXTENSION. A—IN THE ARTERIES. Of Aneurysms. First Section.—OF ANEURYSMS IN GENERAL. Lauth, T., Scriptorum Latinorum de Aneurysmatibus collectio. cxv Icon. Argent, 1785. 4to. contains,— (a) Bonnet, above cited, p. 595. flechisseurs de la Main et des Doigts. Paris, (b) Doubovitzki, P., Memoire sur la Sec- 1841. tion sous-cutanee des Muscles pronateurs- KINDS OF ANEURYSM. 467 Lancisius, F. M., De Aneurysmatibus. Guattani, G., De externis Aneurysmatibus. Rom., 1772. Murray, A., In Aneurysmate femoris animadversiones, 1781. Treu, G. J., Aneurysmatis spurii post venee basiliea? sectionem orti historia et curatio. Norimb. Asman, C, De Aneurysmate, 1773. Weltinus, J., De Aneurysmate vero pectoris externo,1750. Matani, De aneurysmaticis praecordiorum morbis. Francof., 1766. Verbrugge, J., De Aneurysmate. L. B., 1773. Nicholls, On Aneurysms in general; in Phil. Trans., vol. xxxv. p. 440. 1729. Penchienati, Recherches anatomico-pathologiques sur les Anevrysmes des Ar- teres de l'Epaule et du Bras—des Arteres crurales et popliteos; in Mem. de l'Acad. des Sciences de Turin, 1784-85. p. 131-191. Palletta, Sull'Aneurisma. Deschamps, Sur la Ligature des principales Arteres blessees et particulierement sur l'Anevrysme de l'Artere poplitee. Paris, 1797. Caillot, R., Essaies sur l'Anevrysme. Paris, an vii. Ayrer, A. H., Ueber die Pulsadergeschwiilste und ihre chirurgiche Behandlung. Gotting., 1800. Flajani, Sull'Aneurisma degli Arti inferiori. Roma, 1790. Scarpa, A., Sull'Aneurisma Reflessioni ed Osservazioni Anatomico-chirurgische. fol. Pavia, 1804. Translated by Wishart as a Treatise on the Anatomy, Pathology, and Surgical Treatment of Aneurism. 8vo. Edinb., 1808. Second Edition, 1819, here quoted. Freer, George, Observations on Aneurism and some Diseases of the Arterial (System. Birmingham, 1807. 4to. Hodgson, J., Treatise en the Diseases of the Arteries and Veins, comprising the pathology and treatment of Aneurysms and Wounded Arteries. London, 1814. Spangenberg, G. A., Erfahrungen iiber die Pulsadergeschwiilste; in Horn's Archiv., 1815, p. 209. Scarpa, A., Memoria sulla Legatura delle principali Arterie degli Arti; con una {Appendice all'Opera Sull'Aneurisma. 4to. Pavia, 1817. Translated by Wishart, find attached to the Second Edition ofthe Treatise on Aneurysm. Ehrmann, C A., Structure des Arteres, leurs proprietes, leurs fonctions, et leurs alterations organiques. Strasbourg, 1822. 4to. Seiler, Sammlungeiniger Abhandlungen von Scarpa, Vacca Berlinghieri und Uccelli, iiber Pulsadergeschwiilste. Aus dem Ital. mit Zusatzen. Zurich, 1822. 4to. Cooper, Astley, Surgical Lectures. Edited by Tyrrell, vol. ii. 1825. Turner, Thos., Practical Treatise on the Arterial System ; intended to illustrate the importance' of studying the anastomosis in reference to the rationale of the new operation for aneurysms, and the surgical treatment of haemorrhage. With origi- nal coloured plates. London, 1826. Delpech, Observations et Reflexions sur la Ligature des principales Arteres; in Clinique Chirurgicale de Montpellier, vol. i. p. 1. Guthrie, On the Diseases and Injuries of Arteries, with the operations required for their cure. London, 1830. Dupuytren, Memoire sur les Anevrysms; in Repertoire general d'Anatomie et de Physiologie. vol. v. 1830. Breschet, Memoires chirurgicaux sur differentes especes d'Anevrysmes. Paris, 1834. 4to. * Velpeau, A. L. M., Traite Anatomie chirurgicale. vol. i. ii. Paris, 1825-8. von Bierkowski, L. L, Anatomisch-chirurgische Abbildungen nebst Beschrei- bung der chirurg. Operationen, u., s. w., mit einer Vorrede von Rust. Berlin, 1826 ; with xl. lithogr. plates. Bujalsky, E., Tabulae anatomico-chirurgicaj. Petropol., 1828. Froriep, R., Chirurgische Anatomie der Ligaturstellen des menschlichen Korpers. Weimer, 1830. fol.; with 18 plates. Manec, J. P., Traite theoretique et pratique de la Ligature des Arteres. Paris, 1832. fol. Dietrich G. L., Das Aufsuchen der Schlagadern behufs der Unterbindungen zur Heilung von aneurysmen, nebst Geschichte der Unterbindungen. Nurnberg, 1831. 8vo. 468 KINDS OF ANEURYSM. Hunter, John, Lectures on Surgery; in his Works, edited by Palmer, vol. 1. 1835. Erichsen, John E., Observations on Aneurysm, selected from the works of the principal writers on that disease, from the earliest periods to the close of the last century. London, 1844. 8vo. One ofthe publications ofthe Sydenham Society. 1400. Every swelling produced by partial expansion of the cavity of an artery, or, after previous division of its coats, by effusion of blood into the surrounding cellular tissue, is called an Aneurysm (Aneurysma, Lat.; Pulsadergeschwulst, Germ.; Anevrisme, Fr.) In the former case it is named a true, {Aneurysma verum,) and in the latter a false or spmious Aneurysm (Aneurysma spurium.) Some writers have also mentioned a mixed Aneurysm, (Aneurysma mixtum,) where either after the external arterial coat is divided, the internal expands, or the contrary (a). This designation, however, is also used for the case when a true aneurysm bursts, and the blood is effused into the cellular tissue (b). The mixed aneurysm, taken in the former sense, does not exist. Breschet (c) has, however, by close examination, determined that the middle coat of the artery is torn, and a sac-like expansion produced by the protrusion of the inner coat through the opening in the middle, and by the expansion of the external coat. A combined division and enlargement of an artery and vein is called a Varicose Aneurysm, or Aneurysmal Varix {Aneu- rysma varicosum seu venosum, or Varix aneurysmaticus.) If the expansion affect several branches coming from different trunks, and anastomosing branches and their 'arches, with or without partial lateral enlargement of their walls, such are distinguished as Branching Aneurysm, or Aneu- rysm by anastomosis (Aneurysma anastomosium seu anastomoticum, von Walther ; A. spongiosum seu cirsoideum, Breschet ; Varix arteriosus, A. per anastomosin.) [The writings ofthe ancient physicians show their acquaintance with aneurysm, which they described as of two kinds; one, the consequence of a wound in bleeding from the vein in the arm or spurious aneurysm, which would seem to have been of not unfrequent occurrence, as they are best informed about it; and the other by dilatation of the artery without injury, or true aneurysm. I have selected passages from Galen, ^Etius, and Paul of iEgina, which are the foundation of the opinions long and subsequently held by writers on this subject. Galen (d) says :—" When an artery is expanded, the disease is called an aneu- rysm. This happens when, the vessel being wounded, the adjoining skin cicatrizes, but the wound still remains in the artery, which neither unites nor heals, nor is filled up with flesh. Such diseases are known by the pulsation of the arteries, but when pressed, all the swelling disappears, the substance producing it returning into the artery, and which I have elsewhere shown consists of thin and yellow blood mixed with thin and much spirit. Forthwith is this blood hotter than that in the veins, and when the aneurysm is wounded, it darts forth and can with difficulty be stopped. But in oedema the substance yields to the pressure of the finger, and the limb, pits, but there is no pulsation in this disease, and the colour is whiter, and the adema is much more spread and greater than in aneurysm, except when a thrombus having arisen from it, produces gangrene." In another place (e) Galen says:—" Aneurysm is the dilatation of a vein, or the dispersion of the spirituous matter by its bursting beneath the flesh." ^Etius (/) describes the signs of aneurysm as "a tumour of small or large size, (a) Hunter, William, in Medical Obser. (d) Tltpt v vip^vni Oyxav BiBkiov, chap. vations and Inquiries, vol. i. p. 338. xi. vol. vii. p. 725. Kuhn's Edition. 8vo. (b) Monro, A., in Essays and Observa- (e) Ogo/ lai^/xt/, par. ccclxxviii. vJ. xix. tions of Edinburgh, vol. ii, p, 238. p. 441. Kchn's Edit. (C) Memoire Chirurgicale sur differentes (/) Terptfiifixov, Discourse xv. chap. 10. especes d'Anevrysmes. Paris, 1824. 4to., I have been obliged to use the Latin Trans- with six plates. lation by Janus Cornarius, Basilete, mdxlii. SYMPTOMS OF ANEURYSM. 469 of one colour, free from pain, soft to the touch, and having a spongy looseness. It yields so to pressure of the fingers as to seem almost to disappear, but on the re- moval of the fingers it very quickly returns, which is especially observed in aneurysm and the rest that occur without a wound. But when there has been a previous wound of the artery, and the skin uniting, there is also accompanying dilatation of the vessels, the tumour is not equally soft, for the blood being more copious than the spirits, collects in clots and swells out the tumour." Paul, of iEgina (a), proceeds farther, and distinguishes spontaneous aneurysm from that produced by accident. After having quoted Galen's definition and symp- toms, he says :—" But I distinguish the one from the other thus: those which arise from a dilated artery are more bulky and deeply situated, and on examination with the fingers a sort of noise is heard ; but no noise is heard in those caused by rupture, which are more round and arise superficially. He advises different treatment for the two forms of disease, as will be presently mentioned. John Hunter defines aneurysm as " the dilatation of the coats of an artery, arising probably either from disease or accident, producing weakness, which beeomes the remote cause, while the force of the circulation is the immediate cause. It probably may also arise, however, from a disproportion in the blood's motion, and then the disproportion between the force of the circulation and strength of the artery is both the remote and the immediate cause; but this is probably only in the larger arteries, where the force is greatest." (pp. 543, 44.) ] 1401. In true aneurysm the walls of the artery are either expanded only at a small part of their course, {Aneurysma verum circumscriptum,) or the expansion affects a larger extent, and is gradually lost (Aneurysma verum diffusum.) False aneurysm is also divided into the circumscribed or consequent, {Aneurysma spurium circumscriptum seu consecutivum,) and the diffused or original (Aneurysma spurium diffusum seu primitivum,.) In the former case the blood is effused under the cellular tissue of the artery, and outstretches it into the sac; in the latter, all the coats of the artery are divided, and the blood is .poured forth into the interspaces of the whole limb {par. 278.) Breschet distinguishes four principal kinds of true aneurysm according to the different form of the expansion of the arterial canal. 1. The true sac-shaped aneu- rysm, in which the artery exhibits at one part of its tube a fulness like a little sac, originating in the expansion of all the coats of the arteries. 2. The spindle-shaped aneurysm, in which all the coats of the whole tube of the artery are expanded, but narrow above and below, like a spindle. 3. The true cylindrical aneurysm, in which the canal of an artery is, for a greater or less distance, more or less regularly ex_ panded. 4. The true varicose aneurysm, or aneurysmal varix, in which there is an expansion ofthe artery, to a greater or less extent of its length, often throughout the entire length ofthe trunk of the vessel, and of its principal branches, exactly as in varicosity of the veins. Besides this transverse expansion, there is also a length- ening of the vessel, which becomes bent, and describes more or less numerous and considerable curves. There are also sometimes observed, besides this, sudden ex- pansion of the whole arterial cylinder, at certain parts, knots; or little circumscribed aneurysms, which are true sac-shaped and often mixed aneurysms. Very fre- quently the walls are thinned, softened, and falling together like those of varicose veins, whilst Jn true cylindrical aneurysm the walls are thickened. The artery affected with varix has great resemblance to a varicose vein; the pulsation, hoWr ever, always presents a distinguishing and determinate character, 1402. The symptoms which characterize aneurysm are the following: —A little elastic pulsating swelling, which diminishes on pressure, and soon returns on its withdrawal, arises at some one spot corresponding to the course ofthe artery. The pulsation ceases when the artery is conn pressed between the swelling and the heart, and the former becomes fol., not being able to put hand on a Greek (a) B//Saw stt*, book vi. chap, xxxvii, ps copy__j F s 188. Basilece, mdxxxviii. fol. V'm ■"■' ' 40* 470 SYMPTOMS OF ANEURYSM. generally less tense. If the artery be compressed below the swelling, the pulsation becomes more bounding and distinct. The tumour is usually free from pain, the skin over it unchanged, and it quickly en- larges to a considerable size. In proportion as the swelling increases, the blood contained in it becomes more solid by coagulating, and can be no longer got rid of by pressure; the pulsation is weaker, and often entirely lost (1). When the tumour has acquired considerable size, it acts injuriously by its pressure and expansion upon the neighbouring parts; the circulation in the diseased artery, in the other blood and lymphatic vessels, is interfered with; the nerves are compressed; the nourishment, warmth, and sensation of the part are diminished; the limb becomes cedematously swelled; the tumour is covered with vari- cose vessels, and becomes bluish; and the surrounding muscles, and bones even, may be destroyed by the constant pressure and absorption. In consequence of the expansion of the parts covering the swelling, they at last inflame ; at the most prominent part an abscess, or commonly a slough is formed, after the separation of which the coagulated blood is discharged, and a dangerous or fatal bleeding ensues (2). The cover- ings of the tumour may be also torn by gradual distention. Its size may even become so great, that by the pressure and destruction of the surrounding parts, the nourishment of the limb may be entirely pre- vented, and its death caused (3). If the aneurysmal sac increase, it attaches itself to the surrounding parts, which are thickened by inflammation and by the exudation of plastic lymph, and thus enabled, although the coats of the artery be torn, to prevent the penetration of the blood into all the interspaces of the part. If, however, the aneurysmal sac tear suddenly before these adhesions are formed, the blood is poured forth into all the interspaces of the part. [(1) "The coagulation takes place," observes John Hunter, "at the most dis- tant parts from the direct current of the blood : the firmness and colour of the laminae, in different parts of the tumour, are such that it is easy to distinguish an old coagu- lum from a new one; the external laminae are of a dusty brown colour, and these laminae grow gradually redder as we advance inwards towards the current of the blood. As the dilatation increases, the coats of the artery are thickened by the thick- ening process, or the cellular membrane already thickened becomes firm, and adheres from a consciousness of weakness. When the aneurism proceeds to this state it generally gives way to the circulation. It must be observed that the force of the blood on the sides of the sac diminishes in an inverse ratio to the increase of its sides, which, therefore, are longer in dilating than might be imagined.; but after proceeding to a certain length, the adventitious coat gives way, and the blood is effused into the surrounding cellular membrane, producing distention; and when the artery is a considerable one, there is an obstruction to the blood's motion in the collateral branches, producing mortification. When the artery opens externally, it is always on that side where the artery gives way most." (p. 546.) (2) The mode in which an aneurysm bursts externally is thus described by John Hunter, "When an aneurism is in an artery whose dilatation brings it to the skin, the coagulum comes first, and obstructs the circulation in the skin; the skin inflames and mortifies, forming a black slough, which dries and adheres to the coagulum. As the slough separates there is an oozing of blood at the edges, which becomes more and more, till at last in a large artery, as the aorta, the plug may be wholly pushed off and the patient die instantly. If in a smaller artery, death will be more gradual." (p. 546.) Hidgson makes the following good remarks upon the bursting of "aneurisms, which, like abscesses, generally proceed towards the surface of the body; but in this respect they are very much influenced by the situation and the side of the vessel from which the disease originates. When the sac points externally it rarely or never bursts by laceration, but the extreme distention causes the integuments and SYMPTOMS OF ANEURYSM. 471 investing parts to slough, and upon the separation of the eschar the blood issues from the tumour. A similar process takes place when the disease extends into a cavity which is lined by a mucous membrane, as the oesophagus, intestines, bladder, &c. In such cases the cavity of the aneurism is generally exposed by the separation of a slough which has formed upon its most distended part and not by laceration. But when the sac projects into a cavity lined by a serous membrane, as the pleura, the peritoneum, the pericardium, &c, sloughing of these membranes does not take place, but the parietes of the tumour, having become extremely thin in consequence of distention, at length burst by a, crack or fissure, through which the blood is dis- charged. I have," says he, " examined aneurisms that have burst into the cavities of the pericardium, the pleura, and the peritoneum, and the opening has always been formed by laceration, and not by sloughing: on the other hand, all the instances of this disease that I have seen, in which aneurisms burst upon the surface of the body or into the cavities lined by a mucous membrane, the opening has been the conse- quence of sloughing and ulceration, and not of laceration." (pp. 85, 6.) ] (3) When aneurysms burst into mucous canals, they do not generally seem to protrude much into their cavity, but the walls of the aneurysm and of the canal be- coming adherent, ulceration takes place, and in this way the blood escapes from the sac and often very quickly destroys the patient. The same thing also happens in that very rare termination of aneurysm by bursting into another artery, an example of which is given by Dr. Wells (a), and the nre- paration is in the Museum at St. Thomas's Hospital. The following is an extract of this interesting case :— A fair-complexioned, thin, and temperate man, 35 years old, was in 1789 affected with symptoms supposed to denote the approach of pulmonary consumption, but after some time they disappeared. Nine years after he had a slight attack of he- miplegia, from which, however, he soon recovered. In March, 1804, he was fre- quently troubled with noise in his ears, flatulence, and pains in his hands and feet, from one or other of which he was never after free, but he never complained of any unusual feelings about his chest. On the 11th of August, 1807, having fatigued himself a good deal with walking, and eaten a full dinner, he fell asleep, awoke much refreshed, and played with his children in the garden. " While thus amusing himself, he was suddenly seized between eight and nine in the evening with a sense of great oppression in his chest. He soon after became sick and vomited ; in the matter thrown up some streaks of blood were observed. He now went to bed, but though the weather was warm, and he was covered with bed-cloths, his skin , felt cold to those who were attending on him. Soon after midnight he laboured under a constant desire to cough, and was continually expectorating mucus tinged with blood. His body was moistened with a cold sweat, his pulse was extremely feeble, sometimes it was scarcely perceptible." He continued getting worse through the night, "his breathing became difficult, and he frequently tossed and writhed his body as if he was suffering great pain and uneasiness. About a quarter past five he suddenly became worse and expired. Almost immediately before his death he complained much of heat in his chest, and threw off the cloths to cool himself." On examination, "the blood-vessels of the lungs were found very much distended, and there was also a considerable quantity of blood in the air-cells. The right lung adhered-slightly to the ribs and pericardium -, but-this seemed to have been the con- sequence of some disease which had existed long before death. Each cavity ofthe chest contained about ten ounces of a fluid highly tinged with blood ; the pericar- dium contained about two ounces of a fluid similarly tinged. The ascending aorta was distended to about the size of a large orange. The tumour adhered to the pul- monary artery, just before its division, into the right and left branches. Within the circumference of this adhesion there was a narrow hole, by means of which a com- munication was formed between the two arteries. The cavities of the heart, and the great blood-vessels, were very much distended with blood." (p. 81.) In the Mu- seum at the Royal College of Surgeons, there is one specimen of aneurysm of the arch of the aorta burst into the pulmonary artery close to its valves by an oval open- ino- half an inch in its greatest diameter; and also a second, in which there is a small round aperture between the sac and the trunk of the pulmonary artery. The [a) Transactions of a Society for the Improvement of Medical and Chirurgical know- ledge, vol. iii. 472 DISTINGUISHING CHARACTERS patient died of jaundice and dropsy; but the aneurysm was not indicated during life. It may be here mentioned that the pressure of an aneurysmal sac will sometimes produce obstruction in the neighbouring, vessels. In St. Thomas's Museum there is an example of complete obstruction of the superior vena cava, and vena innominata, by an aneurysm of the aortic arch involving also the arteria innorninata ; in the Museum at Fort Pitt, Chatham, is one in which the superior vena cava is oblite- rated ; and in the College Museum, one in which the superior vena cava is almost obliterated.] 1403. The distinguishing characters of circumscribed true and false aneurysm, are usually describTed as the following:—True aneurysm quickly diminishes on the application of pressure, though it reappears almost as soon as the pressure is removed: false aneurysm only disap- pears gradually, and returns slowly after pressure has been taken off, because the blood can only gradually pass from the sac into the artery, and from it again into the sac. A distinct sound is often observed when the blood again flows into the sac,(l). The pulsation is weaker in false than in true aneurysm, and sooner becomes indistinct in the enlargement of the. swelling. The aperture by which the sac of the false aneurysm is connected with the cavity of the artery, is narrow in comparison with its base; in partial extension of all the arterial coats, the entrance for the blood is just as wide as the base of the sac. When the extension occupies the whole tube of the artery, the swelling is always cylindrical or egg-shaped, yields easily to pressure, and in the dead body is always found smaller than it was during life. The form of the false aneurysm is irregular, and continues the same in the corpse. In the sac of a true aneurysm, layers of coagulated blood are never deposited, which is always the case in false aneurysm, with very rare exceptions (a). The more all the coats of the artery are expanded the more they are thinned, whilst, on the contrary, the sac of a false aneurysm increases in thick- ness (6). However, in true cylindrical aneurysm the walls may be equally thick, so that, if cut through vertically to its axis, the walls do not drop (c). [(1) Lawrence (d) observes:—"There are some instances in which pulsation cannot be felt, in which it may be heard, either by the application of the ear directly applied to the tumour, or through the medium of the instrument called the stetho- scope. The sound that is communicated in either of these cases is very peculiar, the sound produced by the passage of the stream of blood from the opening in the artery leading to the aneurismal sac. . The blood passes through comparatively a contracted orifice, to enter into a large cavity, and each jet ofthe blood propelled into the aneurismal tumour by the contraction of the heart, produces a sound which is something like that of the sound of blowing through bellows—whih, whih, whih; you will hear a succession of these; and hence the French, in my opinion, have very appositely characterised it by the term bruit de soufflet; soufflet is the term used for bellows : and, in fact, it means * noise of a bellows;' and, in short, it cannot by any terms be more clearly illustrated." (p. 160.) I cannot assent to several ofthe conditions laid down by Chelius, as distinguish- ing true from false aneurysm. The diminution ofthe bulk of a true aneurysm de- pends materially on the stage at which it has arrived ; if it be recent and there be little or no lining of clot, it does diminish readily on pressure ofthe artery between the sac and the heart; but the diminution under these circumstances is less and less, in proportion to the increased bulk of the sac, so that in a large aneurysm there is, comparatively, little diminution of size, though the current of blood be stopped, (a) Hodgson, above cited, p. 82. (b) Scarpa. (c) Breschet, above cited. (d) Lect. on Surg.; in Lancet, 1829-30, vol. ii. OF ANEURYSM. 473 False aneurysm diminishes still less, and often, indeed when the blood continues, as it commonly does, pouring into the cellular tissue it there coagulates, scarcely any perceptible diminution of size is made by pressure on the artery between it and the heart. And a true aneurysm which has burst a sac beneath the skin, as some- times happens, is similarly circumstanced. The pulsation is generally less distinct in a false than in a true aneurysm; but this also depends on the period and extent occupied by the blood which has escaped, and is proportionally less, the greater the quantity of blood poured out. The external form of a false aneurysm is und oubtedly irregular, as it much depends upon the looseness of the surrounding cellular tissue, and whether the part be or be not enveloped in a tendinous sheath; but the imme- diate sac, consisting only of more or less numerous layers of coagulated blood, which as they continue to form, thrust the loaded cellular tissue away from the artery, and hollow it out for their own lodgment, is generally of a regular oval form, and has at one or other part an aperture, by which blood continues escaping and gorging the cellular tissue surrounding the false sac, till at last it distends the skin so much that it mortifies and gives way at one or more points, and bloody serum and clots mixed with ill-formed pus, which is commonly produced towards the termination of the disease, begin to be discharged, and increase in quantity till the false sac itself break away and the blood readily make its , way out. I cannot un- derstand the observation, that " in the sac of a true aneurysm layers of coagulated blood are never deposited,?' which is most undoubtedly, incorrect in all cases where the aneurysm results from ulceration or tearing of one or other coats of the artery ; for very speedily after a pouch is formed, layers of clot begin to form. And even when the disease only depends on dilatation ofthe arterial coats, though at first there be no layers of clot, yet as the disease proceeds, they are certainly formed, although Hodgson denies it and says :—" In those sacs which consist either in a general or partial dilatation ofthe coats ofthe vessel, I have never met with it." (p. 82.) As to the difference of thickness of sac in true and false aneurysm, although in the former the coats ofthe artery thin as the disease increases, yet there is a continued slow inflammatory action going on upon the external surface of the sac by which its thickness is preserved, till the parts by which it is surrounded having been either absorbed or stretched to bursting by its size, the sac itself is the only remaining resistant to the impulse of the blood, and in its turn yields, thins, and at last it bursts. As to the thickening of a false aneurysmal sac, it continues indeed so long as the surrounding cellular tissue confines and supports it, but when the tissue is absorbed or sloughs, the want of support is here also felt, and the false sac thins, yields, and bursts as in true aneurysm.—j. f. s.] 1804. The distinction of aneurysm from other swellings is grounded on the pulsation, the diminution by pressure, the reappearance when the pressure is removed, and the position corresponding to that of the course of an artery. When therefore the pulsation is indistinct, or not at all perceptible, and the swelling cannot be diminished by pressure, it must be the more carefully examined, and attention paid to its origin and its early condition. Swellings in the neighbourhood of a large artery, or lying upon it, participate in the pulsation, which, however, to a practised touch is easily distinguishable, as it consists only in a raising and sink- ing of the swelling; but if such swelling contain any fluid which un- dulates by the imparted motion, the diagnosis is doubtful: a degree of certainty, however, may be attained, if the artery be compressed above the swelling, and the latter be then properly examined {a). [Aneurysms are sometimes mistaken for abscesses. Dupuytren witnessed a case in whrich the blood issuing from an aneurysm of the arch of the aorta, made its way behind the breast-bone into the bottom of the neck, and there formed a tumour, which, being mistaken for an abscess, was punctured, and gave rise to repeated, and at last fatal bleedings. Richerand (b) says, that " Ferrand, principal Surgeon at (a) Ribes, Memoirs et Observations d'Anatomie, de Physiologie, de Pathologie, et de Chirurgie, Paris, 1841. vol. i. p. 255. (b) Nosographie Chirurgicale, vol. iv. Fourth Edit. Paris, 1815. 474 CAUSES AND the Hotel-Dieu, thinking to open an abscess in the arm-pit, plunged his knife into an axillary aneurysm, and killed his patient." (p. 72.) Astley Cooper mentions an instance of an aneurysm which had presented in the loin, being punctured, under supposition of it being a lumbar abscess; the mistake, however, being ascertained, the edges of the wound were immediately brought together and healed, and the patient died by the tumour afterwards bursting internally, (p. 35.) I myself recollect a spurious aneurysm, after venesection, having been punctured as an abscess; the bleeding was stopped immediately, but about twenty hours after, as the girl was dressing her hair, the bandage slipped off, a violent gush of arterial blood followed, and she lay in great jeopardy for many hours before she was in a fit state to have the artery secured. On the other hand, a pulsating tumour may be mistaken for an aneurysm, an ex- ample of which is mentioned by Warner (a), in a boy who had his breast-bone much fractured by a fall, and came to Guy's Hospital a fortnight after. " There was an evident separation of the broken parts ofthe bone, which were removed at some distance from each other. The intermediate space was occupied by a tumour of considerable size ; the integuments were of their natural complexion; the swelling had as regular a contraction and dilatation as the heart itself, or the aorta could be supposed to have. Upon pressure, the tumour receded ; upon a removal of the pres- sure the tumour immediately resumed its former size. * * * The event was, the tumour burst in about three weeks from his admission, discharged a considerable quantity of matter, and the patient did well by very superficial application." (p. Sometimes a large varix of the accompanying vein may turn so completely over the artery as to hide it completely, and receive its pulsation. In St. Thomas's Museum there is a very fine example of this disease in the internal jugular vein, the swelling of which, from its size, must have occupied nearly the whole of the one side ofthe neck. Such cases may be distinguished by pressure ofthe swelling at its farthest extremity from the heart, in which case its size will diminish, whilst if pressure be made between it and the heart, its bulk must be increased which is the very reverse to aneurysm. Tumours of any kind upon an artery will often acquire pulsation from it, and be liable to mistake ; their unvarying size, however, and eommonly the cessation of the pulsation when the swelling is lifted up, will generally determine their true cha- racter.—j. f. s.] 1405. Aneurysms arise either of their own accord, or after deter- minate external influence (A. spontaneum and traumaticum.) In the former case they occur generally at more than one spot, either at once or consecutively, and thus show that a peculiar morbid condition spreads more or less over the arterial system. This is observed most commonly in persons who are subject-to rheumatism, gout, scrofula, syphilis, who have used much mercury, and have drank spirits to excess. In these cases there frequently arise inflammation of the internal coat of the artery, ulceration, loosening, thickening, even ossification between the internal and middle coats, by which the walls of the artery yield to the pressure of the blood, or the internal and middle coats are torn or de- stroyed. The external influences which produce aneurysm are wounds, violent efforts in lifting heavy weights, in jumping, in vomiting, cough- ing, and the like. These circumstances (wounds naturally excepted) produce aneurysm the more readily, if the coats ofthe artery have been changed by disease, as above mentioned. [Richerand mentions a curious circumstance in reference to "a class of persons who almost always die of aneurysm, arid whom he noticed whilst engaged with anatomy. These were the servants of the amphitheatre, whose business it was to bring the subjects and remove the refuse of the dissections. I never saw one," says he, " who did not abuse spirituous liquors, and was not constantly drunk; (a) Cases in Surgery. London, 1784. FREQUENCY OF ANEURYSM. 475 and to this were added the feebleness resulting from such excesss, the fatigues of so disgusting and laborious an occupation which occupied their nights, the exertions required to carry bodies often too heavy for a single person, wearied with sleep and drunkenness." (p. 71.) Guthrie also observes:—" The exertion in general is infinitely greater in the man than in the woman; and I think this, combined with the freer use of ardent spirits, a much more likely predisposing cause than either syphilis or mercury." (p. 87.) With regard to the age at which aneurysm occurs, Astley Cooper observes:— "The period of life at which they most frequently occur is between thirty and fifty years; at that age in the labouring classes the exertions of the body are considerable and its strength often becomes diminished: in very old age this complaint is less frequent, as muscular exertion is less. The greatest age at which I have seen aneu- rism has been eighty years; this was in a man for whom I tied the popliteal artery in Guy's Hospital, for popliteal aneurism ; and, notwithstanding his advanced age, I never had an operation succeed better. I also operated on a man of sixty-nine years, and that case also did well. A boy, in St. Thomas's Hospital, had an aneu- rism of the anterior tibial artery, who, I was informed, was only eleven years old. The man of eighty was the oldest, and the' boy of eleven the youngest, which I have seen with aneurism." (pp. 40, 1.) As regards the frequency of aneurysm in the sexes, Wilson (a) remarks, that shortly before John Hunter's death, he heard him state that he had only met with one woman with true or spontaneous aneurysm. Astley Cooper says:—" In forty years' experience, taking the hospital and private practice, I have seen only eight cases of popliteal aneurism in the female, but an immense number in the male. The aneurisms which I have seen in the female, have been the greater number in the ascending aorta or the carotid arteries." (p. 41.) Of the sixty-three cases re- ferred to by Hodgson, seven-only were females, and the other fifty-six males, (p. 87.). Guthrie states, that he " does not recollect having seen more than three women suffering from popliteal aneurism; and it is probable that they are found, on an average, at least, from twenty to thirty times in men, for once in woman. The structure of the vessels is the same, but the mode of life is different." (p. 87.) Lisfranc (b) mentions that of one hundred and fifty-four cases which he had col- lated, one hundred and forty-one were males, and thirteen females. I myself, in the course of thirty years, do not recollect more than three external aneurysms, which were popliteal, in females.—j. f. s.] 1406. Aneurysm may occur in all arteries: the internal arteries are, however, more frequently attacked with it than the external, the reason of which may be, that the nearer the arteries are to the heart, the thinner are their walls in proportion to their diameter, consequently they are less capable of withstanding a violent pressure of the blood. The curves, also, which the arteries describe in their course, have an influence on the more frequent origin of aneurysm. Aneurysm of the arch of the aorta is most frequent; next comes aneurysm of the popliteal, then of the inguinal, axillary, and carotid arteries. False aneurysm, as a con- sequence of the wound of an artery, occurs most commonly in the bra- chial, after an unlucky blood-letting. [The force of the heart, however," says John Hunter, "has some power in operating as a remote or first cause of aneurisms. Aneurisms are most frequent in the larger arteries, as at the arch of the aorta, and more frequent in the second order of arteries than in the third; but they are sometimes found even in the fourth and fifth. * * * The nature ofthe artery contributes likewise, the structure ofthe large arte- ries being chiefly of elastic matter, and not near so muscular as the small ones, which have therefore greater powers of resistance." (pp. 544, 45.)] (a) Lectures on the Blood, and the Ana- (b) Des diverses Methodes et des differens tomy, Physiology, and Pathology ofthe Vas- Procedes pour l'Obhteration des Arteres cular System, London, 1819. 8vo. dans le traitement des Anevrysmes. Paris, 1824. 8vo. 476 ORIGIN OF Of the comparative frequency of aneurysm in the different external arteries, the following tables are given by Hodgson and by Lisfranc :— Hodgson. Lisfranc. Popliteal and Femoral 14 males. Ditto................ 1 female. Carotid.............. 2 males. Subclavian & axillary 5 " Inguinal ............12 " Total..........34 Popliteal.................... 59 Brought forward......165 Femoral, at the groin........ 26 Anterior tibial.............. 3 " other parts........ 18 Gluteal .................... 2 Carotid .................... 17 Internal iliac...........--- 2 Subclavian................. 16 Temporal................... 2 Axillary.................... 14 Internal carotid............. 1 External iliac.............. 5 Ulnar...................... 1 Brachiocephalic............ 4 Brachial.................... 3 Common iliac............... 3 Radial ............... .... 1 Palmar arch................ 1 Peroneal.................... 1 Carried forward..^___165 Total................ 179 Not unfrequently there is more than one aneurysm existing at the same time; it, therefore, becomes a matter of high importance to make a careful examination ofthe whole of a patient's body upon whom it is proposed to operate ; for if there be any internal aneurysm, it is useless to subject him to an operation from which he can derive no real benefit, as the internal aneurysm will sooner or later destroy him. Astley Cooper mentions that "the elder Cline was about to operate upon a man in St. Thomas's Hospital, who had a popliteal aneurysm, but deferred it on account of the patient's complaining of a pain in his abdomen. A few days afterwards the man died suddenly, and, on examination, an aneurysm was found between the two emulgent arteries, which had burst into the abdomen." (p. 30.) Or the excite- ment of an operation may cause the bursting of an internal aneurysm, which hap- pened with a patient upon whom Astley Cooper had commenced operating for popliteal aneurysm. " The patient stretched himself on his back, and his urine flowed from him; * * * he gave a deep gasp, and in a few minutes was dead. The next day," says Cooper, "I opened the body, and found the pericardium dis- tended with blood, which had escaped from an opening seated at the beginning of the aorta, immediately above the semilunar valves;" (p. 29.) The preparation is in the Museum at St. Thomas's Hospital. Sometimes many aneurysms are met with in the same person. Astley Cooper tied the external iliac artery for an aneurysm at the origin of the profunda, and an- other in the middle of the thigh ; the man died afterwards of aneurysm at the bifur- cation of the aorta, which burst into the belly. " Upon examination, an aneurysm was found in each ham; one at the bifurcation of the aorta, one at the origin of the arteria profunda, one in the middle ofthe thigh, and two between the popliteal aneurysm and the femoral, making in all seven aneurysms." Tyrrell, in a note upon this ease, mentions another instance in which he operated on a man who was afterwards found to have seven aneurysms." The operation was performed for a popliteal aneurysm in the left ham. " Whilst feeling in the course of the artery, before commencing the operation, I found," say& Tyrrell, "a small aneurysm near the part in which I had intended to secure the vessel; this led to a more minute examination of the patient, and at that period another aneurysm was found just above the tendon of the triceps, on the same side, making two femoral aneurysms and a popliteal on the left side. On the right side the artery felt dilated in several places, but a little below Poupart's ligament an aneurysm existed as large as an egg. After farther consultation, it was decided that I should tie the femoral artery between the two small aneurysms, as we feared that a ligature in the external iliac would not command the haemorrhage from the aneurysmal sac," (which had been punctured to ascertain its character, previously very doubtful.) The space between the two aneurysms in the femoral was about an inch, or an inch and a half, appeared sound, and a ligature was applied on it. During the following three weeks the limb be- came gangrenous, and the aneurysmal sac in the ham sloughed, exposing the thigh- bone, but amputation was not performed, for fear of the diseased condition of the artery. "The ligature did not separate from the wound until the sixth week, and the patient lingered till the 28th of July," (eight weeks and a-half after the opera- tion.) " The popliteal and inferior femoral aneurysms of the left side had been destroyed by the sloughing; that above the ligature was not closed. On the right side were found three femoral aneurysms, and a small popliteal, making in all seven; besides some dilatation ofthe aorta, immediately above the bifurcation." (pp. 38, 9.) ANEURYSM. 477 Still more remarkable is the case mentioned by Pelletan (a), who observes:—- "I have often seen numerous aneurysms affecting indifferently the large and small arteries, but specially those of size; I counted 63 in one man, from the size of a filbert to that of half a pullet's egg," (p. 1.) And in another case, related by Clo- quet (6) "all the arteries were studded with aneurysmal tumours from the size of a hempseed to that of a large pea. Some were on the. aorta and its principal divi- sions, but they projected little and were much less numerous than on the arteries of the limbs," which, " on many parts of their length, formed kinds of necklaces; all the swellings were numerous and close together. Those of the lower limbs were perhaps less numerous; without exaggeration they might be estimated at several hundreds. The arterial walls seemed unaltered in structure, except at the swellings, where the tunics were dilated and thinned. In none did I observe rupture of the inner or middle coats." (p. 86.)] 1407. The old opinion that spontaneous aneurysm almost always de- pends on an expansion of all the arterial coats, has been disputed by many writers, but most efficiently by Scarpa, and the origin of aneurysm placed in a tearing of the internal coat of the artery, effusion of blood through this tear, and expansion of the cellular sheath of the artery. The correctness of this opinion is grounded on the condition of the arterial coats in their natural state, and on the careful examination of aneurysmal arteries. For the internal and middle coats of arteries cannot, on ac- count of their slight degree of elasticity, permit any great degree of extension without tearing; whilst, on the contrary, their external or cel- lular coat is in the highest degree extensible. Examination shows that in all large aneurysms their proper sac communicates with the cavity of the artery by a large or small opening, frequently, as it were, fringed, and often hard and callous; that, therefore, the swelling never includes the whole tube of the artery, as would be the case in expansion of all the arterial coats, but is connected with the artery like an appendage fixed on a stem. Farther, that in the wall of the artery, opposite the torn part, the several coats are found in their natural condition, and can be decidedly distinguished from each other; that in spontaneous aneurysm the internal coats are usually changed in a manner {par. 1405) which, indeed, favours their tearing, but not their extension. Also, in expansion of all the coats of the artery, no collection of coagulated blood can take place, as the blood always remains within the cavity of the vessel. The reason, however, why it is so easily assumed that the sac of the aneu- rysm is formed of all the coats of the artery, is founded on the cellular tissue being always considerably thickened, and at the commencement of the tear being adherent, in the closest manner, to the internal coats of the artery, which are here always more or less disorganized, often quite brittle. Besides, also, every remark usually applied to aneurysm by expansion, is equally applicable to aneurysm by tearing. Only in the aorta, near to the heart, does Scarpa admit the possibility of simulta- neous expansion of all the arterial coats; however, even here it can only attain a certain degree, without tearing of the internal coat. [John Hunter somewhat inclines to a diseased condition of the artery; for he says:__"It would appear that there must be a specific disease of the artery in most cases, for dilatation is too local for so general a cause as the force of the heart.'* (p. 545.)] 1408. Close and careful, however, as are the observations of Scarpa, and valid as is his opinion against the often too ready assumption of an (a) Clinique Chirurgicale, vol. ii. (&) Pathologie Chirurgicale, Paris, 1831. 4ta Vol. ii—41 478 SPONTANEOUS CURE. extension of all the arterial coats in aneurysm, their truth cannot, how- ever, be admitted in every case. Examinations instituted by the closest observers, show that the arteries are subject to an expansion, not only of their whole tube, but also of particular parts (a). Scarpa himself admits the possibility of extension of all the coats in the arch of the aorta. In old persons, especially females, the expansion of the arch of thecoma without degeneration or tearing, is twice as frequent. Even the trunk of that vessel has been found throughout regularly expanded to nearly double its size {b). Enormous expansion ofthe aorta and pulmonary arteries, are a common appearance in diving animals. On examining an aneurysm in which the internal coat has been torn, and a considerable sac formed in the cellular coat, the area of the artery is often found considerably enlarged, at the place where the tear has occurred, and no other change in the inner and middle coats of the artery, than that they are expanded and thinned. The enlargement of the neighbouring branches of the arteries, if the circulation be in any way checked in the principal trunk, and the frequently considerable ex- pansion ofthe capillary vessels in the branching aneurysm, presently to be considered, contradict Scarpa's opinion. From these reasons, however, it only follows, that a simultaneous expansion of all the arterial coats is possible, but that when it attains a certain degree, tearing of the internal and middle coats occurs; consequently, a false aneurysm is pro- duced from a true aneurysm. 1409. Although the above-mentioned {par. 1372) results are the common terminations of aneurysm, and the disease, if left to itself, nearly always ends fatally, yet, however, it is capable of a spontaneous cure, which may be brought about in different ways. 1. If the aneurysmal sac attain considerable size, it may compress and obliterate the artery. This is the more rare case (1). 2. A severe inflammation which attacks the whole aneurysmal sac, and runs into suppuration or gangrene, may act so violently upon the artery itself, that its adhesion may be produced, and no bleeding occur after the bursting of the sac; but "the suppurating part closes without any trace of aneurysm. 3. A deposit of clot in layers may take place in the sac, by which its cavity may be diminished, and at last even filled up. The clot extends into the canal of the artery, and closes it to the next collateral branch, above or below the swelling (2). This kind of spontaneous cure of an- eurysm is announced by the swelling becoming solid, and by a weaker or completely stopped pulsation (c). 4. The clot contained in the sac may be converted into a solid, fleshy* steatomatous mass, by which the bursting of the sac is prevented; in which case, however, the area of the artery is preserved, and the sac gradually diminished by absorption (d). In simultaneous extension of all the coats of an artery, Spontaneous cure is im- possible, because it never arrives at the deposition of a clot (e). [(1) The obliteration of an artery by the lengthening of an aneurysm into a pouch* (a) Hodgsonj above cited, p. 74. Bres- chet, above cited. (b) Meckel, Handbuch de pathologischen Anatomie, vob ii, pt. i. p. 244. (c) Hodgson, above cited, p. 114. (d) lb., p. 118. (e) Scarpa. TREATMENT OF ANEURYSM. 479 like form, at that side of the sac most distant from the heart, is well explained by John Hunter. He says:—"Even in the last-mentioned situation, (the leg,) the force of the heart directs, in some degree, the swell of the tumour; but that is not until the sac is a good deal enlarged. The force of the blood against the most distant part of the sac endeavours to carry it on farther in the direction of the motion of the blood, which in time makes a pouch; therefore it is elongated in the direction of the sound artery. The sac often, by its increase, presses on the sound part of the artery, and becomes the cause of its obliteration, as I have seen more than once." (pp. 544, 45.) Of this kind of spontaneous cure there is a magnificent specimen in the Museum at St. Thomas's, in an aneursym of the femoral artery, jus| below the profunda, which has formed a large long sac that has descended for several inches below its communicating opening, and has completely compressed the artery, which is full of clot even into the ham. (2) There is in St. Thomas's Museum a very excellent example of a popliteal aneurysm, in course of cure by this proceeding; the clot in the aneurysmal sac is very close and solid, and through its centre is a track, less in diameter than the natural tube of the vessel, by which the blood has been conveyed to the leg, but which has been evidently fast diminishing. Ford's cases, presently to be noticed, appear to have been cured in this way. In the Museum of the College of Surgeons there is a globular axillary aneurysm, about an inch in diameter, filled with laminated clots, and the artery beyond it contracted.—j. f. s.] 1410. What has been said about the spontaneous cure of false aneu- rysm applies also to artificial assistance. For in general the cure of an aneurysm is only possible, in so far as a closing of the artery can be produced, or such a collection of the clot in the sac, as may withstand the pressure ofthe blood, and gradually contracts; the artery, however, remaining pervious. 1411. After the obliteration ofthe trunk of the vessel the circulation is carried on in the limb, by the collateral branches, which enlarge con- siderably, and are connected with each other by numberless anastomoses. In many cases a more direct and manifest anastomosis of the vessels take place, so that after the closure of the principal trunk, the stream of blood at once passes by the neighbouring branches ; in other cases, the colla- teral circulation is only undertaken by small numberless anastomoses (a.) Upon the different ways in which the collateral circulation is produced, and partly also on the point of time when the vessel is examined, after the obliteration of the principal trunk, may depend whether the collateral branches appear more or less, or even not at all, enlarged. The frequent examinations, in which, after the obliteration of the principal trunk of an artery, the other arteries of the limb are found considerably enlarged, do not therefore contradict the equally true observations, in which this enlargement is not found (b). 1412. The remedies which have been proposed, generally, for the treatment of aneurysm, are, rest and antiphlogistic treatment, the applica- tion of cold and contracting remedies to the swelling, the compression, and tying of the aneurysmatic artery. 1413. Strict rest, lowering treatment, restricted diet, repeated blood- letting, even to the greatest degree of weakening, (Valsalva's plan,) and the internal use of digitalis, are the only modes of treatment by which the cure of internal aneurysm may perhaps be effected; in which indeed, under great diminution of the circulating power, the blood coa- (a) Hodgson, above cited, p. 235. (b) Fressling, Dissert, de sistendis hcB- Heilardes Kropfes, u. s, w. Sulzbach, 1817. morrhagiis. Groen., 1804. Walther, Neue p. 65. 480 TREATMENT OF ANEURYSM. gulates in the sac, and the aperture, whereby the sac communicates with the artery, is closed. In certain cases the area of the artery may be at the same time preserved, {par. 1409,) but in others the coagula- tion ofthe blood extends into the artery, and shuts it up. In true aneu- rism, a diminution and contraction of the walls of the artery may thus be effected. 1414. The astringent remedies employed for the purpose of restoring their elasticity to the arterial coats, or for effecting the complete coagula- tion of the blood in the sac, are, applications of cold water, pounded ice (1), bark, oak bark, and so on. If this mode of treatment, which was formerly employed, have in many cases a satisfactory result, it may be in part ascribed to the compression generally at the same time em- ployed with it, and more especially to keeping the patient at rest. Per- haps,'however, all share in the business must not be denied to these topical applications, as they are capable of favouring the coagulation of blood in the sac, and in this way promoting the cure (a). [(Guerin, of Bordeaux, appears to have first proposed the application of pounded ice, or iced water, to the aneurysmal sac (£); and though its beneficial use was much doubted, yet Richerand says, that "subsequent observations have proved the advantage of pounded ice in the treatment of aneurysm. The examinations of the bodies of persons cured in this way, have dissipated all doubts as to the value of this'remedy, and he mentions a case reported in the Bulletin de la Faculte de Mede- cine de Paris, No. 4, 1812, in which a popliteal aneurysm was thus cured. The patient lived a considerable time after the disappearance of the tumour, and the pre- paration is now in the Museum of the School of Medicine. On the contrary, Hodgson says :—" I have seen ice applied to a large inguinal aneurism, but it pro- duced such excruciating pain that its employment was from necessity discontinued." (p. 163.)] 1415. Compression and Ligature of the aneurysmatic arteries are the two modes of treatment which especially apply to the cure of external aneurysms. They agree with each other in effecting the obliteration of the artery ; this takes place slowly by compression, in which case the circulation is gradually restored by the collateral branches, but occurs quickly on tying the artery. Only in a spurious aneurysm, which arises from a wound in an artery, and has not long existed, can a cure by com- pression be effected, without subsequent closure ofthe artery, as has been already granted in wounds of arteries, under certain circumstances {par. 279). 1416. Compression has been employed upon the aneurysmal swelling, above it, and as a swathing ofthe whole limb. Proper apparatus or band- ages have been used for the purpose. 1417. Compression of the swelling alone, is on many grounds ob- jectionable. It is difficult or impossible, on account ofthe depth ofthe artery, and the different size of the swelling, always to employ the com- pression properly, and in the same direction ; the aneurysmal sac may be developed in another direction, and if the compression be made suf- ficiently great, severe pain, inflammation, and bursting of the sac, may be caused. Nor is it certain whether the pressure operates upon that part of the artery above the opening, by which the sac communicates (a) Radeloose, H., Dissert, sur l'emploi (b) Recueil Periodique de la Societe de des refrijjerans dans les Anevrismes externes. Sante, a Paris, No. 3. Paris, 1810. TREATMENT OF ANUERYSM. 481 with the artery, or upon the part below this opening, in which latter case the speedy bursting of the artery may be produced. 1418. Compression of the artery is to be made at that part above the aneurysmal swelling, where the artery is superficial and the surrounding parts afford a proper point of support for the compression; in doing this, however, care must be taken to avoid the collateral vessels above the swelling, especially the larger ones. All the contrivances by which this compression is effected, must be so managed that they compress the limb only on two sides, because otherwise they would check the circulation too much (par. 285.) The compression must be gradually increased, with the greatest care, and so long continued till the obliteration of the artery is effected. This compression is often unbearable, when, for ex- ample, the artery is accompanied by the principal vein of the limb, or by considerable nerves. The femoral artery in its upper third, and the brachial artery, throughout its whole length, bear compression best. The position of the 'median nerve, however, close to the brachial artery, renders this less fitting, and the compression is painful. It is therefore especially applicable only to the femoral artery {a). Here also may be mentioned alternate compression with several tourniquets at different parts. Hutton and Cusack (b) have communicated cases of successful result from com-. pression ofthe femoral artery in aneurysm ofthe popliteal artery, in which the com- pression was employed only for some hours, and repeated every day or at longer intervals. 1419. The compression of the whole limb, by proper bandaging, in which, by the application of graduated compresses along the course of the artery, increased pressure is made, is not usually accompanied with incon- venience to the patient; the cedematous swelling disappears, and the cure may be effected by this simple remedy. The event of the cure in these cases appears always to be the complete coagulation ofthe blood in the aneurysmal sac, depending on the arrest ofthe circulation throughout the. whole limb. [The unsatisfactory results of the treatment of aneurysm by tying the. affected) artery above and below the sac, opening and emptying the latter, either before or. after the ligature, and then inducing it to fill up by granulation, as also the dangers of amputation, led Guattani (c) to consider the possibility of some other proceeding, for the management of "a disease, so evidently incurable, that both medicine and surgery renounced all kind of treatment." He had, however, observed several cases spontaneously cured, in patients who would not submit to either of these operations, and he hoped to succeed by a somewhat similar process. " Many indeed," says he, " were the trials and dangers depending on the varieties of aneurysm, some of which differed from others in their nature; nor did all arise from one and the same spot. But when I especially inquired into those aneurysms which occurred at joints, I was led to suspect that by rest in bed and weakening the whole body, at the same time also restraining the flow of blood in the artery running to the affected part, and finally by gradually compressing the aneurysmal tumour itself by the aid of bandages, \ might be able not only to prevent its increase, but that in course, of time the gru- mous blood would, by little and little, of itself be changed into serum, and rendered fit for circulation, and that the entire resolution of the tumour would at length take! place. A methodical bandaging, which should from day to day more and more compress the affected part, seemed to me the only means which could fulfil all the (a) Guillier Latouche, C. H, Nouvelle (b) Dublin Journal of Medical Science, maniere d'exercer la Compression mediate vol. xxiii., 1843, p. 364. prolonged sur les principales Arteres des (c) Quoted at head of Article in Lautii's Membres Strasbourg, 1825. 4 to. Collect io. 482 TREATMENT OF ANEURYSM indications ; but as in doing this many hindrances occurred to me which seemed ad- verse to a happy result, I continued in doubt, whether I should entirely give it up, or whether at some future time I should be induced to practise it." (p. 129.) In this frame of mind he continued till 1757, when a case of aneurysm ofthe upper part of the femoral artery having occurred, he employed simple bandaging, which to a certain degree controlled the growth of the swelling. But the patient would not submit to the necessary rest, and left Guattani for another surgeon, who tied the artery, and, probably opening the sac at the same time, bound it up very tightly, and the man died of mortification ofthe limb on the third or fourth day. As this could not be considered a satisfactory trial of his plan, he determined on trying it in another ease, a spurious aneurysm, as he calls it, of the popliteal artery, and of which he commenced the treatment in November, 1765, according to the following manner:— "Having for some days previously," says he, "applied lint dipped in vinegar and water, I covered the whole mass of the tumour with lint, and then applied two ob- long pillows across each other, like the letter X, upon the centre of the swelling, in such a way that the upper ends of both embraced the knee above and the lower below; another oblong pillow, wetted with vinegar and water, was then applied along the whole length ofthe femoral artery to the groin, and moistened all the lint surrounding the knee and covering the whole extent of the thigh. I then employed a strong long bandage, three inches wide and no more, and having made the first turn upon the centre of the swelling carried it around both above and below, in the usual way of bandaging the joint, and wound it round sufficiently to cover and com- press it equally. In the same way I bound the whole length of the thigh up to the groin, and in order to render it more secure, made a couple of turns round the trunk, and so completed the bandaging. I took special care that the first turn ofthe roller should not too much constringe the part, and was very cautious that the pressure should be equally kept up, so that every turn of the bandage covered the preceding one rather more than half its breadth; which indeed, in every surgical operation where this indication presents, should always be done." (p. 131.) Bloodletting, low diet, complete rest of the joint, and the application of spirits of wine, were ordered. " I left the bandage undisturbed," he continues, " as long as it performed its duty. If properly applied, it would remain, for eighteen or twenty days. * * * In re-applying I always took care it should be put on somewhat tighter. I also directed moderate blood letting, especially when either the leg or foot swelled in the least, which prevented the renewal ofthe bandage if by chance it became tighter than the patient could bear. Subsequently the lint and pillows were moistened with vinegar and water, that I might prevent too much heat of skin, which coming on might have delayed not a little the cure. By patient and assiduous use of this treat- ment I was delighted to find that the swelling, although it constantly preserved its hardness and pulsation, daily decreased more and more; so that, indeed, after three months, I had the great pleasure of seeing the patient leave the hospital perfectly cured. Nothing remained of it at the place of the torn artery but a callosity, scarcely the size of a large bean." (p. 132.) Such was the treatment Guattani adopted and continued to practise with success, and upon it has been founded the practice of others at a subsequent period. John Hunter tried compression in one of his cases, but the patient could not bear it, and he was obliged to tie the artery. In the beginning of 1802, Blizard (afterwards Sir William) attempted compres- sion of the femoral artery in a case of popliteal aneurysm, with the hope of effecting obliteration, in the following manner: (a)—"The points of support for the instru- ment were the outer part of the knee and the great troclianter, a piece of steel passing from the one to the other: and to the middle of this a semi-circular piece of iron was fixed, which projected over the femoral artery, having a pad at its end moved by a screw, by turning which, the artery was readily compressed, and the pulsation in the aneurysm stopped, without any interruption to the circulation in the smaller vessels.. But although the patient possessed unusual fortitude of mind, and indifn ference to pain, he was incapable of supporting the pressure of the instrument longer than nine hours; and when it was loosened, the pulsation in the tumour returned with unabated force. After a fair trial of this plan the man. quitted the London (a) From a paper of Astlev Cooper's on Aneurism, in Med. andPhys- Journ., voL viii. p. 2,1802. BY COMPRESSION. 483 Hospital; and his femoral artery was tied by Astley Cooper in the following April, in the then usual way, with two ligatures and division of the artery between. He did well. In 1807, Freer, of Birmingham (a), having witnessed two cases in which Guattani's treatment had been adopted, " does not hesitate to recommend the cure of aneurism to be attempted, in the first instance, by pressure, rather than by an operation, which frequently occasions death, even when the patient might have recovered, if left to nature alone." Compression may be applied either on the aneurismal tumour itself, or upon the sound artery above it. In those cases, where pressure has been hitherto applied, it has been upon the tumour itself; and though this mode of application has frequently been attended with success, it is by no means so likely to answer the intention of uniting the sides of the vessels, as when used on the sound part of the artery. From the result of those experiments I made upon the radial artery of a horse, I should recommend the pressure to be applied on the extremities, either by the assistance of Senffio's instrument, or in the following manner:—First, place a bandage moderately tight from one extremity of the limb to the other, then place a pad upon the artery a few inches above the tumour, that you may have a greater probability of its being in a sound state; then, with a common tourniquet surrounding the limb, let the screw be fixed upon the pad, having pre- viously secured the whole limb from the action of the instrument, by a piece of board wider than the limb itself, by which means the artery only will be compressed when the screw is tightened; the tourniquet should then be twisted till the pulsation in the tumour ceases. In a few hours, as by experiment in the horse, the limb will become cedematous and swelled ; the tourniquet may then be removed, and no stronger pressure will be required than can easily be made with the pad and roller. The irritation produced by this mode of pressure, excites that degree of inflammation of the artery which deposits coagulable lymph in the coats of the vessel, thickens them, diminishes the cavity and eventually obstructs the passage ofthe blood." (p. 112, 113.) Hodgson mentions two cases in which this mode of treatment was adopted: in the one, a popliteal aneurysm, the pressure could not be supported longer than two hours, and in the other, where " it was applied to the brachial artery, the pain and swelling of the limb was so considerable that the surgeon was compelled to abandon the practice." (p. 177.) Richerand (b) observes, that if " the compression be made above the aneurysm, the compressed artery must be superficial, and have a solid point d'appui in a neigh- bouring bone. The compression also must not operate on the whole circumference of the limb; if spread over too large a surface, it will be too weak to press down the walls ofthe vessel; it will uselessly cause severe pains, produce swelling of the limb, by opposing the return ofthe lymph and venous blood ; and it will hinder the passage of the blood through the collateral vessels, and consequently tend to produce want of nourishment, and gangrene of the limb, by obliterating all its vessels, on which account circular compression is to be entirely discarded in cases of aneurysm. * * * A tourniquet, or any analogous instrument, should be used, which will make a strong pressure on a particular part of the artery, and at a part directly opposite; whilst the limb remains free from all compression at any other part of its circumference." In illustration of this method, he mentions a case of popliteal aneurysm, in which, for a whole year, complete quiet, lying in bed, low diet, bleeding every month, and pressure, where the artery passed through the tendon ofthe m. triceps femoris,-were employed. "The compression was effected by a semicircular steel spring, like that of a rupture truss; a screw, with a pad at its end, graduated the pressure on the vessel at will. The pain at first prevented its constant application; but, by gradually accustoming himself to it, and increasing the force, he succeeded in weakening, and then in preventing the pulsations of the swelling, which became adherent hardened, and reduced to a little tubercle, formed doubtless by the coagu- lated blo'od, and adherent to the inside of the aneurysmal sac. The practice of Professor Dubois presents many instances of success by the same means." (pp. 95, 96.) Compression for the cure of aneurysm, has, however, been little thought of, or employed in this country, till within the last four years, when it was revived by (a) Quoted at head of Article. (b) Nosographie Chirurgicale, vol. iv. 484 TREATMENT OF ANEURYSM Hutton, of Dublin (a), for a case of popliteal aneurysm, as large as a hen's egg, as the patient would not submit to the operation of tying the femoral artery. " For three or four weeks he maintained the horizontal posture, and a compress and band- ages were applied; but, as the tumour gradually increased in size, and as he suffered pain from the pressure, this treatment was discontinued. On the 1st Nov. 1842, Hutton, therefore applied an instrument, " so contrived as to admit of pressure being made by a screw and pad upon the course of the femoral artery, and the coun- ter-pressure upon the opposite surface of the limb, without interfering with the col- lateral circulation. In the first instance, the compression was made upon the femoral artery in the middle third ofthe thigh; and, although it was effectual in compressing this vessel, it produced so much uneasiness that it could not be sustained, and, after a few applications, the apparatus was removed, and adapted to the upper part of the limb. Nov. 12. The femoral artery was compressed as it passes from the pelvis under Poupart's ligament, and the pressure maintained for more than four hours. Nov. 14. The tumour feels rather more solid; the purring thrill before felt, on the re-entrance of the blood into the sac, is no longer sensible; the pulsation as before. Nov. 22. Duration of compression three hours; the pulsation returned after its removal. Nov. 24. Artery compressed six hours ; same result. He could not bear pressure next day for soreness in the groin; and he had some pain in the tumour. Nov. 26. The compression resumed, and continued for four hours; when the instru- ment was removed, the pulsation had ceased in the tumour, which felt solid, and was free from pain. Nov. 27. The pulsation had in a slight degree returned ; com- pression for six hours. Nov. 28. No pulsation was now felt in the tumour. It had decreased in size, and was solid. Nov. 29. The compression was maintained for six hours; no pulsation felt; compression applied three hours. Dec. 1. An artery, about the size ofthe temporal, is felt pulsating along the surface of the tumour, which is quite solid, much diminished in size, and is altogether free from pulsation. The use ofthe instrument was now discontinued. Dec. 27. The tumour reduced to the size of a small walnut, and very hard. He was this day discharged at his own request." (pp. 364, 365.) Very soon after the termination of this case, Cusack treated a popliteal aneurysm in the same way, beginning first with a bandage over the whole limb, to which subsequently was added a compress on the aneurysmal sac ; this was continued for a month, but without effect. " Feb. 22. Huttox applied his instrument, the pad being screwed down on the femoral artery at as high a point as possible, and with a force sufficient to stop completely the pulsations in the tumour; a compress was then laid over the aneurism, and secured by a flannel bandage, beginning at the toes. He soon began to feel uneasy; but when it had been on for one hour and a half, his face became pale, his pulse weak and slow, and he complained of faintness, with a feeling of weight in the situation ofthe pad, run- ning up to his heart, and a sensation of a rush of blood to his head, accompanied by profuse perspiration on the forehead and vertex; the instrument was now loosened, and he soon rallied. When quite recovered, the pad was again screwed down; but he could not bear it for more than half an hour at a time." The apparatus was con- tinued for five days, the patient screwing down the pad as he could bear it; but no benefit having been gained, it was put aside, and a bandage applied. From the 22d January to the 4th of March, he had been taking ten drops of tincture of digitalis thrice a day; but it was then increased to fifteen drops, which was continued a fort- night longer, and then left off entirely. " March 16; Sir P. Crampton's instrument, modified by Mr. Daly, was put on so as merely to lessen the impulse in the aneurism ; no compress or bandage was put on the tumour. March 18. Bears this instrument much better than the last; has none ofthe unpleasant rush to the head. * * * No change in the tumour. March 22. The tumour is decidedly harder and smaller, the impulse being greatly lessened. At times there is only a thrill in the aneurism ; sometimes there is no motion whatever in the tumour, even when the pressure is removed, but it returns on the slightest movement of the body. March 23. Pulsation has totally ceased ; the tumour is very hard, and about the size of a large walnut; a large artery can be felt running down superficial to the aneurism, over which it can be easily rolled with the finger; it then divides into two branches; the articular vessels do not appear enlarged. March 25. The instrument was removed (a) Dublin Journal of Medical Science, vol. xxiii. 1843. BY COMPRESSION. 485 to-day. The femoral artery can be distinctly traced as far as the opening in the tendons of the triceps and vastus internus. April 1. The tumour is decreasing; the enlarged artery above mentioned is much smaller than at the last report. April 7. Tumour continues to decrease; the entire artery can be traced until it enters the aneurism; but in the lower third of the thigh, and in the ham, the pulsation is so weak that it can only be felt on a careful examination. April 14. The enlarged artery has become very small, while the popliteal artery of the affected limb now pulsates as strongly as that of the sound one; a number of hard cords can be felt passing over the tumour." (pp. 367, 368.) In the spring of the same year (1843) Bellingham (a) treated a case of secondary aneurysm of the right external iliac artery, which had been tied by him a twelvemonth before, and though the sac had suppurated and filled by granulation, reappeared on the 1st of April. He was kept perfectly at rest in the horizontal posture, from the 3d of that month to May 11, five or six ounces of blood twice taken from the arm, and tartar emetic and digitalis given. About ten days after his admission, the integuments became a little dis- coloured. No farther change, however, occurred: and, on May 11, pressure on the distal side ofthe tumour was made, by means ofthe instrument for compressing the femoral artery in popliteal aneurysm, was commenced; but it appeared rather to increase the pulsation in the tumour." The pressure was continued at intervals, and on the next day the pad was applied to the artery at the origin of the profunda. The pressure was kept up the following three days, but discontinued at night; the tumour was smaller, and its pulsation diminished, but after a few days became more perceptible, and the apparatus was therefore left off." Some days subsequently, pressure was applied directly upon the tumour, by means of a compress, adhesive plaster, and bandage tightly round the body." After some days the tumour had diminished in size, and became more flat; the pressure gave no uneasiness, and was continued till the beginning of July, and on the 20th of that month, "some remains of the tumour could still be detected by pressure over its side, but no pulsation or bruit of any kind could be heard ; neither can any pulsation be felt in the femoral artery, from Poupart's ligament downwards. Aug. 17. No tumour can now be felt; there is merely a little hardness in the situation of the former swelling." (p. 243-6.) In 1844, in another case, which was a femoral aneurysm in a man, who, fifteen months previously, had had popliteal aneurysm of the other limb cured by pressure, Bellingham, after one bleeding from the arm, and fifteen drops of tincture of digitalis for five days, applied the same kind of instrument as that which had cured the disease in, the other limb, at the groin, relaxing it at intervals when t;he pressure became painful. On the third day the instrument, having got out of order, required removal, and was temporarily replaced by a tourniquet pad at the groin, upon which a four-pound weight was placed, and this, with a slight pressure ofthe patient's hand, stopped the pulsation. On the following day a seven-pound weight was substituted, the tumour was somewhat more firm, and rather diminished in size; but the pulsation was still very strong when the pressure was removed. Ice was applied a day or two after to relieve the heat felt, in the evening. On the eighth, a bandage was applied round the limb, from the toes over the tumour, and partly up the thigh, and the original pressure apparatus again put on; but on the twelfth day the weight was resumed, as the patient preferred it. On the nineteenth day, the pressure having been kept up steadily, except at night, whilst he sleeps, "the tumour is evidently more firm, and smaller; the patient suffers no pain when it is pressed or handled, and has lost the uneasy feeling about the limb. To-day an instrument, in form of a carpenter's clamp, was applied, the pad of which was fixed upon the artery in the upper third of the thigh, and he retained it on for several hours. However, as it compressed the femoral vein also, the limb swelled, and he was obliged to remove it towards evening." The pressure was continued on the same principle, but with an improved instrument for the following seventeen days, but the tumour continued stationary. On the thirty-sixth day a second similar instrument, "but with a larger arc, so as to permit the pad being placed over the artery in the groin, was applied, and the patient directed to use it alternately with the other upon separate portions of the vessel; and, when the pressure became painful- at one point, to tighten the screw of the other, and then relax it. About three in the afternoon, he fixed the pad of one instrument on the femoral artery, where it (a) Dublin Journal, vol. xxvi. 1845. 486 TREATMENT OF ANEURYSM passes over the horizontal ramus pubis, and the second on the femoral artery lower down, and continued the pressure nearly constantly up to twelve o'clock at night, when, on relaxing the screw, he found that the pulsation of the aneurism had ceased. He, however, persevered in the use of the instruments throughout the night." On the forty-second day, the pulsation had entirely ceased; " a vessel of some size was now, for the first time, felt, which ran superficially in the course of the femoral artery, and had evidently become enlarged since the filling up of the sac of the aneurism. The patient says that last night, about twelve o'clock, when he loosened the screw of the instrument, the aneurism no longer pulsated, from which time he suffered much pain, both in the tumour and about the knee." These symptoms, however, subsided on the following day, when, " in addition to the superficial artery already mentioned in the course of the femoral, the articular arteries about the knee were found enlarged, one of which, on the inside, is nearly as large as the radial artery." On the fifty-seventh day "the tumour was about the size and shape of a small hen's egg, very firm and solid. The pulsation in the femoral artery can be traced from the groin to within a short distance of the obliterated sac of the aneu- rism." (pp. 248-54.) Such are the results of the first three cases, in which aneurysm has been treated by compression by the Irish Surgeons, and Bellingham has enumerated (a) nine other cases in which it has been employed, three of which have been managed in England by Liston, Allan, and GreatRex, and the rest in Ireland, and all cured. Thus Crampton's assertion (b), that " intermediate compression, or compression from without (maintained for a sufficient length of time to allow the blood in the aneurismal sac to coagulate) had been tried and was found ineffectual," (p. 359,) is proved to have been so only on account ofthe inefficient mode of the application of external pressure. From this account, although I have yet had no opportunity of practising this treatment, I must confess I think it highly worthy of serious atten- tion, and am much disposed to think I should try it on a fitting occasion. Belling- ham very justly observes, upon the advantage of alternating pressure upon the artery, that " the principal improvement which has taken place in the treatment of aneurism by compression, consists in the mode of applying the pressure; that is, instead of em- ploying a single instrument, we employ two or three, if necessary; these are placed on the artery leading to the aneurismal sac; and, when the pressure of one becomes painful, it is relaxed, the other having been previously tightened, and, by thus alter- nating the pressure, we can keep up continued compression for any length of time. By this means the principal obstacle in the way of the employment of pressure has been removed ; the patient can apply it with comparatively little inconvenience to himself; time will not be lost owing to the parts becoming painful or excoriated from the pressure of the pad of the instrument; and, as the pressure need not be inter- rupted for any length of time, the duration ofthe treatment will be necessarily con- siderably abridged." (p. 167.) With regard to the treatment ofthe artery which has been thus treated, Bellingham says :—"It will be observed, from the histories of the cases which have been published, that the femoral artery could be traeed, after the cure, to near the sac ofthe aneurism, proving that the artery is never obliterated at the point compressed." (p. 165.) This is a very interesting circumstance, and supports John Hunter's opinion, that "the force of the circulation being taken off from the aneurismal sac, the progress of the disease would be stopped."] 1420. As regards the more precise determination of making use of pressure for the cure of aneurysm, it is advised by many to employ it in all aneurysms, so that even if no cure take place, a progressive expan- sion ofthe collateral branches may be effected. It may be employed if the aneurysm be still recent, if it be not large, especially when the conse- quence of an external injury ; if there be no circumstances which render a speedy cure necessary; if the patient be not very stout, the limb not very much swollen, and the artery so situated, that its walls can be pro- perly brought together by compression. Where beneficial, it soon shows; the experiment of compression is, therefore, never to be persisted in too long, and it should be left off as soon as circumstances occur which may (a) Med.-Chir. Trans., vol. vii. (6) Dublin Journal, vol. xxvii. 1845. BY COMPRESSION. 487 render it dangerous. It is always proper to accompany the pressure with rest, blood-letting, cold applications to the swelling, and the inter- nal use of digitalis, and so on. Samuel Cooper (a) believes, that compression is successful only in about one out of thirty cases, and that a certain number of the successful cases must doubtless be considered rather as spontaneous cures of aneurysm. 1421. Tying the aneurysmal artery (the Operation, for aneurysm) is the most certain mode of treatment; and there are two modes in which it is performed. The one, laid down in the ancient Greek Surgery, by Phil- agrius and Antyllus, which consists in opening the aneurysmal sac3 removing the coagulated blood, and tying the artery above and below it; the other, where the artery is laid bare and tied above the swelling, be- tween it and the heart, upon which the swelling diminishes and disap- pears (1). (1) This mode of operation is usually called the Hunterian. Although it had been previouly practised by Anel (b) and Desault (c),it was,however, first raised to a systematic operation by Hunter (2). In former times, indeed, tying the bra- chial artery above the aneurysmal sac was performed by Aetius, Paulus, ^Egineta, Guillemeau, and Thevenin; subsequently, however, even the sac itself was opened. [(2) The operation of tying the artery at a distance from the aneurysmal sac, and where its coats are healthy, has been justly claimed by English Surgeons, for John Hunter, notwithstanding that till within a few years our French neighbours have laboriously endeavoured to show that it was merely a repetition of the operation per- formed by their countryman Anel, at Rome, in January, 1710, and subsequently by Desault, in June, 1785. Honourable exception to this nationality is offered by Deschamps' able vindication (d) of Hunter's originality in reference to his opera- tion ; and within the last few years his title to it has been almost universally con- ceded. The circumstances, however, are so interesting in reference to this opera- tion and its importance so great, that a short notice of the operations of Anel and of Desault cannot be here misplaced. Anel's operation was performed on the brachial artery of a friar which had been wounded in venesection, but which did not bleed till the fifteenth day after the in- jury, when it was checked by the use of astringents and bandage. Anel's account ofthe disease is exceedingly confused and probably he did not very well understand its true nature, for, he says :—" From the day of venesection to that of the opera- tion, we see that three kinds of aneurysm have occurred in the same artery of the same arm," a true aneurysm, a false one, and a true one again, upon which last he operated. It is probable, however, that during the whole course of the disease it was none other than the ordinary spurious aneurysm following a wound in an artery, which John Hunter (e) observes, "will produce various effects according to the treatment, all of which are called so may aneurisms: but I do not consider a wound in an artery, an aneurism, even if in an aneurism itself." (p. 543.) Anel thus de- scribes the operation performed on the 30th January, 1710:—" Having made my- self master ofthe blood by means of a tourniquet, I made an incision in the integu- ments without touching, in any way, the anuerismal sac; I then sought for the artery, which I found situated below the nerve, which is notcommon. I took every precaution in separating it from this, and having lifted it upon a hook, I ligatured it as near to the tumour as possible. The artery having been tied I loosened the tourni- (a) First Lines of Surgery. London, 1819. cipales Arteres des Extremites,a la suite de vol. i. p. 304. leurs blessures, et dans les Anevrismes, par- (6) Suite de la nouvelle Methode de guerir ticulierement dans celui de l'Artere poplitee, la Fistule lachrymale. Turin, 1714, p. 257. dont deux ont ete operees, suivant la meth- I have copied this account from Eiuchsen's ode de Jean Hunter, Chirurgien anglois. Observations, as the copy of Anel, which I Paris, 1793; and at end of his Traite histo- liave by me, does not contain this notice.— rique et dogmatique de I'Operation de la j.f. s. 'faille, vol. iv. Paris, 1796-97. (c) CEuvres chirurgicales, vol, ii. pt. iv. (e) Lectures on the Principles of Surgery; (d) Observations sur la Ligature des prin- in his Works, edited by Palmer. 488 TREATMENT OF ANEURYSM quet, when a small muscular branch, which I had divided in dissecting the vessel, bled and compelled me immediately to tighten the tourniquet and to tie the artery again a little hio-her up; the tourniquet being loosened, I saw no more bleeding nor any pulsation in the tumour. I then applied the proper dressings and a bandage." (p. 220.) On the following day pulsation of the artery at the wrist was very dis- tinct. "The first ligature separated on the 17th day of February, 1710; and the second on the 27th ofthe same month ; without the supervention of the least hemor- rhage, on the 1st of March in the same year, this friar not only left his room, but went even to church. * * * ' On the 5th of March the wound was perfectly cicatrized." (p. 221.) In his reflections on the case, Anel observes:—" With re- gard to the mode of doing the operation, I performed it in a different way to what authors describe, which I have seen good surgeons adopt, and which I have myself had recourse to several limes; for instead, as is customary, of applying the ligature above and below the aneurism, I only practised it above. Besides, the aneurismal sac is usual opened, but I did not touch it at all; not doubting but that the blood con- tained in it would be dissipated, being at liberty to pass on towards the extremity; that the sac, being once empty, would not fill again; that the layers of membrane that formed it would not fail to collapse; and that thus the tumour would disappear, all which happened as I thought. In this way the operation was less tedious, and much less painful; besides, my incision was not half the usual length, hence there was a smaller cicatrix." (p. 223.) The tumour collapsed in such a way that it would have been impossible to have ascertained the spot where the aneurism ex- isted." (p. 222.) Desault's operation, as stated by Sabatier (a), was performed in June, 1785, upon a popliteal aneurysm which "had acquired the size of a turkey-hen's egg; the patient was thirty years of age. * * "* Desault made an incision about two inches in length at the upper part of the tumour, laid the artery bare, separated it from the nerve and tied it. * * * On the sixth day he tied a ligature of reserve, that he had placed under the artery above the first one. The state of the wound and of the patient was such as to promise a speedy cure." The tumour diminished to half its size and the ligature came away on the eighteenth day. " On the following day the wound discharged a tolerable large quantity of matter mixed with blood, and the tumour disappeared almost entirely; an evident sign of the rupture of the aneurismal sac. After this nothing was left but a fistulous opening which healed in a few days." (p. 403.) Erichsen (b) observes:—" From the following remark by Maunoir it would ap- pear that little importance was attached to the operation at the time even by Desault himself. 'I lived,' says Maunoir, 'two years with Desault,and I do not remem- ber to have ever heard him speak of this operation. It had not been considered of consequence; and in general, it seemed to me, that it was quoted without being un- derstood and after very vague reports.' " (p. 403.) Desault's operation was also performed by Pott after Hunter had performed his new operation, in a case of femoral aneurysm of which E. Home gives a brief and not very clear account in the paper presently to be cited from; it did not, how- ever, succeed, and amputation became necessary, at what period, however, Home does not state. I have heard it mentioned that John Hunter was indebted to Ford, for the sug- gestion at least, if no more, of his mode of operating in cases of aneurysm. It is not at all improbable that Hunter's mind may have been led to the operation he afterwards practised, from his reflection on the two cases of Ford's, presently to be mentioned; but this appears to be all Ford had to do with the matter, as it is very unlikely he should not have taken notice of the subject, had he any claim to it, in the paper (c) he published between two and three years after Hunter's first opera- tion; and, in fact, he utterly discourages any kind of operation. He says:—"An aneurism ofthe larger vessels, when it. occurs in the trunk ofthe body, is a disease that is usually fatal, and it is not uncommonly so when it happens in the extremities; the mode of cure in the latter case, whether by amputation of the limb or by tying the artery being universally allowed to be hazardous. * * * The cases I now com- municate to you serve to establish the fact, that in cases of aneurysm the efforts of (a) Medecine Operato re. Paris, 1796. eurism, with remarks; in London Medical (b) Cited at head of article. Journal, vol. ix. 1788. (c) Cases ofthe Spontaneous Cure of An- BY LIGATURE. 439 nature alone, unassisted by art, have produced in the coats of the vessel a coa- lescence of its sides, firm enough to render the artery impervious to the impetus of the blood, whilst the circulation in the extremity has been amply supported by the col- lateral branches going off above the aneurysmal tumour." (pp. 142, 43.) The first case he met with, several years previous to publishing his paper, was a popliteal aneurysm in a chairman " He was admitted into an hospital, and at the end of three months, when he called upon me," (again,) says Ford, " I found that the tumour had totally disappeared, and that the limb was wasted, and a little weaker than the other, but that he was capable of doing his business. Upon inquiry, I could not learn that the cure could be ascribed to any other means than to the efforts of nature, with which an horizontal position of the body, and a regular diet, might perhaps have co-operated. This man died soon after of a fever, and as the limb was not ex- amined by dissection, and a doubt arose whether the tumour was aneurysmal or not, the circumstances of the case were not deemed strong enough to justify any infe- rence to be made from it." (pp. 143, 44.) The next case was that of a clothes- presser thirty-six years of age, who had "a tumour situated on the anterior and up- per part of the right thigh, about three inches below Poupart's ligament. It was of the size of a turkey's egg, and had a strong pulsation." He had also, " at the same time, a swelling about the size of a pullet's egg in the ham of the other leg, in which was felt a tremulous pulsation." (p. 144.) Two months after, the swell- ing in the right thigh had considerably increased; and from the irritation, probably dependent on a mustard poultice having been applied, and a cordial regimen directed by an empiric to promote suppuration, he had a very severe attack of fever, which, however, by proper treatment was relieved. No operation was proposed for fear of mortification and fatal haemorrhage. " We now examined the other leg," says Ford, " but found no traces left of the swelling I had formerly seen." Six weeks after he died with gangrene of the right thigh, without haemorrhage. On examination of the left ham, " externally there was no mark left ofthe tumour; but upon cuttino- down to the vessel, we found the popliteal artery enlarged to the size of a small hazel nut. On opening the artery, both above and below this tumour, and endea- vouring to pass a director and a probe, it was found to be quite impervious to the in- struments, although some force was used; and upon farther examination, it was found plugged up by a substance of a hard and firm consistence." (p. 148.) The last case was a femoral aneurysm, seen by Ford in September, 1785, when it "was about the size of a middle-sized China orange, and obviously increasing. The si- tuation of it was so high up as to admit of no hope of preserving his life by removing the limb, or by tying up the artery. It was, therefore, only recommended to him to lie in bed, to keep his bowels open by gentle laxatives, and to live upon a very spare diet." (p. 149.) Among the professional people who saw this man, and by whose concurrence compression at the groin was made, but could not be persevered in on account of the severity of the pain. Hunter is mentioned; but this case could not have encouraged or induced him to perform his new operation, because "for four months (from September) those symptoms continued to prevail which usually precede a fatal termination," and it was only " at the end of six months that the man began to think the pulsation was not so strong in the swelling, and that it had ceased to increase. * * * In the month of March, (three months after Hunter had operated on his patient,) the circumference of the tumour was much lessened, and the pain had ceased; the tension was also diminished, the inflammation of the skin had given way, and was now become scabious, putting on a mottled look, and appearing in some parts brown, and in others of an orange colour, (pp. 150, 51.) For two months afterwards the tumour continued to lessen. * * * He was sent into the country, where he soon recovered his strength and the use of his limbs so much, that in three months he was able to walk several miles with a stick." After the lapse of two years, he was fully recovered ; but " the thigh was two inches and a half in circum- ference larger than the other, and there was a hard incompressibla»tumour where the aneurism was, but which gave him no uneasiness." (pp. 151, 52.) From this ac- count, it is quite clear that the second is the only case which could at all have at- tracted the attention of such a mind as that of Hunter, and lead to the proposal of his operation; but neither of the three seems to have impressed Ford beyond the importance of quiet, and its adequacy to effect the natural cure of the disease; and from his review of these, as well as of the cases recited by Guattani, he infers— "1st. That nature is capable of effecting the cure of many aneurisms solely by her Vol. II.—42 490 TREATMENT OF ANEURYSM BY LIGATURE. own efforts. 2d. That these efforts have been successful even when counteracted by improper treatment, as in the (second) case of the popliteal aneurism (no men- tion, however, is made of such improper treatment in the recital of the case. j. f. s.;) but that a quiet position of the limb, with an antiphlogistic regimen, contributes to the cure. 3d. That the cure by nature is a permanent one. 4th. That the inert mass left behind is not likely to produce any mischief. 5th. That the unsuccessful event ofthe operation for the popliteal aneurism, does not principally depend on any particular hazard in consequence of an obstructed circulation in the ham, but upon other causes." (p. 155.) The first notice of John Hunter's improvement in the operation for aneurysm, was given by Everard Home in the year 1786 (a), and in that subsequent, the dis- section of the case. He also published another paper (b), giving the history of all the cases on which Hunter operated, together with some by other surgeons. In the first paper Home introduces the case with the following remarks:— " The common method of operating in cases of popliteal aneurism having, in many instances, proved unsuccessful, the operation itself has been condemned by some of our most eminent surgeons. If we consider the cases in which it has been per- formed, and where the patients have died, we shall probably find that in all of them the artery had been diseased at the part enclosed by the ligature, and had either sloughed off, or had been cut through where it was tied, so that the sides of the artery, though brought together, had not remained a sufficient length of time in that situation to unite by the first intention, and the patients lost their lives from the con- sequent haemorrhage. The femoral and popliteal arteries are portions of the same trunk, presenting themselves on different sides of the thigh, and are readily come at in either situation; but where the artery is passing from the one side to the other, it is more buried in the surrounding parts, and cannot be exposed with- out some difficulty. In performing the operation for the popliteal aneurism, espe- cially when the tumour is large, the ligature is commonly applied on the artery at that part where it emerges from the muscles. This will be too limited a space, should it prove diseased for some way higher up; and if the artery should after- wards give way from any of the causes above mentioned, there will not be a suffi- cient length of vessel remaining to allow of its being again secured in the ham. To follow the artery up through the insections of the triceps muscle, to get at a portion of it where it is sound becomes a very disagreeable part of the operation; and to make an incision on the fore part of the thigh, to get at and secure the femoral artery, would be breaking new ground—a thing to be avoided, if possible, in all operations. From these considerations, suggested by the accident of the artery giving way, which happened several times to Mr. Hunter, he proposed, in performing this ope- ration, that the artery should be taken up at some distance from the diseased part, so as to diminish the risk of haemorrhage, and admit of the artery being more readily secured, should any such accident happen. The force of the circulation being thus taken off from the aneurismal sac, the cause of the disease would, in Mr. Hunter's opinion, be removed; and he thought it highly probable that if the parts were left to themselves, the sac, with the coagulated blood contained in it, might be absorbed, and the whole of the tumour removed by the actions of the animal economy, which would consequently render any opening into the sac unnecessary." (p. 391-93.) 1422. The operation for aneurysm is generally indicated—1. If com- pression be not applicable. 2. When, as regards the position of the artery, it can be employed, but cannot be borne. 3. When the aneu- rysm, already large, threatens to burst, or has burst. 4. In spurious diffused aneurysm, when the effusion of blood is considerable. The result of the operation for aneurysm is extremely doubtful, if several * (a") An account of Mr. Hunter's Method the Popliteal Aneurism, containing all the of performing the operation for the Cure of cases on which he had then operated; in the Popliteal Aneurism; in London Medical Transactions of a Society for the Improve- Journal, vol. vii. 1786, vol. viii. 1787. ment of Med. and Chir. Knowledge, vol. i. (b) An Account of Mr. Hunter's Method i793. of performing the Operation for the Cure of HUNTER'S OPERATION. 491 aneurysms exist in the same person, if the patient be in years, or weakly, if from the size ofthe swelling, destruction ofthe bones and neighbour- ing parts have been produced, whereby, perhaps, the collateral branches have been closed; if the arterial coats be rigid, or in any other way changed by disease, and compression, by swathing the limb, have been too long employed. The larger the principal trunk to be tied is, the more doubtful is the prognosis ; the assistance rendered by nature by the enlargement of the collateral circulation is, however, very remarkable, and under the most unfavourable circumstances the treatment often pre- sents the happiest results. [E. Home has justly observed, "that surgeons have laid too much stress on the necessity of large collateral branches being present, to ensure the success of this operation; this must have arisen more from their anatomical knowledge, than from observations made from practice, since we find the trunk of the femoral artery may be taken up in any part of the thigh, without producing mortification of the limb. In one patient afflicted with aneurism, whose limb Mr. Hunter examined after his death, though there was great reason to believe that the artery had been obliterated above the great muscular branch, the limb had been very well nourished." (p. 399.) As regards the size of an aneurysm, best suited for operation, John Hunter says:—"I wish never to see one, that can be made the subject of an operation, larger than a walnut before it is operated on." (p. 543.) Surgeons, however, at present, rarely care about the size of an aneurysm, provided the skin be healthy, and there be sufficient space to apply a ligature between it and the heart, on a presumed healthy part of the artery.—j. f. s.l 1423. In the operation for aneurysm, by opening the sac, after the cir- culation into the artery is arrested by the application of a tourniquet above the aneurysmal part, the skin covering the swelling is to be divided by a cut, which must extend from above to below it; the sac ofthe aneurysm is to be opened in the same direction, all the blood-clot removed, and the cavity cleansed. The surgeon then endeavours to find out the proper opening of the artery, introduces into it a probe or a female catheter, with which the artery is to be raised above the sac and separated from the surrounding parts; a ligature is then to be passed round it with Deschamps' needle (1) and tied. In this way the artery is to be isolated and tied above the swelling. (What will subsequently be said, in reference to the form of the ligature, applies here.) The cavity ofthe sac is then cleansed, filled lightly with lint, covered with sticking plaster and a compress, and the whole kept in its proper place with a four-headed bandage. (1) Deschamps' needle is the most convenient instrument for a ligature; if made of silver, it can assume every necessary curve. Weiss's and Kirby's needles are suitable for some cases of very deep-lying arteries. As to the numerous varieties of aneurysmal needles, compare— Arnemann, Uebersicht derberiihmtesten und gebrauchlichsten Instrumente alterer und neuerer Zeit. Gottingen, 1796, p. 193. Krombholz, Akologie, p. 391. Holtze, De arteriarum ligatura. Berol., 1827. 4to., pi. ix. 1424. Hunter's mode of operation requires the laying bare and iso- lation of the artery at a suitable distance above the seat of aneurysm (1). It is here especially to be remembered, that the artery should be sepa- rated from its surrounding cellular sheath only as far as is necessary to carry around it, with Deschamps' needle, a round, but not too thick ligature, which is to be firmly tied upon the artery with two single knots (2). The ends of the thread should be laid in one or other angle 492 HUNTER'S OPERATION of the wound, the edges of which are to be brought into close contact with sticking-plaster, in order to effect the cure, if possible, by quick union. The ligature separates, according to the size of the artery, be- tween the eighth and sixteenth day. I consider tying the artery with a single round ligature, by which its inner and middle coats are divided, (ascertained by the artery forming a swelling above and below the ligature, and by the ligature being heaved up by the impulse of the blood,) with the simultaneous simple treatment of the wound, as the most preferable mode of treatment (pars. 283, 285.) The different modifications must, however, be here mentioned, which have been proposed for the more certain attainment of a suc- cessful result. Scarpa (a) holds, in opposition to Jones, (who concludes from his own experi- ments, that the division of the internal coat of the artery, with a single round liga- ture, favours the formation of a plug of blood, the adhesive inflammation, and the pouring out of plastic lymph within and without the artery,) that this result happens less frequently in men than in animals, that after-bleeding occurs the more quickly, as on the setting up of suppuration, the external coat of the artery is less capable of withstanding the impulse ofthe blood, and that this happens so much the earlier, as the division of the arterial coats by the ligature-thread resembles more a torn and bruised, than a cut wound. Also that the ligature-thread does not bring both the divided coats together, but only the wrinkled walls ofthe external. As the internal coat of the artery is very much disposed to adhesive inflammation, and plastic exu- dation, so a pressing together of the artery is sufficient to bring about adhesion. Upon these grounds, Scarpa prefers, to all other modes, tying the artery with a small band of waxed threads, between which and the artery, a little linen cylinder, smeared with cerate, is placed. In this mode, however, the artery must be laid bare, no farther than necessary to carry the band round it, nor the cylinder be longer than a line, or thereabouts, beyond the ligature, which, for the largest artery, should be about a line. The band must not be drawn excessively, but only sufficiently tight to keep the uninjured walls in close contact. By this plan of tying, a closure of the artery is produced by the actual joining together of the touching walls ofthe artery. Such flattening ofthe artery and touching of its walls, had been previously performed with broad ligatures, with the underlaying of a piece of wood or cork (3). Deschamps (b), more recently Crampton (c), Assalini (d), and Kohler (e) have attempted to operate with peculiar arterial compresses; these metallic contrivances are, however, dangerous, and in reference to their operation on the coats of the artery, and the parts surrounding it, not comparable to the soft cylinder which adapts itself to the periphery of the artery. Jones (f) advanced the opinion, that, if upon a large artery several circular liga- tures be made near each other, whereby as many tears of the internal coat are pro- duced, and the threads be immediately removed, the plastic lymph effused into the cavity of the artery is sufficient for its obliteration. Hodgson (g) has, by experi- ment, disproved this opinion. Travers (h) recommended, but subsequently disad- vised such treatment. Cases, however, are given, in which the ligature was removed twenty-four hours (i), and fifty and a half hours (j), after tying, and the cure ensued. Scarpa also has observed, that the closure of the artery follows, if the ligature, with its subjacent linen cylinder, be removed on the third or fourth day; only in weakly (a) Memoria sulla Legatura delle princi- pali Arterie degli Arti; con una Appendice all' Opera sull' Aneurisma. 4 to. Pavia, 1817.—Vacca Berlinghieiu, A., Istoria di una Allacciatura dell' Iliaca eslerna e Ro- flessioni sull' Allacciatura temporaria delle grandi Arterie. Pisa, 1823. (6) Above cited, f. 1-1. (c) In Medico-Chirurg. Trans., vol. vii. pi. v. f. 2. (d) Grossi. (e) Dissert, sistens qucedam de Aneurys- matibus scalpelli ope ra curandis, Berol., 1818. (/) A Treatise on the Process employed by Nature in suppressing Haemorrhage, &c, and on the use ofthe Ligature, &.c. London, 1810. 8vo. (g) Above cited, p. 228. (h) Med. Chir. Trans, vol. iv. p. 435, vol. vi. p. 632. (i) The Medical and Surgical Register, consisting chiefly of cases in the New York Hospital, by J. Watts, V. Mott, A. H. Ste- vens. New York, 1818. p. 157-163. (j) Roberts, W.; in Med, Chir. Trans., vol, xi. pt. i. p.. 100. FOR POPLITEAL ANEURYSM. 493 persons is it necessary to leave the ligature till the sixth day. Scarpa, as well as others, have made known cases favourable to this mode of treatment. His mode of applying the ligature with a subjacent cylinder specially facilitates its removal. Scarpa uses a peculiar grooved probe, cleft in front and open, and a small knife for loosening the ligature. The proposals of Palletta and Roberts must be here mentioned; by means of a sliding thread, the tightened principal loop may be again loosened; by Giuntini, one thread is attached to a little roller, in order to draw it out after the loop is cut through; Uccelli introduces a small metal half cylinder between the linen roller and the loop (a). Vacca Berlinghieri (b) is in favour of Scarpa's mode of tying with the linen roller, but not for the removal ofthe liga- ture on the fourth day. The experiments, as regards the temporary ligature on the human subject, are not yet sufficiently numerous to decide whether it should be generally employed, or only in particular cases, perhaps in old subjects and so on. It is always to be remembered, that the removal ofthe roller acts as an interruption, for it is firmly pressed on the artery by the loop, clings tight to it, and cannot be removed without tearing, even after the loop has been cut through. In order to get rid ofthe inconvenience dependent on the threads hanging out of the wound, Law- rence (c) proposed tying the artery with a fine silk thread, cutting it off at the knot, and closing the wound, (for the same reason, Astley Cooper (d) used silk-worm gut previously moistened in warm water,) as the retained knots are either absorbed or enclosed in a cellular capsule. Many cases, however, decide against this mode of tying (e). Maunoir (/) and Abernethy (g), under the supposition that the tied artery retracts actively, and thereby especially produces tearing and secondary bleed- ing, advised the application of two ligatures, and the division of the artery between (4). The rarity of secondary bleeding after amputation, which has been considered as a reason for the preference of this mode of tying, is on more than one ground inappli- cable; experience is opposed to this method of tying; besides, in many cases, it cannot be undertaken, on account of the want of space, or the deep situation of the artery. The application of the so-called reserve ligature, that is, some threads which in case of secondary bleeding may be drawn together, is not only useless, but dangerous, and therefore to be rejected. [(1) The operation of tying the femoral artery, for popliteal aneurysm, the first upon which John Hunter (h) operated by his new method, Dec. 1785, was con- ducted in the following manner:—"A tourniquet was previously applied but not tightened, that the parts might be left as much in their natural situation as possible; and he began the operation by making an incision on the fore and inner part of the thicrh, rather below its middle, which incision was continued obliquely across the lower edcre of the sartorius muscle, and was made large to give room for the better performing of whatever might be necessary in the course of the operation; the fascia, which covers the artery, was then laid bare for about three inches in length, and the artery being plainly felt, a slight incision, about an inch long, was made through this fascia along the side ofthe vessel, and the fascia dissected off, by which means the artery was exposed. Having disengaged the artery from its lateral connexions by the knife, and from the parts behind it by means of the end of a thin spatula, a double ligature passed behind it by means of an eyed probe, and the artery tied, by both portions of the ligature, but so slightly as only to compress its sides together; a similar application of ligature was made a little lower; and the reason for passing four ligatures was to compress such a length of artery as might make up for the want of tightness, as he chose to avoid great pressure on the vessel at any one part. The ends of the ligature were carried directly out at the wound, the sides of which were now brought together and supported by sticking-plaster and a linen roller, that they micrht unite by the first intention. * * * The fourth day, on the removal of the dressings, the edges of the wound were found united through its whole length, (a) Lettera dell' Prof. Scarpa, al Dottori (e) Cross: in London Medical Repository, Omodei sulla Legatura temporaria delle vol. vii. p. 363.—Cooper, A., Lectures on grosse Arterie degli Arti. Milano, 1823 Surgery, vol ii. p. 57. (6) Seiler's Sammlung von Abhandlun- (/) Dissert, sur la Section del'Artereentre sen u s w —Seiler has made some experi- deux Ligatures dan Dubliu Journal of MedicaPscience, (b) Surgical Works, vol. ii. &c, vol. xii. p. 335. 1838 (c) Medico-Chirurgical Journal, vol iii. (g) Zeitschnft fur die gesammte Medicen, P- '■ „ ,. vol ilh part 1. (a) Medico-Chirurgical Transact.,, voL i. p.L TYING THE COMMON CAROTID ARTERY. 509 right side; these symptoms continued with increasing debility, and on the forty-ninth day after the attack of convulsions, the child died. The vascular naevus had for some days disappeared, leaving only a few folds of the skin. No examination was allowed. Kuhl (a), of Leipzig, has tied both carotids with success at an interval of twenty- seven days, for a pulsating aneurysmal tumour of the scalp, consequent on wound on the occiput, from which there were repeated bleedings. The application of the liga- ture was followed by convulsions, other troublesome symptoms, heaviness and throbbing of the head, for whiclrrt was necessary to employ venesection, though the case at last did well.] 1437. Tying the common trunk ofthe carotid artery may be performed at three different places, according to the different seat ofthe aneurysm, viz.: first, immediately above the collar bone; second, below the part where the m. omo-hyoideus crosses the carotid; third, above that point. If the seat and extent of the swelling do not permit the ligature below the aneurysm, it must be applied above (par. 1433.) The patient is to be placed horizontally upon a couch, the head supported by a pillow, and the diseased side of the neck turned properly towards the light. 1438. In tying the carotid artery immediately above the collar-bone, a cut of two inches and more should be made through the skin and m. platysma myoides, from the top of,the breast-bone along the inner edge ofthe m. sterno-cleido-mastoideus. When the edge of this muscle is laid bare, it must be separated from its cellular connexion with the m. sterno- hyoideus and sterno-thyroideus, and drawn outwards, whilst the latter two muscles are drawn inwards, with a blunt hook, by an assistant. The m. sterno-cleido-mastoideus is now to be relaxed by inclining the head to the affected side. The internal jugular vein appears in the wound, and must, be drawn outwards, with the forefinger of the left hand from the artery, the sheath of which is then to. be opened with delicate and careful strokes of the scalpel; or, when the vein has been fixed exter- nally by an assistant, the sheath is to be raised with forceps, and care- fully cut into ; the artery should be carefully isolated with the handle of the knife, and the ligature applied round it with Deschamps' needle. The operation is always most difficult at this part, on account of the depth of the artery beneath the m. sterno-cleido-mastoideus, and because it is entirely covered by the jugular vein. Zang (b) has proposed that an incision, beginning from the top of the cricoid cartilage, should be carried outwards between the two portions ofthe m. sterno-cleido- mastoideus, and terminate at a quarter of an inch from the collar-bone; the skin and m.platysma myoides, and the edges of the wound must be kept asunder with the blunt hook, the cellular tissue and fascia ofthe neck divided, and thus the triangular space formed by the sternal and clavicular insertion of the sterno-mastoid muscle reached. The internal cervical fascia is then to be cut through, the thyroid gland drawn inwards, the jugular vein and pneumo-gastric nerve outwards, the artery taken hold of by the forceps, gently raised, and a ligature passed with a proper needle close to the part where the artery is covered by the m. omo-hyoideus. According to Dietrich's proposal (c), an incision is to be made on the mesial line ofthe windpipe, from the semilunar notch at the top of the breast bone, to the cricoid cartilage, from two and a half to three inches in length, through the skin, cellular tissue, m. platysma myoides, and external cervical fascia, by which the small veins runnino- from above downwards are avoided. The tendinous connexion between the m. sterno-hyoides and sterno-thyroideus is then to be divided, the edges of the (a) Radius und Clarus, Beit, zur prakt. (b) Blutige Operationen, vol. i. p. 233. Heilkunde. Leipz., vol. ii. p. 245. (c) Above cited, p. 162. 510 TYING THE COMMON AND wound drawn asunder with a blunt hook, and the muscles just mentioned pushed from the windpipe, with the handle of the knife, and carried towards the shoulder. The branches of the inferior thyroideal vein, as well as the thyroid gland, which ap- pears from the middle to the upper end ofthe wound, must be avoided. The finger is to be introduced into the wound downwards and outwards, after the cellular tissue has been divided with the handle of the knife, and the vessel is felt enclosed in its sheath, which is then to be opened, the artery a little raised and the ligature intro- duced. As upon the left side the carotid artery lies deeper and nearer to the pleura, the jugular vein and pneumo-gastric nerve higher, and the thoracic duct close behind the sheath of the artery, the performance of the above mode of treatment the more difficult. The following method, proposed by Coates (a), is more easy and more sure. A cut from two to two and a half inches long, is to be carried upwards from the upper edge ofthe breast-bone, upon the inner edge ofthe sterno-mastoid muscle; from the lower end of this incision, a second is to be made parallel to the upper edge of the collar-bone, to the inner edge of the clavicular part of the sterno-mastoid muscle, about an inch and a half long, the cellular tissue m. platysma myoides, and external cervical fascia, is to be divided into two cuts. A director is then to be carefully thrust under the sternal portion of the sterno-mastoid muscle, which should be cut through three lines from the upper edge of the collar-bone, together with the internal cervical fascia. The flap is turned somewhat upwards, and held back with a blunt hook. The cellular tissue is then to be divided, and if there be much fat, it must be removed partly with the scissors, forceps, or bistoury, so that the vessels, with their sheath, behind the collar-bone, and on the outer edge of the m. sterno-hyoideus may be brought into view. These muscles are to be inclined with the handle of the knife towards the wind-pipe, and the sheath opened with the greatest care, and without any violence, as the delicate walls of the thoracic duct, which lies close behind the sheath, are torn with the slightest violence. The isolation and tying-of the artery is effected in the way already described. 1439. If the aneurysm be higher up, the tying of the carotid artery must be effected below the part at which the m. omo-hyoideus crosses. A cut is to be made through the skin and m. platysma-myoides, in an oblique direction along the inner edge of the m. sterno-mastoideus, commencing at the top of the cricoid cartilage, and terminating an inch from the sternal end of the collar-bone. When the edge of the sterno-mastoid muscle is exposed, it must be separated carefully from the sterno-hyoid muscle, and drawn outwards; the omo-hyoid muscle then appears crossing over the vessels of the neck, and the carotid artery, jugular vein, and pneumo- gastric nerve enclosed in their sheath, with the descending branch ofthe hypoglossal nerve upon it. The omo-hyoid muscle is now to be drawn outwards and upwards, the thyroid gland inwards, and the jugular vein with the forefinger of the left hand outwards, and there kept (1). The sheath is now to be opened, immediately where it covers the carotid artery, either with a director, or, if carefully raised with the forceps, with the scalpel held fiat, or, what is best, with some careful strokes of the scalpel. The artery should now be separated from the surrounding parts with the handle of the knife, to an extent sufficient for passing around it the ligature with Deschamp's needle. As the swelling up of the jugular vein often renders the isolation of the aTtery very difficult, this may be facilitated by applying compression on the vein above, with the finger. For the purpose of not injuring the important surrounding parts in isolating and tying the artery, it is to be borne in mind that the jugular vein lies on its outer side, and upon it; the pneumo-gastric nerve between the vein and artery, and the sympathetic nerve behind them. As important varieties in the course of the (a) Medico-Chir. Trans., vol. xi. pt. ii. EXTERNAL CAROTID ARTERIES. 511 vessels of the neck, in connexion with this operation, it must be remembered that the division of the carotid artery often takes place deep in the bottom of the neck, and that the vertebral artery arises from the aorta, or the subclavian ascends along the side of the carotid, and close behind it. If the artery be laid bare, as proposed, to a great extent, two ligatures must be applied, and the artery tied at the upper and lower part ofthe exposed portion (a). [(1) Astley Cooper (b) observed in his first operation for carotid aneurysm, that "the motion of the internal jugular vein produced the only difficulty in the opera- tion, as, under the different states of breathing, it sometimes presented itself to the knife tense and distended, and then as suddenly collapsed." (p. 3.) This, how- ever, is not always the case, as in an instance mentioned by Hodgson where the carotid artery was tied for a spurious aneurysm, the result of wounding the vessel with a penknife, " the jugular vein afforded no trouble in the operation; it was not even seen." (p. 332.) And in another operation, by Dr. John Brown, of Meath (c), for wounded carotid by a penknife, the vein " did not appear, nor was it a source of the slightest inconvenience in the operation." (p. 305.) If, however, the vein be wounded in the operation, it must be tied as was done by Simmons, of Manchester (rf).] 1440. If the carotid be tied above the crossing ofthe m. omo-hyoideus, (which is only possible when the aneurysm is seated in the branches of that vessel, or when the aneurysm is deep, and the artery must be tied above it,) the cut must be carried either from the top ofthe cricoid carti- lage two inches upwards, in the direction of the inner edge of the sterno- mastoid muscle, or commenced at the upper edge of the thyroid cartilage, and, on the contrary, carried down a sufficient length along the inner edge of the sterno-mastoid muscle. In this case the operation is to be proceeded with as before, only the omo-hyoid muscle must be drawn downwards. In other cases, when the skin, m. platysma myoides and cellular tissue are divided, the edges ofthe wound must be held asunder, a thin layer of cellular tissue divided ; and, in the triangular space formed at the lower end of the wound, by the crossing omo-hyoid muscle, at the upper end ofthe wound, by the digastric muscle, and externally, by the inner edge of the sterno-mastoid muscle, the artery must be isolated, as already mentioned (e). The superior thyroideal vein above the cricoid cartilage, crosses the common carotid artery, and with it the laryngeal and pharyngeal vein, as well as some branches anastomosing with the external jugular vein, run together before the caro- tid, and partially form some anastomoses. These veins must be avoided, and drawn upwards (1), and the superior thyroideal artery inwards. [(1)1 have on one or two occasions seen these veins wounded in tying the carotid artery; they bled very freely, but were soon stopped by a little pressure.—j. f. s.] 1441. When in one or other way the ligature has been carried round the carotid artery, it must be fastened sufficiently tight with two single knots ; the one end of the ligature cut off near the knot, the other brought out of the wound by the shortest course, and the union of the edges ofthe wound effected with sticking plaster. Such symptoms may occur after the operation as have been already generally mentioned. The patient should be kept quiet in bed, with his head somewhat raised, and bent forwards. On the fourth or fifth day the dressing is to be renewed. The patient should be treated antiphlogistically, according to the symptoms, and with suitable antispasmodics, if cramps come on. After tying the carotid, it is not uncommon that, on account of the great anastomosis, (a) Hodgson, above cited, p. 342. (d) Cyclopaed. of Pract. Surgery, vol. i. p. (b) Med. Chir. Trans., vol. i. 26f_ (c) Dublin Hospital Reports, vol. i. (0 Dietrich, above cited, p. 180. 512 TREATMENT OF ANEURYSM. the pulsation in the sac reappears ; no farther increase, however, is to be feared; it gradually becomes weaker, and the sac diminishes. For the history of the ligature ofthe common trunk of the carotid artery, and the collection ofthe hitherto known cases, see Dietrich (a). l"The following is the account ofthe dissection of the second case in which Astley Cooper tied the left common carotid artery in 1808, for aneurysm (b), the patient having died thirteen years after of apoplexy (c). " The disease of which he died sufficiently attested the freedom of the circulation, as well as its force in the cerebral vessels on the side on which the carotid had been tied. The arteries on the left side of'the brain were rather larger than those on the opposite side. The anterior cerebral artery was of the same size as its fellow: the middle cerebral larger than that on the right side, which was filled with coagulum and did not admit the injec- tion. The large size of the latter vessel is accounted for by the increased size of the communicating branch ; which receiving its blood from the basilary, had become as large as an ordinary radial artery. The basilary appeared to be of its usual capacity, although it was evidently the channel which supplied the middle cerebral artery. The blood probably found an easier course from the basilary, through the left com- municating branch, than into the right corresponding vessels, which appeared rather diminished in size. From an inspection of the base of the brain after the vessels had been injected it immediately struck the observer, that the left side ofthe arterial circle of Willis was much more developed than the right, and that the left side of the brain received its full share of arterial blood. The anterior cerebral artery received its supply from its fellow by means of the transverse branch : these vessels seemed to be of their usual size. The internal carotid was pervious for about half an inch, and of its ordinary capacity. The external vessels were not so well dis- played. Those of the face did not receive the injection. The common carotid trunk was impervious throughout its whole extent, being reduced to a mere cord. The external carotid was injected at its commencement: and the superior thyroideal was filled from the arteries of the opposite side ; but beyond this the arteries were empty and therefore could not be satisfactorily traced. The free communication of the branches of the external carotids, in their natural state, affords an ample channel of supply, when the circulation in one is cut off. The aneurism must, as Sir Astley Cooper suspected, have been situated in the internal carotid artery, (p. 57.) The preparation of the carotid arteries of this case isin the Museum at St. Thomas's.] 1442. If an aneurysm be seated in the branches of the carotid, the tying of the affected artery must, if possible, be performed. This tying may also be required on account of other diseased conditions. We must therefore consider tying the external carotid, the lingual, the external maxillary, the temporal, the occipital, and the posterior aural. Tying the superior thyroideal artery will be mentioned in the treatment of bronchocele. 1443. Tying the external carotid artery is considered as one of the most difficult operations, on account of the vessel being surrounded with arteries, veins, and nerves, and therefore also it is usually recommended to tie the common trunk instead of it {d). It has, however, been per- formed successfully by Bushe (e), on account of aneurysm by anastomosis: by Mott (f) in removal of the lower, and by Lizars {g) in that of the upper jaw-bone. Dietrich {h) has proposed the most convenient mode of operating; a ringer's breadth from the lower edge of the lower jaw, at a distance of half an inch from the inner edge of the sterno-mastoid muscle towards the larynx, a cut should be made obliquely upwards, and parallel to the (a) Above cited, p. 132. (/) American Journal of Medical Sci- (6) Med. Chir. Trans , vol. i. p. 222. 1809. ences, vol. ix. 1845. (c) Guy's Hospital Reports, vol. i. 1836. (g) Lancet, 1829-30, vol. ii. p. 54. (d) Manec, above cited, pi. iv. (h) Above cited, p. 186. (e) Lancet, 1827-28, vol. ii. p. 482. TYING THE LINGUAL ARTERY. 513 edge ofthe sterno-mastoid muscle, through the skin, cellular tissue, and m. platysma myoides. After the division of a thin layer of cellular tissue, the external cervical fascia appears, upon which run some veins, which are to be raised, and the fascia and the cellular tissue divided with the handle of the knife. The internal cervicalfascia is then to be cut through with slight strokes of the knife, and, whilst the edges of the wound are held asunder with blunt hooks, the inner edge of the sterno-mastoid muscle appears on the outer edge of the wound ; at its inner edge the tongue-bone is felt; at the upper angle of the wound are seen the sub- maxillary and parotid gland; at the under edge, the digastric muscle; and at the lower angle the omo-hyoid. With the greatest care the fat and cellular tissue filling the bottom ofthe wound must now be divided, keeping towards the upper angle of the wound, for the purpose of best avoiding the venous branches, to wit, the superior thyroideal, sublingual and facial, and thus the artery is exposed, partially covered by the com- mon trunk of the facial veins, £Jow begins the most difficult part of the operation, to wit, the isolation of the artery from the surrounding im- portant parts. At the upper angle of the wound the artery crosses the lower edge of the digastric muscle, as well as the principal trunk of the hypoglossal nerve, which runs parallel to the edge of the muscle ; on the inside some twigs pass down from the hypoglossal nerve, and, at the same time, the superior thyroideal artery and vein run down from above to the internal jugular vein. The trunk of the facial veins lies in part upon the artery, and upon the wall of the artery descends a branch of trie hypoglossal nerve. On the outside of the artery are the internal carotid artery, and the internal jugular vein, which frequently covers the latter artery; together with them descend the pneumo-gastric and sym- pathetic nerves, which divide into many branches. Between, and rather behind the two arteries, passes up with, and very near it, the ascending pharyngeal artery, from the external carotid. The laryngeal nerve, as well as branches of the hypoglossal nerve, cross it deeply, passing on the back and inner part inwards and upwards. The external carotid artery is best tied either above the giving off of the superior thyroideal, or where it crosses the lower edge of the digastric muscle. This muscle, and the hypoglossal nerve, must therefore be somewhat separated from the cellular sheath, and with the submaxillary gland drawn upwards with a hook by one assistant, whilst another draws the internal carotid artery, the internal jugular vein, and the nerves outwards. When the operator has now in part pressed the trunk of the facial veins lying on the artery, aside and inwards, he opens the sheath ofthe artery with the handle of the scalpel, and passes the ligature with Deschamps' needle from without inwards. 1444. Beclard (a) has proposed tying the lingual artery in bleeding after deep extirpation of the tongue, and the like. Tying it on one side is sufficient, as the bleeding from the other side of the tongue may be staunched by cauterization. The patient lies with his head somewhat bent back, and with his face turned towards the sound side; the operator thoroughly satisfies himself of the position of the tongue-bone, which, (a) Manec, above cited, pi. iii.—Bell, Charles, Operative Surgery, vol. ii. p. 307— Wise; in Averill, above cited, p. 53. Vol. ii.—44 514 FACIAL, TEMPORAL, AND OCCIPITAL ARTERIES. during the whole operation, must guide him, and makes a cut from an inch to an inch and a quarter long, which he commences a little behind the horn of the tongue-bone, and carries upwards and forwards, hall an inch over the body of that bone. The skin and m. platysma myoides are thus divided, avoiding the facial vein, which is to be turned backwards. The cellular sheath ofthe submaxillary gland is then to be opened, and the gland raised without injuring it, upon which the digastric and stylo- hyoid muscles, as well as the hypoglossal nerve, appear. If these different parts be very near the tongue-bone, as happens with persons who have short necks, they must be gently raised, so as to expose the outer side of the hypoglossal muscle, some fibres of which are to be seized with the forceps, raised, the director introduced under them and then divided, upon which the artery is exposed, and easily isolated. Dietrich (a) makes the cut as in tying the external carotid artery, only with this difference, that he begins three lines from the under edge of the lower jaw, and car- ries it two inches downwards, through the skin, cellular tissue, m. platysma myoides, and external cervical fascia. The vein being avoided, and the second fascia divided, the edges of the wound are to be kept asunder with hooks, when the submaxillary gland and lower edge of the digastric muscle appear at the upper angle of the wound. The cellular tissue, connecting the gland with the muscle, is to be divided, and the gland raised up, which exposes the stylo-hyoideal muscle. Both muscles and the hypoglossal nerve are to be drawn downwards or upwards, and the two layers of cellular tissue being divided with the handle of the knife, the artery now appears close to the trunk of the external carotid artery, from which it is given off. In front of the artery passes the lingual vein; often, also, on its inner and outer side the facial vein; and still farther, the superior laryngeal nerve. The nerve must be drawn down, the vein up, and the artery tied from below upwards, immediately above the great horn of the tongue-bone. If the artery is to be tied still more distant from its origin, it is not necessary to cut into the fleshy fibres of the hypoglossal muscle. The artery otherwise runs through sufficient extent before it passes under any muscle. 1445. The external maxillary or fascial artery is tied at the angle of the lower jaw in the following manner. A cut is to be made on the in- ner edge of the masseter muscle, running obliquely downwards and out- wards to the extent of an inch or a little more through the skin, the cel- lular tissue, and fibres of the m. platysma myoides. In this direction the cellular tissue and some threads ofthe facial nerve are cut through; and the edges ofthe wound being separated, the artery appears on the inner edge of the masseter muscle, lying on the periostaeum; and close to it, on the outer side, is the facial vein; these are drawn outwards, and the ar- tery isolated with ease. This artery can be tied in its submaxillary part only with the greatest difficulty. Manec (b) declares himself against this operation, because the artery lies very deeply, and is covered by very many parts. Velpeau and Dietrich have given the modes of proceeding in this operation. By the former, an incision is made from the submaxillary gland to the inner edge of the sterno-mastoid muscle, and then a second from the hinderend ofthe great horn ofthe tongue-bone to the inner pdge of the masseter muscle, through the skin and m. platysma myoides, and the flap so formed should be turned back upwards. The edges of the wound are to be kept asunder, the flap held up, and the now displayed aponeurosis, from which the artery is only separated by cellular tissue, must be cut through, in doing which the facial vein is sometimes di- vided, between the submaxillary gland and digastric muscle; after this the artery is to be isolated and tied between the great horn of the tongue-bone and the submax- illary gland. According to Dietrich, the cut should be made two lines from the (a) Above cited. (b) Above cited, pi. iv. TYING THE POSTERIOR AURAL. 515 under edge ofthe jaw, directly down, rather obliquely outwards and downwards, to the inner edge of the sterno-mastoid muscle. The facial vein is never to be cut through, but separated from the submaxillary gland, and carried outwards or in- wards, as may be most convenient. The hypoglossal nerve is to be taken care of. The artery passes under the stylo-hyoid muscle, at the point where it is perforated by the digastric muscle, about half an inch from its insertion in the tongue-bone. The muscles together with the nerves, are to be separated from the cellular tissue, and carried downwards, and the ligature passed around the vessel from without in- wards, and from below upwards. 1446. Aneurysms of the temporal artery, occurring after wounds, maybe often cured by compression, as I have seen in one instance, when aneu- rysm occurred after arteriotomy; if this be not possible, the temporal artery must be tied. The position of the artery is to be first well ascer- tained by feeling with the finger, and then along its course a cut an inch in length is to be made through the skin, midway between the joint of the jaw and the auditory passage; a director is then to be introduced be- neath the pretty thick cellular tissue by which the artery is covered, and this being divided the artery is to be isolated. The accompanying vein lies to the outer side. 1447. Aneurysms ofthe occipital artery rarely occur, though Meyer {a) mentions a case in which, on account of aneurysm, many branches and the trunk of the occipital artery were tied. J. Burns (b) also tied this vessel for an aneurysmal swelling. A cut is to be made half an inch behind and a little beneath, the tip of the mastoid process, and continued obliquely upwards and backwards, to the extent of an inch or an inch and a quarter. The skin and aponeurosis of the sterno-mastoid muscie are to be divided, and the finger carried under the upper lip of the wound, in order to feel the base ofthe mastoid process. The m. splenius is then to be divided the whole length of the wound, and the pulsation of the artery being felt, should be carefully isolated, so as not to injury the ac- companying veins. 1448. To tie the posterior aural artery, a cut half an inch long should be made from the lobe of the ear to the inner edge ofthe sterno-mastoid muscle, and continued upwards along its inner edge an inch upwards; this cut divides the skin, fatty cellular tissue, and the muscular aponeu- rosis. An assistant with a blunt hook separates the edges of the wound, and then is seen at the lower angle of the wound, a portion of the pa- rotid gland; but in the upper angle, the lower edge ofthe lower retractor ofthe auricle; in the middle ofthe wound the artery is to be sought for, isolated and tied (c). Syme (d) tied a branch ofthe posterior aural on account of aneurysm. [Astley Cooper (e) had a case of "aneurism of the posterior aural artery from a blow; he opened the sac, and was compelled to tie not only the vessel which led into the sac, but numerous others entering in all parts of the circumference of the swelling." (p. 82.) Begin (/) gives the account of an aneurysm of the middle meningeal artery, in which the bone having been absorbed, the tumour became superficial, and, being (a) Dissert, de aneurysmate arterim occi- (d) Edinburgh Med. and Surg. Journ., vol. pitalis, 180L—Scarpa, Translation, p. 199. xxxi. p. 66. 1829. note (e) Surgical Lectures. (b) In his brother's Surgical Anatomy of (/) Dictionnaire de Medecine et de Chir. the Head and Neck, p. 374.—Manec, above urgic partiques, vol. ii. p. 533—article, An. cited, pi. v.—Dietrich, above cited, p. 209. evrysme. (c) Dietrich, above cited, p. 211. 516 TYING THE AXILLARY ARTERY. mistaken for an encysted tumour, was extirpated. An ineffectual attempt was made to stop the bleeding by plugging; but the patient could not be saved. The branches of the internal carotid artery within the skull sometimes become aneurysmal. A remarkable instance of this kind occurred to Dr. (afterwards Sir Gilbert Blane) («),in a female of sixty-four years old, who "was suddenly seized with a fit of giddiness and dimness of sight, succeeded by acute pain in the forehead which remained for some time. The indistinctness of vision continued for six months; after this, she was at intervals seized with giddiness, headache, and imper- fect vision. She had a similar attack two years after the first, from which also she recovered to a certain degree. From this period she continued subject from time to time, to the above-mentioned symptoms as long as she lived. She for some time saw objects double, but the particular period of this could not be ascertained." (pp. 193, 94.) She afterwards betrayed signs of mental derangement, and became maniacal, and died in that state five years after her first attack. On examination there was found more water than usual in the ventricles of the brain; upon the falx some spi- cule of bone; and the optic nerves were smaller than usual, as if they had been wasted. " The morbid appearance in this case, which was so singular, and to which the symptoms of complaint seemed chiefly referable, was to bulbs about five-eighths of an inch in diameter, filling up the hollow on each side of the sella tursica, which were evidently dilatations ofthe carotid arteries, and, from their being filled with laminae of coagulated blood, there could be no doubt of their being aneurisms of these arte- ries. The one on the left side was the largest; that on the right communicated with the cavity of the artery, which was not the case with the other." Blane ob- serves :—" It is probable that one of the aneurisms arose five years before her death, occasioning the first attack described, and that the other arose two years afterwards, occasioning the other attack. It is also probable that it was between these two at- tacks that she saw objects double, from the unequal compression on the optic nerves." (pp. 196, 97.) Hodgson mentions an instance of a small aneurysm in the anterior cerebral artery, filled with a solid coagulum, and another in the basilar artery was seen by Serres.] II —OF ANEURYSMS OF THE SUBCLAVIAN AND AXILLARY ARTERIES. 1449. Aneurysm ofthe axillary artery in general increases quickly, as the surrounding parts offer little opposition. The swelling raises the great pectoral muscle, spreads towards the collar-bone, and thrusts it up- wards. It is, therefore, rarely that this aneurysm is so early observed, that there is still space sufficient (b) for tying the axillary artery, and this operation is usually possible only in aneurysms at the upper part of the brachial artery. 1450. Tying the axillary artery may be performed in two situations, namely, first, by cutting through the great pectoral muscle, under the collar-bone ; and second, by division of the tendinous interspace between the pectoral and deltoid muscles. The patient either lies on a bed or sits on a sloping chair, with the shoulders somewhat depressed; an assistant stands behind, and is ready to compress the subclavian artery, if bleed- ing should occur during the operation. 1451. In the first mode of operating, a cut must be made through the skin, commencing an inch from the sternal end of the collar-bone, and continued along its under edge towards the coracoid process of the blade- (a) History of some cases of Disease irv. (b) Keate; in London Medical Review, the Brain; in Trans, of a Society for the Im- 1801.— PELLETAN.Cliniquc Chirurgicale vol' provement of Med. and Chir. Knowledge, ii. p. 49.—(hambkrlaine, Medico-Chir. vol. ii. 8vo. 1800. Trans., vol. vi. p. 128. TYING THE AXILLARY ARTERY. 517 bone, as far as the cleft which separates the pectoral and deltoid mus- cles. In this direction the connexions of the great pectoral muscle with the collar-bone are divided, and thus the lessor pectoral muscle is ex- posed, which, beginning from the coracoid process, crosses the lower angle of the cut. The point of the finger is then to be introduced between the coracoid process and the lower edge of the collar-bone, and the artery is there found surrounded, upon the outer side, and partially covered by the brachial plexus, and upon the inner side by the brachial vein. The artery is now to be carefully separated from the vein and nerves, and a single ligature carried round it with Deschamps' needle, before with- drawing which, the artery should be compressed upon it, for the purpose of ascertaining that it alone is taken hold of. The small arteries wounded during the operation are to be tied at once, and the wound kept clear of blood. The dressing and after-treatment are to be conducted according to the former general rules. The direction of the wound in this mode of operation is variously advised. The mosi important variations are—that recommended by Lisfranc, in which the cut is com- menced half an inch from the sternal end of the collar-bone, in the pit formed by the clavicular and sternal parts ofthe great pectoral muscle, and carried three inches be- low the collar-bone; and the practice recommended by Zang and others, who carry the cut close beneath the collar-bone, beginning from its middle, and continue it for two and a half inches downwards and outwards, nearly to the coracoid process. 1452. In the second mode of treatment, if the artery be not tied so near the collar-bone, a cut is made of two and a half inches in length, from the lower edge of the outer third of the collar bone, towards the inside ofthe upper arm, on the interspace between the great pectoral and deltoid muscles. The lesser pectoral muscle is cut off at its insertion to the shoulder-blade. The forefinger is now to be carried deeply into the wound, and passed upon the surface of the m. serratus magnus, till its tip reach the shoulder-blade. The finger is now curved, and, following the inner surface ofthe subscapular muscle, is again carried forwards, up to the outer lip ofthe wound in the skin. In this way is the whole armpit swept round, and the entire mass of vessels and nerves, collected imme- diately under the collar-bone, are without difficulty brought to the ex- ternal parts between the edges of the wound, and fixed with the finger. Here the artery is easily isolated and tied {a). [The operation of tying the axillary artery in either mode above recommended, or indeed in any other way, has not met with much favour among practical surgeons; the position of the vein so much in front of it, and its almost complete envelopment by the axillary nerves, together with its great depth, render it a very hazardous and diffi- cult operation. As to dragging up the whole mass of vessels and nerves to the sur- face, and then selecting the artery to be tied, as recommended by Delpech, no per-i son who had had any experience in tying arteries, would think of doing, on account of the necessary detachment of the vessel from its connexions, which would put it into a very unfavourable condition for the effusion of adhesive matter on its exteriory and interfere with its healing up. And indeed, though this might be done on a ves- sel undiseased, yet if any aneurysmal swelling existed, there would not be room to attempt it. Nor is there any good reason to perform so troublesome and dangerous an operation, when tying the subclavian above the collar-bone will answer all the purposes required, with greater ease and safety. If the artery were wounded and its ends exposed, as in Hall's case, related by J. Bell (b), and Maunoir's case men- fa) Delpech, Chirurgie Clinique de Mont- of Wounds. Third Edit., Edinburgh, 1812, pellier, vol. i. P- 59> (b) A Discourse on the Nature and Cure 518 TYING THE tioned by Scarpa (a), then tying the ends of the wounded' vessel would, as under ordinary circumstances, be required. But for aneurysm of this vessel, tying the subclavian is always preferable.—j. f. s.] 1453. If an aneurysm situated upon the commencement ofthe axillary artery, or at a deep part of its commencement, so extend, that it reach the collar-bone, the subclavian artery must be tied above the collar-bone. The patient being seated on a chair, or laid horizontally upon a table, and the shoulder ofthe ailing side depressed as much as possible, a cut is made through the skin, extending from the outer edge of the sterno- mastoid muscle, along the collar-bone, to the clavicular insertion of the m. trapezius. Then the m. platysma myoides is to be divided carefully in the same direction, so that the external jugular vein may not be wounded, which, when laid bare, is to be drawn towards the shoulder with a blunt hook. The cellular tissue in the midst of the wound is next divided with the knife, or more safely with the finger, or a director, till the edge ofthe m. scalenus anticus be reached with the finger, where the artery is found lying on the first rib, and the ligature is to be carried round it with Deschamps' or Desault's needle. The cut for tying the subclavian artery, should, according to Zang, be made in the middle of the triangle, formed by the hind belly of the m. omo-hyoideus, and the hind edge ofthe clavicular part ofthe m. ster- no-cleido-mastoideus, and should be commenced two inches above the collar-bone, at the hind edge of the latter muscle, and carried some- what obhquely outwards and downwards to the middle of the collar- bone. I have found this operation easiest on the dead subject; the subclavian vein lies on the inside of the artery, the nervous plexus on the outside, and partially covering it. A little stud on the first rib, which is felt at the inner side of the artery, and the hol- low made by the artery in that rib, are given as the certain marks for directing the finger upon the artery. Taking up this artery is often extraordinarily difficult? and even impossible (b), if, from the size ofthe swelling, the collar-bone be very much thrust up; the operation should therefore always be performed early. The same also happens in tying the ligature for which Liston (c) has proposed a peculiar contri- vance. As the artery is partially eovered with the plexus of nerves, one of the ^tedtolt^6 " "P and Ued inStead °f the 3rtery' aS Pu,sation is Papa- in one case where the ordinary mode of treatment was inapplicable, Dupuytren (e) eut through the m. scalenus anticus. Hodgson, Lisfranc, and Graefe, have pro- posed the same in their modes of practice, that, after a long cut has been made through the skin and the m. platysma myoides, from the hind edge of the sterno- mastoid muscle, from two to two and a half inches along the collar-bone, the opera- tor should d.p deeply, and seek for the m. scalenus anticus, pass beneath it a curved d™°r' v*6/' UP- an1 ™l l\ throu£h either from without inwards, or carefully across, without previously introducing a director. *HCTh! a^™*}™ of tying the subclavian artery above the collar-bone was first ITcr^ A ^ fTL-Ef C°0PELR m the SPrin£ of 1809' but "the aneurysm was very S\l nJc6 ? T16 W3f thruU3t UpWards b>' the tumour< so as t0 ^ke it impos- of thpTr^iff1"6 U^Pr ^ artery.£ithout incur»ng the risk of including some of the nerves of the axillary plexus. The attempt was therefore abandoned'' (/). (a) Wishart's Translation, above cited, BibliothekfilrChirurgieundOphthalmlogoie tto'n * t ,. vol iii. p.269, pi. i. f. 2, pi. ii. f. i. (b) Cooper, A., London Medical Review, (d) Manec, al.ove cited, pi. iv. fr^PrfS, km j- 4 c T (e} Le£°ns 0rilles.vo1 »'. p. 530. J Ivf d 34? ? L; Smg; Jovrna1, (^ London Medical Revi™> v°l- «• P- 300. xou xvi. p. . 331. (k) Burns, A., above cited, p. SO. (c) Above cited, p. 43. TYING THE ARTERIA INNOMINATA. 521 pneumo-gastric nerve and carotid artery, and drawn back with a blunt hook towards the shoulder by an assistant, who also draws the sternal portion of the muscle in the same direction. The subclavian artery, enclosed in its thick cellular sheath, now becomes visible; its branches, the inferior thyroideal, transverse cervical, vertebral, and internal mammary, are given off somewhat above. The thoracic duct, which here forms its curvature, lies on the inner edge of the sheath of the artery, and also behind the carotid. The artery is now to be somewhat isolated with the handle of the scalpel, the sheath opened on the outside with a careful stroke of the knife, by which injury of the thoracic duct is best avoided, and then with a curved blunt hook the ligature should be carried round the artery from behind forwards, and from above downwards. [(1) In reference to this most important point it may be mentioned, that there are in the Museum at St. Thomas's Hospital two preparations. The one, an aneu- rysm of the arch of the aorta, involving part of the arteria innominata, and mistaken for carotid aneurism; a parallel instance to Allan Burn's case. The other, an aneurysm from the curvature between the origins of the left carotid and subclavian arteries, which communicated by a narrow canal with a large bag in the neck, and having the carotid artery behind it. The latter was the case to which Astley Cooper referred, when advising Burns to be cautious in undertaking a proposed operation for a pulsating tumour above the clavicle, which was at first thought to be a subclavian aneurysm. In the Museum at Fort Pitt, Chatham, there is a prepara- tion of an aneurysm as large as a walnut between the origins of the arteria innomi- nata and left carotid. And also another, bounded by the brachio-cephalic trunks in front, the sac of which is deeply indented by the arteria innominata.—j. f. s.] 1455. Allan Burns (a) and Hodgson (1) proposed tying the arteria innominata, and showed, by injecting the dead body, that the circula- tion can be supported after the obliteration, and that on the subject, the operation can be performed without great difficulty, if the head be bent back, the sternal portion of the sterno-mastoid, sterno-thyroid and hyoid muscles be separated, and the artery followed to its origin. Mott {b), Graefe (c), Arendt {d), Hall (e)^ Bujalsky, Bland, and Lizars (/), have performed this operation on the living subject, but not success- fully. In Mott's case, the patient died on the twenty-sixth day, in Graefe's, on the sixty-seventh, and in Arendt's, on the eight day; in the two former cases from repeated bleeding, and in the third, in consequence of severe inflammation of the aneurysmal sac, of the pleura, and lung. Mott, beginning from the aneurysmal swelling, made a cut above the collar-bone, lengthened it to that bone, and continued it on the windpipe, above the upper end of the breast-bone. From thence he made a second cut of about the same length, and carried it along the inner edge of the sterno-mastoid muscle. He then separated the skin from the m. platysma myoides beneath it, cut through the latter, and carefully separated the sternal part ofthe sterno-mastoid muscle in the direction of the former cut. The internal jugular vein, which had ad- hered to the swelling, was now separated, the sterno-hyoid, sterno- thyroid muscles cut through, and turned back over the air-tube. The carotid now laid bare for some lines above the breast-bone, was sepa- rated from the pneumo-gastric nerve, and the internal jugular vein, (a) Burns, above cited, p. 31. Gebiete der Heilkunde von einer Gesellschaft ib) Medic, and Surg. Register of New praktischen Aerzte zu St. Petersburg. Sa- York 1818 vol. i. P. 8.—von Graefe und muel, iv. 1830, p. 18b. von Walther's Journal, vol. iii. pt. iv. p. 569. (e) Baltimore Medic and Surg. Journal (c) Journal above cited, and vol. iv. pt. iv. tad Review Oct 1833 pi 33 eg. » (/) Lancet, 1836-7, vol. u. p. 445, p. 602. ' (d) Vermischte Abhandlungen aus dem 522 DIFFERENT MODES OF TYING which were drawn to the outer side. He now exposed the subclavian artery, in which he particularly used the handle of the scalpel, and a small narrow knife, with a rounded cutting end. In this way he pene- trated to the division of the arteria innominata, following it under the breast-bone, freed it with the handle of the knife from all the surrounding cellular tissue, and after drawing the recurrent and phrenic nerve aside, he applied a round silk thread around the artery, about half an inch above its division. Graefe makes an incision on the inner edge of the sterno-mastoid muscle two inches long, and continues it two inches downwards upon the first portion of the breast-bone. He then separates the lips of the wound with blunt hooks, and passes the fore-finger of his left hand, be- tween the sternal part of the sterno-mastoid and sterno-hyoid muscles, not farther than the top of the breast-bone, separating the cellular tissue up to the carotid artery. The patient's head is to be then bent much backwards by an assistant, and the operator carries his finger down along the carotid. Having reached the inner surface ofthe top ofthe breast-bone, he finds a blue swelling, under which his finger must be introduced. With the aid of his finger, and the handle of the scapel, he proceeds down to the place where the arteria innominata divides into the carotid and subclavian arteries. Then continues for half an inch farther down, takes the hook, armed with a thread, in the right hand, passes it close to the finger of the left hand, down to the arteria innominata, and carrying it around it, draws the threads, and applies Graefe's ligature-apparatus. Mott used the instruments employed by Parrish, Hartshorne, and Hewson (a), which he recommends as sufficient for tying deep arteries. He carries a blunt- ended needle, having two eyes at the two ends, with a needle-holder, around the artery, carefully avoids the pleura, then introduces a hook into the eye of the needle, which is brought into view, with which, after freeing the needle-holder, he draws the needle out, and with it the ligature, which is then to to be gradually drawn together and tied with two single knots. No effect upon the heart or lungs was noticed. [(1) Chelius is mistaken as regards Hodgson on this point, for he neither pro- posed nor advised this operation. He merely quotes the operation proposed by Burns, and as to his opinion of it he observes:—" The ligature of the arteria in- nominata, or of the subclavian artery, on the tracheal side of the scalenus, must be regarded as peculiarly hazardous. I have thought it proper, however, to treat of these operations, because, under particular circumstances, a surgeon may conceive it his duty to undertake them." (p. 384.)—j. f. s.] 1456. Besides these operations performed on living subjects, Bujal- sky, King, Dietrich, and Manec, have proposed other methods for tying the arteria innominata. According to Bujalsky, the cut through the skin should be made on the inner edge of the sternal portion of the sterno-mastoid muscle, be- tween it and the windpipe, as long as the breadth of four fingers, a little to the inner sider ofthe muscle above, commencing at the middle of the neck, and extending down to the middle of the notch of the breast-bone. The fibres of the m. platysma myoides are now apparent at the upper angle of the wound, but at the lower, there is a considera- ble quantity of fat. The cut is to be continued deeper, and in the mid- dle of the wound the sterno-hyoid muscle is exposed, and to be cut (a) Eclect. Repos., vol. iii. p. 229. THE ARTERIA INNOMINATA.' 523 through obliquely; beneath it is the sterno-thyroid muscle, which is also to be divided. The operator should keep as much as possible to the inner edge, because the internal jugular vein runs along the outer edge. The inferior thyroideal vein, which in the wound passes obli- quely under the muscles, is to be drawn upwards or downwards. Suf- ficient depth having now been attained, the artery is to be isolated and tied. In King's (or, rather, O'Connell's) mode, a cut from fifteen to eigh- teen lines long is to be made on the inner edge of the sterno-mastoid muscle ofthe left side, through the skin, m. platysma myoides and fascia of the neck ; the finger is then passed between the sterno-thyroid mus- cles, and under the right of those muscles, the cervical fascia divided, the finger introduced beneath it, and carried down to the arteria inno- minata, lying upon it. Dietrich has correctly shown the impracticability of King's opera- tion, and proposes the following:—The patient's head should be bent a little backwards, and a cut from two and a half to three inches long, according as the neck is longer or shorter, and more or less fat, should be made from the middle of the base of the breast-bone directly up- wards, in the mesial line of the windpipe. After dividing the cellular tissue and fascia, several little veins appear, enclosed in loose cellular covering; these may very easily be put aside, as they run in the same direction as the windpipe, and terminate in a large vein, which is visi- ble at the lower angle of the wound. The cellular tissue is to be re- moved, and now the internal cervical/ama appears; on both sides lie the sterno-hyoideal muscles, separated by an interspace of two or three lines, and the fascia occupying it being cut through, the windpipe is reached. With a blunt hook the right sterno-hyoid, and sterno-thyroid muscles, are to be drawn outwards, which exposes the second inferior thyroideal vein, in the bottom of the wound, sometimes considerably expanded. If it be ofthe usual size, the point of the scalpel should be carried on its outer side, and the fatty cellular tissue carefully divided, the handle of the scalpel carried downwards, and so the arteria inno- minata reached. But if this vein be considerably enlarged, it must be got under from within outwards, and the cellular tissue in that way divided; this, however, must only be done with the handle ofthe knife, as otherwise there is no safety against wounding it, which is here of the greatest importance, as this vessel empties itself into the vena cava descendens, and, if wounded, severe bleeding would occur from the re- flux of the blood. The hook is to be carried under the artery from left to right. Manec (a) directs the head ofthe patient to be bent much backwards, so that the neck shall be greatly stretched, and the vessel to be tied brought up to the upper edge of the breast-bone ; and the face is to be inclined a little towards the left shoulder. A cut of three inches' length is to be made from the middle of the space dividing the two sterno-mas- toid muscles, towards the right shoulder, half an inch above the collar- bone, through the skin and m. platysma myoides; in the same direction the sterno-mastoid muscle is to be divided, and a director having been (a) Above cited, pi. ii. 524 CIRCULATION AFTER TYING SUBCLAVIAN ARTERY. passed under the sterno-hyoid and sterno-thyroid muscles, they also are to be divided. For isolating the artery, the operator uses only the handle of the knife. If the inferior thyroideal vein, and some fibres of the hypoglossal and first cervical nerve require division, this must be done with the knife. The artery is to be isolated at its outer and back part with great care, so as not to injure the pleura. After this is done, Deschamps' needle should be introduced from the outside, between the pneumo-gastric nerve and the pleura, carried out upon the other side between the artery and the windpipe, and the ligature then drawn in. 1457. When the entire trunk of the subclavian artery is obliterated, the blood flows from the superior thyroideal and occipital arteries, into the inferior thyroideal, cervical, transverse scapular, and numerous anastomoses, which spread over the neck and shoulder, into the sub- scapular, supra-scapular, and posterior-scapular arteries, from which it passes into the trunk ofthe brachial artery. If the obliteration be at the lower end of the subclavian, or at the axillary artery, the passage of the blood is much more ready, as it is carried by the anastomoses of the cervical, transverse cervical, and transverse scapular arteries, with the branches of the subscapular and posterior-scapular into the brachial artery (1). That in many cases, after tying the axillary artery for a wound, the sensation and nourishment of the arm are injured, depends not on the too small flow of blood, but on the injury of the plexus of nerves, caused by the wound, or by the tying (2). (1) The following is the account of the mode in which the circulation was main- tained in a case of axillary aneurysm, for which Key had tied the subclavian artery twelve years previously (a); the circumstances of which had been already de- scribed (b). " The subclavian trunk had undergone no material alteration in size from its origin to the point where the ligature had been applied, just on the outer edge of the scalenus muscle. Here the vessel became suddenly obliterated, assuming the form of a dense flattened cord, which was continued for about two inches and a half into the axilla, and terminated in the remains of the aneurismal sac. The precise spot where the artery had been tied was clearly indicated by a deep indentation; but the continuity of the vessel above the ligature with the obliterated portion below it, was not destroyed, or, more, properly speaking, had been restored, after the separa- tion of the silk, by a process of adhesion, which connected the two extremities to each other, and glued them to the contiguous structures. The aneurismal sac still existed in the axilla, where it formed a firm and solid, but at the same time some- what elastic and yielding tumour about the size of a small hen's egg, * * * and presented a smooth uniform exterior, bearing altogether considerable resemblance to those cysts which are occasionally found to form themselves around foreign bodies. The obliterated portion of the axillary trunk terminated in the upper and back part ofthe sac; while, from its under surface, the continuation of the artery was seen to emerge as a perfect vessel; having been restored to nearly its natural calibre by the entrance of a large branch, which was originally given off immediately below the tumour, and through which the blood had afterwards assumed a retrograde course. On opening the sac, the coats of which were remarkably dense and hard, it was found to contain a firm and solid coagulum, which readily separated from the sur- rounding cyst, and on being removed, retained the precise shape ofthe tumour. A section of it clearly evinced that it consisted of fibrin, apparently inorganized, dense and tough in its texture, and of a dirty-yellowish colour." The anastomosing ves- sels consisted of three sets:—" 1. A posterior set, consisting of the suprascapular and posterior scapular branches of the subclavian, which anastomosed with the infra- scapular from the axillary. 2. An internal set, produced by the connexion of the internal mammary on the one hand, with the long thoracic arteries and the infra- scapular on the other. 3. A middle or axillary set, which consisted of a number of (a) Guy's Hospital Reports, vol. i. 1836. (6) Med. Chir. Trans., vol. xiii. p. 1. 1827. TYING INTERNAL MAMMARY AND VERTEBRAL ARTERIES. 525 small vessels derived from branches of the subclavian above, and passing through the axilla to terminate either in the main trunk, or some of the branches of the axil- lary below. This last set presented, most conspicuously, the peculiar character of newly-formed, or rather dilated, arteries. They were excessively tortuous and formed a complete pkxus, which was almost inseparably connected with the axillary nerves; many of the branches penetrating into the midst of the nervous fibres, so as to render their separation a work of great difficulty and labour. The chief agent in the restoration of the axillary trunk below the tumour was the infrascapular artery, which communicated most freely with the internal mammary, suprascapular, and posterior scapular branches of the subclavian; from all of which it received so great an influx of blood, as to dilate it to three times its natural size. The infrascapular artery was, in this subject, given off much higher than usual; and its origin had been included in the aneurysmal dilatation; in fact the artery opened into the sac itself; and, under the restored state of the circulation, the blood had to traverse a small portion of the cavity in order to reach the commencement of the axillary trunk. The continuity between the two vessels had been preserved through the coagulum contained in the tumour, which, for a short space, actually constituted the arterial coats; thus, when the contents were removed, the injected wax became exposed at the bottom ofthe cyst; while a corresponding deep sulcus in the coagulum indicated the channel through which the blood had passed. The suprascapular artery was, in this instance, given off by the superficial cervical, and became augmented just as it reached the scapula, by a branch which arose from the obliterated portion of the main trunk, but which had again been rendered available, as a medium of circulation, by receiving a vessel from the subclavian above. The common origin of the short thoracic and humeral-thoracic arteries had become obliterated as it came off from the sac itself; but the two vessels had subsequently regained their original size; the one being supplied by its connexion with the internal mammary, the other by com- munications with the superficial cervical." (p. 63-5.)] This preparation is in Guy's Hospital Museum. (2) Not only do weakness and numbness occur when the axillary nerves are injured, but even gangrene has happened in the case mentioned by White, of Man- chester (a), in which three ofthe nerves were tied in, and in Desault's case, (b), in which the whole axillary pkxus was included in the ligature.—j. f. s.] 1458. The tying of two branches of the subclavian artery, to wit, the internal mammary, and the vertebral artery have yet to be mentioned. 1459. The internal mammary artery may be tied without much difi> culty in the second, third, or fourth intercostal space; in the first, its nearer position to the edge of the breast-bone renders it's tying more dif- ficult. In either of the just-named intercostal spaces, a cut made from the edge of the breast-bone, and on the upper edge of the lower rib, is carried outwards, and a little upwards towards the lower edge of the upper rib, so that its whole extent occupies an inch and a half, and by its termination, just below the under edge ofthe upper rib, it is secured from injuring the intercostal artery. The skin, celklar tissue, and aponeurosis ofthe great pectoral muscle are divided, and also the muscle itself. There still appear some layers of cellular tissue, and beneath them the ligamenta nitentia; these are to be divided with some slight strokes of the knife, as well also as some fibres of the intercostal muscles hereupon seen, with which usually a small arterial branch is cut through, and must be at once tied. A thin layer of cellular tissue still covering the artery is now to be carefully divided, the artery isolated from the accompanying vein, and a needle carried round it, from within outwards. In the third and fourth interspace the artery lies upon the fibrous expan- (a) London Medical Journal, vol. iv. p. 159. (b) ffiuvres Chirurgicales, vol. ii. p. 553. Vol. II.—45 526 TYING THE VERTEBRAL ARTERY. sion ofthe m. triangularis sterni; so that, in carrying round the needle, there is no fear of wounding the pleura {a). Velpeau's practice of making a cut three inches long, parallel to the side edge of the breast-bone, and which must be deepened to get at the artery, is unfitting. On the contrary, I have very frequently found the artery by a cut, commencing on the side edge of the breast-bone, and running directly in the middle of the costal inter- space, more frequently than in the way just described. 1460. For the possible case of tying the vertebral artery, Dietrich (b) has proposed two modes of treatment, according as the artery is to be looked for between the atlas and dentate vertebra, or between the atlas and occipital bone. In the former case, the head ofthe patient being inclined to the oppo- site side, and a little forwards, a cut is to be made two fingers' breadth from the lobe of the ear, or one finger, behind the mastoid process, beginning half an inch above the latter, and carried for two inches along the outer hinder edge of the sterno-mastoid muscle. From the upper fourth ofthe length of this cut, a second is to be carried backwards, and obliquely downwards, to the extent of an inch. After dividing the skin, some cellular tissue appears in both cuts, which should be divided, and then in the first is seen the outer and hinder edge of the sterno-mastoid muscle; and in the second, the m. splenius covered with aponeurotic expansion. The wound is now to be deepened, through the aponeurotic and cellular tissue, and in the second cut the fibres ofthe m. splenius are to be divided, at which time a small artery will be wounded. After the division of this muscle a second aponeurotic layer appears, which must be divided with some light strokes of the knife, and under it pass some branches of arteries and nerves. An assistant with blunt hooks holds the edges of the wound apart, and now a layer of fat appears, in which the vertebral artery is enveloped. At the same time also the outer edge of the m. obliquus capitis inferior is seen at the inner edge of the second wound, and is to be drawn somewhat inwards. Two branches of the occipital artery, also enclosed in cellular tissue, pass across the wound. The cellular tissue is now to be divided with the handle ofthe knife, and the arterial branches drawn upwards or downwards. Two branches of the second cervical nerve also now show themselves, and are to be drawn up or down out of their place; after which the isolation of the artery is no longer prevented. This done the needle is to be carried round the artery from without inwards, in order more certainly to avoid the internal carotid artery, which lies very near the vertebral, and is only separated from it by cellular membrane. If the vertebral artery be tied between the atlas and occiput, the cut should be made, as in the former case; but the first is to be begun a quarter of an inch above the mastoid process, by which the second cut, which, in like manner, passes from the upper fourth of the length of the former backwards and obliquely downwards, runs somewhat more up- wards. After cutting through the skin, fascia, and m. splenius, the occipital artery appears in the upper angle of the first wound, as also at the front edge on the upper fourth, the hind edge of the m. obliquus capitis superior; but in the whole surface ofthe wound a layer of aponeu- rosis, and under it cellular tissue, loaded with fat, the former of which (a) Dietrich, above cited, p, 89. (b) Ibid., p. 81. TYING THE BRACHIAL, ULNAR, AND RADIAL ARTERIES. 527 must be carefully divided. The edges of the wound are now to be held asunder with blunt hooks by an assistant, and then a triangle appears, formed by the m. rectus capitis posterior, and m. obliquus capitis superior and inferior, filled with fat and cellular tissue, which covers the artery. This is then to be carefully divided, turned back, and, if in large quantity, should be partially removed, upon which the artery appears below the m. obliquus capitis superior, and runs backwards nearly an inch before it perforates the occipito-atlantal ligament. The vessel is then to be iso- lated, and the ligature, by the aid of a ligature-needle, passed obliquely from below upwards, for the purpose of more surely avoiding the nerves and vein. Nuntiante Ippolito, who saw two cases of aneurysm of the vertebral artery, has proposed the following mode of tying it. After having found the triangular space formed by the external jugular vein, the hind edge of the sterno-mastoid muscle, and the upper edge of the collar-bone, a cut is to be made through the skin, from its top to the base, not exceeding two inches in length. The operator continues penetrating in this direction till he reach the inner edge of the m. scalenius anticus, and thus the artery is easily struck upon, without injuring one twig of a nerve (a). Mobus (b) mentions a case of aneurysm of the vertebral artery, originating in wound which was cured by compression, the application of ice, and so on. [An example of this very rare disease (aneurysm of the vertebral artery) has recently occurred in the Northern Infirmary at Liverpool; the carotid artery could be distinctly traced over the pulsating swelling, of the actual nature of which there were some doubts, as to what kind of aneurysm it was, or whether only a pulsating tumour. It was decided to tie the common carotid artery. The tumour rapidly increased after the operation, and in about a fortnight the patient died by bursting of the aneurysm into the trachea. On examination, an aneurysm of the vertebral artery, between the transverse processes of the fourth and fifth cervical vertebras was found.— j. f. s.] Upon the importance of tying the vertebral arteries, and its greater danger in com- parison with tying the carotid arteries in animals, see Astley Cooper (c). [The arteries of the brain sometimes become affected with aneurysm. In the Museum of the Royal College of Surgeons, there is an example of a small conical aneurysm in the cerebral artery.—j. f; s.] Ill,—OF ANEURYSM OF THE BRACHIAL, ULNAR, AND RADIAL ARTERIES. 1461. Aneurysms ofthe brachial artery, and its branches, are almost always consequent on wounds, and occur most frequently at the bend of the arm, after a wound of the artery in bleeding. In these aneu- rysms therefore compression is commonly employed with the best results. [" I do not recollect," says Astley Cooper, " to have seen a case of aneurysm from disease in the brachial artery." (p. 78.) Hodgson observes:—" I have never seen an aneurysm in the arm which was not produced by accidental violence." (p. 389.) Liston (d) also speaks of the rarity of spontaneous aneurysm at the bend of the elbow; and says :—" I have treated but one such case in the person of an old ship-carpente'r. While at work, as usual, he felt something snap in his arm, a pul- sating tumour was soon after noticed, and it had attained, during four months, fully (a) Froriep's Notizen, 1835. p. 304. and the Pneumo-gastric, Phrenic and Sym- (b) von Graefe und von Walther's pathetic Nerves; in Guy's Hospital Reports, Journal vol. xiv. p. 98. vol. i. p. 457, and p. 654. (c) Some Experiments and Observations (d) Practical Surgery, 1838. Second Edit. on tying the Carotid snd Vertebral Arteries, 8vo. 528 TYING THE BRACHIAL, the size of a hen's egg, and was evidently, in part, made up of solid matter. The brachial artery was tied, and every thing went on favourably, (p. 181.) J 1462. If the aneurysm be seated in the trunk of the brachial artery, at the bend of the arm, or in the ulnar (1), radial (2), or interosseal artery near the bend, it is sufficient to tie the brachial artery {a). But if it be situated in the middle of the fore-arm, in the region of the wrist, it is necessary to tie the. artery near the aneurysmal sac, because the free anastomosis on the back of the hand, is sufficient to support the aneurysm by ihe reflux ofthe blood (6). The free anastomosis ofthe arteries ofthe arm always renders it advisable to un- dertake tying the artery near the sac, because in many cases the regurgitation of the blood continues the growth of the sac, and causes its bursting (par. 1423.) In an aneurysm originating from wound ofthe artery, in the middle of the arm, when the sac does not extend far upwards, the opening of the sac is to be effected according to Hunter's first plan. [(1) Astley Cooper had seen " only one ease of aneurism of the ulnar artery from disease; it was seated where the artery dips under the pronator radii teres and flexor muscles of the hand." The artery was tied above the swelling with great difficulty, and "the patient died from the constitutional irritation resulting from this operation." (p. 81.) _ (2) Liston says he has "secured the radial and ulnar arteries in all parts of then course for small aneurysms." (p. 187.) In the College Museum there is a prepara- tion of aneurysm ofthe radial artery an inch above the origin ofthe superficial volar branch. Astley Cooper mentions a case in which William Cooper, formerly surgeon at Guy's Hospital, "in performing this operation, (tying the radial artery,) found the upper portion of the radial artery obliterated, and that the aneurism was supported by regurgitation from the hand, from the free anastomosis with the ulnar artery." (p. 81.)] 1463. In aneurysm upon the back or front of the hand, tying one or other of the large arteries of the fore-arm does not, on account of the extensive communications which the ulnar and radial arteries have with each other in the hand, prevent the blood flowing back with suffi- cient power to keep up the aneurysm. If in this case pressure be in- sufficient for curing the aneurysm, the sac must be opened, and the artery, tied above and below; and if this be not possible, one ofthe princi- pal arteries of the fore-arm must be tied, the sac opened, and the bleed- ing arrested by pressure. The same rules must be followed in wounds of the arteries of the fore-arm and hand (c). 1464. The brachial artery may be tied in any part of its course, from the arm-pit to the bend of the elbow. Its tying, therefore, must be con- sidered, first, at the end of the axillary artery, where it passes beneath the lower edge of the great pectoral muscle; second, in the middle of the upper-arm; and third, at the elbow-joint. * 1465. If the artery be to be tied in the arm-pit, the arm must be separated from the trunk, and the fingers carried along the inner edge of m. biceps into the arm-pit for the purpose of ascertaining the course ofthe muscle, and the position of the artery. A cut is then to be made along the inner edge ofthe m. biceps, of two inches in length, which is to extend upwards to the middle of the neck of the upper arm-bone. The skin first and then the aponeurosis is to be divided, with a careful (a) Scarpa, above cited, p. 384.—Roux, Nouveaux Elemens de Medecine Operatoire, vol. i. pt. ii. p. 759.—Hodgson, above cited, p. 393.—Walther, above cited p. 58. (6) Hodgson, above cited, p. 394. (c) Scarpa, above cited, p. 407. RADIAL AND ULNAR ARTERIES. 529 cut; or the latter is first raised with the forceps, and cut into with ihe bistoury held flat, so as to admit a director, upon which it is to be divided. The edges of the wound are now to be separated with blunt hooks from each other, when the inner edge of the m. coraco-brachialis and biceps, together with the median nerve, are now seen, and behind the latter lies the artery. The nerve is drawn carefully inwards, and the artery which is between it and the edge of the just-mentioned muscles isolated, and the needle carried carefully around it, so as not to include the internal cutaneous nerve. If the operator keep on the inner edges of the m. biceps and coraco-brachialis, in the manner recommended, and draw the median nerve inwards, there is no danger of erring, which may easily be done if he keep somewhat more inwards, where the radial or ulnar nerve are met with; and if one of these be mistaken for the median, the artery will be sought in vain. The following is the relative position of the artery:—The artery is separated from the edge of the m. biceps and coraco-brachialis only by the median nerve; on its inner side is the internal cutaneous nerve, and these two nerves at once cover the front of the artery. Near the cutaneous nerve lies the vein, which frequently forms two or three branches, and these render the iso- lation of the artery difficult. Still further inwards lie the radial and ulnar nerves. 1466. In order to tie the brachial artery in the middle of the upper arm, a cut, two and a half inches long, is made through the skin, along the inner edge ofthe m. biceps. The aponeurotic expansion is then to be divided, and the artery is found on the inner edge of the just-named muscle covered with the median nerve, between its two accompanying veins. The edge of the m„ biceps is to be taken hold of, and the me- dian nerve drawn somewhat inwards, between which and the edge of the muscle the artery appears, and is easily isolated with the handle of a knife; the ligature is to be carried round it with Deschamps' needle.. The brachial artery frequently divides high up. If the ulnar artery be given off high up, it is always observed to penetrate the fascia of the upper arm, and take a superficial course. If the radial originate high up, it for the most part accompanies the ulnar artery to the elbow-joint, and then separates from it (a). Tiedemann (b), who has very often noticed the high division of the brachial artery in the corpse, found in such cases the radial artery nearly always very superficial at the elbow-joint, im- mediately under the aponeurotic expansion, from the aponeurosis of the m. biceps ,- on which account it is very easily wounded, but can also be as easily tied. The ulnar artery lies beneath this aponeurosis of the m. biceps. If, on laying bare the brachial artery, two arteries are found, they must be alternately compressed, in order to ascertain whether the pulsation in the aneurysm- be stopped, for the purpose of tying that one in which it is seated. 1467. To tie the brachial artery at the bend of the arm, a cut two inches Iona is to be made through the skin on the extended arm, in the direction ot a line imagined to be drawn from the middle, between the two condyles ofthe upper arm-bone, obliquely inwards and upwards towards the inner edge of the m. biceps. The veins lying beneath the skin are to be avoided, the superficial aponeurosis of the m. bicepses to be opened without or with a director introduced, and the artery isolated, for which purpose the fore-arm should be somewhat bent. The median nerve here lies upon the inside of the artery three or four lines distant from it- the median basilic vein.lies,sometimes.upon, sometimes at the side of, and-, frequently beneath the artery ; and farther outward is the median cephalic vein. 1468. To lay bare the radial artery ifi the upper third of the fore-arm, (a) Hodgson, above cited p. 391. (V Walther, above cited,.p. 63'. Tabula Artenarum, pi. xiv. xv. 530 TYING THE BRACHIAL, RADIAL AND ULNAR ARTERIES. a cut should be made, about two inches long, through the skin, a little below the insertion of the tendon of the m. biceps, in the oblique direction of the ulnar edge of the m. supinator longus. The aponeurosis of the fore-arm is to be divided in the same direction, and.the edge of the just- mentioned muscle inclined somewhat outwards, when the artery appears in the interspace between it and the m. flexor carpi radialis. A branch of the musculocutaneous nerve lies upon the outer side of the artery, which is accompanied by one or two veins. In laying bare the ulnar artery in the upper third of the fore-arm, a cut two inches and a half long is to be made between the radial edge ofthe m. flexor carpi ulnaris, and the m. flexor digitorum sublimis, through the skin and aponeurosis of the fore-arm. The artery lies rather under the edge of the m.fiexor digitorum sublimis, accompanied by a vein, and on its outer side by the ulnar nerve. In the lower part of the fore-arm, where these arteries are quite super- ficial, they are very easily laid bare. "With the radial artery the cut falls on the radial side ofthe tendon of the m.fiexor carpi radialis; with the ulnar artery between the tendons ofthe m.fiexor carpi ulnaHs and flexor sublimis digitorum. If the ulnar artery be tied in the region of the wrist, a cut an inch and a half long, and three or four lines to the outside of the pisiform bone, should be made through the skin and fatty cellular tissue, which often fills up the whole wound, and, in such case, must be in part removed. The ulnar nerve is now found opposite the pisiform bone, and to its outer side the ulnar artery, accompanied by two veins. The artery should be isolated, and the ligature applied above the origin of its hinder branch which anastomoses with the deep palmar arch. To tie the end of the radial artery, the hand must be brought prone, and bent somewhat towards the fore-arm. A cut is to be made from the outside ofthe styloid process ofthe spoke--bone, to the vupper part ofthe interspace separating the first and second metacarpal bones. After cut- ting through the skin, the veins coming into view are to be drawn out- wards or inwards, and the delicate branches of nerves which cross the wound divided. The position of the tendons of the m. extensor longus and brevis pollicis is now to be ascertained, and between them, and towards the most depending part of the carpus, a kind of soft and thick aponeurosis, which covers this part, is to be divided. Beneath it are some little masses of fat, which, if in the way, are to be removed, and then upon the carpal bones a thin aponeurotic layer is seen, which allows the artery, with its accompanying veins, to show through. This layer is then divided upon the director, and the artery easily isolated (a). 1469. The supply of blood to the arm, after tying the brachial artery, is effected by the branches ofthe arteria profunda humeri, and the anas- tomoses of the recurrent radial, ulnar, and interosseal arteries. If the brachial be tied above the origin ofthe arteria profunda, the blood flows through the ramifications of the circumflex humeral and subscapular arteries, into the ascending branches of the arteria profunda, and the recurrent radial and ulnar arteries. [White, of Manchester (b), has given a beautiful engraving of the circulating {a) Manec, above cited, pi. vii. viii. (ft) Cases in Surgery, p. 133. London, 1770. 8vo. TYING THE AORTA. 531 branches fourteen years after the brachial artery had been tied just above the bend of the elbow, for a wound in bleeding. In the Museum at St. Thomas's Hospital are two beautiful preparations of the anastomotic branches enlarged after the brachial artery had been tied. In the one a long portion of the artery had been obliterated, and sets of vessels are descending on either side from above the obliteration, to be received into others which ascend in similar manner from below it. In the other the obliteration is less extensive, and a single curved artery about as big as a crow-quill passes from the upper to the lower open part of the artery.—j. f. s.] IV.—OF ANEURYSM OF THE EXTERNAL AND INTERNAL ILIAC ARTERY. 1470. Astley Cooper (a), in an aneurysm which extended four inches above and as many below Poupart's ligament, and had burst, undertook to tie the abdominal aorta. For this purpose he made a cut into the white line three inches in length, in the middle of which was the navel, which, by a curve in the wound, was placed on its left side, and then a small opening made into the peritonaeum, which was lengthened with a button-ended bistoury to the extent of the external wound. He then passed his finger between the intestines, down to the spine, scratched with his nail through the peritonaeum on the left side, carried his finger gradu- ally between the spine and aorta, and then passed a single ligature with a blunt aneurysmal needle around it. The ligature was carefully tied without including intestine, and the wound brought together with the quill suture and sticking plaster. The patient died forty hours after the operation ; sensation and warmth had, however, returned on the thigh of the healthy side, but that of the diseased side was cold and bluish. James (b), on account of an aneurysm ofthe external iliac artery, first tied the femoral, according to Desault's and Brasdor's proposal; and the aneurysm>at first diminished a little, but soon increased. He then proceeded to tie the abdominal aorta as Astley Cooper had done, only that he began his cut in the white line an inch above, and terminated it two inches below the navel. The patient died the same evening. Murray (c) tied the aorta on account of a very extensive iliac aneu- rysm. He made a cut through the skin and muscles, beginning from the jutting extremity of the tenth rib, and continuing it about six inches down, curving in a direction backwards to an inch from the upper front spine of the hip-bone. He divided the transverse fascia on a director, separated with his hand, carried in flat, the peritonaeum from the sheath ofthe m. iliacus internus and psoas, and easily reached the aorta. Passing the finger between the spine and aorta was more difficult, as also was the separation of the nervous plexus and the sheath of the aorta, which he effected partly with his nail, and partly with an elevator. Passing the aneurysmal needle was also very difficult. Drawing the ligature together did not excite any pain. The patient lived twenty-three hours after the operation. It may be more convenient, as recommended by Astley Cooper, in tying the (a) His and Travers' Surgical Essays, (c) London Medical Gazette, vol. xiv. p„ vol. i. pt. i. p. 393. 68,1834. (fr) Medico-Chirurg. Trans., vol. xvi. p. 1. 532 TYING THE COMMON ILIAC ARTERY. abdominal aorta, to make the cut about an inch distant from the epigastric artery, outwards and running parallel to it, and to proceed as in tying the internal iliac artery. According to Guthrie's recent views, it is in no case necessary to tie the aorta, because in an aneurysm of the external or internal iliac, the common iliac on the diseased side can always be got at, and if not there, yet on the healthy side, for the purpose of carrying a ligature around it. [The aorta was also tied by C. D. Monteiro (a) at Rio Janeiro, Aug. 5, 1842, for an aneurysm of the femoral artery, close to the groin, which on examination turned out to be spurious, by the vessel having burst and formed a large swelling, occupy- ing a great portion of the right under part of the belly. The incision was made on the left side, from the tip of the last false rib to the upper front iliac spine, through the abdominal walls, avoiding the peritonaeum. The fingers were then earried down to the aorta, and a ligature with great difficulty passed around it by means of a liga- ture-needle. But little blood was lost. As soon as the ligature was tied, the aneurysm sunk down, but the artery swelled up (1), and for some time remained as a thick large knot. The case went on well till the eighth day; at three, p. m., arte- rial blood escaped through the dressings; it did; notr however, affect the pulse, but patient's countenance was sunken and hollow. The bleeding continued, and on the tenth day, at 10 a. m., he died. The ligature had been placed two lines above the bifurcation of the aorta,- a small opening was found on the left side of the vessel, immediately above the ligature.] 1471. If an aneurysm be situated on the external or internal iiiac artery, or if it have extended so far upwards that there is not sufficient space between the aneurysm and the origin of these arteries to apply a ligature, tying the common iliac artery is indicated. Gibson {b) tied this artery for a wound; Mott (c) on account of an aneurysm ofthe internal iliac artery, Crampton (d) ancfSALAMON (e)on account of a large external iliac aneurysm ; Liston for secondary haemorrhage ; Guthrie for a pre- sumed aneurysm ofthe gluteal artery; also Syme, Deguise, and Peace^jT); but Mott's, Salamon's, Deguise's, and Peace's operations alone were successful. 1472. In order to tie the common iliac artery, an imaginary line must be drawn from the upper front spine of the hip-bone directly towards the white line: two and a half inches above this line, and two lines from the outer edge ofthe m. rectus abdominis, a cut should be begun, earried obliquely downwards and outwards, and terminated an inch and a half below the line, so that it has a length of from four to five inches. In this direction, the skin, the fascia of the external oblique muscle, the muscle itself, and then the fascia of the internal oblique muscle, are cut through; the transverse muscle with its aponeurosis is then divided with some careful strokes of the knife, or a director is introduced, and they are divided upon it. Any spouting vessel must be tied; the edges of the wound drawn asunder with blunt hooks by an assistant, and with the finger passed down into the wound, or with the handle ofthe knife, the cellular connexion of the peritonaeum with the surrounding external parts must be divided. The patient's trunk is then to be inclined towards the (a) From a letter of Lallement's ; in (d) London Medical and Surgical Journal, Schmidt's Jahrbucber der in und auslan- vol. v. p. 382. dischen gesammten Mcdecin. Jahrgang, (e) Froriep's Notizen, vol. iv. Now 3, 1843. Leipz. 1837. (6) American Medic, and Surg. Recorder, (/) Dublin Journal of Medical Science, 1820, vol. iii. p.. 1^5. vol. xxiii. p. 214, 1843, extracted from the (c) American Journal of Medical Sciences, Philadelphia Medical Examiner. vol. i. p. 156, 1827. TYING THE INTERNAL ILIAC ARTERY. 533 healthy side, so that the intestines may drop away from the wound, and the division of the outer and under parts be facilitated. If there be not any diseased thickening, the separation is easy; but if there be, the bis- toury must be used with the greatest care. The peritoneum with the ureter is now to be borne upwards, and being kept in that position with a spatula, by an assistant, the finger is to be carried down to the artery, which lies in a position corresponding with the cut. Below the artery and a little inwards, the accompanying vein lies; and at the lower angle of the wound pass branches of the ilio-lumbar artery and veins. The sheath of the artery must be torn with the nail of the forefinger, or with the handle of the scalpel, according as it is thinner or thicker ; the artery is then isolated, and the needle carried round it, whilst the vein is pressed inwards (a). Mott made a cut, five inches long, beginning immediately above the external abdominal ring, and continued in a semi-lunar direction half an inch above Poupart's ligament, to a little above the front spine of the hip-bone; he then divided the external and internal oblique and transverse muscles, and separated the peritonaeum from its cellular connexions. Crampton carried a cut, seven inches long, from the seventh rib, downwards and forwards, to the front spine of the hip-bone, in a semicircular form, with its concavity towards the navel, cut through the three abdominal muscles, and separated theperi- tonxum. According to Anderson (b), the cut should be commenced from the upper and front spine of the hip-bone, half an inch above Poupart's ligament, parallel with it, continued towards the share-bone, and curved somewhat upwards, so that it is four inches long; cutting through the three abdominal muscles, and so on. Salamon made a cut about an inch from the upper front spine of the hip-bone, proceeding at similar height from it, and in parallel direction to the epigastric artery, terminating about a finger's breadth below the last false rib, and from four to four and a half inches long. The division of the abdominal muscles and transversal fascia, and so on. 1473. If an aneurysm be situated on a branch of the internal iliac artery, to wit, on the isehiatic or gluteal artery, tying the internal iliac is indicated, as the practice followed by J. Bell (c) in a case of isehiatic aneurysm arising from injury, viz., opening the sack and tying the artery above and below the wound is extremely dangerous, and only in few cases can be permissible. W. Stevens (d) tied the'internal iliac artery for an aneurysm above the isehiatic notch; J. Atkinson (e) on account of a gluteal aneurysm, so also White .(/); Mott {g), for a gluteal or isehiatic aneurysm. Atkinson's and Mott's cases were unfortunate, but the other two had the happiest result (1). [(1) The internal iliac artery has also been tied successfully by a Russian army- Surgeon (h); also by my friend Thomas, of Barbadoes, but the patient died, and the preparation is in Guy's Museum (i).] 1474. To tie the internal iliac artery, a cut of five inches in length is to be made through the skin and three muscles, upon the under and outer side of the belly, parallel to the course of the epigastric artery, and an inch to its outer side. The exposed peritonaeum is to be separated with (a) Dietrich, above cited, p. 288. (b) System of Surgical Anatomy, p. 1. (c) Principles of Surgery, vol. i. P-421. (d) Medic. Chir. Trans, vol. v. p. 422. (e) London Medical and Phys. Journal, vol. xxxviii. 1816. (/) American Journal of Medical Sci- ences, vol. i. p. 304. 1828. (g) Ibid., vol. xx. p. 1, 1837. (It) Avkrill's Operative Surgery, p. 79. (i) Med. Chir. Trans., vol. xvi. p. 230. 534 TYING THE INTERNAL ILIAC, the finger from the m. iliacus internus and psoas magnus, and the finger carried down to the internal iliac artery which should be detached by it from its connexions; and about half an inch below its origin a ligature is to be carried round it with an aneurysmal needle. In this way Stevens proceeded, and this operation is most proper and safe. White made a semicircular cut seven inches long, beginning two inches from the navel, and continuing it nearly down to the external inguinal ring. According to Anderson and Bujalsky, the cut should be begun a finger's breadth above the upper front spine of the hip-bone, or even higher, and half an inch distant from Poupart's ligament, but continued parallel to it for about three inches towards the share-bone. Cutting through the three abdominal muscles, separation of the peritonaeum and retracting it together with the spermatic cord upwards. [The following are the particulars of Owen's dissection (a) of Stevens' case. The woman died ten years after the internal iliac artery had been tied. The internal iliac artery had become impervious at the part where the ligature had been applied, and "the ilio-lumbar appears to have arisen just above this point, the obliteration in consequence had not extended to the origin of the external iliac. In the state of a ligamentous cotd, the internal iliac descended towards the isehiatic notch for the space of an inch, and then suddenly resuming its natural diameter it again became pervious, and so continued for the extent of half an inch; the glutaeal artery arising from the lower part of this space; a sacro-lateral vessel from about the middle; and the obturator artery from the upper part of it. The latter vessel was, however, entirely obliterated, but the sacro-lateral artery was pervious, of the size of a crow quill, and passed inwards to the second sacral foramen; whilst the glutaeal artery, of its natural size, received close to its origin two vessels as large as the preceding, given off from the sacro-lateral artery, near the third and fourth sacral foramina of the left side. The anastomoses ofthe sacro-lateral arteries with each other and the sacro-median were large and tortuous. Immediately after the origin of the gluteeal artery, the isehiatic, obliterated and cord-like, passed on to the lower part of the isehiatic notch ; the sanatory processes set on foot by the application of the ligature being uninterrupted by the enfeebled current of blood passing from small canals to a large one. Many vessels met with in the course of the dissection of the glutaeus maximus and medius were found to have received the injection. The glutaeal artery was in a healthy condition, and of the natural size; but an elongated tumour, situated between the tuberosity of the ischium and the great trochanter indicated the true sea* of the original disease. This tumour in length three inches and a half, and above two-thirds of an inch in breadth, was ofthe sciatic artery, and consisted of layers of condensed cellular membrane and the peculiar fibrous arterial coat. It contained a quantity of dark-coloured granular not lamellated coagulum, which, when removed, showed the internal surface of the sac to be somewhat irregular and raised in small patches by the deposition of soft matter. In some places it appeared to retain the smooth character of the arterial lining membrane. From the isehiatic notch to the tumour, the artery was completely obliterated, its texture altered and the remains of the cavity filled with indurated and partly calcareous matter. From the lower part of the tumour the sciatic artery was continued down the posterior part of the thigh of an uncommon size, nearly as large as the femoral artery in front; its calibre did not, however, correspond with the apparent magnitude, for its coats were thicker, by at least one-half than any artery of the same size with itself. It was obliterated for about the space of an inch below the sac, and became pervious after receiving an anastomosing vessel from the arteria profunda. A vessel ramifying between the glutaeus maximus and medius, and distributing branches to these muscles, was con- nected to the commencement of the sac, from which it had probably arisen; it did not, however, open into the sac, but after becoming contracted near the point of attachment, it there gave off a small artery to the quudraius femoris and received its blood by anastomosing near the crista ilii, with a superficial branch of the glutaeal artery. A smaller vessel was similarly attached to the lower part of the aneurysmal sac, but neither did it communicate with that cavity, for the blood which it received trom branches ramifying in the neighbourhood was diverted from the sac by a small branch given off at the point of attachment." (pp. 222-25.)] (a) Med. Chir. Trans, vol. xvi. GLUTEAL, ISCHIATIC, AND PUDIC ARTERIES. 535 1475. If the gluteal artery is to be tied, a cut three inches long should be made through the skin and cellular tissue, commencing at the upper hinder spine ofthe hip-bone, and carried in the direction ofthe fibres of the great gluteal muscle, towards the great trochanter. The fibres ofthe great and middle gluteal muscle are to be divided in the same direction, to the lower edge of the hip-bone and the artery found. Carmichael (a) tied the gluteal artery, for spurious aneurysm, by a penknife wound in the way just directed. From one to two pounds of coagulated blood were emptied out. The vessel could not be taken up with a tentaculum; but a ligatuTe, with a large common needle, having been passed round it, was tied, and came away in six days. The boy was convalescent in sixteen days. To tie the isehiatic artery, a cut two and a half inches long must be made through the skin and cellular tissue, commencing immediately be- low the under hind spine of the hip-bone, and continue along the fibres ofthe great gluteal muscle, towards the outside of the tuberosity of the haunch-bone, where it is connected with the rump-bone, and the artery is found lying on the ischio-sacral ligament {b). 1467. If the common pubic artery is to be tied, a cut of an inch or an inch and a half long should be made along the inside ofthe descending branch of the haunch-bone, through the skin, cellular-tissue, fascia of the great gluteal muscle, and through the muscle itself. The edges of the wound are to be kept asunder with blunt hooks, by which a layer of fat is exposed, and beneath it lies the artery. This is to be divided, or partially removed till the m. erector penis be laid bare, on the inner side of which muscle lies the vessel, accompanied by two veins and a branch of the pudic nerve. The transverse perinaeal artery also accompanies the pudic, running almost parallel with it. The artery is to be carefully isolated, and the needle carried round it, from within outwards (c). [In the Museum ofthe Royal College of Surgeons there is an example of aneu- rysm of the pudic artery an inch in diameter, and nearly filled with clot. Whilst alive, the patient had a strongly pulsating tumour under the left great gluteal muscle; he was much out of health, and died. On examination, there was found beneath the hinder edge of the muscle a tumour, as large as a walnut, upon the isehiatic notch, and adhering to the isehiatic nerve as it left the pelvis. The artery was the internal pudic, and it was healthy above till it at once dilated into an aneurysm, below which it was obliterated, so that there was no outlet for the blood: the coats were strong like the coats of many cysted tumours.—j. f. s.] V—OF ANEURYSM OF THE FEMORAL AND POPLITEAL ARTE- RIES AND THEIR BRANCHES. 1477. Abernethy {d) was the first who tied the external iliac artery in the groin for aneurysm. This case, although not successful, showed the possibility of the limb being sufficiently supplied with blood after ob- literation of the artery. [The first time Abernethy tied the external iliac artery was" in the early part (a) Dublin Journ., vol. iv. p. 231, 1833. Physical JoaniaLvoL vii p. 97 1802, and (b) Zang Operationslehre. Third Edition, in his Surgical Works, vol. i. p. 254. The t i 203 case mentioned is cited from the °(c) Dietrich above cited, p. 244. latter, and the second from the former work. (d) On Aneurysms; in the Medical and —J. f. s. 536 TYING THE EXTERNAL of the year, 1796, on a patient in St. Bartholomew's Hospital who had popliteal aneurysm in one, and femoral aneurysm in the other leg. The femoral artery was tied for the cure ofthe former by Sir Charles Blicke with two ligatures, between which it was divided; the upper ligature came away on the tenth and the lower on the fifteenth day, and the cure was perfected. " About five weeks after this opera- tion, the aneurism in the opposite thigh was almost ready to burst, the tumour having acquired a pyramidal form, and the skin covering the apex having yielded so much as to form a kind of process from the tumour. Indeed the integuments at this part were so thin, that we every hour expected them to give way. The aneurism was situated so high, as to make it probable that the disease extended above the place where the arteria profunda is sent off," and prevented pressure being made upon the artery, except at the place for incision; but even here it did not stop the pulsa- tion, and troublesome bleeding occurred during the operation. A small opening made in the fascia of the thigh admitted the finger, upon which it was divided up to Poupart's ligament, and down to the sac. The pulsation directed the finger and thumb to the artery, which was tied with two ligatures, the upper half an inch from the os pubis, and the lower the same distance from the arteria pro- funda, but the artery was not divided between them. "The tumour diminished greatly after the operation, and the blood contained in it became coagulated, which it did not appear to have been before the operation." * * * Every thing went off well till the fifteenth day, when the upper ligature separated, and the blood gushed in a full stream from the open extremity of the vessel. The bleeding was stopped by pressure. The stream of blood which flowed upon any remission or wrong application of the pressure was so large that we did not dare to remove the patient even from the bed on which he lay. Mr. Ramshen undertook, in this situa- tion, to prevent the further escape of blood from the vessel, whilst I proceeded to tie the artery above Poupart's ligament. Accordingly, I first made an incision, about three inches in length, through the integuments of the abdomen, in the direction of the artery, and thus laid bare the aponeurosis of the external oblique muscle, which I next divided from its connexion with Poupart's ligament, in the direction of the external wound, for the extent of about two inches. The margin of the internal oblique and transversalis muscles being thus exposed, I introduced my finger beneath them for the protection of the peritonaeum, and then divided them. Next with my hand I pushed the peritonaeum and its contents upwards and inwards, and took hold ofthe external iliac artery with my finger and thumb, so that I was enabled to command the flow of blood from the wound. It now only remained that I should pass a ligature round the artery and tie it; but this required caution, on account ofthe contiguity of the vein to the artery. I could not see the vessels, but I made a separation between them with my fingers. Having, however, only a common needle with which to pass the ligature, I several times withdrew the point from apprehension of wounding the vein. After having tied the artery about an inch and a half above Poupart's ligament, I divided that part, and thusMaid bare the new and former wound into one. # * # n0 adhesion took place between the divided parts; the edges of the wound were open and sloughy. * * * Still no greater mischief appeared till the fifth day after the operation, when a haemorrhage of arterial blood took place in such quantity that there was no doubt but that it arose from the principal artery, though the ligature with which it was tied still remained firm." No further attempt at tying the vessel higher up was made, but compresses were fixed with a bandage. and continued for three days, but there was still occasional, though not profuse bleeding. "In the course of the eighth day after the last operation he died." On examination, it was found, that "for nearly two inches above the part which was tied, the lymphatic glands covering the artery were considerably enlarged. The ex- ternal surface of one of them next the wound had ulcerated, and the ulceration pene- trated through the gland, and communicated with the artery. * * * The ulce- rated opening from the artery, through the diseased gland, admitted the passage of a moderate-sized bougie." (pp. 254-66.) Abernethy remarks:—In this case I thought I disturbed the peritonaeum too much, and tied the artery higher than was necessary." (p. 269.) This accordingly he avoided in his second operation on the 24th of Octo- ber, 1801, and having divided the edges ofthe internal'oblique and transversal mus- cles, "I noW introduced," says he, "my finger beneath the bag of the peritonaeum, and carried it upwards by the side of the psoas muscle, so as to touch the artery about two inches above Poupart's ligament. I took care to disturb the peritonaeum ILIAC ARTERY. 537 as little as possible, detaching it to no greater extent than would serve to admit my two fingers to touch the vessel." (p. 99.) The artery was then tied with two liga- tures and divided between. He went on tolerably till the fifth day when "the wound and contiguous parts looked remarkably well, but a bloody sanies was dis- charged which I felt unable to account for. On the sixth day the state of his health and limb continued as well, if not improving. The bloody discharge, however, had increased in quantity, insomuch that it ran through the coverings of the wound and soiled the bed; it had also become foetid. * * * I could not believe that a healthy wound would secrete such a sanies, and I felt apprehensive lest the wound should spread from disease. Nothing, however, took place to confirm this idea. It seemed probable, also, that if the aneurysmal sac were not entire, some of the blood being exposed to the air, might tinge the discharge from the wound and grow putrid. I frequently pressed on the tumour, but could press no blood from the wound." On the ninth day he " appeared like a man advanced in typhus fever. * * * On ex- amining the wound, with a view to discover the cause of this great and sudden al- teration, and pressing on the tumour beneath Poupart's ligament, I forced out a great quantity of blood rendered fluid and highly foetid by putrefaction." He continued slowly sinking, and died " on the twenty-third day after the operation. A few days before his death both ligatures came away with the dressings." On examination, it was found that " the peritonaeum was separated from the loins, and from the poste- rior half of the left side of the diaphragm, by a considerable collection of blood which extended below, to Poupart's ligament, and communicated under that ligament with the aneurysmal sac. This opening was situated in the direction of that crevice which is found between the internal iliac and psoas muscle. The only rational expla- nation that can be given of the formation of this collection is, that the blood had burst its way from the aneurysmal sac in the vacancy between the muscles just mentioned, after which it would readily and extensively separate the peritonaeum in the manner described. * * * The extremities of the external iliac artery, which had been divided in the operation, were united together by a fine newly-formed sub- stance; the sides of each extremity were perfectly closed, and a small plug of coagu- lated blood was found in each. * * * It seems evident that, in the present instance, the operation was too long delayed. It would be desirable in future to perform the operation before an extensive diffusion of blood had taken place; indeed, could the adequateness ofthe collateral arteries for the supply of the limb be established, it would be proper to operate before the artery had burst." (pp. 101-104.) Aber- nethy's third case operated on the 11th of October, 1806, on which the ligatures came away,—the lower on the fifth, and the upper on the fourteenth day,—succeed- ed, as did also his fourth on the 25th of February, 1809, in which the ligatures came away on the tenth day. Abernethy's case, was not, however, the first successful one as on the 4th of October, 1806, Freer (a) tied the external iliac artery with a single ligature, which came away on the sixteenth day, just anticipated Abernethy's by five days. Within the year, Tomlinson of Birmingham also successfully tied the same vessel with a single ligature, which separated on the twenty-sixth day. Astley Cooper's first case, also successful, is most important of all, though not performed till the 22d of June, 1808, as he had the opportunity on the patient's death, 18 years after, of examining the condition of the tied vessel and of the anastomosing arteries. Both external iliac arteries have been taken up in the same subject at the inter- val of a week, in one instance by Tait (b), and in the other by Arendt (c), and did well.] 1478. Tying the external iliac artery is not merely indicated in aneurysms above the arteria profunda femoris, but also in those below the origin of that artery, which extend so close to Poupart's ligament, that there is no space for the operation between it and the aneurysm; which practice is certainly preferable to opening the sac, with compres- (a) Above cited, p. 80. . n (f> Velpeau Nouv. Elemens de Medecine (b) Samuel Cooper's Surgical Dictionary, Operatoire, vol. i. p. 175. p. 157. Vol. II.—46 538 DIFFERENT MODES OF TYING sion ofthe femoral artery on the horizontal branch ofthe share-bone, in order to avoid the arteria profunda. 1479. The external iliac artery, is to be tied in the following manner. The patient being placed on a couch with his buttocks somewhat raised, the operator stands on the side on which the operation is to be performed, and makes a cut through the skin and cellular tissue, commencing half an inch to the inside of the upper front spine of the hip-bone, and termi- nating at the middle of Poupart's ligament. The cut should be con- tinued in the same direction, through the aponeurosis ofthe external ob- lique muscle, the muscular fibres of the internal oblique muscle, and with the greatest care through the thin aponeurosis of the transverse muscle., srj as not to wound the peritonaeum. The exposed peritonaeum is to be separated with the finger at the lower angle of the wound, from its yielding connexion with the m. iliacus internus; and pressing it in- wards, the external iliac artery is felt, accompanied on the inside by the vein, and on the outside by the crural nerve. It is then to be iso- lated with the finger or with the handle of the knife, and the ligature carried round it with Deschamps' needle; this last proceeding can, at least in the dead body, be facilitated by bending the thigh at the hip- joint. The decisions as to the direction and size of the cut in this operation are very various. They may be arranged in three classes. 1. With a nearly straight cut. Abernethy made a cut four inches long, commencing an inch and a half from the upper front spine of the hip-bone, nearer the white line, and carried it down in the direction ofthe external iliac artery to half an inch above Poupart's ligament. He divided first the skin, then the aponeurosis of the external oblique abdominal muscle, and carried his finger under the lower edge of the internal oblique and transverse muscles in order to protect the peritonaeum whilst he divided those muscles with a common or button-ended bistoury. The peritonaeum was pressed back with the finger. According to Charles Bell, the cut should be commenced at the outer pillar of the abdominal ring, carried outwards and upwards, and terminated half an inch above the upper front spine of the hip-bone, and two fingers' breadth to its inner side. The aponeurosis of the external oblique muscle is then to be divided from the ring upwards, upon a director, the lower edge ofthe internal oblique muscle raised, the spermatic cord drawn inwards and upwards, with a blunt hook, the cellular tis- sue put aside, and the artery isolated. But if there be not sufficient space to apply the ligature, the internal oblique muscle must be divided upwards and out- wards. Scarpa begins the cut half an inch under the upper front spine of the hip- bone, and an inch and a half from it nearer the white line, and carried down near to the crural arch. Division of the three abdominal muscles and separation of the peritonaeum. (2) With a semilunar cut. Astley Cooper makes a semielliptical cut, beginning near the spine of the hip- bone and terminating a little above the inner edge of the outer abdominal ring. The aponeurosis of the external oblique is divided in the same direction. This flap being now a little raised, the course of the spermatic cord is seen, and if followed by the finger under the edge of the internal oblique muscle, the open- ing in the fascia transversalis (inner ring) is entered, and the finger touches the ar- tery (4). The practice of Lisfranc and Anderson agrees with this, but the latter makes the cut less curved and a little shorter, (not quite three inches,) separates the skin upwards and downwards, and dividing the aponeurosis ofthe external oblique mus- cle, terminates the cut a little before the external abdominal ring. The aponeurosis THE EXTERNAL ILIAC ARTERY. 539 is then to be separated from the internal oblique muscle, with the handle of the knife: the spermatic cord now exposed, is to be raised, and its sheath lifted up and cut through with the knife or scissors. Through this aperture the little finger of the right hand is to be carried to the internal ring, and the artery being reached, is then to be separated from the iliac fascia and vein by the introduction of a silver aneurys- mal needle, and tied. Rust considers that the cut should be made in the same way, only three and a half inches long, through the three abdominal muscles and the epigastric artery, which. must at once be tied. (3) With an oblique incision. Lagenbeck, Delpech, and others, determine that the cut should be commenced two fingers' breadth from the upper front spine of the hip-bone, and continued across towards the m. rectus a finger's breadth from Poupart's ligament, so that the cut should be four fingers broad. The division of the three abdominal muscles and so on. Wright, Post, (a), in a case of an aneurysm extending high up, made a cut four inches long, from the upper end of the swelling, to a point, between the navel and the upper front spine ofthe hip-bone. The peritonaeum much thickened by the pres- sure of the swelling needed cutting. Bujalsky also makes the incision in the same direction. Compare Dietrich (b) on the preference and objections to these different opera- tions. [(4) Upon Cooper's mode of tying the external iliac Guthrie observes:—It of- fers the advantage of greater space, which enables the surgeon to see better what he is doing; but it does not so readily admit of the artery being tied high up, with- out an additional incision being made in a direction different from the first, which is after all a matter of no consequence, if it were found necessary to do it." (p. 375). He also mentions that he "has seen the epigastric artery divided in this operation. * * * If the surgeon has unluckily divided it, either in this or in any other operation, all that he has to do is to enlarge the incision and tie both the divided ends; and I have no hesitation in saying it will not be of any consequence, either in this operation or in one for hernia. If a man has been so unfortunate as to have a wound in his peritonaeum of a quarter or of half an inch in extent, two ligatures on the epigastric artery, and a slight increase on the extent of the external incisions, add little or nothing to the danger, which only takes place in reality when the wound is closed up, and the artery is allowed to bleed internally." (p. 376.) Dupuytren did not, however, find this to be exactly the case when he divided the epigastric ar- tery in 1821; the bleeding was very copious, and though he stopped it by putting on two ligatures, the patient died in a few days of peritonitis (c).] 1480. If there be room beneath Poupart's ligament to apply a ligature around the femoral artery, a cut is to be made midway between the iliac spine and pubic symphysis, beginning at the edge of Poupart's ligament and continued somewhat obliquely from above downwards. The skin and underlaying fat are to be divided, the glands separated, and the su- perficial layer of the fascia lata divided, where the artery is found in the canal formed by the two layers of that fascia, having the vein on the in- ner, and the nerves on the outer side. The femoral artery commonly gives off the arteria profunda an inch and a half, or two inches below Poupart's ligament; but it frequently arises before the femo- ral artery has passed under Poupart's ligament. For this reason the direction to beoin the cut an inch below Poupart's ligament is improper, because here, mani- festly, although the cut may be several inches long, yet the space is too confined for isolating the artery. juir-ui uiri_ Textor and Robert Froriep make a cut two and a half inches long, half an inch below Poupart's ligament, and parallel to its lower edge, so that it corresponds to the middle of the femoral ring. In the same direction the cellular tissue and (a) American Med. and Phil. Register, (b) Above cited, p. 284. vol iv. p. 443. (*) Averill's Operative Surgery, p. 73. 540 CIRCULATION AFTER TYING fascia are to be divided upon a director, in doing which the director is only to be introduced a short distance, and the division to extend three lines from the two edges of the wound. 1481. The vessels by which the circulation is kept up, after tying the external iliac artery, are the anastomoses, between the gluteal, isehiatic, internal pudic, and obturator, with the circumflex arteries, which arise from the deep artery, from the external pudic, epigastric, and circumflex iliac arteries. If the obturator arise from the epigastric, a large quantity of blood passes through its anastomosis with the internal pudic and is- ehiatic, and the branches ofthe circumflex artery ofthe thigh. The epigas- tric and circumflex iliac artery also convey blood by their anastomoses with the internal mammary, with the intercostal, lumbar, and sacral ar- teries. If, therefore, the aneurysm be below the epigastric artery, there may be, after the obliteration of the external iliac artery, a flow of blood above the seat of aneurysm into the artery, but no enlargement of the aneurysm from it is to be feared (1). There are a considerable number of cases in which the external iliac artery has been tied. Fifteen out of twenty-two have been (according to Hodgson) cured; a very good proportion, if it be remembered that many of the patients had been already much weakened by previous bleeding from the sac (a). [Mott (b) tied the external iliac artery fourteen days after tying the femoral of the other limb; in both on account of aneurysm. The case did well. The following are the principal points in the dissections of three of the cases in which Astley Cooper tied the external iliac artery. In the case (r), which died ten weeks and six days after the operation, " it was found that the femoral, tibial, and fibular arteries were still open, and that the blood was conveyed into the femoral artery by the following anastomoses. The internal pudendal artery formed several large branches upon the side of the bulb of the penis, and these branches freely communicating with the external pudendal artery had de- termined the blood into that artery, and by this channel into the femoral; the lateral sacral artery also sent a branch on the iliacus internus muscle, into the femoral ar- tery, and the ilio-lumbar artery freely communicated with the circumflexa ilii,- so that, by these three routes, the blood found direct ingress to the femoral artery. Nu- merous branches of arteries also passed from the lateral sacral to the obturator and epigastric arteries, the obturator in this case having its origin from the epigastric. Besides these arteries, a free communication existed between the arteria profunda and circumflex arteries, with the branches of the internal iliac; first, the gluteal ar- tery sent a branch under the glutaeus medius muscle to the external circumflex artery; secondly, the isehiatic artery gave two sets of branches of communication, one upon the glutaeus maximus muscle to the arteria profunda, and another upon the sciatic nerve to the internal circumflex artery; the internal pudendal artery also sent a branch of communication to the internal circumflex; lastly, the obturator freely com- municated with the internal circumflex." (pp. 428, 29.) In Cooper's second case (d), "examined, at three years after tying the external iliac artery," the external iliac and the femoral arteries were obliterated, excepting about an inch of the femoral artery, just below Poupart's ligament, which still re- mained open, and continued to convey a portion of the blood; but, below this part, it had become simply a ligamentous cord. The internal iliac artery sent first a very large artery of communication to the epigastric and obturator artery, so that the epigas- tric was supplied with blood from the internal iliac; secondly, the internal iliac sent an artery of communication upon the sciatic nerve, to the internal circumflex artery. The gluteal artery gave a large branch to the origin of the profunda; lastly, the internal pu- dendal artery largely anastomosed with the obturator; the obturator, therefore, sprang in this case from two new sources, viz. from the internal iliac, and from the internal (d) Hodgson, above cited, p. 416. (e) Med.-Chir. Trans., vol. iv. 1813. (6) American Journal of Medical Sciences, (d) Ibid. vol. i. p. 483. THE EXTERNAL ILIAC ARTERY. 541 pudendal artery, and the obturator thus formed sent two branches of communication to the internal circumflex artery. The arteria profunda was in this case supplied from two sources directly from the gluteal, and more indirectly from the internal circumflex, by the obturator and isehiatic arteries. The external iliac artery was obliterated to the origin ofthe internal iliac, as other arteries usually are when liga- tures are made upon them to the first large anastomosing vessel. The principal agents then of the new circulation are the gluteal artery with the external circumflex, the obturator artery with the internal circumflex, and the isehiatic with the arteria profunda, and the obturator artery is supplied with blood principally by the internal pudendal when the obturator arises from the epigastric artery." (p. 429-31.) Both preparations are in St. Thomas's Museum. In Cooper's third case (a), eighteen years after the operation, "the external iliac artery was pervious to the extent of rather more than an inch from the bifurcation of the common iliac, but had become somewhat diminished in size, and altered in shape. No branches were given off from this portion of the vessel, which, when filled with injection, presented a conical form, tapering downward to a mere point, and termi- nating in a rounded cord which constituted the remaining part, or the obliterated portion of the artery, and was continued down to the spofwhere the operation had been performed. The ligature had probably been applied just above the origin of the circumflex and epigastric branches, although no evidence remained to indicate the precise spot. Just above Poupart's ligament the iliac artery became suddenly restored, (apparently by the influx of blood from the branches mentioned above,) and assumed about half its natural size. The obliterated vessel presented the ap- pearance of a continuous unbroken cord, from the cessation of the iliac above to its, restoration below. * * * The vessel having regained about half its natural size, passed into the thigh and was continued without receiving any accession from coL lateral vessels, until it reached the origin of the profunda; from which branch the trunk appeared to derive a large quantity of blood, sufficient to restore it to the ordinary extent of calibre which the femoral possesses in a stout muscular limb; the remaining portion of the femoral artery below the profunda presented nothing un- usual in its appearance, and bore no indication of having received any farther influx of blood through collateral branches. Just above the origin of the profunda, the femoral artery had become distorted, and irregular in shape, and was rendered some-. what obscure by its connexion with what appeared to be the remains of the aneurismal sac adhering to the anterior surface of the vessel and gluing it to the adjacent mus^ cles and fascia. There can be but little doubt that the original opening of commu- nication between the sac and the femoral trunk had existed at this spot, viz. just above the profunda branch; but it would seem equally apparent that, as the aneurismal tumour became obliterated in the progress of the cure after the operation, the opening into the vessel also became closed, while the integrity of the arterial trunk, above and below the sac, was maintained continuous and entire. The collateral circulation had, in this instance been established by the junction of the ilio-lumbar, obturator, gluteal and isehiatic, branches from the internal iliac, with the circumflex and epi- gastric of the external iliac and the profunda of the femoral. They consisted of three sets of communicating vessels which descended respectively over the fore part, the internal side, and the posterior surface ofthe hip-joint, and may be described as forming a circular plexus around the articulation, ramifying among the muscles of that region. * * * The ilio-lumbar, gluteal, and isehiatic arteries are enormously dilated" The internal pudic is also of large size, but it does not appear to furnish any direct communication with the femoral." (p. 48-50.) This preparation is in the Museum of Guy's Hospital.] 1482. If the aneurysm be situated in the lower third of the thigh, or at the knee-joint, it is'best to tie the femoral artery in the following man- ner. The pulse of the artery should be followed from the groin down- wards, and where it is only indistinctly felt is to be the end of a cut, which begins about two and a half inches below Poupart's ligament, and descends on the inner edge of the m. sartorius, in the triangular space formed by the m. adductor secundus and vastus internus, The skin. (a) Guy's Hospital Reports, vol. i, 1836. 46* 542 TYING THE and fascia lata being divided, and the edge of 'the m. sartorius drawn somewhat outwards, the artery is found enclosed in its cellular sheath, with the femoral vein under it, and the branches of the crural nerve on its outer side. When the artery is properly isolated, the ligature is to be carried round it with the aneurysmal needle {a). John Hunter tied the femoral artery in the lower half of the thigh; dividing the skin and fascia lata on the inside of the m. sartorius to the extent of three inches, he laid bare the edge of this muscle, isolated the artery lying beneath, and tied it near the place where it passes through the tendon of the m. adductor (b). If the artery be tied in the upper half ofthe thigh, he thinks it best done at the inner edge of the m. sartorius ,- and if in the lower half, at the outer edge (c), which, after having been laid bare by a cut three inches long, is to be drawn somewhat inwards, where the artery is covered with a slip of aponeurosis, passing from the m. adductor to the m. vastus internus,- this must be cut through, and the artery isolated in the way already mentioned. 1483. If an aneurysm be in the ham or on the upper part of the arte- ries of the leg, there may be sufficient space for tying the artery in the ham; but on account of the depth of the vessel, of the difficulty of its isolation, its nearness to the joint, and so on, this operation is to be con- sidered as by far more dangerous and less safe than that of tying the femoral artery. In aneurysms, tying the femoral artery is to be uncon- ditionally preferred, and only in cases of wound of the popliteal artery is its tying indicated, in which sufficient enlargement of the wound is usually necessary. As for the rest, the popliteal artery has been tied in three different parts, at the middle, upper, and lower part of the ham. 1484. If the artery is to be laid bare in the middle of the ham, the patient having been placed on his belly, and the thigh perfectly extended, a cut, three inches long, is to be made a little to the inner side of the mesial line of the ham, through the skin and aponeurosis, taking care to avoid the vena saphena; the edges of the wound being then separated, the surgeon penetrates deeper with careful cuts, and with the handle of the knife through the cellular tissue, often much loaded with fat, down to the popliteal nerve, vein, or artery itself. The nerve lies on the outer side, and between it and the artery is the vein, which covers the outside ofthe artery. The nerve should be drawn aside, and the artery sepa- rated with the greatest care from the vein, so as.to wound neither the articular veins nor arteries. When the needle is to be carried round the artery, the leg must be somewhat bent. If the artery be tied in the upper part of the ham, a cut is to be made somewhat on the inside of the base of the triangular space formed on the inside by the m. semi-tendinosus and se7ni-me»Lb7'anosus, and on the out- side by the m. biceps femoris, to the top of this triangle, the skin and aponeurosis are divided, and the rest ofthe operation performed as in the former case. In tying the popliteal artery at the lower part of the ham, the cut is to be made somewhat on the inside of the mesial line, and some lines be- low the knee-joint, from three to four inches long, above the hind part of the leg, through the skin, cellular tissue> and aponeurosis; the inter- (a) Scarpa, Translation, p. 278. (6) Transactions of a Society for the Im- (c) Caillot, above cited, p. 72.—Wece- provement of Medical and Surgical Know, hausen, in Rust's Magazin fur die gesammte ledge, vol. i. p. 148. Heilkunde, vol. ii. p. 408. POPLITEAL ARTERY. 543 space between the two* heads of the m. gastrocnemius then appearing, these are to be separated, and the trunk of the vessel and the sural branches come into view with the veins and posterior cutaneous nerves of the leg. These parts are to be drawn aside by an assistant, and the cellular tissue being divided with the handle of the knife, the popliteal artery is found on the inner side, the vein in the middle, and the nerve on the outside. If the cut be somewhat lengthened in this proceeding, the posterior tibial artery may be tied at its upper part (a). Jobert (b) ties the artery in the internal epicondyloid pit, viz., in the triangular depression bounded within by the m. sartorius, gracilis, semi-tendinosus and semi- membranosus. The knee is to be half bent,,and a cut made on the outer edge of these muscles, two inches long, through the skin to the fatty tissue. The skin is to be then drawn outwards, and a second cut across the former made, but without wounding the skin, by which the tendinous expansion ofthe m. adductor magnus is divided. The forefinger is to be passed beneath the tendinous expansion, and a button-ended bistoury introduced upon it, to cut through the superficial layer of the aponeurosis which covers the artery. The pulsation of the artery is then felt, and in some thin persons may even be seen. The fatty tissue is to be penetrated with a director, which is carried with the greatest care between the artery and vein. 1485. If the aneurysm be situated at the commencement ofthe tibial artery, the femoral must be tied in the way mentioned (1). But if it be lower on the tibial artery, the inflow of blood, after tying the femoral artery, is sufficient, in large aneurysms of the foot, to keep up the dis- ease, and it is therefore necessary to tie the .affected artery in the neigh- bourhood ofthe aneurysmal sac (2). [(1) The following case of aneurysm of the posterior tibial artery is a good example of the practice recommended :— Case.—M. H., aged 38 years, was admitted, Sept. 13, 1832, with a pulsating tumour at the back of the upper part of the right leg. He had fallen dQwn stairs a twelvemonth since upon a brush, and at the same time twisted his leg, which laid him up with great pain and swelling for ten days, but after that time he seemed to get well, excepting that he had a little continual pain and always a throbbing behind and below the head of the fibula. Six months since, after having walked a considerable distance, his leg began to swell and be so painful as to compel him to keep at rest. There is now distinct pulsation below the head of the fibula and at an opposite point on the inside of the leg beneath the gastrocnemial muscles. The posterior tibial artery does not pulsate at the ankle; and the anterior tibial beats but feebly. The girth ofthe affected leg at this part is nearly sixteen inches, whilst in the other it is only thirteen and a half inches. The temperature of the limb is diminished; and he has numbness and pricking of the whole limb below the tumour, more particularly affecting the foot. Pressure of the femoral artery at the groin, or on the sides of the swelling, diminishes it half an inch, but it fills immediately, when the pressure is withdraVn. Sept. 21. My colleague Green tied the femoral artery at the usual place in the middle ofthe thigh. The pulsation ceased when the ligature was tightened. Oct. 2. Has been going on well; the limb about an inch smaller, but more yield- ing : the pricking and numbness of the foot have ceased. Oct. 30. The ligature came away. After which the wound soon healed; but at two months' end the size of the limb had only diminished an inch. Astley Cooper mentions a case of " anterior tibial aneurism a little below the head of the fibula, for which the femoral artery was tied; the pulsation ceased in the aneurism, and the swelling for a time subsided. The case did not ultimately recover, for a slough ofthe aneurismal sac took place." (p. 63.) (a) Bierkowsky, Anatomisch-chirurgische Dietrich,above cited, p. 334.—Manec, above Abbildungen, pi. viii. figs. 1, 2.; pi. x. fig. 3. cited, pi. xi. A B.—Froriep, R., above cited, pi. xn.— (fr) Nouvelle Bibhotheque Medicale, 1827, ' Feb. 544 TYING THE TIBIAL AND PERONEAL ARTERIES. (2) The younger Cline had a case of aneurysm of the anterior tibial artery "on the upper part of the foot, and he tied the anterior tibial artery at the lower part of the leg, but the pulsation in the aneurism continued when the boy left the hospital." "It will therefore be right," says Astley Cooper, "to tie the artery by opening the sac, so as to secure it above and below the aperture, if the aneurism be seated low down in the limb, as the anastomosis with the plantar arteries is exceedingly free." (p. 63.)] 1486. In laying bare the anterior tibial artery somewhat above the mid- dle ofthe leg, the space between the anterior tibial muscle and the long extensor of the great toe, is to be chosen and the great toe moved whilst the finger is carried outwards from the crest of the shin-bone. The skin and aponeurosis ofthe leg are to be divided for two and a half inches in the direction of this space; then with the finger, or with the handle of the knife, these muscles are separated, and at the depth of an inch the anterior tibial artery is found, with its accompanying single vein and nerve. In the neighbourhood ofthe instep the artery is quite superficial, covered by the skin and aponeurosis of the leg, between the tendons of the m. tibialis anticus and extensor pollicis longus. If the dorsal artery of the foot is to be laid bare, a cut is made in the direction of the second toe, on the back ofthe foot, through the skin and aponeurosis, and the artery is found between the tendons ofthe m. extensor pollicis and the first ten- don of the m. extensor brevis digitorum. 1487. The exposure of the posterior tibial artery in the middle or in the upper third ofthe leg is very difficult, on account of its depth and ofthe expansion of the aponeurosis being tightened by the contraction of the muscles of the calf. A cut is made along the inner edge of the shin- bone, for three or four inches thiough the skin, and the attachment of the m. soleus divided throughout the whole of this extent. The muscle must then be turned a little aside, and the aponeurotic expansion, sepa- rating the muscles of the calf into a superficial and deep layer, divided, under which the artery is found, between two veins, and accompanied with the tibial nerve on its fibular side (1). At its lower part the poste- rior tibial artery lies very superficial, and may easily be exposed by a cut, two inches long, between the inner ankle and the Achilles' tendon. It lies closer to the heel than the tendons of m. tibialis posticus, and flexor digitorum pedis, and is surrounded with fat and cellular tissue. [(1) It will not be out of place here to give a caution as to the treatment of a wound of the posterior "tibial artery, by any instrument or other body penetrating from the outside ofthe leg. I well recollect the case of a man, who whilst mowing in company with others, received the point of the scythe of the labourer next behind him, in the outside of the upper part of his leg. The scythe passed inwards, and wounded the posterior tibial artery, without piercing the skin on the inside of the leg. The wound was freely enlarged, and great pains taken to get at the vessel, but its depth was so great, that after many efforts, the attempt was given up. A cut was then made on the inside of the leg, as above directed, and the vessel reached and tied with great ease. In a similar case, the like practice should be adopted. The only difficulty in the operation consists in forgetting that the artery and deep layer of muscles are overspread with a light fascia, which may possibly be mistaken for the interosseous ligament. The artery cannot be reached till this be opened very freely, as it is very unyielding.—j. f. s.] 1488. If the peroneal artery be tied in the minddle of the leg, a cut is to be made from any one part of the outer side of the Achilles' tendon, CIRCULATION AFTER TYING THE FEMORAL ARTERY. 545 and carried obliquely upwards and outwards to the hinder outer surface of the splint-bone. The external saphenous vein is to be avoided, the aponeurosis divided, and the forefinger, passed before the Achilles' tendon, is carried upon it before the muscles of the calf, so as to sepa- rate them from the deep layer. The fascia covering the deep muscles is to be cut through, and the inner edge of the m. flexor pollicis raised up- wards and outwards. The artery is found sometimes between the fibres of this muscle, and sometimes between it, the splint-bone, and the inter- osseous membrane. If the artery be looked for deeper than the middle ofthe leg, as Charles Bell proposes, its hinder branch only is found. 1489. What has been already said about aneurysms on the front and back of the hand, applies also to those on the sole, and on the back of the foot. If here it be not permissible, on account of the position of the aneurysm, to open the sac, and tie the artery above and below, the flow of blood must be prevented by tying the affected artery still higher, and, after opening the sac, it must be completely prevented by pressure. This treatment must also be followed in wounds of arteries on the back of the foot and in the sole (a). 1490. When the femoral artery is obliterated at the origin of the ar- teria profunda, the blood passes from the branches of the internal iliac arteries into the circumflex arteries of the thigh, and.by the descending branches of the a. profunda into the articular arteries, whence it passes into the trunk of the femoral. If the obliteration occur in the lower third, the circulation is kept up, not merely by the anastomosis between the a. profunda and the arteries of the knee, but also by many anastomotic or muscular branches. If a part of the popliteal artery, or even the origin ofthe upper or lower arteries of the knee be obliterated, the blood passes by the anastomosis of the a. profunda into the upper, thence into the lower arteries ofthe knee and from them into the recurrent branches of the tibial arteries. [The following is Astley Cooper's account (6) of the dissection of almost seven years after the femoral artery had been tied for popliteal aneurysm. " The femoral artery which is necessarily obliterated by the ligature, was here converted into a cord, from the origin ofthe arteria profunda down to the ham. The whole ofthe popli- teal artery was also changed into a similar substance; and thus the natural channel of the blood from the groin to the lower part of the knee was entirely destroyed. The muscles therefore which usually receive blood vessels from the femoral artery, as the sartorius, rectus and vasti, had no branches but from the arteria profunda and circumflex arteries; and the articular arteries from the popliteal, although they were still capable of receiving blood, derived it, not from the popliteal artery, but from the communicating vessels of the profunda. The arteria profunda formed the new channel for the blood; considerably enlarged in its diameter, although still not equal in size to the femoral artery at the groin, it took its u^ual course to the back of the thigh on the inner side of the thigh-bone, and sent branches of a larger size than usual to the flexor muscles of the leg, and just midway on the back of the thigh it began to send off those arteries which became the support of the new circulation. The first artery sent off passed down close to the back of the thigh-bone, and entered the two superior articular branches ofthe popliteal artery, which vessels supply the upper part of the knee-joint. The second new large vessel arising from foe pro- funda at the same part with the former, passed down by the inner side of the biceps muscle to an artery of the popliteal, which was distributed to the gastrocnemius muscle.' Whilst a third artery dividing into several branches, passed down with (a) Scarpa, p. 225.—Roux, Nouveaux Elemens de Medecine Operatoire, vol. i. pt. ii. p. 698. (6) Medico-Chir. Trans., vol. ii. 1811. 546 ANEURYSMAL VARIX. the sciatic nerve behind the knee-joint, and some of its branches united themselves with the inferior articular arteries of the popliteal, with some recurrent branches of those arteries, which arteries passing to the gastrocnemii, and lastly with the origin of the anterior and posterior tibial arteries; and these new large communicating branches were readily distinguished from others by their tortuous course. It ap- pears then that it is those branches of the profunda which accompany the sciatic nerve, that are the principal supporters of the new circulation. They were five in number, besides the two deep-seated arteries which do not accompany the nerve. The external circumflex was considerably larger than usual for the supply of branches to the muscles on the fore part of the thigh, but it had no branches for the new cir- culation. The obturator artery did not appear larger than usual, and although much pains were taken to trace any enlarged communicating branches between the isehi- atic arteries and profunda, yet no vessels capable of receiving so large an injection could be found." (pp. 254-56.)] VI.—OF ANEURYSMAL VARIX AND VARICOSE ANEURYSM. Hunter, Wm., M.D., Medical Observations and Inquiries, vol. i. p. 340. vol. ii p. 390. Guattani, De cubiti flexurae aneurysmatibus; in Lauth's Collectio Scriptorum. &c, p. 203. r Scarpa, above cited, p. 421. Translation. Hodgson, above cited, p. 496. Adelmann, P., Tractatus anatomico-chirurgicus de aneurysmate spuric-varicose Wirceb., 1821. 4to; with two lithographic plates. Schottin, Merkwiirdiger Fall einer aneurysmatischen Venengfeschwulst. Alten- burg, 1822. Breschet, Memoires chirurgicaux sur differentes especes d'Anevrvsmes. Paris. 1834, p. 98. J 1491. If a vein and an artery connected with it be so injured, that by the subsequent adhesion of the edges of the wounded vessels, an im- mediate communication between the two vessels is produced, it is called an Aneurysmal Varix {Varix aneurysmaticus, Aneurysma pertrans- fusionem. A. arterioso-venosum.) It occurs most frequently at the el- bow-joint, as consequence of blood-letting ; it is, however, also observed in other parts (1). (1) On the upper arm, by Riecherand, Cloquet, Jaeger; on the radial artery, and cephalic vein, by Schottin; on the subclavian, by Larrey; on the carotid by Lar- rey and Marc ; on the temporal by Bushe and myself; on the femoral artery, by Siebold, Barnes, Dupuytren Breschet ; on the popliteal, by Lassus, Sabatier Richerand, Boyer, Larrey, Hodgson; on the external iliac, by Larrey; and on the division of the aorta and vena cava, by Syme. [My friend Mackmurdo has very recently had a case of aneurysmal varix be- tween the internal jugular vein and carotid artery close to the skull. Its existence was not known prior to death. The man had had scrofulous enlargement of the glands of the neck near the angle of the jaw, which suppurated; a sinous ulcer formed, from which arterial haemorrhage occurred twice, and Mackmurdo thought it advisable to tie the common carotid artery which arrested the bleeding; but the patient sunk af- ter seven days, and on examination, besides large destruction of the bifurcation of the carotid artery and of the internal jugular vein, the aneurysmal varix, already mentioned, was found.—j. f. s.j 1492. Aneurysmal varix is characterized by a circumscribed swelling of blue colour, and small extent, which is formed by expansion of the vein, and in which a peculiar tremulous motion, and whizzing noise are observed, produced by the overflowing of the blood from the artery into the vein. The swelling is generally, at least at the bend of the arm, not ANEURYSMAL VARIX. 547 larger than a nutmeg, (on the femoral and subclavian, it has been seen as large as an egg, and even as big as the fist,) accompanied with vari- cose swelling of the neighbouring veins; it subsides entirely by pressure, shows less pulsation if the part on which it is situated be raised; but is greater it the part hang down, or if pressure be made upon the vein be- low this swelling. If the artery be compressed above the swelling, the pulsation at once ceases, but returns directly the pressure is withdrawn. The trunk of the artery above the swelling pulsates more strongly than on the opposite side, and is much distended; below the swelling, the pul- sation is weaker, but after long continuance the diameter of the artery also is increased, and the artery often becomes tortuous. The size of the swelling depends on the size of the opening of communication be- tween the artery and vein, though the swelling usually diminishes some- what; if the neighbouring veins be enlarged, it then increases no more, and no longer causes any particular inconvenience. In other cases, however, it is accompanied with a diminution of the pulse in the lower part ofthe artery, with a diminution of temperature, sensation, and mo- tion of the parts below the aneurysmal varix, which fall into a state of complete torpor. Breschet (a) has proved, by careful observation and experiment, that in the systole the blood flows out of the artery into the vein; and in the diastole, out of the vein into the artery; and that, on the latter condition depend, the enlargement of the lower part of the artery, which is often tortuous, and of which, on account of its weaker pulsation, it has been falsely asserted that it is diminished in diameter, as well as the other circumstances and changes of the arterial walls, into a condition similar to that of the veins. By the passage of the arterial blood into the veins, the walls of the latter are thickened, and resemble, in a degree, those of arteries. As in the extremities, the passage of the blood from the vein into the artery takes place more readily than in aneurysmal varix on the neck and head; so he explains how the symptoms are milder, and why in the latter, often only during the horizontal position ofthe head, symptoms as fainting, and the like, occur, they being grounded on the overflow of the blood from the vein into the artery. [Sennertus (b) is first considered to have described aneurysmal varix,- his de- scription, however, is only a little improvement on Galen's account, already men- tioned, (p. 197.) He says :—" The proximate cause of aneurysm is an opening of the internal, with a dilatation of the external coat of an artery. But very commonly it is opened by a wound, when unskilful surgeons open the artery for the vein, or the artery with the vein. Hence, the external coat being softer and more like a vein more readily unites; whilst the interior being harder, remains open, in consequence of which the blood and vital spirits endeavour to escape through the aperture, and so distending the external tunic, this kind of tumour is produced." Dr. William Hunter, however, in a paper entitled " The History of an Aneurysm of the Aorta, with some remarks on Aneurysms in general," published in 1757 (c), first drew the attention of the profession to aneurysmal varix. He asks:—" Does it ever happen in Surgery, when an artery is opened through a vein, that a commu- nication of anastomosis is afterwards kept up between these two vessels. It is easy to conceive this case; and it is not long since I was consulted about one, which had all the symptoms that might be expected, supposing such a thing to have actually happened, and such symptoms as otherwise must be allowed to be very unaccount- able. In his second paper (d) William Hunter says :—" We must suppose that the wound of the skin, and of the adjacent or upper side of the vein, heal up as usual; but that the wound of the artery, and of the adjacent or under side of the (a) Above cited. (c) Med- 0bs- aQd Inquiries, vol. i. (6) Opera, vol. iii. book v. chap, xliii. p. (d) Ibid., vol. iv. 797. Paris, 1611, fol. 548 ANEURYSMAL VARIX. vein remain open, (as the wound of the artery does in a spurious aneurysm,) and by that means the blood is thrown from the trunk of the artery directly into a trunk of the vein. Extraordinary as this supposition may appear, in reality it differs from the common spurious aneurysm in one circumstance only, viz., the wound remaining open in the side ofthe vein, as well as in the side of the artery. But, this one cir- cumstance will occasion a great deal of difference in the symptoms, in the tendency of the complaint, and in the proper mode of treating it: upon which account the knowledge of such a case will be of importance in surgery. " It will differ in its symptoms from the common spurious aneurysm principally thus. The vein will be dilated or become varicose, and will have a pulsatile jarring motion, on account of the Stream from the artery (1). It will make a hissing noise, which will be found to correspond with the pulse for the same reason." (pp. 391, 392.) In the young lady's case, " there was a hissing sound, and a tremulous jarring motion in the veins, which was very remarkable at the part that had been punctured, and became insensible at some distance, both upwards and downwards." (p. 397.) In the porter it is stated :—" There is a remarkable tremulous motion, (as well as a considerable pulsation,) both in the bag and in the dilated vein, as if the blood was squirted into it through a small hole. It is like what is produced in the mouth by continuing the sound of the letter R in a whisper, (p. 403.) This motion is not only felt, and seen distinctly, but heard, too, if the ear be held near the part; and if the ear touches the skin, the sound is much more loud and distinct. It is a hissing noise, as if there was a blast of air through a small hole, and inter- rupted, answering precisely and constantly to the stroke of the heart, or diastole of the artery. * * * The patient is so sensible of the noise, that he often finds it keeps him from falling asleep, when the arm happens to be near his head." (p. 404.) " The blood of the tumour will be altogether or almost entirely fluid, because kept in constant motion. The artery, I apprehend, will become larger in the arm and smaller at the wrist than it was in the natural state, which will be found out by comparing the size and the pulse of the artery in both arms at these different places," (p. 392) ; the reasons for which he thus gives:—" Why is the pulse and the wrist so much weaker in the diseased arm than in the other? Surely, the reason is obvi- ous and clear. If the blood can easily escape from the trunk of the artery directly into the trunk of the vein, it is natural to think that it will be driven along the extreme branches with less force, and in less quantity. Whence is it that the artery is enlarged all the way down the arm ! I am of opinion, that it is somehow the consequence of the blood passing so readily from the artery into the vein, and that it will always so happen in such cases. That it is not owing to any particular weakness in the coats ofthe artery, like that in a true aneurysm, naturally and con- stantly tending to rupture, but it has rather such an extension as happens to all arteries in growing bodies, and to the arteries of particular parts, when the parts themselves increase in their bulk, and, at the same time, retain a vascular structure. * * * I presume that the derivation of blood to the arm by the wound ofthe artery has been the cause of the dilatation of that vessel; and that in the living body an artery will as certainly become larger, when the resistance to the blood is taken off, as it will become smaller when it is compressed, or, as it will shrink and become a solid cord when the blood is not allowed to pass through it at all. * * * In order to conceive how or why the trunk of the artery will become larger, in consequence of an immediate and free communication with the trunk of the vein, let us take another view of it, thus:—Suppose that instead of a single aperture, there was a large branch added to the artery of the same diameter as the aperture, and that it ramified in the common way through some adventitious vascular part, a wen, for example, and terminated in corresponding veins, and that these ended in the com- mon trunk of the basilic vein, every body must see, that in this case the trunk of the artery would dilate till it became proportionable in capacity to its branches; for till then the trunk would be the narrowest part of the canal,—the part where there would be the most resistance, and therefore the yielding coats of the artery would give way till the just proportion was established between the trunk and all its branches. These two cases, I apprehend, are similar as to the principal point, but differ in some particulars. In the case of an aperture, the resistance to the blood is diminished ; thence it will move with more celerity; the trunk ofthe artery will be less enlarged, and the branches will shrink a little. But in the case of an additional TREATMENT. 549 branch, the resistance, I presume, would be as great as before; the celerity, there- fore, would not be increased, the old branches would continue of the same dimen sions, and the trunk would therefore increase still more." (p. 407-411.) (1) Lawrence (a) observes on this point:—"The sensation is almost the same as that which is communicated to the hand by the vibration of the cord of a musical instrument, and it is particularly described by some writers, who call it a rilling noise; some call it a whizzing, and some a vibratory noise. This noise is not only heard in the swollen part of the vein, but it also extends along the course of the vessel up the arm." (p. 166.) Liston (6) says:—"On applying the ear close to the tumour, or listening through the stethoscope, the peculiar noise is not only felt, but heard of almost startling intensity, somewhat resembling the noise of compli- cated and powerful machinery softened and confused by distance." (p. 676;) Liston relates an excellent instance of aneurysmal varix in the femoral vein and artery, consequent on a deep chisel-wound in the lower part of the thigh, which at the time bled profusely, but having been stuffed and compressed, healed in course of eight days." A twelvemonth afterwards, troublesome pulsation was perceived in the part; at the same time, the veins of the leg became varicose, and a succession of ulcers formed on the lower and anterior portion of the limb. The affection attracted little attention till between twelve and thirteen years after, wThen he ob- served a considerable swelling in the site of the wound, beating strongly, and the pulsations accompanied with a peculiar thrilling sound and feel—not confined to the tumour, though strongest there, but extending to the groin along the course of the femoral vein, which was evidently much dilated throughout its whole course. Six months after, the tumour was nearly equal to the fist in size, of regular and globular form, pulsating very strongly, and imparting to the hams the peculiar sensation of aneurismal varix, remarkably distinct and powerful. The pulsation and thrilling are continued in a less degree to Poupart's ligament, and down to the calf of the legt # # # He feels little pain, but exercise and exertion of every kind are seriously impeded." (p. 676.) Firm and constant pressure of the swelling, with uniform compression of the whole limb, were employed, and Liston informs me with success. There is at the present time, (April, 1846,) in St. George's Hospital, a case of vari- cose aneurysm in the thigh resulting from a knife-stab.—j. f. s. William Hunter also points out the marked distinction between aneurysmal varix and false aneurysm. " The natural tendency of such a complaint," says he, "will be very different from that of the spurious aneurysm. The one is growing worse every hour, because of the resistance to the arterial blood; and if not reme- died by surgery, must at last burst. The other in a short time comes to a nearly permanent state; and if not disturbed, produces no mischief, because there is no considerable resistance to the blood that is forced out of the artery." (p. 393.) In the first case which he saw, at the end of 14 years, the swelling, nothing having been done to it, was nearly in the same state. The second case, in which the swelling had the size of a large nutmeg, so remained, when seen five years after- wards.] 1493. The cure of the aneurysmal varix may be in many cases effected by continual compression, which either effects obliteration of the artery, or brings the wall of the vein so into contact that the aperture of the artery is closed. But as this mode of treatment, if the walls of both vessels be not connected, exposes the patient to the danger of a complication with aneurysm, so may it be employed only in recent cases, and in young or thin persons, where the walls of the vessel can be sufficiently compressed, and the patient recommended abstinence from all exertion of the part, when from that evil no farther symptoms are caused (c). But if the above- mentioned inconveniences of diminished nutrition, sensation, motion, and so on occur, the operation is indicated, and not indeed, as by many ad- visedly tying the affected artery above the aneurysmal part, but according (a) Lectures, above cited. (0 Scarpa, above cited, p. 432.-BrE. (6) Elements of Surgery, part ii. London, schet, above cited. 1840. Vol. II.—47 550 VARICOSE ANEURYSM. to the old method, by cutting into the sac, and applying a ligature round the artery above and below the wounded part (1). (1) Breschet has, from the above-mentioned causes, proved that the tying ofthe artery, according to Hunter's plan, in aneurysmal varix, which has existed for some time, produces only temporary improvement, but that all the symptoms soon recur, as before the operation, and render tying the artery below the wounded place neces- sary; as the opening of communication between the artery and vein does not close, and is kept up by the introduced collateral circulation of the previous condition. He also doubts the benefit of simply tying the artery below the wounded part, as recom- mended by Brasdor. In an .aneurysmal varix of the temporal artery, in which, by tying the common carotid artery, I obtained only temporary improvement, Stromeyer produced a radical cure by tying the vein (a). He divided the varix; at the bottom of the sac found with trouble a small opening, into which he introduced a probe. He freely separated the lower part of the mnch-expanded vein, and applied two ligatures around it; a third ligature tied a vein from the occiput, which communicated with the sac. After the bleeding was thus stanched, the wound was closed with six interrupted stitches. [The advice which Dr. Hunter gave to the young lady was " to do nothing while there should be no considerable alteration" (p. 398) in the swelling, which she fol- lowed with advantage for fourteen years. And in the second case not a hint is given about tying the artery. Astley Cooper says:—"No operation has been required for this disease, in any case which I have seen of it, as it is not a dangerous state, either to the life, or even to the arm. It renders the arm weaker, and nothing more serious arises from it." (p. 84.) Atkinson, of York (b), however, in a large and increasing size of an aneurysmal varix, thought it necessary to take up the brachial artery, but the patient died of mortification.] 1494. If a vein, wounded in the way described, be not in immediate contact with the artery wounded at the same time ; or if on account of the oblique position of the wound, or by the compression employed, the blood find no obstruction in flowing into the vein, the cellular tissue which connects the artery and vein expands into an aneurysmal sac by which the two vessels communicate with each other. The vein is some- what distant from the artery, and the blood flows from the sac into the vein, and thus is formed a Varicose Aneurysm {Aneurysma varicosum.) In this case the aneurysmal sac enlarges, and, it is to be feared, will burst. Clot forms in the sac, and, together with the tremulous swelling of the vein, is felt a firm pulsating swelling, of defined extent, which, if the artery be compressed above, does not, as in varix, subside. The above- described symptoms are also present. Tying the artery above the sac, held by Scarpa (c) and Hodgson {d) most favourable for the cure, is for the above-mentioned reasons most uncertain on account of the speedy danger of a relapse; and tying above and below the sac is the most proper (e). [William Hunter was also well aware of this form of the disease. He says:— " Another difference in such cases will arise from the different manner in which the orifice of the artery may be united or continued with the orifice of the vein. In one case, the trunk of the vein may keep close to the trunk of the artery, and the very (a) Burckhardt, Achiv. der physiolo- (e) Park, in Medical Facts and Observa- gischen Heilkunde von Roser und Wunder- tions, vol. iv. p. 111.—Physick, in Medical lich, 1843 Museum, vol. i. p. 65.—Richerand, above (6) Cooper's Lectures, vol. ii. p. 84. cited.—Breschet, above cited.— [Nokris, in (c) Above cited, p. 443. American Journal of Medical Sciences, vol. {d) Above cited, p. 507. v., n. s. 1843.—g. w. n.J VARICOSE ANEURYSM. 551 thin stratum of cellular membrane between them may, by means of a little inflam- mation and coagulation of the blood among the filaments, as it were, solder the two orifices of these vessels together, so that there shall be nothing like a canal going from one to the other; and then the whole tumefaction will be more regular, and more evidently a dilatation of the veins only. (Such is the aneurysmal varix. j. f. s.) In other instances the blood that rushes from the wounded artery, meeting with some difficulty of admission and passage through the vein, may dilate the cellular mem- brane between the artery and vein, into a bag, as in a common spurious aneurysm, and so make a sort of canal between these two vessels. The trunk of the vein will then be removed to some distance from the trunk of the artery, and the bag will be situated chiefly upon the under side ofthe vein. The bag may take on an irregular form, from the cellular membrane being more loose and yielding at one part than at another, and from being unequally bound down by the fascia of the biceps muscle. (Such is a varicose aneurysm, j. f. s.) And if the bag be very large, especially if it be of an irregular figure, no doubt coagulations of blood may be formed, as in the common spurious aneurysm." (pp. 394, 95.)] In operating on such a varicose aneurysm, when, after the application of a tourniquet, the swelling is cut into throughout its whole length, and the blood absorbed with a sponge, at the bottom of the cavity is seen the aperture made by the lancet, in the hinder wall of the expanded vein. If a probe be introduced into it, it passes into a second sac, but not into the artery, which is ascertained by the ease with which the probe moves around and the difficulty with which it can be carried in the direction of the artery. After the introduction of the probe, this opening is to be en- larged, and the second sac, which is full of coagulated blood and layers of membrane, laid open throughout its whole extent. After emptying and cleaning the sac, the wound of the artery appears in the bottom, through which the sound is to be introduced, and the ligature applied above and below. [My friend Green had some years ago a case of varicose aneurysm, as he con- sidered it, in the frontal branch of the temporal artery and vein, about the size of a walnut, and which resulted from, these vessels having been wounded in cupping. The artery entered one end of the sac, but it did not pass out at the other, so that the vein alone had two orifices in it. He removed the whole mass and the prepara- tion is in King's College Museum. The highly interesting case described by Perry (a) under the name of varicose aneurysm, does not appear to me to correspond at all with the conditions which the term varicose aneurysm generally implies, and in which it is used by both Hodgson and Chelius. The former specially observes:—"If the vein be not in immediate contact with the artery, or if the blood meet with obstruction in its passage from one to the other, in consequence ofthe obliquity ofthe wound, the employment of com- pression, or any other cause, the cellular membrane connecting the vein and artery may be dilated into an aneurysmal sac, through which the two vessels will com- municate with each other. In this case the vein will be removed to some distance from the artery, and the aneurismal sac will be situated between the two vessels,- the blood will first pass from the artery into the aneurismal sac, and from the aneurismal sac into the dilated vein. This variety of disease may with propriety be denominated varicose aneurism, to distinguish it from aneurismal varix." (p. 507.) In Perry's case, however, there was nothing of this kind. He says:—" At the spot in the thigh where the communication had been presumed to exist between the artery and vein there was an aneurismal sac about as large as a walnut, firmly ossified within, which, by the pressure it had exerted upon the vein, had caused absorption of its coats, so as to form a circular opening of about two lines in diameter, into which the aneurism had burst* thus inducing a free and persistent communication between the vessels. Just below the aperture,°the vein was obliterated at a single point, below which it was again pervious. In all the rest of its course up the thigh it was diminished in size and thickened." (p. 42.) From this it will be clearly seen, there was neither (a) Med. Chir. Trans, vol. xx. 1837. 552 BRANCHING ANEURYSM. condition of a varicose aneurysm, neither an intermediate sac, nor a dilated vein, but exactly the contrary. Neither was it an aneurysmal varix, for there was no special tumour ofthe vein, nor was it enlarged, but just the contrary, "diminished in size and contracted." If the account of the case be carefully examined, I think it must be admitted that it is none other than a simple case of aneurysm, having the very rare termination of bursting into a vein, just as in the cases already mentioned (par. 1402, note) where aneurysms of the aorta have burst into the pulmonary artery, which in reality belongs to the venous system, as it conveys the spoiled blood to the lungs for purification. That so far as the femoral artery was concerned, it was subject to aneurysm by dilatation cannot be disputed, for Perry says "the coats of the femoral artery, throughout its whole course, were scarcely, if at all thicker than those of a vein, the attenuation having, as careful dissection afterwards proved, taken place equally in all its coats. Immediately below the origin of the profunda the vessel was greatly dilated, having the appearance of an aneurysmal sac. Its coats were here softened and much attenuated, large enough to admit the point of the ring- finger." (pp. 41, 42.) The ossification of the aneurysmal sac at which the artery communicated with the vein has nought to do with the question.—j. f. s.] B.—UNNATURAL EXPANSION IN THE BRANCHES AND RAMIFI- CATIONS OF THE ARTERIES. von Walther, Journal fur Chirurgie und Augenheilkund, vol. v. p. 244. Breschet, above cited. 1495. An unnatural expansion of an artery to a greater or less extent, often throughout its whole length, and in its most principal ramifications, with simultaneous lengthening of the vessel, which becomes tortuous, and, with numerous curvings and windings, forms swellings of various size, on many parts presents knotty elevations, or little circumscribed aneurysmal swellings, which sometimes are true sac-like aneurysms, sometimes also mixed aneurysms, with torn internal coat, (Breschet,) produces Branching Aneurysm {Aneurysma racemosum, A. cirsoideum, A. anastomoticum seu anastomosium, Varix arterialis, Tumour sanguineus arteriosus.) It occurs most commonly in arteries of the third or fourth order; on the branches of the carotid, labial, temporal, occipital, ophthal- mic, and superior thyroidal arteries; on the arteries of the fore-arm and leg; in the arterial arches on the palm and sole; and in the vessels of the periosteum. 1496. This aneurysm is characterized by a more or less strong pulsa- tion of the several expanded arteries, and their various arches and branchings and by knotty, soft, livid, pulsating swellings, forming dis- tinct tumours of various size, which lie contiguously in rows, or even upon, each other. Every increased congestion of blood by exertion, overheating, and so on, increases the pulsation, which, by compression ofthe principal trunk, is diminished or entirely stopped, and at the same time the swelling subsides and becomes relaxed. From the various situa- tions of this aneurysm, to wit, on the head, peculiar symptoms may arise; the patient hears violent pulsation, has whizzing and roaring in the head, which disturb him in his sleep; often shooting pain in the course ofthe arteries; and if the swelling lie on a bone, it is absorbed by the pressure, or groove-like depressions are formed on it in the eourse of the severally enlarged vessels. With the quicker or slower enlargement of the swelling, the skin thins more and more, and bleedings at last take place sponta- BRANCHING ANEURYSM. 553 neously, or from trifling causes, which are often difficult to stanch, are frequently repeated, and cause death. 1497. The branching aneurysm is distinguished from other swellings by the distinct pulsation and the considerable expansion of the arteries to a great extent of their course, and by the pulsation of the compressi- ble swelling. The diseased expansion of the capillary vessels or Tele- angiectasy, never presents any such pulsation and expansion of single vessels; but both may occur at once, the branching aneurysm may sub- side into a teleangiectasy, or may be developed from it. Examination of branching aneurysm shows the walls of the expanded arteries thin, soft, and falling together, when cut through like veins, and especially resembling expanded veins. At the situation of the most knotty emi- nences there are either sac-like expansions of all the thinned arterial coats, or the middle coat is torn and the internal coat protruded with it through this opening under the cellular coat {a). 1498. The causes of branching aneurysm are either accidental, as wounds ofthe arteries, contusions, continued irritation, and thereby con- tinued congestion, especially in suppressed ordinary discharges of blood or rheumatic affections. Most commonly there appears to be a general co-operating diathesis; for rarely is the affection confined to one part; mostly a more or less general affection of the arterial system shows itself, especially softening of the arterial walls, which increases in proportion to their expansion. Females of middle age and of delicate bodily frame are most frequently subject to it. 1499. The prognosis in branching aneurysm, when it has attained a high degree of development, or when a general diatliesis exists, is ex- tremely unfavourable. The treatment must be directed especially to the origin and seat of the evil. With a defined extent, and when the seat of branching aneurysm is defined, a proportionate and sufficiently great compression with rest, and the local and internal use of astringent reme- dies, may be sufficient (Breschet.) If the swelling be superficial, for instance, on the face, and the vessels going to it be not expanded to a great extent, they may be extirpated; this, however, is rarely the case, and the extirpation, on account of the severe bleeding, easily becomes dangerous; and in such cases, as well as in a rather large extent of swel- ling, its simple or manifold tying, as proposed in teleangiectasy, is proper. The simple tying of the swelling and pressure (1) is also applicable, only to a certain extent, but is also accompanied with danger of severe bleed- ing and irritation, which happen also from the employment of caustics and the actual cautery. Where the vessels leading to the swelling are expanded to a great extent, they, to wit, the temporal, occipital, and other arteries have been severally tied, but their manifold anastomoses have in such cases nearly always soon produced a relapse, even when continued pressure has been kept upon the swelling. Tying the principal trunk, the branches of which are expanded, is in such cases always the most advisable, although experience also shows that even therewith a relapse frequently ensues; in which case the swelling subsides only for a short time, but soon arises again, and increases together with the pulsation caused by the introduced collateral circulation. After tying the princi- pal) Breschet, above cited, pi. ii. fig. 3. 47* 554 ANEURYSM OF THE pal trunk it is therefore always advisable to employ a corresponding an- tiphlogistic treatment, cold applications and pressure (2). If the dis- ease occur on the limbs, and in such degree that the modes of treatment recommended are inapplicable or ineffectual, amputation of the limb is the only remedy, but it rarely has a satisfactory issue. (1) Graefe, in the largest pulsating swellings, made a long and deep cut, imme- diately pressed down firmly a large sponge, and, before the blood could escape, quickly applied a soft agaric between the edges of the wound, covered the whole with a sponge an inch thick, and confined it with strips of sticking plaster laid cross- ways and a circular bandage. The result was favourable. (2) Travers (a), Dalrymple Cb), and Wardrop (c) have, in such aneurysms in the orbit, tied the carotid artery with success, which is accounted for by the smaller and less numerous anastomoses. Rogers (d) cured an aneurysm by anastomosis of the external maxillary artery by tying the carotid. On the contrary, Dupuytren (e) tied the carotid on account of such swelling situated on the ear and region of the occiput, for which compression and tying of the temporal, auricular, and occipital arteries had been performed without success; the swelling diminished, the pulsation ceased, but it returned about the seventeenth day, and continued, only less strong than before, in spite of a compressing apparatus. Mussey (/) tied both carotids, on account of such swelling upon the erown of the head, with little benefit, as the pul- sation recurred four weeks after the second tying; and in the extirpation which was performed two quarts of blood were lost, and forty vessels tied. With equally various result was the carotid tied. (Dupuytren.) I have seen one case, where the femoral artery was tied without benefit, and amputation of the thigh became necessary. 1500. With branching aneurysm in the soft partsx those swellings which depend on similar diseased changes of the arteries in bones, actually agree, and are therefore distinguished by Breschet as Aneurysm of the arteries of bones, and by Scarpa as Aneurysms by anastomosis of bones. Pearson (g) communicated the first observations on such swellings, and after him Scarpa (h). More recently Lallemand has made known a similar observation; and Breschet (i) has added remarks, as well as historical inquiries upon the exist- ence of similar cases in the earlier writers, with several observations by Dupuytren. Scarpa (j) also has subjected this disease to a special inquiry. 1501. Frequently, from sudden and undiscernible causes, often a shorter or longer time after the operation of any external violence, more or less severe pain occurs upon some one spot of a bone, most frequently in the neighbourhood of the joint-ends of tubular bones, wdiich, when the patient is quiet, diminishes, or even for a time subsides; but then returns more severely. A swelling appears, the veins of the whole limb swTell; the pain spreads over the entire limb, which has a bluish-red colour. Pul- sation is soon felt in the swelling-, which is at first indistinct, but subse- quently becomes stronger, and as strong as in aneurysm. This pulsation is synchronous with that ofthe artery, without a rush, and, if the disease have previously made much progress, with extension of the swelling in (a) Med. Chir. Trans., vol. ii. p. 1. (b) Ibid., vol. vi. p. 111. (c) Ibid., vol. ix. p. 203; and Lancet, vol xii. p. 267. (d) American Journal of Medical Sciences,, vol. xiii. p. 271. Ij-33. (e) Rust's Magazin, vol. viii. p. 116.— Breschet, above cited, p. 76 (/) London Medical Gazette, vol. vi. p. 76. (g) Medical Communications, vol. ii. Lon- don, 1790; p. 95. (h) On Aneurysm above cited, p. 478. (i) Observation sur une Tumeur Aneuris- male,accompagneedecirconstancesinsolites, par M. Lallemand, suivie des observations et des reflexions sur des turneurs sanguines d\m caractere equivoque, qui paraissent etre des Aneursymes des Arteres des Os. Paris, 1827. 4to. (j) Annali Universal! ni Medicina. May, June, 1830. ARTERIES OF BONES. 555 every direction. Pressure on the principal artery of the limb, between the swelling and the heart, completely stops the pulsation, by which the swelling loses its tension and subsides, but returns immediately the com- pression of the artery is removed. The patient has often continued pain in the affected part, which is swollen or wasted, and the motions of which are entirely, or only at the joint, in the neighbourhood of which is the swelling, prevented. If the swelling be pressed with the fingers, there is often observed at some parts a crackling, as in squeezing parchment to- gether, or in breaking an egg-shell. If the bone be completely destroyed, the part may be moved in every direction (a). If the swelling be deve- loped in the neighbourhood of a large artery, it may most commonly be followed over the swelling. Nicol (b) has communicated, a case precisely like mine. 1502. On examining these swellings after death or amputation of the affected part, the principal vessels have been found throughout their whole course unhurt, and neither by injection nor by the closest examination could any trace of disturbance of their continuity be observed. On open- ing the swelling, the condition of the parts varied according to the dif- ferent degree of development of the disease. When the bone was entirely destroyed, the aneurysmal sac, of which the walls were very thick, often cartilaginous, and formed of periosteum, contained a quantity of fibrous layers, like those commonly found in aneurysmal sacs, and in it the re- mains of the destroyed bone. The internal surface of this sac was fiocky, irregular, very much like that part of the placenta connected with the womb, and presents numerous openings of freely branching vessels, from which, if the part be injected, a portion of the injection flows into the sac. In a slighter degree of the disease the external table of the bone was still found, but very thin, destroyed in some places, in others but slightly re- sisting the pressure of the finger, resembling a cartilaginous plate, which yields to pressure and again rises, or breaks like an egg-shell. The neighbouring joint was always healthy, even when separated from the aneurysmal sac only by the layers of the loosened joint cartilages. The fibrous clot was collected in the cavity of the bone, or the sac presented several cavities filled with it, wherewith every single artery of the sac corresponds. Upon the external surface of the sac the arteries were very numerously expanded and enlarged, and often wrere so to a tolerable dis- tance around the sac. 1503. These swellings are developed on the various bones of the body, not unfrequently on several bones of one and the same person; on the skull, trunk, and limbs, most frequently on the upper part of the leg, below the knee, on the shin, or splint bone alone, or on both bones at once (Pearson, Lallemand, Dupuytren) ; but hardly ever in the middle of the long tubular bones. The occasional causes of these swellings are commonly external vio- lence a kick, blow, fall, or any violent exertion in lifting a heavy weight, and s'o on, in which the patient feels a crack at the spot where subse- quently the disease is developed; the interval, however, between the (a) Chelius Zur Lehre von den schwammigen Auswilchsen der bartenHirnhaut und de Schadels. Heidelberg, 1831 fol. Erste Beobachtung, p. 43. (6) Edinburgh Medical and Surgical Journal,. 1834. July. 556 ANEURYSM OF THE operation of such cause and the origin of the disease is very great, and during this time the patient often feels no pain, or only indistinct and transient pain. Lallemand observed this disease occur after acute rheumatic swelling of the knees. Ordinarily the swelling has a general internal cause, manifestly corresponding with which is its not unfrequent origin without any distinguishable cause, the simultaneous or subsequent origin of several happening in one and the same subject, and especially the circumstance that the disease even reappears in some parts after am- putation of the affected limb. On these grounds such swellings cannot be placed, as they have been by Breschet and others, in the same rank with teleangiectasy of the soft parts, which is always a local disease, and so remains, even when of considerable extent, whilst this, on the contrary, is usually connected with a constitutional disease. 1504. These diseased changes in the bones appear always to be pre- ceded by an inflammatory condition, in consequence of which the nourishment ofthe bone is altered; loosening, softening, and absorption ofthe hard bony mass, a more rich development and enlargement ofthe vessels, congestion of blood, and complete destruction of the bone are produced. That these diseased changes proceed from the interior to the exterior of the bone, is admitted by all observers, and the cases in which the external plate of bone has been found similar to a thin fragile shell, prove it. But whether this disease be not also developed from the external surface of the bone and from the periosteum, and whether the condition of other organic diseases of bone be not changed by an angiec- tasic complication, as in these swellings, must be decided by farther examination and observation. [It must not be supposed that all pulsating tumours in bone are to be referred to the peculiar form of disease now under consideration, for Stanley (a) has shown that " three distinct sources of pulsation in such tumours can be recognised. First. The proximity of a large arterial trunk. Second. The development of blood vessels and blood cells, constituting a sort of erectile tissue within the tumour. Third. Enlargement of the arteries of the bone in which the tumour has originated." (p. 303.) Of the first kind he mentions several examples, in two of which " the tumour occupied the whole circumference of the upper arm in its upper third, and possessed throughout an equal and strong pulsation, which ceased on compressing the subcla- vian artery above the clavicle. In each case the disease was considered to be an aneurism of the axillary artery." One of these cases was, on examination, found to be " an encephaloid tumour originating in the humerus, and covered by the articular cartilage of the head of the bone. * * * There were no large vessels distributed through it. In the other case, the tumour originated in the humerus, and was com- posed of a firm gelatinous substance, about half an inch thick, and forming the walls of a large cavity, filled by a serous fluid. * * * In this instance no remarkable dis- position of vessels through the tumour was observed. * * * In both these cases the brachial artery was perfectly healthy and with its accompanying veins and nerves was found closely united by cellular tissue to the tumour through its whole extent." In a third case, which was under Lawrence's care, and following a fall, "shortly afterwards a painful swelling arose immediately above the knee, and gradually extended around the back part and sides of the lower third of the thigh. Near the tendon ofthe biceps, a softening ofthe swelling indicated the probability of its con- taining matter, and accordingly a small puncture was here made into it from which about four ounces of arterial blood freely flowed. On examining the swelling more closely, pulsation in it was now discovered." On consultation it was presumed to he an aneurysm, the femoral artery was therefore tied, the pulsation ceased and the (a) On the Pulsating Tumours of Bone, with the account of a case, &c.^ in Med. Chir. Trans., vol. xxviii. 184&. ARTERIES OF BONES. 557 size of the swelling at first diminished but afterwards it again " enlarged, became painful, and the skin covering it sloughed, the sloughing extended deeply into the tumour, but was unaccompanied by haemorrhage. * * * He shortly afterwards sunk from exhaustion." On examination, " the tumour was found to consist of a compound of soft fibrous and dense osseous tissue, the latter situated deeply, and extending around the femur, in which it appeared to have originated. The whole series of femoral, inguinal, and lumbar absorbent glands were converted into osseous tumours. The femoral and popliteal arteries were sound. In the lower part of the thigh, the femoral artery was a little compressed and displaced by the ossified ab- sorbing glands which were closely united to it." (p. 304-6.) Under this head Stanley mentions two cases of Hodgson's, of encephaloid tumours in the tibia just above the inner ankle, of which Hodgson observes:—"To what these tumours owed their pulsation I know not, but I thought it was derived from contiguous arteries." Also a case of Lawrence's (a) of "medullary tumour developed in the head ofthe tibia, attended at one period with pulsation and suppression of the pulse in the anterior and posterior tibial arteries at the ankle. In the account of the examination of the limb, Mr. Lawrence states that the medullary tumour had protruded from the bone just at the division of the popliteal artery, and the passage of the anterior tibial through the interosseous ligament," which " circumstance accounts for the pulsation felt in the tumour at an early period; for the suppression of the pulse in the tibial arteries when the morbid growth was confined by the fascia ofthe leg, and its subse- quent return when the progress of the swelling through the fascia had liberated the arteries from pressure." Stanley also refers to a case of Guthrie's (b), in which there was a tumour on the nates as large as an adult's head, which was considered to be an aneurysm; " the pulsation was decidedly manifest in every part; and, on putting the ear to it, the whizzing sound attendant on the flowing of blood into an aneurism could be very distinctly heard. * * * The ligature of the common iliac was followed by a diminution of the tumour to the extent of one half, and the recovery from the operation was complete. Five months afterwards the tumour again enlarged, and she gradually sunk. On examination the tumour was found to be composed of cerebriform substance. The arteries were healthy." Of the second kind, was Stanley's own case:—"The pulsating tumour originated in the ilium, it was soft, spongy, and dark-coloured, with cells dispersed through it, each about the size of a pea, and filled with blood. Bunches of convoluted vessels were drawn out of this spongy substance, and, when macerated, this substance was reduced to a tissue closely resembling that of a swelled spleen or placenta. Here was a structure capable of enlargement by the distension of its vessels and cells; and, assuming these to have been directly continuous with the arterial system, it may be added, that the rush of blood into such a structure would give to the whole mass a pulsation resembling that of aneurism; at all events, it is certain that this tumour did possess such pulsation, which ceased directly the aorta was compressed through the abdomi- nal parietes; moreover, that the tumour enlarged and became tense when the femoral artery below it was compressed, as an aneurism, under similar circumstances, would have done." Similar to this, is the case given to Stanley by the younger Law- rence, of Brighton, in which the tumour in the right groin having " gradually increased to the size of an egg, was then observed to pulsate, after which it rapidly increased. The pulsation continued, was uniform over the whole tumour, and accompanied by a distinct bruit." The man died, and, on examination, the tumour was found to consist " of vessels intermixed with soft gelatinous substance. The vessels formed more than half the tumour, were about the size of sewing thread, and very convoluted; and were directly continuous with the arterial system." (pp. 309, 310.) The third form is the disease which Breschet and Scarpa here refer to, and with the cases which they have given mustbe included Luke's case, which Stanley relates in which a man of 20 years broke his thigh; " at the end of seven weeks it was firmly united. A month afterwards, by a second accident, the bone was again broken at the same place. Reunion of the fracture ensued, but very slowly and unevenly. A tumour now formed in the situation of the injury; it was hard in some parts soft and elastic in others. A grooved needle was introduced into it, and a jet of blood followed. The tumour increased to the size of a large melon, became very ln\ Observations on Tumours; in Med. (6) London Medical and Su-gical Journal, Chir. Trans, vol. xvii p. 39. 1832. vol. v. p. 831, ld43; and vol. vi. p. 101,1835. 558 ANEURYSM OF THE ARTERIES OF BONES. painful, and pulsation in *t was now discovered. Suspicion of its being an aneurism in consequence arose, and in consultation it was determined to tie the femoral artery; this was done with the effect of stopping the pulsation ofthe tumour, and producing a diminution in it to the extent of an inch in its circumference. About a month afterwards the tumour again enlarged, but without the return of pulsation, and it was now deemed right to amputate the limb. The surface of the stump bled so profusely, that more than 40 ligatures were required. The medullary artery was greatly enlarged, and threw out a forcible jet of blood. The man left the hospital with the stump healed, and in every respect well. On examining the limb, the lower third of the femur was found expanded into a spherical tumour, in the interior of which were cells of varying size, some of the largest about an inch in diameter, and filled with blood. The femoral and popliteal artery were entire and healthy." (pp. 311, 312.) Although Stanley places this case among the third kind of pulsating tumours, yet it seems, from the history, that it has greater resemblance to the second. From the recital of these cases, one important point immediately attracts attention, which is, the absence of any peculiar character by which either form of swelling could be distinguished from aneurysm, for which they seem to have been almost universally mistaken.—j. f. s.] 1505. In treating this disease, in some cases applications of various kinds, leeches, rubbing in, mercurial treatment in presumed syphilitic diseases, and so on, have.been employed, but without any result. Only can a strict and sufficiently long continued antiphlogistic treatment, with attention to the general, causes standing in somewhat causal relation, perhaps prevent the development of this disease. If the swelling have already acquired a certain stage, according to our present experience, tying the principal arterial trunk, or amputation (if the situation of the disease permit) can alone effect a cure. [Norris, in American Journal ofthe Med. Sciences, vol. xxv. p. 283. 1839.—g. w. n.] 1506. Tying the principal trunk of the artery gives the more hope, according as it is undertaken early, even before considerable destruction of the bone has taken place. Lallemand's case proves that a perma- nent cure may be effected; but when the diseased change in the bone has so far advanced, only temporary diminution of the swelling and removal of the aneurysmal symptoms are effected, whilst the disease of the bone continues spreading, as shown by Dupuytren's (a) case, in which, seven years after the femoral artery had been tied for such swell- ing at the upper part of the shin-bone, amputation was required, as, without the reappearance of any aneurysmal symptoms, it had attained an enormous size. In all cases where the destruction of the bone has already far advanced, amputation can only be considered as a means of deliverance ; it must not, however, be herein overlooked that with exist- ing constitutional disease, €ven after the operation, without any cause, the disease may be set up again, as shown in Scarpa's (6) first case, in which, five years after amputation, during which time the patient's health was good, the disease, without any cause, again showed itself on the stump of the thigh-bone. (a) Breschet, above cited, p. 15. (b) Above cited, p. 483. TELEANGIECTASY. 559 C—UNNATURAL EXPANSION IN THE CAPILLARY-VASCULAR SYSTEM. Bell, J., Principles of Surgery, vol. ii. p. 456. On the Aneurysma per anasto- mosin. Graefe, C. F., De notione et cura angiectaseos labiorum. Lipsiae, 1807. 4to. Ibid., Angiektasie ein Beitrag zur rationellen Kur und Erkenntniss der Gefassaus- dehnungen. Leipz., 1808. 4to; with copper-plates. Richerand, Nosographie Chirurgicale, vol. iv. p. 120. Hodgson, above cited, p. 441. Roux, Relation d'un Voyage fait a Londres en 1814 ; on Parallele de la Chirurgie anglaise avec la Chirurgie francaise. Paris, 1815, p. 211. Maunoir, J. P., Memoire sur les Fongus medullaire et nematode. Paris and Geneva, 1820. 8vo. von Walther, Ueber Verhartung, Scirrhus, hartenund weichen Krebs, Medullar- sarcom, Blutschwamm, Teleangiektasie, und Aneurysma per Anastomosin; in Journal fur Chirurgie und Augenheilkunde, vol. v. p. 189. [Watson, I., On the Nature and treatment of Teleangiectasis in the American Journal of the Medical Sciences, vol. xxiv. 1839.—g. w. n.] 1507. By the unnatural expansion of the capillary vessels are pro- duced soft elastic swellings, which, consisting merely of numerous ves- sels tortuous and connected together with loose cellular tissue, can in respect to their internal structure, be compared with nothing better than the placenta. The different designations, Fungus haematodes, Tumor fungosus sanguineus, Aneurysma per anastomosin, Aneurysma spongiosum, Blutschwamm, Teleangiektasie, Tumeur erectile, Splenoide have been applied to them. I consider teleangiectasy the best of all these designations. The term bloody fun- gus (Fungus hsematodes) I employ here, but not in the sense of Hey and others, who thereby designate another degeneration, for which I consider the term Fungus medulr laris more appropriate; at least, I cannot, after numerous examinations, admit (as Walther does) any other Fungus haematodes besides teleangiectasy and medullary fungus. 1508. These swellings, which originally have their seat in the skin and underlying cellular tissue, occur either in children or adults, or are congenital. It generally begins with a red or bluish spot, which at first is little or not at all elevated above the skin, and increases in a shorter or longer time to a variously shaped swelling, in which the patient feels a peculiar crawling and beating, which on closer examination may be more or less distinctly perceived. The colour of the swelling is some- times more red, sometimes more bluish; it enlarges and pulsates more distinctly at every exertion, by which the circulation of the blood is quickened. When it has attained a great extent, single fluctuating spots arise, the skin thins, bursts, and considerable bleeding ensues, which frequently recurs. The apertures often close with a seemingly firm scar; and often red, fungous granulations spring up from them, which consist merely of clotted blood. The interior of such swelling exhibits a con- volution of innumerable vessels enveloped in loose cellular tissue, many cavities filled with blood, and frequently single vessels full of holes, out of which the blood trickles. If these swellings exist in the cellular tissue beneath the skin, the latter retains its natural'condition for a longer time; a deceptive sensation of fluctation is felt; the skin is gradually altered in 560 TREATMENT OF the way mentioned; the disease rarely extends between the deep-lying organs. Swellings of this kind may be very easily mistaken for fungus medullaris. The fungous growths, after the bursting of teleangiectasy, result from clotted blood and considerable developement of the parenchyma of the swelling; but there never exists in them any specific degeneration (a transition into fungus haematodes, accord- ing fo Walther's opinion) if no definite general dyscrasy be present. I have seen many bursten and fungous teleangiectasies, but never any extension to a distant organ, as in medullary fungus. Also in this degree, if teleangiectasies arise after local diseases, they especially affect the constitution by repeated loss of blood. Upon this, also, depend the favourable results produced by suppuration and scarring, as also the circumstance that bursten teleangiectasies are often closed by a tough scar. 1509. These swellings originate in an unnatural extension, and cer- tainly also in a large development of the capillary vessels; but since these must be considered as the terminations of the arterial, and the com- mencement of the venous system, we find in such swellings both, but sometimes the arterial, sometimes rather the venous side of the capillary- vascular system affected. This difference manifests itself by the appear- ance of the swelling, and the circumstances accompanying its develop- ment. In teleangiectasy, which affects rather the arterial side of the capillary system, the redness is brighter, the pulsation more distinct, and the enlargement more rapid; but in the venous blood-fungus the redness is more dull, bluish, the pulsation less, frequently not at all perceptible, and the growth slower. Jaeger's assertion, that teleangiectasy, never exhibits pulsation, and that this is only the case when it is accompanied with Aneurysma anastomosium, is incorrect. Certainly, it never is perceived in flat though extensive teleangiectasy, but it cer- tainly is, when it has risen up to actual swelling, and especially in great agitation of the vascular system, when the crawling pulsation is perceptible even to the patient himself. 1510. Besides the considerable ramification and development of the vessels, various changes may also arise in such swellings from thicken- ing and degeneration of the uninjectable part of their cellular tissue, whereby the swelling varies more or less (1) from that above described. Teleangiectasy may also, especially by continued irritation, be accom- panied with aneurysma anastomosium, if situated where there are nu- merous arterial ramifications and anastomoses. Teleangiectasy then increases more rapidly, stronger pulsation is felt in the neighbouring branching arteries, and the pulsation in the swelling itself even, is greater. {par. 1496.) (1)1 have seen one such teleangiectasy between the thumb and metacarpal bone of the forefinger, as a dusky red swelling, expanding at certain parts into thin blood sacs, with crawling pulsation, additional swelling, and redness in hanging down of the hand, in diminution of these appearances on raising the fore-arm, or compressing its vessels or the swelling itself with the fingers, in which the sac felt as if full of wool. I applied to it the name of Teleangiectasis lipomatodes. Tying the radial artery diminished the extent, and all the other appearances of the swell- ing (a). 1511. The causes of this disease are obscure. It occurs at all ages, and in all constitutions, though most commonly in young subjects of flabby habit, in children, and women. It is developed in all organs, (a) Heidelberg Med. Annalen, vol. i. p. 101. pi. iv. TELEANGIECTASY. 561 but especially on the upper part ofthe body, in the skin ofthe skull, of the cheeks, ofthe eyelids, and on the lips. A contusion frequently gives rise to it. r n J & I must deny von Walther's assertion that teleangiectasy must be always conge- nital, because that peculiar vascular development, and alteration ofthe injectable part of the substance of the organ, which happens in teleangiectasy, cannot arise at a later period of life, if it be not a vice of the first formation during the embryonic state, although unapparent; for I have often seen teleangiectasy, commence and be developed in the skin of adults, without any preceding trace ; but in such instances the progress will be, for manifest reasons, always exceedingly slow. 1512. Teleangiectasy is throughout a local disease, and the prognosis is guided by the nature and condition of the swelling, by its seat, and origin, by the age and constitution of the person affected with it. The congenital red spot often enlarges very quickly after birth, often later; but its enlargement is always to be dreaded at the period of puberty, when even the swelling, whose growth is already determined, at that time acquires increased extent. Bleeding has also been observed from such swellings at the time of menstruation. These teleangiectasies have, however, a spontaneous retrocession, and are capable of cure, as I have observed, at different periods of time, in congenital teleangiectasy; and even frequently in those cases in which, from the pale red colour, a quicker enlargement is to be feared. When this occurs, the colour becomes paler; instead of the uniform redness, single vessels appear, between which the skin gradually acquires its natural condition, and the vessels shrink, so that no trace of the disease remains. 1513. The cure of teleangiectasy may be effected by compression, by removal either by extirpation or tying, by destruction with caustic or with the actual cautery, by exciting a pretty violent inflammation and suppuration, and by tying the principal trunk of the artery, with the branches of which the swelling is connected. The choice and prefe- rence of the several modes of treatment depend on the condition and seat of the disease, and we must be especially careful in the selection of these, that the teleangiectasic tissue be capable of sufficient inflamma- tion and suppuration, and that the scar thereby produced can be con- verted into a tough tissue, with obliteration of the vessels, without it being necessary to destroy or remove it entirely. 1514. Compression of teleangiectasy, either alone or in connexion, at the same time with astringent remedies or cold, can only be employed in a slight degree ofthe complaint, in congenital red spots, if their seat permit it, with some degree of success (a). I have, however, from this mode of treatment, frequently as I have tried it, never obtained any satis- factory result. Abernethy (b) recommends pressure, and if this be inapplicable, the application of cold rose water and alum. I have instituted several experiments with kreosote, but have never observed the slightest result (c). Compression has been used, ac- cording to the different seat of the disease, with flat plates and stirrup-shaped com- pressors, and even with plaster of Paris. 1515. Extirpation of teleangiectasy with the knife, is always accom- panied with more or less considerable bleeding; as, if the patient be (a) Roux, above cited, p. 248. (cj Heidelberg Med. Annalen, vol. i. pt. i. (6) Surgical Works, vol ii. p. 228. Vol. ii.—48 562 TREATMENT OF young, and the seat of the disease such that it is not possible to complete the operation quickly, the danger may be eminent and even fatal. Every thing depends on the cut which is carried round the swelling being made at sufficient distance from it in the healthy parts, as otherwise, on account of the very numerous and largely-distended vessels, severe bleeding ensues; and if a part of the swelling be left, its recurrence is to be feared. If it be requisite to leave part of the swelling, the actual cautery must be applied, or caustics with subsequent pressure, in order to cause destruc- tion, and at the same time to stanch the bleeding. After extirpation, the wound is to be treated according to the general rules. This treatment is often tedious, because frequently no satisfactory suppuration ensues, and the edges of the wound long continue loose. In large and flat te- leangiectasies, therefore extirpation can never be employed, but especi- ally only in those which are elevated and have a narrow base. I have known two instances in which children died upon the operating table in extirpating a teleangiectasy from the face; and, at least in one of the cases, no one could doubt the capability of the highly-distinguished operator. 1516. Tying a teleangiectasy has always this great advantage over extirpation, that nothing is to be feared from bleeding. Its employment is specially applicable to projecting swellings with narrow base; but even in the large and out-spreading teleangiectasies, which are prominent, this mode may, according to White (a), Lawrence (6), and Brodie (c) be employed with the best result, as also has happened to me in several cases. Lawrence penetrates the base of the swelling with a strong, slightly curved needle, carrying a double thread, which is firmly tied on both sides. As soon as the mass of the swelling blackens, it may be cut off with the knife, and the ligature removed. Brodie thrusts a hare-lip needle through the swelling a quarter of an inch from its edge, and a straight needle with a double thread at a right angle with this needle and beneath it; the double ligature is then separated, and each tied under the first needle. [I prefer Brodie's method with the two needles, as thereby the whole base ofthe swelling is more completely included within the thread. If the swelling be large, it will not be possible, at once, to compress it with the ligature, so as to stop the cir- culation and cause sloughing. In such case it is better to take hold of the middle of the tumour, and having lifted up and squeezed it, so as to empty out the blood, to pass a needle, armed with double thread through its base. The threads are then to be carefully separated, and each pair of ends being carried round the half bases of the tumour, are tied firmly on opposite sides, and then attached to Graefe's little Bcrew tourniquet, a most excellent instrument for the purpose, with which, as the threads, ulcerating the skin, become loose, they are to be everyday or two tightened, till the strangulation and mortification of the swelling is effected. In this way I operated, six years ago, on a child, twelve months old, who had teleangiectasies on the temple and ear. She was born with one, about the size of a sixpence, and bright-coloured, on the temple, just above the auricle, which soon became sore, and occasionally exuding a few drops of blood. In the course of nine months, it ac- quired the size of half-a-crown. When the child was about six months old, two other little ones, about as large as a pins head, were noticed on the ear, one on the back of the helix, and the other on that of the concha. All continued growing, but were flat and distinct from each other for the next three months, when they began to rise above the skin, having previously been fiat, and soon ran into one another, form- (a) MedicChir. Trans., vol. xiii. pt. ii. p. (6) Ibid., p. 420. 444. (c) Ibid., vol. xv. pt i. TELEANGIECTASY. 563 ing one mass. The principal and most elevated portion was on the head, immedi- ately above the auricle, extending back to the occipital bone, as large as a crown piece, and gradually rising towards the centre, which was half an inch above the surface of the skin. From the lower part it continued on the auricle, covering the top of the concha, spreading over the upper part of the helix, and turning round upon the front of the ear, as low as the tragus. The pulsation in the temporal portion was very distinct; the vessels could be easily emptied by pressure, but immediately on its re- moval the tumour resumed its usual size, and swelled out when the child cried. Its colour was bright scarlet, and it had the feel of a mass of small vessels, or rather that of a sponge. The temporal portion was operated on, as I have advised; but although the ligatures were tightly drawn, strangulation could not be effected; the bright colour remained, and the tumour swelled when the child cried ; Graefe's screw was attached, and the threads drawn as tight as possible, but without change. On the third day, serum freely oozed from the surface; and on the day following the ligatures were hidden, but with scarcely any appearance of having cut into the base, and the bright colour remained. The screws were tightened but no change followed. On the seventh day, the ligatures had begun to cut through, and there was a free discharge from the track, but the granulations of the skin were inosculating with the under surface of the tumour, which seemed hardly at all separated. On the eleventh day, the'screws were again tightened, but without producing any change in the appearance of the swelling. On the following day the hinder ligature came away, but no part of the tumour separated with it; a piece of lint was gently in- sinuated beneath it. On the thirteenth day, the whole swelling appeared about to fall off; it was a little shrunk, but the bright red colour still remained. On the sixteenth day, it came off, leaving a granulating surface which slowly healed and contracted. The child was at this time taken into the country, with the promise of bringing her back again, to have the remaining part on the auricle, which thrust it away from the head, and turned it down at right angle, operated on; but I regret that she never returned. So far, however, as it went, the operation was completely success- ful.—j. f. s.] 1517. The destruction of teleangiectasy by caustic is, in all cases, to be considered as the most proper, where the swelling is broad and super- ficial, especially in children, as here extirpation with the knife is accom- panied with difficulty, and speedy danger of imminent bleeding; and often, on account ofthe seat ofthe disease and the delicacy of the child, can be as little relied on as the ligature. The most proper caustic is caustic potash, applied as a paste in an aperture of sticking plaster, put on around the teleangiectasy, or smeared over the part to be destroyed, for the purpose of making a slough of sufficient thickness and size, and then covered with sticking plaster. When the slough is thrown off by suppuration, it is to be treated simply as a suppurating part; healing follows with a corresponding scarcely perceptible scar. In very much spreading teleangiectasy, if on the first cauterization, the disease be not entirely destroyed, and shows itself afresh, I have never noticed its quicker spreading, and it is always cured by repeated cauterization. In adults, I have also employed Hellmund's remedies for destroying tele- angiectasy with the best result; it must, however, be recommended for children always with great caution, as, in its extensive application the possibility of absorption of the arsenic is not to be denied (a). The ap- plication of caustic potash is especially efficient in congenital teleangiec- tasy which appear as little superficial red spots in the skin, by which they may be certainly removed, as every other treatment is declined by the parents on account of the inconsiderable appearance of the disease. (a) Heidelberg, klinische Annalen, vol. iv. p. 499, vol. iii. p. 331, 564 TREATMENT OF The application of caustic potash is, on every account, to be preferred to the actual cautery. [I have not had much opportunity of watching the result of this practice, as I al- ways either remove a teleangiectasy with a ligature or the knife ; but from the few instances I witnessed, I am not inclined lo hold so high an opinion of it as does Chelius. In one case, especially, in which a great part of the scrotum of a child was affected with this disease, the application of muriatic acid, to produce constric- tion of the vascular mass, had only the effect of exciting irritation and hastening the growth, so that it soon acquired the bulk of an orange. It was then removed by a double ligature, excepting a very small portion, which occupied six weeks, as the ligature was not kept tight. Caustic potash was then applied over the whole granulating surface, after which the sore was allowed to heal; but the vessels were soon again found to enlarge, as well as the little portion of the swelling which had been left. The muriatic acid was again applied, but as unsuccessfully as before, and was followed by abscess ofthe healing of which the swelling soon re-acquired the size of an orange. And occasionally bled. I unfortunately lost sight of the case, so that I know not how it terminated, but it was quite evident the use of acid in this way was fruitless. I certainly would not on any account apply caustic to produce an eschar in cases Of this kind, and of large size ; as sloughing in children, when once set up, is not always controllable and often dangerous ; and a small tumour can be removed with greater readiness, and with less pain, by ligature or the knife, than by caustic. --J. F. S.] 1518. For the production of a sufficiently violent inflammation and sup- puration, to consolidate the tissue of the teleangiectasy and convert it into a mass of scar, various remedies have been employed. First, the fre- quently repeated and slight touching the teleangiectasy from its circum- ference towards its centre with caustic potash; by which, after every falling off of the thin slough, suppuration is kept up for a longer time. Second, in children who have not been yet vaccinated, the introduction of the cow-pock into the teleangiectasy; several slight punctures are to be made into it and its neighbourhood with a lancet moistened with lymph, and at regular distances apart. If there be bleeding, some lymph is to be at once introduced into the wound with a lancet, and even some folds of linen, steeped in the lymph, applied to the teleangiectasy. Ve- sicles form in the ordinary manner, and after the slough falls off, the te- leangiectasy has ceased (a). Similar to this treatment is the application of the u?ig. seu emplastr. tartari stibiati (Hickmann;) after the production of pustules, poultices are to be applied, and after the separation of the slough, the parts are to be touched with lunar caustic, and bound up with sticking plaster. Third, the practice recommended by Marshall Hall (b), of piercing with a fine needle through the whole of the mass of the teleangiectasy, close to the sound part, and its repetition in from eight to ten different directions. The punctured canals heal and the tissue is thereby changed. Where possible, pressure may still be em- ployed, but it has no particular effect. Fourth, according to Lalle- mand (c), cutting into or cutting out a piece of the teleangiectasy, and uniting the edges of the wound with the twisted suture, or the introduc- tion of long and thick needles through the swelling, which are not, how- (a) Hodgson; in Med. Chir. Review, vol. (b) London Med. Gazette, vol. vii. p. 677.— vii. p. 280.—Lancet, vol. xii. p. 760.—Young ; Lancet, 1834. April. in Glasgow Med. Journal, vol. i. p. 93.— (c) Archives generales de Medecine. May, Downing ; in Lancet, vol. ii. p. 237. 1815. TELEANGIECTASY. 565 ever, used for twisting round the thread, but their points only bent up, and the part defended with a proper covering. When the needles have suppurated out, if the swelling still continue they must be introduced again. We need not be uneasy at the bluish, almost brackish, appear- ance of the swelling immediately after the introduction ofthe needles; it is a good sign that the inflammation will attain sufficient height. A frequent repetition of the lunar caustic is necessary; perhaps the appli- cation of nitrate of silver is better. Fifth, the introduction of a seton by means of a needle, through the teleangiectasy, by which the bleeding from the needle-stab is stanched, and by it remaining in a proper degree of inflammation, suppuration is produced (a). If the latter do not occur, some irritating injection should be thrown into the puncture, as Lloyd (b) has recommended, without the previous introduction of a seton. The advantage of this, as well also of Hall's practice is that the skin upon the swelling is preserved and a smaller scar made. Of these different modes of treatment, which are especially employed in flat and spreading teleangiectasy, I must, after considerable experience, give the preference to the cauterization which I have proposed (1). (1) In a case of teleangiectasy spreading over the whole right side of the face, and nearly over the entire upper lip, and which at several parts, especially on the upper lip, was very puffy and prominent, after all other means had been quite useless, I entirely removed it, and converted it into a smooth mass of scar by very frequently repeated cauterization with nitrate of silver, by which the upper lip was at the same time brought back to its natural thickness. [Pattison (c), of New York, in a case of teleangiectasy as big as a pigeon's egg, on the shoulder of an infant eleven months old, varied Hall's operation, by passing " needles made red hot with a spirit-lamp, in rapid succession, about twenty times, into the tumour in all directions. There was no haemorrhage, and the child apparently suffered little pain. The operation was repeated twice afterwards, after intervals of a week, and in the course of a month the tumour had entirely sloughed away, and the part healed without a vestige of the diseased structure being left." Smith (d), of Baltimore, recommends the introduction of threads soaked in a solution of lunar caustic, and dried at the fire, by a needle passed through the base ofthe tumour at different parts. Tyrrell was in the habit of injecting these teleangiectasies with strong solution of alum, first making a puncture with a lancet, and then inserting an Anel's syringe. The operation generally required repetition two or three times; after each of which the swelling became more and more solid, and subsequently shrunk away. No inflammation of consequence ensued.—J. f. s.] 1519. If the seat and extent of the teleangiectasy admit neither ofthe prescribed treatments, or if they be employed without benefit, or if ex- pansion of the anastomosing branches of the arteries exist at the same, time with the teleangiectasy, the final remedy is tying the principal trunk of the arteries with which the swelling is connected, and if this be in- sufficient in teleangiectasy ofthe extremities, amputation ofthe affected part must be performed. It is always advisable to apply a ligature before proceeding to amputation, as the latter can always be done if the former fail and the swelling increase, after the vessel has been tied, by the col- fa) Fawdington; in North of England (c) London and Edinburgh Monthly Medical and Surgical Journal, vol. i. p. 66- Journal of Med. Science 1842, p. 552. Macilwain; in MedicChir. Trans., vol. (d) Americanq Journal of Med. Science, xviii p 189. vol. vi.p. 260,1843. (b\ London Medical Gazette, October, 1836. 48# 566 TREATMENT OF TELEANGIECTASY. lateral circulation; it is therefore of the utmost importance to apply the ligature as near as possible to the swelling. In extensive teleangiectasy on the head, experience shows that tying the common trunk of the carotid artery even on both sides, has rarely permanent result. Besides the early-mentioned cases of tying the carotid artery on one and both sides, (par. 1436,) and in branching aneurysm, (par. 1200,) compare also the case of a very large teleangiectasy on the ear, in which tying the carotid artery produced only momentary benefit (a). Mott in a child of three years old obtained only imperfect result from tying the carotid artery, and subsequently tied the carotid on the other side. Moller, in a child of four years old, tied both carotids with success (b.) I knew a case, where in very extensive teleangiectasy of the ear and its neighbour- hood, tying both carotids, continued pressure and deep cuts which were successively made in the sound skin in the neighbourhood ofthe swelling, to produce a satisfac- tory scar, had no permanent result. When Jaeger (c) asserts that amputation in simple teleangiectasy is never neces- sary, and that where undertaken it would not succeed on account of fungus, I must deny this assertion. Teleangiectasy is of itself able, without branching aneu- rysm or other degeneration, to attain so frightful an extent, that no other means than amputation remains. 1 have seen one case in which a teleangiectasy showed itself after birth, as a small red spot in the middle of the upper arm, and in six months the frightful spreading had reached over the whole arm, from the elbow up to the shoulder and shoulder-blade ; but the parents of the child would not decide on per- mitting any thing to be done for it. In the case of an extensive teleangiectasy on the knee, which I formerly mentioned, where tying the femoral artery was unsuc- cessful, amputation was the only means of restoring the patient. The Tattooing of moles on the skin, proposed by Pauli, has yet to be mentioned. The part should be washed with soap and water, and rubbed till the blood is intro- duced into the most delicate branches of the erectile tissue; the skin is then made tight, and eovered with colour similar to the natural colour of the skin, which is formed of white lead and carmine. Three needles, sunk into a cork pad so that their points project, are then thrust into the skin, and their points from time to time dipped in the paint. In extensive spots we must proceed gradually, so as not to produce too great swelling. The most difficult part is the choice of colour corresponding to that of the skin. (a) von Walther, above cited, p. 241. (6) Jaeger, Handworterbucb, vol. i. p. 497. (c) Above cited, p. 298. [ 567 ] D.—OF UNNATURAL EXPANSION OF THE VEINS. Of Varices. I.—OF VARICES IN GENERAL. Desault, CEuvres Chirurgicales, vol. ii. Petit, Traite des Maladies Chirurgicales, vol. ii. Volpi, Saggio di Osservazioni e di Esperienze Medico-Chirurgiche, &c. Miliana et Pavia, 1814-16 8vo. vol. ii. Velpeau, Legons Orales de Clinique Chirurgicale. Paris, 18 . Hodgson Joseph, On Diseases of Arteries and Veins above cited. Brodie, Observations on the Treatment of Varicose Veins of the Leg; in Med.- Chir. Trans., vol. vii. p. 195. ----, Lectures illustrative of various subjects in Pathology and Surgery. 8vo. London, 1846. Bell, Charles, System of Operative Surgery. London, 1807-9. 8vo. Vol. i. p. 89. [Watson, John, On the Pathology and Treatment of Varices; in the American Journal ofthe Medical Sciences. Vol. 5, N. S. 1843.—g. w. n.] 1520. The veins are, on account of the weakness of their membranes, subject to a great degree of sensibility, and then form swellings which are called Vein-knots {Varices, Lat.; Blutaderknoten, Krampfadern, Germ.; Varices, Fr.) 1521. Expansion of the veins generally takes place very slowly, and at first is not accompanied with any inconvenience; it gradually increases, the veins describe, in their course, larger curves, form unequal, defined, bluish or blackish prominences, which diminish on the application of pressure, but quickly return on its withdrawal, and cause a sensation of weight, and often severe pain in the part where it is situated. Varicose veins by their lying together, often produce large swellings and op.dema of the whole part: the coats of the veins thicken, adhere to the neighbouring parts; the skin covering them inflames, abscesses form, ulcerations also take place in the skin, and cellular tissue, (varicose ulcers,) which are closely connected with this varicose state, and so long as it continues cannot readily be induced to heal (1). Often by bursting of the vein considerable bleeding ensues; and sometimes the blood is poured into the cellular tissue by tearing of the vein. Often the blood coagulates in the expanded vessel, and the knots thereby produced are hard and incompressible (2). For the most part only the superficial, more rarely the deep-seated veins, in many cases not only the venous trunks, but also the minute branches, sometimes they alone, are expanded, and con- siderable swellings arise here and there. rfn Brodie says:__"For the most part, the effect ot inflammation of a varicose cluster is not to produce either abscess or ulcer. It is very remarkable that the blood in inflamed varicose veins coagulates; and they become choked up with the coagu- 568 VARIX. Ium. There seems to be something in an inflamed vein that is unfavourable to the fluidity of the blood which it contains. You observe this not only when varicose veins of the leg are inflamed, but when the veins are inflamed under other circum- stances, as in a case of piles. A patient comes to you with an external pile, which is large and very tender—it is inflamed. At first it contains fluid blood, but in a day or two it becomes filled with solid matter, and if you slit it open you find a solid lump of dark-coloured fibrine. If you slit open an inflamed varicose cluster in the leg, under these circumstances, you will also find that the cavity is filled up in like manner with coagulated blood. * * * The coagulum fills up the vein, and the vein; becomes obliterated. Other varicose clusters may appear afterwards, but this one is cured. * * * By degrees the inflammation subsides; the coagulum becomes gradually absorbed; as the absorption proceeds, the sides of the vein approximate, and it assumes the appearance of a narrow cord. In old cases of varicose veins, you will frequently find the skin becomes affected with a chronic inflammation; that is, it will look red, and be very irritable and lender. Sometimes the cuticle is, as it were, abraded, and an ichorous discharge takes place from the red cutis. Occasion- ally the whole of the skin of the leg is in this condition. In other cases there is a chronic inflammation ofthe cellular membrane. There is an effusion of serum into it, and the limb becomes cedematous. * * * These inflammations are analogous to what we meet with in other cases of venous congestion. But in some instances you find inflammation taking place of a different kind in the cellular membrane, immediately surrounding the varicose cluster. The cellular membrane becomes in- filtrated with coagulated lymph, so that the varicose cluster is, as it were, imbedded in a mass of solid substance. At first you would suppose that these veins are obli- terated, but they are not so. The lymph which has been deposited becomes organ- ized, and the coats of the vessel thickened, but they remain pervious nevertheless, containing fluid blood, which may be perceived with the finger, flowing freely through the gristly mass. Where there is this deposit of lympfiin the cellular mem- brane round the vein, the skin becomes inflamed near it, and this may give rise to a troublesome ulcer. The more usual history of a varicose ulcer, however, is as fol- lows:—the skin is distended at some point, and a scab forms upon it. When the scab comes off there is an ulcer and the ulcer spreads. The varicose ulcer in most instances begins about the inner ankle, but it may occur in other parts of the leg. * * * Such ulcers are inclined to assume an oval form, the long diameter of the oval extending in the course of the vein upwards and downwards. They are gene- rally nearly on a level with the surrounding skin. The surface of them is dark- coloured, when the patient is erect, and when the small veins are filled with blood; but when the patient lies down it becomes florid; the change taking place very speedily from dark to florid and from florid to dark. The skin and the margin of the ulcer are generally of a dingy-red colour and partly deprived of the cuticle, so that it is often difficult to say where the latter terminates and the ulcer begins. Va- ricose ulcers are generally very irritable and painful. If the patient be very much upon his feet, they assume a foul and sloughy appearance, and not infrequently are disposed to bleed." (pp. 165-168.) (2) Hodgson (a) says correctly:—" The deposition does not in general fill the vessel, but, by diminishing its calibre, it retards the flow of blood, and causes the dilatation to increase in the inferior portion of the vein, and in the branches which opened into it. Petit, who had observed this circumstance (b), was accustomed to open varicose veins, and draw out the string of coagulum. By removing this cause of obstruction, not only the increase of the disease was prevented, but the dilated vessels frequently diminished after the operation. Sometimes, however, the coagu- lum accumulates to sueh an extent as completely to obliterate the canal of the di- lated vessel: " I have seen," says Hodgson, "-four cases in which this event ter- minated in the spontaneous cure of varices." (p. 541.)] 1522. The cause of varix is every hindrance to the flow of blood in the veins, as pressure and constriction, with continued flow of blood from the arteries, increased venosity, pressure of the gravid womb, cos- tiveness, peculiar direction and position of the body, for instance, the erect posture and so on (1). Sometimes varix occurs without any per- (a) Above cited. (fc) Above cited, p. 41, p. 63. varix. 569 ceptible hindrance to the circulation in different parts of the body, and seems to depend on weakness of the venous coats. Varices mostly show themselves where under natural circumstances the return of the blood is somewhat difficult therefore especially in the lower limbs (2), in the veins ofthe rectum and spermatic cord. The expansion ofthe veins is closely connected with the constitutional relations ofthe patient and cer- tain diseased conditions, so that in a manner it operates favourably, and belongs to the well-being of the patient. [(1) Dr. Baille (a) mentions a case of obliteration of the vena cava inferior, "which was found to be changed into a ligamentous substance, from the entrance of the emulgent veins even to the right auricle of the heart. The cavity here was so entirely obliterated, as not only to prevent all circulation of blood through this part ofthe vein, but even in a great measure to prevent the admission of air by inflation. # * # The blood being prevented from passing through the vena cava inferior, flowed into the lumbar veins, enlarging them gradually, as that vein became con- tracted, till they were of sufficient size to receive the whole blood which returns by the vena cava. * * * The enlarged veins were in some places thrown into varices, as must naturally take place under the circumstances we have mentioned, (pp. 127, 28.) Brodie (b) says he has seen varicose veins of the fore-arm to a considerable extent. There had been inflammation of the median-cephalic and cephalic veins. These had become obliterated, and in consequence of their obliteration, the blood did not easily return from the fore-arm, so that the veins became varicose." (p. 159.) Scarpa (c) observes:—" The celebrated Mr. Cline having found in the body of a man, the inferior vena cava obliterated a little above its bifurcation, in consequence of a steatomatous tumour, which had formed in the cellular tissue behind the perito- naeum, and which occupied a part of the pelvis and lumbar region, remarked that the epigastric veins were become as large as the little finger, and that the superficial veins of the abdomen, as well as the lumbar, and those of the internal cavity of the abdomen, were in a similar manner very much dilated; the internal mammary vein likewise greatly enlarged, and also the epigastric, with which it anastamosed, opened, as usual, into the superior cava, near to the origin of the subclavian veins; by which circumstance the venous blood of the lower extremities was poured into the superior cava, by means of the mammary vein, and into the inferior cava by the lumbar veins above the compression caused by the steatomatous tumour, (p. 21, note.) , . , Brodie relates the case of "a man who had varicose veinsall down the right arm, and to a considerable extent down the right side of the chest. He had difficulty of breathing, and cough. One day he felt as if he had received a blow on one side of the chest, and immediately a large abscess presented itself externally, as big as an orange, which had evidently made its way from the ins.de of the chest through one of The intercostal spaces. Immediately upon the appearance of this swelling, the varicose veins disappeared. The man died, and on examining the body after death, it was found that there was disease in the bronchial glands; suppuration had taken place in them, and a large abscess had been confined in the inside of the chest which pressed on the right subclavian vein, and this caused the blood to stagnate in the veins in which it had its origin, and which had in consequence become ya- ric se."In anothercase, « the superficial veins of the chest and upper extremities were extensively varicose. * * * On examining the body, a large medullary tu- mour was discovered within the chest, which by its pressure on the lower part of foe tracheaand on the junction ofthe two subclavian veins, had obstructed at once .the entrance of air into the lungs, and the return of the blood to the superior vena 'T^'G^neraflv shaking, the superficial veins are most prone to become varicose, and spe^iaUy mLeof the fewer limbs. Hodgson says:-" The only instance ofvanx, (a) Of uncommon appearances of Disease in Blood-vessels; in Trans. Med. and Chir., vol. i. 1793. / n 0n Aneurysm (Translation.) (b) Above cited. w J 570 varix. in the upper arm with which he was acquainted, is mentioned by Petit (a); it was situated at the bend of the arm, and the patient was so fat that no other vein could be found for the purpose of venesection, which operation Petit repeatedly performed by puncturing this varix." (p. 539.) Brodie's cases just mentioned are also examples, though from different cause. Velpeau says he has seen in two persons the arms, fore-arms, and hands covered with varicose swellings; also a mass of varices as big as the fist, between the angle of the jaw and the right clavicle, in a young man; a varix as large as the thumb under the edge of the orbit in a girl; and a pretty large one, in a man, upon the course of the sagittal suture, which seemed to come from the longitudinal sinus. And he mentions another, as big as the thumb, beneath the tongue, (p. 420 ) But the deep veins also occasionally are so affected, as in the instance just cited even within the great cavities of the trunk. I have also very recently seen in St. Thomas's Hospital, a varicose enlargement ofthe femoral vein, immediately below Poupart's ligament, as big as half a pigeon's egg, and in the seat of femoral rup- ture, for which it might have been easily mistaken. Hodgson also says:—Mr. Cline described in his lectures the case of a woman who had a large pulsating tumour in her neck, which burst, and proved fatal by haemorrhage. A sac proceeded from the internal jugular vein. The carotid artery was lodged in a groove at the posterior part of this sac." (p. 539.) I have no doubt that this is the brief history of a preparation in the Museum at St. Thomas's, which precisely corresponds with the account.—j. f. s.] 1523. The cure of varix first requires the removal ofthe cause which hinders the circulation in the veins; and this done it frequently disap- pears of itself. Obstruction in the bowels must be got rid of, the mode of living properly regulated, continual standing, and the like, forbidden. The most proper remedy, if after the removal ofthe causes the knots do not subside, or if they depend on local weakness, is the suitable com- pression of the whole part with bandages, the effect of which is assisted, by the employment at the same time of strengthening contracting re- medies. A radical cure thereby is rarely effected, for when the com- dression is removed, the swellings of the veins, oedema and varicose ulcers return. [Brodie says:—"In many cases where the disease is limited, you may apply merely a partial bandage of adhesive plaster, which will answer the purpose per- fectly, giving the patient scarcely any inconvenience. There being, for example, only two or three varicose clusters of small size, you need not trouble the patient with a complete bandage for the whole leg. * * * Having marked the place, (whilst the patient stands erect,) let him recline with the foot raised so that it may be the most elevated part of the whole body. Then, the varix having been thus completely emptied, apply one of the pieces of adhesive plaster (three or four inches long, and an inch or an inch and a half wide) across the varicose vessels, and after- wards apply the others in the same manner, drawing up the skin under them, and taking care that the plaster is not thrown into folds. The plasters being applied in this manner, and being strained on the skin beneath, prevent the vein from becoming distended when the patient stands erect." (p. 169,) If the skin be irritated by the resin in the adhesive plaster, he recommends instead emp. thur. comp. with a little soap cerate, or soap plaster spread on amadou. "In those cases, however, in which the veins of the leg are extensively varicose, this partial compression will not be sufficient, and you must apply a bandage for the whole leg." (p. 170.) Calico, flannel, or stocking-web roller; the Indian rubber web confines too much heat, and does not, in most instances, afford sufficient support to the weak vessels. Laced' stockings, either of nankeen, Indian rubber cloth, or spiral wire are sometimes used, but the latter two are objectionable, on account of the heat. If the varicose veins become inflamed, the patient should be kept in bed in the recumbent posture, have cold lotions applied, and his bowels freely opened; and occasionally it may be necessary to employ leeches, on the use of which Brodie (a) Traite des Maladies Chirurg., vol. ii. p. 49, TREATMENT OF VARIX, 571 mves the following very pertinent advice:—"Do not apply them immediately over the veins; they should be applied higher up on the leg, on the sound skin. The bite of a leech over an inflamed vein will give the patient a good deal of pain, and the little wound will be difficult to heal. If you apply the leeches on the sound skin on the thigh, or the upper part of the leg, you will relieve the varicose veins just as much as it you had applied them on the veins themselves, without giving the patient pain at the time, or trouble afterwards." (p. 173.)] 1524. In order to effect a radical cure of varices by closure with a clot of blood, and by obliteration of the vein, various remedies have from the earliest times been proposed. First, puncture; second, incision; third, extirpation ; fourth, tying; fifth, cutting through; sixth, application of caustic; seventh, piercing with needles or threads; eighth, lateral com- pression ofthe veins. According to Gottschalk (a), the destruction of a vein never produces a radical cure; on the contrary, the especial cause of varicosity, to wit, a slow circulation in the veins, is farther increased; hence there results from tying a venous trunk oedema of the limb, and aggravation of the disease, in addition to the danger of tying the vein. Support of all the veins by simultaneous compression is the true mode of cure, and there is nothing more proper for this than a paste roller. A moist roller is first applied, and then smeared with paste, and over it a second paste roller. The moisture cools the limb pleasantly, and the regular pressure removes all the weight depending on expansion of the veins. 1525. Puncture of the varix with a lancet (anciently proposed by Hippocrates) must especially be employed in varices largely filled with coagulated blood, as well also as in those which are very painful, in- flamed and much expanded; and, after the removal of the blood, pres- sure, together with cold applications and the horizontal posture are to be employed. 1526. In cases of larger size and greater extent, the skin and the vein must be cut into, by an incision two inches long, upon the largest knot, the escaping blood kept back with the finger, the cavity of the vein plugged with sponge or lint introduced into it, and the bleeding stanched by the application of compresses and circular bandages. If the varicose expansion be only on the leg, one cut is sufficient; if it extend to the middle of the thigh, one cut is to be made above the ankle, a second close above the knee, and if the whole thigh be affected, a third cut is to be made at equal distance. The limb is then to be bandaged, and cold applications to it used for some days. Inflammation takes place in the vein which so spreads from the principal to the other varix, that a greater degree of plasticity arises in them, and the neighbouring varices disappear (A). 1527. In some very prominent knots; or even in swellings formed by the agglomeration of various veins, extirpation, {cirsotomia,) originally proposed by Celsus, has been practised. In the separate knots, the skin, if moveable, should be cut through in a single fold, so that the cut may reach from above to below, over the knot, which is then to be raised with the hook, separated, and cut off above and below. If the skin be adherent, it must be taken away as well as the knot. In the same man- ner the large swellings are to be treated, and the divided vein tied at its (a) Oppenheim's Zeitschrifl fur die ge- (b) Graefe, in his Introduction to C. Bammte Medicin, vol. ixii. pt. ii. Bail's Surgery, 572 TREATMENT OF upper and lower end; or, if the position permit it, the bleeding is to be stanched by pressure {a). 1528.. Tying (proposed anciently by Aetius and Paulus ^Egineta) is to be performed in varix of the lower extremity, on the principal trunk of the saphenous vein, above the swollen part, which is to be laid bare by a suitable cut through the skin, freed from cellular tissue, and the ligature carried round it with a probe; after which, pressure is to be kept up in the horizontal posture {b). Ricord (c) removes the subcuta- neous connexion ofthe vein, lifts up the vein in a fold of the skin, and thrusts a suture needle, armed with a double thread, through the skin behind the vein, then lets go the vein, without leaving hold ofthe skin, and carries the needle back through the same holes reversed above the vein, so that the vessel is caught in a subcutaneous loop, both ends of Which being held together at the same wound in the skin, are tied on a piece of elastic bougie as in the quill suture. In a similar way, but with two loops, the subcutaneous tying may be performed, according to Tavignot's method, {par. 1432.) [The practice of tying the saphenous vein was revived by Sir Everard Home, for varicose veins of the leg, either with or without ulcers; and he stated (d), " that in the course of a week after the operation, the veins in general were very much diminished in size; and in all the cases the ulcers put on a much more healthy appearance in less than three days after the operation; and from that time, where no circumstance occurred to prevent it, went on healing like ulcers in healthy parts." Cp. 330.) It, however, happened after this statement, that several patients died from inflammation of the vein following the ligature; and I recollect being present at an operation of this kind, after which the patient became extremely ill and delirious; and, though she recovered of the operation, lost her senses, and was obliged to be placed in a madhouse. These results put a stop to this dangerous practice, vaunted as it had been by Home ; and there are, I apprehend, few persons who would now venture on performing it.—j. f. s.] 1529. Solera practised cutting through the vein above and below the Icnot, above the knee and low on the leg; he made a longitudinal cut by the side of the vein, cut through the vein, and prevented its union by the introduction of lint. Brodie (e) makes the subcutaneous division of the vein, but he thrusts a narrow, very pointed, slightly-curved bistoury, flat on the side of the vein, between it and the skin, and, in withdrawing it, cuts through the vein without wounding the skin. The bleeding is stanched by pressure. [In reference to the sub-cutaneous division of varicose veins, Brodie observes:— " Although there may be danger from operations on the vena saphena, we have no right to expect danger from operations on its smaller branches" (p. 188); and it was upon these he formerly operated. " With my present experience," he, how- ever, observes, "it really appears to me that, in ordinary cases, it is not worth the patient's while to submit to it, as I always observed that, if I cured one cluster, two smaller ones appeared, one on each side, and that, ultimately, I left the patient no better than I found him. The operation, however, is proper where there is a vari- cose cluster much distended, and liable to burst and bleed. Here you may actually save the patient's life by having recourse to it; and you may do so without con- (a) Boyer, Traite des Maladies Chirurgi- Ligature sous-cutanee des Veines; in Bullet. cales, vol. ii. general de Therapeutique. July, 1839. (6) C. Bell, above cited, p. 91.—Hodgson, (d) Practical Observations on Ulcers. above cited, p. 550.—Moulinie, J. Second Edit. 8vo. 1801. (c) Du Traitement des Varices par la (c) Above cited. VARIX. 573 sidering whether fresh clusters are or are not likely to form afterwards." (pp. 189, 90.)] 1530. The application of the actual cautery (according to Celsus, upon the knot laid bare by a cut through the skin) and the destruction of the skin and the knot with caustic potash (Pare, Brodie) have been given up on account of the obstinate ulcers to which they gave rise (1); but the employment of caustic potash is again recommended by Bonnet (a) and Laugier (&). Bonnet at the same time employs the introduction of needles after Davat's method, and the latter applied the caustic upon the vein, after laying it bare with a cut through the skin, von Froriep overlays very large expanded veins of the lower extremity with com- presses, moistened with concentrated, not smoking nitric acid, till the skin becomes erysipelatous, and the swelling firm and painful, and repeats it, after the subsidence of these symptoms, till the cure. [(1) Mayo (c) has also recommended the use of caustic potash, or a caustic paste on the sub-cutaneous venous trunks of the leg in cases of varix. "The vein," he says, " is often tender during several days, for the extent of three or four inches above the place at which the caustic is applied. The obstructed part does not exceed more than half an inch to an inch in length. I have never known acute phlebitis su- pervene in employing this practice." (p. 433.) Brodie, however, is now entirely opposed to it; he says:—"The application of the caustic potash was very painful; the slough took a long time to separate; the sore took a long time to heal; and where one cluster was cured, other clusters appeared. Altogether it was a very tedious process, and my own experience does not lead me to recommend it." (p. 187.)] 1531. The introduction of needles through the walls of a vein produces either only slight irritation of the vein, and the formation of a clot, which fills its area, and finally causes its obliteration; or, with a less degree of irritation of the opposite points of the internal coat of the vein, and their simultaneous contact, produces its obliteration. In the first proceeding a pin (an insect-pin) is to be carried transversely through the vein, and left there for from two to six days with rest, and corresponding dietetic treatment of the patient. On the second day swelling around the pin begins, which is caused partially by the clot formed in the vein, partially by the slight inflammatory process set up in, and around it. The swell- ing increases on the following days, becomes at the wound, more rarely throughout its whole extent, of a pale rosy-red colour, and at the same time the vessel, as well as its neighbourhood, without pain on pressure, feels more compact. The earlier this appearance sets m, the sooner may the pin be removed. With small veins one pm is sufficient; but in the larger it is better to introduce two or three, in which case the one brings the front, the other the hind wall of the vessel nearer together, and the third is thrust through the middle of the vein. Experience is strongly in favour ofthe symptoms ensuing, and ofthe results arising from this mode of treatment (d). In the second proceeding, a pin is to be thrust trans- versely under the vein, which is to be raised up by it, so that a second pin may be thrust through it twice, in the longitudinal direction. With this object a second pin generally straight or curved, round or flattened, is introduced through the skin and vein, about a line below the place (a) Archives generales de Medecine. June, (d)Kvn, C, Die Heilung der Blutader. bqq & Erweiterungen durch Acupunctur. Breslau, (b) Bulletin Chirurgical. August, 1839. 1838. le) Outlines of Human Pathology. Vol. II.—49 574 TREATMENT OF VARIX. where the transverse pin cuts the axis of the vessels, carried upwards beneath that pin, and thrust from within outwards through the vein and skin—the two pins, forming a cross, are to be surrounded with a thread. One pin may be also thrust transversely through the skin and vein, and a thread twisted round it, like a figure of Qfl. The pin is to be left till it have excited inflammation (about five days.) The little fistulous wound soon heals. This mode of treatment should be preferred before all the rest, on account of its slightness, of its less pain and danger, and the cer- tainty of the cure (a). Experience, however, shows that wide and deep- spreading phlegmonous inflammation, with fever, redness of the tongue, sooty colour of the teeth, irritation of the mucous membrane of the sto- mach, swelling of the inguinal glands, extensive suppuration, and even death may ensue from this practice (b). According to Franc (c), the pin should be thrust through the skin near the vein, carried behind it, thrust out at the other side, and a thread wound around it. Two days are sufficient to produce complete obliteration of the vein (1). Fricke {d) introduces, with a moderately strong needle, one, and, in great varicosity, several threads dipped in oil through the vein, and ties the ends upon the skin in a bow. In from twenty-four to thirty-six hours the threads are to be removed, the patient kept quiet, without any dressing, and, on the appearance of inflammation, cold water or lead wash are to be applied. [(1) Velpeau (e) says, that he "never saw, in more than one hundred cases in which he had performed his operation, any troublesome symptom ; a slightly spread- ing external phlebitis, some little phlegmonous swellings, and small abscesses, were nearly all the consequences. Often pleasing myself," says he, "with my continual success, you may judge what fear I had of it coming to an end. Unfortunately, at last it came." A patient was operated on by him on April 4, 1839, two of the pins were removed on the sixth, and the other two, with the ligatures, on the following day, the tied parts being scarred, and the patient free from pain. On the eleventh night, however, he was attacked with intermitting shiverings accompanied with nausea and vomiting; and on the following morning the leg was red and swollen, which extended next day up the thigh, and where the ligatures had been applied the skin assumed a violet-colour, and livid spots appeared on different parts of the body; he became delirious, had continued tremors, and weak quick pulse. On the four- teenth day the face had become purple, the lips dry, and he was very comatose: large and distinct spots appeared on the inside of the arms, and the hands were swollen and bluish; the whole of the limb which had been operated on was enor- mously swollen; the extremities became cold, and he died the same morning. The only important points in the examination were the fluidity of the blood, and the enor- mous distention of the vena cava; incipient ulceration in the intestines: the vein which had been tied had not been perfectly obliterated, (pp. 442, 43.)] 1532. Lateral compression of the vein (according to Breschet's prac- tice in Varicocele) has been performed by Sanson {f) by means of for- ceps, between which a pair of metal plates, fifteen lines long, covered with leather, which compressed the vein, raised up in a fold of skin suffi- ciently to prevent the blood circulating through it. The forceps are to (a) Davat, These, De l'Obliteration des Chirurgicales. 1835. July.—Velpeau, in Ro- Veines. Paris, 1833 ; in Archives generales vue Medicale, July, 1838.—Melwin, in Lon- de Medecine. May, 1S33.—Du Traitement don Med. Gazette, Oct. 1838.— ( uppi, in curatif des Varices par l'Obliteration des Annali TJnivers. di Medic, 1837, Nov., Dec. Veines a l'aide d'un Point de Suture tern- (d) Medicinische Zeitung. Berlin, Aug. poraire. Paris, 1836. 1833. Hamburg. Zeitscb, vol. i. pt. i. p. 12. (b) Dufreise, in Journal Hebdomad. 1836, (e) Legons Orales. p. 265.-—Landouzy, H., Du Varicocele, et en (/) Gazette Medicale, 1836. Feb. Ham- particulier de la cure radicate de cette affic- burg. Zeitsch., vol. ii. pt. ii. p. 250.—Fro- tion. Paris, 1838. 8vo. rikp's Chirurgisch. Kupfertaf., pi. ccclxxxvi. (c) Journal -des Connaissances Medico- VARICOCELE. 575 be frequently applied at different places, so that no slough should be formed. A plug of blood is thus produced, which stops up the vein. 1533. In reviewing these different modes of treatment for the radical cure of varix, it must be remembered that in all those accompanied with wound of the vein, there is danger of venous inflammation arising, which often spreads widely and causes death. This is the more important, as per- sons who are subject to varix have, for the most part, accompanying gouty or rheumatic affections, stoppage, and fulness in the belly, and extensive alterations in the venous system at the same time, whence they are the more disposed to such inflammations; so that it must not be overlooked that, on account of the causal relations of varix to such general diseased condition, it often belongs to the relative well-being of the patient, and that after its removal other symptoms set in, or expansions in other parts of the venous system occur. Such radical cure of varix must therefore never be undertaken without careful review of the patient's general con- dition, and never without important reason, and pressing demand. In old persons it has never any benefit. Puncture is least dangerous; but, in regard to its result, a radical cure, very uncertain. Tying and incision most frequently set up dangerous inflammation; less so do extirpation and the introduction of threads. But even in the latter seemingly trifling proceeding, inflammation of a very severe degree may ensue, though less after the simple introduction ofthe needle or thread, (Kuh, Fricke,) than in tying the vein at the same time, (Davat, Franc, and others,) in which the circulation through it is entirely arrested. In this respect the simple compression ofthe vein, after Sanson's plan, deserves especial notice, if farther observation should prove the certain closure of the vein thereby. II.—OF VARICOCELE. (Varicocele, Cirsocele. Lat.; Krampfaderbruch, Saamenaderbruch, Saamenader- geschwiilst, Germ.; Varicocele, Fr.) Richter, Observationes chirurgicae, fasc. ii. p. 22. Ibid., Anfangsgriinde der Wundarzneikunde, vol. vi. p. 165. Murray resp. Bonsdore, Dissert, de cirsocele. Upsal, 1784. Leo, F., Dissert, de cirsocele. Landish, 1826. Benedict, Ueber Hydrocele, Sarcocele und Varicocele. Leipzig, 1831. Landouzy, above cited. Fritschi, J., Ueber die Radicalkur der Phlebectasia spermatica interna oder sogenn. Varicocele, u. s. w. Freiburg, 1839. 1534. Varicocele or Cirsocele is a varicose expansion of the veins of the spermatic cord, and in a more advanced state of those also of the epididymis and testicle. The disease always commences in the spermatic cord, and generally makes itself known by a heavy, often smart pain, which from time to time darts to the testicle and loins; the ailment, however frequently developes itself without any inconvenience. An irregular'swelling, consisting of several threads, is felt along the course ofthe spermatic cord, which diminishes on slight compression. In pro- portion as the swelling gradually increases, it approaches nearer the testicle which enlarges, and becomes heavier; by degrees the varicose condition extends to the epididymis, and thence to the testicle itself, which is loosened into a soft, doughy mass, and presents only a convo- 576 VARICOCELE. lution of expanded vessels, probably simultaneous thickening of their walls, and of the cellular tissue connecting them. The purse also is expanded, and the patient feels a troublesome or painful weight in the testicle, which sensation extends to the loins, especially when it has existed a long time. The characteristic signs of varicocele are the ready disappearance of the swelling on compression, its quick reappearance when the pressure is withdrawn, as well as its increase on long-continued standing. As these appearances belong to ruptures, and as in a large varicocele the swelling enters the abdominal ring, by which it is enclosed, and its condition, when touched, has resemblance to that of omental rupture, the history of the disease, and the characters already described {par. 1200) must give the diagnosis. The words cirsocele and varicocele are used with different significations. Many writers apply the former only to a simple swelling of the superficial veins of the purse; but the second to a swelling of the spermatic veins. Some employ varicocele in this double acceptation, and cirsocele as a swelling ofthe vessels ofthe epididymis and testicle: again, others consider both designations as of similar import. According to Breschet (a) spermatocele is a swelling of the spermatic cord, and especially ofthe epididymis, depending on retention ofthe semen. It begins with a sensation of [pressure, distention, and more or less severe pain. If the semen he not voided by pollution or by connexion, inflammation, bursting of the swelling, and actual fistula ensues, which is characterized by the escape of the semen (1). This affection of the epididymis is especially observed in gonorrhoea, and the swell- ing of the testicle ensuing in proportion to the decrease and entire cessation of the gonorrhoea, which always begins in the epididymis, depends on the retention of the semen. In this spermatocele, connexion, moderate living, avoidance of exciting the imagination, cold washes to the generative organs, and, in inflammation, the appli- cation of leeches are to be recommended. In fistula nothing can be done directly. [(1) Spermatocele is often a sore nuisance to young people; the testicle become so exceedingly tender that the mere pressure of the dress upon it causes great pain. It is not generally accompanied, at least in the cases I have seen, with much swell- ing and I have never seen it followed by suppuration, as Breschet states. But I have known it recur very frequently, at intervals of two or three months, for as many years, between sixteen and two or three and twenty. I do not believe it will have usually the results stated; but it is a most troublesome and annoying complaint, compelling the patient to keep himself completely at rest, and is not very easily controlable. Keeping the bowels free, and avoiding excitement of all kinds, bodily or mental, with a cool dressing, and supporting the testicles with a suspensory bandage, is almost all that can be done; and that not of much benefit. Usually after a time it is outgrown, and the disposition to it ceases.—j. f. s.] 1535. The causes of varicocele are various, though in some cases often not at all determinable. For the most part it depends on weakness of the spermatic veins, produced by great congestion, in consequence of venereal excesses, onanism, or from long-continued libidinous appetite, or after previous inflammation of the testicle, from obstructed return of the blood in persons of sedentary habits, in swellings and costiveness of the bowels, from a truss pressing the spermatic cord, from particular employments, and so on. The disease occurs more frequently on the left than on the right side, the ground of which is to be sought for iii various causes (1). Sometimes it is accompanied with haemorrhoidal inconvenience. The disease is most commonly noticed in young per- sons, from fifteen to thirty years of age, rarely in older people. In many cases, however, the setiology of this disease is quite obscure, and it is (a) Observations et Reflexions sur la Fistule spermatique ou Spermatocele; in Journal general de Medecine, 1826, June, p. 348. TREATMENT. 577 indeterminable what share the above-mentioned causes have on its origin. I he complaint often remains in a slight degree stationary, although, on account ofthe mode of living and employment of the patient, its increase is on every ground to be feared (a). (1) Many derive this disease from pressure of the sigmoid flexure ofthe colon on the vessels of the spermatic cord. Morgagni and A. Cooper place the cause in the entrance of the spermatic vein of the right side into the vena cava ascendens, in an almost parallel direction with that vessel, whereby its emptying is more readily effected; whilst the vein on the left side terminating in the emulgent vein, the cir- culation produces an obstacle, as the two streams do not take the same direction. The length of the veins ofthe spermatic cord, on the left side, has also been charged with it, as well as the narrowing of the mouth of the left inguinal canal, in conse- quence of the contraction of the abdominal muscles, in the exertion of raising weights, on account of the bending over to the right side (Lenoir.) 1536. If the disease be left to enlarge, it changes the structure of the testicle by overspreading it, rendering it useless for its function, or atro- phic: by the enlargement of the swelling are produced swellings ofthe veins of the purse, inconvenience from its weight, and not unfrequently considerable pain, especially on long-continued standing, or any over- exertion, and even the impossibility of walking without a suspender. In general there is also a greater secretion of the scrotal skin. Where a quick course of the disease, with violent pain and speedy wasting of the testicle have been observed, (Pott, A. Cooper,) it appears to depend less on the varicocele than on another and indeed traumatic influence. 1537. The treatment of varicocele must principally depend on its cause, and when this is known, it must be removed according to the general rules laid down. In a trifling degree of the disease, the purse may be supported by means of a well-fitting suspender; and by the repeated use, during the day, of cold astringent applications of lead wash, solution of alum, aromatic decoctions, frequent washings with these remedies, or with cold water and spirits of wine, or with liq. mineralis Hoffm., naphtha, and so on; even blisters may be applied to the purse to increase the contractility of the part. The patient must at the same time avoid all exertion, constant standing, and walking; and especially he must properly regulate his living. In most cases, however, the in- convenience of the patient is only lessened, and a check given to the progress of the disease. 153S. In the more advanced state of varicocele, if it cause consider- able inconvenience or be connected with rupture, various modes of treatment have been proposed with a view to the radical cure, as extir- pation of the varicose vessels, tying all (1), or a single bundle of the swollen veins (2), tying the spermatic artery (3), carrying through threads or needles, or a simultaneous surrounding of the latter with threads (4), excision of a part ofthe purse or its inclusion in a ring (5), the ensheathing of the skin of the purse (6), and the continuance of pressure by means of a compressor or a pair of forceps (7). (I) According to Celsus the superficial veins were cauterized with a pointed iron, and the whole bundle of deep veins tied and extirpated. In the same way have Pare Heister, Petit, Cumano, Key, and others, proceeded with some modifica- tion, in whieh they have only removed the veins, or even the testicle itself. (2) Charles Bell considered the separate tying of one or more-venous strings sufn- la) Delpech, Precis elementaire, vol. iii. p. 2G6. 49* 578 TREATMENT cient. The veins are to be laid bare by a longitudinal cut through the skin and ge- neral scrotal covering, one of the largest venous strings grasped with the fingers, separated and tied with a thread. When this disease is very large, two and even three strings must be tied ; and the wound closed. The ligatures separate in a few days. Delpech (a) divides the skin by a cut of two inches long, parallel to the sperma- tic cord, cuts through the m. cremaster and sheath with the forceps and bistoury, raises one vein from the rest, isolates it, passes under each a' piece of thick soft Ger- man tinder, and then puts a single ligature on the latter. The ligature is only to be drawn so as merely to bring the walls of the vein together, and prevent the flow of blood through it; whereupon great swelling of the varicose vein ensues. The wound is to be lightly filled with lint and covered with a softening poultice. The ligature is to be removed on the third day. Delpech has noticed, after the perform- ance of this operation, the restoration of the function of the testicle. Tavignot's subcutaneous ligature in the way already mentioned, (par. 1432.) (3) Maunoir, (b) Brown, (c), Amussat (d) and Jameson (e), have tied the sper- matic artery successfully, but, Graefe (/) without success. According to Mau- noir, the cut should be made half an inch long, below the abdominal ring in the course ofthe cord, its sheath opened, the artery separated, a double ligature applied, and the vessel divided between them. If the varicocele exist in such a degree that simultaneous loosening of the spermatic cord and testicle expand the scrotum to a large swelling, this proceeding is more difficult, and it would be better to make, close above the external abdominal ring, a eut two inches long, obliquely upwards and outwards, to cut through the outer walls of the inguinal canal, to open the sheath of the exposed spermatic cord with a shallow incision, and carefully to sepa- rate the artery. In this case it must not be overlooked that the spermatic artery also divides below the external ring (g). (4) According to Fricke apart of the purse should be grasped with the left hand, so that one of the expanded veins may be found between the fingers, upon which with a common needle the skin and vein are to be pierced obliquely, and a thread introduced which is to be tied upon the skin. This operation, which may be re- peated on one or two other veins, is easily performed and little painful. The purse should be kept horizontal and supported on a pillow. If, on the next day, redness of the skin and sensibility of the testicle occur, the thread is to be withdrawn. The swelling gradually subsides, and the veins are converted into solid strings, free from pain. According to Kuh (h) every single vein of the plexus, on both sides ofthe purse, is to be grasped with the fingers and perforated with a needle, each needle to be en- sheathed in a proper cork, and the purse supported with compresses or a suspender. According to Davat and Franc (i), the varicose veins should be separated from the vas deferens, and one or two needles thrust between them ; a waxed thread is to be twisted several times round such needles, and tied fast, by which the vein is con- stricted and obliterated. Franc believes that two days, and even a shorter period, is sufficient to produce complete obliteration of the vein. Raynaud's practice (j) agrees with this, but that he applies a linen cylinder on the skin, upon which he ties the threads together ; by tightly tying, he divides the spermatic cord till the skin alone remains undivided, which after the ligature has been drawn out, is divided upon a director, and the superficial wound heals quickly afterwards. (5) Wormald (k) passed the lower part of the purse through a soft, wide silver ring, an inch in diameter, and covered with leather, whilst the patient reclined, and the veins were empty, and fastened it so tightly together that the parts could not escape. This was done every morning, whereby inconvenience was avoided. A. (a) Memorial des H6pitaux du Midi, (d) La Clinique des Hftpitaux, vol. iii. No. 1830.—Journal von Graefe u. Walther, 82_ vol. xvii. p. 329. (e) Medical Recorder, 1825, April, p. 271. (b) Nouvelle Methods de traiter le S'arco- (/) Klinischer Juhresbericht, 1822. cele, sans avoir recours & ^extirpation du (g) Dietrich, above cited, p. 448, testicule, etc. Geneve, 1820—Journal von (h) Above cited, p. 58. Graefe und Walther, vol. iii. p. 3^69. (i) Above cited. (c) New York Medical and Phys. Jeur- (j) Gazette Medicale, Dec. 1837.—Fro- aaL. 1824.,. March.. riep's, N. Notizen,. Febr. 1839. No. 99. (4) Loudon Medical Gazette, 1838, April. OF VARICOCELE. 579 Cooper (a) objects to this proceeding, and recommends cutting off a sufficiently large flap of skin from the purse, after which the suture is to be so applied that the lower flaps of the wound should support the testicle like a suspender. By this means the varicocele is diminished, thouo-h not removed, but all inconvenience is got rid of. (6) In a similar manner the ensheathing and shortening of the purse, proposed by Lehmann (b), acts. The whole ofthe front of the purse is thrust up with the fore- finger of the left hand, so high beneath the skin ofthe belly, till the bottom of the purse is brought above the horizontal branch of the share-bone, and the testicle lies pretty close to the belly. Gerdy's rupture-needle, armed with a double thread, is then introduced into the bottom of the ensheathed canal, the purse, and the over- lying skin of the belly, penetrated with its point, so that the eye with the threads may project some lines. With the assistance of a pin, the end of one thread is to be freed from the eye and the needle being drawn back, is then thrust through again in the same way, half an inch deeper, and the other end of the thread pulled out. The ensheathed skin is drawn with the thread loop so close to the belly, that the testicle lies hard by it. The two ends of one thread are then tied upon a wooden cylinder, as big as a crow quill, about an inch and a half long, and covered with sticking plaster; and afterwards the other. (7) Breschet (c) has proposed a simple and certain mode for employing com- pressors, both for the swollen veins ofthe purse, and also for those of the spermatic cord; and from his practice are, to a certain extent, those of a recent date derived. Compare also Landouzy, above cited.—Rognetta; in Bulletin de Therapeutic, vol. vii. pt. i. 1539. Of these various modes of treatment for the radical cure of varicocele, both according to my own and other's experience, that pro- posed by Breschet as regards its easy employment, its applicability to the different stages of the disease, its certainty, and its freedom from dan- ger, is to be esteemed the most proper and the most preferable. Extirpa- tion ofthe testicle, and tying the whole bundle of veins, can bear no com- parison with it. Tying the separate veins as proposed by Bell, has not been supported either by others'or by my own experience; and Bell him- self subsequently did not advise it {d). Tying the spermatic artery is very difficult, often scarcely possible, on account of its intimate connex- ion with the other tissues of the cord, without injuring them, and on ac- count of the variety of its ramifications uncertain in its result. Piercing' the veins with needles or threads often risks the danger of inflamma- tion and has uncertain success. The introduction of one or several threads, or of a single thread below the bundle of veins, may also pro- duce severe symptoms, is more tedious, more painful, and consequently less favourable than the practice of Breschet (e). The drawing into a ring, and cutting off flaps ofthe scrotal skin, are merely palliative. 1540. In order to include all the veins, in the operation after Bre- schet's method, the patient must walk about for some hours previously in summer, and in winter keep in a very warm bed, by which the veins are filled with blood. The purse is to be shaved, and the patient placed in front of the operator, who with his left hand grasps the right side of the purse, with the fore and middle finger behind, and the thumb in front, with its tip on the septum, whilst the two fingers support the testicle; the finger of the right hand is to be applied to the left side of the purse, so that the fingers may touch. The vas deferens is now to be found, which (a) Guv's Hopilal Reports, 1838, p. 9. cocele, lu a l'Academie def Sciences le 13 (b) Pr-Vereinszeitung, 1840, No. 49, 50. Janvier. 1834. (c) Memoire sur une nouvelle Methode de (d) Bell, Charles, vol. i. p. 95. traiter et de gueTir le Cirsocele, et le Vari- (e) Dufresse, above cited.—Landouz*. 580 TREATMENT OF VARICOCELE. is easily done, in consequence of its position at the back of the cord, its string-like character, its equal thickness (that of a crow quill,) throughout, its-hardness but elasticity, and by its peculiar painfulness when pressed. The vas deferens is now to be kept back with the finger and thumb against the septum, whilst the veins are drawn out from it with the same fingers of the right hand, in doing which especial care must be taken that not a single vein remain with the vas deferens. The penis is to be kept by an assistant lying upwards upon the belly, for the purpose of preserving on its under surface a sufficient length of skin, so as to prevent painful dis- tention in the often recurring erections. The compressing forceps are then to be applied, first the upper as high as possible on the purse, though at sufficient distance from the penis as not to produce excoriation; the under one half an inch below the first, without, however, touching the testicle. The forceps are applied so across, that their arms grasp nearly the whole breadth of the left side of the purse, up to the septum, that the vas deferens remains unenclosed, and only the outer edge ofthe purse, to the breadth of from two to three lines, without the veins, is contained in t)ie space between the arms of the forceps, and when they are closed is not squeezed. The arms of the forceps are nowr closed as tightly as pos- sible with a screw, then by means of more violent pressure on a narrower space, a concealed plate on the upper arm is pushed forwards next the screw on the septum, and then that on the other arm screwed tight. The patient is then put to bed, the forceps kept against the belly by long strips of sticking plaster, and the purse supported with a cloth or with a ball of lint. The same method serves for the left side, on which varicocele is most frequent, as that described for the right side, only the position of the hands is reversed. For the above described compressing forceps, and their mode of application, see Landouzy, f. 1,2, 3. Breschet's original forceps, their improvement by a movea- ble plate, to effect pressure on three sides. I have employed the latter always with the best result. 1541. In the first hours after the operation, the patient feels a sharp pain in the purse and in the groin, but this subsides. Applications of lead-wash are to be made to the purse. When on the second or third day the forceps become loose, the plate is to be screwed tighter, which, if it be now only as at first properly done, does not cause much pain. When suppuration ensues, between the fifth and sixth days, the forceps are to be removed, and the remaining suppurating parts treated simply. If painful erections of the penis take place, which are most surely pre- vented by keeping the penis against the belly during the application of the forceps and subsequently, which I have never practised in my ope- rations, small doses of camphor, with nitre, may be employed. The time necessary for the cure varies between three and six weeks. It is advisable, for some months after the cure, to wear a well-fitting suspen- der, and to use the cold bath and lead-washes. HEMORRHOIDS OR PILES. 581 III.—OF HEMORRHOIDS OR PILES. Haemorrhoids, Lat.; Haemorrhoidalgeschwulste, Germ.; Hemorrhoides, Fr. Theden, Chirurgische Wahrnehmungen, vol. i. p. 56. Richter, Anfangsgriinde, vol. vi. p. 393. Abernethy, Surgical Works, vol. ii. p. 231. New Edition. 1815. Kirby, J., Observations on the Treatment of certain severe forms of Haemorrhoidal Excrescence. Dublin, 1825. 8vo. Copeland, T., Observations on the principal Diseases of the Rectum and Anus. London, 1814. 8vo. Whyte, W., Observations on Strictures of the Rectum and other Affections, etc. Third Edit. Bath, 1820. 8vo. Howship, J., Practical Observations on the symptoms, discrimination, and treat- ment of the most common Diseases of the Lower Intestines and Anus, etc. Lon- don, 1820. 8vo. Dupuytren, De l'Excision des Bourrelets Hemorrhoidaux; in Lecons Orales de Chirurgie Clinique, vol. i. p. 339. [Physick, The double canula and wire recommended in the operation for Haemorrhoidal Tumours; in Philadelphia Journal of Medical and Physical Sciences, vol. 1. p. 17. 1820. Smith, N. R., On the Pathology and Treatment of Haemorrhoidal Tu- mours, in North American Archives of Med. and Surg. Sciences, vol. 2. 1835.—g. w. n.] Brodie, Sir Benjamin, On Haemorrhoids; in London Medical Gazette, vol. xv., 1835. Bushe, George, M. D., A Treatise on the Malformations, Injuries, and Diseases ofthe Rectum and Anus. New York, 1837. 8vo. Syme, James, On the Diseases ofthe Rectum. Edinburg, 1838. 8vo. [Watson, John, On the Pathology and Treatment of Haemorrhoids in N. Y. Journ. of Med. for July, 1844.—g. w. n.] 1542. Haemorrhoids or Piles are varicose expansions of the veins in the lower part of the rectum, in which, by the collection of blood in these vessels, unnatural bags and sacs of different size, from that of a pea to that of a walnut, are produced. These swellings are commonly called blind piles, {Haemorrhoides caecae,) to distinguish them from flowing piles {Hcemorrhoides fluentes, apertae;) they swell periodically, and again be- come lax, so that only the empty bags remain. If they have considerable size, they are called sac piles {Hamorrhoides saccate;) if small, tubercular piles {Tubercula haemorrhoidalia.) The blood coagulates in the sacs often into a hard mass, so that a firm swelling is formed. Only when these swellings are not very large, may they be formed simply by expan- sion of the walls of the veins; but if they be of greater size, the blood is poured out beneath the inner coat of the rectum, and expands it into a sac; hence the large size which the swellings often attain. It often happens that in cutting them off little or no bleedino- occurs, and it is then distinctly perceived that they consist only of skin. Thev have°also frequently a peculiar form, which varix cannot so easily acquire. This is proved especially by Kirby's careful observations, viz., that these excre- scences do not consist of expanded veins, but of a sac-like lengthening ofthe thick- ened cellular tissue, surrounded with some veins, and covered with the integuments of the folded maro-in of the anus. The veins are branches of the internal iliac. In everv case of internal piles the structure was the same, but the veins appeared wider, and were branches of the hemorrhoidal vein. Brodie, on the contrary, asserts that in all Les he found the haemorrhoidal knots only as expanded veins. In those of amer size more indeed than simple expansion of the veins is found, as there is effusion of lymph and thickening in the neighbourhood ofthe expanded vein. 582 TREATMENT 1543. These swellings are often seated on the outer edge of the anus, or on the inside of the rectum, in the region of the m. sphincter ani or above it. 1544. The consequences resulting from piles are, inflammation and suppuration, discharges of mucus from the rectum, and considerable bleed- ing. If these swellings attain a large size, if, on going to stool, the piles within the rectum be protruded, they are often grasped by the aperture of the anus, swell considerably, are protuberant, and very painful. The pain often spreads over the whole belly, and the patient feels extremely painful tenesmus; the piles even become gangrenous. If they go on to suppuration, in which case syphilitic causes are mostly in play, suppura- tion may easily spread into the loose cellular tissue of the rectum, pro- ducing great destruction and fistula. Not unfrequently do these piles become converted into a hard fleshy mass, and even into cancer. [Bushe has detailed an awful account of the symptoms of piles, most of which, however, result from the constitutional excitement they produce when inflamed, and are then occasionally very severe. The local symptoms are well described by him : —"A feeling of weight in. the loins, hips, and groins; dull throbbing pain in the rectum, attended with a sense of increasing heat, tenesmus, mucous discharge, and occasionally darting sensations, resembling those of electricity; itching of the anus, and finally painful, difficult, and frequent micturition."—(p. 146.) "Frequently the loss of even a small quantity of blood," observes Bushe, "re- lieves the feeling of weight and tension in the perinaeum, rectum, and lower part of the back, as well as any other disagreeable symptoms which may have existed. The amount of haemorrhage, however, is not always in proportion to the severity of the symptoms denoting the loaded state of the haemorrhoidal vessels—the quantity being sometimes very great, though not preceded by well-marked premonitory signs; while, in other cases, the discharge of blood is trifling, notwithstanding the fluxionary movement may have been well marked. Generally it ceases after a few days ; yet not unfrequently it continues for months. In some instances it occurs but once in life; again, it may return in the course of a few weeks, months, or even years. Occasionally it assumes a periodical character, returning with the season or month. The amount of blood lost varies; a drachm, an ounce, or even a pint may be dis- charged at a time, though it must be confessed, that the admixture of other fluids is apt to impose, upon the inexperienced, the belief that the loss of blood is much greater than it really is."—(pp. 146, 147.)] 1445. The causes of hemorrhoid, besides predisposition, which is ascribed, to walking upright, to the difficult flow of the blood into the portal system, which is unprovided with valves, to hereditary habit, and to the flow of blood into the abdominal organs in advanced old age, are stoppages and costiveness ofthe intestines, much sitting, pressure of the pregnant womb, local irritation of the rectum from hard stools and continual riding, or of the neighbouring parts; for instance, of the blad- der in urinary stone, and so on. 1546. The treatment of haemorrhoids is various, according to the cir- cumstances in which they are found. If they be inflamed, cooling reme- dies must be employed, cream of tartar with sulphur, leeches to the perinaeum, cold applications; and if these cannot be borne, mild ointment and soothing fomentations. If the inflammation result from strangulation of the piles, their return must be attempted with the finger oiled, the patient being placed with his rump raised high, and all pressure removed; and if this be not easily effected, to empty them with a simple lancet cut. If they suppurate, the abscess must be soon opened to prevent burrow- ing ofthe pus, and if the ulceration depend on a syphilitic affection, the OF PILES. 583 proper local and general remedies must be employed. If the bleeding from the haemorrhoidal vessels be very severe, so that the patient is much weakened or his life endangered, rest and the horizontal position, best on a hard mattress, is to be recommended; internally, milfoil or other astringent remedies; externally, cold hip-baths, cold water with vinegar or spirits of wine, cold decoctions of astringent vegetables, or solution of alum and the like, may be employed as injections into the rectum, or as fomentations with a sponge. If these means be not of use, and the danger pressing, the bleeding must be stopped by plugging in the way described {par. 934.) 1547. If the piles produce by their size or hardening constant incon- venience, bloody, mucous, or purulent discharges exhausting the pa- tient's powers, continual pain, and the like, if they be external to the rectum, or project at every time of going to stool, and prevent the dis- charge ofthe motions, their removal is indicated. It is, however, to be remembered, that after the destruction of the piles by the reflection of inflammation upon the other veins, their tone is raised, and thus in part the cause ofthe haemorrhoids is removed. Where, however, they are a healthy habitual emptying, or when they have causal relations with in- curable diseases, as, for example, phthisis pulmonalis, we must be cau- tious with their removal; it must either be not undertaken at all, or, at least, all the piles must not be removed at once. 1548. Extirpation of the haemorrhoids has been proposed in three different ways. First. A ligature to be applied around the base of the whole swelling, and this gradually, and not at once, tightened, till the knots have fallen off (1). Second. The external skin of the pile is to be divided with a cut down to its base, and separated on both sides from the under-lying skin, which is to be cut off" with scissors. The advan- tage of this practice is, that the remaining external skin covers the seat of the vein, and prevents the bleeding. Third. The pile is to be grasped with the forceps, drawn forwards and cut off" with scissors in such way that some still remains on the base, by which the wound is partially covered. In external ha?morrhoids, the cut is to be made in the parts below the sphincter. The entire surface of the wound retracts into the rectum, and by the action of the sphincter is contracted, whence the danger of bleeding is very much diminished. If the wound be retracted above the sphincter, internal bleeding may take place. This practice is easy, and preferable to the others, as after the ligature there is often severe pain, inflammation, vomiting, retention of urine, and so on; as the division of the external, and the extraction of the internal skin, is always difficult, and in many cases, on account of their union, impossible. The large haemorrhoids, also, are mostly formed by effusion of blood beneath the internal coat ofthe rectum. (1) Rousseau, J. C. (a), passes a needle with two threads of different colours, from the anus outwards, through the swelling ; then two-thirds of an inch farther back again from without to the anus, thus leaving between the stitches a loop of three or four inches long, and thus carries it around the whole swelling. He then cuts through the loop of the one colour to the outer, and that of the other on the inner side towards the anus. In this way is each part of the swelling surrounded with a ligature, which is to be drawn tight, and cut off short. If the swelling be large, the (a) American Medical Recorder, vol. ix, p. 282. 584 TREATMENT dead part, when it has become insensible, is to be removed, but not too close to the ligature. The ligatures usually fall off in seven or eight days. Delpech (a) divided with a single cut the fibres of the sphincter muscle towards the coccyx, introduced a pessary, and let it be drawn with a string attached to it by an assistant, by which the swelling was reversed and cut off with a scalpel, but was then introduced, the string carried through the opening of another pessary, and tied upon a piece of wood so as to compress the anus between the two pessaries. [Copeland and Brodie lay down as a general rule that internal piles should be removed by ligature. Bushe also prefers this mode, and says:—"I have now per- formed it, I am sure, upwards of a hundred times, and I have never seen a bad symptom follow it." (p. 187.) And Syme observes:—" I feel warranted, after very extensive employment of ligature, to state, that it may be used without the slightest risk of serious or alarming inconvenience." (p. 76.) It must not, how- ever, be forgotten that serious inconvenience and fatal results will, occasionally, follow the application of the ligature to piles. Petit (b) mentions the case of a woman in whom, under very favourable circumstances, he tied three piles, which at first did not cause much pain; but, five hours after, she was attacked with violent colicky symptoms, for which she was bled four times without benefit; the ligatures were then removed, the symptoms yielded, and the patient recovered. In another case related by Petit, five ligatures were applied at once, inflammation and swelling of the belly, vomiting and hiccough ensued ; the ligatures were removed, but the pa- tient died. And he observes:—" I compare these symptoms with those, accom- panying a rupture, in which a small portion of intestine is strangulated; if this kind of rupture be not speedily relieved, the patients die, sometimes in thirty or forty hours, of gangrenous inflammation of the whole belly, but particularly of the intes- tines ; thus this patient died before the conclusion of the second day." (p. 125.) Kirby mentions two similar cases, one of which was scarcely saved, and the other died of tetanus. Brodie relates two fatal cases after ligature, in one of which the the patient died, " in consequence of diffuse inflammation ofthe cellular membrane running up on the outside ofthe gut as high as the mesentery; but it was in a con- stitution broken down by long-continued haemorrhage, and in whom any slight ac- cident might have produced equally bad consequences." In the other case, the pa- tient, "a week after the operation, and having been quite well in the interval, had an attack of pain in the abdomen, and shivering attended with fever, and died. An examination of the body not having been allowed, the precise cause of death was not ascertained." p. 844. "The safest and best way," says Copeland, " is to pass a ligature round one only of the tumours at a time, the most painful and troublesome of them, and to wait until the patient has quite recovered from this operation before any thing more be at- tempted, if any thing more should be still necessary. * * * It is better that this operation by ligature should be repeated two or three times, if it should become necessary, than that the tumours should all be removed at once, at the imminent risk of the life of the patient." (pp. 64, 5.) It is right that the day before the operation the patient's bowels should be cleared with castor oil or rhubarb, which prevents the necessity for disturbing them for a few days afterwards. Brodie recommends that the piles should be well protruded by sitting "over a pan of hot water, which will relax the sphincter muscle, and at the same time cause the veins ofthe rectum to become filled with blood. If this be not sufficient, let the patient have a pint or two of warm water thrown up as an enema, and when that comes away, the piles will probably descend. * * * Let the patient lean over a table, or lie on one side in bed, with his knees drawn up, the nates being held apart by an assistant. Each separate pile must be separately tied. If it be of a very small size, you may just take it up, with a double tenaculum, draw it out, and tie a ligature round its base. But if the piles be of large size, a large curved needle, armed with a strong double ligature, is to be introduced through the base of one of the piles, and the needle then cut off. The double ligature, is now divided into two single ones, which are tied round the base ofthe pile; one on one Bide, and the other on the other, with a single knot. * * * When each pile is thus secured, cut off the convex portion of each pile, so as to make an opening into (a) Memorial de la Clinique de Montpellier, 1830, Sept. p. 545. (6) CEuvres Posthumes, vol. ii. OF PILES. 585 the cavity ofthe convoluted vein which forms it. Thus you take off the tension produced in the pile by the blood which it contains, and are enabled to draw the ligature tighter than before. It should be drawn as tight as possible; for then the subsequent pain will be less, and the separation of the slough quicker. A double knot having been made on each ligature, threads are to be cut off close to the knots, and the piles, and the remains of the ligatures returned into the rectum. In about a week the ligatures are generally detached ; and at this period the bowels should be kept gently open with lenitive electuary and sulphur, and cold water be thrown up the rectum every morning, in order to prevent a recurrence of the disease." (p. 844.)] 1549. The extirpation of the large swellings, degenerated piles, is performed in the following way. After the bowels have been emptied by a purge, and shortly before the operation by a clyster, the patient is to be placed on his belly with his buttocks raised, or upon his knees and elbows, or upon the side, in which case the opposite thigh is to be drawn up towards the belly, and the buttocks separated by an assistant. In internal piles, the swelling having been protruded by the pressure and straining of the patient, also after the employment of a warm hip or vapour bath, is to be grasped with broad-bladed forceps drawn for- wards, and the projecting part cut off at one or morestrokes with curved scissors. In the same manner external haemorrhoids are to be treated. The most important thing to be dreaded, after the operation is bleed- ing; often is it inconsiderable, stops of itself, or can be stanched with cold water. When it is more severe, it may be most certainly stanched by cauterizing the bleeding part with a bean-shaped iron. The patient must always at first be attended by an experienced assistant, as after- bleeding, especially if it be not cauterized, is always to be dreaded (1). After the removal of an internal pile, there may be imminent danger without it being noticed. The patient always feels an increased warmth in the rectum, which is accompanied with the symptoms of concealed bleeding. A cold clyster must be immediately given; by straining and forcing, the blood must be discharged, and the bleeding part protruded, upon which the hot iron is to be applied. The inflam- matory and spasmodic symptoms, as fever, colic, retention of urine, and so on, which soon come on after the operation, especially if cauteriza- tion be employed ; must be got rid of according to circumstances by blood-letting, fomentations to the belly, introduction ofthe catheter, and anti-spasmodics. After the removal of large haBmorrhoidal swellings, a moderately thick bougie, smeared with cerate, must be introduced from time to time, to prevent a narrowing of the rectum (2). Plugging the rectum may, indeed, be employed for stanching the bleeding; incon- veniences are, however, connected with it, especially the continual pressure, ex- tremely tiresome to the patient. The plug is also easily displaced, and its effect is not so certain as that of the hot iron (a). T(l) When the bleeding after the removal of internal piles is profuse, and the pa- tient will not submit to the actual cautery, Bush advises the use of an instrument which he " had constructed for suppressing haemorrhage after lithotomy. This in- strument is seven inches long, tubular, about as thick as a swan's quill, terminated with a button at one end, to facilitate its introduction, and with a stop-cock at the other One inch from the stop-cock, and half an inch from the button, there are two proiectino- rino-s, and on the proximal side of the distal ring the tube is per- forated bv a number of holes. Finally, a portion of intestine is bound by means of waxed silk on the tube, behind the ring. This instrurment should be introduced, and then inflated. In some little time we can let off the air and withdraw the in- to) Dupuytren, above cited. Vol. II.—50 586 TREATMENT OF PILES. strument, provided the haemorrhage has ceased ; but if we find that it returns on the removal ofthe pressure, we must again inflate the intestine." (p. 185.) (2) The elder Cline was accustomed to cut off piles; and Astley Cooper (a), for a time, followed the same practice, " thinking excision the best mode, because he found the pain produced by it very trifling as compared with the ligature." (p. 75.) But he met with several fatal cases from this method, which he very candidly mentions. In one case, "a very few days after removal of internal piles with the scissors, the patient complained of pain by the side of the rectum ,- an abscess formed under the glutaeus muscle, which discharged abundantly; his constitution was already broken up, and he died in consequence of the discharge." In the second case he had removed internal piles, by excision, from a nobleman, without ill con- sequences ; but, two years after, a similar operation having been performed on the same person, it was followed by frequent desire to go to stool, and four times he discharged a considerable quantity of blood. On examining, with a speculum ani, "one ofthe haemorrhoidal arteries in the centre of one of the piles, which had been removed, was found divided." Cooper took it up; but the patient, being advanced in years and much weakened, was attacked with a severe rigor, grew gradually worse, and in four days died. The third case, operated on by another surgeon, died from bleeding, on the fourth day. In the fourth case mentioned by Cooper, there was not any haemorrhage; but, three days after, the woman was attacked with peri- tonaea! inflammation, and died ten days subsequent to the operation. On opening the body, the peritonaeum was found much inflamed, and had the appearance of death from puerperal fever, (p. 75-7.) Brodie employed excision for a time, but afterwards had three cases in which considerable quantities of blood were lost, and in the last, he observes, "so much, that he only wondered the patient did not actu- ally die." Since then he has "never removed large internal piles except bv lifia- ture." (p. 843.) V * ' * (a) Lecture on Surgery; in Lancet, 1823, 24, vol. ii. Third Edition. 1826. END OF VOL. n. CATALOGUE OF BLANCHARD & LEA'S MEDICAL AND SURGICAL PUBLICATIONS. PHILADELPHIA, DECEMBER, 1853. TO THE MEDICAL PROFESSION. In submitting the following catalogue of our publications in medicine and the collateral sciences, we beg to remark, that no exertions are spared to render the issues of our press worthy a continuance of the confidence which they have thus far enjoyed, both as-regards-the high character ofthe works themselves, and in respect to every point of typographical accuracy and mechanical execution. Gentlemen desirous of adding to their libraries from our list, can in almost all cases procure the works they wish from the nearest bookseller, who can readily order any which he may not have on hand. From the great variation in the expenses of transportation through territories so extensive as those of the United States, prices cannot be the same in all sections, of the country, and therefore we are unable to affix retail prices to our publications. Information on this point may be had of booksellers generally,, or from ourselves, and all inquiries respecting any of. our books will meet with prompt attention by addressing BLANCHARD & LEA, Philadelphia. December, 1853. TWO MEDICAL PERIODICALS, FREE OF POSTAGE, FOR FIVE DOLLARS PER AWWIJM. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to postage, when not paid for in advance, - -.....$5 00 THE MEDICAL NEWS AND LIBRARY, invariably in advance, - - 1 00 or, both periodicals furnished; free of postage, fer Five Dollars remitted in advance. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M, D., is published Quarterly, on the first of January, April, July, and October. Each number contains at least two hundred a$d, eighty large octavo pages, appropriately. illustrated, wherever necessary, by engravings on copper, stone, or wood.' It has now been issued regularly for a period of thirty- five years, during a quarter of a century of which it has been under the control of the present editor. Throughout this long space of time, it has maintained its position in the highest rank of medical periodicals both at home and abroad, and has received the cordial support ofthe entire pro- fession in this country. Its list of Collaborators Will be found to contain a large number of the most distinguished naonesof the profession in every section of the United btates, rendering the de- partment devoted to ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to ail practitioners. As the aim ofthe Journal, however, is to oombwie the advantages presented by all the different varieties of periodicals, in its REVIEW DEPARTMENT will be found extended and impartial reviews of all important new works, presenting subjects of novelty and interest, together with very numerous BIBLIOGRAPHICAL NOTICES, „„,„,.„ n-ttriv aii the medical, publications, pf the day, both in this country and Great Britain, with a clSSchon oflhe"more 'important continental works. This is followed by the 2 BLANCHARD & LEA'S MEDICAL QUARTERLY SUMMARY, being a very full and complete abstract, methodically arranged, of the IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. This department of the Journal, so important to the practising physician, is the object of especial care on the part ofthe editor. It is classified and arranged under different heads, thus facilitating the researches of the reader in pursuit of particular subjects, and will be found to present a very full and accurate digest of all observations, discoveries, and inventions recorded in every branch of medical science. The very extensive arrangements of the publishers are such as to afford to the editor complete materials for this purpose, as he not only regularly receives ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, but also twenty or thirty of the more important Journals issued in Great Britain and on the Conti- nent, thus presenting in a convenient compass a thorough and complete abstract of everything interesting or important to the physician occurring in any part ofthe civilized world An evidence of the success which has attended these efforts may be found in the constant and steady increase in the subscription list, which renders it advisable for gentlemen desiring the Journal,.to make known their wishes at an early day, in order to secure a year's set with certainty, the publishers haying frequenlly been unable to supply copies when ordered late in the year. To their old subscribers, many of whom have been on their list for twenty or thirty years, the publish- ers feel that no promises are necessary; but those who may desire for the first time to subscribe, can rest assured that no exertion will be spared to maintain the Journal in the high position which it has occupied for so long a period. By reference to the terms it will be seerj that, in addition to this large amount of valuable and practical information on every branch of medical science, the subscriber, by paying in advance, becomes entitled, without further charge, to THE MEDICAL NEWS AND LIBRARY, a monthly periodical of thirty-two large octavo pages. Its "News Department" presents the current information ofthe day, while the " Library Department" is devoted to presenting stand- ard works on various branches of medicine. Within a few years, subscribers have thus received, without expense, the following works which have passed through its columns :— WATSON'S LECTURES ON THE PRACTICE OF PHYSIC. BRODIE'S CLINICAL LECTURES ON SURGERY. TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. Parts I., II., and III., with numerous wood-cuts. WEST'S LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. MALGAIGNE'S OPERATIVE SURGERY, with wood-cuts, and SIMON'S LECTURES ON GENERAL PATHOLOGY. While the year 1853, presents THE CONTINUATION OF TODD & BOWMAN'S PHYSIOLOGY, BEAUTIFULLY ILLUSTRATED ON WOOD. KF* Subscribers for 1853, who do not possrss the commencement of Todd and Bowman can obtain it, in a handsome octavo volume, of 552 pages, with over 150 illustrations, by mail free of postage, on a remittance of $2 50 to the publishers. Tt will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber will obtain a Quarterly and a Monthly periodical, EMBRACING ABOUT FIFTEEN HUNDRED LARGE OCTAVO PAGES mailed to any part of the United States, free of postage. These very favorable terms are now presented by the publishers with the view of removing all difficulties and objections to a full and extended circulation of the Medical Journal to the office of every member of the profession throughout the United Sates. The rapid extension of mail facili- ties, will now place the numbers before subscribers with a certainty and dispatch not heretofore attainable; while by the system now proposed, every subscriber throughout ihe Union is placed upon an equal footing,, at the very reas0nable price of Five Dollars for two periodicals, without further expense. r ' Those subscribers who do not pay in advance will bear in mind that their subscription of Five Dollars will entitle them to the Journal only, without the News, and that (hey will be at the expend ot their own postage on the receipt of each number. The advantage of a remittance when order- ing ihe Journal will thus be apparent. . . . As the Medical News and Library is in no' case sent without advartce payment, its subscribers will always receive it free of postage. "*" It should also be borne in mind that the publishers will now take the risk of remittances bv mail only requiring, in cases of loss, a certificate from the subscriber's Postmaster, that the money was duly mailed and forwarded. r< •. T O \r ,t f - , .», «»cy was EF Funds at par at the subscriber's place of residence received in payment of subscriptions. Address, BLANCHARD & LEA, Philadelphia. AND SCIENTIFIC PUBLICATIONS. 3 ASHWELL (SAMUEL), M.D. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. With Additions by Paul Beck Goddaed, M. D. Second American edition. In one octavo volume, of 520 pages. One of the very best works ever issued from the press on the diseases of females.—Western Lancet. This is an invaluable work.—Missouri Medical and Surgical Journal. We strongly recommend Dr. Ashwell's Treatise to our readers as a valuable book of reference, on an extensive, complicated, and highly important class of diseases.—Edinburgh Monthly Journal of Med. Sciences. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-lechnical language. A new edition, by Isaac Hays, M. 1). Complete in one octavo volume, of 484 pages, with about two hundred illustrations. ABERCROMBIE (JOHN), M. D. PATHOLOGICAL AND PRACTICAL RESEARCHES ON DISEASES OF THE STOMACH, INTESTINAL CANAL, &c. Fourth.edition, in one small octavo volume, of 260 pages. BENNETT (HENRY), M.D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Founh American, from the third and revised London edition. In one neat octavo volume, of 430 pages, with wood-cuts. (Now Ready.) This edition will be found materially improved over its predecessors, the author having carefully revised it, and made considerable additions, amounting to betweeu seventy-five and one hundred pages. We shall not call it a second edition, because, as i us. The important practical precepts which the Dr. Bennett truly observes, it is really a new work, author inculcates are all rigidly deduced from facts. It will be found to contain not only a faithful histo- ... Every page of the book is good, and eminently ry of ihe various pathological changes produced by practical. . . . So far as we know and believe, it is inflammation in the uterus and its annexed organs, the best work on the subject of which it treats.— in the different phases of female life, but also an ac- | Monthly Journal of Medical Science. curate analysis of the influence exercised by intlam- . mation in the production of the various morbid con- ! *Ve refer our readers with satisfaction to this work ditions of the uterine system, hitherto described and for information on a hitherto most obscure and d»ffi- treated as functional.—British and Foreign Medico- Chirurgical Review. Few works issue from the medical press which are at once original and sound in doctrine ; but such, we feel assured, is the admirable treatise now before cult class of diseases.—London Medical Gazette. One of the best practical monographs ambngst modern English medical books.—Transylvania Med. Journal. BEALE (LIONEL JOHN), M. R. C. S., &c. THE LAWS OF HEALTH IN RELATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one handsome volume, royal 12mo., extra cloth. BILLING (ARCHIBALD), M. D. THE PRINCIPLES OF MEDICINE. Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth, 250 page*. BLAKISTON (PEYTON), M.D., F.R.8., tc. PRACTICAL OBSERVATIONS ON CERTAIN DISEASES OF THE CHEST, and on the Principles of Auscultation. In one volume, 8vo, pp. 384. BENEDICT (N. D.), M. D. rnvPFNDTTIM OF LECTURES ON THE THEORY AND PRACTICE OF MEDICINE, delivered by Peofessoe Chapman iu the University of Pennsylvania. , ta one octavo volume, of 258 pages. ____________ BURROWS (GEORGE), M. D. ™ ™«m?r>ERS OF THE CEREBRAL CIRCULATION, and on the Con- ON U10UIU/J3JX Affeclions 0f the Brain and Diseases of the Heart. In one Svo. vol., with nei'lion between inc "■»« colored plates, pp- , M. D., &c. OLINICAL LECTURES ON SURGERY. 1 vol. 8m, eloth. 850pp. BY THE SAME AUTHOR. PATHOLOGICAL AND SURGICAL OBSERVATIONS ON THE DIS- EASES OF THE JOINTS. 1 vol. 8vo., cloth, pp. 216. BY THE SAME AUTHOR. lvol. LECTURES ON THE DISEASES OF THE URINARY ORGANS. 8vo., cloth, pp. 214. *** These three works may be had neatly bound together, forming a large volume of" Brodie's :Surgical Works." pp. 780. BIRD (GOLDING), A. M., M. D.f &.c. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. A new American, from the third and improved Loudon edition. With over sixty illustrations. In one royal 12mo. volume, extra cloth, pp. 338. The new edition of Dr. Bird's work, though not anqreased in, size, has been greatly modified, and much of it rewritten. It now presents, in a com .p.endious form, the gist of all that is known and re- liable in this department. From its terse style and 'convenient size, it is particularly applicable to the student, to whom we cordially command it.—The ■ Medical Examiner. It can scarcely be necessary for Us to say anything • of the merits of this well-known Treatise, which so ratfmirably brings into practical application the re- sults of those microscopical und chemical researches regarding the physiology and pathology of the uri- nary secretion, which have contributed so much to the increase- of our diagnostic powers, and to the extension-and satisfactory employment of our thera- peutic resources. In the preparation of this new ?°It>°n of his work, it is obvious that Dr. Goldinu Bird has spared no pains to render it a faithful repre- sentation of the present state of scientific knowledge on the subject it embraces. Although, of course, there are many topics which are open to differences of opinion, we cannot point to any well-substaatiated result of inquiry which the author has overlooked.- The British and Foreign Medtco-Chirurgical Review. BY THE SAME AVTHOE. ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro- ductioh to the Physical Sciences. Illustrated with nearly four hundred wood-cuts From the third London edition. In one neat volume, royal 12mo. pp. 402. AND SCIENTIFIC PUBLICATIONS. 5 BARTLETT (ELISWA), M*D., Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and 8urgeohs, New York. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. Third edition, revised and improved. In one octavo volume, of six hundred pages, beautifully printed, and strongly hound. In preparing a new edition of this standard work, the author has availed himself of such obser- vations and investigations as have appeared since the publication of his last revision, and he has endeavored in every way to render it Worthy of a continuance of the wry marked favor with which it has been hitherto received. Of the value and importance of such a work, it is needless here to speak; the profession of the United States owe much to the author for. the very able volume which he has presented to them, and for the careful and judicious manner in which he has exe- cuted his task. No one volume with which we are acquainted contains so complete a history of our fevers as this. To Dr. Bartlett we owe our b«st thanks for the very able volume he has given us, as embodying certainly the most complete, methodical, and satisfactory account of our fevers anywhere (o be met with.— The Charleston Med. Journal and Review. The masterly and elegant treatise, by Dr. Bartlett is invaluable to the American student and practi- tioner.—Dr. Hqltnes^s Report to the Nat. Med. Asso- ciation. We regard it, from the examination we have made of it, the best work on fevers extant in our language, and as such cordially recommend it to the medical public.—St. Louis Medical and Surgical Journal. Take it altogether, it is the most complete history of our fevers which has yet been published, and every practitioner should avail himself of its con- tents.— The'Western Lancet. BY THE SAME AUTHOR. AN INQUIRY INTO THE DEGREE OF CERTAINTY IN MEDICINE, and into the Nature and Extent of its Power over Disease. In one volume, royal 12mo. pp. 84. BOWMAN (JOHN 5.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. J» one seat volume, royal 12mo., with numerous illustrations, pp. 288. BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. With numerous illustrations. In one neat volume, royal 12mo. pp. 350. BARLOW (GEORGE H.), M. D. A MANUAL OF THE PRINCIPLES AND PRACTICE OF MEDICINE. In one octavo volume. (Preparing-) COLOMBAT DE L'ISERE. A TREATISE ON THE DISEASES OF FEMALES, and on the Special Hygiene of their Sex. Translated, with many Notes and Additions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, octavo, with numerous wood-cuts. pp. 720. The treatise of M. Ctrfojnbat is a learned and la- i M. ColnmfeatDe L'fsere baa not consecrated ten borious commentary on these diseases, indicating years of studious toil and research to the frailer sex very considerable research, great accuracy of judg- in vain; and although we regret to hear it is at the ment pad no inconsiderable personal experience, expense of health, he has imposed a debt of gratitude With che copious notes and additions of its experi- as well upon the. profession, as upon the mothers and enced aad very erudite translator and editor, Dr. daughters of beautiful France, which that gallant Meier* it presents, probably, one of the most com- nation knows best how to acknowledge.—iVeiu Or- plete and comprehensive works on the subject we j leans Medical Journal. possess.—American Med. Journal. COPLAND (JAMES), M. D., F. R. S.f &,€. OF THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY, and of the Forms, Seats, Complications, and Morbid Relations of Paralytic and Apoplectic Diseases. In one volume, royal 12mo., extra cloth, pp. 326. CHAPMAN (PROFESSOR N.), M. D., &c. LECTURES ON FEVERS, DROPSY, GOUT, RHEUMATISM, &c. &c. In ooe neat 8vo. volume, pp. 450. CLYMER (MEREDITH), M. D., &.C. FEVERS- THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT. Prepared a'nd Edited, with large Additions, from the Essays on Fever in Tweedle'is Library of ti..oi..;~,i TVf^i^ine. In one octavo volume, of GOO.pages. MEDICA oae very neat octavo 6 BLANCHARD & LEA'S MEDICAL CARPENTER (WILLIAM B.), M. D., F. R. S., &.C., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. Fifth American from the fourth and enlarged London edition. With three hundred and fourteen illustrations. Edited, with additions, by Francis Gurney Smith, M. D., Professor ofthe Institutes of Medicine in the Pennsylvania Medical College, &c. In one verv large and beautiful octavo volume, of about 1100 large pages, handsomely printed and strongly bound in leather, with raised bands. New edition. (Just Issued.) From the Author's Preface to the present Edition. " When the author, on the completion of his ' Principles of General and Comparative Physiology,' applied himself to the preparation of his ' Principles of Human Physiology,' for the press, he found that nothing short of an entire remodelling ofthe preceding edition would in any degree satisfy his notions of what such a treatise ought to be. For although no fundamental change had taken place during the interval in the fabric of Physiological Science, yet a large number of less important modifications had been effected, which had combined to produce a very considerable alteration in its aspect. Moreover, the progressive maturation of his own views, and his increased experience as a teacher, had not only rendered him more keenly alive to the imperfections which were inherent in its original plan, but had caused him to look upon many topics in a light very different from that under which he had previously regarded them ; and, in particular, he felt a strong desire to give to his work as 'practical a character as possible, without foregoing the position which (he trusts he may say without presumption) he had-succeeded in gaining for- it, as a philosophical exposition of one important department of Physiological Science. He was led, therefore, to the determination of, in reality, producing a new treatise, in which only those parts of the old should be retained, which might express the existing state of knowledge, and of his own opinions on the points to which they relate." •-. ... ■ ■• The American edition has been printed from sheets prepared for the purpose'by the author, who has introduced nearly one hundred illustrations not in the London edition ; while it has also enjoyed the advantage of a careful superintendence on the part of the editor, who has added notices of such more recent investigations as had escaped the author's' attention. Neither care nor expense has been spared in the mechanical execution of the work to render it superior to former editions, and it is confidently presented as in every way one of the handsomest volumes as yet placed before the medical profession in this country. The most complete work on the science in our The best texwbook in the language on this ex- language.—4»». Med. Journal. tensive subject.—London Med. Times. The most complete exposition of physiology which "tit Cv0 a/r5'6 cy.cloPslJia of this branch of science. any. language can at present give.—Brit, and For. ■"• *• Med. Times. Med.-Chirurg. Review. We have thus adverted to some of the leading I the alterations anTadditTonsTwhich'tonb^ml™ "■additions and alterations," which have been in- \ would require a review "f the wh^work "fnce troduced by the author into this edition of his phy- | scarcely a subject has not"beenr«wi"ed and altered Biology. These will be found, however very far to , added to, or entirely remodelled to adapt it to the exceed the ordinary limits of a new edition. " the present state of the science.—Charleston M,d To*™ old materials having been incorporated with the Anv r«iHf>r whnH«.«s,„ ' • •'»»••'»»"»■ new, rather than the new with the old." It now < mav Ufljmlelf enMrpW* 'r^186 °,n Phys">,0Sy certainly presents the most complete treatise on the WelteniMeTand SuHLffe ,m orderin§ thls— ■ubjept within the reach of the American reader; WesUrn Med- and ^urS- Journal. ■ TheitinlarTdof authority on physiological sub- jects.*1 * * In the present edition, to particularize and while, for availability as a text-book, we may perhaps regret its growth in bulk, we are sure that Che student of physiology wilFfeel the impossibility From this hasty and imperfect allusion it will be seen by our readers that the alterations and addi- tions to this edition render it almost a new work— of presenting a thorough digest of the facts of the t and we can assure our readers lhat it is onex»f the science within a more limited compaBs—iATedtcaZ ; best summariesof the existing fact* of physiological Examiner. science within the reach of the English Btudent and | physician.—N. Y. Journal of Medicine. The greatest, the most reliable, and .the best hook i Th„ „-„<•_„_;„„ „* ft- „_,„»„. _ ., on the subject'which we know of in the English JCr^rS^yS^^^^^S'VkA Perhapa also laniriia nave >nxiously and for some time awaited language.—otemoscope. the announcement of this new edition of Carpenter's The most complete work now extant in our Ian- | Human Physiology. His former editions have for guage.—N. O. Med. Register. many years been almost the only text-book on Phy- , . siology in all our medical schools, and its circola- The changes are too numerous to admit of an ex- i tion among the profession has been unsurpassed bv tended notice in this place. At every point where any work in any department of medical science the recent diligent labors of organic chemists and | it is quite unnecessary for us to speak of this micrographers have furnished interesting and valu- | work as its merits would justify. The mere an- able facts, they have been appropriated, and no pains nouncement of its appearance will afford the highest have been spared, in so incorporating and arranging pleasure to every student of Physiology whife its them that the work may constitute one armonious , perusal will be of infinite service in advancing system.—Southern Med. and Surg. Journal. \ physiological science.—OAto Med. and Surg. Jourii. BY THE SAME AUTHOR. PRINCIPLES OF GENERAL AND COMPARATIVE PHYSIOLOGY Intended as an Introduction to the Study of Human Physiology; and as a Guide to the Philo- sophical pursuit of Natural History. New and improved edition, (preparing.) BY THE same author. (Preparing.) THE MICROSCOPE AND ITS REVELATIONS. In one handsome volume beautifully illustrated with plates and wood-cuts. ' AND SCIENTIFIC PUBLICATIONS. CARPENTER {WILLIAM B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume. (Lately Issued.) In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution ofthe word " Elements" for that of '" Manual," and with the author's sanctiou the title of "Elements" is still retained as being more expressive of the scope of the treatise. A comparison of the present edition with the former one will show a material improvement, the author having revised it thoroughly, with a view of rendering it completely on a level with the most advanced state of the science. By condensing the less important portions, these numerous additions have been introduced without materially increasing the bulk of the volume, and while numerous illustrations have been added, and the general execution of the work improved, it has been kept at its former very moderate price. To say that it is the best manual of Physiology now before the public, would not do sufficient justice to the author .—Buffalo Medical Journal. In his former works it would seem that he had exhausted the subject of Physiology. In the present, he gives the essence, as it were, ofthe whole.—N. Y. Journal of Medicine. Those who have occasion for an elementary trea- tise ou Physiology, cannot do better than to possess themselves of the manual of Dr. Carpenter.—Medical Examiner. The best and most complete expose1 of modem Physiology, in one volume, extant in the English language.—St. Louis Medical Journal. With such an aid in his hand, there is no excuse for the ignorance often displayed respecting the sub- jects of which it treats. From its unpretending di- mensions, it may not be so esteemed by those anxious to make a parade of their erudition; but whoever masters its contents will have reason to be proud of his physiological acquirements. The illustrations are well selected and finely executed.—Dublin Med. Press. f BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of scientific words. In one neat 12mo. volume. (Now Ready.) This new edition has been prepared with a view to an extended circulation of this important little work, which is universally recognized as the best exponent of the laws of physiology and pathology applied to the subject of intoxicating liquors, in a form suited both for the profession and the public. To secure a wider dissemination of its doctrines the publishers have done up copies in flexible cloth, suitable for mailing, which will be forwarded through the post-office, free, on receipt of fifty cents. Societies and others supplied in quantities for distribution at a liberal deduction. CHELIUS (J. M.), M. D., Professor of Surgery in the University of Heidelberg, &c. A SYSTEM OF SURGERY. Translated from the German, and accompanied with additional Notes and Beferences, by John F. South. Complete in three very large octavo volumes, of nearly 2200 pages, strongly bound, with raised bands and double titles. We do not hesitate to pronounce it the best and most comprehensive system of modern surgery with which we are acquainted.—Medico-Chirurgical Re- view. The fullest and ablest digest extant of; all that re- lates to the present advanced state of surgical pa- thology.—American Medical Journal. As complete as any system of Surgery can well be.—Southern Medical and Surgical Journal. The most learned and complete systematic treatise now extant.—Edinburgh Medical Journal. A complete encyclopedia of surgical science—a very complete surgical library—by far the most complete and scientific system of surgery in the English language.—N. Y. Journal of Medicine. The most extensive and comprehensive account of the art and science of Surgery in our language.-— Lancet. CHRISTISON (ROBERT), M. D., V. P. R. S. E., &c. A DISPENSATORY j or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tion* U«es and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved with a Supplement containing the most important Ne\v Remedies. Wuh copious Add*. tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M.JD. In one very large and handsome octavo volume, ot over 1000 pages. It is not needful that we should compare it with the other pharmacopoeias extant, which enjoy and merit the confidence of the profession : il» enou«J to env that it appears to us as perfect as a Dispensa- ory, in the present state of rJharmaceutical « enc , jJIk be ^™^^£7l\%$£ 'hTa T^S"iESs^choi^^ There is not in any language a more complete and perfect Treatise.—N. Y. Annalist. In conclusion, we need scarcely sair that we strongly recommend this work to all classes of our readers. As a Dispensatory and commentary on the Pharmacopoeias, it is unrivalled in the English or any other language.—The Dublin Quarterly Journal. We earnestly recommend Dr. Christjsonte Dis- pensatory to all our readers, as an indispensably companion, not in the Study only, but in theSurgery also.—British and Foreign Medical Review. 8 B.LANCHAB/D &j LEA'S MEDICAL CONDIE (D. F.), M. Dk, &.c. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN: Fourth edition, revised and augmented.. In one large volume, 8yo., of. nearly 750 pages. (NowReady-) Feqm the Author's, Preface. The demand for another edition has afforded tbe author an opportunity of again subjecting the entire treatise to a careful revision, and of incorporating in it every important observation recorded since the appearance ofthe last edition, hi reference to the pathology and therapeutics ofthe several diseases ofwhich it treats. In the preparation of the present edition, as in those which have preceded, while the author has appropriated to his use every important fact that he has found recorded in the works of others, having a direct bearing upon either of the subjects of which he treats, and the numerous valuable observations—pathological as Well as practical—dispersed throughout the pages of the medical journals of Europe and America, he has, nevertheless, relied chiefly Upon his own observations and experience, acquired during a long and somewhat extensive practice, and under circumstances pe- culiarly well adapted for the clinical study ofthe diseases of early life. Every species of hypothetical reasoning has, as much as possible,.been avoided. The author has endeavored throughout the work to confine himself to a simple statement of well-ascertained patho- logical facts, and plain therapeutical directions—his chief desire being to render it what its title imports it to be, a practical treatise on the diseases of children. Dr. Condie's scholarship, acumen^ industry, and, We feel assured from actual experience that no practical sense are manifested in this^asin all his physician's library can be complete without a copy numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the SMrV^aTjoVroaT practitioner in this country will rise with the great- ' est satisfaction —Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. Perhaps the most full and complete work now be- fore the profession ofthe United States; indeed, we of this work.—N. Y. Journal of Medicine. A veritable paediatrie encyclopaedia, and an honor to American medical literature.—Ohio Medical and We feel persuaded that the American medical pro- fession will soon regard it not only as a very good, but as the vert best " Practical Treatise on the Diseases of Children."—American Medical Journal: We pronpunced the first, edition to be the best work, on the diseases of children in the English may say in the English language. It is vastly supe- language, and, notwithstanding all that has been rior to most of its predecessors.—Transylvania Med, published, We still regard it in that light.—Medical Journal. [ Examiner. COOPER (BRANSBY B.), F. R. S., Senior Surgeon to Guy's Hospital, &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. Iti one very large octavo volume, of 75P pages. {Lately Issued), For twenty-five years Mr. Bransby Cooper has I Cooper's Lectures as a most valuable addition to been surgeon to Guy's Hospital; and the volume | our surgical literature, and one which cannot fail before us may be said to consist of an account of I to be of service both to students and to those who the result* of his surgioa.1 experience during that .are actively engaged in the practice of their profes- long period. We cordially recommend JVJr. Bransby I sjjon.—TA« Lancet, COOPER (SIR ASTLEY P.), F. R. S., &c. A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS Edited by Braksby B. Cooper, F. R. S , &c. With additional Observations by Prof J c" Sfon wood nCW roe"Can edH10n- In one handsome octavo volume, with numerous illustra- BY THE SAME AUTHOR, ON THE ANATOMY AND TREATMENT OF ABDOMINAL HERNIA One large volume, imperial 8vo., with over 130 lithographic figures. ■--■■■• BY THE SAME AUTHOR. °?he thy™gS^o-^P- DIS^SES 0F THE TESTIS, AND ON 1ME THYMUS GLAND. One vol. imperial 8vo., with 177 figures, o» W plajea, BY THE SAME AUTHOR. Og THE ANATOMY AND DISEASES OF THE BREAST mth twentv fiye^cellaneous and Surgical Papers. One large volume, linp^^, w^»4JS« h J^!^t3re,eJV°,U^es ?omPlete the surgjpal writings of Sir Astley Cooper,, Thev are verv JSJ^S^^^T"^ ^ "'^P^ates, executed in ll^&^'H awj suiivNTIFIC PUBLICATIONS. 6 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American, from ihe last and improved English edition. Edited, with Notes and Additions, by D. Francis Oondie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 139 illustrations. In one very handsome octavo volume, pp. 510. (Lately Issued.) To bestow praise on a book that has received such marked approbation would be superfluous. We heed only say, therefore, that if the first edition was thought woTthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo. retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—^London Medical Gazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he wbose^ necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. The most popular work on midwifeTy ever issued from the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but one work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.—Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr, Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on the subject which exists.—N. Y. Annalist. No work holds a higher position, or is more (de- servfyg of being placed in the hands of the tyTO, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received With marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually-accurate and able exposition of every important particular embraced in the department of midwifery. # # The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if hot the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this department of medical science. —N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manualfor the frequent consultation of the young practitioner.— American Medical Journal. BY THE SAME AUTHOR. ON THE DISEASES OF INFANTS AND CHILDREN. handsome volume of over 600 pages. In one large and We regard this volume as possessing more claims to completeness than any other of the kind with which we are acquainted. Most cordially and earn- estly, therefore, do we commend it to our profession- al brethren, andwe feel assured that the sjamp.of their approbation wilVinduetime be impressed upon it. After an attentive perusal of its contents, we hesitate not to say, that it is one of the most com- prehensive ever written upon the diseases of chil- dren, and that, for copiousness of reference, extent of research, and perspicuity of detail, it is scarcely to be equalled, and not to be excelled, in any lan- guage.—Dublin Quarterly Journal. After this meagre, and we know, very imperfect notice of Dr. Churchill's work, we ahall conclude by sayingj that it is one that cannot fail from its co- piousness, extensive research, ind general accuracy, to exalt still higher the reputation of the author in this country. The American reader wil 1 be particu- larly pleased to find that Dr. Churchill has done full justice throughout his work to the various American authors on this subject. The names of Deweea, Eberle, Condie, and Stewart, occur on nearly every page.'and these authors are Constantly referred toby the author in terms of the highest praise, and with the most liberal courtesy.— The Medical Examiner. The present volume will sustain the reputation acquired by the author from his previous Works. The reader will find in it full and judicious direc- tions for the management of infants at birth, and a compendious, but clear account of the diseases to which children are liable, and the most successful mode of treating them. We must not close this no- tice without calling attention to the author's style, which is perspicuous and polished to a degree, we regret to say, n,ot generally characteristic of medical works. We recommend the work of Dr. Churchill most cordially, both to students and practitioners, as a valuable and reliable guide in the treatment of the diseases of children.—Am. Journ. of the Med. Sciences. We Vnow of no work on this department of Prac- tical Meflicihe'whlch pre'sents so candid and unpre- judiced a, statement or posting up of our actual knowledge as this.—N. Y. Journal of Medicine. Its claims to merit both as a scientific and practi- cal work, are of the higfiest order. Whilst we would not elevate it above every other treatise on the same subject, we certdinly believe "that ve"ry few are equal to it, and none superior.—Southern Med. and Surgical Journal. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- riTT 1AH TO WOMEN Selected from the writipgsof British Authors previous to the close ©f the Eighteenth Century. ' In one heat octavo volume, of about four hundred and, fifty pages. n, n. „„„„,= TV Churchill has appended notes, demies of that disease. The whole forms a very T° AhSZ Whatever' info.malion has been laid be-' valuable collection of papers, by professional writers embodying, wha evern»« W™^^,, tilrte. He haS^eniinence.ion sdmeoT the nJosJ.iQiportant accidents fore thepiofes««,n."n|? "«; ^Vuefperal Fever, to whieh the. puerperal f>male is hMe.-Amcrican ^nU'lccuuv theh^er porUon o? the volurae,,an Journal oftteAital Sciences. , ^^rtting^TstorlcaT^kefch of the principal epi- 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. I. A., &c. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children." In one large and handsome octavo volume, with wood-cuts, pp. 684. (Just Issued.) From the Author's Preface. In reviewing this edition, at the request of mv American publishers, I have inserted several new sections and chapters, and I have added, I believe, all the information we have derived from recent researches; in addition to which the publishers have been fortunate enough to secure the services of an able and highly esteemed editor in Dr. Condie. We now regretfully take leave of Dr. Churchill's book. Had our typographical limits permitted, we should gladly have borrowed more from its richly stored pages. In conclusion, we heartily recom- mend it to the profession, and would at the same time express our firm conviction that it will not only add to the reputation of its author, but will prove a work of great and extensive utility to obstetric practitioners.—Dublin Medical Press. Former editions of this work have been noticed in previous numbers.of the Journal. The sentiments of high commendation expressed in those notices, have only to be repeated in this; not from the fact that the profession at large are not aware of the high merits which this work really possesses, but from a desire to see the principles and doctrines therein contained more generally recognized, and more uni- versally carried out in practice.—N. Y. Journal of Medicine. We know of no author who deserves that appro- bation, on " the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. The former editions of this work have been com- mended strongly in this journal, and they have won their way to an extended, and a well-deserved popu- larity. This fifth edition, before us. is well calcu- lated to maintain Dr. Churchill's high reputation. It was revised und enlarged by the author, for his American publishers, and it seems to us that there is scarcely any species of desirable information on its subjects that may not be found in this work.—The Western Journal of Medicine and Surgery. We are gratified to announce a new and revised edition of Dr. Churchill's valuable work onthe dis- eases of females We have ever regarded it as one of the very best works on the subjects embraced within its scope, in the English language; and the present edition, enlarged and revised bv the author, renders it still more entitled to the confidence ofthe profession. The valuable notes of Prof Huston have been retained, and contribute, in no small de- gree, to enhance the value of the work. It is a source of congratulation that the publishers have permitted the author to be. in this instance, his own editor, thus securing all the revision winch an author alone is capable of making.—The Western Lancet. Asa comprehensive manual for students, or a work of reference for practitioners, we only speak with common justice when we say that it surpasses any other that has ever issued on the same sub- ject from the British press.—The Dublin Quarterly Journal. DEWEES (W. P.), M.D., &c. A COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occa- sional Cases and many Engravings. Twelfth edition, with the Author's last Improvements and Corrections. In one octavo volume, of 600 pages. (Just Issued.) BY THE SAME AUTHOR. A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. Tenth edition. In one volume, octavo, 548 pages. (Just Issued.) BY THE SAME AUTHOR. A TREATISE ON THE DISEASES OF FEMALES. Tenth edition. one volume, octavo, 532 pages, with plates. (Just Issued.) In DICKSON (PROFESSOR S. H.), M.D. ESSAYS ON LIFE, SLEEP, PAIN, INTELLECTION, HYGIENE, AND DEATH. In one very handsome volume, royal 12mo. DANA (JAMES D). ZOOPHYTES AND CORALS. In one volume, imperial quarto, extra cloth, with wood-cuts. ALSO, AN ATLAS TO THE ABOVE, one volume, imperial folio, with sixty-one mag- nificent plates, colored after nature. Bound in half morocco. ON THE STRUCTURE AND CLASSIFICATION OF ZOOPHYTES. Sold separate, one vol., cloth. DE LA BECHE (SIR HENRY T.), F. R. 8., &c. THE GEOLOGICAL OBSERVER. In one very large and handsome octavo volume, of 700 pages. With over three hundred wood-cuts. (Just Issued.) AND SCIENTIFIC PUBLICATIONS. 11 DRUITT (ROBERT), M.R. C.S., fitc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the last and improved London edition. Edited by F. W. Sargent, M. D., author of " Minor Surgery," &c. Illustrated with one hundred and ninety-three wood-engrav- In one very handsomely printed octavo volume, of 576 large pages. accessible to the American student, has had much currency in this country, and under its present au- spices promises to rise to yet higher favor. The il- lustrations ofthe volume are good, and, in a word, the publishers have acquitted themselves fully of their duty.—The Western Journal of Medicine and Surgery. ings. No work, in our opinion, equals it in presenting so much valuable surgical matter in so small a compass.—St. Louis Med. and Surgical Journal. Druitt's Surgery is too well known to the Ameri- can medical profession to require, its announcement anywhere. Probably no work of the kind has ever been more cordially received and extensively circu- lated than this The fact that it comprehends in a comparatively small compass, all the essential ele- ments of theoretical and practical Surgery—that it is found to contain reliable and authentic informa- tion on the nature and treatment of nearly all surgi- cal affections—is a sufficient reason for the liberal pntronage it has obtained. The work before us is a new edition, greatly enlarged and extended by the author—its practical part having undergone a tho- rough revision, with fifty pages of additional matter. The editor. Dr. F. W. Sargent, of Philadelphia, has contributed much to enhance the value ofthe work, by such American improvements as are calculated more perfectly to adapt it to our own views and practice in this country. It abounds everywhere with spirited and life-like illustrations, which to the young surgeon, especially, are of no minor consi- deration. Every medical man frequently needs just such a work as this, for immediate reference in mo- ments of sudden emergency, when he has not time to consult more elaborate treatises. Its mechanical execution ieof the very best quality,and as a whole, it deserves and will receive from the profession, a liberal patronage.—The Ohio Medical and Surgical Journal. The author has evidently ransacked every stand- ard treatise of ancient and modern times, and all that is really practically useful at the bedside will be found in a form at once clear, distinct, and interest- ing.—Edinburgh Monthly Medical Journal. Druitt's work, condensed, systematic, lucid, and practical as it is, beyond most works on Surgery The most accurate and ample resumfe of the pre- sent state of Surgery that we are acquainted with.— Dublin Medical Journal. A better book on the principles and practice of Su rgery as now understood in England and Ameri ca, has not been given to the profession.—Boston Medi- cal and Surgical Journal. An unsurpassable compendium, not only of Sur- gical, but of Medical Practice.—London Medical Gazette. This work merits our warmest commendations, and we strongly recommend it to young surgeons as an admirable digest of the principles and practice of modern Surgery.—Medical Gazette. It may be said with truth that the work of Mr. Druitt affords a complete, though brief and con- densed view, of the entire field of modern surgery. We know of no work on the same subject having the appearance of a manual, which includes so many topics of interest to the surgeon ; and the terse man- ner in which each has been treated evinces a most enviable quality of mind on the part of the author, who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the pen. It is a useful handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student.— Provincial Medical and Surgical Journal. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound. *#* This work contains no less than four hundred and eighteen distinct treatises, contributed by 6ixty-eight distinguished physicians. The most complete work on Practical Medicine extant; or, at least, iu our language.—Buffalo Medical and Surgical Journal'. For reference, it is above all price to every prac- titioner.—Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. We rejoice that this work is to be placed within the reach of the profession in this country, it being unquestionably one of very great value to. the prac- titioner. This estimate of it has not been formed from a hasty examination, but after an intimate ac- quaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many of the most eminent professors and teachers of London, Edinburgh, Dub- lin, and Glasgow. It is, indeed, the great merit of this work that the principal articles have been fur- nished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them, and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority.—American Medical Journ. DUNGLISON (ROBLEY), M.D., Professor of the Institutes of Medicine, ia the Jefferson Medical College, Philadelphia. ^ HUMAN HEALTH; or, the Influence of Atmosphere and Locality, Change of A' and Climate, Seasons, Food, Clothing, Bathing, Exercise, Sleep, &c. &c, on Healthy Man ; constituting Elements of Hygiene. one octavo volume, of 464 pages. Second edition, with many modifications and additions. In 12 BLANCHARD & LEA'S MEDICAL DU.NGLI90N (ROBLEYJ, M. D.t Professor of Institutes pf Medicine in the.Jefferson Medipal College, Philadelphia, MEDICAL LEXICON; a Dictionary of, Medical Science, containing a concise Explanation ofthe various Subjects and Terms of Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence, &c. With the French and other Synonymes; Notices of Climate and of celebrated Mineral Waters; Formulae for various Officinal, Empirical, and Dietetic Preparations, etc. Tenth edition, revised. In one very thick octavo volume, of over nine hundred large double-columned pages, strongly bound in leather, with raised bands. (Just Issued.) Every successive edition of this work bears the marks of the industry of the author, and of his determination to keep it fully on a level with the most advanced state of medical science. Thus the last two editions contained about nine thousand subjects and terms not comprised in the one immediately preceding, and the present has not less than four thousand not in any former edition. Asa complete Medical Dictionary, therefore, embracing over FIFTY THOUSAND DEFINI- TIONS, in all the branches of the science, it is presented as meriting a continuance of the great favor and,popuJ,arity which have carried it, within no very long space of time, to a ninth edition. Every precaution has been taken in the preparation of the present volume, to render its mecha- nical execution and typographical accuracy worthy of its extended reputation and universal use. The very extensive additions have been accommodated, without materially increasing the bulk of the volume by the employment of a small but exceedingly clear type, cast for this purpose. The press has been watched with great care, and every effort used to insure the verbal accuracy so ne- cessary to a work of this nature. The whole is printed on fine white paper; and, while thus exhi- biting in every respect so great an improvement over former issues, it is presented at the original exceedingly low price. A miracle of labor and industry in one who has written able and voluminous works on nearly every branch of medical science. There could be no more useful book to the student or practitioner, in the present advancing age, than one in which would be found, in addition to the ordinary meaning and deri- vation of medical terms—so many of which are of modern introduction—concise descriptions of their explanation and employment; and all this and much more is contained in the volume before us. It is therefore almost as indispensable to the other learned professions as to our own. In fact, to all who may have occasion to ascertain the meaning of any word belonging to the many branches of medicine. From a careful examination ofthe present edition, we can vouch for its accuracy, and for its being brought quite up to the date of publication ; the author states in-his preface that he has added to it aboutfour thou- sand terms, which are not to be found in the prece- ding one. — Dublin Quarterly Journal of Medical Sciences. On the appearance of the last edition of this valuable work, we directed the attention of our readers to its peculiar merits; and we need do little more than state, in reference to the present reissue, that, notwithstanding'the large additions previously made to it, no fewer thail four thou- sand terms, not to be found in the preceding edi- tion, are contained in the volume before us.-<- Whilst it is a wonderful monument of its author's erudition; and intiustry, it is ajso a work of great practical utility j as we can testify from our own experience; for we keep it constantly within out reach, and make very frequent reference to it, nearly always, finding in it the information we seek. —British and Foreign Med.-Chirurg. Review. It has the rare merit that it certainly has no rival in the English language for accuracy and extent qf references. The terms generally include short physiological and pathological descriptions, so that, as thp author justly observes, the reader does not possess in this work a mere dictionary, but a book, which, while it instructs him in medical etymo^ logy, furnishes hiru with a large amount of useful information. The author's labors; have been pro- perly appreciated by hisowncountrymen; and. we can only confirm their judgment, by recommending this most useful volume to the notice of our cisat- lantic readers. No medical library will be complete without it.—London. Med. Gazette. It is certainly more complete and comprehensive than any with which we are acqduinted in the English language. Few, in fact, could be found better qualified than Dr. l)unglison for the produc- tion of such a work. Learned, industrious, per- severing, and accurate, he brings to the task'all the peculiar talents necessary for its successful performance; while; at the same time, hia fami- liarity With the writings of the ancient.and modern "masters of our art," renders him skilful to note the exact usage of the several terras of science, and the various modifications which medical term- inology has undergone with the change of theo- ries or the progress of improvement. — American: Journal ofthe Medical Sciences. One of the most complete and copious known to the cultivators of medical science.—Boston Med. Journal. , , A most complete Medical Lexicon—certainly one of the best works of the kind in the language.— Charleston Medical Journal. The most complete Medical DiotioBary in the English language.— Western Lancet. It has not ifs superior, if indeed its equal, in the F.nglish language.—St. Louis Medical and Surgical Journal. Familiar with nearly all the medical dictiona- ries now in print;' we consider the one before us the most complete, and an indispensable adjunct to every medical library.—British American Medical Journal. We repeat our declaration, that this is the best Medical Dictionary in the language.—West. Lancet. The very best Medical Dictionary now extant.— Southern Medical and Surgical Journal. The most comprehensive and best English Dic- tionary of medico) terms extant.—Buffalo Medical Journal. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Patbolbgy and The- rapeutics. Third Edition. In two large octavo volumes, of fifteen hundred pages. Upon every topic embraced in the work the latest information will be found- carefully posted lip.— Medical Examine*. The student of medicine will find, in these two elegant volumes, a mine of facts elegant volumes, a mine of facts, a gathering of ; cin. ', s' .„ precepts and advice from the warfd of experience, * * &Mrfffr* ferings of the race.—Boston Medical and Surgical Journal. It is certainly the most complete treatise of which we have any knowledge.—Western Journalof Medi- that will nerve him with courage, and faithfully I One of the most elaborate treatises of the kind direct him in his efforts to relieve the physical suf- 1 we have.—Soutiurn Med. and Surg. Journal* AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M. D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Seventh edition. Thoroughly revised and exten- sively modified and enlarged, with nearly five hundred'illustrations. In two large and'hand- somely printed octavo volumes, containing nearly 1450'pages. On no previous revision of this work has the author bestowed more care than on the present, il having been subjected to an entire scrutiny, not only as regards the important matters of which it treats, but also the language in which they are conveyed; and on no former occasion has he felt as satisfied with his endeavors to have ike work on a level with the existing state ot the science. It hae long since taken rank as one of the medi- cal classics of our language. To say that it is by far the best text-book of physiology ever published in this country, is but echoing the general testi- mony of the profession.—iV. Y. Journal of Medicine. There is no single book we would recommend to the student or physician, with greater confidence than the present, because iu it, will be found a mir- ror of almost every standard physiological work of the day. We most cordially recommend the work to every member of the profession, and no student should be without it. It is . THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Process of Parturition. Sixth American, from the last London edition. Illustrated with one hundred and forty-eight Figures, on fifty-five Lithographic Plates. In one large and handsomely printed volume, imperial octavo, with 520 pages. , In this edition, the plates have all been redrawn, and the text carefully read and corrected. It is therefore presented as in every way worthy the favor with which it has so long been received. From Prof, Hodge, of the University of Pet. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulationWill, I trust, be extensive throughout our country. We recommend tha. student who desires to mas- ter this difficult subject with the least possible trouble, to possess himself ut once of a erted; and it is the immense labor consequent upon the vast number of observations re- quisite to carry out this plan, which has so long delayed the appearance of its completion. Part IV, wiih numerous original illustrations, is now appearing in the Medical News and Library for 1853. Tho>e who have subscribed since the appearance of the preceding portion of the work eao have the three parts by mail, on remittance of $2 50 to the publishers. TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. VOLUME VI, for 1853, large 8vo., of 870 pages, with numerous colored plates and wood-cuts. ^ Also to be had. a few sets of the Transactions from 1848 to 1853, in six large octavo volumes, price $25. These volumes are published by and sold on account ofthe Association. WATSON (THOMAS), M. D., &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Third American, from the last London edition. Revised, with Additions, by D. Francis Condie, M. D , aulhor of a "Treatise on the Diseases of Children," &c. In one octavo volume, of nearly eleven hundred large pages, strongly bound with raised bands. To say that it is the very best work on the sub- ject now extiint, is but to echo the sentiment of the medical press throughout the country. — N. O. Medical Journal. Ofthe text-books recently republished Watson is very justly the principal favorite.—Holmes's Rep. to Nat. Med. Assoc. By universal consent the work ranks among the Very best text-books in our language.—Illinois and Indiana Med. Journal. Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medicine extant.— St. Louis Med. Journal. Confessedly one of the very hest works on the principles and practice of physic in the English or any other language.—Med. Examiner. Asa text-book it has no equal; as a compendium of pathology and practice no superior.—New York Annalist. We know of no work better calculated for being placed in the hands of the student, and for a text- book ; on every important point the author seems to have posted up his knowledge to the day.— Amer, Med. Journal. One of the most practically UBeful books that ever was presented to the student. — JV. Y. Med. Journal. WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London. DISEASES OF THE HEART, LUNGS, AND APPENDAGES; their Symptoms and Treatment. In one handsome volume, large royal 12mo., 512 pages. We consider this as the ablest work in the En- glish language, on the subject of which it treats; ithe author bei^ the first st.ethoscopist of the day. —Charleston Medical Journal. The examination we have given the above work, convinces us that it is a complete system or treatise upon the great speciality of Physical Diagnosis. To give, the reader a more perfect idea of what it con- tains, we should be glad to copy the whole table of contents and make some extracts from its pages, but our limits forbid. We have no hesitation in recom- mending the work as one of the most complete on this subject in the English language.; and yet it is not so voluminous as to Jbeobjectionable on this ac- count, to uny practitioner, however pressing his engagements.—Ohio Medical and Surgical Journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority of the London Society for Medical Observation. In one very handsome volume, royal 12mo , extra cloth (Just Issued.) Did not the perusal of the work justify the high opinion we have of it, the names of Dr. Walshe, the originator, and of Dr. Ballard, as the editor of the volume, would almost of itself have satisfied us that it abounds in minute clinical accuracy. We need not say that the execution of the whole reflects the highest credit not only upon the gentlemen men- tioned, but upon all those engaged upon its produc- tion. In conclusion, we are convinced that the possession of the work will be almost necessary to every member of the profession—that it will be found indispensable to the practiced.physician,.the pathologist, the medical jurist, and above all to the ■medicul student.—London Medical Times. correct diagnosis, it will prove exceedingly valua- ble. The great difficulty with beginners, who'have not been under the immediate training of an expe- rienced physician, is continually found to be in the appreciation of the.true condition of the organs and tissues. Let such provide themselves with this work and study it thoroughly, and they -will find much of the difficulty removed.—Southern Medical and Surgical Journal. This is truly a very capital book. The whole medical world, will reap advantages from its publi- cation. The thedicar journals will soon show its in fluence on the character of the ; - Reports of Cases'' which they publish. Drs. Ballard and Wnlshe have We hail the appearance of this book as the grand given to the world, through a small but useful desideratum.—Charleston Medical Journal. | medical organization; a cheap but invaluable book. This little work, if carefully read by even old practitioners, cannot fail to be productive 4>f much ?;ood; as a guide to the younger members of the pro- ession in directing their attention specially to the best mode of investigating cases so as to arrive at We do advise every reader of this notice to buy it and use it. Unless he is so vain as to imagine him- self superior to the ordinary human capacity, he will in six months see its inestimable advantages.— Stethoscope. AND SCIENTIFIC PUBLICATIONS. 29 WILSON (ERASMUS), M.D., F. R. S., Lecturer on Anatomy, London. A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- ^n- from'he Jast English edition. Edited by Paul B. Goddard, A. M., M. D. With two hun- dred and fifty illustrations. Beautifully printed, in one large octavo volume, of nearly six hun- dred pages. ° ' In many, if not all the Colleges of the Union, it has become a standard text-book. This, of itself, is .sufficiently expressive of its value. A work very desirable to the student; one, the possession of which will greatly facilitate his progress in the study of Practical Anatomy.—New York Journal of Medicine. Its author ranks with the highest ofc Anatomy.— Southern Medical and Surgical Journal, It offers to the student all the assistance that can be expected from such a work.—Medical Examiner. The most complete and convenient manual for the student we possess.—American Journal of Medical Science. In every respect, this work ns an anatomical guide for the student and practitioner, merits our warmest and most decided praise.—London Medical Gazette. BY THE SAME AUTHOR. THE DISSECTOR; or, Practical and Surgical Anatomy. Modified and Re- arranged, by Paul Beck Gqddard, M. D. A new edition, with Revisions and Additions. In one large and handsome volume, royal 12mo., with one hundred and fifteen illustrations. In passing this work again through the press, the editor has made such additions and improve- ments as the advance of anatomical knowledge has rendered necessary to maintain the work in the high reputation Which it has acquired in the schools ofthe United States, as a complete and faithful guide to the student of practical anatomy. A number of new illustrations have been added, espe- cially in the portion relating to the complicated anatomy of Hernia. In mechanical execution the work will be found superior to former editions. BY THE SAME AUTHOR, ON DISEASES OF THE SKIN. Third American, from the third London edition. In one neat octavo volume, of about five hundred pages, extra cloth. (Just Issued.) Also, to be had done up with fifteen beautiful steel plates, of which eight are exquisitely colored; representing the Normal and Pathological Anatomy of the Skin, together with accurately colored delineations of more than sixty varieties of disease, most of them the size of nature. The Plates are also for sale separate, done up in boards. The increased size of this edition is sufficient evidence that the author has not been content with a mere republication, but has endeavored to maintain the high character of his work as the standard text-book on this interesting and difficult class of diseases. He has thus introduced such new matter as the experience of the last three or four years has suggested, and has made such alterations as the progress of scientific investigation has rendered expedient. The illustrations have also been materially augmented, the number of plates being increased from eight to sixteen. The "Diseases of the Skin," by Mr. Erasmus Wilson, may now be regarded as the standard work in that department of medical literature. The plates by which this edition is accompanied leave nothing to be desired, so far as excellence of delinea- tion and perfect accuracy of illustration are con- cerned.—Medico-Chirurgical Review. As a practical guide to the classification, diag- nosis, and treatment of the diseases of the skin, the book is complete. We know nothing, considered in this aspect, better in our language; it is a safe authority on all the ordinary matters which, in this range of diseases, engage the practitioner's attention, and possesses the nigh quality—unknown, we believe, to every older manual—of being on a level with science's high-water mark; a sound book of practice.—London Med. Times. Of these plates it is impossible to speak too highly. The representations of the various forms of cuta- neous disease are singularly accurate, and the color- ing exceeds almost anything we have met wiih in point of delicacy and finish.—British and Foreign Medical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, beautifully printed, with four exqui- site colored plates, presenting more than thirty varieties of syphilitic eruptions. This, in many respects, is a remarkable work, pre- senting views of theory and principles of practice which, if true, must change completely the existing state of professional opinion.—New York Journal of Medicine. Dr. Wilson's views on the general subject of Syphilis appear to us in the main sound and judi- cious, and we commend the book as an excellent monograph on the subject. Dr. Wilson has pre- sented us a very faithful and lucid description of Syphilis and has cleared up many obscure points in connection with its transinissibility, pathology and sequeltE. His facts and references will, we are satis- fied, be received as decisive, in regard to many questiones vexatte. They appear to us entitled to notice at some length. We have perhaps been some- what prodigal of space in our abstract of this book. But it is certainly a very good resume of received opinions on Syphilis, and presents, to many, original and Btriking views on the subject.—Med. Examiner. WHITEHEAD (JAMES), F. R. C. S.f &c. THE CAUSES AND TREATMENT OF ABORTION AND STERILITY; bein* the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus'! In one volume, octavo, 368 pages. 30 BLANCHARD & LEA'S MEDICAL WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, with illustrations. (Now Ready.) So little is generally known in this country concerning the causes, symptoms, and treatment of aural affections, that a practical and scientific work on that subject, from a practitioner of Mr. Wilde's great experience, cannot fail to be produciive of much benefit, by attracling attention to this obscure class of diseases, which too frequently escape attention until past relief. The im- mense number of cases which have come under Mr. Wilde's observation for many years, have afforded him opportunities rarely enjoyed for investigating this branch of medical science, and his work may therefore be regarded as of the highest authority. WEST (CHARLES), M. D., Senior Physician to the Royal Infirmary for Children, Ac. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD In one volume, octavo, of four hundred and fifty pages. The Lectures of Dr. West, originally published in the London Medical Gazette, form a most vulual ' addition to this branch of practical medicine. For many years physician to the Children:s Infirmary, his opportunities for observing their diseases have been most extensive, no less than 14,000 children having been brought under his notice during the past nine years. These have evidently been studied with great care, and the result has been the production of the very best work in our language, so far as it goes, on the diseases of this class of our patients. The symptomatology and pathology of their diseases are especially exhibited most clearly ; and we are con- vinced that no one can read with care these lectures without deriving from them instruction of the most important kind.—Charleston Med. Journal. Every portion of these lectures is marked-by a ge- neral accuracy of description, and by the soundness of the views set forth in relation to the pathology and therapeutics of the several maladies treated of. The lectures on the diseases of the respiratory ap- paratus; about one-third of the whole number, are particularly excellent, forming one of the fullest and most able accounts of these affections, as they present themselves during infancy and childhood, in the English language. The history of the seve- ral forms of phthisis during these periods of exist- ence, with their management, will be read by all with deep interest.—The American Journal of the Medical Sciences. WILLIAMS (C. J. B..i, M. D., F. R. S., Professor of Clinical Medicine in University College, London, tec. PRINCIPLES OF MEDICINE; comprising General Pathology and Therapeu- tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and Hygienics. Edited, with Additions, by Meredith Clymer, M. D. Fourth American, from the last and enlarged London edition. In one octavo volume, of nearly five hundred pages. Now Ready. This new edition has been materially enlarged and brought up by the editor. It possesses the strongest claims to the attention of the medical student and practitioner, from the admirable manner in which the various inquiries in the different branches of pathology are investigated, combined, and generalized by an experienced practical physician, and directly applied to the investigation and treatment of disease.—Editor's Preface. The best exposition in our language, or, we be- lieve, in any language, of rational medicine, in its present improved and rapidly improving state.— British and Foreign Medico-Chirurg. Review. Few books have proved more useful, or met with a more ready sale than this, and no practitioner should regard his library as complete without it. —Ohio Med. and Surg. Journal. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE . RESPIRATORY ORGANS; including Diseases of the Larynx, Trachea, Lungs, and Pleurae. With numerous Additions and Notes, by M. Clymer, M. D. With wood-cuts. In one octavo volume, pp. 508. YOUATT (WILLIAM), V. S. THE HORSE. A new edition, with numerous illustrations; together with a general history of the Horse; a Dissertation on the American Trotting Horse; how Trained and Jockeyed; an Account of his Remarkable Performances; and an Essay on the Ass and the Mule. By J. S. Skinner, formerly Assistant Postmaster-General, and Editor of the Turf Register. Oiie large octavo volume. BY THE SAME AUTHOR. THE DOG. Edited by E. J. Lewis, M. D. With numerous and beautiful illustrations. In one very handsome volume, crown 8vo., crimson cloth, gilt. ILLUSTRATED MEDICAL CATALOGUE. BLANCHARD & LEA have now ready a Catalogue of their Medical and Surgical Publi- cations, containing descriptions of the works, with Notices of the Press, and specimens of the Illustrations, making a pamphlet of forty-eight large octavo pages. It has been prepared with great care, and without regard to expense, forming one of the most beautiful specimens of typographical execution as yet issued in this country. Copies will be sent by mail, and the postage paid, on application to the Publishers, by inclosing a three cent postage stamp. AND SCIENTIFIC PUBLICATIONS. 31 B. & L. subjoin a condensed list of their publications in general and educational literature, of which more detailed catalogues will be furnished on application. HISTORY AND BROWNING'S HISTORY OF THE HUGUE NO IS. I vol. 8vo. CAMPBELLS (LORD) LIVES OF THE LORD CH ANCELLORS OF ENGLAND, from the earl- iest rimes to the Reign of George IV. In seven handsome crown octavo volumes, extra cloth or half morocco. 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